RESUMEN
BACKGROUND: Point prevalence surveys (PPSs) collect data on hospital-acquired infections (HAIs) at one point in time but do not provide information on incidence over the entire admission or impact on patients or healthcare resources. Retrospective record review examines the entire admission to determine adverse event prevalence, incidence, preventability, physical impairment and additional length of stay. AIM: To establish whether European HAI surveillance definitions can be applied to the Irish National Adverse Events Study (INAES) retrospective record review data to determine HAI burden. METHODS: In the INAES, 1574 admissions were reviewed using a two-stage methodology and 247 adverse events were found. These were examined against European HAI case definitions to determine whether the event was an HAI. Results were compared with the 2011/12 European PPS data for Ireland. FINDINGS: The prevalence of HAI adverse events in INAES was 4.4% (95% confidence interval (CI) 3.1-6.1%) with an incidence of 3.8 (95% CI 2.5-5.2) HAI adverse events per 100 admissions. The PPS HAI prevalence for Ireland was 5.2%. HAI types and micro-organisms were similar in INAES and the PPS. Approximately three-quarters of INAES HAI adverse events were preventable, 7% caused permanent impairment and 7% contributed to death. A mean of 10 additional bed days were attributed to HAI adverse events, equivalent to 9400 per event. CONCLUSION: Retrospective record review is an accurate source of information on HAI incidence, preventability and impact that complements PPS prevalence rates. HAI adverse events result in higher costs to the healthcare system than other adverse events.
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Infección Hospitalaria/epidemiología , Métodos Epidemiológicos , Registros Médicos/estadística & datos numéricos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Europa (Continente)/epidemiología , Femenino , Humanos , Incidencia , Tiempo de Internación , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , Encuestas y Cuestionarios , Adulto JovenRESUMEN
BACKGROUND: Few studies have addressed the challenges associated with international students as they adapt to studying medicine in a new host country. Higher level institutions have increasing numbers of international students commencing programmes. This paper explores the experiences of a cohort of students in the early years of medical school in Ireland, where a considerable cohort are from an international background. METHODS: A mixed exploratory sequential study design was carried out with medical students in the preclinical component of a five year undergraduate programme. Data for the qualitative phase was collected through 29 semi-structured interviews using the peer interview method. Thematic analysis from this phase was incorporated to develop an online questionnaire combined with components of the Student Adaptation to College Questionnaire and Student Integration Questionnaire. First year students were anonymously surveyed online. The Mokken Scaling procedure was used to investigate the students' experiences, both positive and negative. RESULTS: Three main themes are identified; social adjustment, social alienation and cultural alienation. The response rate for the survey was 49% (467 Respondents). The Mokken Scaling method identified the following scales (i) Positive experience of student life; (ii) Social alienation, which comprised of negative items about feeling lonely, not fitting in, being homesick and (iii) Cultural alienation, which included the items of being uncomfortable around cultural norms of dress and contact between the sexes. With the threshold set to H = 0.4. Subscales of the positive experiences of student life scale are explored further. CONCLUSIONS: Overall student adjustment to a western third level college was good. Students from regions where cultural distance is greatest reported more difficulties in adjusting. Students from these regions also demonstrate very good adaptation. Some students from the host country and more similar cultural backgrounds were also struggling. Acculturation is more complex than being associated with cultural distance and worthy of further exploration.
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Ajuste Social , Estudiantes de Medicina/psicología , Aculturación , Cultura , Femenino , Humanos , Entrevistas como Asunto , Irlanda , Masculino , Facultades de Medicina , Aislamiento Social , Encuestas y CuestionariosRESUMEN
We investigated how young adults aged 18-29 years would like to be notified of chlamydia screening test results, and, when they test positive, their willingness and preferred mechanism for informing their partners. We conducted a cross-sectional survey of 6085 young adults and found that a call to their mobile phone was their preferred way of receiving positive test results (selected by 50%), followed by email. Text messages (short message service [SMS]) and calls to landline phones were unpopular options, selected by between 5 and 10%. Over 75% of respondents stated they would inform their current partner of a positive chlamydia diagnosis, and 50% would inform their previous partners. Most were willing to receive yearly reminders to go for a chlamydia test. Young adults preference for being informed of chlamydia test results by mobile phone call, rather than by email or SMS text, especially if they test positive, suggests they place high value on the security of the communication mechanism. Offering a range of mechanisms for receipt of test results may increase the acceptability and coverage of sexually transmitted infection (STI) control strategies.
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Confidencialidad/legislación & jurisprudencia , Trazado de Contacto/métodos , Linfogranuloma Venéreo/diagnóstico , Tamizaje Masivo/métodos , Aceptación de la Atención de Salud/estadística & datos numéricos , Adolescente , Adulto , Estudios Transversales , Femenino , Humanos , Masculino , Satisfacción del Paciente/estadística & datos numéricos , Adulto JovenRESUMEN
Depression is associated with increased cardiovascular risk in acute coronary syndrome (ACS) patients, but some argue that elevated depression is actually a marker of cardiovascular disease severity. Therefore, disease indices should better predict depression than established theoretical causes of depression (interpersonal life events, reinforcing events, cognitive distortions, type D personality). However, little theory-based research has been conducted in this area. In a cross-sectional design, ACS patients (n = 336) completed questionnaires assessing depression and psychosocial vulnerabilities. Nested logistic regression assessed the relative contribution of demographic or vulnerability factors, or disease indices or vulnerabilities to depression. In multivariate analysis, all vulnerabilities were independent significant predictors of depression (scoring above threshold on any scale, 48%). Demographic variables accounted for <1% of the variance of depression status, with vulnerabilities accounting for significantly more (pseudo R² = 0.16, χ²(change) = 150.9, df = 4, p < 0.001). Disease indices accounted for 7% of the variance in depression (pseudo R² = 0.07, χ² = 137.9, p < 0.001). However, adding the vulnerabilities increased the overall variance explained to 22% (pseudo R² = 0.22, χ² = 58.6, df = 4, p < 0.001). Theoretical vulnerabilities predicted depression status better than did either demographic or disease indices. The presence of these proximal causes of depression suggests that depression in ACS patients is not simply a result of cardiovascular disease severity.
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Síndrome Coronario Agudo/psicología , Angina Inestable/psicología , Trastorno Depresivo/psicología , Evaluación de la Discapacidad , Infarto del Miocardio/psicología , Rol del Enfermo , Factores Socioeconómicos , Temperamento , Adaptación Psicológica , Anciano , Estudios Transversales , Cultura , Trastorno Depresivo/diagnóstico , Femenino , Humanos , Control Interno-Externo , Acontecimientos que Cambian la Vida , Masculino , Persona de Mediana Edad , Inventario de Personalidad/estadística & datos numéricos , Psicometría , Factores de RiesgoRESUMEN
Brief, non-harmful seizures can activate endogenous protective programmes which render the brain resistant to damage caused by prolonged seizure episodes. Whether protection in epileptic tolerance is long-lasting or influences the subsequent development of epilepsy is uncertain. Presently, we investigated the relationship between hippocampal pathology, neuropeptide Y rearrangement and spontaneous seizures in sham- and seizure-preconditioned mice after status epilepticus induced by intra-amygdala kainate. Seizure-induced neuronal death at 24 h was significantly reduced in the ipsilateral hippocampal CA3 and hilus of tolerance mice compared to sham-preconditioned animals subject to status epilepticus. Damage to the CA3-hilus remained reduced in tolerance mice 21 days post-status. In sham-preconditioned mice subject to status epilepticus correlative statistics showed there was a strong inverse relationship between CA3, but not hilar, neuron counts and the number of spontaneous seizures. A strong positive association was also found between neuropeptide Y score and spontaneous seizure count in these mice. In contrast, there was no significant association between spontaneous seizure count and CA3 neuron loss or neuropeptide Y rearrangement in the tolerance mice. These data show that tolerance-conferred neuroprotection is long-lasting and that tolerance disrupts the normal association between CA3 damage, synaptic rearrangement and occurrence of spontaneous seizures in this model.
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Región CA3 Hipocampal/patología , Ácido Kaínico , Neuropéptido Y/metabolismo , Convulsiones/prevención & control , Estado Epiléptico/prevención & control , Amígdala del Cerebelo , Animales , Recuento de Células , Muerte Celular , Citoprotección , Masculino , Ratones , Ratones Endogámicos C57BL , Fibras Musgosas del Hipocampo/patología , Neuronas/patología , Convulsiones/patología , Convulsiones/fisiopatología , Estado Epiléptico/inducido químicamente , Estado Epiléptico/fisiopatología , Sinapsis/patología , Factores de TiempoAsunto(s)
Aspirina/uso terapéutico , Enfermedades Cardiovasculares/tratamiento farmacológico , Comprimidos Recubiertos/uso terapéutico , Anciano , Peso Corporal , Cardiología/métodos , Humanos , Persona de Mediana Edad , Cooperación del Paciente , Suero/química , Tromboxanos/química , Factores de TiempoRESUMEN
BACKGROUND: Too little is currently known about the prevalence of and risk factors for depression and carer strain among informal carers of community-dwelling elderly mentally ill. This study seeks to assess the prevalence of depression, using the Geriatric Depression Scale-15 (GDS-15), the degree of carer burden/strain, and their risk factors among the primary informal carers of patients referred to our community-based old age psychiatry service. METHODS: A cross-sectional study design was used, with the subjects comprising 100 primary informal carers of patients who live at home and were referred to our service. The main carer measures were the GDS-15 and an adapted version of Gilleard's Strain Scale. Patients were assessed the Clifton Assessment Procedure for the Elderly-Survey version, the GDS-15 and the Mini-mental State Examination. RESULTS: Depression was found in 21% of the carers (a score of 5 or more on the GDS-15). The more problem behaviors identified and the greater the functional impairment of the patient, the higher the strain score deciles and the more likely the carer was to be depressed. Spouses were associated with lower carer strain scores. Patient diagnoses did not affect carer depression or carer strain. CONCLUSION: We found high levels of depression in the primary carers of community-dwelling patients attending an old age psychiatric service. The patients' behavior and their cognitive and functional ability conferred greater risk of carer depression or strain than their diagnosis. These risk factors may help identify carers at risk of strain and depression.
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Cuidadores/psicología , Demencia/rehabilitación , Trastorno Depresivo/epidemiología , Hogares para Ancianos/estadística & datos numéricos , Derivación y Consulta/estadística & datos numéricos , Actividades Cotidianas/psicología , Adaptación Psicológica , Adulto , Anciano , Anciano de 80 o más Años , Enfermedad de Alzheimer/psicología , Enfermedad de Alzheimer/rehabilitación , Cuidadores/estadística & datos numéricos , Demencia/psicología , Trastorno Depresivo/diagnóstico , Trastorno Depresivo/psicología , Femenino , Evaluación Geriátrica , Psiquiatría Geriátrica , Atención Domiciliaria de Salud/psicología , Humanos , Masculino , Trastornos Mentales/epidemiología , Trastornos Mentales/rehabilitación , Persona de Mediana Edad , Prevalencia , Escalas de Valoración Psiquiátrica , Cuidados Intermitentes/métodos , Factores de Riesgo , Estrés Psicológico/epidemiología , Estrés Psicológico/psicología , Encuestas y CuestionariosRESUMEN
Molecular crosstalk, including reciprocal stimulation, is theorized to take place between epithelial cancer cells and surrounding non-neoplastic stromal cells. This is the rationale for stromal therapy, which could eliminate support of a cancer by its genetically stable stroma. Epithelial-stromal crosstalk is so far poorly documented in vivo, and cell cultures and animal experiments may not provide accurate models. The current study details stromal-epithelial signalling pathways in 35 human colon cancers, and compares them with matched normal tissues using quantitative proteomic microarrays. Lysates prepared from separately microdissected epithelium and stroma were analysed using antibodies against 61 cell signalling proteins, most of which recognize activated phospho-isoforms. Analyses using unsupervised and supervised statistical methods suggest that cell signalling pathway profiles in stroma and epithelium appear more similar to each other in tumours than in normal colon. This supports the concept that coordinated crosstalk occurs between epithelium and stroma in cancer and suggests epithelial-mesenchymal transition. Furthermore, the data herein suggest that it is driven by cell proliferation pathways and that, specifically, several key molecules within the mitogen-activated protein kinase pathway may play an important role. Given recent findings of epithelial-mesenchymal transition in therapy-resistant tumour epithelium, these findings could have therapeutic implications for colon cancer.
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Carcinoma/metabolismo , Neoplasias del Colon/metabolismo , Proteínas de Neoplasias/metabolismo , Proteómica , Transducción de Señal , Anciano , Anciano de 80 o más Años , Carcinoma/patología , Proliferación Celular , Neoplasias del Colon/patología , Células Epiteliales/metabolismo , Células Epiteliales/patología , Femenino , Humanos , Linfocitos , Masculino , Mesodermo/metabolismo , Mesodermo/patología , Persona de Mediana Edad , Análisis por Matrices de Proteínas , Proteínas Proto-Oncogénicas c-akt/metabolismo , Células del Estroma/metabolismo , Inhibidor Tisular de Metaloproteinasa-2/metabolismoRESUMEN
BACKGROUND: General practitioners (GPs) are often the first to assess mental health difficulties after acute coronary syndrome (ACS). AIMS: To determine whether GPs observed an increase in mental health difficulties one-year post-hospitalisation for ACS. METHODS: Postal survey. RESULTS: GPs rated patients (n = 442) as having probable (GP assessed 10%) or definite (formally assessed 7%) mental health difficulties pre-hospitalisation. Post-hospitalisation the prevalence of probable cases increased significantly to 19% (OR = 4.3, 95% CI 2.1-10.2, P < 0.001). In multivariate analysis, only smoking at index hospitalisation was associated with being assessed as a new case of probable/formal mental health difficulties (RR = 2.1, 95% CI 1.3-3.4, P = 0.003). Forty-seven percent of cases were prescribed some medication for this problem. CONCLUSIONS: GPs recorded a significant increase in mental health difficulties in ACS patients 12 months after hospitalisation, with smoking used as an indicator of new cases.
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Síndrome Coronario Agudo/psicología , Salud Mental , Adulto , Ansiedad/epidemiología , Depresión/epidemiología , Medicina Familiar y Comunitaria , Femenino , Estado de Salud , Encuestas Epidemiológicas , Humanos , MasculinoRESUMEN
The objective of the study is to translate the Rose Questionnaire (RQ) into a Bahasa Melayu version and adapt it cross-culturally, and to measure its inter-rater and intrarater reliability. This cross sectional study was conducted in the respondents' homes or workplaces in Kelantan, Malaysia. One hundred respondents aged 30 and above with different socio-demographic status were interviewed for face validity. For each inter-rater and intra-rater reliability, a sample of 150 respondents was interviewed. Inter-rater and intra-rater reliabilities were assessed by Cohen's kappa. The overall inter-rater agreements by the five pair of interviewers at point one and two were 0.86, and intrarater reliability by the five interviewers on the seven-item questionnaire at poinone and two was 0.88, as measured by kappa coefficient. The translated Malay version of RQ demonstrated an almost perfect inter-rater and intra-rater reliability and further validation such as sensitivity and specificity analysis of this translated questionnaire is highly recommended.
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Angina Inestable/epidemiología , Encuestas y Cuestionarios/normas , Adulto , Anciano , Estudios Transversales , Femenino , Humanos , Entrevistas como Asunto , Lenguaje , Malasia/epidemiología , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , TraducciónRESUMEN
AIMS: The SCORE project was initiated to develop a risk scoring system for use in the clinical management of cardiovascular risk in European clinical practice. METHODS AND RESULTS: The project assembled a pool of datasets from 12 European cohort studies, mainly carried out in general population settings. There were 20,5178 persons (88,080 women and 11,7098 men) representing 2.7 million person years of follow-up. There were 7934 cardiovascular deaths, of which 5652 were deaths from coronary heart disease. Ten-year risk of fatal cardiovascular disease was calculated using a Weibull model in which age was used as a measure of exposure time to risk rather than as a risk factor. Separate estimation equations were calculated for coronary heart disease and for non-coronary cardiovascular disease. These were calculated for high-risk and low-risk regions of Europe. Two parallel estimation models were developed, one based on total cholesterol and the other on total cholesterol/HDL cholesterol ratio. The risk estimations are displayed graphically in simple risk charts. Predictive value of the risk charts was examined by applying them to persons aged 45-64; areas under ROC curves ranged from 0.71 to 0.84. CONCLUSIONS: The SCORE risk estimation system offers direct estimation of total fatal cardiovascular risk in a format suited to the constraints of clinical practice.
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Enfermedades Cardiovasculares/mortalidad , Adulto , Distribución por Edad , Anciano , Anciano de 80 o más Años , Enfermedad Coronaria/mortalidad , Angiopatías Diabéticas/mortalidad , Métodos Epidemiológicos , Europa (Continente)/epidemiología , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Cephalopelvic disproportion (CPD) is a recognised obstetric problem with potential risk to both mother and infant. Identification of those mothers at risk of CPD is difficult and has concentrated in the past on such measurements as maternal shoe size and height. Our objective in this study was to examine new anthropomorphic parameters as indicators of CPD. This was a case controlled study of sixty consecutive women, and their partners, who had caesarean section performed for CPD and 60 case matched controls. Measurements included maternal and paternal head circumference, height, shoe-size, body mass index (BMI), infant weight and head circumference. Parity, gestation at delivery, and mode of onset of labour were recorded. Data were analysed using Stata Release 6. Prognostic factors were tested for association with CPD using conditional logic regression. The most important anthropomorphic risk factors for CPD were maternal head circumference in relation of height (P < 0.001), and paternal head to height ratio (P = 0.017). Head to height ratio is taken as the head circumference in centimeters divided by the height in metres. Body mass index was higher in CPD cases (maternal case mean = 27.1, control mean = 25.5; paternal case mean = 27.2, control mean = 26.2). Infant head circumference was not a predictor. Primiparity was an important independent predictor (P<0.001), regardless of the mode of onset of labour. Maternal or paternal shoe-size, induction of labour and gestation at delivery were not predictors. The risk profile for CPD which emerges is one of a tall father where both mother and father have large head-to-height ratios.
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Antropometría , Complicaciones del Trabajo de Parto/diagnóstico , Adulto , Estudios de Casos y Controles , Cesárea , Femenino , Humanos , Masculino , Embarazo , Factores de RiesgoRESUMEN
STUDY OBJECTIVE: The purpose of the study was to determine the relations between maternal work, ambulatory blood pressure in mid-pregnancy, and subsequent pregnancy outcome. DESIGN: Data were studied on 933 healthy normotensive primigravidas who had been enrolled into a study on the predictive value of ambulatory blood pressure measurement performed between 18 and 24 weeks gestation. They were classified into three groups depending on whether they were at work (working group, n=245), not working (not working group, n=289), or normally employed but chose not to work (ENK group, n=399), on the day monitoring was performed. SETTING: The Rotunda Hospital (a large maternity hospital), Dublin, Ireland. MAIN RESULTS: Adjusted for age, body mass index, smoking, drinking, and marital status, women at work had higher mean daytime systolic (p<0.01) and diastolic (p<0.01) and 24 hour systolic pressures (p=0.03) compared with those not working. The rate of subsequent development of pre-eclampsia was significantly higher (odds ratio 4.1, 95% CI 1.1 to 15.2, p=0.03) among those at work compared with those not working. The association between pre-eclampsia and maternal work remained significant (odds ratio 5.5, 95% CI 1.1 to 27.8, p=0.04) even after allowing for the confounding factors of age, smoking, body mass index, and marital status. When daytime systolic and diastolic blood pressure were added to the regression analysis the risk ratios for pre-eclampsia remained high but did not quite reach statistical significance (odds ratio 4.7, 0.90 to 24.8, p=0.066). Birth weight and placental weight were not predicted by work status or blood pressure. CONCLUSIONS: A significant independent relation was found between maternal work and ambulatory blood pressure levels in mid-pregnancy. In addition, it was found that maternal work was significantly associated with the subsequent development of pre-eclampsia
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Monitoreo Ambulatorio de la Presión Arterial , Empleo , Preeclampsia/etiología , Complicaciones Cardiovasculares del Embarazo/etiología , Adulto , Femenino , Humanos , Oportunidad Relativa , Valor Predictivo de las Pruebas , Embarazo , Resultado del Embarazo , Segundo Trimestre del Embarazo , PronósticoRESUMEN
The Maasai have high rates of death from neonatal tetanus, partly due to their custom of packing the umbilical stump with cow dung. We report on the effect of a simple health promotion programme, designed in consultation with the local community and carried out by local women. After introduction of the programme in 1981, neonatal (<6 weeks of age) tetanus rates fell sharply, and by 1988 annual death rates had dropped to 0.75 (range 0-3) per 1000 births in the intervention areas compared with 82 (74-93) per 1000 in control areas.
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Promoción de la Salud , Atención Perinatal/métodos , Tétanos/mortalidad , Tétanos/prevención & control , Características Culturales , Femenino , Humanos , Recién Nacido , Kenia/epidemiología , Tanzanía/epidemiología , Resultado del TratamientoRESUMEN
BACKGROUND AND AIMS: We have previously reported a reduction in risk of diarrhoeal disease in children who used solar disinfected drinking water. A cholera epidemic, occurring in an area of Kenya in which a controlled trial of solar disinfection and diarrhoeal disease in children aged under 6 had recently finished, offered an opportunity to examine the protection offered by solar disinfection against cholera. METHODS: In the original trial, all children aged under 6 in a Maasai community were randomised by household: in the solar disinfection arm, children drank water disinfected by leaving it on the roof in a clear plastic bottle, while controls drank water kept indoors. We revisited all households which had participated in the original trial. RESULTS: There were 131 households in the trial area, of which 67 had been randomised to solar disinfection (a further 19 households had migrated as a result of severe drought). There was no significant difference in the risk of cholera in adults or in older children in households randomised to solar disinfection; however, there were only three cases of cholera in the 155 children aged under 6 years drinking solar disinfected water compared with 20 of 144 controls. CONCLUSIONS: Results confirm the usefulness of solar disinfection in reducing risk of water borne disease in children. Point of consumption solar disinfection can be done with minimal resources, which are readily available, and may be an important first line response to cholera outbreaks. Its potential in chorine resistant cholera merits further investigation.
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Cólera/prevención & control , Países en Desarrollo , Desinfección , Luz Solar , Vibrio cholerae/efectos de la radiación , Abastecimiento de Agua , Preescolar , Estudios de Seguimiento , Humanos , Lactante , Kenia , Oportunidad Relativa , Ensayos Clínicos Controlados Aleatorios como Asunto , RiesgoRESUMEN
First-year medical students were surveyed by questionnaire to assess levels of stress and physical symptoms resulting from their experience of the anatomy room. There was a 100% response rate from the 188 students. Most students (95%) found the prospect of their first visit to the anatomy room exciting. A small number initially experienced physical symptoms, but these had improved significantly 10 weeks later. Most students suffered very little or no stress (80%) on their first visit with only 2% of respondents rating their stress levels as high. Ten weeks later, 87% experienced little or no stress with only 1% stating that they had high stress levels. The anatomy room was rated to be less stressful than workload and assessments. Students reported that the anatomy room provoked thoughts of mortality, and 27% suggested that there should be more preparation before the first visit to the anatomy room. Our findings support previous studies suggesting that American/Canadian students in particular find anatomy stressful. However, the wisdom of interpreting adverse reactions as symptomatic of post-traumatic stress disorder is questioned. This study shows the anatomy room to be a positive learning experience for the students of the Royal College of Surgeons in Ireland.
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Anatomía/educación , Actitud Frente a la Muerte , Disección/psicología , Estrés Psicológico , Estudiantes de Medicina/psicología , Adolescente , Adulto , Cadáver , Femenino , Humanos , Masculino , Encuestas y CuestionariosRESUMEN
HYPOTHESIS: Patency after primary percutaneous transluminal angioplasty (PTA) and stenting of superficial femoral artery (SFA) occlusions is better than historical experience with PTA alone. DESIGN: Consecutive case series of primary PTA with stenting, and follow-up with duplex imaging every 6 months (mean +/- SD follow-up, 32 +/- 15 months). SETTING: Veterans Affairs medical center. PATIENTS AND METHODS: Patients were 57 previously untreated men with 71 limbs having chronic atherosclerotic SFA occlusion with suprageniculate reconstitution and patent tibial runoff. Critical ischemia (Society for Vascular Surgery [SVS] category, 4-6) was present in 7 (10%), the remainder had intermittent claudication only (SVS, 1-3). INTERVENTIONS: Guidewire recanalization followed by PTA, Wallstent deployment, and adjunctive thrombolysis as necessary; 19 limbs (27%) required thrombolysis to manage periprocedural thrombosis. MAIN OUTCOME MEASURES: Cumulative patency, limb salvage, and complications. RESULTS: Length (mean +/- SD) of occlusion was 14.4 +/- 9.9 cm. Length of stented artery was 24.3 +/- 11.1 cm. Ankle brachial index increased from 0.59 +/- 0.14 to 0.86 +/- 0.16 (P<.001) after stenting. One- and 3-year patencies were as follows: primary, 54.6% +/- 6.3% and 29.9% +/- 6.6%; assisted primary, 72.3% +/- 5.6% and 59.0% +/- 6.8%; and secondary, 81.6% +/- 4.8% and 68.3% +/- 6.5%. Three-year secondary patency when periprocedural thrombolysis was required was 35.7% +/- 12.5% compared with 70.6% +/- 7.4% for limbs not requiring periprocedural thrombolysis (P=.02); the differences in occlusion length and severity of ischemia were not significant between these 2 groups. Limbs undergoing adjunctive PTA during angiography 6 to 12 months after initial stenting had 63.0% +/- 13.3% patency at 3 years compared with 100% patency in limbs not requiring PTA at 6 to 12 months angiography (P=.046). Periprocedural mortality and morbidity were 2.8% and 15.5%, respectively. Three of the 7 limbs with critical ischemia underwent amputation during follow-up compared with 2 (3%) of 64 limbs with functional ischemia (chi(2) test, P<.006). A mean of 1.8 endovascular interventions per limb were performed. CONCLUSIONS: Percutaneous transluminal angioplasty and stenting yielded higher patency rates than historical controls undergoing PTA alone. When periprocedural thrombolysis is required, subsequent patency appears to be significantly worse. Poor results after PTA and stenting of limbs with critical ischemia and the need for additional endovascular therapy limit the technique's utility.
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Angioplastia de Balón , Arteriosclerosis/terapia , Arteria Femoral , Stents , Terapia Trombolítica , Anciano , Estudios de Seguimiento , Humanos , Masculino , Activadores Plasminogénicos/uso terapéutico , Factores de Tiempo , Resultado del Tratamiento , Activador de Plasminógeno de Tipo Uroquinasa/uso terapéutico , Grado de Desobstrucción Vascular/fisiologíaRESUMEN
PURPOSE: To improve the patency rate for angioplasty in chronic occlusion of the superficial femoral artery by deploying stents after angioplasty. MATERIALS AND METHODS: Angioplasty and stent placement were performed in 61 arteries in 48 male patients. The mean occlusion length was 13.5 cm and the mean stent length was 30 cm. Patency rates were analyzed at 6 months and at 1, 2, 3, and 4 years. The predictors of restenosis were analyzed by univariate and multiple logistic regression. RESULTS: Patency rates were 87% at 6 months, consisting of 74% primary, 6% primary assisted, and 7% secondary; 79% at 1 year, consisting of 47% primary, 19% primary assisted, and 13% secondary; 72% at 2 years, consisting of 36% primary, 26% primary assisted, and 10% secondary; 70% at 3 years, consisting of 26% primary, 22% primary assisted, and 22% secondary; and 63% at 4 years, consisting of 25% primary, 0% primary assisted, and 38% secondary. There was a 15% morbidity rate and one mortality as a result of retroperitoneal bleeding. Better patency rates were noted at all time intervals in diabetic limbs, 7-mm-diameter versus 10-mm-diameter stents, shorter obstructions and shorter stents, nonsmokers, in limbs in which urokinase was not necessary after stent deployment, and in limbs with an International Society of Cardiovascular Surgery (ISCVS) classification under 3. Patency rates were not affected by age, race, number of trifurcation vessels patent, experience in performing the procedures, and procedures requiring less time. By multivariate logistic analysis, the independent predictors of patency at 6 months were postprocedure ankle/brachial index (ABI) and shorter stent length; at 1 year, preprocedure ABI, shorter stent length, and the presence of diabetes; at 2 years, preprocedure ABI and the presence of diabetes; and at 3 years, the preprocedure ABI. CONCLUSIONS: The techniques used to reestablish antegrade flow in these superficial femoral arteries yielded a high success rate. In addition, the use of angioplasty with stents may improve patency rates over angioplasty without stents.
Asunto(s)
Angioplastia/métodos , Arteriopatías Oclusivas/terapia , Arteria Femoral , Stents , Adulto , Anciano , Angiografía , Arteriopatías Oclusivas/diagnóstico por imagen , Distribución de Chi-Cuadrado , Arteria Femoral/diagnóstico por imagen , Arteria Femoral/cirugía , Humanos , Modelos Logísticos , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Resultado del Tratamiento , Grado de Desobstrucción VascularRESUMEN
BACKGROUND: Although a raised plasma homocysteine is a risk factor for vascular disease, it is not known whether it is associated with an adverse cardiac outcome in patients admitted with acute coronary syndromes. We evaluated the relationship between plasma homocysteine and short-term (28 days) and long-term (median 2.5 years) prognosis in acute coronary syndromes. METHODS AND RESULTS: We evaluated the relationship of quintiles of homocysteine to fatal and nonfatal coronary disease early (28 days) and late (29 days to a median of 2. 5 years) after admission to a single unit of patients with unstable angina (n=204) and myocardial infarction (n=236). The end points studied were cardiac death (n=67) and/or myocardial (re)infarction (n=30). Cox regression and logistic regression were used to estimate the relationship of homocysteine to coronary events. The event rate within the first 28 days (22 cardiac deaths and 5 nonfatal infarctions) was not related to the admission homocysteine level. In the 203 unstable angina and 214 myocardial infarction survivors, an apparent threshold effect was seen on long-term follow-up, with a significant step-up in the frequency of events between the lowest 3 quintiles (14 cardiac deaths and 11 nonfatal infarctions) and the upper 2 quintiles (31 fatal and 12 nonfatal events). Patients in the upper 2 quintiles (>12.2 micromol/L) had a 2.6-fold increase in the risk of a cardiac event (95% CI, 1.5 to 4.3, P<0.001). CONCLUSIONS: Elevated total homocysteine levels on admission strongly predict late cardiac events in acute coronary syndromes.