Adjunctive stent implantation following directional coronary atherectomy in patients with coronary artery disease

Objectives. This prospective case-control study evaluated the acute and long-term results of stent implantation preceded by debulking of the plaque by means of directional coronary atherectomy.

Background. In comparison with balloon angioplasty, intracoronary stenting produces a larger luminal diameter, maintains artery patency and reduces the incidence of restenosis. Optimal stent deployment is a pivotal factor for achieving the best results, but the bulk of the atherosclerotic plaque opposes stent expansion and may limit the success of the procedure. Debulking of the plaque may provide a better milieu for optimal stent deployment.

Methods. Directional coronary atherectomy followed by a single Palmaz-Schatz stent implantation was attempted in 100 patients. The successes, complications and angiographic results of the combined procedure were evaluated both acutely and during follow-up. Matched patients undergoing successful Palmaz-Schatz stent implantation alone during the same period served as controls.

Results. Atherectomy followed by stent implantation was performed in 94 patients with 98 lesions; periprocedural complications were observed in four cases. The stenosis diameter decreased from 76 ± 9% at baseline to 30 ± 13% after atherectomy (p < 0.0001), and 5 ± 9% after stent implantation (p < 0.0001); it increased to 27 ± 15% at 6-month angiography (p < 0.0001). During the 14 ± 10 months of follow-up, none of the patients died or experienced myocardial infarction, but three patients underwent target lesion revascularization. The patients undergoing stent implantation alone achieved smaller acute gains, tended to have a higher late lumen loss, had a higher restenosis rate (30.5% vs. 6.8%, p < 0.0001) and showed a greater incidence of clinical events during follow-up (p < 0.0001).

Conclusions. Debulking atherosclerotic lesions by means of directional coronary atherectomy before stent implantation is a safe procedure with a high success rate and a low incidence of restenosis at follow-up.     

Unsedated colonoscopy: A neverending story

Although sedation and analgesia for patients undergoing colonoscopy is the standard practice in Western countries, unsedated colonoscopy is still routinely provided in Europe and the Far East. This variation in sedation practice relies on the different cultural attitudes of both patients and endoscopists across these countries. Data from the literature consistently report that, in unsedated patients, the use of alternative techniques, such as warm water irrigation or carbon dioxide insufflation, can allow a high quality and well tolerated examination.     

Psychological Stress and Disease Activity in Ulcerative Colitis: A Multidimensional Cross-sectional Study

Objectives: It is not known whether any link exists between life stress and disease activity in ulcerative colitis; attempts to demonstrate one have been complicated by recall bias, distressing psychological consequences of disease, psychogenic symptom exaggeration, and an irritable bowel component of inflammatory bowel disease symptoms. We therefore studied the relationship between psychological measures and two different aspects of ulcerative colitis activity. Methods: The relation of perceived stress, depression, state anxiety, trait anxiety, and life events with endoscopic appearance of the rectal mucosa was studied "blind" in 46 asympto-matic outpatients with known ulcerative colitis. The same measures were then examined in relation to subjective activity, comparing the group in clinical remission with 32 ulcerative colitis outpatients who reported symptoms. Results: Among asymptomatic patients, the level of stress over the past 2 yr on the General Perceived Stress Questionnaire was higher in the 11 with mucosal abnormalities than in the 35 with a normal rectal mucosa ( p = 0.004). Among the entire population, symptomatic patients were more likely to recall major life events in the previous 6 months than the asymptomatic group ( p = .02). Adjustment for smoking and for duration of remission did not substantially alter these findings. Conclusions: Life stress is associated with both objective and subjective aspects of activity in ulcerative colitis. Although the association of life events with reported symptoms may be subject to recall bias, the association of perceived stress with rectal mucosal abnormalities in asymptomatic patients is strongly suggestive of a true link between psychological factors and ulcerative colitis activity.     

Hostile attributional bias and aggressive behavior in global context

We tested a model that children’s tendency to attribute hostile intent to others in response to provocation is a key psychological process that statistically accounts for individual differences in reactive aggressive behavior and that this mechanism contributes to global group differences in children’s chronic aggressive behavior problems. Participants were 1,299 children (mean age at year 1 = 8.3 y; 51% girls) from 12 diverse ecological-context groups in nine countries worldwide, followed across 4 y. In year 3, each child was presented with each of 10 hypothetical vignettes depicting an ambiguous provocation toward the child and was asked to attribute the likely intent of the provocateur (coded as benign or hostile) and to predict his or her own behavioral response (coded as nonaggression or reactive aggression). Mothers and children independently rated the child’s chronic aggressive behavior problems in years 2, 3, and 4. In every ecological group, in those situations in which a child attributed hostile intent to a peer, that child was more likely to report that he or she would respond with reactive aggression than in situations when that same child attributed benign intent. Across children, hostile attributional bias scores predicted higher mother- and child-rated chronic aggressive behavior problems, even controlling for prior aggression. Ecological group differences in the tendency for children to attribute hostile intent statistically accounted for a significant portion of group differences in chronic aggressive behavior problems. The findings suggest a psychological mechanism for group differences in aggressive behavior and point to potential interventions to reduce aggressive behavior.Why do children in some ecological contexts and cultural groups across the world exhibit more chronic aggressive behavior problems than children in other contexts? We assert that groups differentially socialize a key psychological process of attribution of hostile intent, which mediates the display of aggression in response to threat (i.e., it statistically accounts for differences in reactive aggressive behavior), which, when repeated in interpersonal interactions over time, grows into chronic aggressive behavior problems.Some evolutionary theorists posit the adaptive function of deescalating aggressive conflict in response to ambiguous provocation or threat. Axelrod’s computer simulations and empirical tests of ambiguous conflicts in political science suggest (but do not prove) that the response strategy responsible for the containment of violence and the evolution of cooperation is a “tit for tat” tactic characterized by a benign interpretation of another’s ambiguous intentions (1). He asserts that an alternate two-step strategy of attributing hostile intent to another and retaliating with aggression leads to escalation of conflict and eventual mutual destruction.Despite Axelrod’s assertions that the long-term adaptiveness of reactive aggression is poor, certain ecological contexts have been found to encourage hostile attributions and reactive aggression in response to ambiguous provocations. For example, rhesus macaque mothers who hold high dominance ranks socialize their 9-mo-old infants to display a pattern of high vigilance to threatening faces, probably as a short-term adaptive strategy to enable the offspring to maintain high rank (2). In the US South, a unique “culture of honor” promotes vigilance toward provocateurs, perceptual readiness to attribute hostile intent to others, and retaliatory aggression in response to being dishonored (3). Qualitative accounts of urban violence among minority males also point toward the importance of retaliating against being “dissed,” as in disrespected (4). Recent “Stand Your Ground” laws in the United States excuse retaliation against a perceived provocateur.A pattern of hypervigilance to threat, hostile attribution of intent, and reactive aggression in response to provocation often comes at a cost to an individual within a society and to that society’s long-term health and well-being. A large body of psychological research in the United States indicates that, when an individual attributes hostile intent to a peer provocateur, the individual is likely to become anxious and escalate reactive aggression, leading in turn to chronic aggressive behavior problems (5). Children who consistently make hostile attributions about others have been shown to escalate aggression in response to provocation, to become chronically anxious, and to increase their aggressive behavior problems over time and grow into violent adults (6).How do we reconcile the universality of Axelrod’s tit for tat pattern of benign attributions and cooperation with known ecological group differences in chronic aggressive behavior rates? A social ecological model that embeds behavior in a widening circle of ecological contexts (e.g., family, community, culture) posits that a child’s cultural-ecological context of local norms, values, and affordances will influence that child’s attention and attribution processes, which, in turn, will account for that child’s aggressive behavior (ecological context → child hostile attribution bias → child aggression) (7). We assert that some environments socialize a pattern that consists of high vigilance to threat, hostile attributions of another’s intent, and reactive aggression. The reasons for group differences in socialization patterns are beyond the scope of this study but likely grow in response to local environmental challenges such as genuine threat from outside groups, political conflict, and relative economic disadvantage, and are perpetuated through transmission across generations.We propose a model of hostile attributional bias, depicted in Fig. 1, which builds on these ideas. We posit that Axelrod’s universal axiom that the psychological act of making a benign attribution about another’s provocation leads to the deescalation of conflict (and, reciprocally, that a hostile attribution leads to reactive aggression). We hypothesize that variation in a child’s reactive aggressive behaviors across the situations that a child experiences will co-occur within that child with the attribution of hostile intent toward a provocateur. We further hypothesize that individual differences across children in reactive aggression in response to provocation will be accounted for partially by individual differences across children in the tendency to make hostile attributions and that both hostile attributional biases and reactive aggressive responses to provocation will predict present and future individual differences in chronic aggressive behavior problems even controlling for prior individual differences in chronic aggression.Open in a separate windowFig. 1.Hypothesized model of how ecological context affects chronic aggressive behavior by influencing hostile attributional biases.Finally, and most importantly, we assert that ecological group differences in rates of chronic aggressive behavior problems are due in part to culturally socialized differences in how children are reared to become vigilant toward threat and to make hostile attributions about others under conditions of ambiguous provocation. If this model is supported, it suggests interventions to reduce a group’s rate of chronic aggressive problems, and it has implications for understanding some cross-group conflicts (e.g., Arab-Israeli conflict and racial conflict within the United States), which could be understood as a function of group differences in how attributions of outgroup intentions are socialized and used to justify cross-group violence. Study of antecedents of cross-group conflict is beyond the present scope and is not pursued further here.To test the tenets of this model, we used identical methods with large samples of children followed prospectively across diverse ecological socializing contexts around the world. The goal of the current study was to test three sets of hypotheses in a sample of 8-y-old boys and girls from 12 different groups around the world followed annually over 4 y.The first hypothesis (the within-child hypothesis) is that variation in reactive aggressive behavior in response to provocation situations within a child will be statistically accounted for by variation in the attributions that child makes across peer provocation situations. We hypothesize that this relation will hold universally in each ecological context and in each sex.The second hypothesis (the between-children hypothesis) asserts that measurements of a child’s attributions about peers’ intentions will yield internally consistent individual differences across children, called hostile attributional bias, which acts like an acquired personality trait to correlate with and predict chronic aggressive behavior. We hypothesize that variation across children in hostile attributional bias will be correlated with children’s chronic tendencies to assert that they would react aggressively in response to a provocation; furthermore, we hypothesize that children’s hostile attributional biases will predict their current and future chronic aggressive behavior problems as measured by themselves and their mothers even controlling for prior aggressive behavior problems, and these relations will hold in each ecological context and each sex.The third hypothesis (the between-context hypothesis) asserts that ecological-cultural group differences in children’s rates of mother-rated and self-rated chronic aggressive behavior problems will be partially statistically accounted for by group differences in children’s hostile attributional biases and self-predicted tendencies to react aggressively in response to ambiguous threat.