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Kirkham SG, Gray RJ. Multiple carpometacarpal dislocations and an ipsilateral scapho-trapezium-trapezoid fracture-dislocation: a rare pattern of injury. J Orthop Surg (Hong Kong) 2004; 12:267-9. [PMID: 15621921 DOI: 10.1177/230949900401200226] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [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: 11/17/2022] Open
Abstract
We report a rare case of simultaneous dorsal dislocation of 4 ulnar carpometacarpal joints and dorsoradial dislocation of the trapezium with an associated fracture of the scaphoid tuberosity. The injuries were diagnosed early and treated successfully with closed reduction and transfixation using Kirschner wires. The functional results were excellent at 17-month follow-up.
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Abstract
BACKGROUND In 1994, the Eastern Cooperative Oncology Group (ECOG) initiated for the Breast Intergroup a randomized clinical trial (E3193) in premenopausal patients with early-stage breast carcinoma (lymph node-negative and receptor-positive, with tumors measuring < or = 3 cm) comparing tamoxifen as adjuvant systemic therapy with tamoxifen and ovarian ablation by one of three different methods. Ovarian ablation could be accomplished either via radiotherapy (RT) (20 Gray [Gy]/10 fractions to a modified pelvic volume), surgical oophorectomy, or goserelin/leuprolide injections as per patient/physician choice. In the current study, we report the efficacy of pelvic RT with this dose-fractionation scheme in the induction of ovarian ablation. METHODS Twenty-two of 174 patients (13%) who were randomized to treatment with tamoxifen and ovarian ablation received RT for ovarian ablation. RT quality assurance was performed. Of the 22 patients, 19 were treated per protocol, 1 patient had a minor violation (20 elapsed days for 10 RT fractions), and 2 patients had major violations (1 patient who was treated with RT as per protocol but who was treated at a non-Intergroup center, and 1 patient who was treated at a dose of 15 Gy/5 fractions). RESULTS No acute Grade 3 or 4 (according to the Common Toxicity Criteria of the National Cancer Institute) toxicities were reported during RT. Of the 22 patients receiving RT, evaluable follow-up data were available for 20 patients. Based on postmenopausal levels of estradiol or follicle-stimulating hormone at varying intervals after the completion of RT, 15 of 20 patients (75%) achieved successful ovarian ablation with RT. At a median follow-up of 54 months (range, 21-66 months), no Grade 3 or 4 complications from RT were observed. CONCLUSIONS Ovarian ablation by RT as performed in the current trial (given at a dose of 20 Gy in 10 fractions to a modified pelvic treatment volume) was found to be effective for ovarian ablation in the majority of patients, but may take some months to be complete. Consequently, patients should be evaluated to ascertain that ablation has been accomplished.
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Affiliation(s)
- Lorie L Hughes
- Department of Radiation Oncology, WellStar Kennestone Hospital, Marietta, GA 30060, USA.
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Abstract
Estimation of regression parameters in linear survival models is considered in the clustered data setting. One step updates from an initial consistent estimator are proposed. The updates are based on scores that are functions of ranks of the residuals, and that incorporate weight matrices to improve efficiency. Optimal weights are approximated as the solution to a quadratic programming problem, and asymptotic relative efficiencies to various other weights computed. Except under strong dependence, simpler methods are found to be nearly as efficient as the optimal weights. The performance of several practical estimators based on exchangeable and independence working models is explored in simulations.
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Affiliation(s)
- Robert J Gray
- Department of Biostatistical Science, Dana-Farber Cancer Institute, Boston, MA 02115, USA.
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al-Ani MZ, Gray RJ, Davies SJ, Sloan P. A study of the relationship between lateral guidance and temporomandibular joint internal derangement. Eur J Prosthodont Restor Dent 2003; 11:65-70. [PMID: 12868209] [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] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
The aim of this study was to examine the relationship between lateral retrusive and lateral protrusive tooth guidance and temporomandibular joint disc displacement. The control group comprised 55 symptomless students and dental nurses. The patient group consisted of 117 patients (90 women and 27 men). Fifty-four patients had temporomandibular joint clicking on the right side and 63 patients had clicking on the left side. The incidence of ipsilateral lateral retrusive tooth guidance was significantly higher in the patient group (87%) than in the control group (18.5%).
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Affiliation(s)
- M Z al-Ani
- University Dental Hospital of Manchester, Higher Cambridge Street, Manchester M15 6FH, UK.
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Goldhirsch A, Gelber RD, Yothers G, Gray RJ, Green S, Bryant J, Gelber S, Castiglione-Gertsch M, Coates AS. Adjuvant therapy for very young women with breast cancer: need for tailored treatments. J Natl Cancer Inst Monogr 2002:44-51. [PMID: 11773291 DOI: 10.1093/oxfordjournals.jncimonographs.a003459] [Citation(s) in RCA: 132] [Impact Index Per Article: 6.0] [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] [Indexed: 11/14/2022] Open
Abstract
Breast cancer rarely occurs in women below the age of 35 years. Data from various sources indicate that diagnosis at such an age is associated with a dire prognosis mainly because of a more aggressive presentation. Although the effect of chemotherapy for premenopausal patients is substantial, recent evidence on 2233 patients suggested that very young women with endocrine-responsive tumors had a statistically significantly higher risk of relapse than older premenopausal patients with such tumors. In contrast, results for younger and older premenopausal patients were similar if their tumors were classified as endocrine nonresponsive. Information from studies on 7631 patients who were treated with chemotherapy alone in trials of three major U.S. cooperative groups showed a similar interaction between the effect of age and steroid hormone receptor status of the primary tumor. Better treatments for very young patients are required and may involve ovarian function suppression in addition to other endocrine agents in patients with endocrine responsive tumors and a more precise investigation of chemotherapy and its timing, duration, and intensity in those with endocrine nonresponsive tumors. Very young women with this disease are faced with personal, family, professional, and quality-of-life issues, which further complicate the phase of treatment decision making. The development of more effective therapies for younger patients requires tailored treatment investigations and cannot rely on information predominantly contributed from older premenopausal women.
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Affiliation(s)
- A Goldhirsch
- International Breast Cancer Study Group (IBCSG), Bern, Switzerland.
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107
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108
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Abstract
The choice of weights in estimating equations for multivariate survival data is considered. Specifically, we consider families of weight functions which are constant on fixed time intervals, including the special case of time-constant weights. For a fixed set of time intervals, the optimal weights are identified as the solution to a system of linear equations. The optimal weights are computed for several scenarios. It is found that for the scenarios examined, the gains in efficiency using the optimal weights are quite small relative to simpler approaches except under extreme dependence, and that a simple estimator of an exchangeable approximation to the weights also performs well.
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Affiliation(s)
- Robert J Gray
- Department of Biostatistical Science, Dana-Farber Cancer Institute, Boston, MA 02115, USA.
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109
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Abstract
The difference between paediatric dentistry and most other branches of dentistry is that in the child the occlusion is changing. Consequently 'Good Occlusal Practice' in children is a matter of making the right clinical decisions for the future occlusion. The clinician needs to be able to predict the influence that different treatment options will have on the occlusion when the child's development is complete.
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Affiliation(s)
- S J Davies
- University Dental Hospital of Manchester.
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110
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Abstract
Periodontal disease does not directly affect the occluding surfaces of teeth, consequently some may find a section on periodontics a surprising inclusion. Trauma from the occlusion, however, has been linked with periodontal disease for many years. Karolyi published his pioneering paper, in 1901 'Beobachtungen uber Pyorrhoea alveolaris' (occlusal stress and 'alveolar pyorrhoea'). (1) However, despite extensive research over many decades, the role of occlusion in the aetiology and pathogenesis of inflammatory periodontitis is still not completely understood.
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Affiliation(s)
- S J Davies
- University Dental Hospital of Manchester.
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111
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Gray RJ, Salud C, Nguyen K, Dauway E, Friedland J, Berman C, Peltz E, Whitehead G, Cox CE. Randomized prospective evaluation of a novel technique for biopsy or lumpectomy of nonpalpable breast lesions: radioactive seed versus wire localization. Ann Surg Oncol 2001; 8:711-5. [PMID: 11597011 DOI: 10.1007/s10434-001-0711-3] [Citation(s) in RCA: 217] [Impact Index Per Article: 9.4] [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: 10/25/2022]
Abstract
BACKGROUND Standard wire localization (WL) and excision of nonpalpable breast lesions has several shortcomings. METHODS Ninety-seven women with nonpalpable breast lesions were prospectively randomized to radioactive seed localization (RSL) or WL. For RSL, a titanium seed containing 125I was placed at the site of the lesion by using radiographical guidance. The surgeon used a handheld gamma detector to locate and excise the seed and lesion. RESULTS Both techniques resulted in 100% retrieval of the lesions. Fewer RSL patients required resection of additional margins than WL patients (26% vs. 57%, respectively, P = .02). There were no significant differences in mean times for operative excision (5.4 vs. 6.1 minutes) or radiographical localization (13.9 vs. 13.2 minutes). There were also no significant differences in the subjective ease of the procedures as rated by surgeons, radiologists, and patients. All WLs were carried out on the same day as the excision, whereas RSL was performed up to 5 days before the operative procedure. CONCLUSIONS RSL is as effective as WL for the excision of nonpalpable breast lesions and reduces the incidence of pathologically involved margins of excision. RSL also reduces scheduling conflicts and may allow elimination of intraoperative specimen mammography. RSL is an attractive alternative to WL.
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Affiliation(s)
- R J Gray
- Department of Surgery, H. Lee Moffitt Cancer Center and Research Institute at the University of South Florida, Tampa 33612, USA
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Abstract
BACKGROUND Radioguided surgery can also be used for the simultaneous guidance to a nonpalpable primary tumor and sentinel lymph nodes. METHODS Retrospective review of a prospective database. The surgeon used a gamma probe for guidance to an iodine-125 labeled titanium seed at the primary lesion and technetium-99 labeled sulfur colloid at the sentinel lymph node. RESULTS Forty-three patients with nonpalpable breast carcinoma underwent dual isotope radioguided surgery. The radioactive seed and primary lesion were retrieved in the first excision in all 44 patients (100%). Eleven patients (25%) had pathologically involved margins. Sentinel lymph node mapping was successful in 42 patients (98%). A mean of 2.4 sentinel nodes were excised and metastatic carcinoma was present in four patients (10%). CONCLUSIONS Dual isotopes can be effectively used in breast cancer patients for simultaneous radioguidance to both a nonpalpable primary lesion and sentinel lymph node and allows for improved logistics.
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Affiliation(s)
- R J Gray
- Department of Surgery, H. Lee Moffitt Cancer Center at the University of South Florida, 12902 Magnolia Dr., Tampa, FL 33612, USA
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Abstract
Axillary lymph node metastases dramatically worsen the prognosis of patients with breast cancer. Despite this prognostic significance, routine histologic examination of axillary lymph nodes examines less than 1% of the submitted material. It is therefore obvious that micrometastatic disease is missed with this rather cursory examination, and the question arises as to the significance of this missed disease. Most lines of evidence suggest that missed axillary micrometastases exist and contribute to patient mortality. Most large studies of breast cancer micrometastases have suggested that undetected axillary micrometastases can be identified with more detailed examinations of the regional lymph nodes and that this group of patients has a poorer prognosis than those with no metastases identified. In addition, small-volume nodal disease, too small to be detected by traditional hematoxylin and eosin staining, has been shown to be capable of producing tumors in animal models. Finally, micrometastases have been shown to be of significance in other diseases. This article reviews the lines of evidence and the ongoing studies that are attempting to clarify the significance of micrometastatic disease in patients with breast cancer.
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Affiliation(s)
- R J Gray
- Department of Surgery, H. Lee Moffitt Cancer Center, University of South Florida, Tampa, Florida 33612, USA
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Cox CE, Nguyen K, Gray RJ, Salud C, Ku NN, Dupont E, Hutson L, Peltz E, Whitehead G, Reintgen D, Cantor A. Importance of lymphatic mapping in ductal carcinoma in situ (DCIS): why map DCIS? Am Surg 2001; 67:513-9; discussion 519-21. [PMID: 11409797] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023]
Abstract
The appropriateness of sentinel lymph node biopsy in the management of patients with biopsy diagnoses of ductal carcinoma in situ (DCIS) or DCIS with microinvasion (DCISM) has not been established. Three hundred forty-one patients presented with a biopsy diagnosis of DCIS or DCISM. Two hundred forty (70%) underwent sentinel node biopsy at their definitive procedure. All clinical and pathologic data were collected prospectively. Of 224 patients with a biopsy diagnosis of DCIS 23 (10%) were upstaged to infiltrating ductal carcinoma (IDC) at their definitive therapy and of 16 patients with a biopsy diagnosis of DCISM seven (44%) were upstaged to IDC. Excisional biopsies were no more sensitive for detecting IDC than was core biopsy. Lymph node metastases were detected in 26 of 195 (13%) patients with a definitive diagnosis of DCIS, in three of 15 (20%) with a definitive diagnosis of DCISM, and in eight of 30 (27%) with a definitive diagnosis of IDC. Sentinel lymph node biopsy is a valuable tool in the treatment of patients with DCIS and DCISM and is particularly needed in those undergoing mastectomy. No "high-risk" group of patients can be identified for selective sentinel lymph node biopsy.
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Affiliation(s)
- C E Cox
- Department of Surgery, University of South Florida College of Medicine, Tampa, USA
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115
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Abstract
Occlusal splints are one form of treatment in the management of patients with a temporomandibular disorder. Appliances are often used in conjunction with other forms of treatment such as physiotherapy or medication. A variety of splints is described in the literature and the dentist must ensure that the splint prescribed is of a design that has a proven success rate for the specific diagnosis. General principles that apply to the provision of all splints are outlined in this paper.
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Affiliation(s)
- R J Gray
- Department of Dental Medicine and Surgery, University Dental Hospital of Manchester, Manchester
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116
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Abstract
UNLABELLED We present a prospective study of manipulation of the temporomandibular joint (TMJ) under a general anaesthetic undertaken to find out the success rate in an effort to reduce the number of patients referred for invasive surgery. RESULTS Of the 55 patients invited to participate in this study, 15 improved, 15 did not, 6 showed partial improvement, and 19 were not treated. The median pre-treatment opening was 20mm (range 13-27). Among those who improved after manipulation, the median opening after treatment was 38mm (range 35-56). Some of those who improved experienced a return of TMJ clicking but not of joint or muscle tenderness. CONCLUSION Manipulation under general anaesthesia helps some patients with disc displacement without reduction.
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Affiliation(s)
- M E Foster
- Consultant Oral and Maxillofacial Surgeon, University Dental Hospital of Manchester, Manchester, UK
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117
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Gray RJ, Levitin A, Buck D, Brown LC, Sparling YH, Jablonski KA, Fessahaye A, Gupta AK. Percutaneous fibrin sheath stripping versus transcatheter urokinase infusion for malfunctioning well-positioned tunneled central venous dialysis catheters: a prospective, randomized trial. J Vasc Interv Radiol 2000; 11:1121-9. [PMID: 11041467 DOI: 10.1016/s1051-0443(07)61352-9] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.6] [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: 11/17/2022] Open
Abstract
PURPOSE To compare central dialysis catheter patency rates after stripping procedures with those after urokinase (UK) infusion. MATERIALS AND METHODS Fifty-seven tunneled catheters with either (i) flow rates less than 250 mL/min and established baseline flow rates > or = 300 mL/min or (ii) flow rates 50 mL/min less than higher established baseline flows were prospectively randomized to undergo stripping procedures (n = 28) or UK infusion (n = 29) at 30,000 U/h via each port concurrently, for a total 250,000 U. Success and patency were determined by dialysis at normal flow rates (> or = 300 mL/min) or at the previously established higher baseline rate. Flow rates were monitored weekly. Primary patency ended with catheter malfunction or removal. Kaplan-Meier survival analysis was used to construct survival curves. RESULTS In the stripping group, initial clinical success was 89% (25 of 28). The 15-, 30-, and 45-day primary patency rates were 75% (n = 20), 52% (n = 13), and 35% (n = 8), respectively. The median duration of additional function was 32 days (95% CI: 18-48 d). In the UK group, initial clinical success was 97% (28 of 29). The 15-, 30-, and 45-day primary patency rates were 86% (n = 21), 63% (n = 13), and 48% (n = 9), respectively. The median duration of additional patency was 42 days (95% CI: 22-153 d). The Wilcoxon test for equality detected no significant difference in the survival curves for the two treatment groups (P = .236). CONCLUSION There is no significant difference in time to primary patency between the two methods. Both allow temporary catheter salvage in most patients.
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Affiliation(s)
- R J Gray
- Department of Radiology, Washington Hospital Center, DC 20010, USA.
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Abstract
An estimator of the regression parameters in a semiparametric transformed linear survival model is examined. This estimator consists of a single Newton-like update of the solution to a rank-based estimating equation from an initial consistent estimator. An automated penalized likelihood algorithm is proposed for estimating the optimal weight function for the estimating equations and the error hazard function that is needed in the variance estimator. In simulations, the estimated optimal weights are found to give reasonably efficient estimators of the regression parameters, and the variance estimators are found to perform well. The methodology is applied to an analysis of prognostic factors in non-Hodgkin's lymphoma.
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Affiliation(s)
- R J Gray
- Department of Biostatistical Science, Dana Farber Cancer Institute and Harvard School of Public Health, Boston, Massachusetts 02115, USA.
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119
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Abstract
Keratoacanthoma is a common, benign cutaneous neoplasm that displays rapid growth on sun-exposed skin. Keratoacanthomas usually involute spontaneously after several months but rarely progress to squamous cell carcinoma. Because this is a benign, self-limited lesion of exposed skin, effective treatment should emphasize patient comfort and cosmetic results in addition to effectiveness. The authors present 2 patients with keratoacanthomas treated with topical 5-fluorouracil. Both patients had complete resolution of their lesions within 8 weeks. The cosmetic result was superb in both patients. Patient satisfaction with this therapy was excellent. Treatment can be instituted based on a clinical diagnosis; no diagnostic biopsy is necessary. Most keratoacanthomas respond to topical 5-fluorouracil therapy within 3 weeks, whereas squamous cell carcinomas respond poorly. Any lesion that shows a poor response after 3 weeks of therapy or that does not resolve within 8 weeks should undergo prompt excisional biopsy for definitive diagnosis and treatment. Topical 5-fluorouracil is an effective, convenient, relatively inexpensive treatment for keratoacanthoma that produces excellent cosmetic results. It should be added to the therapeutic armamentarium of all physicians who treat keratoacanthoma.
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Affiliation(s)
- R J Gray
- Department of Surgery, Mayo Clinic Scottsdale, AZ 85259, USA
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Jaroszewski DE, Schlinkert RT, Gray RJ. Laparoscopic splenectomy for the treatment of gastric varices secondary to sinistral portal hypertension. Surg Endosc 2000; 14:87. [PMID: 10854516 DOI: 10.1007/s004649901203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/1999] [Accepted: 06/23/1999] [Indexed: 01/11/2023]
Abstract
Portal hypertension presents significant challenges to the laparoscopic surgeon. Here we review the case of a successful laparoscopic splenectomy in a patient with sinistral portal hypertension. The value of preoperative splenic artery embolization is highlighted.
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Affiliation(s)
- D E Jaroszewski
- Department of Surgery, Mayo Clinic Scottsdale, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
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Gray RJ, Sacks D, Martin LG, Trerotola SO. Reporting standards for percutaneous interventions in dialysis access. Technology Assessment Committee. J Vasc Interv Radiol 1999; 10:1405-15. [PMID: 10584659 DOI: 10.1016/s1051-0443(99)70252-6] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- R J Gray
- Department of Radiology, Washington Hospital Center, Washington, DC 20010-2975, USA
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123
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Aruny JE, Lewis CA, Cardella JF, Cole PE, Davis A, Drooz AT, Grassi CJ, Gray RJ, Husted JW, Jones MT, McCowan TC, Meranze SG, Van Moore A, Neithamer CD, Oglevie SB, Omary RA, Patel NH, Rholl KS, Roberts AC, Sacks D, Sanchez O, Silverstein MI, Singh H, Swan TL, Towbin RB. Quality improvement guidelines for percutaneous management of the thrombosed or dysfunctional dialysis access. Standards of Practice Committee of the Society of Cardiovascular & Interventional Radiology. J Vasc Interv Radiol 1999; 10:491-8. [PMID: 10229481 DOI: 10.1016/s1051-0443(99)70071-0] [Citation(s) in RCA: 106] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- J E Aruny
- Society of Cardiovascular & Interventional Radiology, Fairfax, VA 22030, USA
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Abstract
OBJECTIVE To delineate management strategies and outcomes for true aneurysms involving arteries of the upper extremity distal to the axillary artery. The management of these rare lesions has not been well established in the literature. METHODS Retrospective chart review was performed at tertiary referral centers. All patients who received the diagnosis of true upper extremity aneurysms distal to the axillary artery between 1975 and 1995 were included in the review. Nineteen patients were found; seven were excluded because no confirmatory diagnostic imaging study or operative exploration was performed. This represents the largest reported series of true upper extremity arterial aneurysms. RESULTS Twelve patients (9 men or boys) had 12 confirmed true aneurysms of the brachial or more distal arteries. The average diameters were as follows: brachial artery 4.6 cm, radial artery 2.0 cm, ulnar artery 1.4 cm, and digital artery 0.8 cm. The mean age was 51 years (range, 10 to 86 years). The most common presentation was the presence of a mass. This occurred among eight patients (67%). Four patients (33%) reported pain or paresthesia. One patient (8%) had cold intolerance only. Three patients (25%) had thromboembolic complications. Complications did not consistently correlate with size or presence of intramural thrombus. Three aneurysms (25%) were initially managed nonoperatively and followed for a mean period of 71 months. One of these required operative repair after 5 months because of progressive pain. Ten patients (83%) were treated surgically as follows: five underwent ligation and excision only, and five underwent excision and revascularization. Morbidity was minimal, and there were no perioperative deaths. CONCLUSION True arterial aneurysms of the upper extremity distal to the axillary artery are rare and most commonly caused by blunt trauma. Fifty-eight percent of these lesions present with symptoms or complications. Thirty-three percent of asymptomatic lesions later become symptomatic. These factors combined with the minimal morbidity associated with repair suggest that operative repair should be routinely performed for these aneurysms. Revascularization can be performed selectively.
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Affiliation(s)
- R J Gray
- Department of Surgery, Mayo Clinic Arizona, Scottsdale 85259, USA
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125
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O'Connor PJ, Pronk NP, Tan AW, Rush WA, Gray RJ. Does professional advice influence aspirin use to prevent heart disease in an HMO population? Eff Clin Pract 1998; 1:26-32. [PMID: 10345257] [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] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
OBJECTIVE Aspirin use seems to reduce coronary artery disease events in some groups of patients. Factors associated with use of aspirin to prevent heart disease in an HMO population were examined. DESIGN A population-based survey. SETTING A large HMO in the midwestern United States. PARTICIPANTS 8000 health plan members 40 years of age and older. MAIN OUTCOME MEASURES The survey assessed use of aspirin, professional advice to use aspirin, and coronary heart disease risk factors and status. The sample was stratified by whether members had none, one, or more than one of the following chronic conditions: diabetes, hypertension, lipid disorder, or heart disease. The mailed survey had a corrected response rate of 82.4%. RESULTS Overall, 38% of respondents reported using aspirin at least three times a week to prevent heart disease. Aspirin use did not vary in owned versus contracted clinics. Aspirin use was 71.3% in patients with and 27.7% in patients without diagnosed coronary heart disease (P < 0.001). In logistic regression models, professional advice to take aspirin was strongly associated with self-reported use of aspirin (odds ratio, 13.86) (P < 0.001) after adjustment for age, sex, level of education, and chronic disease status. CONCLUSIONS Aspirin is widely used by HMO members with coronary artery disease to prevent subsequent coronary artery disease events. Professional advice to use aspirin seems to be strongly related to aspirin use.
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Affiliation(s)
- P J O'Connor
- Health Partners Research Foundation, St. Paul, MN, USA
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126
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Rundback JH, Gray RJ, Rozenblit G, Poplausky MR, Babu S, Shah P, Butt K, Tomasula J, Garrick R, Goodman A, Dolmatch B, Horton K. Renal artery stent placement for the management of ischemic nephropathy. J Vasc Interv Radiol 1998; 9:413-20. [PMID: 9618099 DOI: 10.1016/s1051-0443(98)70292-1] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.3] [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: 02/07/2023] Open
Abstract
PURPOSE To evaluate the angiographic and clinical results of percutaneously implanted renal artery endoprostheses (stents) for the treatment of patients with ischemic nephropathy. MATERIALS AND METHODS During a 52-month period, 45 patients with azotemia (serum creatinine > or = 1.5 mg/dL) and atheromatous renal artery stenosis untreatable by, or recurrent after, balloon angioplasty were treated by percutaneous placement of Palmaz stents. Stent implantation was unilateral in 32 cases and bilateral in 11 cases. Clinical results were determined by measurements of serum creatinine and follow-up angiography. Clinical benefit was defined as stabilization or improvement in serum creatinine level. Angiographic patency was defined as less than 50% diameter recurrent arterial stenosis. RESULTS Stent placement was technically successful in 51 of 54 (94%) renal arteries. Technical failures were stent misdeployment requiring percutaneous stent retrieval (n = 2) and inadvertent placement distal to the desired position (n = 1). Complications included acute stent thrombosis (n = 1) and early initiation of hemodialysis (within 30 days; n = 1). There were two periprocedural deaths. With use of life-table analysis, clinical benefit was seen in 78% of patients at 6 months (n = 36), 72% at 1 year (n = 24), 62% at 2 years (n = 12), and 54% at 3 years (n = 3). In patients with clinical benefit, average creatinine level was reduced from 2.21 mg/dL +/- 0.91 before treatment to 2.05 mg/dL +/- 1.05 after treatment (P = .018). Lower initial serum creatinine level was associated with a better chance of clinical benefit (P = .05). No other variables affected outcome, including patient age, sex, diabetes, implanted stent diameter, unilateral versus bilateral stent placement, or ostial versus nonostial stent positioning. Conventional catheter angiography or spiral computed tomographic (CT) angiography performed in 19 patients (28 stents) at a mean interval of 12.5 months demonstrated primary patency in 75%. Maintained stent patency appeared to correlate with renal functional benefit. CONCLUSIONS Percutaneous renal artery stent placement for angioplasty failures or restenoses provides clinical benefit in most patients with ischemic nephropathy.
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Affiliation(s)
- J H Rundback
- Department of Radiology, New York Medical College, Westchester Medical Center, Valhalla 10595, USA
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128
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Abstract
This paper considers a family of penalized likelihood score tests for group variation. The tests can be indexed by a measure of degrees of freedom. At one extreme, with degrees of freedom one less than the number of groups, is the usual score test for a fixed effects alternative using indicator variables for the groups, while at the other extreme, in the limit as the degrees of freedom-->0, is a test closely related to a score test based on a random effects alternative. Asymptotic power comparisons are made for the tests in the family. As would be expected, different members of the family are more efficient for different alternatives. Generally the tests with smaller degrees of freedom appear to have better power than the standard test for alternatives focusing on differences among the larger groups, and lower power for alternatives focusing on differences among the smaller groups. Simulations indicate the asymptotic approximation to the distribution performs better for the tests with small degrees of freedom.
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Affiliation(s)
- R J Gray
- Department of Biostatistical Science, Dana-Farber Cancer Institute, Boston, MA 02115, USA.
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D'Ambra MN, Gray RJ, Hillman R, Jones JW, Kim HC, Rawitscher R, Schnaper H, Szymanski I, Vlahakes GJ, Kaplan D, Lynch KE, Guilfoyle M, Abels RI. Effect of recombinant human erythropoietin on transfusion risk in coronary bypass patients. Ann Thorac Surg 1997; 64:1686-93. [PMID: 9436556 DOI: 10.1016/s0003-4975(97)00839-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.2] [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: 02/05/2023]
Abstract
BACKGROUND Patients having a cardiac operation frequently require allogeneic blood transfusions despite surgical blood-conservation techniques. Recombinant human erythropoietin (Epoetin alfa) may augment this conservation by stimulating erythropoiesis. The safety and efficacy of perioperative use of Epoetin alfa to reduce the need of allogeneic transfusion was studied. METHODS A multicenter double-blind, placebo-controlled, parallel-group study involved 182 patients having coronary artery bypass grafting and randomized to receive Epoetin alfa (300 or 150 IU/kg) or placebo subcutaneously for 5 days before, on the day of, and for 2 days after operation. RESULTS Perioperative Epoetin alfa resulted in greater increases in baseline to preoperative hemoglobin levels and hematocrit (300 IU/kg) and in presurgery to postsurgical day 1 reticulocyte counts versus placebo (p < or = 0.05). However, there was no significant difference in transfusion requirements. Incidences of adverse events were similar in all study groups. CONCLUSIONS Lower incidences of allogeneic blood exposure were observed in both Epoetin alfa-treated groups; however, the differences between all treatment groups were not significant. This was probably due to the relatively short 5-day preoperative course of Epoetin alfa therapy. There were no significant differences between the three groups relative to safety. Epoetin alfa was well tolerated in this population.
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Affiliation(s)
- M N D'Ambra
- Cardiac Anesthesia Group, Massachusetts General Hospital, Boston 02114-2696, USA
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Davies SJ, Gray RJ. The pattern of splint usage in the management of two common temporomandibular disorders. Part III: Long-term follow-up in an assessment of splint therapy in the management of disc displacement with reduction and pain dysfunction syndrome. Br Dent J 1997; 183:279-83. [PMID: 9375440 DOI: 10.1038/sj.bdj.4809495] [Citation(s) in RCA: 26] [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: 02/05/2023]
Abstract
OBJECTIVE To assess the long-term follow-up of patients successfully treated for disc displacement with anterior repositioning splint therapy and patients successfully treated for pain dysfunction syndrome with stabilisation therapy. DESIGN Retrospective analysis. SETTING Dental school clinic unit. METHODS Maintenance of improvement was assessed by a postal questionnaire or by direct telephone contact 3 years after cessation of splint treatment. RESULTS 90% of patients successfully treated for disc displacement with reduction and 88% of patients successfully treated for pain dysfunction reported maintenance of improvement after 3 years. In both groups the reported improvement was independent of the pattern of splint usage. CONCLUSIONS The short-term use of an appropriate occlusal splint for a specific temporomandibular disorder leads to a long-term resolution of the problem.
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Affiliation(s)
- S J Davies
- Department of Dental Medicine and Surgery, University Dental Hospital of Manchester
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Davies SJ, Gray RJ. The pattern of splint usage in the management of two common temporomandibular disorders. Part II: The stabilisation splint in the treatment of pain dysfunction syndrome. Br Dent J 1997; 183:247-51. [PMID: 9364091 DOI: 10.1038/sj.bdj.4809478] [Citation(s) in RCA: 27] [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: 02/05/2023]
Abstract
OBJECTIVE To examine whether the stabilisation splint is a suitable treatment for pain dysfunction syndrome and to determine the most appropriate pattern of usage. DESIGN Prospective random control clinical trial. SETTING Dental school clinic unit. SUBJECTS 70 patients diagnosed with pain dysfunction syndrome were treated with a stabilisation splint for 3 months. Group 1 (23 patients) wore the splint 24 hours/day. Group 2 (19 patients) wore the splint only during the day. Group 3 (28 patients) wore the splint only at night. RESULTS There was no statistically significant advantage to any pattern of splint usage; all groups showed a marked improvement by subjective and objective assessment. CONCLUSIONS Patients being treated for pain dysfunction syndrome by a stabilisation splint need wear the splint only at night.
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Affiliation(s)
- S J Davies
- Department of Dental Medicine and Surgery, University Dental Hospital of Manchester
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Davies SJ, Gray RJ. The pattern of splint usage in the management of two common temporomandibular disorders. Part I: The anterior repositioning splint in the treatment of disc displacement with reduction. Br Dent J 1997; 183:199-203. [PMID: 9345797 DOI: 10.1038/sj.bdj.4809466] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [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: 02/05/2023]
Abstract
OBJECTIVE To examine whether the anterior repositioning splint is suitable treatment for temporomandibular joint disc displacement with reduction and to determine the most appropriate pattern of usage. DESIGN Prospective random control clinical trial. SETTING Dental school clinic unit. SUBJECTS Three groups of patients were treated, wearing the splint either during the day or at night or all the time. RESULTS 69% of patients could be classed as improvers, by subjective and objective assessments, at final review (3 months after treatment with an anterior repositioning splint). 88% of patients who wore the splint for 24 hours per day improved over the 3-month period; this improvement was statistically significant when compared with the other two groups. CONCLUSIONS An anterior repositioning splint is an appropriate method of treatment for disc displacement with reduction. Patients should wear the splint 24 hours a day.
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Affiliation(s)
- S J Davies
- Department of Dental Medicine and Surgery, University Dental Hospital of Manchester
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Gray RJ, McCord JF, Murtaza G, Siddique M. The incidence of temporomandibular disorder signs in patients wearing complete dentures compared to patients with a natural dentition. Eur J Prosthodont Restor Dent 1997; 5:99-103. [PMID: 9487804] [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] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The aim of this study was to determine the incidence of signs of a temporomandibular disorder in patients wearing complete upper and lower dentures and to compare this to the incidence of signs in dental out-patients with a natural dentition. One hundred and sixty patients were assessed using a questionnaire and clinical examination. The results showed statistically significant differences between the two groups regarding the presence of temporomandibular disorder signs, the dentate group having a higher incidence (P < .04).
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Affiliation(s)
- R J Gray
- Clinical Academic Group of Restorative Dentistry, University Dental School, Manchester, UK
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Gray RJ, Davies SJ. Emergency treatment of acute temporomandibular disorders: Part II. Dent Update 1997; 24:186-189. [PMID: 9515367] [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] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
In this, the second part of a presentation on the emergency treatment of an acute temporomandibular disorder, we will address the problems of joint sounds, open and closed locking and psychological considerations. The management of pain and muscle spasm was considered in the previous paper.
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Affiliation(s)
- R J Gray
- Unit of Dental Medicine and Surgery, University Dental Hospital of Manchester
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Gray RJ, Davies SJ. Emergency treatment of acute temporomandibular disorders: Part 1. Dent Update 1997; 24:170-3. [PMID: 9515364] [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] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The purpose of this short series of articles is to provide guidance in the management of patients who present with an acute temporomandibular disorder. This article is the first of two, highlighting the role of the general dental practitioner in the primary care of acute temporomandibular disorders.
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Affiliation(s)
- R J Gray
- Temporomandibular Disorder Services, University Dental Hospital of Manchester
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Affiliation(s)
- R J Gray
- Department of Interventional Radiology, Washington Hospital Center, Washington, DC 20010, USA
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Abstract
The administration of PRN medication by mental health nurses is an important, yet poorly explored aspect of psychiatric inpatient care. An examination of nurses' reasons for administering PRN medication is essential in ensuring its appropriate and effective use. Data were gathered from the drug charts of 44 inpatients on two acute psychiatric wards. Most PRN medication was given orally and the most frequently administered drugs were procyclidine, lorazepam, ibuprofen, diazepam and droperidol. The main reason for administering PRN medication was because patients had 'requested' it. Results were broadly consistent with previous research. It is recommended that nurses should give clear and specific reasons for administering PRN medication based on a valid assessment. Implications for clinical practice and further research are also discussed.
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Affiliation(s)
- R J Gray
- Bethlem and Maudsley NHS Trust, London
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Gray RJ, Nessim S, Khan SS, Denton T, Matloff JM. Adverse 5-year outcome after coronary artery bypass surgery in blacks. Arch Intern Med 1996; 156:769-773. [PMID: 8615710] [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] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
BACKGROUND Coronary heart disease is the leading cause of death among blacks, but little is known about the late results of coronary artery bypass surgery in this population. It is not known whether differences in preoperative medical characteristics or medical health insurance affect outcome. We studied the effects of medical risk factors on survival outcome after coronary artery bypass surgery in a population of medically insured black and white patients. METHODS Racial status and outcomes from surgery were determined in 3728 consecutive patients who had coronary artery bypass surgery at the authors' institution from January 1, 1984, to June 30, 1992. Coronary artery bypass surgery (excluding valve replacement) was performed in 115 black and 3113 white patients. RESULTS Late survival probability was worse for blacks than whites at 1 year (84% vs 92%) and at 5 years (64% vs 82%, P=.001, Wilcoxon test). Most deaths were due to cardiac events in both groups (68% in blacks vs 67% in whites). Blacks had more hypertension (84% vs 54%), diabetes mellitus (36% vs 23%), and more were current smokers (21% vs 14%) (all P<.05, Fisher's exact test). Medical insurance coverage for blacks and whites was as follows: Medicare (60% vs 57%), private (38% vs 42%), and Medi-Cal (2% vs 2%). Operative mortality (30 days) was similar (5.2% for blacks vs 4.1% for whites; P=.48, Fisher's exact test). In a Cox regression model, race predicted long-term survival and persisted as an important risk factor after adjusting for preoperative factors related to patient survival (adjusted hazard ratio, 2.10; 95% confidence interval, 1.43 to 3.07). CONCLUSIONS In this group of predominantly medically insured patients undergoing coronary artery bypass surgery, the risk of death in blacks at 5 years was twice that of whites.
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Affiliation(s)
- R J Gray
- Department of Cardiothoracic Surgery and Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, Calif, USA
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Rotter JI, Bu X, Cantor RM, Warden CH, Brown J, Gray RJ, Blanche PJ, Krauss RM, Lusis AJ. Multilocus genetic determinants of LDL particle size in coronary artery disease families. Am J Hum Genet 1996; 58:585-94. [PMID: 8644718 PMCID: PMC1914567] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Recent interest in atherosclerosis has focused on the genetic determinants of low-density lipoprotein (LDL) particle size, because of (i) the association of small dense LDL particles with a three-fold increased risk for coronary artery disease (CAD) and (ii) the recent report of linkage of the trait to the LDL receptor (chromosome 19). By utilizing nonparametric quantitative sib-pair and relative-pair analysis methods in CAD families, we tested for linkage of a gene or genes controlling LDL particle sizes with the genetic loci for the major apolipoproteins and enzymes participating in lipoprotein metabolism. We confirmed evidence for linkage to the LDL receptor locus (P=.008). For six candidate gene loci, including apolipoprotein(apo)B, apoAII, apo(a), apoE-CI-CII, lipoprotein lipase, and high-density lipoprotein-binding protein, no evidence for linkage was observed by sib-pair linkage analyses (P values ranged from .24 to .81). However, in addition, we did find tentative evidence for linkage with the apoAI-CIII-AIV locus (chromosome 11) (P=.06) and significant evidence for linkage of the cholesteryl ester transfer protein locus (chromosome 16) (P=.01) and the manganese superoxide dismutase locus (chromosome 6) (P=.001), thus indicating multilocus determination of this atherogenic trait.
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Affiliation(s)
- J I Rotter
- Departments of Medicine and Pediatrics, Cedar-Sinai Medical Center, Los Angeles, CA 90048, USA
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Gray RJ. Current status of anticoagulation and thrombosis-related issues in mechanical valves. Tex Heart Inst J 1996; 23:36-41. [PMID: 8680272 PMCID: PMC325300] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- R J Gray
- Department of Internal Medicine, University of North Dakota School of Medicine, Grand forks 58203, USA
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Gray RJ, Horton KM, Dolmatch BL, Rundback JH, Anaise D, Aquino AO, Currier CB, Light JA, Sasaki TM. Use of Wallstents for hemodialysis access-related venous stenoses and occlusions untreatable with balloon angioplasty. Radiology 1995; 195:479-84. [PMID: 7724770 DOI: 10.1148/radiology.195.2.7724770] [Citation(s) in RCA: 140] [Impact Index Per Article: 4.8] [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: 01/26/2023]
Abstract
PURPOSE To determine whether the Wallstent endoluminal prosthesis can be used to maintain patency of venous stenoses and occlusions related to hemodialysis access. MATERIALS AND METHODS Wallstents were placed in 52 patients with 56 lesions. Thirty-two lesions were in central veins and 24 were in peripheral veins. Stents were placed immediately after failed angioplasty in 39 patients, because of early restenosis after angioplasty in four, and for treatment of a lesion unsuitable for angioplasty in eight. The remaining five lesions were treated at the operator's discretion after predilation. RESULTS The procedural success rate was 96%. The cumulative primary patency rate was 46% at 6 months and 20% at 12 months; however, with repeat treatment, the cumulative assisted patency rate was 76% at 6 months and 33% at 12 months. Known causes of recurrence included intimal hyperplasia in or near the stent, stent slippage, and remote stenoses. Complications included two stent migrations due to central line placement and one stent-related pseudoaneurysm. CONCLUSION Wallstents are safe to deploy for dialysis access. Wallstents are useful for treating lesions that fail angioplasty and catheter-related central venous occlusions.
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Affiliation(s)
- R J Gray
- Department of Radiology, Washington Hospital Center, Washington, DC 20010, USA
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Dolmatch BL, Gray RJ, Horton KM, Rundback JH, Kline ME. Treatment of anastomotic bypass graft stenosis with directional atherectomy: short-term and intermediate-term results. J Vasc Interv Radiol 1995; 6:105-13. [PMID: 7703574 DOI: 10.1016/s1051-0443(95)71071-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [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: 01/26/2023] Open
Abstract
PURPOSE Areas of anastomotic stenosis in lower-extremity bypass grafts (BPGs) were treated by means of directional atherectomy (DA) in hopes of achieving better patency rates than have been reported with percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS During a 4-year period, 17 patients (11 men and six women) with 23 areas of anastomotic stenosis in 18 lower-extremity BPGs were selected for treatment with DA. Urokinase thrombolysis was initially performed in eight BPGs that were thrombosed at the time of presentation. Adjunctive preatherectomy PTA was performed in six lesions, and postatherectomy PTA was performed in three lesions. RESULTS The technical success rate for DA was 92% (23 of 25 sites). There was less than 50% restenosis at 74% of the areas of stenosis (14 of 19 sites), with a mean follow-up time for the sites of 13 months. The graft patency rate was 88% (14 of 16 grafts), with a mean follow-up time for the grafts of 14 months. Areas of stenosis treated with DA alone had the same patency rates as those treated with DA and PTA. CONCLUSIONS DA is an effective treatment method for anastomotic peripheral arterial BPG stenosis. The intermediate-term patency rates following DA are superior to those reported for PTA and similar to those reported for surgical revision.
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Affiliation(s)
- B L Dolmatch
- Department of Radiology, Washington Hospital Center, Washington, DC, USA
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Gray RJ, Rundback JH, Dolmatch BL, Horton KM. Ergonomic vascular access needle with blood-containment capability: clinical evaluation during arterial access procedures. J Vasc Interv Radiol 1995; 6:115-8. [PMID: 7703575 DOI: 10.1016/s1051-0443(95)71073-9] [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] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
PURPOSE To evaluate the performance of the ergonomic vascular access needle (EVAN), which is designed to contain blood while allowing for observation of pulsations before passage of a guide wire, in arterial catheterization. MATERIALS AND METHODS EVANs were used for initial puncture in 118 arterial access procedures. Visualization of pulsatile blood motion and containment of blood were prospectively evaluated. Results from 82 separate procedures performed with standard access needles were used as a control. Success or failure of guide-wire passage through the needle, number of attempts, guide-wire type, findings on the access vessel arteriogram, and complications were recorded for both groups. RESULTS In the EVAN group, 92% of procedures were successfully completed, usually within two attempts (82%). Success was independent of guide-wire type (P = .4) and was not significantly different from that of the control group (96%) (P = .37). In 89% of the EVAN procedures, contained pulsatile blood motion was observed before attempted guide-wire passage. Uncontrolled spraying of pulsatile blood did not occur unless the hemostasis valve was removed. In 16%, slow oozing of blood occurred through the needle hub, mainly during guide-wire passage. Oozing was common with floppy-tipped guide wires (46%) but was uncommon with stiffer-tipped wires (6%). There were no needle-related complications. CONCLUSION The EVAN provides protection from blood spray while allowing for successful guide-wire passage into the arterial system as often as standard access needles. However, slow periwire leakage occurs frequently with floppy-tipped guide wires.
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Affiliation(s)
- R J Gray
- Department of Radiology, Washington Hospital Center, Washington, DC 20010, USA
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Abstract
A 33-year-old woman with Budd-Chiari syndrome for 9 years presented with worsening right upper quadrant pain and progressive liver dysfunction. Hepatic venography demonstrated hepatic vein occlusions, without significant IVC obstruction. Attempts at stenting a stenotic middle hepatic vein were unsuccessful. Transjugular access, however, allowed puncture from the stump of the right hepatic vein into the engorged right intrahepatic vein that had been demonstrated by retrograde hepatic venography. Two Palmaz stents were used to form the veno-venous reanastomosis. Initial success was documented angiographically and by pressure measurements before and after shunting. Followup at 7 and 16 months confirmed patency of the anastomosis without intimal hyperplasia. The patient noted near-complete resolution of her pain, and her liver function stabilized.
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Affiliation(s)
- B L Dolmatch
- Department of Radiology, Washington Hospital Center, Washington, DC 20010, USA
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DeMeester CA, Bu X, Gray RJ, Lusis AJ, Rotter JI. Genetic variation in lipoprotein (a) levels in families enriched for coronary artery disease is determined almost entirely by the apolipoprotein (a) gene locus. Am J Hum Genet 1995; 56:287-93. [PMID: 7825589 PMCID: PMC1801290] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Lipoprotein (a) (Lp[a]) is a cholesterol-rich lipoprotein resembling LDL but also containing a large polypeptide designated apolipoprotein (a) (apo[a]). Its levels are highly variable among individuals and, in a number of studies, are strongly correlated with the risk of coronary artery disease (CAD). In an effort to determine which genes control Lp(a) levels, we have studied 25 multiplex families (comprising 298 members) enriched for CAD. The apo(a) gene was genotyped among the families, using a highly informative pulse-field gel electrophoresis procedure. In addition, polymorphisms of the gene for the other major protein of Lp(a), apolipoprotein B (apoB), were examined. Quantitative sib-pair linkage analysis indicates that apo(a) is the major gene controlling Lp(a) levels in this CAD population (P = .001; 99 sib pairs), whereas the apoB gene demonstrated no significant quantitative linkage effect. We estimate that the apo(a) locus accounts for < or = 98% of variance of Lp(a) serum levels. Approximately 43% of this variation is explained by size polymorphisms within the apo(a) gene. These results indicate that the apo(a) gene is the major determinant of Lp(a) serum levels not only in the general population but also in a high-risk CAD population.
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Affiliation(s)
- C A DeMeester
- Department of Medicine, University of California, Los Angeles 90024
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Affiliation(s)
- R J Gray
- Department of Dental Medicine and Surgery, University Dental Hospital of Manchester
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Affiliation(s)
- R J Gray
- Department of Dental Medicine and Surgery, University Dental Hospital of Manchester
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