Baltimore, MD, United States
Baltimore, MD, United States

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Gharwan H.,Johns Hopkins Hospital | Yarlagadda L.,Saint Agnes Hospital | Duffy A.,U.S. National Cancer Institute
Case Reports in Oncology | Year: 2012

The propensity of colon cancer to metastasize to bones is very low compared to prostate, breast or lung cancer. The reason for this is not yet understood, although an explanation for the osteotropism of certain primaries has been offered by the 'seed and soil' concept, suggesting that the bone microenvironment provides a favorable 'soil' for metastasis and proliferation of some tumor cells ('seeds') [1]. Here, we report an unusual case of colon cancer with metastasis to the finger at initial presentation, and exophytic sclerotic lesions to other bones. The incidence of metastases to fingers/toes (acrometastases) is reported to be only 0.1%, even after including involvement of primary sites other than the colon. The etiology and characteristics of acrometastases are reviewed in this case report. Copyright © 2012 S. Karger AG, Basel.


Rothfield K.P.,Saint Agnes Hospital | Rothfield K.P.,University of Maryland, Baltimore | Crowley K.,Saint Agnes Hospital
Surgical Oncology Clinics of North America | Year: 2012

This article outlines the anesthetic management of patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy. This includes a discussion of preoperative evaluation, hemodynamic monitoring, fluid and electrolyte therapy, and temperature management. An understanding of the unique physiologic consequences of this procedure is essential to ensure good outcomes and avoid patient injuries. © 2012 Elsevier Inc.


Alderaan K.,Johns Hopkins University | Alderaan K.,King Fahad Specialist Hospital | Sekicki V.,Saint Agnes Hospital | Magder L.S.,University of Maryland, Baltimore | Petri M.,Johns Hopkins University
Rheumatology International | Year: 2015

Cataract is the most common ocular damage in systemic lupus erythematosus (SLE). We analyzed data from the Hopkins Lupus Cohort longitudinally to identify the factors that predict onset of cataract prior to 60 years of age. The Hopkins Lupus Cohort is a clinical cohort of patients with SLE seen quarterly. This analysis was based on the follow-up experience prior to age 60 of 2,109 SLE patients who had not had a cataract prior to cohort entry. Patients saw their ophthalmologist every 6 months. Cataract was defined by the SLICC/American College of Rheumatology Damage Index. The rate of incident cataract was calculated in subsets of the follow-up defined by patient characteristics and history. Multivariable logistic regression models were fit to identify predictors of cataract while controlling for potential confounding variables. The analysis was based on 11,887 persons-years of follow-up, with median follow-up time of 4.1 years per patient. The incidence of cataract was 13.2/1,000 persons-years. Adjusting for other predictors, a cumulative prednisone dose equivalent to 10 mg/day for 10 years was a strong predictor of cataract (RR = 2.9, P = 0.0010). Disease activity measured by SELENA–SLEDAI (P = 0.0004) and higher systolic blood pressure (P = 0.0003) were associated with cataract. Duration of SLE, diabetes mellitus, smoking, cholesterol, renal involvement, immunological profile and medication history other than prednisone were not associated with cataract. Cataract development in SLE patients is multifactorial with prednisone, systolic blood pressure and disease activity all playing a role. © 2014, Springer-Verlag Berlin Heidelberg.


Mackey R.V.,Saint Agnes Hospital | Kowdley G.C.,Saint Agnes Hospital
American Surgeon | Year: 2014

There is a paucity of clinical data available on specific treatment in the oncogeriatric population with breast cancer. The purpose of this study was to evaluate treatment patterns and survival outcomes in the elderly to address any disparities at our community hospital. We retrospectively identified a total of 1749 patients diagnosed and treated for breast cancer at our institution between 2001 and 2011. Patient demographics, surgical treatment, stage of disease, tumor characteristics, adjuvant therapy, and 5-year survival data were obtained from tumor registry records. Comparisons between study groups were made using the Pearson χ2 test and Student's t test. We found more favorable prognostic makers among women older than 70 years of age. Of the women with lymph node-positive disease, 84 per cent of those younger than 70 years and 33 per cent in the older than 70 years of age study group received chemotherapy. Adjuvant chemotherapy and radiation therapy were more frequently performed in the younger group. Overall 5-year survival was 90 per cent and 71 per cent for younger than 70 years and older than 70 years groups, respectively. Women older than 70 years of age have more favorable breast cancer characteristics compared with younger women and received less aggressive treatment and experienced a higher mortality rate. Prospective trials are needed to assess the impact of aggressive multimodality therapy in this oncogeriatric population. © 2014, Southeastern Surgical Congress. All rights reserved.


Cross W.,Saint Agnes Hospital | Kumar A.,Saint Agnes Hospital | Kowdley G.C.,Saint Agnes Hospital
American Surgeon | Year: 2014

Ventral hernia repair in contaminated fields is a significant problem for surgeons. We performed a systematic review regarding the use of biological mesh in contaminated fields for abdominal wall reconstruction. The primary end points were recurrence and infection of the hernia repair. An independent search of scientific papers in the English language was performed by three reviewers. Articles were chosen based on reference to ventral hernias, their use in infected fields, and in human subjects. Papers were scored using the Methodological Index for Non-Randomized Studies and those with a score of 8 or more were combined to evaluate the end points. A total of 16 studies from six different mesh products met our criteria. These papers comprised 554 patients with an overall infection rate of 24 per cent and a recurrence rate of 20 per cent. The largest study used 116 patients. All papers were case series. Overall the data for use of biological mesh products in contaminated fields are limited. Further controlled studies are needed to address this important and clinically relevant question. Caution should be used when using biological mesh products in infected fields because there is a paucity of controlled data and none have U.S. Food and Drug Administration approval for use in infected fields.


Ramirez S.I.,Saint Agnes Hospital | Scholle M.,Saint Agnes Hospital | Buckmaster J.,Saint Agnes Hospital | Paley R.H.,Saint Agnes Hospital | Kowdley G.C.,Saint Agnes Hospital
American Surgeon | Year: 2012

Paramount to staging and patient management is accurately measuring the size of invasive breast cancers. We assessed the accuracy of mammography (MG), ultrasonography (US), and magnetic resonance imaging (MRI) at our community-based hospital in which multiple radiologists and imaging machines are used in the care of our patients. We performed a retrospective analysis of a prospectively maintained database of 277 patients seen at our breast center from 2009 to 2010.We tabulated MG, US, and MRI-reported tumor sizes in 161 women with pathology-proven invasive breast cancer and compared the preoperative size measurements with final pathologic tumor size. In the 161 patients, 169 lesions were identified. Imaging using all three modalities was available in 47 patients. When compared with final pathology, MRI had a correlation of r = 0.75 to mean tumor size as compared with US (r = 0.67) and MG (r = 0.76). Mean tumor size was 1.90 cm by MG, 1.87 cm by US, 2.40 cm by MRI, and 2.19 cm by pathology. We were able to achieve an excellent correlation of pathologic tumor size to preoperative imaging. The absolute differences in size between the modalities were small. MRI, in select patients, added to the assessment of tumor size based on US and MG.


Nazarian A.,Saint Agnes Hospital | Cross W.,Saint Agnes Hospital | Kowdley G.C.,Saint Agnes Hospital
American Surgeon | Year: 2012

The significance of post percutaneous endoscopic gastrostomy (PEG) pneumoperitoneum (PNP) is unclear. We studied patients in our intensive car unit who underwent PEG placement to better understand the significance of post PEG PNP at our institution. We identified all intensive care unit patients who underwent PEG placement between the years of 2000 and 2009. A review of 318 consecutive PEG procedures was performed. Radiographic imaging was reviewed for up to 14 days post PEG, noting the presence of PNP. The presence of common comorbidities and PEG-related complications were recorded. Of the 318 patients, radiologic imaging was not taken within 14 days in 37 patients. Forty-five patients were found to have PNP on imaging for an incidence of 16 per cent (45/281). Eight patients were found to require either surgical or endoscopic emergent intervention post PEG. Four of these had PNP on imaging. Post PEG PNP was associated with increased likelihood for complications requiring emergent surgical intervention (P = 0.0078) and 30-day mortality post PEG insertion (P = 0.0216). The presence of common comorbid conditions was not a significant determinant of post PEG PNP.


Haddad A.,Saint Agnes Hospital | Tapazoglou N.,Saint Agnes Hospital | Singh K.,Saint Agnes Hospital | Averbach A.,Saint Agnes Hospital
Obesity Surgery | Year: 2012

Background: Anastomotic leaks and strictures of the gastrojejunostomy are a cause of major morbidity following laparoscopic Roux-en-Y gastric bypass (LRYGB). Reported rates of leaks vary between 0 and 5.2 %. This has led bariatric surgeons to use a variety of intraoperative methods to detect incompetent suture lines. The aim of the study was to evaluate the role of intraoperative endoscopy in reducing the rate of postoperative anastomotic complications. The setting of this study is in a community teaching hospital. Methods: Medical records of 2,311 patients who underwent a LRYGB from 2002 to 2011 were retrospectively reviewed utilizing the hospitals' bariatric surgery database. Demographics, weight, body mass index, intraoperative endoscopy results, and postoperative outcomes within 90 days after surgery were analyzed. Results: Endoscopy was attempted in 2,311 patients and completed in 2,308 (99.9 %). Intraoperative leak was detected in 80 (3.5 %) patients; suture line was reinforced in 46 patients (2 %), while in the other 34 patients the leak was transient at only high insufflation pressure. Postoperative clinical leaks were detected in four cases (0.2 %) two of which had initial leaks intraoperatively. In two cases, the anastomosis was too tight and required reconstruction. Twenty-five patients (1.1 %) developed early postoperative strictures requiring endoscopic dilatation within 90 days. Three patients (0.1 %) had iatrogenic injury at the time of intraoperative endoscopy, all three healed without delayed morbidity. Conclusions: The routine use of intraoperative endoscopy in LRYGB with the linear stapler anastomosis technique is associated with a complication/failure rate of 0.3 % and low gastrojejunostomy-related morbidity after LRYGB within 90 days (leak rate of 0.2 % and stricture rate of 1.1 %). © 2012 The Author(s).


Goussous N.,Saint Agnes Hospital | Kowdley G.C.,Saint Agnes Hospital | Sardana N.,Saint Agnes Hospital | Spiegler E.,Saint Agnes Hospital | Cunningham S.C.,Saint Agnes Hospital
Digestion | Year: 2014

Background: Motility disorders of the biliary tree [biliary dyskinesia, including both gallbladder dysfunction (GBD), and sphincter of Oddi dysfunction] are difficult to diagnose and to treat. Summary: There is controversy in the literature in particular regarding the criteria that should be used to select patients for cholecystectomy (CCY) in cases of suspected GBD. The current review covers the history, diagnosis, and treatment of GBD. Key Messages: Only >85% of patients with suspected GBD have relief following CCY, a much lower rate than the nearly 100% success rate following CCY for gallstone disease. Unfortunately, the literature is lacking, and there are no universally agreed-upon criteria for selecting which patients to refer for operation, although cholecystokinin (CCK)-enhanced hepatobiliary iminodiacetic acid scan is often used, with emphasis on an abnormally low gallbladder ejection fraction or pain reproduction at CCK administration. There is a clear need for large, well-designed, more definitive, prospective studies to better identify the indications for and efficacy of CCY in cases of GBD. © 2014 S. Karger AG, Basel.


Miller A.,Saint Agnes Hospital | Kowdley G.C.,Saint Agnes Hospital
American Surgeon | Year: 2012

Reconstruction after mastectomy is an elective procedure. To date many factors have been associated with the choice of operation in these patients including socioeconomic status, insurance, age, comorbidities, and community factors. In an effort to understand the characteristics of patients who undergo reconstruction at our hospital, we performed a retrospective review of patients who received mastectomy at our institution. A total of 354 patients underwent mastectomy from 2006 to 2010 at our hospital. Data from 332 patients undergoing reconstruction within 1 year of mastectomy were then analyzed and χ2 analysis was performed to identify factors significant in the choice of reconstruction. Age younger than 50 years (odds ratio [OR], 3.87), age older than 70 years (OR, 0.09), presence of insurance (OR, 2.89), diabetes (OR, 0.401), hypertension (OR, 0.379), and Medicare (0.182) were found to be significant factors associated with a choice of reconstruction among our patients. When age was corrected for, insurance status was no longer a significant factor in choice of reconstruction. Over 90 per cent of patients underwent implant or tissue expanders for reconstruction. This study reflects the reconstruction choices of patients in our community, city-based hospital. Copyright Southeastern Surgical Congress. All rights reserved.

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