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Biomedical subjects

Robert L Grubb

Publications and source records attributed to Robert L Grubb.

At least 19 recordsLinked to original sources
PubMed2006

Clinical features and outcome in North American adults with moyamoya phenomenon.

BACKGROUND AND PURPOSE: To describe baseline clinical features and outcomes of adults with moyamoya phenomenon treated at a single North American institution. METHODS: We identified 34 adults with moyamoya phenomenon by review of angiographic records. Clinical presentation and baseline stroke risk factors were obtained by chart review. Follow-up was obtained prospectively. A 5-year Kaplan-Meier stroke risk was calculated. RESULTS: The median age was 42 (range 20 to 79) years. Twenty-five were women. The initial symptom was ischemia, hemorrhage, or asymptomatic in 24, 7, and 3 patients, respectively. Twenty-two had bilateral involvement and 12 had unilateral moyamoya vessels. Baseline stroke risk factors were similar between groups. The median follow-up in 31 living patients was 5.1 (range 0.2 to 19.6) years. Fourteen patients were treated with surgical revascularization (20 total hemispheres). In medically treated symptomatic hemispheres, the 5-year risk of recurrent ipsilateral stroke was 65% after the initial symptom and 27% after angiographic diagnosis. Patients with bilateral involvement presenting with ischemic symptoms were at the highest risk of subsequent stroke (n=17, 5-year risk of stroke with medical treatment after first symptom of 82%). In surgically treated hemispheres, the 5-year risk of perioperative or subsequent ipsilateral stroke or death was 17%. This was significantly different compared with medical treatment after first symptom (P=0.02) but not after angiographic diagnosis. CONCLUSIONS: Moyamoya phenomenon in North American adults is associated with a high risk of recurrent stroke, particularly those with bilateral involvement and ischemic symptoms. These data suggest a potential benefit with surgery if diagnosis could be made earlier.

Adult↗
PubMed2006

Minimally invasive approaches to localized prostate carcinoma.

Prostate cancer is an increasing medical problem. Radical prostatectomy and radiation therapy are effective treatments, but have the risk of significant morbidity. Clinicians have strived to develop new modalities of treatment that can maintain the excellent treatment outcomes of radical prostatectomy, but diminish the morbidity. Improved instrumentation, optics, and robotic technology have allowed the application of laparoscopic techniques to radical prostatectomy. Patients can have less blood loss and expect more rapid recovery. Intermediate oncologic outcomes appear similar to radical prostatectomy with good functional results. Cryotherapy and HIFU are tissue ablative approaches rather than extirpative approaches to prostate cancer treatment. They attempt to use nonsurgical methods to treat prostate cancer with the hope of providing oncologic control comparable to surgery and radiation while minimizing morbidity.

Cryosurgery↗
PubMed2006

Prostate volume and prostate-specific antigen levels in men enrolled in a large screening trial.

OBJECTIVES: Prostate volume correlates both with prostate-specific antigen (PSA) values and with the presence of benign prostatic hyperplasia (BPH). Here we examine the relationship between prostate volume and PSA level in a large, geographically diverse sample of men undergoing prostate cancer screening. METHODS: We followed 35,323 men enrolled in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial. Each man was screened with digital rectal examination (DRE) and PSA levels for up to 4 years. Prostate volume was estimated by DRE performed by trained examiners at the PLCO sites. Linear and logistic regression was used to assess the effect of prostate volume and age on PSA levels. Regression coefficients were adjusted for the effect of prostate volume measurement error. RESULTS: Prostate volume estimated by DRE showed considerable measurement error. Averaging volume over screening visits and accounting for examiner bias greatly reduced this error. Linear regression analysis showed a slope of 0.030/cm3 of log PSA on prostate volume when correcting for measurement error (95% confidence interval [CI], 0.029 to 0.031). Age was independently associated with (log) PSA, with a slope of 0.022 per year. Logistic regression analysis of the risk of having an elevated PSA value (exceeding 4 ng/mL) showed an odds ratio of 1.9 (95% CI, 1.8 to 2.0) associated with a 10 cm3 increase in prostate volume. The correlation of log PSA and prostate volume was 0.37. Prostate volume was not correlated with body mass index and showed weak correlation (r = 0.14) with age. CONCLUSIONS: Prostate volume and age are independently associated with increased PSA levels in a population of men undergoing screening.

Aged↗
PubMed2005

Prostate Cancer Screening in the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial: findings from the initial screening round of a randomized trial.

BACKGROUND: The benefit of screening for prostate cancer using prostate-specific antigen (PSA) testing and digital rectal examination (DRE) is uncertain and is under evaluation in a randomized prospective trial, the Prostate, Lung, Colorectal and Ovarian (PLCO) Cancer Screening Trial. Although the final results are several years away, the initial round of screening is complete. We describe the population enrolled in the PLCO trial, their baseline PSA and DRE screening results, and diagnostic follow-up results during the first year of follow-up. METHODS: A total of 38,350 men were randomly assigned to the screening arm of the PLCO trial from November 1993 through June 2001. Men were advised to seek diagnostic follow-up from their primary care provider if their DRE was suspicious for cancer and/or if their serum PSA level was higher than 4 ng/mL. PLCO trial staff obtained records related to diagnostic follow-up. RESULTS: Compliance with both screening tests was high (more than 89%). At screening, 7.5% of men had a positive DRE (i.e., suspicious for cancer) and 7.9% had a PSA level higher than 4 ng/mL. Of the men with positive screening tests, 74.2% underwent additional diagnostic testing, and 31.5% underwent a prostatic biopsy within 1 year. Overall, 1.4% of the men in the screening arm were diagnosed with prostate cancer, the majority of whom had clinically localized cancer. These compliance, biopsy, and cancer detection rates appear to be representative of contemporary practice patterns. CONCLUSION: The PLCO trial is evaluating PSA- and DRE-based screening for prostate cancer in a clinically valid manner. Whether such screening will result in a reduction of prostate cancer mortality cannot be answered until the randomized comparison is completed.

Aged↗
PubMed2005

Ventricular catheter tack-down suture: technical note.

Tubing migration accounts for a significant number of shunt complications. In an attempt to reduce the likelihood of disconnection and tubing migration, we have developed a technique to rigidly fix the proximal catheter to the skull. The method involves the placement of a small twist drill hole adjacent to the catheter burr hole through which a suture is passed. The suture is then used to rigidly bind the proximal shunt tubing and valve to the skull. This approach provides an efficient and effective means for reducing complications related to shunt tubing migration.

Cerebral Ventricles↗
PubMed2005

Management of von Hippel-Lindau-associated kidney cancer.

Von Hippel-Lindau disease (VHL) is an autosomal-dominant inherited condition that predisposes patients to develop renal cysts and tumors, most commonly in the second to fourth decades of life. Renal cysts and tumors have historically been a major cause of disease-related morbidity and mortality, so urologists are often called on to manage patients with VHL. Knowledge of the extrarenal manifestations of VHL (hemangioblastomas of the central nervous system and retina, endolymphatic sac tumors, pancreatic cysts, epididymal and broad-ligament cysts, and pheochromocytomas) and integration of nonurologic specialties into management teams for VHL patients will help to achieve successful outcomes. Screening for renal manifestations of VHL, by regular imaging of the abdomen, begins late in the second decade of life. Because renal tumors in VHL can be multifocal and bilateral, management can be complex. Radical nephrectomy removes all tissue at risk for forming renal tumors; however, this necessitates renal replacement therapy. In an effort to control cancer effectively while preserving native renal function and minimizing intervention, some researchers have proposed an observational strategy. Patients are screened until the largest tumor reaches 3 cm in diameter, at which time operative intervention is recommended. Nephron-sparing surgery is undertaken, whenever technically feasible, with the goal of removing all tumors in that renal unit. The role of minimally invasive technologies is currently being evaluated in selected patients with VHL renal masses. Elucidation of molecular pathways associated with VHL renal tumors may facilitate development of effective medical treatments for these lesions in the future.

Humans↗
PubMed2005

Indications for cerebral revascularization for patients with atherosclerotic carotid occlusion.

Patients with complete carotid occlusion and recent ischemic symptoms are at high risk for subsequent stroke, particularly those with evidence of severe hemodynamic impairment due to poor collateral flow. Treatment options for these patients include direct extracranial to intracranial arterial bypass, or interventions aimed at improving collateral sources of flow such as endarterectomy or angioplasty and stenting of the ipsilateral external carotid artery, the contralateral carotid artery, or the vertebral arteries. The evidence supporting the use of these procedures for patients with complete occlusion of the carotid artery will be the focus of this article. The use of physiologic imaging to select subgroups of patients at high risk due to hemodynamic factors will also be discussed.

Journal Article↗
PubMed2005

Highlights from the Society of Urologic Oncology 4th annual meeting.

PURPOSE: The 4th annual meeting of the Society of Urologic Oncology (SUO) was held December 5-6, 2003 in Bethesda, Maryland. The meeting was attended by urologists, medical and radiation oncologists, and researchers whose focus is genitourinary (GU) malignancies. More than 500 participants registered for the meeting. MATERIALS AND METHODS: The agenda for the SUO meeting included more than 50 speakers and discussion panels, and addressed a broad range of topics in GU oncology. Transcripts of the proceedings and submitted slide presentations were reviewed for content following the meeting, and the highlights were summarized. These written materials can be accessed through the SUO web site at http://societyofurologiconcology.org. RESULTS: Reviewed session topics included epidemiology of GU malignancies, biomarkers for GU malignancies, cancer genomics, bladder cancer, testis cancer, minimally invasive treatments for GU malignancies, molecular therapeutics and advanced prostate cancer. Significant advances in these fields have directly impacted clinical care and improved patient outcomes across the many disciplines associated with treatment of GU cancers. CONCLUSIONS: The SUO meeting is unique in its multidisciplinary forum and focus on urological oncology. The 2003 meeting highlighted recent advances in epidemiology, clinical management and emerging molecular approaches in the diagnosis and treatment of urological malignancies with several state-of-the-art presentations.

Humans↗
PubMed2005

Evaluation and management of renal tumors in the Birt-Hogg-Dubé syndrome.

PURPOSE: Herein we describe the evaluation and management of renal tumors in Birt-Hogg-Dubé (BHD), an autosomal dominant disorder predisposing to cutaneous fibrofolliculomas, pulmonary cysts, spontaneous pneumothorax and renal tumors. MATERIALS AND METHODS: A total of 124 affected individuals underwent comprehensive clinical evaluation, including body computerized tomography, to determine cutaneous, pulmonary and renal manifestations of BHD. Of these individuals 14 had their renal tumors managed at our institution. RESULTS: Of the 124 BHD affected individuals 34 (27%) had renal tumors of various histologies, most commonly hybrid oncocytic tumor and chromophobe renal carcinoma. Average age at renal tumor detection was 50.4 years and multiple tumors were found in a majority of patients. Some patients with renal tumors were identified that did not have the characteristic cutaneous hallmarks of BHD. In 4 of the 14 patients treated at our institution small (less than 3 cm) renal tumors were observed, while 10 others underwent a total of 12 renal procedures, including 4 radical and 8 partial nephrectomies. At a median of 38 months of followup 5 of these 10 patients remained free of disease, 3 had small renal tumors and 2 died of metastatic renal cancer. CONCLUSIONS: Patients with BHD are at risk for multiple renal tumors that are often malignant and can metastasize. Individuals at risk or affected by BHD should be radiographically screened for renal tumors at periodic intervals and they are best treated with nephron sparing surgical approaches. Genetic testing for this syndrome is now available.

Adult↗
PubMed2005

Delays in cancer detection using 2 and 4-year screening intervals for prostate cancer screening with initial prostate specific antigen less than 2 ng/ml.

PURPOSE: The American Urological Association and American Cancer Society advocate annual screening with serum prostate specific antigen (PSA) and digital rectal examination starting at age 50 years in the general population and earlier in men at high risk. Some groups have suggested that screening at 2 or 4-year intervals may be sufficient in men with initial PSA 2 ng/ml or less. We reviewed the records of men enrolled in a PSA and digital rectal examination based prostate cancer screening study to determine the extent to which the diagnosis of cancer would have been delayed using a 2 or 4-year screening interval. MATERIALS AND METHODS: We evaluated 18,140 volunteers in a prostate cancer screening study in whom PSA was less than 2 ng/ml at initial screening and who were screened at 6-month to 1-year intervals for up to 8 years. We evaluated the cancers detected in these intervals to determine the possible delay in cancer diagnosis that would occur using prolonged screening intervals. We report the overall cancer detection rate, clinical and pathological tumor stage, and Gleason grade of the cancers detected. RESULTS: Excluding 70 men in whom prostate cancer was detected at initial evaluation 2.0% had prostate cancer detected during the next 8 years (mean 21.6 cancers per 6 months, median 20, range 12 to 33). Using a hypothetical 2-year screening interval cancer detection 62% would have been delayed by 4 to 20 months. Using a hypothetical 4-year screening interval cancer detection would have been delayed in 77% of men by 4 to 44 months. Of the tumors detected 100% were clinically localized, 77% were pathologically organ confined and 29% had a Gleason score of 7 or greater. CONCLUSIONS: The 2 or 4-year PSA screening interval in men with initial serum PSA less than 2 ng/ml would result in substantial delays in prostate cancer detection. To our knowledge the extent to which these delays would affect treatment outcomes is undetermined.

Biomarkers, Tumor↗
PubMed2005

Results of compliance with prostate cancer screening guidelines.

PURPOSE: Current guidelines of the American Cancer Society and the National Comprehensive Cancer Network recommend offering annual prostate cancer screening with prostate specific antigen (PSA) and digital rectal examination (DRE) beginning at age 50 (age 45 in high risk men). There are limited data concerning outcomes if all men followed screening guidelines. We report early outcome data on men who entered a prostate cancer screening study, complied with the screening guidelines and were subsequently diagnosed with prostate cancer. MATERIALS AND METHODS: We reviewed records of men 45 to 59 years old at study entry with a PSA less than 2.6 ng/ml and benign DRE who underwent annual DRE and PSA testing in a screening study between 1991 and 2001. Of 10,174 men with these characteristics, 232 (2.3%) were subsequently diagnosed with prostate cancer. We evaluated PSA, Gleason score, clinical and pathological tumor stage, and treatment outcomes in these men. RESULTS: Median PSA at diagnosis was 3.1 ng/ml (range 0.4 to 9.6). Gleason scores ranged from 4 to 9. All patients had clinically localized disease. Management included predominantly radical prostatectomy (87%) and radiation therapy (10%). Of cancers in which tumor volume was assessed 13% were considered possibly harmless tumors by previously published criteria and 2% were considered possibly rapidly progressive tumors by criteria we set in this study. CONCLUSIONS: Prostate cancer screening using some current guidelines results in the detection of cancers that are organ confined in 79% of patients, possibly harmless in less than 15% and possibly rapidly progressive in 2%.

Guideline Adherence↗
PubMed2005

Highlights from the Society of Urologic Oncology, 5th Annual Meeting, December 3-4, 2004, Bethesda, Maryland, United States of America.

PURPOSE: The fifth annual meeting of the Society of Urologic Oncology was held December 3 and 4, 2004 in Bethesda, Maryland. The program provides a forum for the discussion of important issues in genitourinary malignancies among urologists, radiation oncologists and medical oncologists. MATERIALS AND METHODS: Agenda topics included kidney cancer, bladder cancer and prostate cancer. Several sessions featured new developments in basic, translational and clinical research. Each session was reviewed for content following the meeting and the highlights were summarized. The Young Urologic Oncologists' Forum was again a successful component of the meeting but it is beyond the scope of this summary. RESULTS: Sessions on kidney cancer focused on molecular genetics and advances in molecular therapeutics. Radio frequency ablation of renal masses was also addressed. Topics discussed in bladder cancer included screening and surgical management. Dr. Donald Skinner received the Huggins Medal and he addressed the society on the management of invasive bladder cancer. Reviewed session topics in prostate cancer included neoadjuvant treatment paradigms, radiation treatment and adjuvant therapy in patients in whom primary treatment has failed. A state-of-the-art lecture addressed hereditary prostate cancer. CONCLUSIONS: The Society of Urologic Oncology meeting is unique in its multidisciplinary forum and focus on urological oncology. The meeting this year highlighted emerging trends, and the current state-of-the-art in kidney, bladder and prostate cancer. Additional focus was given to new molecular based diagnostic and therapeutic strategies for genitourinary malignancies.

Carcinoma, Renal Cell↗
PubMed2005

Effect of normal saline bolus on cerebral blood flow in regions with low baseline flow in patients with vasospasm following subarachnoid hemorrhage.

OBJECT: Arterial vasospasm is the most common cause of delayed ischemic neurological deficits (DINDs) and one of the major causes of disability following subarachnoid hemorrhage (SAH). Current management of vasospasm involves intravascular volume expansion and hemodynamic augmentation with the goal of increasing cerebral blood flow (CBF). The purpose of this study was to examine the effects of volume expansion on regional (r)CBF in patients with DIND following SAH. METHODS: The authors measured quantitative rCBF on positron emission tomography (PET) scans in six patients with aneurysmal SAH who had developed clinical signs of vasospasm. All patients were kept in a euvolemic state prior to the onset of vasospasm. At the onset of vasospasm, global and rCBF were measured before and after the administration of a normal saline bolus of 15 ml/kg administered over 1 hour. Two patients then received saline infusions of 5 ml/kg x hr over the following 2 to 3 hours and underwent hourly serial CBF measurements. Global and rCBF data were calculated in each patient. The mean rCBF in areas with low flow at baseline (< or = 25 ml/[100 g x min]) increased from 19.1 +/- 3.0 to 29.9 +/- 9.7 ml/(100 g x min) (p = 0.02) with volume expansion. This change was sustained over the following 2 to 3 hours. Pulmonary capillary wedge pressure, mean arterial blood pressure, cardiac output, and central venous pressure did not change significantly during this intervention. CONCLUSIONS: In euvolemic patients with vasospasm, intravascular volume expansion with a normal saline bolus raised CBF in regions of the brain most vulnerable to ischemia.

Adult↗
PubMed2004

Extracranial-intracranial arterial bypass for treatment of occlusion of the internal carotid artery.

Extracranial-intracranial arterial bypass was frequently utilized in the 1970s and early 1980s to treat patients with atherosclerotic occlusive carotid arterial lesions not amenable to extracranial arterial revascularization procedures. After a large randomized trial reported in 1985 that there was no benefit of surgery in these patients, the procedure was generally abandoned as a treatment for symptomatic atherosclerotic cerebrovascular disease. In the past two decades, multiple studies have shown that patients with impaired cerebral hemodynamics distal to an occlusive cerebrovascular lesion have a significantly increased risk of subsequent stroke. Two new randomized, controlled clinical trials of extracranial-intracranial arterial bypass in patients with symptomatic atherosclerotic occlusive cerebrovascular disease that are using cerebral hemodynamic criteria for patient selection are currently in progress. At the present time, extracranial-intracranial arterial bypass should not be performed on these patients outside of a clinical trial.

Carotid Artery Thrombosis↗
PubMed2004

Transitional cell carcinoma of the renal pelvis associated with hypercalcemia in a patient with autosomal dominant polycystic kidney disease.

We present a case of transitional cell carcinoma (TCC) of the renal pelvis in a patient with autosomal dominant polycystic kidney disease (ADPKD) who presented with hypercalcemia. Hypercalcemia is rare in TCC and has not been independently associated with ADPKD. Preoperative magnetic resonance imaging findings suggested a diagnosis of TCC. The patient underwent left nephroureterectomy, which confirmed the diagnosis, and received adjuvant chemotherapy. The hypercalcemia had not recurred, and she was without evidence of disease recurrence at 36 months. This case is unique in that we did not find any previously reported cases of TCC associated with ADPKD and hypercalcemia.

Adult↗
PubMed2004

The relationship between renal tumor size and metastases in patients with von Hippel-Lindau disease.

PURPOSE: Patients with von Hippel-Lindau disease are at risk for multiple, bilateral, recurrent renal tumors and metastases. We previously evaluated the relationship between tumor size and metastases in families with hereditary renal cancer. We update our findings with about twice the number of patients with von Hippel-Lindau disease. MATERIALS AND METHODS: Screening affected kindred or retrospective review of medical records identified 181 patients with von Hippel-Lindau disease and renal cell carcinoma. Patients with small tumors were followed with serial imaging until the largest tumor reached 3 cm, at which point surgery was recommended. Surgical resection was recommended to patients with tumors larger than 3 cm. Patients not undergoing screening often had large renal tumors. RESULTS: A total of 108 patients with von Hippel-Lindau disease and solid renal tumors on computerized tomography imaging smaller than 3 cm (group 1) were followed a mean of 58 months (range 0 to 244). Metastatic disease did not develop in any of these patients. Renal tumors larger than 3 cm developed in 73 patients with von Hippel-Lindau disease (group 2). Mean followup of group 2 was 72.9 months (range 0 to 321). The proportion of procedures that were nephron sparing was higher in group 1 than in group 2 (120 of 125 [97%] compared to 85 of 125 [69%], Fisher's exact test p <0.0001). Metastases developed in 20 of 73 (27.4%) patients in group 2. The frequency of renal tumor metastases increased with increasing tumor size. CONCLUSIONS: No renal tumor metastases were found in patients with renal tumors less than 3 cm in diameter. We advocate a 3 cm threshold for parenchymal sparing surgery in patients with von Hippel-Lindau disease to decrease the risk of metastatic disease while preserving renal function, avoiding or delaying the need for dialysis and/or renal transplant, and decreasing the number of operations which a patient may undergo. We stress the importance of early screening in the kindred of patients with von Hippel-Lindau disease and vigilant followup thereafter.

Adolescent↗