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Rhodin KE, Goins S, Kramer R, Eckhoff AM, Herbert G, Shah KN, Allen PJ, Nussbaum DP, Blazer DG, Zani S, Lidsky ME. Simple versus radical cholecystectomy and survival for pathologic stage T1B gallbladder cancer. HPB (Oxford) 2024; 26:594-602. [PMID: 38336604 DOI: 10.1016/j.hpb.2024.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 12/16/2023] [Accepted: 01/22/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Radical cholecystectomy is recommended for T1B and greater gallbladder cancer, however, there are conflicting reports on the utility of extended resection for T1B disease. Herein, we characterize outcomes following simple and radical cholecystectomy for pathologic stage T1B gallbladder cancer. METHODS The National Cancer Database (NCDB) was queried for patients with pathologic T1B gallbladder cancer diagnosed from 2004 to 2018. Patients were stratified by surgical management. Overall survival (OS) was compared with Kaplan-Meier and multivariable Cox proportional hazards methods. RESULTS Altogether, 950 patients were identified with pathologic T1B gallbladder cancer: 187 (19.7 %) receiving simple and 763 (80.3 %) radical cholecystectomy. Median OS was 89.5 (95 % CI 62.5-137) and 91.4 (95 % CI 75.9-112) months for simple and radical cholecystectomy, respectively (log-rank p = 0.55). Receipt of simple cholecystectomy was not associated with greater hazard of mortality compared to radical cholecystectomy (HR 1.23, 95 % CI 0.95-1.59, p = 0.12). DISCUSSION In this analysis, we report comparable outcomes with simple cholecystectomy among patients with pathologic T1B gallbladder cancer. These findings suggest that highly selected patients, such as those with R0 resection and imaging at low risk for residual disease and/or nodal metastasis, may not benefit from extended resection; however, radical cholecystectomy remains standard of care until prospective validation can be achieved.
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Affiliation(s)
- Kristen E Rhodin
- Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA.
| | - Stacy Goins
- Duke University School of Medicine, 40 Duke Medicine Circle, Durham, NC 27710, USA
| | - Ryan Kramer
- Duke University School of Medicine, 40 Duke Medicine Circle, Durham, NC 27710, USA
| | - Austin M Eckhoff
- Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Garth Herbert
- Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Kevin N Shah
- Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Peter J Allen
- Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Daniel P Nussbaum
- Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Dan G Blazer
- Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Sabino Zani
- Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA
| | - Michael E Lidsky
- Department of Surgery, Duke University, 2301 Erwin Rd, Durham, NC 27710, USA
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DeLaura I, Sharib J, Creasy JM, Berchuck SI, Blazer DG, Lidsky ME, Shah KN, Zani S. Defining the learning curve for robotic pancreaticoduodenectomy for a single surgeon following experience with laparoscopic pancreaticoduodenectomy. J Robot Surg 2024; 18:126. [PMID: 38492057 DOI: 10.1007/s11701-023-01746-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 12/02/2023] [Indexed: 03/18/2024]
Abstract
Robotic pancreaticoduodenectomy (RPD) has a learning curve of approximately 30-250 cases to reach proficiency. The learning curve for laparoscopic pancreaticoduodenectomy (LPD) at Duke University was previously defined as 50 cases. This study describes the RPD learning curve for a single surgeon following experience with LPD. LPD and RPD were retrospectively analyzed. Continuous pathologic and perioperative metrics were compared and learning curve were defined with respect to operative time using CUSUM analysis. Seventeen LPD and 69 RPD were analyzed LPD had an inverted learning curve possibly accounting for proficiency attained during the surgeon's fellowship and acquisition of new skills coinciding with more complex patient selection. The learning curve for RPD had three phases: accelerated early experience (cases 1-10), skill consolidation (cases 11-40), and improvement (cases 41-69), marked by reduction in operative time. Compared to LPD, RPD had shorter operative time (379 vs 479 min, p < 0.005), less EBL (250 vs 500, p < 0.02), and similar R0 resection. RPD also had improved LOS (7 vs 10 days, p < 0.007), and lower rates of surgical site infection (10% vs 47%, p < 0.002), DGE (19% vs 47%, p < 0.03), and readmission (13% vs 41%, p < 0.02). Experience in LPD may shorten the learning curve for RPD. The gap in surgical quality and perioperative outcomes between LPD and RPD will likely widen as exposure to robotics in General Surgery, Hepatopancreaticobiliary, and Surgical Oncology training programs increase.
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Affiliation(s)
- Isabel DeLaura
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA
| | - Jeremy Sharib
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA
| | - John M Creasy
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA
| | - Samuel I Berchuck
- Department of Statistical Science, Duke University, Durham, NC, 27710, USA
| | - Dan G Blazer
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA
| | - Michael E Lidsky
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA
| | - Kevin N Shah
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA
| | - Sabino Zani
- Department of Surgery, Division of Surgical Oncology, Duke University, Medical Center 3247, 456E Seeley G. Mudd Bldg, Durham, NC, 27710, USA.
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Rhodin KE, Thornton SW, Leraas HJ, Beckhorn CB, Alseidi A, Greenberg JA, Shah KN, Migaly J, Tracy E. Roles, Responsibilities, and Expectations of Medical Students on Surgical Subinternships: A Modified Delphi Consensus Study. Acad Med 2024:00001888-990000000-00781. [PMID: 38442205 DOI: 10.1097/acm.0000000000005685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
PURPOSE Surgical subinternships are important rotations for students preparing for a career in general surgery; however, these rotations often vary by institution and service. This modified Delphi study was conducted to reach a consensus set of roles, responsibilities, and expectations of fourth-year medical students on their surgical subinternships. METHOD Candidate statements on roles, responsibilities, and expectations of subinterns were categorized into 7 domains: rotation structure, rounding and patient care, operating room conduct, technical skills, knowledge base, clinic, and professionalism. Expert panels were assembled of key stakeholders: program directors, clerkship directors, other education faculty, trainees, and recent subinterns. Three Delphi rounds were conducted from January to April 2023 to reach consensus defined a priori as a Cronbach α ≥ 0.8 and 80% or greater panel agreement. RESULTS Forty-six expert panelists were recruited to participate in Delphi rounds, with 100%, 95.7%, and 97.8% response rates in the first, second, and third rounds, respectively. By the third round, 67 statements reached consensus as essential roles, responsibilities, and expectations of surgical subinterns. Key themes from these 67 statements included subinterns approximating the role of an intern with respect to work hours, patient care responsibilities, basic technical skills, and knowledge base. Panelists rated rounding and patient care as the most important domain, followed closely by professionalism. Additional key domains for evaluation in descending order were knowledge base, operating room conduct, clinic, and technical skills. By the third round, notable disagreements in the Delphi process included technical skills and rounding and patient care (93.3% and 88.9% agreement, respectively). CONCLUSIONS This study provides a national consensus on core roles, responsibilities, and expectations for medical students completing surgical subinternships. Students can use these recommendations to prepare for subinternships, whereas faculty as well as residents and fellows can use them to evaluate applicants for general surgery residency positions.
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Affiliation(s)
- Kristen E Rhodin
- K.E. Rhodin is a general surgery resident, Duke University Medical Center, Durham, North Carolina
| | - Steven W Thornton
- S.W. Thornton is a general surgery resident, Duke University Medical Center, Durham, North Carolina
| | - Harold J Leraas
- H.J. Leraas is a general surgery resident, Duke University Medical Center, Durham, North Carolina
| | - Catherine B Beckhorn
- C.B. Beckhorn is a medical student, Duke University School of Medicine, and research assistant, Department of Surgery, Duke University School of Medicine, Durham, North Carolina
| | - Adnan Alseidi
- A. Alseidi is professor of surgery and vice chair of education, University of California San Francisco, San Francisco, California
| | - Jacob A Greenberg
- J.A. Greenberg is associate professor of surgery, Duke University School of Medicine, Durham, North Carolina
| | - Kevin N Shah
- K.N. Shah is assistant professor of surgery and associate program director for general surgery residency, Duke University School of Medicine, Durham, North Carolina
| | - John Migaly
- J. Migaly is associate professor of surgery and vice chair of education, Duke University School of Medicine, Durham, North Carolina
| | - Elisabeth Tracy
- E. Tracy is assistant professor of surgery and program director, general surgery residency, Duke University School of Medicine, Durham, North Carolina
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4
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Masoud SJ, Rhodin KE, Kanu E, Bao J, Eckhoff AM, Bartholomew AJ, Howell TC, Aykut B, Kosovec JE, Palta M, Befera NT, Kim CY, Herbert G, Shah KN, Nussbaum DP, Blazer DG, Zani S, Allen PJ, Lidsky ME. Comparing Survival After Resection, Ablation, and Radiation in Small Intrahepatic Cholangiocarcinoma. Ann Surg Oncol 2023; 30:6639-6646. [PMID: 37436606 PMCID: PMC10529950 DOI: 10.1245/s10434-023-13872-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/24/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Hepatectomy is the cornerstone of curative-intent treatment for intrahepatic cholangiocarcinoma (ICC). However, in patients unable to be resected, data comparing efficacy of alternatives including thermal ablation and radiation therapy (RT) remain limited. Herein, we compared survival between resection and other liver-directed therapies for small ICC within a national cancer registry. PATIENTS AND METHODS Patients with clinical stage I-III ICC < 3 cm diagnosed 2010-2018 who underwent resection, ablation, or RT were identified in the National Cancer Database. Overall survival (OS) was compared using Kaplan-Meier and multivariable Cox proportional hazards methods. RESULTS Of 545 patients, 297 (54.5%) underwent resection, 114 (20.9%) ablation, and 134 (24.6%) RT. Median OS was similar between resection and ablation [50.5 months, 95% confidence interval (CI) 37.5-73.9; 39.5 months, 95% CI 28.7-58.4, p = 0.14], both exceeding that of RT (20.9 months, 95% CI 14.1-28.3). RT patients had high rates of stage III disease (10.4% RT vs. 1.8% ablation vs. 11.8% resection, p < 0.001), but the lowest rates of chemotherapy utilization (9.0% RT vs. 15.8% ablation vs. 38.7% resection, p < 0.001). In multivariable analysis, resection and ablation were associated with reduced mortality compared with RT [hazard ratio (HR) 0.44, 95% CI 0.33-0.58 and HR 0.53, 95% CI 0.38-0.75, p < 0.001, respectively]. CONCLUSION Resection and ablation were associated with improved survival in patients with ICC < 3 cm compared with RT. Acknowledging confounders, anatomic constraints of ablation, limitations of available data, and need for prospective study, these results favor ablation in small ICC where resection is not feasible.
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Affiliation(s)
- Sabran J Masoud
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Kristen E Rhodin
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Elishama Kanu
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Austin M Eckhoff
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Thomas C Howell
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Berk Aykut
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Juliann E Kosovec
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Manisha Palta
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | | | - Charles Y Kim
- Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Garth Herbert
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kevin N Shah
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Daniel P Nussbaum
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Dan G Blazer
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Peter J Allen
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Michael E Lidsky
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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5
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Masoud SJ, Rhodin KE, Kanu E, Bao J, Eckhoff AM, Bartholomew AJ, Howell TC, Aykut B, Kosovec JE, Palta M, Befera NT, Kim CY, Herbert G, Shah KN, Nussbaum DP, Blazer DG, Zani S, Allen PJ, Lidsky ME. ASO Visual Abstract: Comparing Survival After Resection, Ablation, and Radiation in Small Intrahepatic Cholangiocarcinoma. Ann Surg Oncol 2023; 30:6649-6650. [PMID: 37537481 DOI: 10.1245/s10434-023-14042-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Affiliation(s)
- Sabran J Masoud
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Kristen E Rhodin
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Elishama Kanu
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Austin M Eckhoff
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Thomas C Howell
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Berk Aykut
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Juliann E Kosovec
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Manisha Palta
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, USA
| | - Nicholas T Befera
- Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Charles Y Kim
- Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Garth Herbert
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kevin N Shah
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Daniel P Nussbaum
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Dan G Blazer
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Peter J Allen
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Michael E Lidsky
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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6
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Rhodin KE, Liu A, Bartholomew A, Kramer R, Parameswaran A, Uronis H, Strickler J, Hsu D, Morse MA, Shah KN, Herbert G, Zani S, Nussbaum DP, Allen PJ, Lidsky ME. ASO Visual Abstract: Trends in Receipt of Adjuvant Chemotherapy and Impact on Survival in Resected Biliary Tract Cancers. Ann Surg Oncol 2023; 30:4824-4825. [PMID: 37183199 DOI: 10.1245/s10434-023-13637-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Affiliation(s)
- Kristen E Rhodin
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Annie Liu
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Alex Bartholomew
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Ryan Kramer
- Duke University School of Medicine, Durham, NC, USA
| | | | - Hope Uronis
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - John Strickler
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - David Hsu
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - Michael A Morse
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - Kevin N Shah
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Garth Herbert
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - Daniel P Nussbaum
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - Peter J Allen
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - Michael E Lidsky
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
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7
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Rhodin KE, Liu A, Bartholomew A, Kramer R, Parameswaran A, Uronis H, Strickler J, Hsu D, Morse MA, Shah KN, Herbert G, Zani S, Nussbaum DP, Allen PJ, Lidsky ME. Trends in Receipt of Adjuvant Chemotherapy and its Impact on Survival in Resected Biliary Tract Cancers. Ann Surg Oncol 2023; 30:4813-4821. [PMID: 37188803 PMCID: PMC10330866 DOI: 10.1245/s10434-023-13567-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/11/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Resection remains the cornerstone of curative-intent treatment for biliary tract cancers (BTCs). However, recent randomized data also support a role for adjuvant chemotherapy (AC). This study aimed to characterize trends in the use of AC and subsequent outcomes in gallbladder cancer and cholangiocarcinoma (CCA). METHODS The National Cancer Database (NCDB) was queried for patients with resected, localized BTC from 2010 to 2018. Trends in AC were compared among BTC subtypes and stages of disease. Multivariable logistic regression was used to identify factors associated with receipt of AC. Survival analysis was performed with Kaplan-Meier and multivariable Cox proportional hazards methods. RESULTS The study identified 7039 patients: 4657 (66%) with gallbladder cancer, 1159 (17%) with intrahepatic CCA (iCCA), and 1223 (17%) with extrahepatic CCA (eCCA). Adjuvant chemotherapy was administered to 2172 (31%) patients, increasing from 23% in 2010 to 41% in 2018. Factors associated with AC included female sex, year of diagnosis, private insurance, care at an academic center, higher education, eCCA (vs iCCA), positive margins, and stage II or III disease (vs stage I). Alternatively, increasing age, higher comorbidity score, gallbladder cancer (vs iCCA), and farther travel distance for treatment were associated with reduced odds of AC. Overall, AC was not associated with a survival advantage. However, subgroup analysis showed that AC was associated with a significant reduction in mortality among patients with eCCA. CONCLUSIONS Among the patients with resected BTC, those who received AC were in the minority. In the context of recent randomized data and evolving recommendations, emphasis on guideline concordance with a focus on at-risk populations may improve outcomes.
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Affiliation(s)
- Kristen E Rhodin
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Annie Liu
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Alex Bartholomew
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Ryan Kramer
- Duke University School of Medicine, Durham, NC, USA
| | | | - Hope Uronis
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - John Strickler
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - David Hsu
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - Michael A Morse
- Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - Kevin N Shah
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Garth Herbert
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - Daniel P Nussbaum
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - Peter J Allen
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
| | - Michael E Lidsky
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
- Duke Cancer Institute, Durham, NC, USA
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8
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Ronald J, Triana B, Shah KN. Intravascular Ultrasound-Guided Transcaval Cholangiography to Facilitate Percutaneous Biliary Drain Placement in a Nondilated System. J Vasc Interv Radiol 2023; 34:303-305. [PMID: 36288755 DOI: 10.1016/j.jvir.2022.10.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/27/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- James Ronald
- Division of Vascular and Interventional Radiology, Department of Radiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710.
| | - Brian Triana
- Division of Vascular and Interventional Radiology, Department of Radiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC, 27710
| | - Kevin N Shah
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC
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Landa K, Schmitz R, Farrow NE, Rushing C, Niedzwiecki D, Cerullo M, Herbert GS, Shah KN, Zani S, Blazer DG, Allen PJ, Lidsky ME. Surgical resection is associated with improved long-term survival of patients with resectable pancreatic head cancer compared to multiagent chemotherapy. HPB (Oxford) 2022; 24:1153-1161. [PMID: 34987008 DOI: 10.1016/j.hpb.2021.12.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 12/02/2021] [Accepted: 12/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Standard of care for resectable pancreatic cancer is a combination of surgical resection (SR) and multiagent chemotherapy (MCT). We aim to determine whether SR or MCT is associated with superior survival for patients receiving only single-modality therapy. METHODS Patients with stage I-IIb pancreatic head adenocarcinoma who received either MCT or SR were identified in the NCDB (2013-2015). Following a piecewise approach to estimating hazards over the course of follow-up, conditional overall survival (OS) at 30, 60, and 90 days after treatment initiation was estimated using landmark analyses. RESULTS 3103 patients received MCT alone (60.3%) and 2043 underwent SR alone (39.7%). SR had an OS disadvantage at 30 (HR 3.99, 95% CI 3.12-5.11) and 60 days (HR 1.85, 95% CI 1.4-2.45), but an OS advantage after 90 days (HR 0.59, 95% CI 0.55-0.64). In a landmark analysis conditioned on 90 days survival post treatment initiation, median OS was improved for SR (17.0 vs. 12.2 months, p < 0.0001); SR improved 3-year OS by 21.3% (p < 0.05), despite patients being older (median 72 vs. 67 years, p < 0.0001) with higher Charlson-Deyo comorbidity scores (≥2: 11.2 vs. 8.6%, p = 0.006). CONCLUSION For patients with resectable pancreatic cancer, SR is associated with superior long-term survival compared to MCT.
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Affiliation(s)
- Karenia Landa
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Robin Schmitz
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA.
| | - Norma E Farrow
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Christel Rushing
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC 27710, USA
| | - Donna Niedzwiecki
- Department of Biostatistics & Bioinformatics, Duke University, Durham, NC 27710, USA
| | - Marcelo Cerullo
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Garth S Herbert
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Kevin N Shah
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Dan G Blazer
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Peter J Allen
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
| | - Michael E Lidsky
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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10
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Moris D, Rushing C, McCracken E, Shah KN, Zani S, Perez A, Allen PJ, Niedzwiecki D, Fish LJ, Blazer DG. Quality of Life Associated with Open vs Minimally Invasive Pancreaticoduodenectomy: A Prospective Pilot Study. J Am Coll Surg 2022; 234:632-644. [PMID: 35290283 PMCID: PMC10166568 DOI: 10.1097/xcs.0000000000000102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND This prospective study was designed to compare quality of life (QoL) among patients who underwent open (O-PD) vs minimally invasive pancreaticoduodenectomy (MI-PD), using a combination of validated qualitative and quantitative methodologies. STUDY DESIGN From 2017 to 2019, patients scheduled for pancreaticoduodenectomy (PD) were enrolled and presented with Functional Assessment of Cancer Therapy-Hepatobiliary surveys preoperatively, before discharge, at first postoperative visit and approximately 3 to 4 months after operation ("3 months"). Longitudinal plots of median QoL scores were used to illustrate change in each score over time. In a subset of patients, content analysis of semistructured interviews at postoperative time points (1.5 to 6 months after operation) was conducted. RESULTS Among 56 patients who underwent PD, 33 had an O-PD (58.9%). Physical and functional scores decreased in the postoperative period but returned to baseline by 3 months. No significant differences were found in any domains of QoL at baseline and in the postoperative period between patients who underwent O-PD and MI-PD. Qualitative findings were concordant with quantitative data (n = 14). Patients with O-PD and MI-PD reported similar experiences with complications, pain, and wound healing in the postoperative period. Approximately half the patients in both groups reported "returning to normal" in the 6-month postoperative period. A total of 4 patients reported significant long-term issues with physical and functional well-being. CONCLUSIONS Using a novel combination of qualitative and quantitative analyses in patients undergoing PD, we found no association between operative approach and QoL in patients who underwent O-PD vs MI-PD. Given the increasing use of minimally invasive techniques for PD and the steep learning curve associated with these techniques, continued assessment of patient benefit is critical.
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Affiliation(s)
- Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Christel Rushing
- Duke Cancer Institute-Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Emily McCracken
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kevin N. Shah
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Alexander Perez
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Peter J. Allen
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Donna Niedzwiecki
- Duke Cancer Institute-Biostatistics, Duke University Medical Center, Durham, NC, USA
| | - Laura J. Fish
- Duke Family Medicine and Community Health, Duke University, Durham, NC, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Dan G. Blazer
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Moris D, Lim JJ, Cerullo M, Schmitz R, Shah KN, Blazer DG, Lidsky ME, Allen PJ, Zani S. Empiric nasogastric decompression after pancreaticoduodenectomy is not necessary. HPB (Oxford) 2021; 23:1906-1913. [PMID: 34154924 DOI: 10.1016/j.hpb.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 04/16/2021] [Accepted: 05/12/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The aim of the present study was to evaluate the impact of routine NGT decompression after PD on postoperative outcomes in the era of an enhanced recovery after surgery (ERAS) protocol. MATERIALS AND METHODS A retrospective review of all patients undergoing PD between January 2015 and October 2017 at our institution was performed comparing routine post-operative NGT decompression versus omission. The incidence of delayed gastric emptying, post-operative pancreatic fistula, hospital length of stay, operative time, 30-day readmission rate as well the time to first oral intake were evaluated. RESULTS Out of 149 patients who underwent PD, 65 maintained post-operative NGT decompression while post-operative NGT decompression was omitted in 84 patients. No differences were noted in delayed gastric emptying rates (both p>0.05). The median length of stay (9 days for NGT group versus 8.5 days for no NGT group) and 30-day readmission rates (13.8% versus 15.5%, respectively) were similar (p=0.781). Compared with patients who had routine post-operative NGT placed, those who had omission of a post-operative NGT had a lower need for reinsertion, shorter time to PO intake, and a lower likelihood of extended length of stay. CONCLUSIONS In the era of ERAS protocols, we observed no association between routine post-operative NGT decompression after PD and improved postoperative outcomes.
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Affiliation(s)
- Dimitrios Moris
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Jenny J Lim
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Marcelo Cerullo
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Robin Schmitz
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Kevin N Shah
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Dan G Blazer
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Michael E Lidsky
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Peter J Allen
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Sabino Zani
- Division of Surgical Oncology, Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Turner MC, Masoud SJ, Cerullo M, Adam MA, Shah KN, Blazer DG, Abbruzzese JL, Zani S. Improved overall survival is still observed in patients receiving delayed adjuvant chemotherapy after pancreaticoduodenectomy for pancreatic adenocarcinoma. HPB (Oxford) 2020; 22:1542-1548. [PMID: 32299656 DOI: 10.1016/j.hpb.2020.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/01/2020] [Accepted: 03/08/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Adjuvant chemotherapy (AC) is associated with improved survival following resection of pancreatic adenocarcinoma but is frequently delayed or deferred due to perioperative complications or patient deconditioning. The aim of this study was to assess impact of delayed AC on overall survival after pancreaticoduodenectomy for pancreatic head adenocarcinoma. METHODS Patients with stage I-III pancreatic head adenocarcinoma in the 2006-2015 National Cancer Database were grouped by timing of AC (<6-weeks, 6-12-weeks, and 12-24-weeks). Overall survival was compared using Cox proportional hazard models adjusting for patient, tumor, and hospital factors. Subgroup analyses were conducted to assess the impact of comorbidities, readmission or extended hospital stay, and receipt of single- versus multi-agent chemotherapy. RESULTS Of 13438 patients, 4552 (33.9%) received no AC, 2112 (15.7%) received AC <6-weeks following resection, 5580 (41.5%) within 6-12 weeks, and 1194 (8.9%) within 12-24 weeks. AC was associated with improved overall survival (adjusted hazard ratio [HR] <6-weeks: 0.765, 6-12-weeks: 0.744, and 12-24-weeks: 0.736 (p < 0.001)). This survival advantage persisted for patients with comorbidities, those with postoperative complications, and in those receiving single- or multi-agent regimens. CONCLUSIONS For patients with stage I-III pancreatic adenocarcinoma, receipt of AC is associated with improved overall survival, even if delayed up to 24-weeks.
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Affiliation(s)
- Megan C Turner
- Department of Surgery, Duke University Medical Center, Durham, NC, USA.
| | - Sabran J Masoud
- Duke University School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Marcelo Cerullo
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mohamed A Adam
- Department of Surgery, Duke University Medical Center, Durham, NC, USA; Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kevin N Shah
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Dan G Blazer
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Sabino Zani
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
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Elizabeth McCracken EK, Samsa GP, Fisher DA, Farrow NE, Landa K, Shah KN, Blazer DG, Zani S. Prognostic significance of primary tumor sidedness in patients undergoing liver resection for metastatic colorectal cancer. HPB (Oxford) 2019; 21:1667-1675. [PMID: 31155452 PMCID: PMC7243173 DOI: 10.1016/j.hpb.2019.03.365] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 01/25/2019] [Accepted: 03/14/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately 38% of patients with colorectal cancer will develop isolated liver metastases. Sidedness of colon tumor is identified in non-metastatic and unresected metastatic cancers as predictive of survival, yet its dedicated analysis in resected liver metastases is minimal. Our primary aim was to assess whether left-sided primary tumors improve prognosis in stage IV cancer patients undergoing curative-intent liver metastasectomy; it was hypothesized that it would. METHODS This is a retrospective, observational cohort study from 1996 to 2016 in a single tertiary-care facility. Survival from diagnosis was calculated via Kaplan-Meier method and compared between the right and left sides via log-rank analysis. RESULTS Median survival differs significantly between colorectal tumors of the right and left origins after hepatic metastasectomy in 612 patients. In patients with right-sided tumors, median survival from diagnosis was 4.5 years (IQR 4.1-5.3), and 6.3 years (IQR 5.6-6.9) in those with left tumors (HR 1.5, 95% CI 1.38-1.60, p < 0.001). CONCLUSION As in studies on earlier-stage or unresected metastatic disease, tumor sidedness is an important prognostic factor in patient survival with liver metastasectomy. Clinical risk scores should include side of primary tumor. Further work is needed to determine the molecular basis for this difference.
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Affiliation(s)
- Emily K. Elizabeth McCracken
- Department of Surgery, Duke University Medical Center, Department of Surgery, Geisinger Medical Center, United States
| | - Gregory P. Samsa
- Department of Biostatistics & Bioinformatics, Duke University Medical Center, United States
| | - Deborah A. Fisher
- Division of Gastroenterology, Department of Medicine, Duke University Medical Center, United States
| | - Norma E. Farrow
- Department of Surgery, Duke University Medical Center, United States
| | - Karenia Landa
- Department of Surgery, Duke University Medical Center, United States
| | - Kevin N. Shah
- Division of Advanced Oncologic and Gastrointestinal Surgery, Department of Surgery, Duke University Medical Center, United States
| | - Dan G. Blazer
- Division of Advanced Oncologic and Gastrointestinal Surgery, Department of Surgery, Duke University Medical Center, United States
| | - Sabino Zani
- Division of Advanced Oncologic and Gastrointestinal Surgery, Department of Surgery, Duke University Medical Center, United States
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Moris D, Tsilimigras DI, Kostakis ID, Ntanasis-Stathopoulos I, Shah KN, Felekouras E, Pawlik TM. Anatomic versus non-anatomic resection for hepatocellular carcinoma: A systematic review and meta-analysis. Eur J Surg Oncol 2018; 44:927-938. [DOI: 10.1016/j.ejso.2018.04.018] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/30/2018] [Accepted: 04/20/2018] [Indexed: 02/07/2023] Open
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Tselos A, Moris D, Tsilimigras DI, Fragkiadis E, Mpaili E, Sakarellos P, Vailas M, Shah KN, Papalampros A. Robot-Assisted Retroperitoneal Lymphadenectomy in Testicular Cancer Treatment: A Systematic Review. J Laparoendosc Adv Surg Tech A 2018; 28:682-689. [PMID: 29474141 DOI: 10.1089/lap.2017.0672] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Retroperitoneal lymph node dissection (RPLND) in testicular cancer is a documented treatment along with active surveillance and chemotherapy. This study aims to summarize the current evidence on the use of Robot-assisted RPLND (RARPLND) in comparison with the laparoscopic and open approach. MATERIALS AND METHODS A search was conducted in the existing literature focusing on reports with outcomes of RARPLND for stage I-IIB testicular tumor. RESULTS Eleven studies complied with the inclusion criteria, including 116 patients. The average follow-up of 21.2 months showed no retroperitoneal recurrence. The median lymph node yield was 22.3 and the overall positive rate was 26%. Complications were encountered in 8% of the patients. The robotic approach showed similar results to the laparoscopic approach and outperformed the open procedure in perioperative parameters. CONCLUSIONS Relapse-free survival, nodal yield, and complication rates during RARPLND for clinical stage I-IIB are acceptable. Further studies are required to establish these findings and determine benefit from the use of robotic approach.
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Affiliation(s)
- Aggelos Tselos
- 1 1st Department of Surgery, Laikon General Hospital, University of Athens , Athens, Greece
| | - Demetrios Moris
- 2 Department of Surgery, Duke University Medical Center , Durham, North Carolina
| | | | - Evangelos Fragkiadis
- 3 1st Department of Urology, Laikon General Hospital, University of Athens , Athens, Greece
| | - Eustratia Mpaili
- 1 1st Department of Surgery, Laikon General Hospital, University of Athens , Athens, Greece
| | - Panagiotis Sakarellos
- 1 1st Department of Surgery, Laikon General Hospital, University of Athens , Athens, Greece
| | - Michail Vailas
- 1 1st Department of Surgery, Laikon General Hospital, University of Athens , Athens, Greece
| | - Kevin N Shah
- 2 Department of Surgery, Duke University Medical Center , Durham, North Carolina
| | - Alexandros Papalampros
- 1 1st Department of Surgery, Laikon General Hospital, University of Athens , Athens, Greece
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Vora HH, Mehta SV, Shah KN, Brahmbhatt BV, Desai NS, Shukla SN, Shah PM. Cytoplasmic Localization of BAG-1 in Leukoplakia and Carcinoma of the Tongue: Correlation with p53 and C-Erbb2 in Carcinoma. Int J Biol Markers 2018; 22:100-7. [PMID: 17549665 DOI: 10.1177/172460080702200203] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The present study evaluated the clinical significance of BAG-1, an antiapoptotic protein, in leukoplakia and carcinoma of the tongue. Methods BAG-1 expression was evaluated by immunohistochemistry in paraffin-embedded tissues of leukoplakia (n=25) and carcinoma of the tongue (n=61). Results Cytoplasmic expression was predominantly seen in 80% and 70% of patients with leukoplakia and carcinoma, respectively. BAG-1 expression was found to be significantly lower in tobacco users than in non-tobacco users. BAG-1 expression in tobacco-using leukoplakia and carcinoma patients was compared by grouping the carcinoma patients according to lymph node status and disease stage. Carcinoma patients with tumor-positive lymph nodes had significantly lower BAG-1 expression than patients with negative lymph nodes and leukoplakia. Further, a trend towards an inverse correlation was observed with p53 and c-erbB2. In univariate and multivariate survival analysis, patient subgroups with 2+ or 3+ marker positivity (BAG-1 negativity, p53 and c-erbB2 positivity) had a reduced overall survival compared with patient subgroups with 1+ marker positivity or negativity. Conclusion BAG-1 negativity in association with p53 and c-erbB2 positivity identified a subgroup of tongue cancer patients with an aggressive phenotype. Hence, an antiapoptotic protein, BAG-1, was found to be down-regulated in chewing-tobacco-mediated tongue carcinogenesis.
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Affiliation(s)
- H H Vora
- Immunohistochemistry Division, The Gujarat Cancer and Research Institute, Ahmedabad, Gujarat, India.
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17
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Shah KN, Majeed Z, Yang H, Guido JJ, Hilton TN, Polesskaya O, Hall WJ, Luque AE. FUNCTIONAL LIMITATIONS AND ADIPOKINES IN HIV-INFECTED OLDER ADULTS. J Frailty Aging 2015; 4:41-46. [PMID: 26312240 PMCID: PMC4547479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND There is a significant increase in the number of HIV-infected older adults (HOA). This population may experience functional decline at a much younger age. Little is known about the relationship between functional limitations and systemic adipokines in HOA. OBJECTIVE Our study aimed to evaluate the relationship between functional limitations and systemic adipokine levels in HOA population. DESIGN Cross-sectional. SETTING Academic hospital-based infectious disease clinic. PARTICIPANTS The study investigated community-dwelling HIV-infected adults >50 years old and compared this group with age, gender and BMI comparable healthy controls. MEASUREMENTS We measured functional status, body composition and plasma concentrations of adipokines. RESULTS Fifty-four HOA were studied (mean: age 57 years, BMI 29 kg/m2, CD4 604, duration of HIV 17 years) and compared with thirty-two age, gender and BMI comparable healthy controls. The HOA group showed significantly higher functional limitations compared to the age, gender and BMI comparable controls (p<0.05). Levels of adipokines were significantly different between the two groups (p<0.05). Multiple regression analyses indicated that adiponectin and visfatin were significantly correlated with several physical function measures after controlling for age, sex, and metabolic comorbidities. Adiponectin was negatively correlated with functional limitations, and this relationship was stronger in the control group compared to the HOA group. Conversely, visfatin was positively correlated with functional limitations only in the HOA group. CONCLUSION HOA have significant functional limitations and alteration in adipokine levels compared to controls. Adiponectin and visfatin were associated with functional limitations. Visfatin was a correlate of physical function only in the HOA group. Prospective longitudinal studies could provide further insight on the role of adipokines in HIV-related functional decline.
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Affiliation(s)
- K N Shah
- Division of Geriatrics and Aging, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Z Majeed
- Division of Geriatrics and Aging, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - H Yang
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - J J Guido
- Department of Biostatistics and Computational Biology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - T N Hilton
- Department of Physical Therapy, Ithaca College, Rochester, New York
| | - O Polesskaya
- Department of Microbiology and Immunology, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - W J Hall
- Division of Geriatrics and Aging, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - A E Luque
- Division of Infectious Disease, Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York
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Shah KN, Faridi JS. Abstract P3-12-07: Voyagers and their aids: The role of interactions between tumor and endothelial cells in brain metastasis. Cancer Res 2012. [DOI: 10.1158/0008-5472.sabcs12-p3-12-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Clinically, brain metastases are most commonly observed in breast, lung, and melanoma cancers. When a tumor cell leaves its site of origin, it enters a nearby blood vessel on a voyage to find a new tissue to invade. These circulating tumor cells will act as voyagers and they interact with a endothelial cell. For example, in the case of brain metastasis, tumor cells need to adhere to brain endothelial cells before they can invade into the surrounding brain tissue. Thus, investigating the mechanisms of tumor and endothelial cell interactions can serve as a very powerful tool to inhibit the voyage of these tumor cells and prevent the formation of metastases. In this study, we performed trans-endothelial migration assay using HBMVEC cells to study tumor-endothelial interactions. In general, HBMVEC cells were seeded to BD-Falcon cell culture inserts at a density of 2 × 105 cells and allowed to grow for 24 hours to form a confluent monolayer and GFP expressing tumor cells (MCF-7, Akt3 overexpressing MCF7, MDA-MB-231 and MDA-MB-231-BR) were incubated at suitable interval at 37°C. At the end of incubation period, cells were fixed and number of tumor cells that will penetrate the monolayer of HBMEC were counted using Phase-contrast microscope in 12 different visual fields. Transmigrating tumor cells are thought to be able to overcome the endothelial barrier by inducing changes within endothelial cells. We identified the molecular changes responsible for such adhesion and invasion by cell sorting for gene expression analysis. After co-culturing the HBMEC (after transfecting with Mcherry protein) with GFP expressing tumor cells and Mcherry labeled HBMEC, we used cell sorting to separate tumor and HBMEC cells. After sorting the tumor cells and endothelial cells from co-culture, (MCF-7 monolayer vs MCF-7 co-cultured, MDA-MB-231 monolayer vs MDA-MB-231 co-cultured, HBMEC monolayer vs HBMEC co-cultured) gene expression analysis was performed using SABiosciences cell adhesion assay kit to accurately capture the genetic changes that occured in the tumor and endothelial cells upon co-culture.
Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-12-07.
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Affiliation(s)
- KN Shah
- University of the Pacific, Stockton, CA
| | - JS Faridi
- University of the Pacific, Stockton, CA
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Phadke M, Lokeshwar MR, Bhutada S, Tampi C, Saxena R, Kohli S, Shah KN. Kearns Sayre Syndrome--case report with review of literature. Indian J Pediatr 2012; 79:650-4. [PMID: 22231766 DOI: 10.1007/s12098-011-0618-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 11/15/2011] [Indexed: 12/22/2022]
Abstract
Kearns-Sayre Syndrome is form of rare mitochondrial cytopathy, first described by Thomas P. Kearns and George Pomeroy Sayre in 1958 and is characterized by progressive external opthalmoplegia, cardiac conduction block, pigmentary retinal degeneration, variable number of red ragged fibers on muscle biopsy. It presents before the child reaches the age of twenty. Kearns-Sayre syndrome may affect many organ systems and additional features may include myopathy, dystonia, bulbar symptoms in the form of dysarthria and nasal regurgitation and bilateral facial weakness. Endocrine abnormalities (e.g., diabetes, growth retardation/short stature, and hypoparathyroidism), bilateral sensorineural deafness, dementia, cataracts, and proximal renal tubular acidosis, skeletal muscle weakness (proximal more than distal) and exercise intolerance are additional features. Kearns Sayre Syndrome occurs as a result of large-scale single deletions (or rearrangements) of mitochondrial DNA (mtDNA), which is usually not inherited but occurs spontaneously, probably at the germ-cell level or very early in embryonic development. No disease-modifying therapy is available for Kearns-Sayre syndrome (KSS). Management is supportive vigilance for detection of associated problems. In the future, potential treatment in patients with Kearns-Sayre syndrome may attempt to inhibit mutant mtDNA replication or encourage replication of wild-type mtDNA.
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Affiliation(s)
- Meghana Phadke
- Department of Pediatrics, Lilavati Hospital and Research Center, Mumbai, India
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Kulkarni S, Hegde A, Shah KN. Hemifacial seizures and cerebellar tumor: a rare co-existence. Indian Pediatr 2007; 44:378-9. [PMID: 17536142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
We report a 4-year-old boy with multiple daily episodes of abnormal eye movements, hemifacial spasms. Neuro-imaging revealed a cerebellar tumor. We believe that this association constitutes a rare but important syndrome of epilepsy characterized by seizures of cerebellar origin.
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Affiliation(s)
- Shilpa Kulkarni
- Department of Neurosciences, Bai Jerbai Wadia Hospital for Children, Parel, Mumbai, India.
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Rajadhyaksha S, Shah KN. Controversies in febrile seizures. Indian J Pediatr 2000; 67:S71-9. [PMID: 11129896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Febrile seizures are benign, self limiting, common neurological problems encountered in children between 3 months and 5 years. Controversies exist regarding its definition and it is important to distinguish between the terms febrile seizures and convulsions with fever. In the vast majority, febrile seizures occur within the first 24 hours of illness, and an encephalitic process should be considered if it occurs later, especially with exanthema. The temperature threshold varies in the same child and from one child to another. Febrile seizures are classified as simple and complex and debate continues regarding the usage of these terms and their prognostic value. Practice parameters are suggested regarding the performance of lumbar puncture in a child with first febrile seizure, but they should be used as guidelines and the decision depends on the experience and judgement of the physician. EEG is of limited value and not a guide to treatment or prognosis and neuroimaging not recommended. The predictors of recurrent febrile seizures include younger age, lower threshold of temperature, onset within one hour of fever and positive family history. Whether the syndrome of mesial temporal sclerosis beginning with prolonged febrile seizure has a causal relationship with pre existing brain disease is a matter of debate. There are effective therapies to prevent febrile seizures but the potential side effects of drugs outweigh their benefit. Intermittent prophylaxis during fever may be effective but long term prognosis is not influenced by the treatment applied in early childhood. A practical approach to a child with febrile seizure is suggested.
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Affiliation(s)
- S Rajadhyaksha
- Epilepsy Center, Bai Jerbai Wadia Hospital for Children, Parel, Mumbai
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Rajadhyaksha S, Shah KN, Kanhere S, Naik N, Mehta R. Does treatment change the outcome of seizures and computerized tomographic lesions in intracranial granulomas? J Trop Pediatr 1999; 45:161-5. [PMID: 10401195 DOI: 10.1093/tropej/45.3.161] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
In children, intracranial granuloma diagnosed on computerized tomography (CT) scan and presenting with seizures as the sole manifestation has traditionally been treated with antitubercular (ATB) therapy or albendazole (Alb) in addition to antiepileptic drugs (AED). This study was conducted to determine whether AED therapy alone or specific treatment (ATB + Alb) influences the outcome of seizures and the CT lesion. Sixty-eight children presenting with seizures along with intracranial granuloma on CT scan were selected for the study. They were randomly divided into two groups. Group A (n = 34) was treated with AED alone and group B (n = 34) received antitubercular therapy and albendazole in addition to AED. Seizure type was noted and electroencephalogram (EEG) and CT scan were done in all. They were followed up for a period of 2 to 9 years, during which a record of seizure count and type was maintained. CT scans were repeated at 3 monthly intervals and EEGs were repeated whenever indicated. Four patients in each group were lost to follow-up. Seizures persisted in four out of 30 in group A and six out of 30 in group B. There was no statistically significant difference (p > 0.05) in the outcome of seizures in the two groups. Taking the whole group together (n = 60), of the 13 who had presented with multiple seizures at onset, epilepsy was a sequela in five (p < 0.05); and of the 17 in whom the lesion had calcified, seizures persisted in seven (p < 0.05), irrespective of treatment modality. In conclusion, though specific treatment did not alter the outcome of seizures, children with multiple seizures at presentation and calcification of CT lesion had epilepsy as a sequela.
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Affiliation(s)
- S Rajadhyaksha
- Department of Pediatrics, Bai Jerbai Wadia Hospital for Children, Parel, Mumbai, India.
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Abstract
Ten children, five boys and five girls with true precocious puberty at an early age were found to have hypothalamic hamartomas on brain imaging. Very early onset of puberty, varying from a few weeks to three years of age, and rapid progression were characteristic. Accelerated growth velocity and markedly advanced bone age were evident in all. Gonadotropin and gonadal hormone levels were elevated above the prepubertal range. Six children had associated developmental delay or hyperactivity.
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Affiliation(s)
- M P Colaco
- Division of Pediatric Endocrinology, Bai Jerbai Wadia Hospital for Children, Bombay
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Merchant RH, deSouza CE, Shah KN, Sakhalkar VS. Proptosis: management of 22 patients. Indian Pediatr 1993; 30:61-6. [PMID: 8406710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The clinical features and management of 22 cases with proptosis is highlighted. Proptosis was unilateral in fifteen and bilateral in seven cases. The common etiologic factors were neoplasms, infections and bleeding diatheses. Of the ten cases with neoplasms as many as 7 expired, whereas of nine cases due to infections only one expired and one developed phthisis bulbi. All three patients with proptosis due to bleeds recovered completely without sequelae. Orbital CT scan was done in fourteen and ultrasound in eight cases, while in five cases both investigations were done. As neoplasms are a frequent cause of proptosis in children and there is a high mortality in this group, a thorough systemic examination and hematological profile is essential to arrive at a speedy diagnosis. CT and USG are useful imaging modalities of the orbit, the latter being particularly useful for follow up of the lesion.
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Affiliation(s)
- R H Merchant
- Department of Pediatrics, B.J. Wadia Children Hospital, Bombay
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26
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Abstract
Venogenic impotence was detected in 37 out of 141 patients who attended our clinic with a complaint of erectile dysfunction. Eighteen patients presented with primary impotence and the rest had progressive secondary impotence. All 37 patients have shown partial or poor response to 60 mg of intracavernosal papaverine. The corporovenous leak (CVL) was diagnosed on the careful workup of dynamic pharmacocavernosometry and cavernosography. Concomitant arterial cause was noted in 10% cases on the basis of penile duplex Doppler ultrasound study. 24 patients in the age group of 23-60 years underwent the penile venous surgery. The CVL was noted in the deep dorsal vein (23 cases), cavernous vein (16) and in the crural vein (2). The operation consisted of deep dorsal vein (DDV) ligation and excision with all tributaries (8 cases) or DDV ligation and excision+cavernous vein ligation (13 cases), through an infrapubic curvilinear incision. One patient had crural vein ligation and corporoplasty through a perineal incision, one had direct corporeal revascularization for associated arteriogenic impotence with venous leak and another had distal spongiolysis and closure of a corporospongiosal shunt. The results were excellent in 11 cases, improved in 6 and 7 had failures. Surgical intervention is effective in CVL in selected cases but limiting factors in the form of increasing age, concomitant arteriogenic cause, significant crural leak, missing tributaries, recurrent venous leak and unknown factors may also be present to prevent total cure.
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Affiliation(s)
- H G Motiwala
- Department of Urology, Institute of Post Graduate Studies and Research, B.J. Medical College, Civil Hospital, Ahmedabad, India
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Shah KN, Rajadhyaksha SB, Shah VS, Shah NS, Desai VG. Experience with the International League Against Epilepsy classifications of epileptic seizures (1981) and epilepsies and epileptic syndrome (1989) in epileptic children in a developing country. Epilepsia 1992; 33:1072-7. [PMID: 1464266 DOI: 10.1111/j.1528-1157.1992.tb01761.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Four hundred eighty-three epileptic children attending the Pediatric Epilepsy Clinic at Bai Jerbai Wadia Hospital for Children, Bombay, India were classified according to the International League Against Epilepsy (ILAE) classification of epileptic seizures (1981) and epilepsies and epileptic syndromes (1989). The predominant seizures were partial (53.6), generalized (40.3%), and unclassifiable (6%). In epilepsies and epileptic syndromes, 55.3% were partial, 27% were generalized, 13.5% were undetermined, and 4.1% were special syndromes. Although our results were similar in many respects to those of other reported series, some differences were observed in the incidence of partial and generalized seizures, and partial and generalized epileptic syndromes and their subgroups, such as idiopathic, symptomatic, and cryptogenic partial syndromes, idiopathic generalized syndromes, and symptomatic specific syndromes. These differences are probably due to different age limits, methods of case ascertainment and inclusion criteria, different genetic and environmental factors, variable interpretation of clinical and EEG features, and lack of facilities for investigation in developing countries. Despite various limitations, we were able to classify most cases; the ILAE classification can be used in developing countries so that comparison can be made with other studies.
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Affiliation(s)
- K N Shah
- Bai Jerbai Wadia Hospital for Children, Bombay, India
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28
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Abstract
A total of 40 cases of neonatal convulsions of different nonmetabolic aetiological factors were studied. Patients with kernicterus were included in the study. Peak plasma phenobarbital concentrations after incremental loading doses of phenobarbital i.e. 10 mg/kg, 15 mg/kg, and 20 mg/kg were determined. Diphenylhydantoin was added if phenobarbital alone was unable to control seizures. In three patients, a combination of phenobarbital and diphenylhydantoin was used as the initial loading therapy. Increase in the loading dose of phenobarbital was associated with an increase in its peak plasma concentration. Despite increase in the plasma phenobarbital concentration beyond the 'therapeutic' levels suggested by the Western studies, doses of 15 mg/kg and 20 mg/kg of phenobarbital were unable to score over the traditional regimen of 10 mg/kg. Convulsions were controlled in 50% of the patients with any of these three regimens, irrespective of the aetiology. Convulsions were controlled in 7 out of the 9 cases where diphenylhydantoin was added, because of the failure of phenobarbital in controlling the convulsions as a single drug. Convulsions of all the three patients, in whom a combination of phenobarbital and diphenylhydantoin was used by random selection as the initial bolus, were controlled. Seizure effects were difficult to distinguish from drug effects but major side effects were not encountered despite the fluctuating drug levels in the sick neonate.
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Affiliation(s)
- Y M Jawadekar
- Department of Pediatrics and Neonatology, B.J. Wadia Hospital for Children, Bombay
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Merchant RH, Sakhalkar VS, Shah KN, Murthy AM, Waingankar VS, Kapur VK. Neonatal gastrointestinal perforations. Indian Pediatr 1992; 29:693-8. [PMID: 1500126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Fourteen neonates presented with clinical and radiological evidence of gastrointestinal perforation, of which 13 were treated by operative intervention. No infant was formula fed, had rectal bleeding or radiological evidence of pneumatosis intestinalis. Operative findings revealed localized perforation in ten of which three were gastric, two distal ileal, three cecal and two in sigmoid colon. Gangrene with extensive perforation of jejunum, ascending colon and transverse colon were seen in one each. Blood cultures were positive in four, one grew E. coli and three Klebsiella while peritoneal cultures were positive in six, one grew E. coli and five Klebsiella. Ten neonates survived and are being followed up. Three of the four cases who died had white blood cell count greater than 25 x 109/L and grew Klebsiella on peritoneal culture. Factors predisposing to gastrointestinal perforations in neonates are discussed, emphasis is made on the cautious use of umbilical, gastric and rectal catheters, and the need for early surgical intervention.
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Affiliation(s)
- R H Merchant
- Department of Pediatrics (Division of Neonatology), Bai Jerbai Wadia Hospital for Children, Parel, Bombay
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30
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Abstract
Two cases of alobar holoprosencephaly and two of Aicardi syndrome are reported for their highly specific electroencephalographic (EEG) changes. The asynchronous sharp waves and spikes over the frontal regions with decreasing gradient of potential to the occipital leads were seen in alobar holoprosencephaly while burst suppression pattern with total asynchrony between the two hemispheres was seen in Aicardi syndrome. Even though EEG changes cannot be pathognomic of any abnormality, it is suggested that as in conditions like subacute sclerosing panencephalitis and petitmal epilepsy, so also in alobar holoprosencephaly and Aicardi syndrome, the characteristic features seen on EEG may provide the initial clue to the correct diagnosis.
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Affiliation(s)
- K N Shah
- Department of Pediatrics, Bai Jerbai Wadia Hospital for Children & Institute of Child Health, Parel, Bombay
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31
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Abstract
Vesicovaginal fistulae are usually traumatic in nature, following obstetric or gynecologic trauma. Here, our experience with vesicovaginal fistula repair in 68 cases, performed transvesically (58 cases) or transperitoneally-transvesically, with pedicled omental interposition in 10 cases over the last 8 years is described. The size of fistulae ranged from 1 to 5 cm, and most were situated near or above the trigone. Two cases required ureteric reimplantation. Recurrent fistulae were found in 4 cases. We attribute our success to the simple access, the construction of a vascularized flap, the tension-free grid-iron closure, and the utilization of Vicryl suture.
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Affiliation(s)
- H G Motiwala
- Department of Urology, B.J. Medical College, Civil Hospital, Ahmedabad, India
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32
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Abstract
Children of various ages and both sexes (numbering 1,004) attending the out-patient department of Conwest Jain Clinic Group of Hospitals were studied for medication compliance (MC). MC was divided into total, partial, poor and excessive. Various parameters influencing MC like acute or chronic illness, age, sex, community, income, parental education and occupation, number of children, number of family members, form of medicine and number of medicines were studied in details. Only three factors e.g. community, occupation of the father and form of medicine were found to influence MC. No single factor consistently influenced MC. Negligence and poverty play a very important role in MC.
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Shah KN, Upadhye PS, Wadia PN. EEG, CT scan correlation in neurological disorders. Indian Pediatr 1987; 24:401-7. [PMID: 3679491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Upadhye PS, Shah KN, Wadia PN, Samuel AM. Electroencephalographic correlation of clinical, radioisotopic brain scan, CT scan and postmortem diagnosis. Indian J Pediatr 1985; 52:625-31. [PMID: 3836969 DOI: 10.1007/bf02749569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Antarkar DS, Pande R, Athavale AV, Shubhangi R, Saoji SR, Shah KN, Jakhmola AT, Vaidya AB. Phase I tolerability study of Yogaraj-guggulu--a popular ayurvedic drug. J Postgrad Med 1984; 30:111-5. [PMID: 6527293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Shah KN, Dalal SJ, Desai MP, Sheth PN, Joshi NC, Ambani LM. White forelock, pigmentary disorder of irides, and long segment Hirschsprung disease: possible variant of Waardenburg syndrome. J Pediatr 1981; 99:432-5. [PMID: 7264803 DOI: 10.1016/s0022-3476(81)80339-3] [Citation(s) in RCA: 130] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Shah KN, Patel ZM, Desai AP, Kulkarni MV, Ambani LM. Campomelic syndrome in phenotypic females with 46,XY chromosomes: evidence of genetic heterogeneity. Clin Pediatr (Phila) 1981; 20:214-6. [PMID: 7471598 DOI: 10.1177/000992288102000308] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Shah KN, Bajaj RT. Pycnodysostosis--case reports of 2 patients. Indian Pediatr 1979; 16:187-90. [PMID: 457234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Shah KN, Desai MP, Shah BN. Acrodermatitis enteropathica: a case report. Indian Pediatr 1978; 15:511-3. [PMID: 721269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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45
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Joshi NC, Desai MP, Shah KN, Babar ST. Idiopathic familial hyperlipaemia (a case report). Indian Pediatr 1971; 8:847-9. [PMID: 5148717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Shah KN, Desai MP. Ascaris lumbricoides from the right ear. Indian Pediatr 1969; 6:92-3. [PMID: 5783830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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