Publications by authors named "Adil Ayub"

31 Publications

Complete gastroesophageal junction avulsion after near drowning: A case report and review of literature.

Int J Surg Case Rep 2020 25;76:11-13. Epub 2020 Sep 25.

Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA. Electronic address:

Introduction: Gastroesophageal (GE) junction injuries are rare in the pediatric population. A complete GE junction separation in a child secondary to trauma has not reported in the literature yet.

Presentation Of Case: A 14-year-old boy presented with a complete GE junction avulsion after a near-drowning experience. He underwent immediate damage control surgery and delayed gastric pull-up esophageal reconstruction in 3-months. At the most recent clinic visit 5 months from the reconstruction, he can tolerate a regular diet without difficulty and is gaining weight and recovering well.

Conclusion: Complete GE junction injuries and avulsions are rare with limited data to guide management. These injuries are associated with mortality rates from 25% to 33%, therefore, high index of suspicion, prompt recognition and careful surgical planning is needed for favorable outcomes.
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http://dx.doi.org/10.1016/j.ijscr.2020.09.167DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7530227PMC
September 2020

Urinary NT-proBNP as a potential noninvasive biomarker for screening of pulmonary hypertension in preterm infants: a pilot study.

J Perinatol 2020 04 7;40(4):628-632. Epub 2020 Jan 7.

Department of Neonatology, University of Texas Medical Branch, Galveston, TX, USA.

Objective: This pilot study aimed to determine the feasibility of urinary NT-proBNP (NT-proBNP) as a potential noninvasive screening marker for pulmonary hypertension (PH).

Study Design: A prospective cross-sectional study was conducted. Preterm infants (PI) (birthweight <1500 gm and <30 weeks gestational age (GA)) were enrolled. Serial urinary NT-proBNP measurements and echocardiograms (ECHO) were performed at 28, 32, and 36 weeks.

Results: Thirty-six patients were included in the final analysis (BPD-PH group = 6, BPD group = 20, control = 10). Urinary NT-proBNP levels were higher in the BPD-PH group compared with BPD and control groups at all study intervals. A urine NT-proBNP cutoff level of 2345 pg/ml at 28 weeks of GA had a sensitivity and specificity of 83.3% and 84.2%, respectively, for detection of BPD-PH (AUC 0.816, p = 0.022).

Conclusion: Urinary NT-proBNP measurement is feasible in preterm infants and appears to be a good noninvasive screening tool for PH.
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http://dx.doi.org/10.1038/s41372-019-0581-9DOI Listing
April 2020

Primary Pediatric Non-Hodgkin Lymphomas of the Gastrointestinal Tract: A Population-based Analysis.

Anticancer Res 2019 Nov;39(11):6413-6416

Department of Surgery, University of Texas Medical Branch, Galveston, TX, U.S.A.

Background/aim: The aim of this study was to present the clinical characteristics, natural history and survival outcomes of primary gastrointestinal non-Hodgkin lymphomas (PGINHL) in the pediatric population.

Patients And Methods: Surveillance, Epidemiology, and End Results (SEER) database was queried for patients aged 0 to 19 years with PGINHL between 1973 and 2014.

Results: A total of 452 cases were identified [mean age 11.0 (±5.1)] years, whites 84.1%, males (76.5%). The majority of tumors were noted in the small bowel (SB) (47.6%), followed by large bowel (LB) (28.5%) and the stomach (10.0%). Overall, the most common histological subtype was Burkitt lymphoma (51.8%), followed by diffuse large B-cell lymphoma (DLBCL) (26.1%). Mean overall survival (OS) of the entire cohort was 33,33 years with a 5-yr, 10-yr and 30-yr survival rate of 86%, 86% and 79%, respectively. Large bowel tumors had the best long-term survival rates whereas; gastric tumors had the worst with 30-yr survival rate 84% and 74%, respectively. Overall, 328 (72.6%) patients received surgery. No significant survival difference was noted between patients who underwent surgery and those who did not.

Conclusion: This study presents the largest dataset of pediatric PGINHL and describes the clinical features and outcomes of these patients in addition to summarizing the literature.
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http://dx.doi.org/10.21873/anticanres.13855DOI Listing
November 2019

Adjuvant Radiation Therapy for Thoracic Soft Tissue Sarcomas: A Population-Based Analysis.

Ann Thorac Surg 2020 01 11;109(1):203-210. Epub 2019 Sep 11.

Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York; Department of Thoracic Surgery, Health Quest, Poughkeepsie, New York. Electronic address:

Background: The role of adjuvant radiation therapy (RT) in the management of thoracic soft tissue sarcomas (STSs) remains unclear. We aimed to study the characteristics of patients with thoracic STS who received RT after surgical resection and investigate the impact of RT on survival outcomes.

Methods: We queried National Cancer Database to identify patients with surgically resected thoracic STS from 2004 to 2012. Factors associated with receiving adjuvant RT were identified. Analyses were performed to identify prognostic factors and compare overall survival (OS) in both unmatched and propensity score-matched cohorts.

Results: Overall, 1215 patients were identified, of whom 557 (45.8%) received adjuvant RT. Tumor grade (odds ratio [OR], 2.87; 95% confidence interval [CI], 2.18-3.77), tumor size (OR, 1.82; 95% CI, 1.36-2.42), and tumor margins (OR, 1.97; 95% CI, 1.43-2.72) were found to be significant predictors of receiving RT. Mean OS of patients receiving RT in the unmatched cohort was 91 months vs 88 months for patients who did not (P = .556). When adjusted for all variables, adjuvant RT was found to be associated with improved survival (hazard ratio, 0.79; 95% CI, 0.61-0.96). Survival analysis of the matched cohort also demonstrated improved survival with adjuvant RT (120 months vs 100 months; P = .02). Subgroup analysis in both the unmatched and matched cohorts showed patients with high-grade tumors more likely to benefit from adjuvant RT.

Conclusions: This population-based analysis is the largest dataset of primary thoracic STSs to date and suggests significant survival benefit associated with adjuvant RT. The improvement in OS was more notable in patients with high-grade tumors. Randomized prospective studies are warranted to further understand the benefit of RT in this group.
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http://dx.doi.org/10.1016/j.athoracsur.2019.07.075DOI Listing
January 2020

Pulmonary hepatoid adenocarcinoma.

J Thorac Cardiovasc Surg 2019 10 20;158(4):e139-e140. Epub 2019 Jun 20.

Division of Cardiothoracic Surgery, University of Texas Medical Branch, Galveston, Tex. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2019.06.023DOI Listing
October 2019

Association of rs10490924 in ARMS2/HTRA1 with age-related macular degeneration in the Pakistani population.

Ann Hum Genet 2019 07 20;83(4):285-290. Epub 2019 Mar 20.

Transalational Genomics Laboratory, Department of Biosciences, COMSATS University Islamabad, Pakistan.

Age-related macular degeneration (AMD) is a disease of the elderly in which central vision is lost because of degenerative changes of the macula. The current study investigated the association of single-nucleotide polymorphisms (SNPs) with AMD in the Pakistani population. Four SNPs were analyzed in this study: rs1061170 in the CFH, rs429608 near CFB, rs2230199 in the C3, and rs10490924 in ARMS2/HTRA1. This case-control association study was conducted on 300 AMD patients (125 wet AMD and 175 dry AMD) and 200 unaffected age- and gender-matched control individuals. The association of the SNP genotypes and allele frequency distributions were compared between patients and healthy controls, keeping age, gender, and smoking status as covariates. A significant genotype and variant allele association was found of rs10490924 in ARMS2/HTRA1 with wet AMD, while the SNPs in CFH, CFB, and C3 were not associated with AMD in the current Pakistani cohort. The lack of association of CFH, CFB, and C3 may be attributed to limited sample size. This study demonstrates that genetic causative factors of AMD differ among populations and supports the need for genetic association studies among cohorts from various populations to increase our global understanding of the disease pathogenesis.
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http://dx.doi.org/10.1111/ahg.12311DOI Listing
July 2019

Robotic Thoracic Surgery Training for Residency Programs: A Position Paper for an Educational Curriculum.

Innovations (Phila) 2018 Nov/Dec;13(6):417-422

Department of General Surgery, Brookdale University Hospital and Medical Center, Brooklyn, NY USA.

Objective: Robotic-assisted surgery is increasingly being used in thoracic surgery. Currently, the Integrated Thoracic Surgery Residency Program lacks a standardized curriculum or requirement for training residents in robotic-assisted thoracic surgery. In most circumstances, because of the lack of formal residency training in robotic surgery, hospitals are requiring additional training, mentorship, and formal proctoring of cases before granting credentials to perform robotic-assisted surgery. Therefore, there is necessity for residents in Integrated Thoracic Surgery Residency Program to have early exposure and formal training on the robotic platform. We propose a curriculum that can be incorporated into such programs that would satisfy both training needs and hospital credential requirements.

Methods: We surveyed all 26 Integrated Thoracic Surgery Residency Program Directors in the United States. We also performed a PubMed literature search using the key word "robotic surgery training curriculum." We reviewed various robotic surgery training curricula and evaluation tools used by urology, obstetrics gynecology, and general surgery training programs. We then designed a proposed curriculum geared toward thoracic Integrated Thoracic Surgery Residency Program adopted from our credentialing experience, literature review, and survey consensus.

Results: Of the 26 programs surveyed, we received 17 responses. Most Integrated Thoracic Surgery Residency Program directors believe that it is important to introduce robotic surgery training during residency. Our proposed curriculum is integrated during postgraduate years 2 to 6. In the preclinical stage postgraduate years 2 to 3, residents are required to complete introductory online modules, virtual reality simulator training, and in-house workshops. During clinical stage (postgraduate years 4-6), the resident will serve as a supervised bedside assistant and progress to a console surgeon. Each case will have defined steps that the resident must demonstrate competency. Evaluation will be based on standardized guidelines.

Conclusions: Expansion and utilization of robotic assistance in thoracic surgery have increased. Our proposed curriculum aims to enable Integrated Thoracic Surgery Residency Program residents to achieve competency in robotic-assisted thoracic surgery and to facilitate the acquirement of hospital privileges when they enter practice.
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http://dx.doi.org/10.1097/IMI.0000000000000573DOI Listing
April 2019

Pulsed Ultrasounds Reduce Pain and Disability, Increasing Rib Fracture Healing, in a Randomized Controlled Trial.

Pain Med 2019 10;20(10):1980-1988

Section of Thoracic Surgery, Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia.

Introduction: Rib fractures are an important health issue worldwide, with significant, pain, morbidity, and disability for which only symptomatic treatment exists.

Objectives: Based on our previous experimental model, the objective of the current study was to assess for the first time whether pulsed ultrasound (PUS) application could have beneficial effects on humans.

Methods: Prospective, double-blinded, randomized, controlled trial of 51 patients. Four were excluded, and 47 were randomized into the control group (N = 23) or PUS group (N = 24). The control group received a PUS procedure without emission, and the PUS group received 1 Mhz, 0.5 W/cm2 for 1 min/cm2. Pain level, bone callus healing rate, physical and work activity, pain medication intake, and adverse events were blindly evaluated at baseline and one, three, and six months.

Results: There were no significant differences at baseline between groups. PUS treatment significantly decreased pain by month 1 (P = 0.004), month 3 (P = 0.005), and month 6 (P = 0.025), significantly accelerated callus healing by month 1 (P = 0.013) and month 3 (P < 0.001), accelerated return to physical activity by month 3 (P = 0.036) and work activity (P = 0.001) by month 1, and considerably reduced pain medication intake by month 1 (P = 0.057) and month 3 (P = 0.017). No related adverse events were found in the PUS group.

Conclusions: This study is the first evidence that PUS treatment is capable of improving rib fracture outcome, significantly accelerating bone callus healing, and decreasing pain, time off due to both physical activity and convalescence period, and pain medication intake. It is a safe, efficient, and low-cost therapy that may become a new treatment for patients with stable rib fractures.
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http://dx.doi.org/10.1093/pm/pny224DOI Listing
October 2019

Radiation therapy improves survival for unresectable postpneumonectomy lung tumors.

J Surg Res 2018 07 12;227:60-66. Epub 2018 Mar 12.

Department of Thoracic Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, New York.

Background: Additional resection for cancer in the single lung is often considered a prohibitive risk. The role of radiation therapy (RT) in this patient population is less clear with very limited available data. In this study, we sought to examine patients with postpneumonectomy lung cancer not amenable to surgery, identify factors associated with receiving RT, and determine the impact of RT on survival outcomes.

Methods: The Surveillance, Epidemiology, and End Results (SEER) database (1988-2013) was queried for patients with inoperable contralateral lung cancer after pneumonectomy. Univariate and multivariate analyses were performed to identify factors associated with the receipt of RT. Survival outcomes were examined using the Kaplan-Meier method.

Results: In total, 191 patients with inoperable postpneumonectomy lung cancer were included. RT was delivered to 122 (63.9%) patients; 69 (36.1%) patients did not receive RT. On multivariate analysis, disease stage was identified as the only predictor associated with receipt of RT (P < 0.001). The median overall survival (OS) and disease-specific survival (DSS) for patients receiving RT were higher than those for patients who did not receive RT (25 versus 8 mo and 29 versus 10 mo, respectively; P < 0.001). Similarly, patients who received RT had a higher 3-y OS (34% versus 14%, P < 0.001) than those who did not receive RT. On subset analysis, survival benefit with RT was observed in patients with all tumor size groups, and there was a trend toward superior survival in patients with stage I/II disease, who received RT compared with those who did not. On multivariate Cox regression analysis, RT use was independently associated with decreased hazards of death after adjusting for other factors (HR, 0.539; P < 0.001).

Conclusions: Based on our analysis of the Surveillance, Epidemiology, and End Results (SEER) database, RT is associated with improved outcomes in inoperable patients with a contralateral lung cancer after pneumonectomy compared with observation alone.
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http://dx.doi.org/10.1016/j.jss.2018.02.015DOI Listing
July 2018

Airway transplantation of adipose stem cells protects against bleomycin-induced pulmonary fibrosis.

J Investig Med 2018 04 21;66(4):739-746. Epub 2017 Nov 21.

Instituto Universitario de Investigaciones Biomédicas y Sanitarias (IUIBS)-BioPharm Group, Universidadde Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain.

Idiopathic pulmonary fibrosis (IPF) is a progressive interstitial lung disease with poor prognosis. Adipose-derived stem cells (ADSC) have demonstrated regenerative properties in several tissues. The hypothesis of this study was that airway transplantation of ADSC could protect against bleomycin (BLM)-induced pulmonary fibrosis (PF). Fifty-eight lungs from 29 male Sprague-Dawley rats were analyzed. Animals were randomly divided into five groups: a) control (n=3); b) sham (n=6); c) BLM (n=6); d) BLM+ADSC-2d (n=6); and e) BLM+ADSC-14d (n=8). Animals received 500 µL saline (sham), 2.5 UI/kg BLM in 500 µL saline (BLM), and 2×10 ADSC in 100 µL saline intratracheally at 2 (BLM+ADSC-2d) and 14 days (BLM+ADSC-14d) after BLM. Animals were sacrificed at 28 days. Blinded Ashcroft score was used to determine pulmonary fibrosis extent on histology. Hsp27, Vegf, Nfkβ, IL-1, IL-6, Col4, and Tgfβ1 mRNA gene expression were determined using real-time quantitative-PCR. Ashcroft index was: control=0; sham=0.37±0.07; BLM=6.55±0.34 vs sham (P=0.006). BLM vs BLM+ADSC-2d=4.63±0.38 (P=0.005) and BLM+ADSC-14d=3.77±0.46 (P=0.005). BLM vs sham significantly increased Hsp27 (P=0.018), Nfkβ (P=0.009), Col4 (P=0.004), Tgfβ1 (P=0.006) and decreased IL-1 (P=0.006). BLM+ADSC-2d vs BLM significantly decreased Hsp27 (P=0.009) and increased Vegf (P=0.006), Nfkβ (P=0.009). BLM+ADSC-14d vs BLM significantly decreased Hsp27 (P=0.028), IL-6 (P=0.013), Col4 (P=0.002), and increased Nfkβ (P=0.040) and Tgfβ1 (P=0.002). Airway transplantation of ADSC significantly decreased the fibrosis rate in both early and established pulmonary fibrosis, modulating the expression of Hsp27, Vegfa, Nfkβ, IL-6, Col4, and Tgfβ1. From a translational perspective, this technique could become a new adjuvant treatment for patients with IPF.
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http://dx.doi.org/10.1136/jim-2017-000494DOI Listing
April 2018

De novo descending aorta thrombus in a patient with metastatic colorectal cancer: A case report.

J Pak Med Assoc 2017 Oct;67(10):1606-1608

Aga Khan University Hospital, Karachi, Pakistan.

Thromboembolic events in patients with cancer are frequently reported in literature and usually involve the venous circulation. De novo thrombus formation in the arterial system without any underlying atherosclerosis, dissection or aneurysm is extremely rare. We report the case of a patient with metastatic colorectal carcinoma who developed a thrombus in the descending aorta without any intervention or risk factors. The patient presented with non-specific gastrointestinal symptoms. A CT scan revealed an aortic thrombus obstructing 70% of the lumen. She opted for no treatment of her thrombus and was later complicated by extensive lower limb emboli. Patients with aortic thrombosis usually present with subtle symptoms which may be underestimated by both the patient and the physician. A high index of suspicion is required for early recognition and prevention of complications.
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October 2017

Knowledge and Perception Regarding Autism among Primary School Teachers: A Cross-sectional Survey from Pakistan, South Asia.

Indian J Community Med 2017 Jul-Sep;42(3):177-179

Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.

Background: Early detection and intervention seem to improve development in autistic children, and teachers form an important part of their early social environment.

Objectives: The objective of this study was to assess baseline knowledge and misconceptions regarding autism among school teachers and evaluate factors influencing their knowledge.

Materials And Methods: This is a cross-sectional survey enrolling primary school teachers using a self-administered questionnaire.

Results: Seventy-three teachers (mean age of 34 years, 66% females) responded. Gaps in awareness and knowledge were found. About 52 (71.2%) teachers identified themselves as having some knowledge about autism, with 23 (44.2%) among this group understanding autism as a neurological/mental disorder. The majority (73.1%) believe that special education is a helpful intervention. The only significant factor that influenced knowledge among teachers was attendance of behavioral classes ( = 0.01).

Conclusion: Results suggest that teachers have an inadequate understanding of autism due to several misconceptions. This calls for increased education of teachers with regard to autism and other childhood disorders.
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http://dx.doi.org/10.4103/ijcm.IJCM_121_16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5561699PMC
August 2017

Quality Assessment Of Focused Antenatal Care Service Delivery In Tertiary Care Health Facility.

J Ayub Med Coll Abbottabad 2017 Apr-Jun;29(2):219-224

Ayub Teaching Hospital, Abbottabad, Pakistan.

Background: Regardless of high maternal deaths in Pakistan, only 37% of pregnant women make four or more antenatal care visits during pregnancy. This proportion has further been diverged between urban and rural. About 62% of women visit clinics for WHO recommended sets of antenatal care (ANC) check-ups in urban as compared to 26% women in rural areas. This study was conducted with the aim to assess quality of Focused ANC service delivery in terms of examination, screening, treatment, counselling and to determine variation in service delivery with provider's clinical qualification and expertise.

Methods: Cross sectional study design was used. Data was collected from pregnant women when they were visiting hospital for their antenatal visits. Direct observation was also made regarding provision of services.

Results: Out of 278, 55% of study women were in 28-33 years age group and 21.2% made at least one visit. While 42.8% reported more than one visit, 98.9% received tetanus toxoid, 82% received proper screening. Counselling was done mostly regarding nutrition and self-care (42.8%), and significant association (p-value <0.05) was observed between provider's clinical qualification and provision of services such as for screening and counselling.

Conclusions: The delivery of antenatal care services to pregnant women varied to some extent. Most of the routine investigation services were in accordance with recommended standards of optimal quality with little divergence from guidelines such as screening for HIV and syphilis. Better quality services were being provided to private participants in terms of counselling and danger sign screening.
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April 2019

Pulmonary Resection for Second Lung Cancer After Pneumonectomy: A Population-Based Study.

Ann Thorac Surg 2017 Oct 12;104(4):1131-1137. Epub 2017 Jul 12.

Department of Thoracic Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, New York. Electronic address:

Background: Pulmonary resection for a second lung cancer after pneumonectomy is generally considered to be at prohibitive risk. Using a population-based database, we examined treatment patterns and survival in patients who underwent pulmonary resection after pneumonectomy for lung cancer.

Methods: We queried the Surveillance, Epidemiology, and End Results (SEER) database (1988-2012) to identify patients who underwent pneumonectomy and subsequently experienced contralateral non-small cell lung cancer (NSCLC). Multivariate logistic regression was performed to identify the factors associated with the receipt of surgical resection. Survival was estimated with the Kaplan-Meier method.

Results: Of 13,370 patients who underwent pneumonectomy, 402 (3.0%) experienced subsequent contralateral NSCLC, and 170 (42%) met the selection criteria. Surgical resection was performed in 63 (37.1%) cases (sublobar n = 56, lobectomy, n = 7). Patients with stage I/II disease and tumor size 2 cm or smaller were more likely to undergo surgical procedures. The 1-month and 3-month mortality after resection was 11.1% (sublobar resection 10.7%, lobectomy 14.3%) and 12.7% (sublobar 12.5%, lobectomy 14.3%), respectively. The overall 1-year and 3-year survival after surgical resection was 79% and 54%, respectively. The patients who underwent sublobar resection had higher median overall survival than did those who underwent lobectomy (42 vs 18 months). Similarly, median survival after resection for metachronous tumors was higher than after resection for metastatic cancers (40 vs 28 months).

Conclusions: On the basis of our analysis of the SEER database, sublobar resection can be performed in selected patients with small tumors (≤2 cm) and early-stage disease (stage I/II). Although perioperative mortality is significant, the favorable 1-year and 3-year survival may justify the role of an additional procedure on the single lung.
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http://dx.doi.org/10.1016/j.athoracsur.2017.04.043DOI Listing
October 2017

Circumferential Three-Dimensional-Printed Tracheal Grafts: Research Model Feasibility and Early Results.

Ann Thorac Surg 2017 Sep 13;104(3):958-963. Epub 2017 Jun 13.

Department of Otolaryngology, Mount Sinai West, Mount Sinai Health System, New York, New York.

Background: Methods for tracheal graft research have presented persistent challenges to investigators, and three-dimensional (3D)-printed biosynthetic grafts offer one potential development platform. We aimed to develop an efficient research platform for customizable circumferential 3D-printed tracheal grafts and evaluate feasibility and early structural integrity with a large-animal model.

Methods: Virtual 3D models of porcine subject tracheas were generated using preoperative computed tomography scans. Two designs were used to test graft customizability and the limits of the construction process. Designs I and II used 270-degree and 360-degree external polycaprolactone scaffolds, respectively, both encompassing a circumferential extracellular matrix collagen layer. The polycaprolactone scaffolds were made in a fused-deposition modeling 3D printer and customized to the recipient's anatomy. Design I was implanted in 3 pigs and design II in 2 pigs, replacing 4-ring tracheal segments. Data collected included details of graft construction, clinical outcomes, bronchoscopy, and gross and histologic examination.

Results: The 3D-printed biosynthetic grafts were produced with high fidelity to the native organ. The fabrication process took 36 hours. Grafts were implanted without immediate complication. Bronchoscopy immediately postoperatively and at 1 week demonstrated patent grafts and appropriate healing. All animals lived beyond a predetermined 1-week survival period. Bronchoscopy at 2 weeks showed significant paraanastomotic granulation tissue, which, along with partial paraanastomotic epithelialization, was confirmed on pathology. Overall survival was 17 to 34 days.

Conclusions: We propose a rapid, reproducible, resource efficient method to develop various anatomically precise grafts. Further graft refinement and strategies for granulation tissue management are needed to improve outcomes.
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http://dx.doi.org/10.1016/j.athoracsur.2017.03.064DOI Listing
September 2017

Three-Dimensional-Printed Bioengineered Tracheal Grafts: Preclinical Results and Potential for Human Use.

Ann Thorac Surg 2017 Sep 11;104(3):998-1004. Epub 2017 Jun 11.

Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York. Electronic address:

Background: We aimed to develop a process using three-dimensional (3D) printing to create bioengineered tracheal grafts (BETGs) for reconstruction of anterior tracheal defects in a large-animal model (porcine) that would have translational relevance for potential human use.

Methods: Preoperative computed tomographic scans were used to create virtual 3D models of the animal airways. Anatomically scaled tracheal grafts were subsequently developed using 3D-printed polycaprolactone and extracellular matrix. A 4-cm anterior tracheal defect (about 50% of the length of the subject trachea) was surgically created in 4-week-old female Yorkshire pigs and reconstructed using the customized grafts. Gross and microscopic analyses of the grafts were performed.

Results: The BETGs were implanted in 7 animals. There was adequate graft-native trachea size match at the operation. The trachea was successfully reconstructed in all cases. Gross examination at autopsy showed a structurally intact, well-incorporated graft. Histologic evaluation showed respiratory mucosal coverage and vascularity of the graft. Five of 7 animals outlived the 3-month study period. The animals had approximately 100% growth during the study period.

Conclusions: We report of a 3D-printed BETG to repair long-segment anterior tracheal defects in a large-animal model. Although the study duration is short, this work presents an efficient strategy for tracheal graft bioengineering with potential translational relevance for human use.
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http://dx.doi.org/10.1016/j.athoracsur.2017.03.051DOI Listing
September 2017

Electrophysiological changes in patients with liver cirrhosis in a tertiary care hospital in Karachi, Pakistan.

J Ayub Med Coll Abbottabad 2016 Oct-Dec;28(4):676-679

Department of Medicine, Section of Gastroenterology, Aga Khan University Hospital, Karachi, Pakistan.

Background: Electrophysiological changes in cirrhosis are well known but least investigated especially in our country hence we wanted to see electrophysiological changes especially QT interval in cirrhotic patients.

Methods: A cross-sectional study was conducted at Aga Khan University Hospital Karachi (AKUH) in which medical records (duration 2008-2010) of cirrhotic patients were reviewed.

Results: Three hundred and eighty cirrhotic patients' charts were studied, 227 (59.7 %) were male and mean age of this cohort was 52.8±12.6 years. The most common cause for CLD was Hepatitis C (CHC) in 260 (68.4%), NBNC in 56(14.7%) and HBV in 51 (13.4%). Only 225 had complete ECG workup, the mean corrected QT interval was 0.44±0.067sec. Among the electrophysiological abnormalities, 79 (35%) had a prolonged corrected QT interval, 7 (3.1%) had a prolonged PR interval (>0.22s) and prolonged QRS duration was seen in 23 (10.4%) patients. QT prolongation was seen in 1 of the 5 patients with Child Class A (20%), 22 of the 73 patients with Child Class B (30.1%), and 25 of the 61 patients with Child Class C (41%). However, this difference however was not statistically significant. (p-value=.331).

Conclusions: We conclude that QT prolongation is more frequent in patients with liver cirrhosis especially when the disease is more advanced like in Child C hence these patients are more prone to sudden cardiac death. Moreover, this study shows that the risk associated with QT prolongation is present through all classes of liver cirrhosis. We recommend that routine cardiac screening with ECG of all cirrhotic patients be performed.
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November 2017

Ozone Therapy Protects Against Rejection in a Lung Transplantation Model: A New Treatment?

Ann Thorac Surg 2017 Aug 24;104(2):458-464. Epub 2017 May 24.

Department of Thoracic Surgery, Mount Sinai Health System, New York, New York.

Background: No satisfactory treatment exists for chronic rejection (CR) after lung transplantation (LT). Our objective was to assess whether ozone (O) treatment could ameliorate CR.

Methods: Male Sprague-Dawley inbred rats (n = 36) were randomly assigned into four groups: (1) control (n = 6), (2) sham (n = 6), (3) LT (n = 12), and (4) O-LT (n = 12). Animals underwent left LT. O was rectally administered daily for 2 weeks before LT (from 20 to 50 μg) and 3 times/wk (50 μg/dose) up to 3 months. CR; acute rejection; and Hspb27, Prdx, Epas1, Gpx3, Vegfa, Sftpa1, Sftpb, Plvap, Klf2, Cldn5, Thbd, Dsip, Fmo2, and Sepp1 mRNA gene expression were determined.

Results: Severe CR was observed in all animals of LT group, but none of the O-LT animals showed signs of CR, just a mild acute rejection was observed in 1 animal. A significant decrease of Hspb27, Prdx, Epas1, Gpx3, Vegfa, Sftpa1, Sftpb, Plvap, Klf2, Cldn5, Thbd, Dsip, and Fmo2 gene expression in the O-LT group was observed CONCLUSIONS: O therapy significantly delayed the onset of CR regulating the expression of genes involved in its pathogenesis. No known immunosuppressive therapy has been capable of achieving similar results. From a translational point of view, O therapy could become a new adjuvant treatment for CR in patients undergoing LT.
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http://dx.doi.org/10.1016/j.athoracsur.2017.02.054DOI Listing
August 2017

Primary Non-Hodgkin's Lymphoma of the Gallbladder: A Population-based Analysis.

Anticancer Res 2017 05;37(5):2581-2586

Department of Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, NY, U.S.A.

Background/aim: Primary Non-Hodgkin's lymphoma of the gallbladder (PNHL-GB) is extremely rare and data on clinical characteristics, optimal management and outcomes of these patients are limited to anecdotal reporting. We, therefore, sought to examine these patients using a population-based database.

Materials And Methods: Surveillance, epidemiology, and end results (SEER) database was queried between 1973 and 2013.

Results: One hundred and six cases with PNHL-GB were identified (mean age=70.5 ±15 years, whites 92%, male: female 1.03:1). The majority of patients had loco-regional disease (61%) and DLBCL histology (33%). Ninenty cases (85%) had undergone surgical resection, 6 (5.6%) received radiotherapy. Median overall survival (OS) of the entire cohort was 41 months with a 5-year survival rate of 40%. Patients receiving adjuvant RT had superior OS compared to surgery alone (140 ±27 vs. 86 ±16 months, respectively) and patients with DLBCL demonstrated lower survival compared to other histologies (13 vs. 53 months, respectively, p=0.034).

Conclusion: Our study presents the largest dataset of PNHL-GB describing clinical features and outcomes of these patients in addition to summarizing the literature.
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http://dx.doi.org/10.21873/anticanres.11602DOI Listing
May 2017

Stents for airway strictures: selection and results.

J Thorac Dis 2017 Mar;9(Suppl 2):S116-S121

Department of Thoracic Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, NY, USA.

Airway stents can provide effective and timely relief in patients with central airway obstruction. Silicone based stents are the most commonly used airway stents worldwide with a long track record of safety. Metallic stents continue to evolve from the earliest uncovered versions to a variety of newly designed covered stents. Despite the availability of a variety of stent materials and designs, minimal advances have been made towards innovation in stent technology and an ideal stent has unfortunately not yet been developed. Nevertheless, the first generation of biodegradable airway stents are available, work on drug-eluted stents is in the pipeline and three-dimensional printing of a customized airway stent may be the future. In this review, we discuss selection and results for most commonly utilized airway stents.
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http://dx.doi.org/10.21037/jtd.2017.01.56DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5384891PMC
March 2017

Selective packing for uncontrollable traumatic thoracic wall bleeding preserving cardiopulmonary function.

Am J Surg 2017 Sep 21;214(3):413-415. Epub 2016 Dec 21.

Department of Thoracic Surgery, Mount Sinai Health System, New York, USA; Icahn School of Medicine, New York, USA.

Background: Uncontrollable chest wall bleeding secondary to thoracic trauma has been a challenging problem faced by surgeons. Thoracic packing has been described as a good alternative although most thoracic surgeons avoid it because of the potential deleterious effects on cardiopulmonary function.

Methods: We describe a selective gauze packing technique of the thoracic wall preserving cardiopulmonary function in 3 patients with uncontrollable bleeding, where gauze packs were placed on bleeding areas holding them in a "sandwich-like" arrangement between the skin and the pleura and tightly fixed with coated wire stitches using internal and external-thoracic Ventrofil® devices.

Results: Successful hemostasis and cardio-respiratory stability were achieved in all cases after selective packing. X-ray showed acceptable lung expansion and no heart compression.

Conclusions: This selective packing technique is simple, feasible and highly effective in managing uncontrollable post-traumatic or even post-operative chest wall hemorrhages when the life of patients is in danger.
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http://dx.doi.org/10.1016/j.amjsurg.2016.11.041DOI Listing
September 2017

Pneumopericardium Leading to Cardiac Tamponade in a Patient with Lung Cancer.

Thorac Cardiovasc Surg Rep 2016 Dec 29;5(1):13-15. Epub 2016 Jan 29.

Department of Thoracic Surgery, Mount Sinai St. Luke's and Mount Sinai West, New York, United States.

Pneumopericardium resulting in cardiac tamponade in patients with lung cancer is not documented. We report a case of squamous cell carcinoma of the lung complicated by pneumopericardium and subsequent cardiac tamponade. The patient underwent an urgent pericardial window with rapid improvement in symptoms. We discuss the possible pathogenesis and treatment options for this rare condition.
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http://dx.doi.org/10.1055/s-0036-1571360DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5177421PMC
December 2016

Primary appendiceal lymphoma: clinical characteristics and outcomes of 116 patients.

J Surg Res 2017 01 31;207:174-180. Epub 2016 Aug 31.

Department of Thoracic Surgery, Icahn School of Medicine, New York, New York.

Background: Primary appendiceal lymphoma (PAL) is extremely rare with limited data available in literature. In this study, we sought to describe clinical features and identify factors affecting survival in patients with PAL using a large population cohort.

Methods: Surveillance, Epidemiology, and End Results database was queried for patients with PAL between 1973 and 2012. Patient demographics, tumor characteristics, and outcomes were assessed.

Results: One hundred sixteen patients with PAL were included. The mean age (standard deviation) at diagnosis was 48 y (±22). PAL primarily afflicted males and white race. Diffuse large B-cell lymphoma was the most common histologic subtype (34.5%). Patients with Burkitt lymphoma presented at an earlier age compared with follicular lymphoma and diffuse large B-cell lymphoma (33 versus 59 and 53 y, respectively, [P < 0.001]). Mean overall survival (OS) for the whole cohort was 185 mo with a 5-y survival rate of 67%. No statistically significant survival difference was observed between gender, race and histologic subtypes. Right hemicolectomy conferred no survival benefit over appendectomy and/or partial colectomy (P = 0.501). In multivariate analysis, increasing age at diagnosis (P < 0.001) was associated with increased hazards of death while gender, race, tumor histology, disease stage, and nature of resection were not significantly associated with OS.

Conclusions: This is the largest series of PALs. Our results demonstrate that age at diagnosis is an independent predictor of poor survival. Gender, race, histologic subtypes have no effect on OS, and hemicolectomy provides no survival benefit over appendectomy and/or partial colectomy. Additional prospective, multicenter studies including details about chemotherapy and immunotherapy are needed to guide management.
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http://dx.doi.org/10.1016/j.jss.2016.08.079DOI Listing
January 2017

Elevated risk of subsequent malignancies in patients with appendiceal cancer: A population-based analysis.

Indian J Gastroenterol 2016 Sep 6;35(5):354-360. Epub 2016 Sep 6.

Division of Thoracic Surgery, Department of Surgery, Icahn School of Medicine, Mount Sinai Health System, New York, NY, USA.

Background: Appendiceal cancer is extremely rare with excellent survival after curative resection. There is a concern for the development of additional cancers in survivors of appendiceal cancer. However, existing data is limited to small anecdotal reports on appendiceal carcinoid only. We aim to investigate the risk of subsequent malignancies in patients with appendiceal carcinoma and correlate the risk according to patient and clinical characteristics.

Methods: We identified 3788 patients with appendiceal cancer from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database between 1992 and 2011. Standardized incidence ratios (SIRs) for the risk of additional cancers were calculated and quantified based on tumor site, gender, race, latency, primary tumor stage, and histology.

Results: Three hundred and fifty-nine subsequent malignancies were identified in 313 patients (mean age 60 years, male to female ratio 1.3:1). The overall risk for a subsequent malignancy was elevated by 20 % compared with the general population. Most common sites with significantly increased risk for subsequent cancers included the small intestine (n=13) and the colon/rectum (n=48). Malignant carcinoid and adenocarcinoma were the dominant histological subtypes at these sites, respectively. Significant elevated risk was observed within the first 5 years of follow up in white males with either localized or regional disease. Adenocarcinomas and goblet cell carcinoid tumors of the appendix were associated with increased risk; whereas, the risk was significantly reduced in patients with malignant carcinoid tumors.

Conclusion: There is an increased risk of subsequent cancers in patients with appendiceal carcinoma.
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http://dx.doi.org/10.1007/s12664-016-0687-3DOI Listing
September 2016

Oncological resection of lung cancer invading the aortic arch In full thickness using a non-fenestrated endograft.

J Surg Oncol 2016 Sep 22;114(4):412-5. Epub 2016 Aug 22.

Department of Thoracic Surgery, Mount Sinai Health System, New York, New York.

T4 lung cancer invading the full thickness of the aortic arch was completely removed in a 78-year-old lady using a non-fenestrated endograft closing the left subclavian artery origin without performing surgical revascularization. Left thoracotomy and upper lobectomy with resection of superior segment of the lower lobe and full thickness of the infiltrated aorta was performed without covering the aortic defect. The margins of the specimen were free of tumor. The patient survived 32 months. J. Surg. Oncol. 2016;114:412-415. © 2016 Wiley Periodicals, Inc.
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http://dx.doi.org/10.1002/jso.24359DOI Listing
September 2016

Treatment of Benign Tracheal Stenosis Using Endoluminal Spray Cryotherapy.

JAMA Otolaryngol Head Neck Surg 2016 11;142(11):1082-1087

Department of Otolaryngology-Head and Neck Surgery, Mount Sinai West, Mount Sinai Health System, New York, New York.

Importance: Tracheal stenosis is a debilitating disorder with heterogeneity in terms of disease characteristics and management. Repeated recurrences substantially alter patients' quality of life. There is limited evidence for the use of spray cryotherapy (SCT) in the management of benign airway disease.

Objective: To report our early results for the use of SCT in patients with benign tracheal stenosis.

Design, Setting, And Participants: Data were extracted from the medical records of a consecutive series of patients with benign airway stenosis secondary to granulomatosis with polyangiitis (GPA) (n = 13), prior tracheotomy or tracheal intubation (n = 8), and idiopathic strictures (n = 5) treated from September 1, 2013, to September 30, 2015, at a tertiary care hospital.

Main Outcomes And Measures: Airway narrowing was quantified on a standard quartile grading scale. Response to treatment was assessed by improvement in airway caliber and the time interval for reintervention.

Exposures: Delivery of 4 5-second SCT cycles and 2 balloon dilatations.

Results: Twenty-six patients (median [range] age, 53 [16-83] years; 20 [77%] female) underwent 48 SCT sessions. Spray cryotherapy was successfully used without any substantial intraoperative or postoperative complications in all patients. In a median (range) follow-up of 11 (1-26) months, all patients had improvement in symptoms. Before the institution of SCT, 23 patients (88%) had grade III or IV stenosis. At the last evaluation after induction of SCT, 4 (15%) had grade III or IV stenosis, with a mean (SD) change of 1.39 (0.51) (P < .001). Patients with GPA required significantly fewer SCT procedures (mean [SD], 1.38 [0.96] vs 2.31 [1.18]; P = .03) during the study period.

Conclusions And Relevance: Spray cryotherapy was a safe adjunct modality to accomplish airway patency in patients with benign tracheal stenosis. Although efficacy evidence is limited for SCT, it may be useful for patients who have experienced treatment failure with conventional modalities. Further analysis of this cohort will determine the physiologic durability of the reported short-term changes. Additional trials are warranted for further evaluation of this modality.
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http://dx.doi.org/10.1001/jamaoto.2016.2018DOI Listing
November 2016

Proton pump inhibitors and other disease-based factors in the recurrence of adverse cardiovascular events following percutaneous coronary angiography: A long-term cohort.

Indian J Gastroenterol 2016 Mar 8;35(2):117-22. Epub 2016 Apr 8.

Department of Medicine, Aga Khan University Hospital, Stadium Road, Karachi, Sindh, Pakistan.

Background: Dual aspirin-clopidogrel antiplatelet therapy (DAPT) has been shown to decrease the risk of adverse cardiac events after percutaneous coronary intervention (PCI). Proton pump inhibitors (PPIs) are used in these patients to decrease the risk of gastrointestinal bleeding and several studies have reported potential interaction and conflicting clinical outcomes with their use. We aim to assess the effect of different PPIs and other factors on the recurrence of cardiovascular (CV) events in patients following PCI.

Methods: We performed a retrospective cohort on patients who underwent PCI in the last 5 years and were discharged with or without PPIs. Strict inclusion criteria were adopted, outcome measures were defined, and patient follow up up to 2 years was collected.

Results: Out of 740 patients, 453 (61.2 %) had received PPIs and 287 (38.8 %) were discharged without PPIs. Ninety-five (12.8 %) patients were readmitted due to adverse CV events. Statistically, there was no significant difference in the recurrence of CV events with the use of different PPIs (p = 0.384) and PPI use had an overall protective effect (p = 0.009, HR 0.58 (CI 0.39-0.88). Patients with history of diabetes mellitus (p = 0.048) had an increased risk of adverse CV events.

Conclusion: We conclude that pharmacokinetic interaction between PPIs and antiplatelet therapy is not associated with adverse CV events. A comprehensive, multicenter, open-label trial including all PPI subclasses and patient and disease-based factors is warranted for a fair evaluation.
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http://dx.doi.org/10.1007/s12664-016-0645-0DOI Listing
March 2016

Primary Hepatic Carcinoid Tumor with Poor Outcome.

J Coll Physicians Surg Pak 2016 Mar;26(3):227-9

Department of Medicine, The Aga Khan University Hospital, Karachi.

Primary Hepatic Carcinoid Tumor (PHCT) represents an extremely rare clinical entity with only a few cases reported to date. These tumors are rarely associated with metastasis and surgical resection is usually curative. Herein, we report two cases of PHCT associated with poor outcomes due to late diagnosis. Both cases presented late with non-specific symptoms. One patient presented after a 2-week history of symptoms and the second case had a longstanding two years symptomatic interval during which he remained undiagnosed and not properly worked up. Both these cases were diagnosed with hepatic carcinoid tumor, which originates from neuroendocrine cells. Case 1 opted for palliative care and expired in one month’s time. Surgical resection was advised to the second case, but he left against medical advice.
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http://dx.doi.org/03.2016/JCPSP.227229DOI Listing
March 2016

Refeeding syndrome in a young girl with anorexia nervosa.

J Coll Physicians Surg Pak 2014 May;24 Suppl 2:S78-80

Department of Medicine, The Aga Khan University Hospital, Karachi.

We report the case of a 20-year-old anorexic girl (BMI=12.9), who was misdiagnosed the first time and developed severe electrolyte imbalances due to lack of awareness about refeeding syndrome. Few cases of RS have been reported in literature and protocols have been suggested for prevention and management of this syndrome, including the awareness of circumstances in which it is most likely to develop, refeeding slowly and building-up micronutrient content over several days. Improved awareness and understanding of refeeding syndrome along with a well-coordinated plan are vital in delivering safe and effective nutritional rehabilitation. We suggest a slow and gradual increase in nutrition along with nutritional counselling and psychotherapy.
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http://dx.doi.org/05.2014/JCPSP.S78S80DOI Listing
May 2014

Wilson's disease: Experience at a tertiary care hospital.

J Coll Physicians Surg Pak 2013 Jul;23(7):525-6

Department of Medicine, The Aga Khan University, Karachi.

Wilson's disease (WD) is a rare autosomal recessive disorder of copper metabolism. Data regarding WD is not available from Pakistan. A cross-sectional study was conducted at The Aga Khan University Hospital, Karachi, and all patients admitted with primary and secondary diagnosis of Wilson's disease were added. A total of 47 patients were seen; 68% (n = 32) were male. The mean age was 26.6 ± 9.97 years. Most of the patients presented with hepatic, (n = 22, 46.8%), neurological, (n = 17, 36.2%) and psychiatric (n = 8, 17%) symptoms. Mean ceruloplasmin level was 0.17 ± 0.13 g/dl; it was < 0.25 g/dl in 39 (86.6%) patients. Serum copper (Cu) was reduced in 32 (68.1%) patients and 24-hr-urinary Cu was raised in 22 (47.6%) patients. Slit lamp examination for Kayser-Fleischer (KF) rings was done on 15 (31.9%) patients and 9 (60%) of them had KF rings. Mean serum aspartate transaminase (AST) / alanine transaminases (ALT) ratio was 1.92 and median alkaline phosphatase / total bilirubin ratio was 79.30 (IQR 35.05; 166.50).
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http://dx.doi.org/07.2013/JCPSP.525526DOI Listing
July 2013
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