Fate of the external carotid artery following carotid interventions

OBJECTIVE:

The external carotid artery (ECA) is an important collateral pathway for cerebral blood flow. Carotid artery stenting (CAS) typically crosses the ECA, while carotid endarterectomy (CEA) includes deliberate ECA plaque removal. The purpose of the present study was to compare the long-term patency of the ECA following CAS and CEA as determined by carotid duplex ultrasound.

METHODS:

Duplex ultrasounds and hospital records were reviewed for consecutive patients undergoing CAS between February 2002 and April 2008, and were compared with those undergoing CEA in the same time period. Preoperative and postoperative ECA peak systolic velocities were normalized to the common carotid artery (CCA) as ECA/CCA ratios. A significant (80% or greater) ECA stenosis was defined as an ECA/CCA ratio of 4.0. A change of ratio by more than 1 was defined as significant. Data were analyzed using Student’s t test and χ² analysis.

RESULTS:

A total of 86 CAS procedures in 83 patients were performed (81 men, mean age 69.9 years). Among them, 38.4% of patients had previous CEA, 9.6% of whom had contralateral internal carotid artery occlusion. Sixty-seven CAS and 65 CEA patients with complete duplex data in the same time period were included in the analyses. There was no difference in the incidence of severe ECA stenosis on preoperative ultrasound evaluations. During a mean follow-up of 34 months (range four to 78 months), three postprocedure ECA occlusions were found in the CAS group. The likelihood of severe stenosis or occlusion following CAS was 28.3%, compared with 11% following CEA (P<0.025). However, 62% of CEA patients and 57% of CAS patients had no significant change in ECA status. Reduction in the patient’s degree of ECA stenosis was observed in 9.4% of CAS versus 26.6% of CEA patients. Overall, immediate postoperative ratios of both groups were slightly improved, but there was a trend of more disease progression in the CAS group during follow-up.

CONCLUSION:

CAS is associated with a higher incidence of post-procedure ECA stenosis. Despite the absence of neurological symptoms, a trend toward late disease progression of ECA following CAS warrants long-term evaluation.     

The impact of early CD4+ lymphocyte recovery on the outcome of patients who undergo allogeneic bone marrow or peripheral blood stem cell transplantation

Background

Different factors influence the clinical outcome of allogeneic transplants, the foremost being good immune recovery.

Materials and methods

The purpose of this study was to evaluate the influence of different factors, such as stem cell source, type of donor, conditioning regimen and acute graft-versus-host disease, on early lymphocyte recovery after transplantation. We then analyzed the impact of early CD4+ cell count on overall survival, transplant-related mortality and disease-related mortality.

Results

Univariate analysis with Spearman’s rho showed a significant correlation between early CD4+ cell recovery and overall survival, transplant-related mortality, stem cell source and type of donor. In multivariate analysis CD4+ cell count was significantly associated with (i) stem cell source, being higher in patients whose haematopoietic progenitor cells were obtained by apheresis than in those whose source of grafted cells was bone marrow, and (ii) type of donor, being higher in patients transplanted from sibling donors than in those whose graft was from an alternative donor. The ROC curve of CD4+ cell count indicated that a cut-off of 115 CD4+ cells/mL could differentiate groups with different outcomes. At 2 years follow-up, patients achieving this CD4+ cell count had significantly lower cumulative transplant-related mortality compared to patients who did not have this count (10%±4% versus 40%±8%, p=0.0026). At the 5-year follow-up, the overall survival rates were 77.5%±0.6% and 36%±7% (p=0.000) in patients with a CD4+ cell count ≥115/mL and in patients with CD4+ cell count ≤ 115/mL, respectively.

Conclusion

Early CD4+ cell recovery after allogeneic transplantation has a relevant impact on overall survival and transplant-related mortality and is influenced by two factors: stem cell source and type of donor.     

Vitamin E does not slow the progression of hypercholesterolemic atherosclerosis

BACKGROUND:

Vitamin E suppresses the development of atherosclerosis but does not regress established hypercholesterolemic atherosclerosis.

OBJECTIVES:

To investigate whether vitamin E slows the progression of established atherosclerosis, and whether this effect is associated with reductions in serum lipids and oxidative stress.

METHODS:

The present study was performed in four groups of rabbits: group I, regular diet (control); group II, 0.25% cholesterol diet (two months); group III, 0.25% cholesterol diet (four months); and group IV, 0.25% cholesterol diet (two months) followed by 0.25% cholesterol and vitamin E (two months). Serum lipids and the chemiluminescent activity of white blood cells (WBC-CL), a measure of oxygen radical production by white blood cells, were measured before and at monthly intervals for the duration of the study. Aortas were removed at the end of the protocol for assessment of atherosclerosis and the chemiluminescent activity of aortic tissue (aortic-CL), a measure of antioxidant reserve.

RESULTS:

Atherosclerosis was associated with hyperlipidemia and increased oxidative stress, indicated by increased nonactivated WBC-CL and alteration of the aortic-CL. Significant areas of the intimal surfaces of the aortas from group II (26.54%±4.11%), group III (69.37%±5.34%) and group IV (65.96%±7.86%) were covered with atherosclerotic lesions. Vitamin E did not alter serum lipids, aortic antioxidant reserve or WBC-CL. Vitamin E was ineffective in slowing the progression of hypercholesterolemic atherosclerosis.

CONCLUSION:

Vitamin E did not slow the progression of hypercholesterolemic atherosclerosis, and this effect was associated with its ineffectiveness in reducing serum lipids and oxidative stress.     

Is Age of 80 Years a Threshold for Carotid Revascularization?

Background and purpose:

Carotid Angioplasty and Stenting (CAS) has emerged as an alternative to Carotid Endarterectomy (CEA) in treatment of carotid stenotic disease. With increasing life expectancy clinicians are more often confronted with patients of higher age. Octogenarians were often excluded from randomized trials comparing CAS to CEA because they were considered high-risk for revascularization. Conflicting results on the peri-procedural outcome of carotid revascularization in these patients have been reported. In order to objectively evaluate whether age above 80 years should be an upper limit for indicating carotid revascularization we systematically reviewed the currently available literature.

Methods:

Literature was systematically reviewed between January 2000 and June 2010 using Pubmed and Embase, to identify all relevant studies concerning CAS and CEA in octogenarians. Inclusion criteria were 1) reporting outcome on either CEA or CAS; and 2) data subanalysis on treatment outcome by age. The 30-day Major Adverse Event (MAE) rate (disabling stroke, myocardial infarction or death) was extracted as well as demographic features of included patients.

Results:

After exclusion of 23 articles, 46 studies were included in this review, 18 involving CAS and 28 involving CEA. A total of 2.963 CAS patients and 14.365 CEA patients with an age >80 years were reviewed. The MAE rate was 6.9% (range 1.6 - 24.0%) following CAS and 4.2% (range 0 – 8.8%) following CEA.A separate analysis in this review included the results of one major registry 140.376 patients) analyzing CEA in octogenarians only reporting on 30-day mortality and not on neurological or cardiac adverse events. When these data were included the MAE following CEA is 2.4% (range 0 – 8.8%)

Conclusions:

MAE rates after CEA in octogenarians are comparable with the results of large randomized trials in younger patients. Higher complication rates are described for CAS in octogenarians. In general, age > 80 years is not an absolute cut off point to exclude patients from carotid surgery. In our opinion, CEA should remain the golden standard in the treatment of significant carotid artery stenoses, even in the very elderly.     

A novel approach to mechanical prophylaxis: calf impulse technology mimics natural ambulation more effectively than sequential calf compression

BACKGROUND:

The risk of thrombosis can be reduced by mechanical compression, but the optimal device is unknown.

OBJECTIVES:

To record the effect of natural ambulation on deep venous flow, providing a reference for evaluating the efficacy of mechanical compression systems, assuming that ambulation is the gold standard against which such systems should be compared; and to compare the hemodynamic effect of the A-V Impulse System CalfPad garment (A-VI) (Orthofix Vascular Novamedix, United Kingdom) with the SCD Express calf compression garment (SCD) (Covidien, USA).

METHODS:

Twelve healthy volunteers were recruited and randomly assigned to either A-VI or SCD in a two-device, two-period crossover design. Peak femoral velocity (PFV) was calculated using custom ultrasound software and compared with baseline values. Ultrasound images were recorded.

RESULTS:

A-VI augmented the mean (± SD) PFV to 59.79±29.07 cm/s compared with 22.86±5.73 cm/s for SCD. The actual percentage increase from baseline was approximately five times greater for A-VI (mean increase 385%±260%) than SCD (mean increase 81%±53%). Using an analysis of covariance model, with baseline fitted as a covariate, a highly statistically significant difference in favour of A-VI was detected (P=0.0002). Least square (adjusted) means (±95% CIs) were 37.24 cm/s (21.39 cm/s to 64.84 cm/s) for A-VI and 6.71 cm/s (3.86 cm/s to 11.69 cm/s) for SCD, representing more than fivefold greater improvement in PFV from rest with the A-VI device than with the SCD device.

CONCLUSION:

Pulsatile impulse calf compression (A-VI) more closely mimics PFV of normal ambulation than slow-squeeze sequential compression (SCD). Pulsatile calf compression may provide superior protection against thrombosis in immobile patients.     

Moderate and severe postendoscopic retrograde cholangiopancreatography pancreatitis despite prophylactic pancreatic stent placement: the effect of early prophylactic pancreatic stent dislodgement

BACKGROUND:

Placement of prophylactic pancreatic stents (PPS) is a method proven to reduce the rate and severity of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in high-risk patients; however, PPS do not eliminate the risk completely. Early PPS dislodgement may occur prematurely and contribute to more frequent or severe PEP.

OBJECTIVE:

To determine the effect of early dislodgement of PPS in patients with moderate or severe PEP.

METHOD:

A total of 27,176 ERCP procedures from January 1994 to September 2007 for PPS placement in high-risk patients were analyzed. Patient and procedure data were analyzed to assess risk factors for PEP, and to evaluate the severity of pancreatitis, length of hospitalization and subsequent complications. Timing of stent dislodgment was assessed radiographically.

RESULTS:

PPS were placed in 7661 patients. Of these, 580 patients (7.5%) developed PEP, which was graded as mild in 460 (6.0%), moderate in 87 (1.1%) and severe in 33 (0.4%). Risk factors for developing PEP were not different in patients who developed moderate PEP compared with those with severe PEP. PPS dislodged before 72 h in seven of 59 (11.9%) patients with moderate PEP and five of 27 (18.5%) patients with severe PEP (P=0.505). The mean (± SD) length of hospitalization in patients with moderate PEP with stent dislodgement before and after 72 h were 7.43±1.46 days and 8.37±1.16 days, respectively (P=0.20). The mean length of hospitalization in patients with severe PEP whose stent dislodged before and after 72 h were 21.6±6.11 and 22.23±3.13 days, respectively (P=0.96).

CONCLUSION:

Early PPS dislodgement was associated with moderate and severe PEP in less than 20% of cases and was not associated with a more severe course. Factors other than ductal obstruction contribute to PEP in high-risk patients undergoing ERCP and PPS placement.     

Prevalence of carotid artery stenosis in Chinese patients with angina pectoris

Background

The prevalence of carotid artery stenosis (CAS) in Chinese patients with angina pectoris is unknown.

Methods

The study population consisted of 989 consecutive patients who were scheduled to undergo nonemergent coronary angiography for suspicion of coronary artery disease (CAD) because of angina pectoris between January 2013 and December 2014. All patients underwent carotid ultrasonography to screen for CAS within one month before or after coronary angiography. We defined cases with 0–50%, 50%–70%, and >70% stenosis as mild, moderate, and severe stenosis, respectively.

Results

CAD was presented in 853 patients (86.2%) of whom 191 patients (19.3%) had 1-vessel disease, 246 patients (24.9%) had 2-vessel disease and 416 patients (42.1%) had 3-vessel disease; left main trunk stenosis present in 137 patients (13.9%). In carotid ultrasonography, the prevalence of mild, moderate, and severe stenosis as well as that of total occlusion of the carotid artery was 54.5%, 13%, 4.7% and 0.8%, respectively. Significant CAS (>50% stenosis and total occlusion) was present in 10.3%, 13.9%, 19.9% and 22.8% of patients with 0-vessel, 1-vessel, 2-vessel and 3-vessel CAD. The severity of CAS was directly correlated (r=0.194, P<0.001) with the extent of CAD. The independent predictors of severe CAS and total carotid artery occlusion were increased age, male sex, hypertension, diabetes mellitus, hyperhomocysteinemia, a previous history of stroke and 3-vessel CAD.

Conclusions

The prevalence of CAS was not rare in China when compared with that in western countries, and the presence of CAS was weakly correlated with the extent of CAD. Screening for CAS should be recommended in Chinese patients with CAD, especially in those with one or more CAS-associated risk factors.     

Effect of fluticasone 250 ��g/salmeterol 50 ��g and montelukast on exhaled nitric oxide in asthmatic patients

BACKGROUND:

Monitoring noninvasive biomarkers of inflammation is an important adjunct in asthma therapy.

OBJECTIVE:

The goal of the present study was to identify airway and alveolar site(s) of inflammation using exhaled nitric oxide (NO) as a marker in asthmatic patients, and to evaluate the NO response to maintenance fluticasone 250 μg/salmeterol 50 μg (F/S) and add-on montelukast 10 mg (M).

METHODS:

Thirty (24 women) nonsmoking, mild to moderate asthmatic patients were studied, mean age (± SD) 43±9 years, treated with F/S for more than one year. All were clinically stable for longer than eight weeks and had not taken oral corticosteroids and/or leukotriene antagonists for eight weeks before the present study. Spirometry, Juniper asthma symptom score, fractional exhaled NO (FENO) 100 mL/s, bronchial NO and alveolar NO concentration (CANO) were measured in a single-blind, nonrandomized crossover study.

PROTOCOL:

Visit 1: baseline F/S; visit 2: after four weeks of F/S plus M; visit 3: after four weeks of S plus M; and visit 4: after four weeks of S only. Values in asthmatic patients were also compared with 34 nonsmoking age-matched healthy controls with normal lung function.

RESULTS:

After 180 μg aerosolized metered dose inhaler albuterol, the forced expiratory volume in 1 s at baseline was 2.6±0.8 L (86%±16% of the predicted value) and the forced expiratory volume in 1 s over the forced vital capacity was 77%±9% (mean ± SD), and was similar at visits 2 to 4. Juniper scores were mildly abnormal at visits 1 to 3, but significantly worse (P=0.03) at visit 4 versus visits 1 to 3. FENO values at visits 1 to 3 were similar but significantly increased (P=0.007) at visit 4. Bronchial NO was higher (P=0.03) at visit 4, versus visits 1 and 2, and was no different at visit 3. Compared with the healthy subjects, FENO and bronchial NO values were abnormal (greater than the normal mean plus 2 SD) in 33% of asthmatic patients at visits 1 to 3. CANO was similar for visits 1 to 4. CANO was abnormal (greater than the normal mean + 2 SD) in 20% of asthmatic patients.

CONCLUSION:

In clinically stable asthmatic patients, despite controller treatment including moderate-dose inhaled corticosteroids and add-on M, 33% of mild to moderate asthmatic patients have ongoing nonsuppressed bronchial sites of increased NO production, compared with healthy control subjects. These controllers have no effect on CANO, which was abnormal in 20% of the asthmatic patients studied. The addition of add-on M to baseline moderate-dose inhaled corticosteroid did not further reduce total exhaled, bronchial and/or alveolar NO production.     

Predictors of early rebleeding after endoscopic therapy in patients with nonvariceal upper gastrointestinal bleeding secondary to high-risk lesions

BACKGROUND:

In an era of increasingly shortened admissions, data regarding predictors of early rebleeding among patients with nonvariceal upper gastrointestinal bleeding (NVUGIB) exhibiting high-risk stigmata (HRS) having undergone endoscopic hemostasis are lacking.

OBJECTIVES:

To determine predictors of early rebleeding, defined as rebleeding before completion of recommended 72 h intravenous proton pump inhibitor infusion postendoscopic hemostasis.

METHODS:

Data from a national registry of patients with upper gastrointestinal bleeding (the REASON registry) were accessed. Univariable and multivariable analyses were sequentially performed to identify significant independent predictors among a comprehensive list of clinical and laboratory characteristics.

RESULTS:

Overall, 393 patients underwent endoscopic hemostasis for NVUGIB with HRS. Forty patients rebled ≤72 h thereafter (32.5% female, mean [± SD] age 70.2±11.8 years, 2.88±2.11 comorbidities), while 21 rebled later (38.1% female, mean 70.5±14.1 years of age, 2.62±2.06 comorbidities). Hematemesis or bright red blood per nasogastric tube aspirate was identified as the sole independent significant predictor of early rebleeding versus later among both NVUGIB and, more specifically, patients with peptic ulcer bleeding (OR 7.94 [95% CI 1.80 to 35.01]; P<0.01, and OR 8.41 [95% CI 1.54 to 46.10]; P=0.014, respectively).

CONCLUSIONS:

When attempting to determine the optimal duration of pharmacotherapy and timing of discharge for patients following endoscopic hemostasis for NVUGIB with HRS, it is noteworthy that individuals who present with hematemesis or bright red blood per nasogastric tube aspirate are at particularly high risk for rebleeding within the first 72 h.     

Functional Capacity of Patients with Pacemaker Due to Isolated Congenital Atrioventricular Block

Background

Isolated congenital atrioventricular block (CAVB) is a rare condition with multiple clinical outcomes. Ventricular remodeling can occur in approximately 10% of the patients after pacemaker (PM) implantation.

Objectives

To assess the functional capacity of children and young adults with isolated CAVB and chronic pacing of the right ventricle (RV) and evaluate its correlation with predictors of ventricular remodeling.

Methods

This cross-sectional study used a cohort of patients with isolated CAVB and RV pacing for over a year. The subjects underwent clinical and echocardiographic evaluation. Functional capacity was assessed using the six-minute walk test. Chi-square test, Fisher''s exact test, and Pearson correlation coefficient were used, considering a significance level of 5%.

Results

A total of 61 individuals were evaluated between March 2010 and December 2013, of which 67.2% were women, aged between 7 and 41 years, who were using PMs for 13.5 ± 6.3 years. The percentage of ventricular pacing was 97.9 ± 4.1%, and the duration of the paced QRS complex was 153.7 ± 19.1 ms. Majority of the subjects (95.1%) were asymptomatic and did not use any medication. The mean distance walked was 546.9 ± 76.2 meters and was strongly correlated with the predicted distance (r = 0.907, p = 0.001) but not with risk factors for ventricular remodeling.

Conclusions

The functional capacity of isolated CAVB patients with chronic RV pacing was satisfactory but did not correlate with risk factors for ventricular remodeling.     

Comparison of carotid and lower limb atherosclerotic lesions in both previously known and newly diagnosed type 2 diabetes mellitus

Aims/Introduction

To compare carotid and lower limb atherosclerotic lesions, and examine if carotid atherosclerotic lesions are in line with lower limb atherosclerotic lesions, and can reflect generalized atherosclerosis in inpatients with type 2 diabetes.

Materials and Methods

This was an observational study carried out in 867 Chinese inpatients with type 2 diabetes, including 573 previously known and 294 newly diagnosed patients. Ultrasonographic assessments of intima-media thickness (IMT), plaques, and stenosis in the carotid and lower limb arteries were evaluated. Atherosclerotic lesions between the carotid and lower limb arteries were compared in both previously known and newly diagnosed diabetes, respectively.

Results

In both the known (77.3% vs 49.4%, P < 0.001) and the newly diagnosed diabetes (55.4% vs 29.9%, P < 0.001), the prevalence of atherosclerotic plaques was significantly higher in the lower limb arteries than in the carotid arteries. Likewise, the prevalence of stenosis was also significantly higher (P < 0.001) in the lower limb arteries (16.9%) than in the carotid arteries (4.2%) in the established diabetes patients. However, there was no significant difference in the mean IMT between common carotid and common femoral arteries in both the previously known (0.90 ± 0.24 mm vs 0.89 ± 0.20 mm, P = 0.675) and the newly diagnosed diabetes patients (0.86 ± 0.22 mm vs 0.85 ± 0.16 mm, P = 0.436).

Conclusions

Carotid plaques might underestimate generalized plaques in inpatients with type 2 diabetes, as shown by its significantly lower prevalence compared with that of the lower extremity arteries. A combined carotid and lower limb ultrasound examination can improve the detection of atherosclerotic lesions in inpatients with type 2 diabetes.     

Debranching Solutions in Endografting for Complex Thoracic Aortic Dissections

Background

Conventional surgical repair of thoracic aortic dissections is a challenge due to mortality and morbidity risks.

Objectives

We analyzed our experience in hybrid aortic arch repair for complex dissections of the aortic arch.

Methods

Between 2009 and 2013, 18 patients (the mean age of 67 ± 8 years-old) underwent hybrid aortic arch repair. The procedural strategy was determined on the individual patient.

Results

Thirteen patients had type I repair using trifurcation and another patient with bifurcation graft. Two patients had type II repair with replacement of the ascending aorta. Two patients received extra-anatomic bypass grafting to left carotid artery allowing covering of zone 1. Stent graft deployment rate was 100%. No patients experienced stroke. One patient with total debranching of the aortic arch following an acute dissection of the proximal arch expired 3 months after TEVAR due to heart failure. There were no early to midterm endoleaks. The median follow-up was 20 ± 8 months with patency rate of 100%.

Conclusion

Various debranching solutions for different complex scenarios of the aortic arch serve as less invasive procedures than conventional open surgery enabling safe and effective treatment of this highly selected subgroup of patients with complex aortic pathologies.     

Asymptomatic Brain Lesions on Cranial Magnetic Resonance Imaging in Inflammatory Bowel Disease

Background/Aims

This study aimed to examine the frequency and type of asymptomatic neurological involvement in inflammatory bowel disease (IBD) using cranial magnetic resonance imaging (MRI).

Methods

Fifty-one IBD patients with no known neurological diseases or symptoms and 30 controls with unspecified headaches without neurological origins were included. Patients and controls underwent cranial MRI assessments for white matter lesions, sinusitis, otitis-mastoiditis, and other brain parenchymal findings.

Results

The frequencies of white matter lesions, other brainstem parenchymal lesions, and otitis-mastoiditis were similar in IBD patients and controls (p>0.05), whereas sinusitis was significantly more frequent in IBD patients (56.9% vs 33.3%, p=0.041). However, among those subjects with white matter lesions, the number of such lesions was significantly higher in IBD patients compared to controls (12.75±9.78 vs 3.20±2.90, p<0.05). The incidence of examined pathologies did not differ significantly with disease activity (p>0.05 for all).

Conclusions

The incidence of white matter lesions seemed to be similar in IBD patients and normal healthy individuals, and the lesions detected did not pose any clinical significance. However, long-term clinical follow-up of the lesions is warranted.     

Coronary Obstruction Following Transcatheter Aortic Valve Implantation

Background

Transcatheter aortic valve implantation (TAVI) was established as an important alternative for high-risk patients with severe aortic stenosis. However, there are few data in the literature regarding coronary obstruction, that although rare, is a potentially fatal complication.

Objective

Evaluate this complication in Brazil.

Methods

We evaluated all patients presenting coronary obstruction from the Brazilian Registry of TAVI. Main baseline and procedural characteristics, management of the complication, and clinical outcomes were collected from all patients.

Results

From 418 consecutive TAVI procedures, coronary obstruction occurred in 3 cases (incidence of 0.72%). All patients were women, without prior coronary artery bypass grafting (CABG), and with mean age of 85 ± 3 years, logistic EuroSCORE of 15 ± 6% and STS-PROM score of 9 ± 4%. All of the cases were performed with balloon-expandable Sapien XT prosthesis. In one patient, with pre-procedural computed tomography data, coronary arteries presented a low height and a narrow sinus of Valsalva. All patients presented with clinically significant severe maintained hypotension, immediately after valve implantation, and even though coronary angioplasty with stent implantation was successfully performed in all cases, patients died during hospitalization, being two periprocedurally.

Conclusion

Coronary obstruction following TAVI is a rare but potentially fatal complication, being more frequent in women and with the balloon-expandable prosthesis. Anatomical factors might be related with its increased occurrence, highlighting the importance of a good pre-procedural evaluation of the patients in order to avoid this severe complication.     

Evaluation of von Willebrand factor in COPD patients

OBJECTIVE:

To compare the absolute serum von Willebrand factor (vWF) levels and relative serum vWF activity in patients with clinically stable COPD, smokers without airway obstruction, and healthy never-smokers.

METHODS:

The study included 57 subjects, in three groups: COPD (n = 36); smoker (n = 12); and control (n = 9). During the selection phase, all participants underwent chest X-rays, spirometry, and blood testing. Absolute serum vWF levels and relative serum vWF activity were obtained by turbidimetry and ELISA, respectively. The modified Medical Research Council scale (cut-off score = 2) was used in order to classify COPD patients as symptomatic or mildly symptomatic/asymptomatic.

RESULTS:

Absolute vWF levels were significantly lower in the control group than in the smoker and COPD groups: 989 ± 436 pg/mL vs. 2,220 ± 746 pg/mL (p < 0.001) and 1,865 ± 592 pg/mL (p < 0.01). Relative serum vWF activity was significantly higher in the COPD group than in the smoker group (136.7 ± 46.0% vs. 92.8 ± 34.0%; p < 0.05), as well as being significantly higher in the symptomatic COPD subgroup than in the mildly symptomatic/asymptomatic COPD subgroup (154 ± 48% vs. 119 ± 8%; p < 0.05). In all three groups, there was a negative correlation between FEV₁ (% of predicted) and relative serum vWF activity (r² = −0.13; p = 0.009).

CONCLUSIONS:

Our results suggest that increases in vWF levels and activity contribute to the persistence of systemic inflammation, as well as increasing cardiovascular risk, in COPD patients.     

The role of matched sibling donor allogeneic stem cell transplantation in pediatric high-risk acute myeloid leukemia: results from the AML-BFM 98 study

Background

The role of allogeneic stem cell transplantation in post-remission management of children with high-risk acute myeloid leukemia remains controversial. In the multi-center AML-BFM 98 study we prospectively evaluated the impact of allogeneic stem cell transplantation in children with high-risk acute myeloid leukemia in first complete remission.

Design and Methods

HLA-typed patients with high-risk acute myeloid leukemia, who achieved first complete remission (n=247), were included in this analysis. All patients received double induction and consolidation. Based on the availability of a matched-sibling donor, patients were allocated by genetic chance to allogeneic stem cell transplantation (n=61) or chemotherapy-only (i.e. intensification and maintenance therapy; n=186). The main analysis was done on an intention-to-treat basis according to this allocation.

Results

Intention-to-treat analysis did not show a significantly different 5-year disease-free survival (49±6% versus 45±4%, P_{log rank}=0.44) or overall survival (68±6% versus 57±4%, P_{log rank}=0.17) between the matched-sibling donor and no-matched-sibling donor groups, whereas late adverse effects occurred more frequently after allogeneic stem cell transplantation (72.5% versus 31.8%, P_Fischer<0.01). These results were confirmed by as-treated analysis corrected for the time until transplantation (5-year overall survival: 72±8% versus 60±4%, P_Mantel-Byar 0.21). Subgroup analysis demonstrated improved survival rates for patients with 11q23 aberrations allocated to allogeneic stem cell transplantation (5-year overall survival: 94±6% versus 52±7%, P_log-rank=0.01; n=18 versus 49) in contrast to patients without 11q23 aberrations (5-year overall survival: 58±8% versus 55±5%, P_log-rank=0.66).

Conclusions

Our analyses defined a genetic subgroup of children with high-risk acute myeloid leukemia who benefited from allogeneic stem cell transplantation in the prospective multi-center AML-BFM 98 study. For the remainder of the pediatric high-risk acute myeloid leukemia patients the prognosis was not improved by allogeneic stem cell transplantation, which was, however, associated with a higher rate of late sequelae.     

Outcomes for Resident-Identified High-Risk Patients and Resident Perspectives of Year-End Continuity Clinic Handoffs

BACKGROUND

Many patients nationwide change their primary care physician (PCP) when internal medicine (IM) residents graduate. Few studies have examined this handoff.

OBJECTIVE

To assess patient outcomes and resident perspectives after the year-end continuity clinic handoff

DESIGN

Retrospective cohort

PARTICIPANTS

Patients who underwent a year-end clinic handoff in July 2010 and a comparison group of all other resident clinic patients from 2009–2011. PGY2 IM residents surveyed from 2010–2011.

MEASUREMENTS

Percent of high-risk patients after the clinic handoff scheduled for an appointment, who saw their assigned PCP, lost to follow-up, or had an acute visit (ED or hospitalization). Perceptions of PGY2 IM residents surveyed after receiving a clinic handoff.

RESULTS

Thirty graduating residents identified 258 high-risk patients. While nearly all patients (97 %) were scheduled, 29 % missed or cancelled their first new PCP visit. Only 44 % of patients saw the correct PCP and six months later, one-fifth were lost to follow-up. Patients not seen by a new PCP after the handoff were less likely to have appropriate follow-up for pending tests (0 % vs. 63 %, P < 0.001). A higher mean no show rate (NSR) was observed among patients who missed their first new PCP visit (22 % vs. 16 % NSR, p < 0.001) and those lost to follow-up (21 % vs. 17 % NSR, p = 0.019). While 47 % of residents worried about missing important data during the handoff, 47 % reported that they do not perceive patients as “theirs” until they are seen by them in clinic.

CONCLUSIONS

While most patients were scheduled for appointments after a clinic handoff, many did not see the correct resident and one-fifth were lost to follow-up. Patients who miss appointments are especially at risk of poor clinic handoff outcomes. Future efforts should improve patient attendance to their first new PCP visit and increase PCP ownership.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-012-2100-y) contains supplementary material, which is available to authorized users.KEY WORDS: outpatient handoffs, signout, resident continuity clinic, year-end transfer, transitions of care     

Mortality and Embolic Potential of Cardiac Tumors

Background

Cardiac tumors are rare, mostly benign with high embolic potential.

Objectives

To correlate the histological type of cardiac masses with their embolic potential, implantation site and long term follow up in patients undergoing surgery.

Methods

Between January 1986 and December 2011, we retrospectively analyzed 185 consecutive patients who underwent excision of intracardiac mass (119 females, mean age 48±20 years). In 145 patients, the left atrium was the origin site. 72% were asymptomatic and prior embolization was often observed (19.8%). The diagnosis was established by echocardiography, magnetic resonance and histological examination.

Results

Most tumors were located in the left side of the heart. Myxoma was the most common (72.6%), followed by fibromas (6.9%), thrombi (6.4%) and sarcomas (6.4%). Ranging from 0.6cm to 15cm (mean 4.6 ± 2.5cm) 37 (19.8%) patients had prior embolization, stroke 10.2%, coronary 4.8%, peripheral 4.3% 5.4% of hospital death, with a predominance of malignant tumors (40% p < 0.0001). The histological type was a predictor of mortality (rhabdomyomas and sarcomas p = 0.002) and embolic event (sarcoma, lipoma and fibroelastoma p = 0.006), but not recurrence. Tumor size, atrial fibrillation, cavity and valve impairment were not associated with the embolic event. During follow-up (mean 80±63 months), there were 2 deaths (1.1%) and two recurrences 1 and 11 years after the operation, to the same cavity.

Conclusion

Most tumors were located in the left side of the heart. The histological type was predictor of death and preoperative embolic event, while the implantation site carries no relation with mortality or to embolic event.