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Chung TK, Hu A, Sardesai MG, Wilcox H, Jiang L, Meyer TK. Evaluating the Effect of Recurrent Respiratory Papillomatosis on Work Productivity. Ann Otol Rhinol Laryngol 2021; 131:709-714. [PMID: 34416839 DOI: 10.1177/00034894211040900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 12/19/2022]
Abstract
OBJECTIVE Patients with recurrent respiratory papillomatosis (RRP) have significant vocal dysfunction which affects their performance at work. This study aimed to evaluate voice-related work productivity before and after ablative treatment for RRP. METHODS This is a prospective case series conducted at 2 academic laryngology outpatient clinics. Adult employed patients with RRP completed the Work Productivity & Activity Impairment instrument (WPAI), Voice Handicap Index (VHI-10), WorkHoarse, Hospital Anxiety and Depression Scale (HADS), and a demographics questionnaire immediately before and 1 month after ablative treatment of papilloma. The primary outcome measure was the change in work productivity impairment domain of the WPAI, and changes in ratings before and after ablation were compared using a Wilcoxon Signed-Rank test. RESULTS The 32 participants (mean age 45, 84% male) had a median (interquartile range) voice-related work productivity impairment score of 48.8% (30.0) at baseline which was improved to 5.0% (10.0) at 1 month after surgical ablation of papillomata (difference 30.0% (30.0) improvement). For the secondary outcome measures, there were significant improvements in VHI-10 (P < .001), self-reported voice quality (P = .002), and Workhoarse (P = .001), but no significant change in HADS. CONCLUSION Patients with RRP experience significant voice-related work productivity impairment, and ablation of papillomata significantly improves work productivity.
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Affiliation(s)
- Thomas K Chung
- Department of Otolaryngology & Communication Enhancement, Boston Children's Hospital, Boston, MA, USA
| | - Amanda Hu
- Division of Otolaryngology - Head & Neck Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Maya G Sardesai
- Department of Otolaryngology Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | - Haley Wilcox
- Department of Otolaryngology Head and Neck Surgery, University of Washington, Seattle, WA, USA
| | - Lan Jiang
- Division of Clinical Pharmacology, Department of Medicine, Vanderbilt Medical Center, Nashville, TN, USA
| | - Tanya K Meyer
- Department of Otolaryngology Head and Neck Surgery, University of Washington, Seattle, WA, USA
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Wan OY, Chan SS, Cheung RY, Chung TK. Mesh-related complications from reconstructive surgery for pelvic organ prolapse in Chinese patients in Hong Kong. Hong Kong Med J 2018; 24:369-377. [PMID: 30065122 DOI: 10.12809/hkmj177173] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Mesh-related complications from reconstructive surgery for pelvic organ prolapse are of international concern. The present study aimed to review the incidence, management, and surgical outcomes of mesh-related complications in a Chinese population compared with existing studies involving Western populations. METHODS This was an analysis of a prospectively collected cohort. Laparoscopic sacrocolpopexy, laparoscopic hystercolposacropexy, or transvaginal mesh surgery were offered with or without concomitant vaginal hysterectomy or continence surgery. Patients were followed up and mesh-related complications were noted. RESULTS Overall, 276 Chinese women who received mesh surgery were included for data analysis. There were 22 mesh-related complications found during a mean follow-up period of 40 months. Mesh exposure accounted for 20 these complications; significantly more occurred after transvaginal than after abdominal mesh surgery (16 vs 4; P=0.01). Median duration from primary operation to the time of mesh exposure detection was 12 months (interquartile range=4.8-32.8 months). Ten patients required surgical excisions of exposed mesh. The re-operation rate after mesh complications was 6.7% (9/134) for transvaginal mesh surgery and 1.4% (2/142) for laparoscopic sacrocolpopexy (P=0.03). All excisions were performed transvaginally and 95% remained well after surgery. Occurrence of mesh exposure was higher in transvaginal mesh surgery (adjusted odds ratio=6.1; P=0.008), in sexually active patients (adjusted odds ratio=5.4; P=0.002), and in obese patients (adjusted odds ratio=3.7; P=0.046). Over 90% were satisfied with the outcome, regardless of mesh complications. CONCLUSIONS The rates of mesh exposure and re-operation were consistent with those reported in the literature, suggesting no significant differences in outcome between Chinese and Western patients for this type of surgery.
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Affiliation(s)
- O Y Wan
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
| | - S S Chan
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
| | - R Y Cheung
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
| | - T K Chung
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong
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Chung TK. 43 Ideal Protein - The Seminal North American Work. J Anim Sci 2018. [DOI: 10.1093/jas/sky073.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- T K Chung
- DSM Nutritional Products Asia Pacific, Singapore, Singapore
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Moore LS, Rosenthal EL, Chung TK, de Boer E, Patel N, Prince AC, Korb ML, Walsh EM, Young ES, Stevens TM, Withrow KP, Morlandt AB, Richman JS, Carroll WR, Zinn KR, Warram JM. Characterizing the Utility and Limitations of Repurposing an Open-Field Optical Imaging Device for Fluorescence-Guided Surgery in Head and Neck Cancer Patients. J Nucl Med 2016; 58:246-251. [PMID: 27587708 DOI: 10.2967/jnumed.115.171413] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 08/10/2016] [Indexed: 01/24/2023] Open
Abstract
The purpose of this study was to assess the potential of U.S. Food and Drug Administration-cleared devices designed for indocyanine green-based perfusion imaging to identify cancer-specific bioconjugates with overlapping excitation and emission wavelengths. Recent clinical trials have demonstrated potential for fluorescence-guided surgery, but the time and cost of the approval process may impede clinical translation. To expedite this translation, we explored the feasibility of repurposing existing optical imaging devices for fluorescence-guided surgery. METHODS Consenting patients (n = 15) scheduled for curative resection were enrolled in a clinical trial evaluating the safety and specificity of cetuximab-IRDye800 (NCT01987375). Open-field fluorescence imaging was performed preoperatively and during the surgical resection. Fluorescence intensity was quantified using integrated instrument software, and the tumor-to-background ratio characterized fluorescence contrast. RESULTS In the preoperative clinic, the open-field device demonstrated potential to guide preoperative mapping of tumor borders, optimize the day of surgery, and identify occult lesions. Intraoperatively, the device demonstrated robust potential to guide surgical resections, as all peak tumor-to-background ratios were greater than 2 (range, 2.2-14.1). Postresection wound bed fluorescence was significantly less than preresection tumor fluorescence (P < 0.001). The repurposed device also successfully identified positive margins. CONCLUSION The open-field imaging device was successfully repurposed to distinguish cancer from normal tissue in the preoperative clinic and throughout surgical resection. This study illuminated the potential for existing open-field optical imaging devices with overlapping excitation and emission spectra to be used for fluorescence-guided surgery.
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Affiliation(s)
- Lindsay S Moore
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Eben L Rosenthal
- Department of Otolaryngology, Stanford University, Stanford, California
| | - Thomas K Chung
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Esther de Boer
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama.,Department of Surgery, University of Groningen, Groningen, The Netherlands
| | - Neel Patel
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Andrew C Prince
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Melissa L Korb
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Erika M Walsh
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama
| | - E Scott Young
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Todd M Stevens
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kirk P Withrow
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Anthony B Morlandt
- Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham, Birmingham, Alabama; and
| | - Joshua S Richman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - William R Carroll
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kurt R Zinn
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jason M Warram
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama
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Abstract
BACKGROUND Intraoperative image guidance is a useful modality for transsphenoidal pituitary surgery. However, the outcomes associated with this technology have not been systematically evaluated. OBJECTIVE The purpose of the study was to quantify complication rates with and without the use of image guidance during transsphenoidal pituitary surgery using a nationwide database with broadly applicable results. METHODS A retrospective analysis of the Nationwide Inpatient Sample was performed from 2007 to 2011. Transsphenoidal pituitary resections for adenomas were identified by International Classification of Diseases-9th Revision, Clinical Modification code. The effect of image guidance on cerebrospinal fluid (CSF) leak complications and cost-benefit was analyzed. RESULTS A total of 48,848 transsphenoidal pituitary resections were identified, of which 77.5% were partial resections and 22.5% were complete. Pathologic indications included benign (89.3%), malignant primary (0.6%), and malignant secondary (0.4%). Complications included same-stay death (0.4%), CSF leak (8.8%), postoperative CSF rhinorrhea (1.9%), diabetes insipidus (12.4%), and meningitis (0.4%). Image guidance was employed in 7% (n = 3401) of all cases. When analyzed by modality, computed tomography (CT)-assisted procedures had lower CSF rhinorrhea rates (1.1%) compared with cases with no image guidance (1.9%), whereas magnetic resonance (MR)-assisted procedures had the highest rates (2.7%, χ2 p < 0.001). Rates of CSF leak demonstrated a similar pattern (CT 6.4%, no image guidance 8.9%, MR 9.2%, χ2 p < 0.001). CT-assisted surgery had significantly shorter length of stay (2.9 days) versus no image guidance (3.7 days, p < 0.001), lower total charges ($47,589 versus $62,629, p < 0.001), and lower total cost ($16,748 versus $20,530, p < 0.001). CONCLUSIONS CT-assisted surgery is associated with a lower rate of CSF leak, shorter length of stay, and lower cost compared with patients without image guidance. Further studies that control for severity and extent of disease are warranted to confirm this finding.
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Affiliation(s)
- Thomas K. Chung
- From the Departments of Surgery/Division of Otolaryngology and
| | - Kristen O. Riley
- Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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Rosenthal EL, Warram JM, de Boer E, Chung TK, Korb ML, Brandwein-Gensler M, Strong TV, Schmalbach CE, Morlandt AB, Agarwal G, Hartman YE, Carroll WR, Richman JS, Clemons LK, Nabell LM, Zinn KR. Safety and Tumor Specificity of Cetuximab-IRDye800 for Surgical Navigation in Head and Neck Cancer. Clin Cancer Res 2015; 21:3658-66. [PMID: 25904751 DOI: 10.1158/1078-0432.ccr-14-3284] [Citation(s) in RCA: 313] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 03/30/2015] [Indexed: 11/16/2022]
Abstract
PURPOSE Positive margins dominate clinical outcomes after surgical resections in most solid cancer types, including head and neck squamous cell carcinoma. Unfortunately, surgeons remove cancer in the same manner they have for a century with complete dependence on subjective tissue changes to identify cancer in the operating room. To effect change, we hypothesize that EGFR can be targeted for safe and specific real-time localization of cancer. EXPERIMENTAL DESIGN A dose escalation study of cetuximab conjugated to IRDye800 was performed in patients (n = 12) undergoing surgical resection of squamous cell carcinoma arising in the head and neck. Safety and pharmacokinetic data were obtained out to 30 days after infusion. Multi-instrument fluorescence imaging was performed in the operating room and in surgical pathology. RESULTS There were no grade 2 or higher adverse events attributable to cetuximab-IRDye800. Fluorescence imaging with an intraoperative, wide-field device successfully differentiated tumor from normal tissue during resection with an average tumor-to-background ratio of 5.2 in the highest dose range. Optical imaging identified opportunity for more precise identification of tumor during the surgical procedure and during the pathologic analysis of tissues ex vivo. Fluorescence levels positively correlated with EGFR levels. CONCLUSIONS We demonstrate for the first time that commercially available antibodies can be fluorescently labeled and safely administered to humans to identify cancer with sub-millimeter resolution, which has the potential to improve outcomes in clinical oncology.
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Affiliation(s)
- Eben L Rosenthal
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Jason M Warram
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Esther de Boer
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama. Department of Surgery, Division of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Thomas K Chung
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Melissa L Korb
- Division of General Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Margie Brandwein-Gensler
- Division of Anatomic Pathology, Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Theresa V Strong
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Cecelia E Schmalbach
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Anthony B Morlandt
- Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Garima Agarwal
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Yolanda E Hartman
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - William R Carroll
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Joshua S Richman
- Division of General Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lisa K Clemons
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Lisle M Nabell
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kurt R Zinn
- Division of Advanced Medical Imaging, Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
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Rosenthal EL, Chung TK, Parker WB, Allan PW, Clemons L, Lowman D, Hong J, Hunt FR, Richman J, Conry RM, Mannion K, Carroll WR, Nabell L, Sorscher EJ. Phase I dose-escalating trial of Escherichia coli purine nucleoside phosphorylase and fludarabine gene therapy for advanced solid tumors. Ann Oncol 2015; 26:1481-7. [PMID: 25899782 DOI: 10.1093/annonc/mdv196] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/15/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The use of Escherichia coli purine nucleoside phosphorylase (PNP) to activate fludarabine has demonstrated safety and antitumor activity during preclinical analysis and has been approved for clinical investigation. PATIENTS AND METHODS A first-in-human phase I clinical trial (NCT 01310179; IND 14271) was initiated to evaluate safety and efficacy of an intratumoral injection of adenoviral vector expressing E. coli PNP in combination with intravenous fludarabine for the treatment of solid tumors. The study was designed with escalating doses of fludarabine in the first three cohorts (15, 45, and 75 mg/m(2)) and escalating virus in the fourth (10(11)-10(12) viral particles, VP). RESULTS All 12 study subjects completed therapy without dose-limiting toxicity. Tumor size change from baseline to final measurement demonstrated a dose-dependent response, with 5 of 6 patients in cohorts 3 and 4 achieving significant tumor regression compared with 0 responsive subjects in cohorts 1 and 2. The overall adverse event rate was not dose-dependent. Most common adverse events included pain at the viral injection site (92%), drainage/itching/burning (50%), fatigue (50%), and fever/chills/influenza-like symptoms (42%). Analysis of serum confirmed the lack of systemic exposure to fluoroadenine. Antibody response to adenovirus was detected in two patients, suggesting that neutralizing immune response is not a barrier to efficacy. CONCLUSIONS This first-in-human clinical trial found that localized generation of fluoroadenine within tumor tissues using E. coli PNP and fludarabine is safe and effective. The pronounced effect on tumor volume after a single treatment cycle suggests that phase II studies are warranted. CLINICALTRIALSGOV IDENTIFIER NCT01310179.
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Affiliation(s)
- E L Rosenthal
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - T K Chung
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | | | - P W Allan
- Southern Research Institute, Birmingham
| | - L Clemons
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - D Lowman
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - J Hong
- Department of Cellular, Developmental and Integrative Biology, University of Alabama at Birmingham, Birmingham
| | - F R Hunt
- PNP Therapeutics, Inc., Birmingham
| | - J Richman
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - R M Conry
- Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - K Mannion
- Department of Otolaryngology Head and Neck Surgery, Vanderbilt University, Nashville, USA
| | - W R Carroll
- Department of Surgery, University of Alabama at Birmingham, Birmingham
| | - L Nabell
- Department of Medicine, University of Alabama at Birmingham, Birmingham
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Abstract
Although mainly developed for preclinical research and therapeutic use, antibodies have high antigen specificity, which can be used as a courier to selectively deliver a diagnostic probe or therapeutic agent to cancer. It is generally accepted that the optimal antigen for imaging will depend on both the expression in the tumor relative to normal tissue and the homogeneity of expression throughout the tumor mass and between patients. For the purpose of diagnostic imaging, novel antibodies can be developed to target antigens for disease detection, or current FDA-approved antibodies can be repurposed with the covalent addition of an imaging probe. Reuse of therapeutic antibodies for diagnostic purposes reduces translational costs since the safety profile of the antibody is well defined and the agent is already available under conditions suitable for human use. In this review, we will explore a wide range of antibodies and imaging modalities that are being translated to the clinic for cancer identification and surgical treatment.
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Affiliation(s)
- Jason M Warram
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Burch MB, Chung TK, Rosenthal EL, Schmalbach CE. Multimodality management of high-risk head and neck basal cell carcinoma requiring free-flap reconstruction. Otolaryngol Head Neck Surg 2015; 152:868-73. [PMID: 25805638 DOI: 10.1177/0194599815575720] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 02/11/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVES (1) Investigate overall survival (OS) and disease-free survival (DFS) for high-risk head and neck basal cell carcinoma (HNBCC) requiring large extirpation with free-flap reconstruction. (2) Determine impact of prognostic features-tumor size, subsite, number of high-risk features, perineural invasion, and bony invasion-on high-risk HNBCC survival. (3) Determine survival benefit of adjuvant radiation for high-risk HNBCC. STUDY DESIGN Case series with chart review (2002-2013). SETTING Academic tertiary care center. SUBJECTS AND METHODS Consecutive head and neck patients (N = 431) required free-flap reconstruction following tumor extirpation, 38 for aggressive HNBCC. All cases were high risk. DFS and OS were examined using Kaplan-Meier analysis. Prognostic variables and adjuvant radiation were analyzed utilizing Student's t test for continuous variables and Fisher's exact testing for categorical dependent variables. Complications were reported. RESULTS Mean tumor diameter was 5.17 cm (range, 1.2-15.0 cm). Mean follow-up was 19.9 months. Overall 2-year survival was 80%, falling to 66% at 5 years. Two-year disease-free survival was 72%. Six patients recurred (n = 5 local, 1 distant). Adjuvant radiotherapy improved DFS (P < .01) but not OS (P = .66). Tumors >2.5 cm did not affect OS (P = .61), regardless of subsite. Bone involvement (44.7% cases) did not affect DFS (P = .39) or OS (P = .18). CONCLUSIONS Larger HNBCC warranting free tissue transfer do not confer worse outcomes, independent of subsite. Adjuvant radiotherapy does not improve OS but significantly affected DFS, allowing for 13.7 additional months of DFS. Bone involvement does not influence DFS or OS and should not preclude surgery, even in advanced cases requiring free-flap reconstruction.
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Affiliation(s)
- M Benjamin Burch
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alabama at Birmingham, Alabama, USA
| | - Thomas K Chung
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alabama at Birmingham, Alabama, USA
| | - Eben L Rosenthal
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alabama at Birmingham, Alabama, USA
| | - Cecelia E Schmalbach
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alabama at Birmingham, Alabama, USA
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Korb ML, Huh WK, Boone JD, Warram JM, Chung TK, de Boer E, Bland KI, Rosenthal EL. Laparoscopic Fluorescent Visualization of the Ureter With Intravenous IRDye800CW. J Minim Invasive Gynecol 2015; 22:799-806. [PMID: 25796218 DOI: 10.1016/j.jmig.2015.03.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 03/08/2015] [Accepted: 03/12/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVES Ureter injury is a serious complication of laparoscopic surgery. Current strategies to identify the ureters, such as placement of a ureteral stent, carry additional risks for patients. We hypothesize that the systemically injected near-infrared (NIR) dye IRDye800CW-CA can be used to visualize ureters intraoperatively. METHODS Adult female mixed-breed pigs weighing 24 to 41 kg (n = 2 per dose) were given a 30, 60, or 120 μg/kg systemic injection of IRDye800CW-CA. Using the Food and Drug Administration-cleared Pinpoint laparoscopic NIR system, images of the ureter and bladder were captured every 10 minutes for 60 minutes after injection. To determine the biodistribution of the dye, tissues were collected for ex vivo analysis with the Pearl Impulse system. ImageJ software was used to quantify fluorescence signal and signal-to-background ratio (SBR) for the intraoperative images. RESULTS The ureter was identified in all pigs at each dose, with peak intensity reached by 30 minutes and remaining elevated throughout the duration of imaging (60 minutes). The 60 μg/kg dose was determined to be optimal for differentiating ureters according to absolute fluorescence (>60 counts/pixel) and SBR (3.1). Urine fluorescence was inversely related to plasma fluorescence (R(2) = -0.82). Ex vivo imaging of kidney, ureter, bladder, and abdominal wall tissues revealed low fluorescence. CONCLUSION Systemic administration of IRDye800CW-CA shows promise in providing ureteral identification with high specificity during laparoscopic surgery. The low dose required, rapid time to visualization, and absence of invasive ureteral instrumentation inherent to this technique may reduce complications related to pelvic surgery.
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Affiliation(s)
- Melissa L Korb
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Warner K Huh
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL
| | - Jonathan D Boone
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL.
| | - Jason M Warram
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Thomas K Chung
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Esther de Boer
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Kirby I Bland
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Eben L Rosenthal
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
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Chung TK, Warram J, Day KE, Hartman Y, Rosenthal EL. Time-dependent pretreatment with bevacuzimab increases tumor specific uptake of cetuximab in preclinical oral cavity cancer studies. Cancer Biol Ther 2015; 16:790-8. [PMID: 25719497 DOI: 10.1080/15384047.2015.1016664] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [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: 10/23/2022] Open
Abstract
Inadequate delivery of therapeutics into tumors has been suggested as a reason for poor response. We hypothesize that bevacizumab, an antibody to vascular endothelial growth factor (VEGF), can improve cetuximab uptake in squamous cell carcinoma tumors. Athymic nude mice were implanted with OSC19 and SCC1 human cancer lines in a subcutaneous flank model. Mice were imaged daily for 14 days after intravenous tail vein injections of the following groups: IgG-IRDye800 (Control), cetuximab-IRDye800 (CTX800 Only), bevacizumab-IRDye800 (BVZ800 Only), cetuximab-IRDye800 + bevacuzimuab-IRDye800 (Simultaneous), and unlabeled bevacizumab followed by cetuximab-IRDye800 3 days later (Neoadjuvant). Within single-agent groups, the CTX800 Only tumor-specific uptake (TSU) was significantly higher than BVZ800 Only at Day 13 (TSU 8.6 vs 2.8, P < 0.001). The Simultaneous treatment with BVZ800 and CTX800 demonstrated no increase in antibody delivery. However, administration of unlabeled bevacizumab 3 days prior to CTX800 (Neoadjuvant group) resulted in significantly higher tumor specific delivery than administration of both antibodies at the same time (11.8 vs Simultaneous 5.0, P < 0.001). This difference can be attributed to a slower decline in tumor fluorescence intensity (-6.8% vs. Simultaneous -11.5% per day, respectively). Structural changes in pericyte coverage and functional vessel changes demonstrating decreased proliferation and tumor growth corroborate these fluorescence results. Although simultaneous administration of bevacizumab with cetuximab failed to increase antibody delivery to the tumor, pretreatment with bevacizumab improved TSU reflecting an increase in tumor-specific uptake of cetuximab as a result of vessel normalization.
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Affiliation(s)
- Thomas K Chung
- a Division of Otolaryngology; Department of Surgery; University of Alabama at Birmingham ; Birmingham , AL USA
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Kim H, Hartman YE, Zhai G, Chung TK, Korb ML, Beasley TM, Zhou T, Rosenthal EL. Dynamic contrast-enhanced MRI evaluates the early response of human head and neck tumor xenografts following anti-EMMPRIN therapy with cisplatin or irradiation. J Magn Reson Imaging 2015; 42:936-45. [PMID: 25704985 DOI: 10.1002/jmri.24871] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 01/28/2015] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To assess the early therapeutic effects of anti-EMMPRIN (extracellular matrix metalloprotease inducer) antibody with/without cisplatin or X-ray radiation in head and neck cancer mouse models using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI). MATERIALS AND METHODS Mice bearing SCC1 (or OSC19) tumor xenografts were treated with anti-EMMPRIN antibody, radiation, cisplatin, or anti-EMMPRIN antibody plus cisplatin (or radiation) for a week (n = 4-5 per group). DCE-MRI was carried out on a 9.4T small animal MR scanner on days 0, 3, and 7, and K(trans) values were averaged in a 0.5-mm-thick peripheral tumor region. Ki67 and CD31 staining were implemented for all tumors after imaging. RESULTS The K(trans) changes of SCC1 and OSC19 tumors treated with anti-EMMPRIN antibody for 3 days were -18 ± 8% and 4 ± 7%, respectively, which were significantly lower than those of control groups (39 ± 5% and 45 ± 7%; P = 0.0025 and 0.0220, respectively). When cisplatin was added, those were -42 ± 9% and -44 ± 9%, respectively, and with radiation, -45 ± 9% and -27 ± 10%, respectively, which were also significantly lower than those of control groups (P < 0.0001 for all four comparisons). In the eight groups untreated (served as control) or treated with anti-EMMPRIN antibody with/without cisplatin or radiation, the mean K(trans) change for 3 days was significantly correlated with the mean tumor volume change for 7 days (r = 0.74, P = 0.0346), Ki67-expressing cell density (r = 0.96, P = 0.0001), and CD31 density (r = 0.84, P = 0.0084). CONCLUSION DCE-MRI might be utilized to assess the early therapeutic effects of anti-EMMPRIN antibody with/without chemotherapy or radiotherapy in head and neck cancer.
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Affiliation(s)
- Hyunki Kim
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Yolanda E Hartman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Guihua Zhai
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Thomas K Chung
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Melissa L Korb
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Timothy M Beasley
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Tong Zhou
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Eben L Rosenthal
- Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Mak SSS, Lee MY, Lee DTF, Chung TK, Au WL, Ip MH, Lam AT. Pressurised irrigation versus swabbing for wound cleansing: a multicentre, prospective, randomised controlled trial. Hong Kong Med J 2014; 20 Suppl 7:42-46. [PMID: 25647827] [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: 06/04/2023] Open
Affiliation(s)
- S S S Mak
- Department of Clinical Oncology, Prince of Wales Hospital, Hong Kong
| | - M Y Lee
- Central Nursing Department, North District Hospital, Hong Kong
| | - D T F Lee
- The Nethersole School of Nursing, The Chinese University of Hong Kong
| | - T K Chung
- Department of Medicine, Shatin Hospital, Hong Kong
| | - W L Au
- Central Nursing Department, North District Hospital, Hong Kong
| | - M H Ip
- Department of Family Medicine, New Territories East Cluster, Hospital Authority, Hong Kong
| | - A T Lam
- Department of Family Medicine, New Territories East Cluster, Hospital Authority, Hong Kong
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Burch MB, Chung TK, Schmalbach CE, Rosenthal EL. Multimodality Management of High-Risk Head and Neck Basal Cell Carcinoma Requiring Free Flap Reconstruction. Otolaryngol Head Neck Surg 2014. [DOI: 10.1177/0194599814541627a99] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: (1) Determine the impact of adjuvant radiotherapy on high-risk head and neck basal cell carcinoma (H&N BCC). (2) Analyze risk factors associated with recurrence and survival. Methods: Case series with planned chart review (2002-2013) in an academic tertiary care center. A total of 431 consecutive patients presented with H&N defects requiring free flap reconstruction, 38 specifically for aggressive BCC. Cases were classified as high risk based on National Comprehensive Cancer Network (NCCN) criteria. Overall and disease-free survival were examined using Kaplan-Meier analysis. Independent variables included: site, recurrent tumor, radiation, bony involvement, and perineural invasion. Complications were reported. Results: Nineteen (50%) lesions were recurrent. Mean tumor diameter was 5.17 cm (1.2-15.0cm). Mean follow-up was 19.9 months. Overall 2-year survival was 80%, falling to 66% at 5 years. Two-year disease-free survival was 72%. Six patients recurred (5 local; 1 distant). Adjuvant radiotherapy was utilized in 17 (44.7%) and did not significantly impact recurrence ( P = .15) or survival ( P = .48). Tumors >2.5 cm did not impact survival ( P = .09), regardless of subsite. Bony involvement was identified in 17 (44.7%) cases, but did not correlate with survival ( P = .18). Complication rates: 4 exposed bone, 4 hematoma/seroma, 3 infection, 2 osteoradionecrosis, 2 donor site evisceration, 2 ear canal stenosis, 1 severe trismus, 1 flap arterial insufficiency, 1 nasal obstruction. Conclusions: Larger H&N BCC do not confer worse outcomes, independent of subsite. Adjuvant radiotherapy does not improve survival or recurrence. Bony involvement does not correlate with survival and should not preclude surgical intervention, even in advanced cases.
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Chung TK, Rosenthal EL, Porterfield JR, Carroll WR, Richman JS, Hawn MT. Examining National Outcomes with Intraoperative Nerve Monitoring During Thyroidectomy. J Am Coll Surg 2014. [DOI: 10.1016/j.jamcollsurg.2014.07.318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Chung TK, Kovar J, Bell W, Brandwein-Gensler M, Rosenthal EL. Intraoperative Tumor Imaging with Indocyanine Green in Head and Neck Cancer Patients. Otolaryngol Head Neck Surg 2014. [DOI: 10.1177/0194599814541627a93] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: (1) Describe the effectiveness of indocyanine green (ICG) as an imaging agent for head and neck tumors. (2) Illustrate the potential of near-infrared imaging for intraoperative visualization of cancers. Methods: Patients underwent intravenous administration of 7.5mg ICG during the surgical procedure. The SPY/LUNA (Novadaq) near-infrared intraoperative imaging system was used prior to resection and the Pearl (LICOR) and Odyssey (LICOR) systems for ex-vivo tumor imaging. Tumor-to-background ratio (TBR) was defined as tumor fluorescence divided by normal tissue fluorescence. Histologic analysis was performed with a head and neck cancer board-certified pathologist. Results: Five patients were enrolled into this study between August and September 2013. Three patients had pharyngeal cancer, one had laryngeal cancer, and one had cutaneous cancer. TBR values of confirmed cancer tissue varied among patients (LUNA TBR 3-9, Pearl TBR 3-18). However, in 2 patients, areas of highest fluorescence were found to be absent of carcinoma on histological analysis. The epidermal portions of the cutaneous SCC lesion were highly fluorescent, but the tumor did not penetrate this layer in multiple sections. Histologic analysis of these tissues confirmed significant areas of acute and chronic inflammation at areas of high fluorescence intensity. Skin, mucosal surfaces, and perivascular areas were most prone to false-positive high fluorescence. Conclusions: While intravenous ICG does accumulate in head and neck tumors sufficiently to distinguish them from normal tissue, it is not specific enough to serve as a tumor visualization agent. Targeted fluorescent probes will likely be needed for image-guided surgery.
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Kang JL, Chung TK, Lancaster RT, Lamuraglia GM, Conrad MF, Cambria RP. Outcomes after carotid endarterectomy: is there a high-risk population? A National Surgical Quality Improvement Program report. J Vasc Surg 2014; 49:331-8, 339.e1; discussion 338-9. [PMID: 19216952 DOI: 10.1016/j.jvs.2008.09.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2008] [Revised: 09/11/2008] [Accepted: 09/11/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) is the standard treatment of carotid stenosis for symptomatic and asymptomatic patients. Carotid angioplasty and stenting (CAS), however, has been proposed as alternative therapy for patients deemed at high-risk for CEA. This study examined 30-day adjudicated outcomes in a contemporary series of CEAs and assessed the validity of criteria used to define a potential high-risk patient population for CEA. METHODS Patients undergoing isolated CEA in private sector hospitals between Jan 1, 2005, and Dec 31, 2006, were identified using the prospectively gathered National Surgical Quality Improvement Program database. The primary study end points were 30-day stroke and death rates. Demographic, preoperative, and intraoperative variables were examined using multivariate models to identify variables associated with the study end points. Variables used to define systemic "high-risk" patients in the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) study (active cardiac disease, severe chronic obstructive pulmonary disease, and octogenarian status) were examined individually and in composite fashion for association with study endpoints. RESULTS Of the 3949 CEAs performed, 59% were in men, 30% were "high-risk" (19% age >80), and 43% had a previous neurologic event. The 30-day stroke rate was 1.6%, the death rate was 0.7%, and combined stroke/death rate was 2.2%. Multivariate analysis showed that intraoperative transfusion (odds ratio [OR], 5.95; 95% confidence interval [CI], 1.71-20.66; P = .005), prior major stroke (OR, 5.34; 95% CI, 2.96-9.64; P < .0001), shorter height (surrogate for small artery size; OR, 1.09; 95% CI, 1.02-1.16; P = .010), and increased anesthesia time (OR, 1.02; 95% CI, 1.00-1.03; P = .008) were predictive of stroke. Critical limb ischemia (OR, 12.72; 95% CI, 3.49-46.40; P < .0001) and poor functional status (OR, 7.05; 95% CI, 2.95-16.82; P < .0001) were independent correlates of death. Systemic high-risk variables, either combined or individually, did not increase risk of stroke or death on multivariate analysis. CONCLUSION CEA is associated with favorable 30-day outcomes across a spectrum of patient comorbidity features including octogenarian status. Anatomic and technical features are the important predictors of perioperative stroke, whereas critical limb ischemia and poor functional status are important predictors of death for patients undergoing CEA. These data refute the concept that CAS is preferred for patients deemed high-risk by virtue of systemic comorbidities.
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Affiliation(s)
- Jeanwan L Kang
- Department of Surgery, Division of Vascular and Endovascular Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA.
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18
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Chung TK, Rosenthal EL, Magnuson JS, Carroll WR. Transoral robotic surgery for oropharyngeal and tongue cancer in the United States. Laryngoscope 2014; 125:140-5. [PMID: 25093603 DOI: 10.1002/lary.24870] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 06/25/2014] [Accepted: 07/14/2014] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS To compare the clinical and cost outcomes of transoral robotic surgery (TORS) versus open procedures following the U.S. Food and Drug Administration approval in December 2009. STUDY DESIGN Retrospective analysis of the Nationwide Inpatient Sample from 2008 to 2011. METHODS Elective partial pharyngectomies and partial glossectomies for neoplasm were identified by International Classification of Diseases, 9th Revision, Clinical Modification code. RESULTS TORS represented 2.1% in 2010 and 2.2% in 2011 of all transoral ablative procedures. Patients undergoing open partial pharyngectomy for oropharyngeal neoplasms (n = 1426) had more severe illness compared to TORS (n = 641). However, after controlling for minor-to-moderate severity of illness, open partial pharyngectomy was associated with longer hospital stay (5.2 vs. 3.7 days, P < 0.001), higher charge ($98,228 vs. $67,317, P < 0.001), higher cost ($29,365 vs. $20,706, P < 0.001), higher rates of tracheostomy and gastrostomy tube placement, and more wound and bleeding complications. TORS was associated with a higher rate of dysphagia (19.5% vs. 8.0%, P < 0.001). The lower cost of TORS remained significant in the major-to-extreme severity of illness group but was associated with higher complication rates when compared to open cases of the same severity of illness. A similar analysis of TORS partial glossectomy for base of tongue tumors had similar cost and length of stay benefits, whereas TORS partial glossectomy for anterior tongue tumors revealed longer hospital stays and no benefit in charge or cost compared to open. CONCLUSIONS Early data demonstrate a clinical and cost benefit in TORS partial pharyngectomy and partial glossectomy for the base of tongue but no benefit in partial glossectomy of the anterior tongue. It is likely that anatomic accessibility and extent of surgery factor into the effectiveness of TORS.
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Affiliation(s)
- Thomas K Chung
- Department of Surgery, Division of Otolaryngology Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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Rosenthal EL, Chung TK, Carroll WR, Clemons L, Desmond R, Nabell L. Assessment of erlotinib as adjuvant chemoprevention in high-risk head and neck cancer patients. Ann Surg Oncol 2014; 21:4263-9. [PMID: 25001094 DOI: 10.1245/s10434-014-3878-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Indexed: 11/18/2022]
Abstract
PURPOSE To determine the tolerability and efficacy of long-term treatment with erlotinib for head and neck squamous cell carcinoma after salvage surgery. METHODS An open-label study was conducted of 150 mg of daily erlotinib for 12 months in patients who completed definitive surgical therapy for recurrent head and neck squamous cell carcinoma. The primary outcome measures were tolerability of prolonged erlotinib therapy and disease-free survival and overall survival at 1 and 2 years. RESULTS Thirty-one patients were enrolled onto this study. Mean duration of erlotinib therapy was 5 months (range 2-374 days), with 8 patients completing the full 12-month course of erlotinib. Of the remaining patients, 8 discontinued therapy as a result of recurrence, 10 for medical or surgical complications deemed unrelated to the study medication, and 3 for drug-related toxicities. There were 25 grade 3 adverse events; 4 were classified as possibly related to study medication. The most common adverse events included acneiform rash (n = 26 patients), fatigue (n = 22), and diarrhea (n = 22). Overall survival was 61 % at 1 year and 56 % at 2 years. Disease-free survival was 54 % at 1 year and 45 % at 2 years. Mean time to recurrence (n = 16) was 8.7 months. CONCLUSIONS Long-term erlotinib is safe and demonstrates some potential survival benefit compared to historical controls. However, despite the absence of grade 3/4 adverse events attributable to the drug, tolerance of long-term erlotinib was a significant barrier to completion of a 12-month course of therapy.
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Affiliation(s)
- Eben L Rosenthal
- Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA,
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20
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Chung TK, Rosenthal EL, Porterfield JR, Carroll WR, Richman J, Hawn MT. Examining national outcomes after thyroidectomy with nerve monitoring. J Am Coll Surg 2014; 219:765-70. [PMID: 25158909 PMCID: PMC4370365 DOI: 10.1016/j.jamcollsurg.2014.04.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 04/08/2014] [Accepted: 04/08/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous intraoperative nerve monitoring (IONM) studies have demonstrated modest-to-no benefit and did not include a nationwide sample of hospitals representative of broad thyroidectomy practices. This national study was designed to compare vocal cord paralysis (VCP) rates between thyroidectomy with IONM and without monitoring (conventional). STUDY DESIGN We performed a retrospective analysis of 243,527 thyroidectomies during 2008 to 2011 using the Nationwide Inpatient Sample. RESULTS Use of IONM increased yearly throughout the study period (2.6% [2008], 5.6% [2009], 6.1% [2010], 6.9% [2011]) and during this time, VCP rates in the IONM group initially increased year-over-year (0.9% [2008], 2.4% [2009], 2.5% [2010], 1.4% [2011]). In unadjusted analyses, IONM was associated with significantly higher VCP rates (conventional 1.4% vs IONM 1.9%, p < 0.001). After propensity score matching, IONM remained associated with higher VCP rates in partial thyroidectomy and lower VCP rates for total thyroidectomy with neck dissection. Hospital-level analysis revealed that VCP rates were not explained by differential laryngoscopy rates, decreasing the likelihood of ascertainment bias. Additionally, for hospitals in which IONM was applied to more than 50% of thyroidectomies, lower VCP rates were observed (1.1%) compared with hospitals that applied IONM to less than 50% (1.6%, p = 0.016). Higher hospital volume correlated with lower VCP rates in both groups (<75, 75 to 299, >300 thyroidectomies/year: IONM, 2.1%, 1.7%, 1.7%; conventional, 1.5%, 1.3%, 1.0%, respectively). CONCLUSIONS According to this study, IONM has not been broadly adopted into practice. Overall, IONM was associated with a higher rate of VCP even after correction for numerous confounders. In particular, low institutional use of IONM and use in partial thyroidectomies are associated with higher rates of VCP. Further studies are warranted to support the broader application of IONM in patients where benefit can be reliably achieved.
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Affiliation(s)
- Thomas K Chung
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Eben L Rosenthal
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - John R Porterfield
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - William R Carroll
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Joshua Richman
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Mary T Hawn
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL.
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Chung TK, Wilson K, Patil YJ. Double deep inferior epigastric arteries encountered during vertical rectus abdominis flap harvest: a case report and literature review. Ear Nose Throat J 2014; 92:E34. [PMID: 23780602 DOI: 10.1177/014556131309200620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The rectus abdominis flap offers a number of advantages over other flaps used in head and neck reconstruction. The flap can be harvested by a separate team and can be tailored to include skin, muscle, and fat. In addition, the available vascular pedicle is long and its large caliber provides an appropriate size match with recipient neck vessels. Central to reconstructive success is defining an arterial and venous pedicle that provides balanced perfusion to all components of the flap. Anomalous vascular anatomy presents principal challenges in reestablishing free flap perfusion. We present a case of double, right deep inferior epigastric arteries encountered during vertical rectus abdominis myocutaneous flap reconstruction of the tongue and floor of the mouth and discuss the clinical outcomes of this reconstruction.
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Affiliation(s)
- Thomas K Chung
- Department of General Surgery, University of Washington, Seattle, WA, USA
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Rutherfurd SM, Chung TK, Moughan PJ. Effect of microbial phytase on phytate P degradation and apparent digestibility of total P and Ca throughout the gastrointestinal tract of the growing pig. J Anim Sci 2013; 92:189-97. [PMID: 24243891 DOI: 10.2527/jas.2013-6923] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The effect of a dietary microbial phytase on mineral digestibility throughout the gastrointestinal tract (GIT) of the growing pig was studied. Thirty-two entire male pigs (~22 kg BW) were allocated equally to 4 corn-soybean meal diets. One diet was adequate in total P and Ca, the second diet was deficient in total P and Ca (low-P diet), and the third and fourth diets were the low-P diet with microbial phytase added at 1,107 U/kg or 2,215 U/kg, respectively. Titanium dioxide (3 g/kg) was included in the diets as an indigestible marker. The pigs were fed their respective diets for 42 d. Fecal samples were collected from d 38 to 41 and stomach chyme, terminal jejunal, and terminal ileal digesta samples were collected after euthanasia on d 42. Phytate P degradability and apparent total P and Ca digestibility were determined at the gastric, jejunal, ileal, and total tract levels. Phytate P degradation and apparent total P and Ca digestibility were not significantly different between the 2 microbial phytase inclusion levels. Across both microbial phytase-low-P diets, phytase supplementation increased (P < 0.05) phytate P degradability at the jejunal, ileal, and total tract levels by 101%, 77%, and 10%, respectively, but not at the gastric level. Total tract phytate P degradation was greater (P < 0.05) than ileal phytate P degradation for both the unsupplemented (52% units greater) and phytase-supplemented, low-P (26% units greater) diets. The latter result was not reflected by the apparent total P digestibility estimate, which was not significantly different between the ileal and total tract levels for both the unsupplemented and phytase-supplemented, low-P diets. Consequently, there appeared to be considerable phytate degradation in the hindgut, presumably due to the action of hindgut microbes, but the phytate P released in the hindgut did not appear to be absorbed. Apparent Ca digestibility was not significantly different among jejunal, ileal, and total tract levels for any of the dietary treatments, but apparent Ca digestibility was greater (P < 0.05) for the phytase-supplemented diets compared with the unsupplemented diets. Overall, dietary microbial phytase supplementation led to greater phytate degradation to the end of the jejunum. Because the phytate P released in the hindgut was not absorbed, ileal estimates, rather than total tract estimates, of phytate degradation appear to more accurately reflect P availability.
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Affiliation(s)
- S M Rutherfurd
- Riddet Institute, Massey University, Palmerston North, New Zealand
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Hines EA, Coffey JD, Starkey CW, Chung TK, Starkey JD. Improvement of maternal vitamin D status with 25-hydroxycholecalciferol positively impacts porcine fetal skeletal muscle development and myoblast activity. J Anim Sci 2013; 91:4116-22. [PMID: 23893976 DOI: 10.2527/jas.2013-6565] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
There is little information available regarding the influence of maternal vitamin D status on fetal skeletal muscle development. Therefore, we investigated the effect of improved vitamin D status resulting from 25-hydroxycholecalciferol (25OHD3) supplementation of dams on fetal skeletal muscle developmental characteristics and myoblast activity using Camborough 22 gilts (n = 40) randomly assigned to 1 of 2 corn-soybean meal-based diets. The control diet (CTL) contained 2,500 IU cholecalciferol (D3)/kg diet, whereas the experimental diet contained 500 IU D3/kg diet plus 50 µg 25OHD3/kg diet. Gilts were fed 2.7 kg of their assigned diet once daily beginning 43 d before breeding through d 90 of gestation. On gestational d 90 (± 1), fetal LM and semitendinosus muscle samples were collected for analysis of developmental characteristics and myoblast activity, respectively. No treatment difference was observed in fetal LM cross-sectional area (P = 0.25). Fetuses from 25OHD3-supplemented gilts had more LM fibers (P = 0.04) that tended to be smaller in cross-sectional area compared with CTL fetuses (P = 0.11). A numerical increase in the total number of Pax7+ myoblasts was also observed in fetuses from 25OHD3-supplemented gilts (P = 0.12). Myoblasts derived from the muscles of fetuses from 25OHD3-fed dams displayed an extended proliferative phase in culture compared with those from fetuses of dams fed only D3 (P < 0.0001). The combination of additional muscle fibers and Pax7+ myoblasts with prolonged proliferative capacity could enhance the postnatal skeletal muscle growth potential of fetuses from 25OHD3-supplemented gilts. These data highlight the importance of maternal vitamin D status on the development of fetal skeletal muscle.
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Affiliation(s)
- E A Hines
- Department of Animal and Food Sciences, Texas Tech University, Lubbock, TX 79409, USA
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Chung TK, Rutherfurd SM, Thomas DV, Moughan PJ. Effect of two microbial phytases on mineral availability and retention and bone mineral density in low-phosphorus diets for broilers. Br Poult Sci 2013; 54:362-73. [PMID: 23662985 DOI: 10.1080/00071668.2013.783902] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
1. The efficacy of supplementation of a low-phosphorus (low-P) maize-soyabean meal diet for broiler chickens with two different microbial (fungal and bacterial) phytases was examined. 2. Broiler chickens received a low-P maize-soyabean meal diet containing either no phytase or one of the two phytases included at one and two times the manufacturer's recommended inclusion level for 21 d. 3. Titanium dioxide was included in the diets as an indigestible marker. Excreta were collected quantitatively from d 18 to 21, and at the end of the study the birds were killed and ileal digesta and leg bone samples collected. 4. No differences were observed for body weight gain and feed intake or apparent metabolisable energy (AME) among all dietary treatment groups. 5. Dietary phytase supplementation improved the apparent retention of Ca, Na and Cu and ileal phytate P absorption from 32% to 44% across inclusion levels. 6. Bone mineral density (BMD) was improved for both phytases across inclusion levels by, on average, 9% for the tibia and 13% for the femur. 7. Dietary phytase supplementation of the low-P diet improved apparent ileal digestibility of serine, glycine, valine, isoleucine, tyrosine, histidine, lysine and arginine. 8. When the results from the present study were combined with the results from other similar published studies and analysed statistically, factors such as dietary P and Ca concentration, as well as bird breed and age, rather than the type or activity of microbial phytase, had the greatest impact on the extent to which dietary supplementation improved P and Ca retention. 9. More work is required to explain the interrelationships between the multiple factors influencing the efficacy of phytase on the availability of dietary minerals.
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Affiliation(s)
- T K Chung
- DSM Nutritional Products Asia Pacific, 2 Havelock Road #04-01, Singapore 059763, Singapore.
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Rutherfurd SM, Chung TK, Thomas DV, Zou ML, Moughan PJ. Effect of a novel phytase on growth performance, apparent metabolizable energy, and the availability of minerals and amino acids in a low-phosphorus corn-soybean meal diet for broilers. Poult Sci 2012; 91:1118-27. [PMID: 22499869 DOI: 10.3382/ps.2011-01702] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [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: 11/20/2022] Open
Abstract
The addition of microbial phytase to diets for broiler chickens has been shown to improve the availability of phytate P, total P, some other minerals, and amino acids. In this study, the effect of a novel microbial phytase expressed by synthetic genes in Aspergillus oryzae on amino acid and mineral availability was assessed. Phytase was incorporated (1,000 and 2,000 U/kg) into low-P corn-soybean meal-based diets for broilers. Broilers received the experimental diets for 3 wk, and excreta were collected from d 18 to 21 for the determination of AME and mineral retention. On the 22nd day, the broilers were killed and the left leg removed and ileal digesta collected. Ileal phytate P and total P absorption, ileal amino acid digestibility, as well as the bone mineral content and bone mineral density were determined. Ileal phytate P absorption and absorbed phytate P content of the low-P corn-soybean meal diet were significantly (P < 0.05) higher after dietary inclusion of the novel phytase (49-60% and 65-77% higher, respectively). Apparent ileal total P absorption and apparent total P retention was 12 to 16% and 14 to 19% higher (P < 0.05), respectively, after dietary inclusion of phytase. The bone mineral content and bone mineral density in the tibia were 32 to 35% and 19 to 21% higher (P < 0.05), respectively, after dietary phytase inclusion. The apparent ileal digestibility of threonine, tyrosine, and histidine increased significantly (P < 0.05) by 14, 9, and 7%, respectively, after dietary inclusion of microbial phytase. Overall, the inclusion of a novel microbial phytase into a low-P corn-soybean meal diet for broiler chickens greatly increased phytate P and total P absorption, bone mineral content and density, as well as the digestibility of some amino acids.
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Affiliation(s)
- S M Rutherfurd
- Riddet Institute, Massey University, Palmerston North, New Zealand.
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Chung TK, Lynch ER, Fiser CJ, Nelson DA, Agricola K, Tudor C, Franz DN, Krueger DA. Psychiatric comorbidity and treatment response in patients with tuberous sclerosis complex. Ann Clin Psychiatry 2011; 23:263-9. [PMID: 22073383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND Behavioral and psychiatric comorbidity are common in tuberous sclerosis complex (TSC), but information regarding psychopharmacologic management is lacking. METHODS We reviewed clinical records of patients evaluated over a 20-month period at a large, quaternary referral center specializing in the comprehensive management of patients with TSC. Data were collected regarding psychiatric diagnoses, psychopharmacologic medications used to treat these disorders, and clinical response to treatment at follow-up. RESULTS There were 113 encounters by 62 pediatric and adult patients with TSC, which were included in the present analysis. Behavioral and anxiety disorders were most prevalent, as were autism spectrum disorders and attention-deficit/hyperactivity disorder. Antipsychotics, antidepressants, and anticonvulsants with mood-stabilizing properties were the most often prescribed psychoactive medications and were associated with an overall improvement or stabilization of psychiatric symptoms 65% of the time. CONCLUSIONS Psychiatric comorbidity, especially behavioral disorders, is very common among patients with TSC. Pharmacologic treatment can be very effective and should be considered for optimal disease management in affected individuals.
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Affiliation(s)
- Thomas K Chung
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, OH 45229, USA
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Conrad MF, Chung TK, Cambria MR, Paruchuri V, Brady TJ, Cambria RP. Effect of chronic dissection on early and late outcomes after descending thoracic and thoracoabdominal aneurysm repair. J Vasc Surg 2010; 53:600-7; discussion 607. [PMID: 21112177 DOI: 10.1016/j.jvs.2010.09.053] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 09/14/2010] [Accepted: 09/15/2010] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Although chronic aortic dissection (CD) has traditionally been considered a predictor of perioperative morbidity and mortality after descending thoracic/thoracoabdominal aneurysm repair (thoracoabdominal aortic aneurysm [TAA]), recent reports have rejected this assertion. Still, few contemporary studies document late outcomes after TAA for CD, which is the goal of this study. METHODS From August 1987 to December 2005, 480 patients underwent TAA; 73 (15%) CD and 407 (85%) degenerative aneurysms (DA). Operative management consisted of a clamp-and-sew technique with adjuncts in 53 (78%) CD and 355 (93%) DA patients (P < .001). Epidural cooling was used to prevent spinal cord injury (SCI) in 51 (70%) CD and 214 (53%) DA patients (P = .007). Study end points included perioperative SCI/mortality, freedom from reintervention, and long-term survival. RESULTS CD patients were younger (mean age 64.5 years CD vs 72.5 years DA, P < .001) and more frequently had a family history of aneurysmal disease (23% CD vs 6% DA, P < .001). Forty-three (59%) CD patients had elective TAA (vs 322 (79%) DA, P = .001). Eleven (15%) CD patients had Marfan's syndrome (vs 0% DA, P < .001), and 17 (23%) CD patients had a prior arch or ascending aortic repair (vs 16 [4%] DA, P < .001). CD patients were more likely to have Crawford type I & II thoracoabdominal aneurysms (44 [60%] vs 120 [29%] DA, P < .001), while only two (3%) CD patients had type IV aneurysms (vs 99 [24%] DA). There was no difference in perioperative mortality between the two groups (11% CD vs 8.6% DA, P = .52), nor was there a difference in flaccid paralysis, which occurred in five (7%) CD and 22 (5%) DA patients (P = .92). At 5 years, 70% of CD patients were free from reintervention versus 74% of DA (P = .36). The actuarial survival was 53% and 32% at 5 and 10 years for CD versus 47% and 17% for DA (P = .07). CONCLUSIONS Despite increased operative complexity, CD does not appear to increase perioperative SCI or mortality after TAA when compared with DA. Long-term freedom from aneurysm-related reintervention is similar for both groups as is survival, despite patients with CD being of younger age at presentation.
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Affiliation(s)
- Mark F Conrad
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass 02114, USA.
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Chou SH, Chung TK, Yu B. Effects of supplemental 25-hydroxycholecalciferol on growth performance, small intestinal morphology, and immune response of broiler chickens. Poult Sci 2009; 88:2333-41. [PMID: 19834083 DOI: 10.3382/ps.2009-00283] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Three experiments were conducted to evaluate the effects of 25-hydroxycholecalciferol (25-OH-D(3)) on the growth performance, small intestinal morphology, and immune response of broiler chickens. In experiment 1, 25-OH-D(3) neither increased nor decreased weight gain and feed efficiency compared with the controls during the 39-d feeding period. Birds fed 25-OH-D(3) exhibited numerically higher phagocytosis (45%) than the controls (35%). In experiment 2, chicks were fed diets similar to those used in experiment 1 and were killed at 7, 14, 21, 28, and 35 d of age to determine the relative weight and histology of the small intestine. The relative weight of the small intestine from birds fed 25-OH-D(3) was numerically lower (P < 0.1) at 7 d of age. It was found that 25-OH-D(3) consistently resulted in longer (P < 0.05) villus length of the duodenum in 21- and 28-d-old birds and of the jejunum in 14- and 28-d-old birds. Shorter (P < 0.05) crypt depth was observed in the duodenum at 14 d of age and in the jejunum at 21 and 28 d of age. A higher (P < 0.05) ratio of villus length to crypt depth was also observed in the duodenum and jejunum at 14, 21, and 28 d of age of birds fed 25-OH-D(3). The thickness of muscle layer increased in the duodenum at 14, 28, and 35 d of age in birds fed 25-OH-D(3). In experiment 3, birds were orally challenged with either Luria-Bertani broth or Salmonella Typhimurium E29 at 7 and 14 d of age. Uninfected birds fed 25-OH-D(3) had lower total serum IgA at 14 d of age and lower total serum IgG at 21 d of age. However, infected birds fed 25-OH-D(3) produced higher (P < 0.1) total serum IgG at 21 d of age. The results of this study suggest that supplemental 25-OH-D(3) improves small intestinal morphology and protective humoral immunity to infection.
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Affiliation(s)
- S H Chou
- Department of Animal Science, National Chung-Hsing University, 250 Kuo-Kang Road, Taichung, 402, Taiwan
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Crawford RS, Pedraza JD, Chung TK, Corey M, Conrad MF, Cambria RP. Functional outcome after thoracoabdominal aneurysm repair. J Vasc Surg 2008; 48:828-35. [DOI: 10.1016/j.jvs.2008.05.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2008] [Revised: 05/05/2008] [Accepted: 05/10/2008] [Indexed: 11/27/2022]
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Kang JL, Patel VI, Conrad MF, Lamuraglia GM, Chung TK, Cambria RP. Common femoral artery occlusive disease: contemporary results following surgical endarterectomy. J Vasc Surg 2008; 48:872-7. [PMID: 18639427 DOI: 10.1016/j.jvs.2008.05.025] [Citation(s) in RCA: 151] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2008] [Revised: 05/01/2008] [Accepted: 05/07/2008] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Proliferation of endovascular techniques with perceived reduction in treatment morbidity repetitively question the precept that surgical endarterectomy is the preferred treatment for occlusive disease of the common femoral artery (CFA). This study details a contemporary experience with common femoral endarterectomy (CFE) with and without concomitantly performed endovascular therapies. METHODS Technical, hemodynamic, and clinical success of CFE performed between 2002 and 2005 were determined according to the Society of Vascular Surgery reporting standards. Primary and assisted patencies of the CFA segment, freedom from reintervention in the ipsilateral limb, and survival were assessed using Kaplan-Meier life-table analysis. Multivariate analysis was performed to evaluate factors associated with patency and survival. RESULTS CFE was performed on 65 limbs in 58 patients (mean age 71 +/- 10; male 77%; diabetes 28%; creatinine >/= 1.5 mg/dL 19%). Forty-four cases (68%) were performed for claudication, and 21 cases (32%) for critical limb ischemia. Thirty-seven cases (57%) were performed as a hybrid procedure wherein concomitant endovascular interventions were performed. Twenty iliac (TASC II A-30%; B-35%; C-20%; D-15%) and 25 femoropopliteal (TASC II A-24%; B-60%; C-12%; D-4%) lesions were treated. Technical success was achieved in 100% of the cases. Hemodynamic success was achieved in 95% of the cases with mean postoperative increase in ankle-brachial index (ABI) of 0.24 +/- 0.24. All but one patient (98.5%) had improvement in symptoms and/or ABI. Average hospital stay was 3.2 days (range 1-12 days). There were 3 (5%) major complications requiring reintervention (early failure secondary to untreated inflow lesion, hematoma, and wound infection), six (9%) minor complications which were treated conservatively (five wound infections, one lymph leak), and no perioperative mortality. With a mean follow-up period of 27 months (range 1-58 months), 1- and 5-year primary patencies were 93% and 91%, respectively. Assisted patency was 100% at both time points. There was no difference in patencies between CFE performed alone or as a hybrid procedure. Multivariate analysis showed congestive heart failure (CHF) as the only predictor of primary failure (odds ratio [OR] 18.5 [2.6-142.9]; P = .004). Freedom from reintervention in the ipsilateral limb was 82% at 1 year and 78% at 5 years, with CHF again as the only predictor of reintervention (OR 5.3 [1.4-19.6]; P =.012). Survival was 89% at 1 year and 70% at 5 years. There were no amputations. CONCLUSIONS These data suggest CFE should remain the standard of care for occlusive disease of the CFA. Its safety and efficacy establish a standard for comparison with emerging endovascular therapies.
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Affiliation(s)
- Jeanwan L Kang
- Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass, USA
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Abbruzzese TA, Kwolek CJ, Brewster DC, Chung TK, Kang J, Conrad MF, LaMuraglia GM, Cambria RP. Outcomes following endovascular abdominal aortic aneurysm repair (EVAR): An anatomic and device-specific analysis. J Vasc Surg 2008; 48:19-28. [PMID: 18440182 DOI: 10.1016/j.jvs.2008.02.003] [Citation(s) in RCA: 221] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2007] [Revised: 01/31/2008] [Accepted: 02/02/2008] [Indexed: 11/27/2022]
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Conrad MF, Ye JY, Chung TK, Davison JK, Cambria RP. Spinal cord complications after thoracic aortic surgery: long-term survival and functional status varies with deficit severity. J Vasc Surg 2008; 48:47-53. [PMID: 18486422 DOI: 10.1016/j.jvs.2008.02.047] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Revised: 02/13/2008] [Accepted: 02/17/2008] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Paraplegia after thoracoabdominal aneurysm (TAA) repair has been associated with poor survival. Little information exists concerning the spectrum of severity that characterizes spinal cord ischemic (SCI) complications. This study stratified SCI by deficit severity to determine its impact on late survival and functional outcomes. METHODS A review of our prospectively maintained thoracic aortic database was performed from May 1987 through December 2005 to identify patients who experienced SCI of any extent after TAA repair. During this period, 576 patients underwent descending thoracic aortic repair (93 open, 105 endovascular [TEVAR]) or open TAA repair (279 extent I to III; 99 extent IV). To stratify severity of SCI, we created a spinal cord ischemia deficit (SCID) scale, which is defined as: I, flaccid paralysis; II, average neurologic muscle grade indicating <50% function; and III, average neurologic muscle grade indicating >50% function. Long-term outcomes were evaluated in relation to these groups by actuarial methods. RESULTS During the study period, 64 (11.1%) patients developed SCI of any severity (7 of 105 [6.6%] TEVAR, 57 of 471 [12%] open). These were stratified by SCID level: I, 24 (37.5%); II, 31 (48.4%); and III, 9 (14.1%). SCI was immediate in 33 (54.1%) and delayed in 28 (45.9%). Most SCI (6 of 7) associated with TEVAR was delayed. The 30-day mortality was significantly higher in the SCI group than the overall patient cohort (15 of 64 [23.4%] vs 41 of 512 [8%], P < .001) and varied by SCID level: I, 11 of 24 (45.8%); II, 4 of 31 (12.9%); and III, 0 of 9 (0%; P = .001). The 5-year actuarial survival for all SCI was lower than for non-SCI patients (25% +/- 6% vs 51% +/- 3%, P < .001) and varied linearly with SCID level but was similar between SCID II/III and the non-SCI patients (41% +/- 10% vs 51% +/- 3%, P = .281). No SCID I patients were alive at 5 years. No patients with SCID I recovered the ability to walk, but eight of 11 (73%) with SCID II and the nine (100%) with SCID III could ambulate with or without assistance at last follow-up. CONCLUSION Survival and functional outcomes correlate with SCI severity. Patients with SCID I have a poor long-term outlook. Survival of SCID II/III patients is similar to non-SCI patients; most recover the ability to ambulate.
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Affiliation(s)
- Mark F Conrad
- Division of Vascular and Endovascular Surgery of the General Surgical Services, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA.
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Jones JE, Atkins MD, Brewster DC, Chung TK, Kwolek CJ, LaMuraglia GM, Hodgman TM, Cambria RP. Persistent type 2 endoleak after endovascular repair of abdominal aortic aneurysm is associated with adverse late outcomes. J Vasc Surg 2007; 46:1-8. [PMID: 17543489 DOI: 10.1016/j.jvs.2007.02.073] [Citation(s) in RCA: 312] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2006] [Accepted: 02/28/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Type 2 endoleak occurs in up to 20% of patients after endovascular aneurysm repair (EVAR), but its long-term significance is debated. We reviewed our experience to evaluate late outcomes associated with type 2 endoleak. METHODS During the interval January 1994 to December 2005, 873 patients underwent EVAR. Computed tomography (CT) scan assessment was performed < or =1 month of the operation and at least annually thereafter. Sequential 6-month CT scan follow-up was adopted for those patients with persistent type 2 endoleaks, and reintervention was limited to those with sac enlargement >5 mm. Study end points included overall survival, aneurysm sac growth, reintervention rate, conversion to open repair, and abdominal aortic aneurysm (AAA) rupture. Preoperative variables and anatomic factors potentially associated with these endpoints were assessed using multivariate analysis. RESULTS We identified 164 (18.9%) patients with early (at the first follow-up CT scan) type 2 endoleaks. Mean follow-up was 32.6 months. In 131 (79.9%) early type 2 endoleaks, complete and permanent leak resolution occurred < or =6 months. Endoleaks persisted in 33 patients (3.8% of total patients; 20.1% of early type 2 endoleaks) for >6 months. Transient type 2 endoleak (those that resolved < or =6 months of EVAR) was not associated with adverse late outcomes. In contrast, persistent endoleak was associated with several adverse outcomes. AAA-related death was not significantly different between patients with and without a type 2 endoleak (P = .78). When evaluating patients with no early endoleak vs persistent endoleak, freedom from sac expansion at 1, 3, and 5 years was 99.2%, 97.6%, and 94.9% (no leak) vs 88.1%, 48.0%, and 28.0% (persistent) (P < .001). Patients with persistent endoleak were at increased risk for aneurysm sac growth vs patients without endoleak (odds ratio [OR], 25.9; 95% confidence interval [CI] 11.8 to 57.4; P < .001). Patients with a persistent endoleak also had a significantly increased rate of reintervention (OR, 19.0; 95% CI, 8.0 to 44.7); P < .001). Finally, aneurysm rupture occurred in 4 patients with type 2 endoleaks. Freedom from rupture at 1, 3, and 5 years for patients with a persistent type 2 endoleak was 96.8%, 96.8%, and 91.1% vs 99.8%, 98.5%, and 97.4% for patients without a type 2 endoleak. Multivariate analysis demonstrated persistent type 2 endoleak to be a significant predictor of aneurysm rupture (P = .03). CONCLUSIONS Persistent type 2 endoleak is associated with an increased incidence of adverse outcomes, including aneurysm sac growth, the need for conversion to open repair, reintervention rate, and rupture. These data suggest that patients with persistent type 2 endoleak (>6 months) should be considered for more frequent follow-up or a more aggressive approach to reintervention.
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Affiliation(s)
- John E Jones
- Division of Vascular and Endovascular Surgery of the General Surgical Services, Massachusetts General Hospital and Harvard Medical School, 15 Parkman Street, Boston, MA 02144, USA.
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Crawford RS, Chung TK, Hodgman T, Pedraza JD, Corey M, Cambria RP. Restenosis after eversion vs patch closure carotid endarterectomy. J Vasc Surg 2007; 46:41-8. [PMID: 17606120 DOI: 10.1016/j.jvs.2007.02.055] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2006] [Accepted: 02/22/2007] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Recurrent stenosis after carotid endarterectomy (CEA), previously reported to occur in 1%/year after operation, is the finite limitation of CEA. Eversion endarterectomy has a perceived lower incidence of recurrent stenosis, although data to support this contention are conflicting. The goal of the present study was to compare the late anatomic results of patch closure (PC) vs eversion CEA. METHODS Between January 1, 1995 and June 30, 2005, 950 CEA were performed by the senior author with adoption of eversion (EV) as the primary technique as of January 1, 2001. With minimum of 1-year follow-up by study inclusion criteria, complete follow-up data (including a duplex scan) was available for 155 PC and 135 EV patients. Incidence of moderate (50% to 70%) and severe (>70%) restenosis was examined at < or =2 months and >1 year after operation. Study end-points included late stroke, survival, and freedom from restenosis (moderate and severe) and were assessed by actuarial methods. RESULTS There were no differences in relevant demographic/clinical parameters, indication for surgery (69% overall asymptomatic) or early perioperative stroke/death (1.1% overall; P = .25) between PC and EV. After correction for different mean follow-up intervals (PC = 5.5 years vs EV = 3.5 years) by actuarial methods, there was no significant difference in late moderate (P = .91) or severe (P = .54) recurrent stenosis between PC and EV. In the group of patients with at least 1-year follow-up, 11/290 (3.8%) patients (4/135 EV, 7/155 PC; P = .39) required reintervention on their operated carotid artery at a cumulative follow-up interval of 4.5 years. Three strokes (3/290; 1.1%) occurred during late follow-up, all in the PC group, with only one related to the operated carotid artery. Late survival was similar between EV and PC, (P = .86). Female gender (odds ratio [OR] 3.72[1.02-13.5], P = .046) was associated with severe restenosis irrespective of surgical technique. Univariate analysis also showed that female gender (OR 7.6[CI: 0.88-66.7], P = .042) was associated with late stroke. CONCLUSION These findings indicate that restenosis rates are similar between eversion and patch CEA and likely represent biological remodeling phenomenon rather than technical variations of operations. While EV offers distinct advantages in certain anatomic circumstances, adoption of EV with the hope of decreasing restenosis is not warranted.
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Affiliation(s)
- Robert S Crawford
- Division of Vascular and Endovascular Surgery of the General Surgical Services, Massachusetts General Hospital and Harvard Medical School, 15 Parkman Street, Boston, MA 02114, USA
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Atkins MD, Kwolek CJ, LaMuraglia GM, Brewster DC, Chung TK, Cambria RP. Surgical revascularization versus endovascular therapy for chronic mesenteric ischemia: a comparative experience. J Vasc Surg 2007; 45:1162-71. [PMID: 17467950 DOI: 10.1016/j.jvs.2007.01.067] [Citation(s) in RCA: 171] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2006] [Accepted: 01/26/2007] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Endovascular therapy (percutaneous transluminal angioplasty [PTA] with stenting) has been increasingly applied in patients with chronic mesenteric ischemia (CMI) to avoid morbidities associated with open repair (OR). The purpose of this study was to compare outcomes of PTA/Stent vs OR in patients with symptomatic CMI. METHODS During the interval of January 1991 to December 2005, 80 consecutive patients presenting with symptomatic CMI underwent elective revascularization. Patients with acute mesenteric ischemia or those with mesenteric revascularization performed as part of complex aneurysm repair were excluded. PTA/Stent (with stenting in 87%) was the initial procedure in 31 patients (42 vessels). OR was performed in 49 patients (88 vessels) and consisted of bypass grafting in 31 (63%), transaortic endarterectomy in 7 (14%), patch angioplasty in 4 (8%), or combined in 7 (15%). Mean follow-up was 15 months in the PTA/Stent group and 42 months in the OR cohort. Study end points included perioperative morbidity, mortality, late survival (Kaplan-Meier), and symptomatic and radiographic recurrence. RESULTS Baseline comorbidities, with the exception of heart disease (P=.025) and serum albumin<3.5 g/dL (P=.025), were similar between PTA/Stent and OR patients. The PTA/Stent group had fewer vessels revascularized (1.5 vs 1.8 vessels, P=.001). Hospital length of stay was less for the PTA/Stent group (5.6 vs 16.7 days, P=.001). No difference was noted in in-hospital major morbidity (4/31 vs 2/49, P=.23) or mortality (1/31 vs 1/49, P=.74). Actuarial survival at 2 years was similar between the groups (88% PTA/Stent vs 74% OR, P=.28). There was no difference in the incidence of symptomatic (7/31 [23%] vs 11/49 [22%], P=.98) or radiographic recurrence (10/31 [32%] vs 18/49 [37%], P=.40) between the two groups. Radiographic primary patency (58% vs 90%, P=.001) and primary assisted patency (65% vs 96%, P<.001) at 1 year were lower in the PTA/Stent group compared with OR. Five (16%) of 31 PTA/Stent patients compared with 11 (22%) of 49 OR patients required a second intervention on at least one index vessel at any time (P=.49). CONCLUSIONS Symptomatic recurrence requiring reintervention is common (overall 16/80 [20%]) after open and endovascular treatment for CMI. PTA/Stent was associated with decreased primary patency, primary assisted patency, and the need for earlier reintervention. In-hospital mortality or major morbidity were similar in patients undergoing PTA/Stent and OR. These findings suggest that OR and PTA/Stent should be applied selectively in CMI patients in accordance with individual patient anatomic and comorbidity considerations.
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Affiliation(s)
- Marvin D Atkins
- Division of Vascular and Endovascular Surgery of the General Surgical Services, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
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Rutherfurd SM, Chung TK, Moughan PJ. The effect of a commercial enzyme preparation on apparent metabolizable energy, the true ileal amino acid digestibility, and endogenous ileal lysine losses in broiler chickens. Poult Sci 2007; 86:665-72. [PMID: 17369537 DOI: 10.1093/ps/86.4.665] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [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: 11/13/2022] Open
Abstract
The effect of a commercial enzyme preparation containing xylanase, alpha-amylase, and beta-glucanase on dietary AME content and the apparent and true ileal amino acid digestibility of a corn-soy broiler diet and endogenous ileal lysine flow was determined. Two predominantly corn-soy diets also containing wheat bran and canola meal were formulated; one diet contained no added enzymes, whereas the other was supplemented with alpha-amylase, beta-glucanase, and xylanase. Titanium dioxide was included as an indigestible marker. The diets were given to broiler chickens, and AME and true ileal amino acid digestibility were determined. Portions of the 2 test diets were guanidinated and fed to similar aged broiler chickens and endogenous lysine flows determined. The chickens appeared healthy throughout the study, and the mean bird weights at the time of slaughter were not significantly different (P < 0.05) among any of the treatment groups. Dietary AME content was significantly (P < 0.05) higher for the enzyme-supplemented corn-soy diet (2,829 kcal/kg) compared with its unsupplemented control diet (2,766 kcal/kg). True ileal amino acid digestibility was significantly (P < 0.05) higher for all amino acids investigated. The increase ranged from 4% for arginine and glutamic acid to 12% for cystine. There was no significant difference in endogenous ileal lysine flow between broilers fed the unsupplemented diet and those fed the enzyme-supplemented diet. Overall, enzyme supplementation with an enzyme blend containing alpha-amylase, beta-glucanase, and xylanase increased the AME content of a corn-soy broiler diet as well as apparent and true ileal amino acid digestibility for all amino acids, but had no effect on endogenous ileal lysine flow.
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Affiliation(s)
- S M Rutherfurd
- Institute of Food, Nutrition and Human Health, Palmerston North, New Zealand.
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Stone DH, Brewster DC, Kwolek CJ, Lamuraglia GM, Conrad MF, Chung TK, Cambria RP. Stent-graft versus open-surgical repair of the thoracic aorta: Mid-term results. J Vasc Surg 2006; 44:1188-97. [PMID: 17145420 DOI: 10.1016/j.jvs.2006.08.005] [Citation(s) in RCA: 229] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2006] [Accepted: 08/01/2006] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Pivotal and comparative trial data are emerging for stent graft (SG) vs open repair of the thoracic aorta. We reviewed procedure-related perioperative morbidity, mortality, and mid-term outcomes in a contemporary series of patients treated with SG of the thoracic aorta. The data were compared with those of a patient cohort concurrently treated with open surgical repair confined to the descending aorta. METHODS A review of patients undergoing SG procedures and open surgery of the thoracic aorta from January 1, 1996, to November 30, 2005, was performed from a prospectively compiled database. Study end points included perioperative complications, late survival, freedom from reinterventions, and graft-related complications. Multivariate methods were used to assess variables potentially associated with study end points; late outcomes were compared with actuarial methods. RESULTS In 105 patients (mean age, 70 years; 66 male [62.9%]) SG repairs were done for 68 degenerative aneurysms (64.7%), 12 penetrating ulcers (11.4%), 15 pseudoaneurysms (14.3%), 9 traumatic tears (8.6%), and 1 acute dissection (0.9%). Mean follow-up was 22 months (range, 0 to 101 months). Eighty-nine (84.8%) SG patients were asymptomatic at presentation and underwent elective repair, whereas 16 (15.2%) presented with acute conditions and underwent urgent repair. Perioperative mortality was 7.6% (8/105), and actuarial survival at 48 months was 54% +/- 7%. The perioperative mortality rate among SG patients treated for degenerative pathology was 10.4% (8/77). Seven (6.7%) of 105 patients experienced spinal cord ischemic complications, including 2 patients with transient paraparesis that resolved by the time of discharge. Reinterventions were performed in 10.5% of patients (11/105), with freedom from reintervention approaching 81% by 48 months. Over the same interval, 93 patients were treated with open-surgical repair for descending thoracic aneurysm (anastomosis cephalad to the celiac axis). Perioperative mortality in the open cohort was 15.1% (14/93; P = .09 vs SG repair), and the 48-month actuarial survival was 64% +/- 6%. The incidence of spinal cord ischemic complications was 8.6% (8/93), including 4 patients with transient paraparesis (P = .44 vs SG repair). Nine patients (9.7%) required surgical reintervention during the follow-up period, with 48-month freedom from reintervention approaching 79% (P = .73 vs SG repair). CONCLUSIONS Operative mortality was halved with SG, with similar late survival for both cohorts. Reinterventions were required at a nearly identical rate for open repair and SG, and both groups experienced similar rates of spinal cord ischemic complications.
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Affiliation(s)
- David H Stone
- Division of Vascular and Endovascular Surgery and the Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Brewster DC, Jones JE, Chung TK, Lamuraglia GM, Kwolek CJ, Watkins MT, Hodgman TM, Cambria RP. Long-term outcomes after endovascular abdominal aortic aneurysm repair: the first decade. Ann Surg 2006; 244:426-38. [PMID: 16926569 PMCID: PMC1856532 DOI: 10.1097/01.sla.0000234893.88045.dc] [Citation(s) in RCA: 225] [Impact Index Per Article: 12.5] [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: 11/27/2022]
Abstract
OBJECTIVE The proper role of endovascular abdominal aortic aneurysm repair (EVAR) remains controversial, largely due to uncertain late results. We reviewed a 12-year experience with EVAR to document late outcomes. METHODS During the interval January 7, 1994 through December 31, 2005, 873 patients underwent EVAR utilizing 10 different stent graft devices. Primary outcomes examined included operative mortality, aneurysm rupture, aneurysm-related mortality, open surgical conversion, and late survival rates. The incidence of endoleak, migration, aneurysm enlargement, and graft patency was also determined. Finally, the need for reintervention and success of such secondary procedures were evaluated. Kaplan-Meier and multivariate methodology were used for analysis. RESULTS Mean patient age was 75.7 years (range, 49-99 years); 81.4% were male. Mean follow-up was 27 months; 39.3% of patients had 2 or more major comorbidities, and 19.5% would be categorized as unfit for open repair. On an intent-to-treat basis, device deployment was successful in 99.3%. Thirty-day mortality was 1.8%. By Kaplan-Meier analysis, freedom from AAA rupture was 97.6% at 5 years and 94% at 9 years. Significant risk factors for late AAA rupture included female gender (odds ratio OR, 6.9; P = 0.004) and device-related endoleak (OR, 16.06; P = 0.009). Aneurysm-related death was avoided in 96.1% of patients, with the need for any reintervention (OR, 5.7 P = 0.006), family history of aneurysmal disease (OR, 9.5; P = 0.075), and renal insufficiency (OR, 7.1; P = 0.003) among its most important predictors. 87 (10%) patients required reintervention, with 92% of such procedures being catheter-based and a success rate of 84%. Significant predictors of reintervention included use of first-generation devices (OR, 1.2; P < 0.01) and late onset endoleak (OR, 64; P < 0.001). Current generation stent grafts correlated with significantly improved outcomes. Cumulative freedom from conversion to open repair was 93.3% at 5 through 9 years, with the need for prior reintervention (OR, 16.7; P = 0.001) its most important predictor. Cumulative survival was 52% at 5 years. CONCLUSIONS EVAR using contemporary devices is a safe, effective, and durable method to prevent AAA rupture and aneurysm-related death. Assuming suitable AAA anatomy, these data justify a broad application of EVAR across a wide spectrum of patients.
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Lai TKK, Wong WC, Chin ACW, Chan RYY, Huang HYH, Li ETH, Chu WS, Chung TK, Chan KL. Unusual bleeding gastric ulcer. Hong Kong Med J 2006; 12:398-9. [PMID: 17028364] [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: 05/12/2023] Open
Affiliation(s)
- T K K Lai
- Department of Radiology, Tseung Kwan O Hospital, Tseung Kwan O, Hong Kong.
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Conrad MF, Cambria RP, Stone DH, Brewster DC, Kwolek CJ, Watkins MT, Chung TK, LaMuraglia GM. Intermediate results of percutaneous endovascular therapy of femoropopliteal occlusive disease: A contemporary series. J Vasc Surg 2006; 44:762-9. [PMID: 17012001 DOI: 10.1016/j.jvs.2006.06.025] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2005] [Accepted: 06/25/2006] [Indexed: 11/27/2022]
Abstract
BACKGROUND Percutaneous endovascular therapy is becoming a primary option for managing infrainguinal occlusive disease. This study examined the results of femoropopliteal percutaneous transluminal angioplasty (PTA) with intermediate (mean, 24 months) follow-up in a contemporary series of patients presenting with critical limb ischemia or claudication. METHODS Femoropopliteal PTA was performed on 238 consecutive limbs (208 patients) from January 2002 to July 2004. Study end points, including primary patency, assisted patency, and limb salvage (Society of Vascular Surgery reporting standards), were assessed by Kaplan-Meier life-table analysis, and factors predictive of hemodynamic or clinical failure, or both, were evaluated by univariate and multivariate methods. RESULTS Clinical and demographic features included a mean age, 72 years; male (62%); critical limb ischemia (46%); diabetes mellitus (49%); and renal insufficiency (creatinine >or= 1.5 mg/dL) (29%). Lesions were classified as TransAtlantic Inter-Society Consensus (TASC) A (11%), B (43%), C (41%), and D (5%). PTA was confined to the femoropopliteal segment in 77 patients (33%), and 161 (67%) underwent concurrent interventions in other anatomic locations. Femoropopliteal interventions included angioplasty only in 183 (78%), and the remaining 53 (22%) received at least one stent. Technical success was achieved in 97% of patients, with no deaths and a major morbidity rate of 3%. The 36-month actuarial primary patency was 54.3%, and assisted patency was 92.6% (37 peripheral reinterventions), resulting in a limb preservation rate of 95.4% in all patients regardless of clinical presentation. Interval conversion to bypass surgery occurred in 19 patients (8%). Comparison between critical limb ischemia and claudication revealed a primary patency of 40.8% vs 64.8%, assisted patency of 93.8% vs 92.6%, and limb salvage of 89.7% vs 100%, respectively. Negative predictors of primary patency determined by multivariate analysis included history of congestive heart failure (P = .02) and TASC C/D (P = .02). However, further evaluation of TASC C/D vs A/B revealed an assisted patency of 89.7% vs 94.3% (P = .37) and limb salvage of 94.3% vs 96.4% (P = .58). CONCLUSIONS Femoropopliteal PTA can be performed with a low perioperative morbidity and mortality. Intermediate primary patency is directly related to TASC classification. Although secondary intervention is often necessary to maintain patency in TASC C/D lesions, these data suggest that it would be appropriate to use PTA as initial therapy for chronic femoropopliteal occlusive disease regardless of clinical classification at presentation or TASC category of lesion severity.
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Affiliation(s)
- Mark Frederick Conrad
- Division of Vascular and Endovascular Surgery of the General Surgical Services, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Abstract
The future success of the translational research spectrum depends on the clinical research enterprise's ability to break through the barriers that constrain its productivity. As more basic science discoveries emerge, our ability to effectively translate this knowledge into improved patient care rests squarely on the manner in which we answer clinical questions. Informatics--the science of effective information use--is poised to help advance the conduct of science. However, incorporating informatics into the enterprise comes with its own set of challenges. To harness the benefits of improved information use, it is important to first establish how information flows within research. A thoughtful implementation of informatics--one that factors in social and organizational nuances--will undoubtedly lead to a more efficient and effective clinical research enterprise.
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Affiliation(s)
- Thomas K Chung
- Department of Biomedical Informatics, Columbia University, College of Physicians and Surgeons, New York, NY 10032, USA
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Lai TKK, Huang HYH, Chan RYY, Chin ACW, Wong WC, Sit CY, Chan LK, Chung TK, Chu WS, Lo CF, Ng TW. Magnetic resonance venogram of intravenous leiomyomatosis. Hong Kong Med J 2005; 11:524-6. [PMID: 16340033] [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: 05/05/2023] Open
Affiliation(s)
- T K K Lai
- Department of Radiology, Tseung Kwan O Hospital, Hong Kong
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Rutherfurd SM, Chung TK, Morel PCH, Moughan PJ. Effect of microbial phytase on ileal digestibility of phytate phosphorus, total phosphorus, and amino acids in a low-phosphorus diet for broilers. Poult Sci 2004; 83:61-8. [PMID: 14761085 DOI: 10.1093/ps/83.1.61] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [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: 11/12/2022] Open
Abstract
The study aimed to assess the effect of a commercially available microbial phytase added to a corn-soybean meal diet on phytate P and total P in terminal ileal digesta as well as on true ileal amino acid digestibility. Three low-P diets containing 0, 500, or 750 U/kg of microbial phytase were fed to 21-d-old broiler chickens. Titanium dioxide was used as an indigestible marker. Ileal contents were collected from euthanized birds and analyzed, along with the diets, for total P, phytate P, and amino acids. Endogenous P determined at the terminal ileum was 446 +/- 59 mg/kg food dry matter (mean +/- SE). Endogenous ileal amino acids ranged from 219 +/- 33 mg/kg food dry matter for tryptophan to 1,255 +/- 166 mg/kg food dry matter for glutamic acid. Supplementation with microbial phytase resulted in a significantly (P < or = 0.05) greater phytate P disappearance (11% greater disappearance vs. unsupplemented control) from the terminal ileum. Similarly, true ileal total P digestibility was (P < or = 0.05) higher (10 to 12%) when microbial phytase was added. True ileal amino acid digestibility was significantly (P < or = 0.05) greater in the presence of microbial phytase for all the amino acids examined with the exception of methionine, tyrosine, histidine, and tryptophan. The mean increase in true ileal amino acid digestibility was 3.4%. The effect of phytase on true ileal phytate P, total P, and amino acid digestibility was similar for the 2 phytase inclusion levels tested. Microbial phytase improved phytate P and total P digestibility, as well as true ileal amino acid digestibility, for a corn-soybean diet.
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Affiliation(s)
- S M Rutherfurd
- Institute of Food, Nutrition and Human Health, Massey University, Palmerston North, New Zealand 5301.
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Abstract
1. The study aimed to assess the effect of a commercially available microbial phytase on phytate phosphorus and total phosphorus content at the terminal ileum as well as true ileal amino acid digestibility. 2. Five diets, each containing a different plant-based feedstuff, were supplemented with microbial phytase and fed, along with a non-supplemented corresponding diet, to 28-d-old broiler chickens, Chromic oxide was used as an indigestible marker. Ileal contents were collected and analysed, along with the diets, for total phosphorus, phytate phosphorus and amino acids. 3. Endogenous phosphorus determined at the terminal ileum was 272 +/- 108 mg/kg food dry matter (mean +/- SE). Endogenous ileal amino acid flows ranged from 58 +/- 10 mg/kg food dry matter for methionine to 568 +/- 47 mg/kg food dry matter for glutamic acid. 4. Supplementation with microbial phytase resulted in a significantly greater phytate P disappearance from the terminal ileum for rice bran (17% units), but not for soyabean meal, maize, wheat or rapeseed meal. Similarly total phosphorus digestibility was significantly (P < 0.05) higher when microbial phytase was added to the rice-bran-based diet but not for any of the other feedstuffs. 5. Amino acid digestibility was significantly greater in the presence of microbial phytase for all the amino acids examined in wheat, for several of the amino acids each in maize and rapeseed meal and for one amino acid in rice bran and soyabean meal. The average increase in amino acid digestibility for those amino acids affected, was 13, 6, 10, 7 and 12% units for wheat, maize, rapeseed meal, rice bran and soyabean meal, respectively. 6. It appears that microbial phytase improves phosphorus digestibility and amino acid digestibility for certain plant-based feedstuffs.
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Affiliation(s)
- S M Rutherfurd
- Institute of Food, Nutrition and Human Health, Massey University, Palmerston North, New Zealand
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Chung TK, Cheung TH, Wang VW, Yu MY, Wong YF. Microsatellite instability, expression of hMSH2 and hMLH1 and HPV infection in cervical cancer and their clinico-pathological association. Gynecol Obstet Invest 2002; 52:98-103. [PMID: 11586036 DOI: 10.1159/000052951] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [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: 01/12/2023]
Abstract
Infection with specific genotypes of human papillomavirus (HPV) has been strongly implicated in cervical carcinogenesis. However, HPV infection alone is insufficient for malignant transformation of the cervical epithelium. An alteration of microsatellite repeats is the result of slippage owing to strand misalignment during DNA replication and is referred to as microsatellite instability (MSI). These defects in DNA repair pathways have been related to human carcinogenesis; however, the role of MSI in the tumorigenesis of cervical cancer remains unclear. The clinical and pathological features of cervical cancers which are MSI-positive have also not been fully characterized. This study investigated the prevalence of MSI in cervical cancer and its relationship to clinico-pathological characteristics and HPV infection. Polymerase chain reaction-based microsatellite assay combined with tissue microdissection was used to examine for MSI in 50 cervical squamous cell carcinomas in Hong Kong women. In addition, the immunohistochemical staining was performed to determine the expression of major DNA mismatch repair genes, hMSH2 and hMLH1. Six cases (12%) displayed a low frequency of MSI (MSL-L) showing MSI at one locus only in 5 loci examined. Seven cases (14%) showed a high frequency of MSI (MSI-H) having MSI at 2 or more loci. Grouping MSI-L and MSI-H cases together as MSI-positive, statistical analysis of HPV infection, tumor grade, clinical stage and clinical status failed to disclose differences between MSI-positive and MSI-negative cases (p > 0.05). However, MSI-H correlated with advanced stage of disease (p < 0.05). Individuals with MSI-H tumors appeared to have reduced overall survival compared to individuals with MSI-L and MSI-negative tumors, but the difference was not statistically significant (p = 0.059). An absence of either MSH2 or MLH1 expression was observed in 2 MSI-L and 4 MSI-H cases, respectively. The results suggest that MSI is present in a subgroup of cervical squamous cell carcinomas, and defects resulting in MSI may be related to tumor progression and possibly poor prognosis in cervical cancer.
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Affiliation(s)
- T K Chung
- Department of Obstetrics and Gynaecology, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong
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Abstract
BACKGROUND A prospective randomized controlled trial was conducted to compare the efficacy and side-effects of vaginal versus oral misoprostol in the medical management of incomplete miscarriage. METHODS Two hundred and one patients who miscarried consented to randomization using computer-generated randomization model prior to treatment. A total of 800 microg of misoprostol was given either vaginally or orally to the randomized subjects. A second dose was repeated 4 h later if the product of conception had not been passed. RESULTS The incidence of complete uterine evacuation following vaginal and oral misoprostol was similar [(58/95) 61.1% versus (67/103) 64.4%]. There was a significantly decreased incidence of diarrhoea [(12/95) 13.6% versus (62/103) 65.3%, P < 0.01] with the use of vaginal misoprostol. CONCLUSIONS Vaginal misoprostol was as effective as oral misoprostol in medical uterine evacuation in patients with incomplete miscarriage. There was also a reduction in the incidence of diarrhoea with the use of vaginal misoprostol.
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Affiliation(s)
- M W Pang
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR.
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Abstract
An immuno-histochemical study of p21 and p27 expression in cervical carcinoma was performed in 73 patients. Positive p21 and p27 staining was detected in 35.6 and 11% of tumour tissues, respectively. p21 expression was significantly correlated with advanced disease stage and negative human papilloma virus infection whilst positive p27 staining was not correlated with any clinical and pathological parameters studied. Kaplan-Meier estimation indicated that survival might be related to disease stage, tumour grade and p21 expression. Cox regression analysis confirmed that advanced stage disease and poorly differentiated tumour are independent prognostic factors for cervical carcinoma.
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Affiliation(s)
- T H Cheung
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, People's Republic of China.
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Lee DT, Cheung LP, Haines CJ, Chan KP, Chung TK. A comparison of the psychologic impact and client satisfaction of surgical treatment with medical treatment of spontaneous abortion: a randomized controlled trial. Am J Obstet Gynecol 2001; 185:953-8. [PMID: 11641684 DOI: 10.1067/mob.2001.117661] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [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: 01/18/2023]
Abstract
OBJECTIVE The purpose of this study was to compare the psychologic impact and client satisfaction of routine surgical evacuation of the uterus with medical evacuation in cases of spontaneous abortion. STUDY DESIGN This was a prospective, randomized controlled trial. Two hundred eighteen women who were admitted to a university teaching hospital after spontaneous abortion and who consented to the study were randomized to routine surgical evacuation or medical evacuation of the uterus with the use of misoprostol. General psychologic well-being, level of depression, fatigue symptoms, psychiatric morbidity, social functioning, client satisfaction, and acceptance were measured in the 2 groups. RESULTS The 2 groups did not differ in any of the measured psychological outcomes. Significantly more participants who experienced successful evacuation of the uterus with the misoprostol protocol would choose the same mode of treatment if they were able to choose again. However, participants for whom the medical treatment failed to evacuate the uterus and subsequent surgical evacuation was required are significantly less satisfied with the treatment. CONCLUSION Medical treatment of spontaneous abortion with misoprostol is psychologically safe and more compatible with the ethnomedical beliefs of our Chinese participants. Client satisfaction and acceptance should be taken into consideration in the evaluation of treatment outcomes.
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Affiliation(s)
- D T Lee
- Department of Psychiatry, the Chinese University of Hong Kong, NT, Hong Kong, China.
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Abstract
OBJECTIVES To assess 5-year compliance with hormone replacement therapy (HRT) in Hong Kong Chinese women and the reasons for long-term compliance or non-compliance. METHODS A telephone survey using a standardized questionnaire was conducted in 187 postmenopausal women who had commenced HRT in a referral-only specialist clinic of a university teaching hospital 5 years previously. Over this 5-year period, the cohort had been referred out to primary care doctors once they had become stabilized on treatment. RESULTS The 5-year compliance rate was 71.1%. The overall compliance rates were nearly the same from 2 and 5 years. 'Doctors' advice' was the most important reason for maintenance of long-term compliance, accounting for 88.0% of all compliant cases. The most frequent reason for non-compliance was that of the experience of side effects. Other important reasons were fear of cancer, fear of other side effects, and discouragement from other doctors. Overall, 16.0% of women expressed concern regarding potential side effects or risk of breast cancer. Younger age at menopause and at time of initial consultation, shorter duration of menopause at presentation and previous history of hysterectomy were associated with a higher degree of compliance at 5 years. Presence or absence of menopausal symptoms, on the other hand, was not a significant factor. CONCLUSIONS The 5-year compliance rate in this cohort of Hong Kong Chinese women was comparable to that reported from predominantly Caucasian populations. The physicians' role in encouraging postmenopausal women to achieve long-term HRT compliance was observed.
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Affiliation(s)
- T N Leung
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, Shatin, Hong Kong.
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Abstract
OBJECTIVE The purpose of this study was to examine if depressive symptomatology in pregnancy is associated with adverse obstetric and neonatal outcomes. METHOD In a prospective observational study, 959 women were followed up longitudinally from early pregnancy to postpartum. The level of depression was measured at baseline (first antepartum visit) and in late pregnancy using the Beck Depression Inventory (BDI). Adverse obstetric and neonatal outcomes were recorded at delivery. RESULTS Depression in late pregnancy was associated with increased risk of epidural analgesia (33% vs. 19%, p =.01, adjusted RR = 2.56, 95% CI 1.24-5.30), operative deliveries (caesarean sections and instrumental vaginal deliveries) (39% vs. 27%, p =.02, adjusted RR = 2.28, 95% CI 1.15-4.53), and admission to neonatal care unit (24% vs. 19%, p =.03, adjusted RR = 2.18, 95% CI 1.02-4.66). These effects remained significant even when controlled for potential confounders, such as antepartum complications. CONCLUSION Previous studies have shown that antepartum anxiety or stress was associated with growth retardation, premature delivery, and epidural analgesia. Our findings add to this body of evidence, which together suggest an adverse impact of antepartum psychological morbidity on maternal and neonatal well-being.
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Affiliation(s)
- T K Chung
- Department of Obstetrics and Gynaecology, The Chinese University of Hong Kong, Prince of Wales Hospital, Sha Tin, NT, Hong Kong.
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