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Alexander A, Willey J, Sun H, Parker CA, Marx AN, Wood AL, Reddy SM, Reuben JM, Bassett RL, Le-Petross HT, Krishnamurthy S, Gong Y, Woodward WA, Valero V, Ueno NT, Lim B. Abstract OT1-02-05: A single arm phase II study of adjuvant anti-PD1 (pembrolizumab) in combination with hormonal therapy in patients with hormone receptor (HR)-positive localized inflammatory breast cancer (IBC) who did not achieve a pathological complete response (pCR) to neoadjuvant chemotherapy. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-ot1-02-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: The pCR rate to conventional chemotherapy in hormone receptor positive IBC has historically been low (7.4% for HR+ HER2-, and 30% for HR+ HER2+), and despite the use of adjuvant endocrine therapy, the recurrence rate is still as high as 40%. To date, no targeted agent is proven to improve the efficacy of adjuvant endocrine therapy within the IBC population to improve this poor disease free survival (DFS). One plausible reason for the poor efficacy of endocrine therapy is a suppressed immune system, which allows tumor cells to avoid detection despite expression of potential immunogenic surface antigens.
Trial Design: This is a single arm trial that will enroll stage III HR+ IBC patients who have completed neoadjuvant therapy but had residual disease at mastectomy. Enrollment should be before or within 2 months of beginning endocrine therapy. Monitoring of DFS will be done with radiological imaging every 3 cycles (starting at cycle 4) as clinically indicated, per standard of care. Pembrolizumab is given on day 1 of each 21 day cycle for up to 2 years if the disease is controlled, and hormonal therapy will be administered per standard of care.
Eligibility Criteria: Clinical stage 3 IBC ER+/PR+ and HER2 negative patients who completed neoadjuvant chemotherapy and surgery with evidence of residual cancer in the breast or lymph nodes, but be clinically disease-free with good performance status at the start of study. Patients also must have adequate hematologic and organ function, and have recovered from the acute effects from prior treatments.
Specific Aims: The primary objective is to determine the disease free survival (DFS) at 2 years of patients with adjuvant therapy using Pembrolizumab in combination with standard adjuvant hormonal therapy. The secondary objective is to determine the safety and toxicity profile of this combination.
Statistical Methods: With a sample size of 37 patients, assuming that 80% are alive (20% increase from historical data) and disease-free at 2 years, and all patients are followed for >2 years after enrollment with no dropout, a 95% confidence interval around the 2-year estimate of DFS will be generated. DFS will then be compared with the historical control rate of 60% by year 2 using a one-sided exponential MLE test.
Accrual: To date we have enrolled 3 patients since activation in January 2017, and the target enrollment is 37 patients.
Contact information: For more information or to refer a patient, please contact study coordinator, Angela Alexander - aalexand@mdanderson.org
Citation Format: Alexander A, Willey J, Sun H, Parker CA, Marx AN, Wood AL, Reddy SM, Reuben JM, Bassett RL, Le-Petross HT, Krishnamurthy S, Gong Y, Woodward WA, Valero V, Ueno NT, Lim B. A single arm phase II study of adjuvant anti-PD1 (pembrolizumab) in combination with hormonal therapy in patients with hormone receptor (HR)-positive localized inflammatory breast cancer (IBC) who did not achieve a pathological complete response (pCR) to neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT1-02-05.
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Alexander A, Kaluve R, Prabhu JS, Korlimarla A, BS S, Manjunath S, Patil S, KS G, Sridhar TS. Abstract P4-10-12: Treatment decision making, and strategies for coping with financial stress in Indian women diagnosed with breast cancer and their families. Cancer Res 2018. [DOI: 10.1158/1538-7445.sabcs17-p4-10-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: In spite of rapid urbanization and modernization the family remains central in the socio-cultural structure of India. The individuals are enmeshed into this unit and tend to be interlinked financially, emotionally and socially. The head of this family unit tends to be a male more often than not. As is well known, despite recent attempts by the governments at the state and centre at providing health coverage for cancer through regional cancer centres, a majority have to raise the money for cancer care by themselves. We have examined the role of the family in treatment decision making and in the strategies employed to raise the money and cope with the financial stress imposed by a diagnosis of breast cancer.
Method: 378 women with breast cancer were enrolled into a longitudinal study at first diagnosis between the years 2008-2012, at two tertiary care hospitals in Bangalore, India. The median follow up as of May 31st 2017 is 78 months with only 2% loss to follow-up over the past 8 years. Follow-up was maintained by frequent meetings between a counselling psychologist (AA) and the patient and/or a family member. The frequency of meetings was monthly during the initial treatment and then quarterly over the next 5 years. Information on demographics was collected during the treatment phase and information on the psychosocial aspects was collected in non-structured interactions subsequently. This information included details of support structure, decision making, and financial arrangements.
Results: This is a predominantly urban cohort with 80% being urban. The median age of patients at first diagnosis was 55 years. Almost all of our patients (99%) had the support of one or more family members. We analysed the pattern of decision making for treatment and in half of all cases either the husband or the son were the decision makers. In an additional 15% daughters and other relatives were the primary decision makers. Approximately a third of women made the decision concerning treatment themselves, and these women tended to be college educated (51% vs 16%) and employed (53% vs 12%).
30% of the patients met the costs incurred through medical insurance plans purchased by the family. Another quarter of patients were able to meet the costs from their savings. 45% had difficulty in finding the money for treatment and 15% took personal loans while 30% had to sell land/gold ornaments or take loans against assets of these sorts. Only (3%) discontinued the treatment due to financial difficulties. As in the case of decision making those who had the financial resources tended to be more educated (41% vs 11%), and were employed (31% vs 21%).
Conclusion: The data from a predominantly urban cohort of breast cancer enrolled between 2008-2012, supports the general belief that in India the family remains the fulcrum of an individual during crises, and not surprisingly education and employment lead to both psychological and economic emancipation of women.
Citation Format: Alexander A, Kaluve R, Prabhu JS, Korlimarla A, BS S, Manjunath S, Patil S, KS G, Sridhar TS. Treatment decision making, and strategies for coping with financial stress in Indian women diagnosed with breast cancer and their families [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-10-12.
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Thulborn KR, Atkinson IC, Alexander A, Singal M, Amin-Hanjani S, Du X, Alaraj A, Charbel FT. Comparison of Blood Oxygenation Level-Dependent fMRI and Provocative DSC Perfusion MR Imaging for Monitoring Cerebrovascular Reserve in Intracranial Chronic Cerebrovascular Disease. AJNR Am J Neuroradiol 2018; 39:448-453. [PMID: 29371256 DOI: 10.3174/ajnr.a5515] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 11/07/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Loss of hemodynamic reserve in intracranial cerebrovascular disease reduces blood oxygenation level-dependent activation by fMRI and increases asymmetry in MTT measured by provocative DSC perfusion MR imaging before and after vasodilation with intravenous acetazolamide. The concordance for detecting hemodynamic reserve integrity has been compared. MATERIALS AND METHODS Patients (n = 40) with intracranial cerebrovascular disease and technically adequate DSA, fMRI and provocative DSC perfusion studies were retrospectively grouped into single vessels proximal to and distal from the circle of Willis, multiple vessels, and Moyamoya disease. The vascular territories were classified as having compromised hemodynamic reserve if the expected fMRI blood oxygenation level-dependent activation was absent or if MTT showed increased asymmetry following vasodilation. Concordance was examined in compromised and uncompromised vascular territories of each group with the Fischer exact test and proportions of agreement. RESULTS Extensive leptomeningeal collateral circulation was present in all cases. Decreased concordance between the methods was found in vascular territories with stenosis distal to but not proximal to the circle of Willis. Multivessel and Moyamoya diseases also showed low concordance. A model of multiple temporally displaced arterial inputs from leptomeningeal collateral flow demonstrated that the resultant lengthening MTT mimicked compromised hemodynamic reserve despite being sufficient to support blood oxygenation level-dependent contrast. CONCLUSIONS Decreased concordance between the 2 methods for assessment of hemodynamic reserve for vascular disease distal to the circle of Willis is posited to be due to well-developed leptomeningeal collateral circulation providing multiple temporally displaced arterial input functions that bias the perfusion analysis toward hemodynamic reserve compromise while blood oxygenation level-dependent activation remains detectable.
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Einstein N, Okubanjo O, Alexander A, Putman M, Watts H. 158 Caring for a Critically Ill Simulated Left Ventricular Assist Device Patient With or Without a Cognitive Aid Improves Physician Comfort. Ann Emerg Med 2017. [DOI: 10.1016/j.annemergmed.2017.07.185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Mahmood J, Jackson I, Pavlovic R, Zhang A, Connors C, Alexander A, Kaytor M, Vujaskovic Z. Treatment With Nano-Genistein for the Prevention of Radiation-Induced Erectile Dysfunction. Int J Radiat Oncol Biol Phys 2017. [DOI: 10.1016/j.ijrobp.2017.06.2102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Nair M, Prabhu J, Remacle J, S H, Korlimarla A, Kaluve R, Alexander A, Patil S, S S, Srinivas S. Examination of the role of integrin β3 in chemoresistance by analysis of residual NACT tumor specimens and knock-in experiments. Ann Oncol 2017. [DOI: 10.1093/annonc/mdx140.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Tyldesley S, Parimi S, Tsang E, Bachand F, Aparicio M, Duncan G, Sunderland K, Olson R, Pai H, Alexander A, Lapointe V, Chi K. EP-1359: Pain response in a Population-based study of Radium-223 for Metastatic Prostate Cancer. Radiother Oncol 2017. [DOI: 10.1016/s0167-8140(17)31794-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Gagne I, Zavgorodni S, Alexander A, Vallieres I. EP-1649: Comparison of two thermoplastic immobilization shells for frameless stereotactic radiotherapy. Radiother Oncol 2017. [DOI: 10.1016/s0167-8140(17)32084-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jiang ZD, Ajami NJ, Petrosino JF, Jun G, Hanis CL, Shah M, Hochman L, Ankoma-Sey V, DuPont AW, Wong MC, Alexander A, Ke S, DuPont HL. Randomised clinical trial: faecal microbiota transplantation for recurrent Clostridum difficile infection - fresh, or frozen, or lyophilised microbiota from a small pool of healthy donors delivered by colonoscopy. Aliment Pharmacol Ther 2017; 45:899-908. [PMID: 28220514 DOI: 10.1111/apt.13969] [Citation(s) in RCA: 126] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 12/29/2016] [Accepted: 01/14/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND Faecal microbiota transplantation (FMT) has become routine in managing recurrent C. difficile infection (CDI) refractory to antibiotics. AIM To compare clinical response and improvements in colonic microbiota diversity in subjects with recurrent CDI using different donor product. METHODS Seventy-two subjects with ≥3 bouts of CDI were randomised in a double-blind study to receive fresh, frozen or lyophilised FMT product via colonoscopy from 50 g of stool per treatment from eight healthy donors. Recipients provided stools pre- and 7, 14 and 30 days post-FMT for C. difficile toxin and, in a subset, microbiome composition by 16S rRNA gene profiling. RESULTS Overall resolution of CDI was 87% during 2 months of follow-up after FMT. Stool samples before FMT had significantly decreased bacterial diversity with a high proportion of Proteobacteria compared to donors. Cure rates were highest for the group receiving fresh product seen in 25/25 (100%), lowest for the lyophilised product 16/23 (78%; P = 0.022 vs. fresh and 0.255 vs. frozen) and intermediate for frozen product 20/24 (P = 0.233 vs. fresh). Microbial diversity was reconstituted by day 7 in the subjects receiving fresh or frozen product. Improvement in diversity was seen by day 7 in those randomised to lyophilised material with reconstitution by 30 days. CONCLUSIONS Comparative efficacy in faecal microbiota transplantation was observed in subjects receiving fresh or frozen faecal product from the same donors. The lyophilised product had a slightly lowered efficacy compared with fresh product, but it resembled other treatments in microbial restoration 1 month after faecal microbiota transplantation.
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Prabhu JS, Kaul R, Korlimarla A, Desai K, Gangadharan C, Rajarajan S, Nair MG, Alexander A, Kaluve R, Manjunath S, Correa M, Prasad MSN, Patil S, Srinath BS, Sridhar TS. Abstract P4-07-10: Epithelial mesenchymal transition associated with high miR-221 and integrin β6 leads to poor prognosis in hormone receptor positive HER2 negative breast cancers. Cancer Res 2017. [DOI: 10.1158/1538-7445.sabcs16-p4-07-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: MicroRNA mediated molecular alterations are involved in the initiation and progression of cancer. Altered expression of multiple microRNAs is associated with endocrine resistance in hormone receptor positive HER2 negative (HR+/HER2-ve) cancer. The role of miR-221 in inducing epithelial to mesenchymal transition (EMT) is well documented especially in cell line model systems. However, the detailed mechanism of specific microRNAs in intrinsic and acquired resistance to endocrine therapy needs to be worked out. In addition, more needs to be done in the documentation of these mechanisms in human breast cancer specimens with complete clinical documentation and long-term follow-up. In this study, we have evaluated the clinical significance of miR-221 and its mechanistic role in EMT using human specimens and cell line models.
Materials and Methods: Formalin fixed paraffin embedded tumor from 129 HR+/HER2-ve breast cancer patients with a median follow up of 63 months were used for estimation of miR-221 by quantitative real time PCR. Expression levels of genes which are direct targets of miR-221 and related genes in EMT were analysed from these tumors. Survival between miR-221 high and low groups was compared by Kaplan Meier survival curves and prognostic relevance was estimated by Cox proportional hazard model.
Cell line experiments to investigate the role of miR-221 in inducing EMT through integrin β6 are underway in both wild type and tamoxifen resistant MCF-7 cell lines (A gift from Prof Ben Ho Park, Johns Hopkins University School of Medicine).
Results: A significant elevated level of miR-221 was observed in small proportion (14%) of HR+/HER2-ve tumors. miR-221 expression had an inverse correlation with both ER protein and ESR1 mRNA levels within HR+/HER2-ve tumors. Tumors with high levels of miR-221 showed significantly higher expression of integrin β6 which is a robust marker of EMT. Patients with high expression of miR-221 had a poorer survival in Kaplan Meier analysis.
Results of interrogation of EMT mediated through integrin related pathways involving miR-221 in cell line models will be presented.
Discussion: The association between miR-221 and integrin β6 in HR+/HER2-ve breast cancer with endocrine resistance suggests a potential link between an epigenetic regulator and a mediator of tumor-stromal interaction. The other mediators involved in this pathway are being investigated. miR-221 could be potentially used as a marker for identification of a poor prognostic subtype within HR+/HER2-ve breast cancers.
Citation Format: Prabhu JS, Kaul R, Korlimarla A, Desai K, Gangadharan C, Rajarajan S, Nair MG, Alexander A, Kaluve R, Manjunath S, Correa M, Prasad MSN, Patil S, Srinath BS, Sridhar TS. Epithelial mesenchymal transition associated with high miR-221 and integrin β6 leads to poor prognosis in hormone receptor positive HER2 negative breast cancers [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-07-10.
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Whiting M, Alexander A, Habiba M, Volk HA. Survey of veterinary clients' perceptions of informed consent at a referral hospital. Vet Rec 2016; 180:20. [PMID: 27738244 DOI: 10.1136/vr.104039] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2016] [Indexed: 11/03/2022]
Abstract
This retrospective questionnaire study evaluates the perceptions of veterinary clients of the informed consent process and the consent form in a veterinary referral hospital. Replicating a validated perception survey from human medicine, 470 clients at the Queen Mother Hospital for Animals were surveyed on their perceptions during the consenting process through postal survey examining their understanding, experience and recall of informed consent. Of the 165 responses (35 per cent response rate), the majority of clients recalled the process and signing the form; however, half of the clients did not feel in control (51 per cent) or reassured (53 per cent) by the process. There was limited understanding of the purpose of consent, with 45 per cent thinking it removed their right to compensation for negligence and 31 per cent thought the veterinarian could do something different from the agreed procedure. Sixty per cent of clients did not read the form, as they trusted their veterinarian, but 33 per cent of clients felt frightened by the process. This survey highlights the need to understand the process of consent from the client's perspective, and adapt the consenting process to incorporate this into professional communication to ensure that the professional and contractual objectives of consent are met fully.
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Gyamfi C, Ndambuki JM, Diabene PY, Kifanyi GE, Githuku CR, Alexander A. Using GIS for spatial exploratory analysis of borehole data: a firsthand approach towards groundwater development. ACTA ACUST UNITED AC 2016. [DOI: 10.4314/just.v36i1.7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Spiegel EA, Alexander A. LXXVIII Vertigo in Brain Tumors, with Special Reference to the Results of Labyrinth Examination. Ann Otol Rhinol Laryngol 2016. [DOI: 10.1177/000348943604500405] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Alexander A, Maroso M, Soltesz I. Organization and control of epileptic circuits in temporal lobe epilepsy. PROGRESS IN BRAIN RESEARCH 2016; 226:127-54. [PMID: 27323941 PMCID: PMC5140277 DOI: 10.1016/bs.pbr.2016.04.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
When studying the pathological mechanisms of epilepsy, there are a seemingly endless number of approaches from the ultrastructural level-receptor expression by EM-to the behavioral level-comorbid depression in behaving animals. Epilepsy is characterized as a disorder of recurrent seizures, which are defined as "a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain" (Fisher et al., 2005). Such abnormal activity typically does not occur in a single isolated neuron; rather, it results from pathological activity in large groups-or circuits-of neurons. Here we choose to focus on two aspects of aberrant circuits in temporal lobe epilepsy: their organization and potential mechanisms to control these pathological circuits. We also look at two scales: microcircuits, ie, the relationship between individual neurons or small groups of similar neurons, and macrocircuits, ie, the organization of large-scale brain regions. We begin by summarizing the large body of literature that describes the stereotypical anatomical changes in the temporal lobe-ie, the anatomical basis of alterations in microcircuitry. We then offer a brief introduction to graph theory and describe how this type of mathematical analysis, in combination with computational neuroscience techniques and using parameters obtained from experimental data, can be used to postulate how microcircuit alterations may lead to seizures. We then zoom out and look at the changes which are seen over large whole-brain networks in patients and animal models, and finally we look to the future.
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Alexander A, Crewson C, Davis W, Mayer M, Cranmer-Sargison G, Kundapur V. PO-0867: Treatment planning study for spatially fractionated minibeam radiotherapy. Radiother Oncol 2016. [DOI: 10.1016/s0167-8140(16)32117-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Alexander A, Ahmed O, Patel M, Jilani D, Ginsburg M, Van Ha T. Effect of stent graft diameter in post-TIPS encephalopathy. J Vasc Interv Radiol 2016. [DOI: 10.1016/j.jvir.2015.12.138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Arnold M, Itzikowitz R, Young B, Machoki SM, Hsiao NY, Pillay K, Alexander A. Surgical manifestations of gastrointestinal cytomegalovirus infection in children: Clinical audit and literature review. J Pediatr Surg 2015; 50:1874-9. [PMID: 26265193 DOI: 10.1016/j.jpedsurg.2015.06.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 06/17/2015] [Accepted: 06/22/2015] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Gastrointestinal sequelae of cytomegalovirus are rare, usually associated with significant immune compromise, and carry a high morbidity and mortality. Gastrointestinal disease frequently requires surgical intervention for diagnosis and management. AIM The aim of the study is to evaluate the incidence, presentation and management of gastrointestinal cytomegalovirus disease in a pediatric population. METHOD Between January 2003 and June 2011, a retrospective folder review was conducted of all symptomatic children with proven CMV disease, presenting to the surgical service. Eligible patients were identified using the surgical, histopathology and serology databases. RESULTS Thirty-eight patients (1.8/1000 surgical admissions) were identified with a median presenting age of 5months (range 3days-12years). Esophagitis (n=18) and small bowel disease (n=16) predominated, but CMV was seen throughout the gastrointestinal tract. Risk factors included HIV infection (n=21, 55%) and recent gastrointestinal surgery or infection (n=10, 26%). Characteristic multiple jejunoileal perforations were seen in six patients. Compared to upper GIT disease, intestinal involvement was associated with younger age and doubled mortality. In HIV-infected children, median CD4 (%) was lower in intestinal compared to upper gastrointestinal disease. Morbidities included anastomotic breakdowns (5), anastomotic strictures (3), relook laparotomies (10), resistant esophageal strictures (5) and prolonged parenteral nutrition (5). Anti-CMV drugs were given in 63%. Overall mortality was 32% (12/38) and was associated with lower GIT disease. CONCLUSION Invasive CMV gastrointestinal disease in our children was predominantly HIV-associated, or followed a major lower gastrointestinal inflammatory insult in infants younger than 6months. Successful therapy requires a high index of suspicion of active CMV disease to allow early implementation of CMV viral load control and aggressive treatment of the underlying immune impairment. Multiple surgical interventions are often required for both tissue diagnosis and management of acute and chronic complications. CMV-viral-load-tailored anti-CMV therapy is supported by recent literature.
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Serban M, Seuntjens J, Roussin E, Alexander A, Tremblay JR, Wierzbicki W. Patient-specific compensation for Co-60 TBI treatments based on Monte Carlo design: A feasibility study. Phys Med 2015; 32:67-75. [PMID: 26498377 DOI: 10.1016/j.ejmp.2015.09.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 09/19/2015] [Accepted: 09/25/2015] [Indexed: 12/22/2022] Open
Abstract
PURPOSE To develop an AP-PA treatment technique for the delivery of total body irradiation (TBI) at extended SSD using a modified Co-60 unit equipped with flattening filter and patient-specific compensators supported by Monte Carlo (MC) simulations and measurements. METHODS An existing Eldorado-78 Co-60 teletherapy unit was stripped of its original collimator and equipped with two beam-defining cerrobend blocks. An acrylic flattening filter was numerically designed based on detailed mapping of the dose distribution of the large open field at a 10 cm depth in water using a primary radiation attenuation calculation. An EGSnrc/BEAMnrc MC model of the resulting unit was developed and experimentally validated and was used to calculate MC dose distributions in whole-body supine and prone CT images of a patient. AP-PA patient-specific compensators were designed based on the supine and prone mid-plane dose distributions. RESULTS The designed flattening filter flattens the beam to within ±2% over a 200 cm × 70 cm area at 10 cm depth in water. Experimental validation of the calculated dose profiles in the open and flattened beams shows agreement of better than 2% and 1%, respectively. Patient MC dose calculations in the flattened, uncompensated beam showed dose deviations from prescription dose most notably in lung, neck and extremities ranging from -5% to +25%. The use of patient-specific compensators reduced inhomogeneities to within -5% to +10%. CONCLUSIONS This work demonstrates that a Co-60 TBI setup upgraded with patient-specific compensators, numerically designed using MC patient dose calculations, is feasible and considerably improves the dose homogeneity.
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Serban M, Renaud M, Maglieri R, Alexander A, Freeman C. EP-1454: Eliminating dosimetric uncertainties in tomotherapy delivery in sarcoma patients using Monte Carlo techniques. Radiother Oncol 2015. [DOI: 10.1016/s0167-8140(15)41446-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Mestrovic A, Fortin D, Alexander A. Sci-Sat AM: Stereo - 08: Stereotactic Ablative Radiotherapy (SABR) for low, intermediate and high risk prostate cancer using Volumetric Modulated Arc Therapy (VMAT) with a 10x Flattening Filter Free (FFF) beam. Med Phys 2014. [DOI: 10.1118/1.4894969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Connell T, Alexander A, Papaconstadopoulos P, Serban M, Devic S, Seuntjens J. Sci-Thur PM: Planning & Delivery - 03: Automated delivery and quality assurance of a modulated electron radiation therapy plan. Med Phys 2014. [DOI: 10.1118/1.4894983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Yeom KW, Lober RM, Alexander A, Cheshier SH, Edwards MSB. Hydrocephalus decreases arterial spin-labeled cerebral perfusion. AJNR Am J Neuroradiol 2014; 35:1433-9. [PMID: 24651817 DOI: 10.3174/ajnr.a3891] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Reduced cerebral perfusion has been observed with elevated intracranial pressure. We hypothesized that arterial spin-labeled CBF can be used as a marker for symptomatic hydrocephalus. MATERIALS AND METHODS We compared baseline arterial spin-labeled CBF in 19 children (median age, 6.5 years; range, 1-17 years) with new posterior fossa brain tumors and clinical signs of intracranial hypertension with arterial spin-labeled CBF in 16 age-matched controls and 4 patients with posterior fossa tumors without ventriculomegaly or signs of intracranial hypertension. Measurements were recorded in the cerebrum at the vertex, deep gray nuclei, and periventricular white matter and were assessed for a relationship to ventricular size. In 16 symptomatic patients, we compared cerebral perfusion before and after alleviation of hydrocephalus. RESULTS Patients with uncompensated hydrocephalus had lower arterial spin-labeled CBF than healthy controls for all brain regions interrogated (P < .001). No perfusion difference was seen between asymptomatic patients with posterior fossa tumors and healthy controls (P = 1.000). The median arterial spin-labeled CBF increased after alleviation of obstructive hydrocephalus (P < .002). The distance between the frontal horns inversely correlated with arterial spin-labeled CBF of the cerebrum (P = .036) but not the putamen (P = .156), thalamus (P = .111), or periventricular white matter (P = .121). CONCLUSIONS Arterial spin-labeled-CBF was reduced in children with uncompensated hydrocephalus and restored after its alleviation. Arterial spin-labeled-CBF perfusion MR imaging may serve a future role in the neurosurgical evaluation of hydrocephalus, as a potential noninvasive method to follow changes of intracranial pressure with time.
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Connell T, Alexander A, Papaconstadopoulos P, Serban M, Devic S, Seuntjens J. Delivery validation of an automated modulated electron radiotherapy plan. Med Phys 2014; 41:061715. [DOI: 10.1118/1.4876297] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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49
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Cooks‐Fagbodun S, McHugh M, Graham M, Scott M, Sleets H, Quarcoo F, Witola W, Alexander A. Molecular identification of Trypanosoma cruzi in Anasa tristis (LB268). FASEB J 2014. [DOI: 10.1096/fasebj.28.1_supplement.lb268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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50
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Hattingh M, Alexander A, Meijering I, van Reenen C, Dicks L. Malting of barley with combinations of Lactobacillus plantarum, Aspergillus niger, Trichoderma reesei, Rhizopus oligosporus and Geotrichum candidum to enhance malt quality. Int J Food Microbiol 2014; 173:36-40. [DOI: 10.1016/j.ijfoodmicro.2013.12.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 12/10/2013] [Accepted: 12/20/2013] [Indexed: 11/29/2022]
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