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Dorin RP, Finnegan KT, Staff I, Wagner JR. Was a Change to a Urologist Owned Pathology Laboratory Associated with a Change in Prostate Biopsy Use? UROLOGY PRACTICE 2014. [PMID: 37537829 DOI: 10.1016/j.urpr.2014.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We assessed the impact of self-referral to urologist owned pathology facilities on prostate biopsy practice patterns, clinical decision making and pathology service use. METHODS We reviewed a transrectal ultrasound guided prostate biopsy database during 2 periods, including 1) August 5, 2008 to April 10, 2010 (613 days) when pathology samples were sent to an independent service laboratory, and 2) June 11, 2010 to February 13, 2012 (613 days) when samples were assessed at a urologist owned pathology laboratory. We also examined data on 3 additional preceding equal length periods before urologist ownership to determine baseline biopsy rates. Billing databases were used to identify the number of new patient visits for increased prostate specific antigen and/or abnormal digital rectal examination. The Student t-test, and Wilcoxon rank sum and chi-square tests were used for statistical comparisons. RESULTS All biopsies were obtained using a standard transrectal ultrasound guided prostate biopsy protocol. The biopsy rate in patients with increased or abnormal digital rectal examination was 39% during the urologist owned pathology laboratory era, and 35%, 40%, 35% and 40% during the 4 preceding independent service laboratory periods of equal length. There was no statistically significant difference in patient age, rate of abnormal digital rectal examination or indications for repeat transrectal ultrasound guided prostate biopsy among the periods. The prostate cancer detection rate was 45% in the independent service laboratory era and 46% in the urologist owned pathology laboratory era. CONCLUSIONS Self-referral of transrectal ultrasound guided prostate biopsy specimens to urologist owned pathology facilities was not associated with a significant variation in the biopsy rate, the repeat biopsy rate, indications triggering repeat biopsy or the cancer detection rate.
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Sussman R, Staff I, Tortora J, Champagne A, Meraney A, Kesler SS, Wagner JR. Impact of active surveillance on pathology and nerve sparing status. THE CANADIAN JOURNAL OF UROLOGY 2014; 21:7299-7304. [PMID: 24978361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION We assessed whether, in comparison to immediate surgery, a time delay in performing radical prostatectomy (RP) in patients electing to undergo a period of active surveillance (AS) of low grade prostate cancer, is associated with adverse pathologic features, biochemical recurrence and the ability to perform effective nerve sparing surgery. MATERIALS AND METHODS From our RP database of 2769 patients, we identified 41 men under AS who subsequently underwent RP. This study group was compared to control group A (164 patients who chose RP rather than AS), matched for prostate-specific antigen (PSA) and initial diagnostic biopsy characteristics. With time, PSA and biopsy characteristics in the AS study group changed, prompting these men to undergo RP. These changes were matched to create a separate control group B (123 patients most of whom did not meet AS criteria). The incidence of nerve sparing surgery, pathologic features, and biochemical recurrence were compared. Outcome variables were compared using Chi-square tests of proportions. Fisher's Exact test was used for recurrence rates due to the low expected frequencies in some cells. RESULTS Compared with control group A, the AS patients experienced higher rates of Gleason score upgrading (33/41; 81.1% versus 76/164; 46.3%, p < 0.001), biochemical recurrence (5/41; 11.4% versus 2/164; 1.3%, p = 0.012) and lower rates of bilateral nerve sparing surgery (31/41; 75.6% versus 154/164; 93.9%, p < 0.001). Control group B and active surveillance group were comparable across all indices measured. CONCLUSIONS Delaying RP, through undergoing a period of AS, had a significant negative impact on the incidence of bilateral nerve sparing surgery and adverse pathologic features when compared to patients with similar parameters at the time of diagnosis. Close monitoring and surveillance biopsies did not improve pathologic outcomes compared to patients from whom a single diagnostic biopsy was obtained (and were not candidates for AS), and who subsequently underwent immediate surgery.
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Rodrigues B, Staff I, Fortunato G, McCullough LD. Hyponatremia in the Prognosis of Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2014; 23:850-4. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.07.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 07/07/2013] [Indexed: 11/24/2022] Open
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Ruscher KA, Modeste KA, Staff I, Papasavas PK, Tishler DS. Retained needles in laparoscopic surgery: open or observe? CONNECTICUT MEDICINE 2014; 78:197-202. [PMID: 24830114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Currently, there is no standard of care on how to manage a retained needle or foreign body (RFB) during laparoscopic surgery. METHODS A survey presented a relevant case and 18 multiple-choice and open-response questions about personal experience with and attitudes toward RFBs, clinical practices, and management. RESULTS From 10/2009-2/2010 we received 255 survey responses. When faced with a patient with a RFB, 45.8% would convert to open, 26.5% would leave needle intraperitoneally, and 27.7% would seek the patient's or family's wishes. When the latter option was eliminated, 54.5% would convert to open, 45.5% would leave the needle intraperitoneally. There were 92.6% who felt that a RFB puts the patient at some degree of future risk, and 89.4% who felt that escalating to laparotomy was of higher risk than the RFB itself. CONCLUSION No current best practice exists regarding approach to RFBs of uncertain injury potential in laparoscopic surgery and similarly in this survey, opinions were split regarding how to proceed.
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Inoa V, Aron AW, Staff I, Fortunato G, Sansing LH. Lower NIH stroke scale scores are required to accurately predict a good prognosis in posterior circulation stroke. Cerebrovasc Dis 2014; 37:251-5. [PMID: 24686370 DOI: 10.1159/000358869] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 01/20/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The NIH stroke scale (NIHSS) is an indispensable tool that aids in the determination of acute stroke prognosis and decision making. Patients with posterior circulation (PC) strokes often present with lower NIHSS scores, which may result in the withholding of thrombolytic treatment from these patients. However, whether these lower initial NIHSS scores predict better long-term prognoses is uncertain. We aimed to assess the utility of the NIHSS at presentation for predicting the functional outcome at 3 months in anterior circulation (AC) versus PC strokes. METHODS This was a retrospective analysis of a large prospectively collected database of adults with acute ischemic stroke. Univariate and multivariate analyses were conducted to identify factors associated with outcome. Additional analyses were performed to determine the receiver operating characteristic (ROC) curves for NIHSS scores and outcomes in AC and PC infarctions. Both the optimal cutoffs for maximal diagnostic accuracy and the cutoffs to obtain >80% sensitivity for poor outcomes were determined in AC and PC strokes. RESULTS The analysis included 1,197 patients with AC stroke and 372 with PC stroke. The median initial NIHSS score for patients with AC strokes was 7 and for PC strokes it was 2. The majority (71%) of PC stroke patients had baseline NIHSS scores ≤4, and 15% of these 'minor' stroke patients had a poor outcome at 3 months. ROC analysis identified that the optimal NIHSS cutoff for outcome prediction after infarction in the AC was 8 and for infarction in the PC it was 4. To achieve >80% sensitivity for detecting patients with a subsequent poor outcome, the NIHSS cutoff for infarctions in the AC was 4 and for infarctions in the PC it was 2. CONCLUSION The NIHSS cutoff that most accurately predicts outcomes is 4 points higher in AC compared to PC infarctions. There is potential for poor outcomes in patients with PC strokes and low NIHSS scores, suggesting that thrombolytic treatment should not be withheld from these patients based solely on the NIHSS. © 2014 S. Karger AG, Basel.
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Zavaski ME, Korus A, Staff I, Champagne A, Fish-Furhman J, Tortora J, Meraney A, Kesler S, Wagner J. Prostate biopsy volume predicts final tumor volume. CONNECTICUT MEDICINE 2014; 78:167-172. [PMID: 24772836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
AIM To assess the ability of prostate biopsy volume to effectively predict actual tumor volume, and whether increasing the number of prostate biopsy cores improves the ability to forecast actual tumor volume. METHODS 765 patients who underwent robotic radical prostatectomy (2009-2010) were identified. Of these, 663 had complete demographics, biopsy, and final pathology data available. The number ofbiopsy samples, biopsy tumor volume, and actual tumor volume were calculated from pathology reports. RESULTS Data from 663 radical prostatectomy specimens indicated a positive linearrelationship between biopsy tumor volume and actual tumor volume (R=0.524, P< 0.0001). The number ofbiopsy samples collected (i.e., < or =6, 7-8, 9-10, 11-12, 13-14, or > or =15) did not affect the ability of biopsy tumor volume to predict final tumor volume. CONCLUSIONS The routine collection of biopsy tumor volume may prove useful in predicting actual tumor volume and the construction of more effective preoperative nomograms.
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San Luis COV, Staff I, Ollenschleger MD, Fortunato GJ, McCullough LD. Percutaneous endoscopic gastrostomy tube placement in left versus right middle cerebral artery stroke: Effects of laterality. NeuroRehabilitation 2013; 33:201-8. [DOI: 10.3233/nre-130946] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Shoup JP, Winkler J, Czap A, Staff I, Fortunato G, McCullough LD, Sansing LH. β-Blockers associated with no class-specific survival benefit in acute intracerebral hemorrhage. J Neurol Sci 2013; 336:127-31. [PMID: 24183854 DOI: 10.1016/j.jns.2013.10.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 09/18/2013] [Accepted: 10/15/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Despite the high mortality, there is currently no specific treatment for intracerebral hemorrhage (ICH). Research investigating optimum degree of blood pressure control in patients presenting with ICH and hypertension is ongoing. However, there is limited understanding of the potential benefits of specific classes of antihypertensive therapy. β-Adrenergic antagonists may provide neuroprotection from inflammation-induced injury by inhibiting sympathetic nervous system mediated immune activation. We examined mortality in ICH patients receiving β-adrenergic antagonists to determine whether this class of antihypertensive therapy was associated with improved survival. METHODS A retrospective analysis of a large, prospectively collected database of patients presenting with acute ICH was performed. Patients were grouped by inpatient β-blocker treatment to determine an effect on mortality during the inpatient stay and at 3 months of follow-up. Additional analysis was conducted comparing β-blocker therapy to any other antihypertensive treatment to determine a class-specific association of β-blocker treatment with mortality. RESULTS The study population included 426 patients with acute, spontaneous ICH. Inpatient β-blocker use was independently associated with decreased rates of inpatient death and mortality at 3 months of follow-up. However, univariate and multivariable analyses comparing β-blocker use to other antihypertensives failed to show any class-specific reduction in mortality at either time point. DISCUSSION Our study demonstrates that the improvement seen in patients treated with β-adrenergic antagonists is not an effect unique to this class. This supports ongoing trials to determine optimum levels of blood pressure control using multiple classes of antihypertensives.
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Montaño A, Staff I, McCullough LD, Fortunato G. Community implementation of intravenous thrombolysis for acute ischemic stroke in the 3- to 4.5-hour window. Am J Emerg Med 2013; 31:1707-9. [PMID: 24060324 DOI: 10.1016/j.ajem.2013.08.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 08/15/2013] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Intravenous (IV) tissue plasminogen activator (tPA) administration for ischemic stroke between 3 and 4.5 hours after onset was found to be safe and beneficial in the ECASS III trial. However, its use has remained controversial, and its benefit as applied in routine practice at community stroke centers is less well defined. METHODS This retrospective database study compared safety and clinical outcomes in 500 patients given IV tPA either from 0 to 3 or 3 to 4.5 hours after onset at a high-volume community center from January 2008 to October 2012. Additional independent variables included for univariate and multivariate analysis were age, sex, hypertension, diabetes mellitus, National Institutes of Health stroke scale on arrival. RESULTS There were no significant differences seen in rates of symptomatic intracranial hemorrhage (3.8% vs 5.8%, P > .05), in-hospital mortality, or Barthel index at 3 months between groups. In addition, tPA administration despite ECASS III contraindications did not appear to be an independent predictor of hemorrhage in the first 24 hours. DISCUSSION Our results show that the conclusions of the ECASS III trial can be applied to routine stroke treatment at a community center and that IV thrombolysis in the 3- to 4.5-hour window results in similar safety and efficacy functional outcome at 3 months compared with administration before 3 hours after onset.
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Kirton OC, Calabrese RC, Staff I. Increasing use of less-invasive hemodynamic monitoring in 3 specialty surgical intensive care units: a 5-year experience at a tertiary medical center. J Intensive Care Med 2013; 30:30-6. [PMID: 23940109 DOI: 10.1177/0885066613498055] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Less-invasive hemodynamic monitoring (eg, esophageal doppler monitoring [EDM] and arterial pressure contour analysis, FloTrac) is increasingly used as an alternative to pulmonary artery catheters (PACs) in critically ill intensive care unit (ICU). HYPOTHESIS The decrease in use of PACs is not associated with increased mortality. METHODS Five-year retrospective review of 1894 hemodynamically monitored patients admitted to 3 surgical ICUs in a university-affiliate, tertiary care urban hospital. Data included the number of admissions, diagnosis-related group discharge case mix, length of stay, insertion of monitoring devices (PAC, EDM, and FloTrac probes), administered intravenous vasoactive agents (β-predominant agonists--dobutamine, epinephrine, and dopamine; vasopressors--norepinephrine and phenylephrine), and mortality. Data from hospital administrative databases were compiled to create patient characteristic and monitoring variables across a 5-year time period, 2005 to 2009 inclusive. Chi-square for independent proportions, 1-way analysis of variance, and Kruskal-Wallis tests were used; tests for trend were conducted. An α level of .05 was considered significant. Statistical Package for the Social Sciences v14 was used for all statistical testing. RESULTS There was a significant change in the type of hemodynamic monitors inserted in 2 of the 3 surgical ICUs (in the general surgery and neurointensive care but not in the cardiac ICU) from PACs to less-invasive devices (FloTrac or EDM) during the 5-year study period (P < .001). There was no change in mortality rate over the time period (P = .492). There was an overall increase in the proportion of monitored patients who received intravenous vasoactive agents (P < .001) with a progressive shift from β-agonists to vasopressors (P < .002). Multivariate analyses indicated that age, case mix, and use of vasoactive agents were all independent predictors of inhospital mortality (P = .001) but that type of monitoring was not (P = .638). CONCLUSIONS In a 5-year period, the decreased insertions of PACs were replaced by increased utilization of less-invasive hemodynamic monitoring devices. This change in practice did not adversely impact mortality.
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Krajewski A, Filippa D, Staff I, Singh R, Kirton OC. Implementation of an Intern Boot Camp Curriculum to Address Clinical Competencies Under the New Accreditation Council for Graduate Medical Education Supervision Requirements and Duty Hour Restrictions. JAMA Surg 2013; 148:727-32. [DOI: 10.1001/jamasurg.2013.2350] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Phipps MS, Zeevi N, Staff I, Fortunato G, Kuchel GA, McCullough LD. Stroke severity and outcomes for octogenarians receiving statins. Arch Gerontol Geriatr 2013; 57:377-82. [PMID: 23815970 DOI: 10.1016/j.archger.2013.05.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 05/26/2013] [Accepted: 05/28/2013] [Indexed: 01/29/2023]
Abstract
Pre-exposure to 3-hydroxy-3-methylgutaryl-coenzyne A reductase inhibitors (statins) appears to improve outcomes in patients with acute ischemic stroke (AIS). Whether this extends to patients over 80 is not known. Patients ≥80 years of age with AIS were retrospectively reviewed from the stroke registry of a tertiary stroke center. Pre-admission statin use, demographics, vascular risk factors, and comorbid conditions were assessed. Primary outcomes were admission National Institutes of Health Stroke Scale (NIHSS) scores and in-hospital mortality/discharge to hospice, and secondary outcomes included subsequent intracerebral hemorrhage (ICH) and modified Barthel index (mBI) at 3 months. Multivariable logistic regression was used to evaluate the association between pre-admission statin use and outcomes among elderly patients. Among 804 patients ≥80, those taking statins prior to AIS admission were overall younger, were more likely to have hypertension, coronary artery disease, diabetes, hyperlipidemia, and were more likely to be on an antiplatelet, but less likely to receive treatment with IV tissue plasminogen activator (tPA). Patients on statin had lower stroke severity (NIHSS>16: 21.9% vs. 27.6%) and in-hospital mortality/discharge to hospice (22.8% vs. 27.6%), but neither was significant. There was no difference in ICH (1.2% vs. 1.9%), and patients on statins had a non-significant trend toward less disability on mBI (27.5% vs. 35.7%). Pre-admission statin use did not show a statistical difference in either outcome, but it did show a trend toward lower stroke severity and improved short-term outcomes. In addition, our study suggests that statins may be safe in elderly stroke patients and may not increase the risk of ICH.
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Chalmers DJ, Scarpato KR, Staff I, Champagne A, Tortora J, Wagner JR, Kesler SS. Does Heparin Prophylaxis Reduce the Risk of Venous Thromboembolism in Patients Undergoing Robot-Assisted Prostatectomy? J Endourol 2013; 27:800-3. [DOI: 10.1089/end.2012.0532] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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San Luis COV, Staff I, Fortunato GJ, McCullough LD. Dysphagia as a predictor of outcome and transition to palliative care among middle cerebral artery ischemic stroke patients. BMC Palliat Care 2013; 12:21. [PMID: 23663757 PMCID: PMC3665461 DOI: 10.1186/1472-684x-12-21] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 04/26/2013] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Middle Cerebral Artery (MCA) territory strokes can be disabling and may leave patients unable to swallow safely. Decisions regarding artificial nutrition and goals of care often arise in patients with severe strokes leading to dysphagia. This study determined some predictors of early transition to palliative level of care among patients with acute ischemic MCA stroke with dysphagia. METHODS This is a retrospective cohort study. Demographic and clinical data of patients presenting to Hartford Hospital with an acute ischemic stroke between January 2005-December 2010 were gathered utilizing the Stroke Center at Hartford Hospital Database. The 236 patients included were divided into "early transition" and "not transitioned" to palliative care cohorts. Primary outcome was transition to palliative care. Factors that were significantly associated with an early transition to palliative level of care in univariate analysis were then entered into a multivariate logistic regression analysis to identify potential independent predictors of early transition to palliative level of care. The significance level was set at p < 0.05. RESULTS 79 patients (34%) were transitioned to palliative level of care after failing the first swallow evaluation within a median of 3 days. Factors predictive of an early transition to palliative level of care after multivariate logistic regression analysis included advancing age (p < 0.001; OR: 1.10; 95% CI :1.056-1.155) , left MCA infarct (p = 0.039; OR: 0.417; 95% CI:0.182-0.956), a high NIHSS score on admission (p = 0.017; OR: 3.038; 95% CI: 1.22-7.555), administration of intra-arterial tPA (p < 0.001; OR: 7.106; 955 CI 2.541-19.873) and the inability to be assessed on the 1(st) swallow evaluation (p < 0.001; OR 0.053; 95% CI 0.022-0.131). CONCLUSIONS The severity of dysphagia influences early transition to palliative level of care in acute stroke patients. Independent predictors of an early transition to palliative level of care among patients with an acute MCA territory stroke and dysphagia included advancing age, a left MCA infarct, a high NIHSS score on admission, administration of intra-arterial tPA and the inability to be assessed on the 1(st) swallow evaluation. This information may guide discussions with families of patients with MCA territory strokes regarding artificial nutrition and goals of care.
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Dorin R, Finnegan K, Staff I, Wagner J. 1243 DOES PHYSICIAN PATHOLOGY LAB OWNERSHIP LEAD TO OVERUTILIZATION? A STUDY OF THE EFFECT OF PHYSICIAN OWNERSHIP ON PROSTATE BIOPSY PRACTICE PATTERNS IN A LARGE URBAN UROLOGY GROUP PRACTICE. J Urol 2013. [DOI: 10.1016/j.juro.2013.02.2597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Chiles K, Staff I, Johnson-Arbor K, Graydon J. 1513 A RANDOMIZED, DOUBLE-BLINDED, PLACEBO-CONTROLLED STUDY COMPARING THE EFFECTS OF HYPERBARIC OXYGEN THERAPY TO ROOM AIR IN POST-PROSTATECTOMY MEN UNDERGOING PENILE REHABILITATION. J Urol 2013. [DOI: 10.1016/j.juro.2013.02.2991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Ginzburg S, Nevers T, Staff I, Tortora J, Champagne A, Kesler SS, Laudone VP, Wagner JR. Prostate cancer biochemical recurrence rates after robotic-assisted laparoscopic radical prostatectomy. JSLS 2013; 16:443-50. [PMID: 23318071 PMCID: PMC3535788 DOI: 10.4293/108680812x13462882736538] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Negative surgical margins for prostate cancer patients undergoing robotic-assisted laparoscopic radical prostatectomy result in lower biochemical recurrence rates for low and intermediate risk groups. Background and Objectives: To determine prostate cancer biochemical recurrence rates with respect to surgical margin (SM) status for patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP). Methods: IRB-approved radical prostatectomy database was queried. Patients were stratified as low, intermediate, and high risk according to D’Amico's risk classification. Postoperative prostate-specific antigen (PSA) values were obtained every 3 mo for the first year, then biannually and annually thereafter. Biochemical recurrence was defined as ≥0.2ng/mL. Patients receiving adjuvant or salvage treatment were included. Positive surgical margin was defined as presence of cancer cells at inked resection margin in the final specimen. Margin presence (negative/positive), margin multiplicity (single/multiple), and margin length (≤3mm focal and >3mm extensive) were noted. Kaplan-Meier curves of biochemical recurrence-free survival (BRFS) as a function of SM were generated. Forward stepwise multivariate Cox regression was performed, with preoperative PSA, Gleason score, pathologic stage, prostate gland weight, and SM as covariates. Results: At our institution, 1437 patients underwent RALP (2003-2009). Of these, 1159 had sufficient data and were included in our analysis. Mean follow-up was 16 mo. Kaplan-Meier curves demonstrated significant increase in BRFS in low-risk and intermediate-risk groups with negative SM. Overall BRFS at 5 y was 72%. Gleason score, pathologic stage, and SM status were significant prognostic factors in multivariate analysis. Conclusions: Negative surgical margins resulted in lower biochemical recurrence rates for low-risk and intermediate-risk groups. Multifocal and longer positive margins were associated with higher biochemical recurrence rates compared with unifocal and shorter positive margins. Documenting biochemical recurrence rates for RALP is important, because this treatment for localized prostate cancer is validated.
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Inoa V, Aron AW, Staff I, Fortunato G, Sansing LH. Abstract TP58: NIH Stroke Scale as Predictor of Prognosis in Posterior Circulation Stroke. Stroke 2013. [DOI: 10.1161/str.44.suppl_1.atp58] [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
BACKGROUND:
The NIHSS is an indispensable tool that aids in the decision-making of acute stroke management. Posterior circulation strokes often have lower NIHSS scores. This may result in withholding treatment with IV tPA and poor outcome in this population. We aimed to assess the predictive value of the NIHSS on poor functional outcome in anterior circulation (AC) versus posterior circulation (PC) strokes.
METHODS:
This was a retrospective analysis of a prospectively collected database from a single center. Adult patients admitted to the stroke service with acute ischemic stroke from January 2000 through December 2011 were included. Data collected included demographics, initial NIHSS, vascular distribution of infarct, complications, and outcome at 3 months. Since this study focused on minor strokes, death or disability was defined as death or a score of < 18 on the modified Barthel Index (BI) scale.
RESULTS:
The analysis included 1,197 patients with AC stroke and 372 with PC stroke. Table 1 lists the characteristics of the two groups. The NIHSS score on admission was lower in PC stroke and the majority (63%) of PC stroke patients had baseline NIHSS scores < 4. AC stroke patients were more likely to be treated with IV tPA or endovascular treatment. Surprisingly, 15% of patients with posterior circulation strokes and admission NIHSS score < 4 had death or disability at 3 months. On multivariable analyses, higher NIHSS score was an independent predictor of death or disability at 3 months in both AC (OR 1.20, 95% CI 1.17-1.23, p <0.001) and PC (1.15, 1.08-1.21, p <0.001) stroke. In PC stroke, treatment with IV tPA was a strong predictor of excellent outcome at 3 months (OR 5.62, 95% CI 1.06-29.9, p < 0.05).
CONCLUSION:
There is a potential risk for death or disability in patients with PC stroke even with low NIHSS scores. These data suggest that treatment with IV tPA should not be withheld from patients with PC stroke syndromes based on the NIHSS score.
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Joseph DK, Kunac A, Kinler RL, Staff I, Butler KL. Diagnosing blunt hollow viscus injury: is computed tomography the answer? Am J Surg 2013; 205:414-8. [PMID: 23375703 DOI: 10.1016/j.amjsurg.2012.12.003] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 12/01/2012] [Accepted: 12/06/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Blunt hollow viscus injury (BHVI) is challenging to diagnose. The purpose of this study was to determine the reliability of physical exam and the role of computed tomography (CT) in the diagnosis of BHVI. METHODS All blunt abdominal trauma (BAT) admissions to a level 1 trauma center from January 2009 through December 2011 were identified through the trauma registry. Data collected included demographics and findings on CT and physical exam. RESULTS Of 2,912 patients with blunt trauma, 340 had BAT, and 30 (9%) had BHVIs. The sensitivity and specificity of CT were 86% and 88%, respectively, whereas the sensitivity and specificity of clinical exam were 53% and 69%. Twenty-seven percent of patients with BAT and bladder injuries had concomitant BHVIs. CONCLUSIONS This is the largest single series of BHVI after BAT. CT is superior to clinical exam in establishing the diagnosis of BHVI. Although associated injuries are common, bladder injury may be an important marker for BHVI.
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Kirton OC, Reilly P, Staff I, Burns K. Development and implementation of an interactive, objective, and simulation-based curriculum for general surgery residents. JOURNAL OF SURGICAL EDUCATION 2012; 69:718-723. [PMID: 23111036 DOI: 10.1016/j.jsurg.2012.05.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 05/14/2012] [Accepted: 05/14/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVE A Steering Committee of residents and faculty initiated a systematic approach to curriculum development, focusing on competency-based education and emphasizing both resident and faculty engagement in the didactic process. SETTING Integrated General Surgery Residency Program at the University of Connecticut School of Medicine, Farmington, Connecticut. PARTICIPANTS Postgraduate year (PGY) 1 through 5 general surgery categorical and preliminary residents. METHODS A Core Curriculum consisting of 45-minute blocks and 2.5 hours of resident time per week was developed by a steering committee composed of faculty and residents. Each block is assigned a faculty and resident moderator, and has defined competency and knowledge-based objectives. An anonymous online evaluation tool collected residents' perceptions of value and satisfaction with the curriculum utilizing 15 5-point Likert items focusing on conferences, objectives, preparation, and quality of presentations, and materials. Measures were taken at the close of the previous academic year (baseline) and at 6 months and 1 year after implementation. The analysis focused on the percent responding in the 2 highest Likert categories (good/excellent, almost always/always, agree/strongly agree). The resulting dichotomous outcomes were compared with time point using χ(2)-tests of proportion; Kruskal-Wallis statistic was also used to compare the full distribution of responses. All analyses were done using SPSS v. 14 with α = 0.05. RESULTS One hundred two surveys were completed on-line (42 at baseline, 38 at 6 months, and 22 at 1 year). All 15 items showed increases from baseline to 1-year follow-up; 9 of the 15 were statistically significant with conferences and presentation quality and interaction showing the greatest improvement. CONCLUSIONS Resident satisfaction with the core curriculum, and their self-reported clinical and academic abilities showed improvement after a systematic collaborative faculty-resident approach to curriculum development and implementation.
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Finnegan KT, Staff I, Meraney AM, Shichman SJ. Reply. Urology 2012. [DOI: 10.1016/j.urology.2012.02.063] [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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Alias M, Staff I, McCullough L. Early Experience with Community Implementation of Thrombolysis Three to 4.5 Hours after Acute Ischemic Stroke (P05.228). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p05.228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Knopf L, Staff I, Gomes J, McCullough L. Impact of a neurointensivist on outcomes in critically ill stroke patients. Neurocrit Care 2012; 16:63-71. [PMID: 21847702 DOI: 10.1007/s12028-011-9620-x] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Current guidelines for management of critically ill stroke patients suggest that treatment in a neurocritical care unit (NCCU) and/or by a neurointensivist (NI) may be beneficial, but the contribution of each to outcome is unknown. The relative impact of a NCCU versus NI on short- and long-term outcomes in patients with acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and aneurysmal subarachnoid hemorrhage (SAH) was assessed. METHODS 2,096 stroke patients admitted to a NCCU or nonneuro ICU at a tertiary stroke center were analyzed before the appointment of a NI, during the NI's tenure, and after the NI departed and was not replaced. Data included admission ICU type, availability of a NI, age, NIHSS, ICH score, and 3 and 12 month outcome. RESULTS For AIS, compared to the time interval with a NI, departure of the NI predicted a worse rate of return to pre-stroke function at 3 months. For ICH, NCCU treatment predicted shorter ICU and hospital LOS but had no effect on short- or long-term outcomes. No effect of a NI was seen. For SAH, availability of an NI (but not an NCCU) predicted improved outcomes but longer ICU LOS. Disposition and in-hospital mortality improved when a NI was present, but continued improvement did not occur after the NI's departure. CONCLUSION Presence of an NI was associated with improved clinical outcomes. This effect was more evident in patients with SAH. Patients with ICH tend to have poor outcomes regardless of the presence of a NCCU or a NI.
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Sussman R, Staff I, Champagne A, Fish-Furhman J, Tortora J, Kesler S, Wagner J. 1462 IS ACTIVE SURVEILLANCE ASSOCIATED WITH ADVERSE PATHOLOGIC OR SURGICAL OUTCOMES IN MEN EVENTUALLY CHOOSING DEFINITIVE TREATMENT WITH ROBOTIC RADICAL PROSTATECTOMY? J Urol 2012. [DOI: 10.1016/j.juro.2012.02.1983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Finnegan KT, Meraney AM, Staff I, Shichman SJ. 864 DA VINCI SKILLS SIMULATOR CONSTRUCT VALIDATION STUDY. J Urol 2012. [DOI: 10.1016/j.juro.2012.02.957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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