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Paul A Levine

Publications and source records attributed to Paul A Levine.

At least 19 recordsLinked to original sources
PubMed2006

Craniofacial resection for malignant melanoma of the skull base: report of an international collaborative study.

OBJECTIVE: To report postoperative mortality, complications, and outcomes in a subset of patients with the histologic diagnosis of malignant melanoma extracted from an existing database of a large cohort of patients accumulated from multiple institutions. DESIGN: Retrospective outcome analysis. SETTING: Seventeen international tertiary referral centers performing craniofacial surgery for malignant skull base tumors. PATIENTS: A total of 53 patients were identified from a database of 1307 patients who had craniofacial resection for malignant tumors at 17 institutions. The median age was 63 years. Of the 53 patients, 25 (47%) had had prior single modality or combined treatment, which included surgery in 22 (42%), radiation in 11 (21%), and chemotherapy in 2 (4%). The margins of resection were close or microscopically positive in 7 (13%). Adjuvant radiotherapy was given in 22 (42%), chemotherapy in 3 (6%), and vaccine or interferon therapy in 2 (4%). Complications were classified into overall, local, central nervous system, systemic, and orbital. Overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) were determined using the Kaplan-Meier method. Predictors of outcome were identified by multivariate analysis. RESULTS: Postoperative mortality occurred in 3 patients (6%) and postoperative complications were reported in 14 patients (26%). Local wound complications occurred in 6 patients (11%), central nervous system in 7 (13%), systemic in 3 (6%), and orbital in 1 (2%). With a median follow-up of 10 months (range, 1-159 months), the 3-year OS, DSS, and RFS rates were 28.2%, 29.7%, and 25.5%, respectively. The extent of orbital involvement and adjuvant postoperative radiation therapy (PORT) were independent predictors of DSS and OS on multivariate analysis, whereas only PORT was an independent predictor of RFS. Patients treated with PORT had significantly better 3-year OS (39% vs 18%; relative risk, 2.9; P = .007), DSS (41% vs 19%; relative risk, 3.0; P = .007), and RFS (39% vs 15%; relative risk, 4.2; P = .001). CONCLUSIONS: Craniofacial resection in patients with malignant melanoma of the skull base has mortality (6%) and complication rates (26%) comparable to other malignant tumors of the skull base. However, malignant melanoma is associated with a much poorer OS, DSS, and RFS. Adjuvant PORT correlated with improved 3-year OS, DSS, and RFS on multivariate analysis. These factors must be taken into account when considering craniofacial resection in a patient with malignant melanoma invading the skull base.

Adolescent↗
PubMed2006

Esthesioneuroblastoma: continued follow-up of a single institution's experience.

OBJECTIVES: To analyze outcomes and to provide follow-up for our increasing patient cohort with esthesioneuroblastoma. DESIGN: Retrospective cohort analysis. SETTING: Patients were examined from September 1, 1976, to May 30, 2004, in a tertiary care academic hospital. PATIENTS: Fifty consecutive patients diagnosed as having esthesioneuroblastoma were treated with a standardized protocol during a 28-year period. Patients with tumors staged Kadish A or B received preoperative radiotherapy followed by craniofacial resection, while patients with Kadish stage C disease were treated with preoperative sequential chemotherapy and radiotherapy followed by a craniofacial resection. The mean follow-up is 93 months (range, 1-330 months). RESULTS: The disease-free survival was 86.5% and 82.6% at 5 and 15 years, respectively. There were 17 patients (34%) who developed recurrent disease, most of which was locoregional (12 patients [71%]). There was a long interval to relapse (mean, 6 years), with the longest time to regional recurrence being 10 years. Distant relapses occurred sooner, with poorer outcomes. Of these 17 patients, 7 (41%) underwent successful salvage surgery, while 3 remain alive with disease. CONCLUSIONS: Excellent outcomes for esthesioneuroblastoma are achievable. Long-term follow-up is necessary because of the extended interval for recurrent disease; unlike most sinonasal malignancies, surgical salvage is possible.

Adolescent↗
PubMed2005

Craniofacial resection for malignant paranasal sinus tumors: Report of an International Collaborative Study.

BACKGROUND: Malignant tumors of the superior sinonasal vault are rare, and, because of this and the varied histologic findings, most outcomes data reflect the experience of small patient cohorts. This International Collaborative study examines a large cohort of patients accumulated from multiple institutions experienced in craniofacial surgery, with the aim of reporting benchmark figures for outcomes and identifying patient-related and tumor-related predictors of prognosis after craniofacial resection (CFR). METHODS: Three hundred thirty-four patients from 17 institutions were analyzed for outcome. Patients with esthesioneuroblastoma were excluded and are being reported separately. The median age was 57 years (range, 3-98 years). One hundred eighty-eight patients (56.3%) had had prior single-modality or combined treatment, which included surgery in 120 (36%), radiation in 79 (23.7%), and chemotherapy in 56 (16.8%). The most common histologic findings were adenocarcinoma in 107 (32%) and squamous cell carcinoma in 101 (30.2%). The margins of resection were close or microscopically positive in 95 (30%). Adjuvant radiotherapy was given in 161 (48.2%) and chemotherapy in 16 (4.8%). Statistical analyses for outcomes were performed in relation to patient characteristics, tumor characteristics, including histologic findings and extent of disease, surgical resection margins, prior radiation, and prior chemotherapy to determine predictive factors. RESULTS: Postoperative mortality occurred in 15 patients (4.5%). Postoperative complications occurred in 110 patients (32.9%). The 5-year overall, disease-specific, and recurrence-free survival rates were 48.3%, 53.3%, and 45.8%, respectively. The status of surgical margins, histologic findings of the primary tumor, and intracranial extent were independent predictors of overall, disease-specific, and recurrence-free survival on multivariate analysis. CONCLUSIONS: CFR for malignant paranasal sinus tumors is a safe surgical treatment with an overall mortality of 4.5% and complication rate of 33%. The status of surgical margins, histologic findings of the primary tumor, and intracranial extent are independent predictors of outcome.

Adenocarcinoma↗
PubMed2005

Electrical characteristics of low atrial septum pacing compared with right atrial appendage pacing.

AIM: The study was designed to compare the electrical characteristics of atrial leads placed in the low atrial septum (LAS) with those placed in the right atrial appendage (RAA) associated with dual chamber pacing. METHODS: In 86 patients an active-fixation (St. Jude Medical's Tendril DX model 1388T) atrial lead was positioned in RAA and in 86 patients the same model atrial lead was placed in the LAS. Pacing thresholds, sensing thresholds, impedances and the Far Field paced R-Wave (FFRW) amplitude and timing were compared at 6 weeks and at 3 and 6 months. RESULTS: The pacing threshold did not differ between groups. Sensed voltage of the P-wave was higher in the LAS compared with the RAA at 3 and 6 months (P=0.004). Impedance was higher in the LAS at 6 weeks and 3 months (P=0.002) but this difference was no longer significant at 6 months (P=0.05). The atrial sensed FFRW voltage was significantly higher in the LAS position compared with the RAA at 3 and 6 months follow-up (P=0.0002). FFRW voltage>1 mV was seen in 87% of the RAA pacing group and in 94% of the LAS pacing group (P=ns). The time between the ventricular pacing stimulus and the sensed FFRW in the atrium, (V spike-FFRW) in RAA was longer than in LAS at all follow-up measurements (P=0.006). CONCLUSIONS: The electrical characteristics of LAS pacing makes this alternative position in the atrium safe and feasible. Though statistical differences were found in P-wave sensing (LAS higher voltage than in the RAA) and FFRW sensing was higher in the LAS compared with the RAA this did not interfere with the clinical applicability of the LAS as alternative pacing site.

Atrial Fibrillation↗
PubMed2005

Effect of short pulse width programming in AutoCapture devices.

Pacing chronaxie can increase over time. The impact of a short pulse duration on threshold (THR) variations, frequency of noncapture episodes, and overall patient safety has not been fully studied. AutoCapture (AC) pacemakers are capable of memorizing THR trends and loss of capture (LOC) episodes. The study included 20 recipients of AC pacemakers (mean age = 76 +/- 9 years, 15 men) followed for 6 months. They were randomly assigned to pulse durations of 0.2 versus 1.0 ms at 1 month, and crossed over to the alternate programming at 3 months. Evoked response (ER) and AC tests were performed at follow-up. At 0.2 ms and 1.0 ms, the mean number of LOC/day was 2.37 +/- 5.81 and 0.91 +/- 0.49, respectively (ns). LOC trends between follow-up were significantly different with 0.2 versus 1.0 ms pulse duration (P < 0.01). AC THR at 1.0 ms was significantly lower (0.44 +/- 0.77) than at 2.0 ms (0.97 +/- 0.26, P < 0.05). No patient reported symptoms related to LOC during the study. Pulse duration programmed near the strength-duration curve is associated with greater variations in THR and LOC. AC responds to these changes by delivering 4.5 V pulses and keeping the capture THR at low, though safe values.

Aged↗
PubMed2004

Automatic adjustment of pacing output in the clinical setting.

BACKGROUND: AutoCapture (AC) is a programmable feature that enables the pacemaker to both track the capture threshold and automatically adjust the output on a beat-by-beat basis. Although AC safely and significantly reduces the current drainage, some authors have argued that the longevity benefit of such a system is overstated. This study aims to estimate the longevity extension that can be obtained, in the clinical routine, by turning the AC on in comparison to pacemakers programmed to operate at the shipped and manually optimized output. METHODS: We selected 83 consecutive patients who received implanted St Jude's Affinity pacemakers >6 months earlier. Eight patients died or were lost to follow-up and in 9 subjects the AC could not be turned on. In the remaining 66 patients, current drain and estimated longevity were compared in 3 situations: (1) AC on; (2) AC off, optimized programming (100%-150% voltage threshold); (3) AC off, shipped output (3.5 V). RESULTS: Five patients had large variations (>1 V) of the AC threshold. Current drainage was 8.0 +/- 0.9 mA in the AC group, 8.7 +/- 1.8 mA with AC off and optimized programming, and 11.3 +/- 2.3 mA at shipped output (P <.01). Estimated longevity was significantly extended (P <.01) by AC (12.1 +/- 1.0 years) when compared to shipped (8.9 +/- 1.7 years) and optimized programming (11.3 +/- 1.4 years). CONCLUSION: Reprogramming the pacemaker output significantly enhanced its estimated longevity; AC added a moderate but significant extension over manual reprogramming and was associated with increased safety in patients with large ventricular threshold variations.

Algorithms↗
PubMed2003

Craniofacial surgery for malignant skull base tumors: report of an international collaborative study.

BACKGROUND: Malignant tumors of the skull base are rare. Therefore, no single center treats enough patients to accumulate significant numbers for meaningful analysis of outcomes after craniofacial surgery (CFS). The current report was based on a large cohort that was analyzed retrospectively by an International Collaborative Study Group. METHODS: One thousand three hundred seven patients who underwent CFS in 17 institutions were analyzable for outcome. The median age was 54 years (range, 1-98 years). Definitive treatment prior to CFS had been administered in 59% of patients and included radiotherapy in 367 patients (28%), chemotherapy in 151 patients (12%), and surgery in 523 patients (40%). The majority of tumors (87%) involved the anterior cranial fossa. Squamous cell carcinoma (29%) and adenocarcinoma (16%) were the most common histologic types. The margins of surgical resection were reported close/positive in 412 patients (32%). Adjuvant postoperative radiotherapy was received by 510 patients (39%), and chemotherapy was received by 57 patients (4%). RESULTS: Postoperative complications were reported in 433 patients (33%), with local wound complications the most common (18%). The postoperative mortality rate was 4%. With a median follow-up of 25 months, the 5-year overall, disease-specific, and recurrence-free survival rates were 54%, 60%, and 53%, respectively. The histology of the primary tumor, its intracranial extent, and the status of surgical margins were independent predictors of overall, disease-specific, and recurrence-free survival on multivariate analysis. CONCLUSIONS: CFS is a safe and effective treatment option for patients with malignant tumors of the skull base. The histology of the primary tumor, its intracranial extent, and the status of surgical margins are independent determinants of outcome.

Adolescent↗