Background Ruptured descending thoracic aortic aneurysm (rDTAA) is a cardiovascular catastrophe, associated with high morbidity and mortality, which can be managed either by open surgery or thoracic ...endovascular aortic repair (TEVAR). The purpose of this study is to retrospectively compare the mortality, stroke, and paraplegia rates after open surgery and TEVAR for the management of rDTAA. Methods Patients with rDTAA treated with TEVAR or open surgery between 1995 and 2010 at seven institutions were identified and included for analysis. The outcomes between both treatment groups were compared; the primary end point of the study was a composite end point of death, permanent paraplegia, and/or stroke within 30 days after the intervention. Multivariate logistic regression analysis was used to identify risk factors for the primary end point. Results A total of 161 patients with rDTAA were included, of which 92 were treated with TEVAR and 69 with open surgery. The composite outcome of death, stroke, or permanent paraplegia occurred in 36.2% of the open repair group, compared with 21.7% of the TEVAR group (odds ratio OR, 0.49; 95% confidence interval CI, .24-.97; P = .044). The 30-day mortality was 24.6% after open surgery compared with 17.4% after TEVAR (OR, 0.64; 95% CI, .30-1.39; P = .260). Risk factors for the composite end point of death, permanent paraplegia, and/or stroke in multivariate analysis were increasing age (OR, 1.04; 95% CI, 1.01-1.08; P = .036) and hypovolemic shock (OR, 2.47; 95% CI, 1.09-5.60; P = .030), while TEVAR was associated with a significantly lower risk of the composite end point (OR, 0.44; 95% CI, .20-.95; P = .039). The aneurysm-related survival of patients treated with open repair was 64.3% at 4 years, compared with 75.2% for patients treated with TEVAR ( P = .191). Conclusions Endovascular repair of rDTAA is associated with a lower risk of a composite of death, stroke, and paraplegia, compared with traditional open surgery. In rDTAA patients, endovascular management appears the preferred treatment when this method is feasible.
To examine practice patterns and compare survival outcomes between total laryngectomy (TL) and larynx preservation chemoradiation (LP-CRT) in the setting of T4a larynx cancer, using a large national ...cancer registry.
Using the National Cancer Database, we identified 969 patients from 2003 to 2006 with T4a squamous cell larynx cancer receiving definitive treatment with either initial TL plus adjuvant therapy or LP-CRT. Univariate and multivariable logistic regression were used to assess predictors of undergoing surgery. Survival outcomes were compared using Kaplan-Meier and propensity score-adjusted and inverse probability of treatment-weighted Cox proportional hazards methods. Sensitivity analyses were performed to account for unmeasured confounders.
A total of 616 patients (64%) received LP-CRT, and 353 (36%) received TL. On multivariable logistic regression, patients with advanced nodal disease were less likely to receive TL (N2 vs N0, 26.6% vs 43.4%, odds ratio OR 0.52, 95% confidence interval CI 0.37-0.73; N3 vs N0, 19.1% vs 43.4%, OR 0.23, 95% CI 0.07-0.77), whereas patients treated in high case-volume facilities were more likely to receive TL (46.1% vs 31.5%, OR 1.78, 95% CI 1.27-2.48). Median survival for TL versus LP was 61 versus 39 months (P<.001). After controlling for potential confounders, LP-CRT had inferior overall survival compared with TL (hazard ratio 1.31, 95% CI 1.10-1.57), and with the inverse probability of treatment-weighted model (hazard ratio 1.25, 95% CI 1.05-1.49). This survival difference was shown to be robust on additional sensitivity analyses.
Most patients with T4a larynx cancer receive LP-CRT, despite guidelines suggesting TL as the preferred initial approach. Patients receiving LP-CRT had more advanced nodal disease and worse overall survival. Previous studies of (non-T4a) locally advanced larynx cancer showing no difference in survival between LP-CRT and TL may not apply to T4a disease, and patients should be counseled accordingly.
Although 3-dimensional conformal radiotherapy (3D-CRT) is the worldwide standard for the treatment of esophageal cancer, intensity modulated radiotherapy (IMRT) improves dose conformality and reduces ...the radiation exposure to normal tissues. We hypothesized that the dosimetric advantages of IMRT should translate to substantive benefits in clinical outcomes compared with 3D-CRT.
An analysis was performed of 676 nonrandomized patients (3D-CRT, n=413; IMRT, n=263) with stage Ib-IVa (American Joint Committee on Cancer 2002) esophageal cancers treated with chemoradiotherapy at a single institution from 1998-2008. An inverse probability of treatment weighting and inclusion of propensity score (treatment probability) as a covariate were used to compare overall survival time, interval to local failure, and interval to distant metastasis, while accounting for the effects of other clinically relevant covariates. The propensity scores were estimated using logistic regression analysis.
A fitted multivariate inverse probability weighted-adjusted Cox model showed that the overall survival time was significantly associated with several well-known prognostic factors, along with the treatment modality (IMRT vs 3D-CRT, hazard ratio 0.72, P<.001). Compared with IMRT, 3D-CRT patients had a significantly greater risk of dying (72.6% vs 52.9%, inverse probability of treatment weighting, log-rank test, P<.0001) and of locoregional recurrence (P=.0038). No difference was seen in cancer-specific mortality (Gray's test, P=.86) or distant metastasis (P=.99) between the 2 groups. An increased cumulative incidence of cardiac death was seen in the 3D-CRT group (P=.049), but most deaths were undocumented (5-year estimate, 11.7% in 3D-CRT vs 5.4% in IMRT group, Gray's test, P=.0029).
Overall survival, locoregional control, and noncancer-related death were significantly better after IMRT than after 3D-CRT. Although these results need confirmation, IMRT should be considered for the treatment of esophageal cancer.
Abstract Conventional diagnostic modalities for assessing arterial circulation or tissue perfusion include blood pressure measurement, ultrasound evaluation, and contrast-based angiographic ...assessment. An infrared thermal camera can detect infrared radiation energy from the human body, which generates a thermographic image to allow tissue perfusion analysis. We describe a smartphone-based miniature thermal imaging system that can be used as an adjunctive imaging modality to assess tissue perfusion. This smartphone-based camera device is noninvasive, simple to use, and cost-effective in assessing patients with lower extremity tissue perfusion. Assessment of patients with lower extremity arterial ischemia can be performed by a variety of diagnostic modalities, including ankle-brachial index, absolute systolic ankle or toe pressure, transcutaneous oximetry, arterial Doppler waveform, arterial duplex ultrasound, computed tomography scan, arterial angiography, and thermal imaging. We herein describe a noninvasive imaging modality using smartphone-based infrared thermography.
Background Although the incidence of patients presenting with concomitant colorectal cancer (CRC) and abdominal aortic aneurysm (AAA) is low, current treatment strategies in patients with both ...lesions remains controversial. Given recent advances in endovascular aortic aneurysm repair (EVAR), we sought to analyze the surgical outcomes of patients with concomitant CRC and AAA. Study Design A retrospective chart review was performed on all patients with CRC and AAA between December 1984 and July 2007. Results A total of 108 patients with concomitant CRC and AAA were identified. Forty-six patients presented with symptomatic or obstructing CRC, which was treated with colectomy followed by either open AAA repair (n = 35, group A) or EVAR (n = 11, group B). Thirty-eight patients underwent either open AAA (n = 26, group C) or EVAR (n = 12, group D) first, followed by staged CRC resection. Eight patients underwent combined CRC and open AAA repair (group E). The time delays after CRC resection to AAA repair in groups A and B were 42 and 35 days (NS), respectively. The time delays after open AAA or EVAR procedures before CRC resection in groups C and D were 115 days and 12 days (p < 0.0001), respectively. Two patients in group B developed sigmoid ischemia after EVAR and were treated with sigmoid resection. Increased perioperative morbidity and mortality rates were noted in group C (p < 0.002). Conclusions In patients with concomitant colorectal cancer and AAA, the symptomatic lesion should be a treatment priority. Because EVAR results in early recovery and a shorter convalescence compared with open aneurysmorrhaphy, this modality offers potential treatment benefits in patients with suitable anatomy who have concomitant CRC. But EVAR treatment should be offered with caution because of the risk of sigmoid ischemia caused by inferior mesenteric artery occlusion.
Background Acute mesenteric ischemia (AMI) is associated with high morbidity and mortality due in part to its diagnostic difficulty and operative challenges. The purpose of this study was to review ...our experience of surgical management in patients with this condition and to identify variables associated with adverse outcomes following surgical interventions. Methods Hospital records and clinical data of all patients undergoing surgical interventions for AMI were reviewed during a recent 12-year period. Clinical outcomes as well as factors influencing mortality were analyzed. Results A total of 72 patients (41 females, overall mean age 65 years, range 34 to 83 years) were included in the study. Thrombosis and embolism were the cause of AMI in 48 patients (67%) and 24 patients (33%), respectively. Abdominal pain was the most common presenting symptom (96%), followed by nausea (56%). Preoperative angiogram was performed in 61 patients (85%). All patients underwent operative interventions, which included thromboembolectomy (n = 22, 31%), mesenteric bypass grafting (n = 33, 46%), patch angioplasty (n = 9, 12%), reimplantation (n = 5, 7%), and endarterectomy (n = 3, 4%). Bowel resection was necessary in 22 patients (31%) during the initial operation, and second-look operation was performed in 38 patients (53%). Perioperative morbidity and 30-day mortality rates were 39% and 31%, respectively. Univariate analysis showed renal insufficiency ( P < .02), age >70 ( P < .001), metabolic acidosis ( P < .02), and symptom duration ( P < .005), and bowel resection in second-look operations ( P < .01) were associated with mortality. Logistic regression analysis showed age >70 ( P = .03) and prolonged symptom duration ( P = .02) were independent predictors of mortality. Conclusions Elderly patients and those with a prolonged duration of symptoms had worse outcomes following surgical intervention for AMI. A high index of suspicion with prompt diagnostic evaluation may reduce time delay prior to surgical intervention, which may lead to improved patient survival. Aggressive surgical intervention should be performed as promptly as possible in patients once the diagnosis of AMI is made.
To identify the optimal dose parameters predictive for local/lobar control after stereotactic ablative radiation therapy (SABR) in early-stage non-small cell lung cancer (NSCLC).
This study ...encompassed a total of 1092 patients (1200 lesions) with NSCLC of clinical stage T1-T2 N0M0 who were treated with SABR of 50 Gy in 4 fractions or 70 Gy in 10 fractions, depending on tumor location/size, using computed tomography-based heterogeneity corrections and a convolution superposition calculation algorithm. Patients were monitored by chest CT or positron emission tomography/CT and/or biopsy after SABR. Factors predicting local/lobar recurrence (LR) were determined by competing risk multivariate analysis. Continuous variables were divided into 2 subgroups at cutoff values identified by receiver operating characteristic curves.
At a median follow-up time of 31.7 months (interquartile range, 14.8-51.3 months), the 5-year time to local recurrence within the same lobe and overall survival rates were 93.8% and 44.8%, respectively. Total cumulative number of patients experiencing LR was 40 (3.7%), occurring at a median time of 14.4 months (range, 4.8-46 months). Using multivariate competing risk analysis, independent predictive factors for LR after SABR were minimum biologically effective dose (BED10) to 95% of planning target volume (PTVD95 BED10) ≤86 Gy (corresponding to PTV D95 physics dose of 42 Gy in 4 fractions or 55 Gy in 10 fractions) and gross tumor volume ≥8.3 cm(3). The PTVmean BED10 was highly correlated with PTVD95 BED10. In univariate analysis, a cutoff of 130 Gy for PTVmean BED10 (corresponding to PTVmean physics dose of 55 Gy in 4 fractions or 75 Gy in 10 fractions) was also significantly associated with LR.
In addition to gross tumor volume, higher radiation dose delivered to the PTV predicts for better local/lobar control. We recommend that both PTVD95 BED10 >86 Gy and PTVmean BED10 >130 Gy should be considered for SABR plan optimization.
The objectives of this national chart audit (January to June 2013) of 6,346 patients with atrial fibrillation (AF; ≥18 years without a significant heart valve disorder) from 647 primary care ...physicians were to (1) describe the frequency of stroke and bleed risk assessments in patients with nonvalvular AF by primary care physicians, including the accuracy of these assessments relative to established predictive indexes; (2) outline contemporary methods of anticoagulation used; and (3) report the time in the therapeutic range among patients prescribed warfarin. An annual stroke risk assessment was not undertaken in 15% and estimated without a formal risk tool in 33%; agreement with CHADS2 score estimation was seen in 87% of patients. Major bleeding risk assessment was not undertaken in 25% and estimated without a formal risk tool in 47%; agreement with HAS-BLED score estimation was observed in 64% with physician overestimation in 26% of patients. Antithrombotic therapy included warfarin (58%), dabigatran (22%), rivaroxaban (14%), and apixaban (<1%). Among warfarin-treated patients, the median international normalized ratio was 2.4 and time in therapeutic range (TTR) was 73%; however, the TTR was <50% in 845 (25%), 50% to 69% in 674 (20%), and ≥70% in 1,827 (55%) patients. In conclusion, we describe a contemporary real-world elderly population with AF at important risk for stroke. There is apparent overestimation of bleeding risk in many patients. Warfarin was the dominant stroke prevention treatment; however, the suggested TTR target was achieved in only 55% of these patients.
Abstract Objective Children with acute lymphoblastic leukemia (ALL) are at elevated risk for nutrition-related morbidities both during and after therapy. We present the demographics and nutrient ...intake at study entry of a prospective cohort evaluating dietary intake in children diagnosed with ALL. Research Methods & Procedures Assessment of dietary intake was collected for participants enrolled on the DFCI ALL Consortium Protocol. Dietary intake was assessed with a food frequency questionnaire and was compared to the Dietary Reference Intake (DRI) by ALL risk group (standard (SR)- and high (HR)-risk). Results Dietary intake was collected in 81% of participants (n=640). We found that 27% of participants were overweight/obese. Intake of total calories and other nutrients exceeded the DRI in up to 79% of children above the DRI. This was evident in both risk groups and pronounced among younger age children. For micronutrients, dietary intake of calcium, vitamin D (females only) and zinc was significantly different between SR and HR ALL. Conclusions This study was successful in collecting dietary intake in a multi-center setting among a pediatric population at the time of cancer diagnosis and at high-risk for nutrition-related morbidities. We identified "at-risk" dietary intakes, which vary by gender and ALL risk group, which may benefit from future dietary interventions.
Pseudoaneurysm formation caused by iatrogenic arterial injury during a regional anesthetic block is a rare complication. We report a case of a 56-year-old male patient who developed an axillary ...artery pseudoaneurysm caused by brachial plexus block performed for an upper extremity dialysis access operation. Successful repair of this pseudoaneurysm was achieved with endovascular stent graft exclusion. The repaired axillary artery with the stent graft remained patent after 10 years of follow-up. The successful long-term patency of this treatment and a strategy to potentially avoid this complication are discussed.
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