Relationship of femoral artery ultrasound measures of atherosclerosis with chronic kidney disease

Background

Chronic kidney disease (CKD) is strongly associated with peripheral artery disease (PAD). Detection of subclinical PAD may allow early interventions for or prevention of PAD in persons with CKD. Whether the presence of atherosclerotic plaque and femoral intima-media thickness (IMT) are associated with kidney function is unknown.

Risk factors for the development of distant metastases in patients undergoing pelvic lymphadenectomy for prostatic cancer

Sixty-two patients with clinically localized prostatic cancer underwent pelvic lymphadenectomy between 1972 and 1975. Thirty-one patients had concomitant total prostatectomy. The objectives of this study included determination of the relation of findings at lymphadenectomy, with and without total prostatectomy, to subsequent clinical course, identification of histologic parameters related to the subsequent appearance of distant metastatic disease, and determination of the vital status of patients initially having a staging pelvic lymphadenectomy. Follow-up of at least 5 years was obtained for 52 patients, including 28 who had concomitant total prostatectomy. Ten patients were lost to follow-up. Fifty-four percent are alive without evidence of disease, 25 percent are alive with metastatic disease, 10 percent have died with metastatic cancer, and 12 percent have died without prostate cancer. Metastases have developed in 11 (37 percent) of 30 patients with negative pelvic lymph nodes, reflecting either seminal vesicle or transcapsular invasion. Minimal lymph node involvement (one or two pelvic nodes) alone may not be as poor a prognostic sign as originally thought. Metastases have developed in 22 percent of nine patients with tumor considered stage B₂. No recurrences or metastases were noted in the seven patients with stage b₁ disease. Patients with high grade lesions were at no increased risk for distant metastases, although they constituted a relatively small segment of our series. Thus the extent of local disease correlates with the subsequent development of distant metastasis. Adjuvant systemic treatment (endocrine manipulation, chemotherapy, or both) has a rational basis in patients with one or more of these identifiable risk factors     

Behavioural factors in burn mortality and length of stay in hospital

Numerous studies have examined the effects of burn size and depth, age, concomitant injury, and illness upon burn patient mortality and duration of stay in hospital, and other studies have stressed the importance of psychosocial factors in the causation of burns. However, scant attention has been given to the effects of psychosocial factors on burn mortality and length of stay in hospital.Data on psychiatric diagnoses, substance abuse, and factors in severity of injury were abstracted from the charts of patients admitted to the San Diego Regional Burn Treatment Center.Mortality data were analysed using logistic regression. After adjusting for severity of the burn injury, statistically significant increases in mortality are associated with the diagnosis of character or personality disorder, schizophrenia, alcohol intoxication at the time of injury, and a variable indicating a psychiatric diagnosis or severe undiagnosed problems. Comments on individual charts suggest that overtly self-destructive behaviour during treatment caused the increased mortality.Data on duration of stay in hospital among survivors were analysed using multiple linear regression. After adjusting for severity of injury, significantly longer stays are associated with suicidal intention, diagnosis of character or personality disorder, schizophrenia, senility and a variable indicating a psychiatric diagnosis or severe undiagnosed problems. Overtly self-destructive behaviour, treatment of psychiatric problems, and the inability of some patients to care for themselves may each contribute to the longer stay in hospital.     

Vascular repair after firearm injury is associated with increased morbidity and mortality

ObjectiveFirearm injuries have high morbidity and mortality. Presentation of injuries requiring concurrent vascular repair and its outcomes are unclear. Our study's objective was to characterize the injury details and to assess the associated mortality and morbidity after vascular repair.MethodsThe National Inpatient Sample was queried from 1993 to 2014 for all firearm injuries. International Classification of Diseases, Ninth Revision codes were used to identify firearm injuries and those who also underwent a vascular repair. Multivariable analysis was used to assess the effect of a concurrent vascular repair on outcomes.ResultsThere were 648,662 firearm injuries identified; 63,973 (9.9%) involved a vascular repair. Overall, 88.7% of patients were male, and Medicaid was the most common insurance (40.2%). Intents were assault or legal intervention (60%), unintentional (24.2%), and suicide (8.6%). Patients undergoing vascular repair were younger, more often of black race and male sex, and on Medicaid insurance, with a lower household income and assault/legal intent (P < .005). Patients who underwent vascular repair had a higher frequency of abdomen/pelvis and extremity injuries as well as an elevated New Injury Severity Score (P < .005). Patients with vascular repair were more frequently treated at urban, teaching, and large hospitals (P < .005). Overall mortality rate was 2.2%; patients who underwent vascular repair had a higher mortality compared with those without (5.51% vs 1.98%; P < .001). Patients with vascular repair had higher rates of acute renal failure (3.1% vs 0.8%), venous thromboembolic events (0.5% vs 0.3%), pulmonary-related events (0.6% vs 0.28%), cardiac-related events (0.8% vs 0.2%), sepsis (1.4% vs 0.5%), and any complication (5.7% vs 2%; all P < .0001). Vascular repair was independently associated with mortality (odds ratio [OR], 2.68; 95% confidence interval [CI], 2.43-2.95; P < .0001). Age older than 46 years (OR, 2.01; 95% CI, 1.71-2.35; P < .0001), male sex (OR, 1.15; 95% CI, 1.05-1.25; P = .003), self-pay/no insurance (OR, 1.6; 95% CI, 1.47-1.75; P < .0001), suicide intent (OR, 3.73; 95% CI, 3.36-4.13; P < .0001), unintentional intent (OR, 1.12; 95% CI, 1.03-1.22; P < .0001), head/neck location (OR, 13.9; 95% CI, 12.5-15.6; P < .0001), Northeast region, and New Injury Severity Score >4 were independently associated with in-hospital mortality. Vascular repair was also independently associated with any complication (OR, 2.12; 95% CI, 1.98-2.28; P < .0001).ConclusionsFirearm injuries with vascular repair were independently associated with higher injury severity score and mortality. A majority of vascular repairs were performed for injury to the abdomen/pelvis and extremity with assault/legal intent, whereas head and neck injury and suicide intent were the least frequent.     

Age modifies the efficacy and safety of carotid artery revascularization procedures

BackgroundSeveral randomized clinical trials have shown that carotid artery endarterectomy (CEA) is safer than carotid artery stenting (CAS) in the elderly. However, those studies were limited by their strict inclusion criteria that might make their findings inapplicable to real-world practice. Therefore, the aim of this study was to evaluate the association of age with the efficacy of CEA and CAS in a population-based registry.MethodsThe Vascular Quality Initiative database was inquired (2005-2017). The primary outcome was 30-day and 2-year stroke and a combined outcome of stroke/death. Logistic regression models with age-by-treatment interaction term were fitted adjusting for patients' characteristics. Restricted cubic spline modelling was also implemented. Two-year events were assessed via survival analysis methods.ResultsOverall, 89,853 patients were included, 26.9% were less than 65 years of age, 39.1% were 65 to 74 years of age, and 34.1% were 75 years of age or older. The CAS-to-CEA odds of 30-day stroke became significant at age 56.5 and doubled at age 72.5 years. After CEA, the risk of stroke rose by 1.3-fold when age increased from 76 to 85 (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.05-1.62). Yet after CAS, when age increased from 65 to 71 years, the OR of stroke was 1.36 (95% CI, 1.04-1.76); from 71 to 76 years, the OR was 1.47 (95% CI, 1.10-1.96), and from 76 to 85 years the OR was 1.38 (95% CI, 1.06-1.81). The superiority of CEA with increasing age extended to 2 years after the procedure. The CAS-to-CEA 2-year hazard of stroke was significant at age 53 and it doubled at 71.5 years.ConclusionsIn this multicenter registry, we confirmed the effect modification role that age plays in the safety and efficacy of carotid revascularizations. The risk-adjusted effectiveness of CAS was particularly sensitive to patient age, whereas CEA performance was relatively stable across various age strata. Of note, the observed effect was more pronounced and a decade earlier than what previously reported in the ideal setting of a randomized clinical trial.     

Analysis of the ROADSTER pivotal and extended-access cohorts shows excellent 1-year durability of transcarotid stenting with dynamic flow reversal

ObjectiveWe report the 1-year outcomes of the Safety and Efficacy Study for Reverse Flow Used During Carotid Artery Stenting Procedure (ROADSTER) multicenter trial. This trial introduced a novel transcarotid neuroprotection system (NPS), the ENROUTE transcarotid NPS (Silk Road Medical Inc, Sunnyvale, Calif). Postoperative results demonstrated that the use of the ENROUTE transcarotid NPS is safe and effective. The aim of this study was to evaluate the safety of transcarotid artery revascularization (TCAR) and to present the 1-year outcomes.MethodsThis study is a prospective, single-arm clinical trial. Current enrollment occurs in 14 centers. Primary end points were incidence rates of ipsilateral stroke at 1 year after TCAR. Occurrence of stroke was ascertained by an independent Clinical Events Committee. Patients with anatomic or medical high-risk factors for carotid endarterectomy (CEA) were eligible to be enrolled in the ROADSTER trial.ResultsOverall, 165 patients were included in the long-term follow-up (112 of 141 patients from the pivotal phase and 53 of 78 patients from the extended access). Mean age was 73.9 years (range, 42.1-91.3 years). Patients aged 75 years and older were 43.3% of the cohort. The majority of patients were white (92.7%) and male (75.2%). Most patients were asymptomatic (79.9%). Anatomic risk factors were distributed as follows: contralateral carotid artery occlusion (11.0%), tandem stenosis of >70% (1.8%), high cervical carotid artery stenosis (25.0%), restenosis after CEA (25.6%), bilateral stenosis requiring treatment (4.3%), and hostile neck (14.6%). Medical high-risk criteria included two-vessel coronary artery disease (14.0%) and severe left ventricular dysfunction with ejection fraction <30% (1.8%). In general, 43.3% of patients had at least one anatomic high-risk factor, whereas 29.9% of patients had medical high-risk factors. Both subsets of factors were present simultaneously in 26.8% of the cohort. At 1-year follow-up, ipsilateral stroke incidence rate was 0.6%, and seven patients (4.2%) died. None of the deaths were neurologic in origin.ConclusionsTCAR with dynamic flow reversal had previously shown favorable 30-day perioperative outcomes. This excellent performance seems to extend to 1 year after TCAR as illustrated in this analysis. The promising results from the ROADSTER trial likely stem from the novel cerebral protection provided through the ENROUTE transcarotid NPS in comparison to distal embolic protection devices as well as the transcarotid approach's circumventing diseased aortic arch manipulation and minimizing embolization. TCAR offers a safe and durable revascularization option for patients who are deemed to be at high risk for CEA.