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Acute Care Surgeons' Response to the COVID-19 Pandemic: Observations and Strategies From the Epicenter of the American Crisis

Klein, Michael J; Frangos, Spiros G; Krowsoski, Leandra; Tandon, Manish; Bukur, Marko; Parikh, Manish; Cohen, Steven M; Carter, Joseph; Link, Robert Nathan; Uppal, Amit; Pachter, Hersch Leon; Berry, Cherisse
PMID: 32675500
ISSN: 1528-1140
CID: 4574222

Viral oncoprotein antibodies as a marker for recurrence of Merkel cell carcinoma: A prospective validation study

Paulson, Kelly G; Lewis, Christopher W; Redman, Mary W; Simonson, William T; Lisberg, Aaron; Ritter, Deborah; Morishima, Chihiro; Hutchinson, Kathleen; Mudgistratova, Lola; Blom, Astrid; Iyer, Jayasri; Moshiri, Ata S; Tarabadkar, Erica S; Carter, Joseph J; Bhatia, Shailender; Kawasumi, Masaoki; Galloway, Denise A; Wener, Mark H; Nghiem, Paul
BACKGROUND:Merkel cell carcinoma (MCC) is an aggressive skin cancer with a recurrence rate of >40%. Of the 2000 MCC cases per year in the United States, most are caused by the Merkel cell polyomavirus (MCPyV). Antibodies to MCPyV oncoprotein (T-antigens) have been correlated with MCC tumor burden. The present study assesses the clinical utility of MCPyV-oncoprotein antibody titers for MCC prognostication and surveillance. METHODS:MCPyV-oncoprotein antibody detection was optimized in a clinical laboratory. A cohort of 219 patients with newly diagnosed MCC were followed prospectively (median follow-up, 1.9 years). Among the seropositive patients, antibody titer and disease status were serially tracked. RESULTS:Antibodies to MCPyV oncoproteins were rare among healthy individuals (1%) but were present in most patients with MCC (114 of 219 patients [52%]; P < .01). Seropositivity at diagnosis independently predicted decreased recurrence risk (hazard ratio, 0.58; P = .04) in multivariate analyses adjusted for age, sex, stage, and immunosuppression. After initial treatment, seropositive patients whose disease did not recur had rapidly falling titers that became negative by a median of 8.4 months. Among seropositive patients who underwent serial evaluation (71 patients; 282 time points), an increasing oncoprotein titer had a positive predictive value of 66% for clinically evident recurrence, whereas a decreasing titer had a negative predictive value of 97%. CONCLUSIONS:Determination of oncoprotein antibody titer assists in the clinical management of patients with newly diagnosed MCC by stratifying them into a higher risk seronegative cohort, in which radiologic imaging may play a more prominent role, and into a lower risk seropositive cohort, in which disease status can be tracked in part by oncoprotein antibody titer. Cancer 2017;123:1464-1474. © 2016 American Cancer Society.
PMID: 27925665
ISSN: 1097-0142
CID: 5386022

Exertional compartment syndrome of the thigh: A rare diagnosis and literature review

King TW; Lerman OZ; Carter JJ; Warren SM
Exercise-induced acute compartment syndrome of the thigh is an uncommon entity. We present a rare case of bilateral exercise-induced three-compartment syndrome of the thighs that required fasciotomies. The objective of this study was to understand the history, physical examination, signs, symptoms, pathophysiology, diagnosis, and treatment of compartment syndrome and rhabdomyolysis. A 42-year-old man presented to the Emergency Department (ED) complaining of worsening pain and swelling in both thighs 45 h after performing a lower extremity exercise regimen. The patient's thighs were tender and swollen, but there was no ecchymosis or evidence of trauma. Admitting serum creatinine kinase (CK) was 106,289 U/L. Treatment for rhabdomyolysis was initiated. The next day, he complained of escalating bilateral thigh pain. Repeat serum CK was 346,580 U/L. The patient was diagnosed with bilateral thigh compartment syndrome and immediately taken to the operating room for fasciotomies. Postoperatively, the patient's symptoms improved rapidly and his serum CK quickly returned to normal. His incisions were closed and he returned to normal activities of daily living. Because exercise-induced compartment syndrome is an extremely rare diagnosis with a high risk of poor outcome, this article serves to emphasize the importance of considering this diagnosis during the work-up of patients presenting to the ED with rhabdomyolysis
PMID: 18597970
ISSN: 0736-4679
CID: 79462

Intensive care unit tracheostomy: a snapshot of UK practice

Veenith, Tonny; Ganeshamoorthy, Sangeetha; Standley, Thomas; Carter, Joseph; Young, Peter
ABSTRACT: BACKGROUND AND METHODS: Tracheostomy is a common procedure in intensive care patient management. The aim of this study was to capture the practice of tracheostomy in Intensive Care Units in the United Kingdom. A postal survey was sent to the lead clinicians of 228 general intensive care units (ICUs) throughout the United Kingdom excluding specialist units. We aimed to identify the current practice of tracheostomy, including timing of insertion, equipment used and post-operative care and follow-up. RESULTS: A response rate of 86.84% was achieved. Percutaneous tracheostomy continues to be favoured over surgical tracheostomy with less than 8% of ICUs opting for surgical tracheostomies > 50% of the time. 89% of units required only 2 operators to perform the technique and single stage dilatation is the technique of choice in 83% of units. The Ciaglia technique, which was strongly favoured less than a decade ago, is currently practiced in less than 5% of ICUs. Bronchoscopic guidance is an important adjunct to the technique of percutaneous tracheostomy with 80% of units using it routinely. Follow-up care of patients remains poor with 59% of ICUs not having routine follow-up once the patient has left the unit. CONCLUSION: The practice of percutaneous tracheostomy remains the preferred technique within the UK. There seems to be a growing preference for single stage dilatational techniques. Timing of tracheostomy remains variable despite evidence to suggest benefit from an earlier procedure. Follow-up of tracheostomised patients after discharge from ICU is still low, which may mean significant morbidity from the procedure is being missed
PMID: 18950520
ISSN: 1755-7682
CID: 96135

The timing of surgery for cholecystitis: a review of 202 consecutive patients at a large municipal hospital

Lee, Ann Y; Carter, Joseph J; Hochberg, Mark S; Stone, Alex M; Cohen, Stuart L; Pachter, H Leon
BACKGROUND: Traditionally, cholecystectomy for cholecystitis is performed within 3 days of the onset of symptoms or after 5 weeks, allowing for resolution of the inflammatory response. This study reviewed the outcomes of cholecystectomy performed for patients with gallstone disease in the acute (n = 45), intermediate (n = 55), and delayed (n = 102) periods after the onset of symptoms. METHODS: The medical records of 202 patients who underwent laparoscopic cholecystectomy at a large municipal hospital were reviewed retrospectively. The primary outcomes studied were length of hospital stay, conversion to open cholecystectomy, and complications. RESULTS: There was no significant difference in the conversion rate (acute [18%] vs intermediate [20%] vs delayed [11%]) or complication rate (acute [16%] vs intermediate [9%] vs delayed [7%]) among the 3 groups. The delayed group had a significantly shorter length of hospital stay than the intermediate or acute group (3.1 +/- 3.8 vs 4.3 +/- 3.8 vs 1.7 +/- 2.1, respectively, P < .001). CONCLUSIONS: Patients who present with acute symptoms of cholecystitis should undergo surgery during the same admission, regardless of the duration of symptoms
PMID: 18361924
ISSN: 0002-9610
CID: 76770

Perioperative immunomodulation with Flt3 kinase ligand or a whole tumor cell vaccine is associated with a reduction in lung metastasis formation after laparotomy in mice

Carter, Joseph J; Feingold, Daniel L; Oh, Anthony; Kirman, Irena; Wildbrett, Peer; Stapleton, George; Asi, Zishan; Fowler, Ryan; Bhagat, Govind; Huang, Emina H; Fine, Robert L; Whelan, Richard L
INTRODUCTION: Laparotomy has been associated with temporary postoperative immunosuppression and accelerated tumor growth in experimental models. In a previous murine study, a whole cell vaccine plus the adjuvant monophosphoryl-lipid A was shown to be effective in decreasing the number of lung metastases that develop after laparotomy. This study was conducted to assess the impact of the adjuvant fetal liver tyrosine kinase 3 (Flt3) ligand on perioperative tumor growth when used alone or with a tumor cell vaccine. METHODS: An intravenous tumor cell injection lung metastases model was used. Sixty female A/J mice were divided into six equal groups designated (1) anesthesia control (AC), (2) AC with Flt3 ligand (ACFlt3), (3) sham laparotomy (OP), (4) OP with Flt3 ligand (OPFlt3), (5) OP with vaccine (OPVac), and (6) OP with Flt3 ligand and vaccine (OPFlt3Vac). Groups 2, 4, and 6 received daily intraperitoneal injections of Flt3 ligand (10 microg/dose with carrier) for 5 days before and 5 days after surgery. Groups 1 and 3 received similar injections of saline on the same schedule. Groups 5 and 6 were vaccinated with irradiated whole Ta3Ha tumor cells intraperitoneally three times before and twice after surgery. Immediately after surgery, all mice were injected with 10(5) Ta3Ha tumor cells via a tail vein. After 14 days, the mice were sacrificed and their lungs and tracheas were excised en bloc. Specimens were stained and counterstained with India ink and Fekete solution, and surface metastases were counted by a blinded observer. Differences between study groups were determined by analysis of variance. The peritumoral inflammatory cell infiltrate of some Flt3 and control specimens was also assessed. RESULTS: Regarding laparotomy, Flt3 ligand (mean, 1.22 metastases), whole cell vaccine (1.12 metastases), and the combination of these two agents (0.1 metastases) were each effective in significantly decreasing the number of surface lung metastases compared with surgery alone (9.88 metastases, P < .05 for all comparisons). There were no differences between the various treatment groups in regards to number of metastases. Only the combination of Flt3 and the vaccine significantly lowered the incidence of tumors (number of mice with > or =1 tumors). Histologic analysis revealed that the Flt3-treated mice demonstrated increased numbers of antigen-presenting cells surrounding the tumors compared with controls. CONCLUSIONS: Perioperative treatment with either Flt3 ligand or a whole cell tumor vaccine significantly reduced the number of lung metastases after laparotomy. The combination of the Flt3 ligand and the vaccine also decreased the incidence of metastases and was the most effective treatment. Further studies regarding perioperative immune modulation in the setting of cancer appear warranted
PMID: 16708154
ISSN: 1553-3506
CID: 96136

Significant reduction of laparotomy-associated lung metastases and subcutaneous tumors after perioperative immunomodulation with flt3 ligand in mice

Carter, Joseph J; Feingold, Daniel L; Wildbrett, Peer; Oh, Anthony; Kirman, Irena; Asi, Zishan; Stapleton, George; Huang, Emina; Fine, Robert L; Whelan, Richard L
Laparotomy has been associated with increased rates of tumor establishment and metastasis formation postoperatively in animal models. The purpose of this study was to determine the impact on postoperative tumor growth of perioperative upregulation of immune function via fetal liver tyrosine kinase 3 (Flt3 ligand). Two murine studies were carried out: the first utilized a lung metastases model, and the second involved a subcutaneous tumor model. Each study included four groups: anesthesia control (AC), AC plus Flt3 ligand (ACFlt3), sham laparotomy (OP), and OP plus Flt3 ligand (OPFlt3). Flt3 ligand was administered by daily intraperitoneal injection (10 mug/dose) beginning 5 days preoperatively and continuing for 1 week postoperatively. In study 1, A/J mice were given tail vein injections of 1.5 x 10(5) TA3Ha cancer cells on the day of surgery. The mice were sacrificed 14 days after surgery, the lungs processed, and the surface metastases counted by a blinded observer. In study 2 C3H/He mice were given a dorsal subcutaneous injection of 10(4) MC-2 cancer cells on the day of surgery. The mice were sacrificed 31 days after surgery, and the injection sites were evaluated for subcutaneous tumors grossly and histologically. In study 1, the median number of surface lung metastases per mouse was 166 in the OP group and 38 in the OPFlt3 (P = .021). Mice in the AC group developed a median 50 lung metastases per animal compared with mice in the ACFlt3 group who had a median of 10 metastases per mouse (P = .001). The OP group had significantly more metastases than the AC group (P = .048). In study 2, the percentage of animals that developed tumors in the AC, OP, ACFlt3, and OPFlt3 groups was 43, 80, 0, and 20, respectively. The incidence of tumors in the OPFLt3 group and the ACFlt3 group was significantly less than their respective control groups (P < .01). The difference between the OP and AC groups was not significant (P > .05). Perioperatively administered Flt3 ligand was associated with significantly fewer lung metastases and a lower incidence of subcutaneous tumor formation after laparotomy and anesthesia alone. Perioperative immunomodulation may limit untoward surgery-related oncologic effects
PMID: 16424952
ISSN: 1553-3506
CID: 96137

Management of complicated peptic ulcer disease [Letter]

Liang, Mike K; Marks, Jenifer L; Berman, Russell S; Carter, Joseph
PMID: 16172300
ISSN: 0004-0010
CID: 96138

Primary squamous cell carcinoma of the colon associated with hypercalcemia and hyperleukocytosis. Report of a case [Case Report]

Yitta, Silaja; Liang, Mike K; Berman, Russell; Carter, Joseph J; Yee, Herman T; Marks, Jenifer L
BACKGROUND/AIMS: Squamous cell carcinoma of the colon is a rare entity. We report a case of a patient who presented with a perforated squamous cell carcinoma of the sigmoid colon. RESULTS: A 45-year-old female presented with a 2-month history of worsening abdominal pain, bloody diarrhea, and vomiting. She underwent an exploratory laparotomy and was found to have keratinizing squamous cell carcinoma of the sigmoid colon that had perforated forming multiple abscess cavities. The postoperative course was complicated by hypercalcemia and persistent hyperleukocytosis, ultimately resulting in the patient's death. CONCLUSIONS: We present the second reported case of squamous cell carcinoma of the colon associated with hypercalcemia and the first reported case of associated hyperleukocytosis
PMID: 16424667
ISSN: 0253-4886
CID: 64455

Safety and reliability of tattooing colorectal neoplasms prior to laparoscopic resection

Feingold, Daniel L; Addona, Tommaso; Forde, Kenneth A; Arnell, Tracey D; Carter, Joseph J; Huang, Emina H; Whelan, Richard L
Accurate tumor localization is critical to performing minimally invasive colorectal resection. This study reviews the safety and reliability of tattooing colorectal neoplasms prior to laparoscopic resection. We retrospectively reviewed 50 consecutive patients with colorectal neoplasms who underwent endoscopic tattooing prior to laparoscopic resection. Data were obtained from medical charts, endoscopy records, and pathology reports. No complications related to endoscopy or tattooing were incurred. Five neoplasms (10%) were in the ascending colon, five (10%) were in the transverse colon, eight (16%) were in the descending colon, 23 (46%) were in the sigmoid colon, and nine (18%) were in the rectum. Tattoos were visualized intraoperatively and accurately localized the neoplasm in 44 patients (88%). Six patients (12%) did not have tattoos visualized laparoscopically and required intraoperative localization. On average, the pathology specimens in this series had a 15 cm proximal margin, a 12 cm distal margin, and 15 lymph nodes. In the context of laparoscopic colorectal resection, preoperative endoscopic tattooing is a safe and reliable method of tumor localization in most cases. Localizing colon and proximal rectal lesions with tattoos may be preferable to other localization techniques including intraoperative endoscopy
PMID: 15239988
ISSN: 1091-255x
CID: 96139