Thirty-one [31] patients with local recurrent or residual adenocarcinoma of the prostate, with no evidence of distant metastases, were treated with second permanent implant using a stereotactic three dimensional system and posterior pararectal CT-guided method. All patients had extensive under local anesthesia or IV sedation pararectal CT-guided biopsy of the prostate and seminal vesicles. All patients except one had 3 month neoadjuvant androgen ablation prior to salvage reimplantation. Twenty [20] of these patients had local recurrence in the prostate and eleven [11] patients had seminal vesicle invasion which was not diagnosed nor treated with the initial brachytherapy. In addition, the patients had PSA failure or local palpable disease, "cold spots" with CT imaging or areas of dosage less than 80% of the prescribed dose with DVH (dose volume histogram). Initial prescribed dose was 120 Gy with (103)Pd loose seeds in 26 patients and 144 Gy with (125)I loose seeds in 5 patients. For the reimplant the dosage in the recurrent site was 100-144 Gy with (125)I seeds in strand in 24 patients (77%) and 100-120 Gy with (103)Pd loose seeds in 7 patients (23%). The preference of (125)I seeds in the second treatment was because only (125)I in strand was available at the time of the reimplant. Eleven [11] patients had second implant twelve to twenty-four months after the initial implant and 20 patients had after twenty-five to eighty-seven months and median follow-up was thirty months. A high level of biochemical control (87%) was achieved in all of these patients who are recognized as high risk due to local recurrence. Four [4] patients experienced grade 2 or 3 GI or GU complications and two [2] patients experienced grade 4 GI complications. Patients with local recurrent prostate cancer following initial brachytherapy including those with seminal vesicle invasion can be successfully treated with pararectal stereotactic CT-guided reimplantation. Assessment of seminal vesicle status is an essential part of staging for local recurrence.
Background:
Coronary angiography to identify coronary artery disease has been foundational to distinguish the cause of dilated cardiomyopathy (DCM), including the assignment of idiopathic or ischemic cardiomyopathy. Late gadolinium enhancement (LGE) with cardiovascular magnetic resonance (CMR) has emerged as an approach to identify myocardial scar and identify etiology.
Methods:
The DCM Precision Medicine Study included patients with left ventricular dilation and dysfunction attributed to idiopathic DCM, after expert clinical review excluded ischemic or other cardiomyopathies. Ischemic cardiomyopathy was defined as coronary artery disease with >50% narrowing at angiography of ≥1 epicardial coronary artery. CMR was not required for study inclusion, but in a post hoc analysis of available CMR reports, patterns of LGE were classified as (1) no LGE, (2) ischemic-pattern LGE: subendocardial/transmural, (3) nonischemic LGE: midmyocardial/epicardial.
Results:
Of 1204 idiopathic DCM patients evaluated, 396 (32.9%) had a prior CMR study; of these, 327 (82.6% of 396) had LGE imaging (mean age 46 years; 53.2% male; 55.4% White); 178 of the 327 (54.4%) exhibited LGE, and 156 of the 178 had LGE consistent with idiopathic DCM. The remaining 22 had transmural or subendocardial LGE. Of these 22, coronary angiography was normal (13), showed luminal irregularities (3), a distant thrombus (1), coronary artery disease with <50% coronary artery narrowing (1), or was not available (4).
Conclusions:
Of 327 probands enrolled in the DCM Precision Medicine Study cohort who had LGE-CMR data available, an ischemic-pattern of LGE was identified in 22 (6.7%), all of whom had idiopathic DCM as adjudicated by expert clinical review.
REGISTRATION:
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT03037632.
Background:
Electronic Health Records (EHRs) and other databases are increasingly used to identify patients with clinical conditions such as heart failure (HF). This process, called phenotyping, has a number of uses including in quality improvement measurement, observational studies, and targeted disease management interventions. To date, patients with HF have largely been identified through diagnosis codes; however, this approach has limitations in sensitivity and positive predictive value (PPV). We hypothesized that we could improve phenotyping of hospitalized patients with HF through use of three readily accessible EHR variables.
Methods:
We conducted a cohort study of all hospitalizations at NYU Medical Center for patients age≥18 in 2012-2014. Hospitalizations were categorized into eight mutually exclusive groups based on the presence or absence of three characteristics: discharge diagnosis of HF, an echocardiogram performed, and loop diuretic administered. To maintain simplicity, we did not use echocardiogram results which are in free text. We randomly sampled a minimum number of charts from each group and performed physician chart review for diagnosis of HF based on the Atherosclerosis Risk in Communities (ARIC) Study criteria. We used a set theory approach to calculate performance characteristics for pre-specified combinations of groups. We calculated variances using the delta method and compared algorithms using Z tests.
Results:
We included 41,349 hospitalizations in the study. Of 315 that were sampled for chart review, 47% (148 of 315) were adjudicated as having acute or chronic HF. Using this gold standard, we found that a discharge diagnosis of HF had a sensitivity of 71.4% and PPV of 92.2% (Table). The presence of at least one of the three characteristics was associated with a sensitivity of 95.9% but PPV of 37.4% (p<0.001 for both when compared to discharge diagnosis only).
Conclusions:
We found a discharge diagnosis code for HF was associated with moderate sensitivity and high PPV. Related algorithms improved sensitivity but had lower PPV. These findings suggest that more complex algorithms are needed to improve EHR-based HF phenotyping.
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