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Ascending aortic pseudoaneurysms (AO PSAs), if left untreated, are complicated by a high rate of rupture resulting in significant morbidity and mortality. New transcatheter modalities have emerged as acceptable surgical alternatives for their management. We present a case of an ascending aortic PSA in which intraoperative two- and three-dimensional transesophageal echocardiography (2DTEE and 3DTEE) provided a comprehensive assessment of the PSA in pre- and postclosure settings.
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Aneurisma Falso/diagnóstico por imagen , Aneurisma Falso/cirugía , Aorta/diagnóstico por imagen , Aorta/cirugía , Ecocardiografía Tridimensional/métodos , Ecocardiografía Transesofágica/métodos , Anciano , Humanos , Masculino , Resultado del TratamientoRESUMEN
INTRODUCTION: Dobutamine stress echocardiography (DSE) has come a long way as establishing itself as a feasible, safe, effective, relatively cheaper non-invasive technique to detect population suffering from coronary artery disease (CAD) and following up patients post revascuralization. Besides these DSE is commonly used to diagnose low gradient, low flow true severe aortic stenosis (AS); differentiating it from pseudo- AS and to follow up patients with dilated cardiomyopathy (DCMP). Various non-invasive techniques have different sensitivity and specificity to accurately judge a viable myocardium and to accurately detect the improvement in regional wall motion abnormality (RWMA) post-revascularization, leading to an overall increase in left ventricular ejection fraction (LVEF). The comparison of various modalities, role of DSE in intermediate coronary lesions (75%) and other important uses and controversies surrounding DSE are discussed; suggesting the incremental value of DSE as a indispensable and versatile a diagnostic technique.
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Estenosis de la Válvula Aórtica/diagnóstico por imagen , Cardiomiopatías/diagnóstico por imagen , Cardiotónicos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Dobutamina , Revascularización Miocárdica , Ecocardiografía de Estrés , Contracción Miocárdica/fisiologíaRESUMEN
Cardiopulmonary interactions or effects of spontaneous and mechanical ventilation (MV) were first documented in the year 1733. Stephen Hales showed that the blood pressure of healthy individual fell during spontaneous inspiration and he later went on to discover the ventilator. A year later Kussmaul described pulsus paradoxus (inspiratory absence of radial pulse) in patients with tubercular pericarditis. Echocardiography can help to diagnose a wide variety of cardiovascular diseases and can guide therapeutic decisions in patients on mechanical ventilation.
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Ecocardiografía , Cardiopatías/diagnóstico por imagen , Cardiopatías/fisiopatología , Hemodinámica/fisiología , Respiración Artificial , Cardiopatías/complicaciones , HumanosRESUMEN
The name mycotic aneurysm was coined by Osler to describe aneurysms associated with bacterial endocarditis with an appearance of fresh fungal vegetations; however majority of them are caused by bacteria. Mycotic aneurysm (MA) is a rare complication of infective endocarditis (IE), seen in 3-15% of IE patients.
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Aneurisma Infectado/diagnóstico , Arteria Poplítea , Aneurisma Infectado/microbiología , Aneurisma Infectado/cirugía , Angiografía , Antibacterianos/uso terapéutico , Diagnóstico Diferencial , Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/diagnóstico , Endocarditis Bacteriana/microbiología , Humanos , Cuidados a Largo Plazo , Angiografía por Resonancia Magnética , Arteria Poplítea/microbiología , Arteria Poplítea/cirugía , Sensibilidad y Especificidad , Tomografía Computarizada por Rayos X , Ultrasonografía Doppler DúplexRESUMEN
Nearly all men with metastatic hormone-sensitive prostate cancer treated with intermittent androgen deprivation therapy (ADT) experience recurrence within 6 mo of testosterone recovery. We conducted a single-arm phase 2 trial to evaluate whether addition of dual androgen receptor pathway inhibitors (ARPIs) and metastasis-directed stereotactic body radiotherapy (SBRT) to intermittent ADT improves recurrence rates for men with between one and five nonvisceral, extrapelvic metastases on prostate-specific membrane antigen positron emission tomography/computed tomography after prior radical prostatectomy. Patients received 6 mo of androgen annihilation therapy (AAT; leuprolide, abiraterone acetate plus prednisone, and apalutamide) and metastasis-directed SBRT. The primary endpoint was the percentage of patients with prostate-specific antigen (PSA) <0.05 ng/ml 6 mo after testosterone recovery (≥150 ng/dl), with the study powered to detect an improvement from 1% to 12%. We enrolled 28 men between March 2021 and June 2022. Median follow-up was 20 mo (interquartile range 16-22). Twenty-six patients (93%) completed SBRT with 6 mo of hormone therapy, of whom six discontinued at least one ARPI; two patients withdrew prematurely. At 6 mo after testosterone recovery, PSA was maintained at <0.05 ng/ml in 13/26 patients (50%, 95% confidence interval 32-67%). Rates of grade 2 and 3 AAT toxicity were 21% and 21%. The results confirm that addition of metastasis-directed SBRT to highly potent systemic therapy can maintain low PSA after testosterone recovery, although further studies are needed to clarify the optimal systemic therapy regimen. PATIENT SUMMARY: We tested a combination of intensified hormone therapy (called androgen annihilation therapy) and radiotherapy targeted at metastases in men with recurrence of metastatic prostate cancer. We found that half of patients were recurrence-free 6 months after their testosterone level recovered, and that less than a quarter of patients experienced a severe drug-related side effect. Overall, this appears to be an effective therapy with acceptable side effects. This trial is registered on ClinicalTrials.gov as NCT03902951.
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Leuprolida , Recurrencia Local de Neoplasia , Neoplasias de la Próstata , Radiocirugia , Humanos , Masculino , Neoplasias de la Próstata/patología , Neoplasias de la Próstata/terapia , Anciano , Leuprolida/uso terapéutico , Persona de Mediana Edad , Acetato de Abiraterona/uso terapéutico , Tiohidantoínas/uso terapéutico , Prednisona/uso terapéutico , Prednisona/administración & dosificación , Antígeno Prostático Específico/sangre , Metástasis de la Neoplasia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Terapia Combinada , Antagonistas de Andrógenos/uso terapéutico , Resultado del Tratamiento , Antineoplásicos Hormonales/uso terapéuticoRESUMEN
Pseudoaneurysms at donor renal-external iliac artery anastomosis is rare, multifactorial and more often leads to transplant nephrectomy.The incidence of such false aneurysms is less than 1%. With a few series of case reports in literature, the management, aetiology and indications for repair always remain very controversial and debatable.
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Aneurisma Falso/diagnóstico , Aneurisma Falso/cirugía , Arteria Ilíaca , Trasplante de Riñón , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/cirugía , Adulto , Femenino , Humanos , Angiografía por Resonancia Magnética , Diálisis Renal , Ultrasonografía Doppler en ColorRESUMEN
BACKGROUND AND PURPOSE: We examined the interfractional variations of clinical target volumes (CTVs), planning target volumes (PTVs), and organs-at-risk (OARs) in patients receiving MRI-guided stereotactic body radiotherapy (SBRT) to the prostate bed and evaluated the potential role of adaptive planning. MATERIALS AND METHODS: 31 patients received 30-34 Gy in five fractions to the prostate bed on a phase II clinical trial. OARs, CTVs, and PTVs were retrospectively contoured on daily pretreatment MRIs (n = 155). Geometric comparisons were made between initial planning contours and daily pretreatment contours. Predicted treatment plans for each fraction were evaluated using the following constraints: CTV V95%>93%, PTV V95%>90%, bladder Dmax < 36.7 Gy, bladder V32.5 Gy < 35%, rectum Dmax < 36.7 Gy, rectum V27.5 Gy < 45%, rectum 32.5 Gy < 30%, and rectal wall V24Gy < 50%. Adaptive planning was simulated for all fractions that failed to meet these criteria. Plans were then re-evaluated. RESULTS: Median change in volume was 0.48% for CTV, -24.5% for bladder, and 6.95% for rectum. Median DSC was 0.89 for CTV, 0.79 for bladder, and 0.76 for rectum. 145/155 fractions (93.5%) met CTV V95%>93%. 75/155 fractions (48.4%) failed at least one OAR dose constraint. Overall, 83/155 fractions (53.5%) met criteria for adapting planning. This affected 24/31 patients (77.4%). Following adaptive planning, all fractions met CTV V95%>93% and PTV V95%>90% and 120/155 fractions (77.4%) met all OAR constraints. CONCLUSION: Due to significant interfractional variations in anatomy, a majority of fractions failed to meet both target volume and OAR constraints. However, adaptive planning was effective in overcoming these anatomic changes. Adaptive planning should be routinely considered in prostate bed SBRT.
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Neoplasias de la Próstata , Radiocirugia , Radioterapia Guiada por Imagen , Radioterapia de Intensidad Modulada , Masculino , Humanos , Próstata , Estudios Retrospectivos , Dosificación Radioterapéutica , Planificación de la Radioterapia Asistida por Computador , Prostatectomía , Imagen por Resonancia Magnética , Neoplasias de la Próstata/diagnóstico por imagen , Neoplasias de la Próstata/radioterapia , Neoplasias de la Próstata/cirugía , Órganos en RiesgoRESUMEN
Predictors of genitourinary toxicity after post-prostatectomy radiotherapy remain elusive. A previously defined germline DNA signature (PROSTOX) has shown predictive ability for late grade ≥ 2 GU toxicity after intact prostate stereotactic body radiotherapy. We explore whether PROSTOX would predict toxicity among patients receiving post-prostatectomy SBRT on a phase II clinical trial.
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PURPOSE: Postoperative radiation therapy (RT) is an underused standard-of-care intervention for patients with prostate cancer and recurrence/adverse pathologic features after radical prostatectomy. Although stereotactic body RT (SBRT) is a well-studied and convenient option for definitive treatment, data on the postprostatectomy setting are extremely limited. The purpose of this study was to evaluate short-term physician-scored genitourinary (GU) and gastrointestinal (GI) toxicities and patient-reported outcomes after postprostatectomy SBRT. METHODS AND MATERIALS: The SCIMITAR trial was a phase 2, dual-center, open-label, single-arm trial that enrolled patients with postoperative prostate-specific antigen >0.03 ng/mL or adverse pathologic features. Coprimary endpoints were 4-year biochemical recurrence-free survival, physician-scored acute and late GU and GI toxicities by the Common Terminology Criteria for Adverse Events (version 4.03) scale, and patient-reported quality-of-life (QOL) outcomes, as represented by the Expanded Prostate Cancer Index-26 and the International Prostate Symptom Score. Patients received SBRT 30 to 34 Gy/5 fractions to the prostate bed ± bed boost ± pelvic nodes with computed tomography (CTgRT) or magnetic resonance imaging guidance (MRgRT) in a nonrandomized fashion. Physician-scored toxicities and patient-reported QOL outcomes were collected at baseline and at 1, 3, and 6 months of follow-up. Univariable and multivariable analyses were performed to evaluate predictors of toxicities and QOL outcomes. RESULTS: One hundred participants were enrolled (CTgRT, n = 69; MRgRT, n = 31). The median follow-up was 29.5 months (CTgRT: 33.3 months, MRgRT: 22.6 months). The median (range) prostate bed dose was 32 (30-34) Gy. Acute and late grade 2 GU toxicities were both 9% while acute and late grade 2 GI toxicities were 5% and 0%, respectively. Three patients had grade 3 toxicity (n = 1 GU, n = 2 GI). No patient receiving MRgRT had grade 3 GU or grade ≥2 GI toxicity. Compared with CTgRT, MRgRT was associated with a 30.5% (95% confidence interval, 11.6%-49.5%) reduction in any-grade acute GI toxicity (P = .006). MRgRT was independently associated with improved any-grade GI toxicity and improved bowel QOL. CONCLUSIONS: Postprostatectomy SBRT was well tolerated at short-term follow-up. MRgRT may decrease GI toxicity. Longer toxicity and/or efficacy follow-up and randomized studies are needed.
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Enfermedades Gastrointestinales , Neoplasias de la Próstata , Radiocirugia , Radioterapia de Intensidad Modulada , Masculino , Humanos , Próstata/patología , Radiocirugia/efectos adversos , Radiocirugia/métodos , Calidad de Vida , Radioterapia de Intensidad Modulada/métodos , Prostatectomía/métodos , Neoplasias de la Próstata/radioterapia , Neoplasias de la Próstata/cirugía , Neoplasias de la Próstata/patología , Enfermedades Gastrointestinales/etiologíaRESUMEN
PURPOSE: To evaluate geometric variations of patients receiving stereotactic body radiotherapy (SBRT) after radical prostatectomy and the dosimetric benefits of stereotactic MRI guided adaptive radiotherapy (SMART) to compensate for these variations. MATERIALS/METHODS: The CTV and OAR were contoured on 55 MRI setup scans of 11 patients treated with an MR-LINAC and enrolled in a phase II trial of post-prostatectomy SBRT. All patients followed institutional bladder and rectum preparation protocols and received five fractions of 6-6.8 Gy to the prostate bed. Interfractional changes in volume were calculated and shape deformation was quantified by the Dice similar coefficient (DSC). Changes in CTV-V95%, bladder and rectum maximum dose, V32.5Gy and V27.5Gy were predicted by recalculating the initial plan on daily MRI. SMART was retrospectively simulated if the predicted dose exceeded pre-set criteria. RESULTS: The CTV volume and shape remained stable with a median volumetric change of 3.0% (IQR -3.0% to 11.5%) and DSC of 0.83 (IQR 0.79 to 0.88). Relatively large volumetric changes in bladder (median -24.5%, IQR -34.6% to 14.5%) and rectum (median 5.4%, IQR - 9.7% to 20.7%) were observed while shape changes were moderate (median DSC of 0.79 and 0.73, respectively). The median CTV-V95% was 98.4% (IQR 94.9% to 99.6%) for the predicted doses. However, SMART would have been deemed beneficial for 78.2% of the 55 fractions based on target undercoverage (16.4%), exceeding OAR constraints (50.9%), or both (10.9%). Simulated SMART improved the dosimetry and met dosimetric criteria in all fractions. Moderate correlations were observed between the CTV-V95% and target DSC (R2 = 0.73) and bladder mean dose versus volumetric changes (R2 = 0.61). CONCLUSIONS: Interfractional dosimetric variations resulting from anatomic deformation are commonly encountered with post-prostatectomy RT and can be mitigated with SMART.
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Síndrome Coronario Agudo/tratamiento farmacológico , Adenosina/análogos & derivados , Inhibidores de Agregación Plaquetaria/uso terapéutico , Clorhidrato de Prasugrel/uso terapéutico , Ticlopidina/análogos & derivados , Adenosina/uso terapéutico , Clopidogrel , Humanos , Ticagrelor , Ticlopidina/uso terapéutico , Resultado del TratamientoAsunto(s)
Aneurisma Falso/diagnóstico por imagen , Aorta/diagnóstico por imagen , Enfermedades de la Aorta/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Cardiopatías/diagnóstico por imagen , Fístula Vascular/diagnóstico por imagen , Adulto , Ecocardiografía , Atrios Cardíacos/diagnóstico por imagen , Humanos , Masculino , Tomografía Computarizada por Rayos XRESUMEN
Expression of carbonic-anhydrase IX (CAIX) in clear cell renal cell carcinoma (RCC) makes it an attractive vaccine target. We developed a fusion-gene construct, granulocyte-macrophage (GM) colony-stimulating factor+CAIX, delivered by an adenoviral vector (Ad) into autologous dendritic cells (DCs) in this phase 1 study. The injected immature DCs were expected to stimulate an antigen-specific immune response against CAIX expressing RCC. Three dose-escalation cohorts (5, 15, and 50×10 cells/administration) were injected intradermally q2wk×3 doses based on a 3+3 design. The primary objective was the safety of the injections. Secondary objectives were immune responses using enzyme-linked immunosorbent spot, a serum biomarker panel, and clinical response. Fifteen patients with metastatic RCC were enrolled, and 9 patients received all 3 doses. No serious adverse events were seen. There were 3 (33%) patients with grade 1 fatigue, 1 of whom subsequently experienced grade 2 fatigue. One patient (11%) experienced grade 1-2 leukopenia. Only 1 patient (11%) experienced grade 2 flu-like symptoms. Of the 9 patients who received treatment, 1 expired of progressive disease, 2 patients were lost to follow-up and 6 patients are alive. Of the 6 patients, 5 have progressive disease, and 1 has completed treatment with stable disease at 27 months follow-up. Immune response measurements appeared more robust in higher dose cohorts, which appeared to be related to patients with stable disease at 3 months. These early data show that autologous immature DC-AdGMCAIX can be safely given to metastatic RCC patients without any serious adverse events with CAIX-specific immune response elicited by the treatment. These preliminary data support further study of Ad-GMCAIX, particularly with combination therapies that may enhance clinical activity.
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Antígenos de Neoplasias/genética , Vacunas contra el Cáncer/administración & dosificación , Anhidrasa Carbónica IX/genética , Carcinoma de Células Renales/terapia , Células Dendríticas/inmunología , Factor Estimulante de Colonias de Granulocitos y Macrófagos/genética , Neoplasias Renales/terapia , Antígenos de Neoplasias/inmunología , Vacunas contra el Cáncer/efectos adversos , Vacunas contra el Cáncer/genética , Vacunas contra el Cáncer/metabolismo , Anhidrasa Carbónica IX/inmunología , Carcinoma de Células Renales/inmunología , Carcinoma de Células Renales/patología , Células Dendríticas/metabolismo , Manejo de la Enfermedad , Factor Estimulante de Colonias de Granulocitos y Macrófagos/metabolismo , Humanos , Inmunoterapia/efectos adversos , Inmunoterapia/métodos , Neoplasias Renales/inmunología , Neoplasias Renales/patología , Resultado del TratamientoRESUMEN
PURPOSE: This study aimed to evaluate the feasibility and safety of prostate stereotactic body radiation therapy (SBRT) neoadjuvant to radical prostatectomy (RP) in a phase 1 trial. The primary endpoint was treatment completion rate without severe acute surgical complications. Secondary endpoints included patient-reported quality of life and physician-reported toxicities. METHODS AND MATERIALS: Patients with nonmetastatic high-risk or locally advanced prostate cancer received 24 Gy in 3 fractions to the prostate and seminal vesicles over 5 days, completed 2 weeks before RP. Patients with pN1 disease were treated after multidisciplinary discussion and shared decision making. Patient-reported quality of life (International Prostate Symptom Score and Expanded Prostate Cancer Index Composite 26-item version questionnaires) and physician-reported toxicity (Common Terminology Criteria for Adverse Events, version 4.03) were assessed before SBRT, immediately before surgery, and at 3-month intervals for 1 year. RESULTS: Twelve patients were enrolled, and 11 completed treatment (1 patient had advanced disease on prostate-specific membrane antigen positron emission tomography after enrollment but before treatment). There were no significant surgical complications. After RP, 2 patients underwent additional radiation therapy to nodes with androgen suppression for pN1 disease. Median follow-up after completion of treatment was 20.1 months, with 9 of 11 patients having a follow-up period of >12 months. Two patients had biochemical recurrence (prostate-specific antigen ≥0.05) within the first 12 months, with an additional 2 patients found to have biochemical recurrence after the 12-month period. The highest Common Terminology Criteria for Adverse Events genitourinary grades were 0, 1, 2, and 3 (n = 1, 4, 4, and 2, respectively), and the highest gastrointestinal grades were 0, 1, and 2 (n = 9, 1, and 1, respectively). At 12 months, incontinence was the only grade ≥2 toxicity. One and 2 of 9 patients had grade 2 and 3 incontinence, respectively. On the Expanded Prostate Cancer Index Composite (26-item version), the mean/median changes in scores from baseline to 12 months were -32.8/-31.1 for urinary incontinence, -1.6/-6.2 for urinary irritative/obstructive, -2.1/0 for bowel, -34.4/-37.5 for sexual function, and -10.6/-2.5 for hormonal. The mean/median change in International Prostate Symptom Score from baseline to 12 months was 0.5/0.5. CONCLUSIONS: RP after neoadjuvant SBRT appears to be feasible and safe at the dose tested. The severity of urinary incontinence may be higher than RP alone.
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Terapia Neoadyuvante/métodos , Prostatectomía , Neoplasias de la Próstata/radioterapia , Neoplasias de la Próstata/cirugía , Radiocirugia , Estudios de Factibilidad , Estudios de Seguimiento , Humanos , Masculino , Próstata/efectos de la radiación , Neoplasias de la Próstata/patología , Calidad de Vida , Vesículas Seminales/efectos de la radiación , Incontinencia Urinaria/etiologíaRESUMEN
Patients presenting with pulmonary embolism (PE) have a wide spectrum of clinical severity. Although, some patients may present with frank hemodynamic collapse and cardiac arrest, others may present with asymptomatic PE that is discovered incidentally during work up of another condition. Fibrinolytic therapy is an option in the treatment of patients with PE. A rational approach to decide whether to indicate fibrinolytic therapy is based on assessment of benefits that each patient will derive from fibrinolytic therapy weighed against risk of major bleeding and intracranial hemmorage. There is a clear benefit/risk ratio for fibrinolytic therapy in patients with PE who present with cardiac arrest and in those who are hemodynamically unstable from a massive pulmonary embolism. With proper risk assessment selected patients with stable hemodynamics and right ventricular dysfunction may also benefit from fibrinolytic therapy. This article sets out to review the literature on tenecteplase in treatment of patients with PE.