scholarly journals Hybrid repair of extensive thoracic aortic aneurysms

2020 ◽  
Vol 58 (5) ◽  
pp. 940-948
Author(s):  
Gabriele Piffaretti ◽  
Santi Trimarchi ◽  
Guido Gelpi ◽  
Claudia Romagnoni ◽  
Sandro Ferrarese ◽  
...  
Keyword(s):  
Aortic Rupture ◽  
Survival Rates ◽  
Final Analysis ◽  
Study Data ◽  
Aortic Aneurysms ◽  
Single Stage ◽  
Two Stage ◽  
Early Results ◽  
Hybrid Repair

Abstract OBJECTIVES Our goal was to report the midterm results of hybrid treatment of extensive thoracic aortic aneurysm (ETAA) with the completion of thoracic endovascular aortic repair after proximal ascending-arch graft replacement. METHODS This was a multicentre, observational study. Data were collected prospectively between January 2002 and March 2019 and analysed retrospectively. Inclusion criteria for the final analysis were the treatment of elective or urgent ETAA performed in a single-stage or a planned two-stage approach. Early and late survival rates were the primary outcomes. RESULTS Indications for repair were degenerative ETAA in 27 (64.3%) patients and dissection-related ETAA in 15 (35.7%). The mean aortic diameter was 68 ± 16 mm (interquartile range 60–75). Five (11.9%) patients had a single-stage repair; and 37 underwent a two-stage approach. Three (7.1%) patients died in-hospital. The median follow-up was 49 months (range 0–204). During the follow-up period, 4 (9.5%) patients underwent aortic reintervention after a median of 32 months; however, no aortic rupture of the treated segment occurred. Overall, the estimated survival rate was 85% ± 6% [95% confidence interval (CI) 70.8–93] at 12 and 36 months and 69.5% ± 9% (95% CI 49.7–84) at 60 months. CONCLUSIONS Hybrid repair of ETAA had satisfactory early results in this cohort of patients. At the midterm follow-up, the aneurysm-related mortality rate was acceptable with the reconstruction proving to be durable and safe with few distal aortic events.

scholarly journals Early results of a low-profile stent-graft for thoracic endovascular aortic repair

PLoS ONE ◽  
2020 ◽  
Vol 15 (11) ◽  
pp. e0240560
Author(s):  
Hazem El Beyrouti ◽  
Mario Lescan ◽  
Marco Doemland ◽  
Migdat Mustafi ◽  
Florian Jungmann ◽  
...  
Keyword(s):  
Stent Graft ◽  
Aortic Rupture ◽  
Clinical Success ◽  
Intramural Hematoma ◽  
Aortic Aneurysms ◽  
Elephant Trunk ◽  
Landing Zone ◽  
Early Results ◽  
Low Profile

Purpose To assess outcomes of a low-profile thoracic stent-graft in the treatment of thoracic aortic pathologies. Methods A retrospective analysis of all consecutive patients with aortic thoracic pathologies treated with the RelayPro device in two university hospitals between October 2018 and July 2019. Results 23 patients (65% men; mean age 63.4 ± 15 years) were treated. Pathologies included aortic dissections (n = 10), 5 residual type A (22%) and 5 type B (22%), 6 degenerative aortic aneurysms (26%), 4 penetrating aortic ulcers (17%), and aortic erosion, intramural hematoma and aortic rupture (n = 1 and 4% in each case). Two cases (9%) were emergent and two urgent. Proximal landing was achieved in zones 0 (4%), 1 (4%), 2 (43%), and 3 (26%). Five grafts were frozen elephant trunk extensions. Technical success was 100% with accurate device deployment in the intended landing zone of the aortic arch in all 23 patients and with no Ia/III endoleaks and three (13%) type II endoleaks. Apposition was adequate in 96%. Two patients had post-implantation syndromes (one fever, one leukocytosis). Mean follow-up was 11.6 ± 3.7 months (range, 2–16) with no other complications, secondary interventions or conversions to open surgery. There was no 30-day mortality and no aortic-related mortality; all-cause mortality was 4% during follow-up. Conclusion A 3–4 French reduced profile in the current generation of stent-grafts facilitates TEVAR particularly in patients with smaller vessels access. Early safety and effectiveness outcomes are favorable, even in endpoints such as deployment accuracy and apposition which may be surrogates for longer-term clinical success and durability.

Hybrid Endovascular Repair of Thoracoabdominal Aorta: Early Results

2014 ◽  
Vol 17 (3) ◽  
pp. 146
Author(s):  
Osman Tansel Darcin ◽  
Mehmet Kalender ◽  
Ayse Gul Kunt ◽  
Okay Guven Karaca ◽  
Ata Niyazi Ecevit ◽  
...  
Keyword(s):  
Endovascular Repair ◽  
Therapeutic Option ◽  
Complete Recovery ◽  
Aortic Aneurysms ◽  
Thoracoabdominal Aorta ◽  
Mortality And Morbidity ◽  
Early Results ◽  
The Mean ◽  
Procedural Success

<p><b>Background:</b> Thoracoabdominal aortic aneurysms (TAAA) present a significant clinical challenge, as they are complex and require invasive surgery. In an attempt to prevent considerably high mortality and morbidity in open repair, hybrid endovascular repair has been developed by many authors. In this study, we evaluated the early-term results obtained from this procedure.</p><p><b>Methods:</b> From November 2010 to February 2013, we performed thoracoabdominal hybrid aortic repair in 18 patients. The mean age was 68 years (12 men, 6 women). All of the patients had significant comorbidities. Follow-up computed tomography (CT) scans were performed at 1 week, 3 months, 6 months, and annually thereafter.</p><p><b>Results:</b> All patients were operated on in a staged procedure and stent graft deployment was achieved. Procedural success was achieved in all cases. All patients were discharged with complete recovery. No endoleaks weres detected in further CT examination.</p><p><b>Conclusion:</b> Our results suggests that hybrid debranching and endovascular repair of extensive thoracoabdominal aneurysms represents a suitable therapeutic option to reduce the morbidity and mortality of TAAA repair, particularly in those typically considered at high risk for standard repair.</p>

Long-Term Follow-Up after Frontline Therapy with the Hyper-CVAD and Imatinib Mesylate Regimen in Adults with Philadelphia (Ph) Positive Acute Lymphocytic Leukemia (ALL).

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 9-9
Author(s):  
Deborah A. Thomas ◽  
Hagop M. Kantarjian ◽  
Farhad Ravandi ◽  
Stefan Faderl ◽  
Guillermo Garcia-Manero ◽  
...  
Keyword(s):  
De Novo ◽  
Survival Rates ◽  
Disease Recurrence ◽  
Lymphocytic Leukemia ◽  
Myelogenous Leukemia ◽  
Multiparameter Flow Cytometry ◽  
Molecular Response ◽  
Cell Transplant ◽  
Early Results

Historically, complete remission (CR) rates with hyper-CVAD (cyclophosphamide, vincristine [VCR], doxorubicin and dexamethasone alternating with methotrexate and cytarabine) in de novo adult Ph-ALL were 90% or better. There was no impact on survival since remissions were brief with median CR duration of 16 mos [Kantarjian, JCO18:547, 2000; Cancer101:2788, 2004]. CR rate of imatinib in relapsed/refractory Ph-ALL or chronic myelogenous leukemia in lymphoid blast phase was 20%, with rapid disease recurrence. A phase II trial of hyper-CVAD and imatinib for Ph-ALL was designed in 2001. Imatinib 400 mg was given days 1–14 of each course, followed by 12 months of continuous imatinib with monthly VCR and prednisone interrupted by 2 intensifications with hyper-CVAD and imatinib. Allogeneic stem cell transplant (SCT) was performed in first CR as feasible. Early results of 20 patients (pts) were encouraging and demonstrated feasibility [Thomas, Blood 103:4396, 2004]. Imatinib was then increased to 600 mg days 1–14 of course 1, continuously with courses 2–8, escalated to 800 mg during maintenance therapy (extended to 24 mos) then imatinib indefinitely. The study has completed accrual. Fifty-four pts with imatinib-naïve de novo or minimally treated Ph-ALL received therapy from April 2001 to September 2006. Forty-five pts had active disease, untreated (n=39) or refractory (n=6) to one induction course; 9 were in CR at start. Median age was 51 years (range, 17–84); 52% were male. Seven pts (13%) had CNS disease at presentation. Of 45 evaluable pts 42 (93%) achieved CR (1 CRp, 1 partial response, 1 died early from sepsis). Median days to response was 21. Molecular response rate (negative by nested PCR) was 52%. Allogeneic SCT was performed in 16 pts within a median of 5 mos from start of therapy (range, 1–13), and did not appear to improve survival (2-yr rates 63% vs 56% without SCT). After median follow-up of 4 years (range, 10–74 mos), eleven relapses (22%) were observed. Eight de novo pts relapsed at 8, 8, 10, 11, 11, 15, 16 and 42 mos from start of therapy (2 after SCT without imatinib maintenance); 2 CR at start at 16 and 19 months, and 1 primary refractory pt at 12 mos. Two pts changed therapy for persistent molecular disease or intolerance and relapsed at 6 and 10 mos. Relapse was preceeded by positive multiparameter flow cytometry with minimal increments in levels of quantitative RT-PCR for bcr-abl in a few cases. Non T315I ABL kinase domain (KD) mutations were identified at relapse in 3 of 8 pts tested. Deaths included 12 pts in CR (5 infections, 4 complications of allogeneic SCT, 1 pancreatitis, 1 intracranial hemorrhage, 1 unknown). The hyper-CVAD and imatinib regimen continues to demonstrate favorable 3-yr disease-free and overall survival rates for the de novo group compared with hyper-CVAD alone (66% vs 14% and 55% vs 15%, respectively, p<0.001). Development of ABL KD mutations was noted at disease recurrence in a few cases. Incorporation of the newer tyrosine kinase inhibitors into combination with therapy with hyper-CVAD is underway.

Systemic capecitabine and oxaliplatin administered with hepatic arterial infusion (HAI) of floxuridine (FUDR) following complete resection of colorectal metastases (M-CRC) confined to the liver: A North Central Cancer Treatment Group (NCCTG) phase II intergroup trial

2006 ◽  
Vol 24 (18_suppl) ◽  
pp. 3525-3525 ◽  
Author(s):  
S. R. Alberts ◽  
M. R. Mahoney ◽  
J. Donohue ◽  
M. S. Roh ◽  
E. M. Green ◽  
...  
Keyword(s):  
Primary Endpoint ◽  
Survival Rates ◽  
Hepatic Metastases ◽  
Hepatic Arterial Infusion ◽  
Patient Characteristics ◽  
Colorectal Metastases ◽  
North Central ◽  
Early Results ◽  
Grade 3

3525 Background: The prognosis for patients with hepatic metastases from M-CRC can be poor. However, surgery followed by HAI FUDR plus systemic (SYS) 5-FU improves 5-yr survival rates. Oxaliplatin (OXAL) combined with capecitabine (CAPE) has demonstrated activity in advanced CRC. We report early results of an analysis of SYS OXAL plus CAPE, alternating with HAI FUDR. The primary endpoint is 2-yr survival (2YS). Methods: Patients with M-CRC liver lesions amenable to resection ± ablation were eligible. HAI + SYS therapy was initiated following metastasectomy. Alternating courses of HAI consisted of 0.2 mg/m2/d FUDR and dexamethasone, d1–14 weeks 1 & 2. SYS therapy included 130 mg/m2 OXAL d1, with CAPE at 1000 mg/m2 p.o. BID, d1–14, weeks 4 & 5. Two additional 3-wk courses of SYS therapy were given. CAPE was reduced to 850 mg/m2/BID after interim review of toxicity (GI Cancer Symposium 2004). Patient Characteristics: 54 of 70 patients were able to initiate HAI FUDR + SYS. 52% had a solitary met and 24% presented with bilobar mets. Results: Patients completed median of 6 cycles (range 1 - 6). Reasons for discontinuation included: refusal/toxicity (10), completed per protocol (32), recurrence (4), and medical/other (3). No post-operative or treatment related deaths were reported. 69% (31/45) of evaluable patients are alive with a minimum 18 mos of follow-up. 6 deaths occurred in less than 2 yrs. 44% (20/45) have recurred, with 40% (8/20) having liver involvement. Median time-to-progression is 32 mos with an estimated 2YS rate of 86% (95% CI 76–97%). Conclusions: The combination of HAI FUDR and SYS therapy appears to improve outcome following resection of hepatic CRC-M. Updated follow-up is necessary to solidify the primary endpoint of 2YS. Supported by NIH Grant CA25224–18, Sanofi-Synthelabo, and Roche Laboratories, Inc. Maximum Severity, Grade 3+ (N=54) [Table: see text] [Table: see text]

Early Results after Staged Hybrid Repair of Thoracoabdominal Aortic Aneurysms

2007 ◽  
Vol 205 (3) ◽  
pp. 420-431 ◽  
Author(s):  
W. Anthony Lee ◽  
Michael P. Brown ◽  
Tomas D. Martin ◽  
James M. Seeger ◽  
Thomas S. Huber
Keyword(s):  
Aortic Aneurysms ◽  
Early Results ◽  
Hybrid Repair

Hybrid Repair of Thoracic and Thoracoabdominal Aortic Aneurysms (Mega Aortic Syndrome) with Lupiae Technique

2011 ◽  
Vol 6 (6) ◽  
pp. 366-372 ◽  
Author(s):  
Giampiero Esposito ◽  
Giangiuseppe Cappabianca ◽  
Gaetano Contegiacomo ◽  
Giuseppe Labriola ◽  
Nunzio Gallo ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Superior Mesenteric Artery ◽  
Mesenteric Artery ◽  
False Lumen ◽  
Celiac Trunk ◽  
Aortic Aneurysms ◽  
Cord Injury ◽  
Hybrid Repair

Objective Several techniques have been described for the treatment of thoracic and thoracoabdominal aneurysms in patients with mega aortic syndrome (MAS), but the incidence of stroke, spinal cord injury, and endoleaks remains high. We present the midterm results of a new hybrid, multistep technique to treat patients with MAS. Methods From November 2005 to January 2011, 80 patients with MAS underwent hybrid repair of thoracic and thoracoabdominal aneurysms with the Lupiae technique. Forty-six patients presented with chronic aortic aneurysms, and 34 patients who had undergone aortic arch debranching with the Lupiae graft for acute aortic dissection presented with an expanding false lumen into the residual aorta. Sixty patients underwent ascending aorta and arch replacement with a Gelweave Lupiae prosthesis plus epiaortic vessel debranching (thoracic Lupiae procedure). Fourteen patients underwent a thoracic Lupiae procedure plus partial visceral debranching (celiac trunk and superior mesenteric artery) through a mini-laparotomy. Six patients underwent a thoracic Lupiae procedure plus a complete visceral debranching (celiac trunk, superior mesenteric artery, and renal arteries) with the implant of a second Lupiae prosthesis to replace the abdominal aorta. After the surgical steps, all the surviving patients underwent an endovascular procedure to implant multiple stent grafts to exclude the residual segment of diseased aorta. Results In-hospital mortality was 8.4%, and the incidence of temporary renal failure was 5.2%. None of the patients had a stroke or a spinal cord injury, and none of the patients presented endoleaks immediately following the procedure or during the follow-up computed tomography scans. No deaths occurred during the 6-year follow-up after the hybrid procedure. Conclusions These preliminary results showed that the Lupiae technique is a safe and effective option for the treatment of patients with MAS. Indeed, the Lupiae technique achieves complete exclusion of thoracic and thoracoabdominal aneurysms with a low risk of paraplegia and endoleaks.

Fenestrated and Branched Endovascular Aortic Repair of Thoracoabdominal Aortic Aneurysm With More Than 4 Target Visceral Vessels due to Renovisceral Arterial Anatomical Variations: Feasibility and Early Results

2021 ◽  
pp. 152660282110164
Author(s):  
Ahmed Eleshra ◽  
Giuseppe Panuccio ◽  
Konstantinos Spanos ◽  
Fiona Rohlffs ◽  
Nikolaos Tsilimparis ◽  
...  
Keyword(s):  
Anatomical Variations ◽  
Celiac Artery ◽  
Renal Arteries ◽  
Aortic Aneurysms ◽  
Endovascular Aortic Repair ◽  
Technical Success ◽  
Early Results ◽  
The Mean ◽  
Accessory Renal Arteries

Purpose: This study describes technical success, feasibility, and early results of fenestrated and branched endovascular aortic repair (F/B-EVAR) for treatment of thoracoabdominal aortic aneurysms (TAAAs) or pararenal aneurysms with more than 4 target visceral vessels (TVs) due to renovisceral arterial anatomical variations. Materials and Methods: Patients with TAAAs or pararenal aortic aneurysms who had more than 4 TVs due to renovisceral arterial anatomical variations of renal, celiac, and/or superior mesenteric arteries and received F/B-EVAR between January 2017 and September 2019 at a single aortic center were included in this study. We analyzed technical success, feasibility, and early outcomes. Results: Twelve patients (mean age 70±10 years, 9 males) were included. The anatomical variations included 6 right accessory renal arteries, 8 left accessory renal arteries, and 1 celiac artery variant. Stent-grafts were fenestrated, branched or combined in 6, 5, or 1 patients, respectively. The mean operating time was 346±120 minutes, the mean fluoroscopy time was 80±29 minutes, and the mean radiation dose area product was 430±219 Gy·cm2. The mean contrast volume was 129±45 mL. The total number of TVs was 64; 5 TVs in 9 patients, 6 in 2 patients, and 7 in 1 patient. Technical success was achieved in all cases. The mean intensive care unit stay was 6±5 days, and the mean total hospital stay was 14±10 days. One patient died early (30-day). Early morbidities included respiratory complication in 1 patient, renal insufficiency in 1 patient, and wound infection in 2 patients. No spinal cord ischemia, stroke, or bowel ischemia occurred. Early computed tomography angiography showed 100% patency of the bridging covered stents and TVs. The mean follow-up was 13±4.3 months. No mortality or adverse major event occurred during the follow-up. Two patients with developed type Ic endoleak related to 1 right renal artery and 1 celiac artery covered stent. Patency of the TVs during follow-up was 100%. Conclusion: The use of F/B-EVAR for the treatment of TAAA with more than 4 TVs due to renovisceral arterial anatomical variations in our own experience is feasible and not related to increased morbidity and mortality.

Endovascular Grafting of Traumatic Aortic Aneurysms in Contaminated Fields

2001 ◽  
Vol 8 (3) ◽  
pp. 262-267 ◽  
Author(s):  
Stefan Krämer ◽  
Reinhard Pamler ◽  
Harald Seifarth ◽  
Hans-Jürgen Brambs ◽  
Ludger Sunder-Plassmann ◽  
...  
Keyword(s):  
Aortic Rupture ◽  
Aortic Aneurysms ◽  
Long Term Results ◽  
White Blood Count ◽  
Stent Grafts ◽  
Transfemoral Approach ◽  
Aortic Lesion ◽  
Stent Grafting ◽  
Reactive Protein

Purpose: To evaluate the potential of endovascular stent-grafts to treat traumatic aortic lesions in contaminated areas. Methods: Four patients (3 women; ages 26–78 years) underwent stent-grafting to repair an aortic rupture sustained in a motorcycle accident, aortic lacerations secondary to surgical treatment of spondylitis in 2 patients, and an aortobronchial fistula following surgical thoracic aortic repair 10 years earlier. Stent-grafts (2 Corvita, 1 Talent, and 1 Vanguard) were placed endoluminally into the infected areas via a transfemoral approach. Follow-up included erythrocyte sedimentation rate, white blood count, C-reactive protein, blood cultures, and computed tomography (CT). Results: The stent-grafts were successfully placed in all cases and excluded the aortic lesion. Under supportive antibiotic therapy, inflammation parameters returned to normal. CT imaging showed no evidence of paraprosthetic infection, nor were there any other complications over a follow-up that ranged from 3 to 34 months. Conclusions: Endovascular therapy may be an alternative in the acute management of aortic ruptures in the setting of infection. Long-term results are required for definitive evaluation of the method.

scholarly journals HYPOSPADIAS REPAIR IN CHILDREN: 10-YEARS EXPERIENCE AT SHAIKH ZAYED HOSPITAL LAHORE.

2019 ◽  
Vol 26 (07) ◽  
pp. 1020-1026
Author(s):  
Muhammad Ali Sheikh ◽  
Tariq Latif ◽  
Jamil Akhter Munir Ahmad
Keyword(s):  
Single Stage ◽  
Paediatric Surgery ◽  
Two Stage ◽  
Proximal Hypospadias ◽  
Tubularized Incised Plate ◽  
Tubularized Incised Plate Urethroplasty ◽  
The Common ◽  
Distal Hypospadias ◽  
Study Setting

Introduction: Hypospadias is one of the common urogenital condition affecting male children. Multiple factors have been reported by different studies that contribute towards hypospadias, including in utero growth retardation, higher maternal age and endocrine disruptors. Usually multiple surgical procedures are required for correction of hypospadias especially in cases of proximal hypospadias associated with chordee. Objectives: The purpose of study was to report the early outcomes after single stage repair for distal hypospadias and staged repair for proximal hypospadias over the last 10 years in our department. Study Design: Descriptive Study. Setting: Department of Paediatric Surgery, Shaikh Zayed Hospital Lahore. Period: January 2006 to December 2016. Materials & Methods: This study was conducted in Department of Pediatric Surgery, Shaikh Zayed Hospital Lahore. All the patients who were operated between January 2006 to December 2016 for hypospadias or their complications in our unit were included. Data was collected from chart review and outpatient follow up. Data for age at presentation, type of anomaly, congenital curvature, testosterone stimulation, surgical procedure and complications with their management were collected. Patients were divided in two groups depending upon whether single stage procedure was performed or two stage surgery was undertaken. All patients with glandular hypospadias had meatal advancement but glanuloplasty was done in selected cases. Patients with distal hypospadias without chordee underwent tubularized incised plate urethroplasty (TIP) repair. Patients with proximal hypospadias had two stage surgery with correction of chordee with grafting and tubularization of graft after 6 months. Data was analyzed by SPSS v 22. Results: During the study period 134 patients with hypospadias or its complication were managed. Out of these 90 patients met our inclusion criteria. The mean age of patients was 5.0 years. Sixty three (70 %) had distal hypospadias. MAGPAI was performed in 12 (13.3%), TIP repair in 51 (56.7%), Bracka I in 25 (27.8%), Bracka II in 18 (20.0%) and Mathieu repair in 2 (2.2%) patients. Both the patients with Mathieu repair had dehiscence. The most common complication in distal cases was meatal stenosis. In patients with distal hypospadias 10.8% developed fistula while 44.5% of patients with proximal hypospadias developed fistula. Conclusion: Repair of proximal hypospadias with chordee is associated with more complications. Outcomes may be improved by specialized training with adequate workload.

scholarly journals Augmentation for Acetabular Deficiencies in Complex Total Hip Arthroplasty

2020 ◽  
Vol 8 (5_suppl5) ◽  
pp. 2325967120S0007
Author(s):  
Gandhi Nathan Solayar
Keyword(s):  
Total Hip Arthroplasty ◽  
Hip Arthroplasty ◽  
Study Data ◽  
Harris Hip Score ◽  
Wound Complications ◽  
Total Hip ◽  
Early Results ◽  
Revision Tha ◽  
The Mean

Introduction: Complex and revision Total Hip Arthroplasty (THA) is a challenging prospect in patients with acetabular bone deficiencies. Augmentation using allograft and trabecular metal (TM) are among some of the options in these situations. This study report the outcomes of 14 cases of complex and revision THA using acetabular augments performed in our institution between 2015 and 2018 Materials and Methods: In this retrospective study, data included demographic features, indication for THA, type of augments and clinical outcomes using the Harris hip score were collected for the to determine early results following THA. Results: The mean cohort age was 51.3 years. Gender distribution was equal with 7 male and female patients each. 7 THAs were augmented with allograft and 7 cases with TM augments. The average duration of follow-up was 16.9 months. Most patients (11 of 14) required complex primary THA following prior traumatic hip dislocations and its subsequent complications. The mean post-operative Harris hip score for functionality was 80.84 in our cohort at final follow-up (from an average of 33.8 pre-operatively). At present, there have been no reports of wound complications, infections or dislocations in this early cohort. Discussions: Complex/revision THA using allografts for acetabular augmentation have been used for decades with good and replicable results as shown in our series. TM is relatively new but current literatures show encouraging results. Both options have resulted in good outcomes in our cohort and further long term studies would be necessary before TM augments were to replace the need for allograft. Conclusions: Both allografts and TM acetabular augments showed good early results post-operatively in our cohort. With the improved flexibility of component selection and the lower risk of allograft infection, TM augments is currently our choice of acetabular augmentation and the early results are promising.

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