RESUMEN
Aortitis is an inflammatory condition that can be due to numerous causes. It is a diagnostic quandary because it commonly shows similar clinical, pathologic, and aortographic features independently of the etiology. A case of aortitis, possibly secondary to bacterial endocarditis, initially misdiagnosed as an atherosclerotic aortic ulcer and managed with an endoprosthesis is presented. On the fourth postoperative day, the patient presented with fever and worsening abdominal pain, which was later diagnosed as infectious aortitis. It required débridement and replacement of the infrarenal aorta with a cadaveric cryopreserved allograft. This case emphasizes the need for early diagnosis and aggressive therapy to avoid life-threatening sequelae.
Asunto(s)
Aortitis/diagnóstico , Endocarditis Bacteriana/diagnóstico , Infecciones Estafilocócicas/diagnóstico , Aorta/trasplante , Aortitis/cirugía , Implantación de Prótesis Vascular , Diagnóstico Diferencial , Humanos , Masculino , Persona de Mediana Edad , Reoperación/métodos , Infecciones Estafilocócicas/cirugía , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: This study assessed the reliability of surgical resident self-assessment in comparison with faculty and standardized patient (SP) assessments during a structured educational module focused on perioperative management of a simulated adverse event. METHODS: Seven general surgery residents participated in this module. Residents were assessed during videotaped preoperative and postoperative SP encounters and when dissecting a tumor off of a standardized inanimate vena cava model in a simulated operating room. RESULTS: Preoperative and postoperative assessments by SPs correlated significantly (P < .05) with faculty assessments (r = .75 and r = .79, respectively), but not resident self-assessments. Coefficient alpha was greater than .70 for all assessments except resident preoperative self-assessments. CONCLUSIONS: Faculty and SP assessments can provide reliable data useful for formative feedback. Although resident self-assessment may be useful for the formative assessment of technical skills, results suggest that in the absence of training, residents are not reliable self-assessors of preoperative and postoperative interactions with SPs.
Asunto(s)
Competencia Clínica , Evaluación Educacional , Cirugía General/educación , Atención Perioperativa , Relaciones Médico-Paciente , Aptitud , Docentes Médicos , Hemorragia/cirugía , Humanos , Internado y Residencia , Masculino , Modelos Educacionales , Neoplasias/cirugía , Satisfacción del Paciente , Reproducibilidad de los Resultados , Autoevaluación (Psicología) , Programas de Autoevaluación , Procedimientos Quirúrgicos Operativos/educación , Revelación de la Verdad , Vena Cava Inferior/cirugíaRESUMEN
BACKGROUND: This pilot project involved the development of a structured, experiential, educational module using a bench model technical skills simulation and standardized patients. It integrated teaching and assessment of clinical, technical, and interpersonal skills, as well as professionalism within the context of an adverse surgical event. METHODS: General surgery residents (postgraduate year [PGY] 2, 3) were asked to participate in the pre-, intra-, and postoperative management of a patient with a retroperitoneal sarcoma. Residents' performances during the module were assessed by standardized patients and faculty, and residents were provided feedback during debriefing sessions. RESULTS: Resident performance during the module was appropriate for the level of training. Residents found this module to be a realistic, challenging, and beneficial learning experience. CONCLUSIONS: Novel educational modules such as this one may serve as a useful addition to resident education in surgery residency programs, particularly in addressing patient safety and the core competencies. Reliability of the model may be enhanced by modifications of the module.
Asunto(s)
Competencia Clínica/normas , Cirugía General/educación , Internado y Residencia/normas , Complicaciones Intraoperatorias/prevención & control , Complicaciones Posoperatorias/prevención & control , Procedimientos Quirúrgicos Operativos/efectos adversos , Humanos , Complicaciones Intraoperatorias/etiología , Proyectos Piloto , Complicaciones Posoperatorias/etiologíaRESUMEN
Because individuals with claudication pain secondary to peripheral arterial disease (PAD) are limited in both walking speed and duration, the benefits of walking exercise may be insufficient to yield a cardiovascular training effect. The objectives of this analysis were to determine whether polestriding exercise training, performed by persons with PAD, would improve exercise endurance, elicit a cardiovascular training benefit, and improve quality of life (QoL). Persons (n = 49) whose claudication pain limited their exercise capacity were randomized into a 24-week polestriding training program (n = 25, 65.8 +/- 7.1 years of age) or a nonexercise attention control group (n = 24, 68.0 +/- 8.6 years of age). Those assigned to the polestriding group trained 3 times weekly. Control group subjects came to the laboratory biweekly for ankle blood pressure measurements. A symptom-limited ramp treadmill test, ratings of perceived leg pain, and QoL data (using the Short Form-36) were obtained at baseline and upon completion of training. After 24 weeks of polestriding training, subjects increased their exercise endurance from 10.3 +/- 4.1 minute to 15.1 +/- 4.5 minute. This was significantly greater than control group subjects whose exercise endurance declined (from 11.2 +/- 4.7 to 10.3 +/- 4.7 minute; P < .001). Relationships between systolic blood pressure (P < .001), heart rate (P = .04), rate pressure product (P = .05), oxygen uptake (P = .016), and perceived leg pain (P = .02) and exercise time improved from the baseline symptom-limited treadmill test to the 6-month symptom-limited treadmill test in the polestriding group compared to the control group. The improvement in the physical component summary score of the Short Form-36 was also greater in the polestriding group (P = .031). Polestriding training significantly improved the clinical indicators of cardiovascular fitness and QoL, and decreased symptoms of claudication pain during exertion.
Asunto(s)
Terapia por Ejercicio/métodos , Tolerancia al Ejercicio , Enfermedades Vasculares Periféricas/rehabilitación , Resistencia Física , Caminata , Anciano , Velocidad del Flujo Sanguíneo , Presión Sanguínea , Distribución de Chi-Cuadrado , Prueba de Esfuerzo , Terapia por Ejercicio/normas , Femenino , Estudios de Seguimiento , Frecuencia Cardíaca , Humanos , Masculino , Consumo de Oxígeno , Dimensión del Dolor , Enfermedades Vasculares Periféricas/diagnóstico por imagen , Enfermedades Vasculares Periféricas/fisiopatología , Enfermedades Vasculares Periféricas/psicología , Calidad de Vida , Encuestas y Cuestionarios , Factores de Tiempo , Resultado del Tratamiento , UltrasonografíaRESUMEN
OBJECTIVE: To evaluate the efficacy and utility of screening renal ultrasonography (RUS) in older patients with a high prevalence of risk factors for renal cell carcinoma (RCC), as with the widespread use of advanced imaging techniques the identification of incidental RCC has increased, and although previous studies in low-risk groups reported little use for screening RUS, its utility in high-risk groups is unknown. PATIENTS AND METHODS: From 1993 to 1997, screening RUS was completed for 6678 consecutive patients in conjunction with the Aneurysm Detection and Management study. Patient demographics, medical and social history were recorded for each patient. Screening RUS was completed by one ultrasonographer using a 3.5-MHz sector scanner. A urologist verified any abnormalities identified by RUS during consultation. Additional imaging tests were obtained selectively and intervention was recommended based on the results of the genitourinary evaluation. RESULTS: From the screened population of 6678 patients, 817 (12.3%) renal anomalies were found, including a solid renal mass in 22 (0.32%), simple renal cysts in 627 (9.4%), hydronephrosis in 21 (0.31%), renal calculi in 121 (1.8%), or other abnormalities in 24 (0.36%). Treatment was completed for 15 renal cancers; 13 were organ-confined on pathological review. At a mean follow-up of >55 months, 12 of the 15 patients with RCC survived. CONCLUSIONS: In this older cohort, retroperitoneal RUS was an effective tool for case-finding by detecting significant findings in an asymptomatic population. The prevalence of solid renal masses (0.32%) was higher than reported with other screening protocols. Although probably not the best method for generalized primary screening, the use of RUS may still be beneficial for 'secondary' screening in a more selected patient population.
Asunto(s)
Carcinoma de Células Renales/diagnóstico por imagen , Neoplasias Renales/diagnóstico por imagen , Anciano , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Humanos , Masculino , Tamizaje Masivo/métodos , Persona de Mediana Edad , Estadificación de Neoplasias/métodos , Factores de Riesgo , UltrasonografíaRESUMEN
BACKGROUND: Patients with chronic venous disease (CVD) often ask whether elective vein surgery could be delayed without consequences. Because the natural history of CVD is not well known, this study was designed to determine its progression in such patients. METHODS: One hundred and sixteen limbs in 90 patients who had at least 2 exams with duplex ultrasound (DU) scanning prior to vein surgery at a university medical center were studied. These were patients who were offered an operation but for various reasons were treated at a later stage. Patients were classified by the CEAP system. RESULTS: The mean age of the patients was 49 years (range, 23 to 81 years). A second DU scan was performed 1 to 43 months after the initial exam (median, 19 months). Eighty-five limbs (73.3%) were unchanged. Thirteen limbs (11.2%) had progression of clinical stage, and seven had progression on DU scanning as well. Seven limbs progressed from C2 to C3, four limbs from C3 to C4, and two limbs from C4 to C6. Thirty-four limbs had a documented change on repeat DU scanning. In 3 of these limbs, reflux was missed on the initial exam; therefore, 31 limbs had progression of disease. The great saphenous vein and tributaries were the most often anatomic sites affected by a change, followed by perforators. Seventeen limbs (14.7%) had extension of pre-existing reflux, and 14 (12.1%) had reflux in a new segment. In 11 of these limbs, a change in the initial plan for treatment was required. Symptomatic or DU changes were noted 6 months or later in 95% of limbs and 74.2% of limbs with disease progression were diagnosed at 12 months or later. All but one of the 13 symptomatic limbs developed symptoms at least a year later. CONCLUSION: Nearly one third of patients with venous reflux had progression. Anatomic extension is frequent with disease progression but not a pre-requisite. Progression was found in most limbs 6 months after the initial study. Patients undergoing treatment for their veins may need another DU exam if this time interval is exceeded.
Asunto(s)
Insuficiencia Venosa/diagnóstico por imagen , Adulto , Anciano , Anciano de 80 o más Años , Enfermedad Crónica , Progresión de la Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Ultrasonografía Doppler DúplexRESUMEN
Patients undergoing endovascular abdominal aortic aneurysm (AAA) repair have lower perioperative morbidity and leave the hospital earlier than patients undergoing open repair. However, potential complications require continuous surveillance of endografts and there are few data regarding their long-term fate. If an open operation were well tolerated, this might be a preferable alternative. The purpose of this study was to identify patients with lower morbidity and shorter hospital stay following open AAA repair and to analyze factors that might point to open repair as the preferred approach. We performed a retrospective review of all patients who underwent AAA repair between 1995 and 2000 at our institution. All patients with ruptured aneurysms and those that required renal, celiac, or superior mesenteric reconstructions during the AAA repair were excluded. Patient demographics, preoperative comorbid conditions, intraoperative data, and postoperative complications were analyzed in detail. A total of 115 patients fulfilled the inclusion criteria. There was only one perioperative death (0.9%). The mean hospital stay was 8.1 days. A history of chronic obstructive pulmonary disease (COPD) and longer operative time were independent factors associated with prolonged hospital stay. Forty-one patients (35.6%) left the hospital in 5 or less days. Compared to the group with hospital stay >5 days, these patients had a lower incidence of COPD (7.3% vs. 25.7%, p < 0.05) and smaller-size AAAs (5.6 vs. 6.4 cm, p < 0.0001), and were more often operated on via a retroperitoneal approach (61% vs. 40.5%, p < 0.05). Their time in the operating room was less (3.5 vs. 4.5 hr, p < 0.0001), and they had less estimated blood loss (750 vs. 1500 cc, p < 0.001) and fewer transfusions (0.95 vs. 2.45 units, p < 0.0001). Patients without COPD and smaller AAAs that can be repaired via a retroperitoneal approach have a lower incidence of perioperative complications and a shorter hospital stay following open AAA repair. Until long-term results for endografts are available, our data suggest that these patients are well served with an open repair.
Asunto(s)
Aneurisma de la Aorta Abdominal/terapia , Alta del Paciente , Procedimientos Quirúrgicos Vasculares , Anciano , Aneurisma Roto/terapia , Arteriopatías Oclusivas/terapia , Femenino , Humanos , Arteria Ilíaca/patología , Arteria Ilíaca/cirugía , Illinois , Incidencia , Tiempo de Internación , Masculino , Análisis Multivariante , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
Currently, the two primary approaches to carotid endarterectomy for extracranial carotid stenosis are carotid endarterectomy with patch angioplasty and eversion carotid endarterectomy. In a retrospective study over a 4-year period from 1998 to 2002, we had an opportunity to compare the two approaches as two surgeons utilized carotid endarterectomy with Dacron patch angioplasty and two other surgeons utilized eversion carotid endarterectomy. During the 4-year period, 189 carotid endarterectomies were performed, 125 with Dacron patch angioplasty (CE-P) and 64 with eversion (EE) endarterectomy. There were no significant differences in age of the patients, operative indication, or associated risk factors between the two groups. Perioperative outcome measurement in the CE-P versus EE included stroke or transient ischemic attack, 1.6 per cent versus 1.56 per cent, cranial nerve injury, 2.4 per cent versus 3.13 per cent; death, 0.8 per cent versus 0 per cent; need for operative conversion or revision, 2.4 per cent versus 7.81 per cent, respectively. Only the need for operative conversion or revision reached significant difference (P < 0.05), although the need decreased to 4 per cent for the last 50 EE cases. Recurrent stenosis of 50 per cent to 79 per cent was 4.88 per cent versus 3.13 per cent and >80 per cent was 0.81 per cent versus 0 per cent in the CE-P versus EE group over a follow up of 16.3 months and 17.0 months, respectively. We conclude that both CE-P and EE are equally efficacious operative approaches to extracranial carotid occlusive disease.
Asunto(s)
Endarterectomía Carotidea/métodos , Anciano , Anciano de 80 o más Años , Endarterectomía Carotidea/mortalidad , Femenino , Oclusión de Injerto Vascular/epidemiología , Humanos , Illinois/epidemiología , Masculino , Persona de Mediana Edad , Tereftalatos Polietilenos , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Mallas Quirúrgicas , Resultado del TratamientoRESUMEN
PURPOSE: The purpose of this study was to review the initial implementation of a same-evening discharge algorithm for patients undergoing carotid endarterectomy (CEA). METHOD: We conducted a retrospective review of a prospective database of patients undergoing CEA over 3 years. RESULTS: From January 2000 to December 2002, 207 patients underwent CEA, of which 186 qualified for same-evening discharge. Fifty-nine patients (32%) who qualified were discharged to home the same evening; none had an adverse event after discharge. The most common reason for patients not to be discharged the same evening was exiting the operating room too late (n = 63, 34%). Thirteen patients chose to stay overnight, and 11 patients did not go home secondary to physician choice. None of these patients experienced any adverse sequelae during the overnight stay. CONCLUSION: Same-evening discharge after CEA is safe and feasible in selected patients. Currently, nearly one third of our patients are discharged within 8 hours of CEA. With appropriate scheduling, patient education, and increasing physician awareness, most patients can be discharged to home the same evening after CEA.
Asunto(s)
Procedimientos Quirúrgicos Ambulatorios/métodos , Endarterectomía Carotidea/métodos , Algoritmos , Procedimientos Quirúrgicos Ambulatorios/psicología , Actitud , Estudios de Factibilidad , Humanos , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECTIVE: We compared long-term health-related quality-of-life outcome after randomization to immediate elective repair or imaging surveillance, and in relation to time of elective repair, in patients with small asymptomatic abdominal aortic aneurysm (AAA). METHODS: This randomized clinical trial was carried out in 16 Veterans Affairs medical centers. Study subjects were patients at good surgical risk, aged 50 to 79 years, with AAAs 4.0 to 5.4 cm in diameter. Interventions included immediate open surgical AAA repair or imaging surveillance every 6 months with repair reserved for AAAs that became symptomatic or enlarged to 5.5 cm. Main outcome measures considered were SF-36 health status questionnaire, prevalence of impotence, and maximum activity level, which were determined at randomization and at all follow-up visits. RESULTS: Eleven hundred thirty-six patients were randomized and followed up for 3.5 to 8 years (mean, 4.9 years). The two randomized groups did not differ significantly for most SF-36 scales at most times, but the immediate repair group scored higher overall in general health (P <.0001), which was particularly evident in the first 2 years after randomization, and slightly lower in vitality (P <.05). The baseline value of one SF-36 scale, physical functioning, was an independent predictor of mortality. Overall, more patients became impotent after randomization to immediate repair compared with surveillance (P <.03), but this difference did not become apparent until more than 1 year after randomization. Maximum activity level did not differ significantly between the two randomized groups, but decline over time was significantly greater in the immediate repair group (P <.02). CONCLUSIONS: For most quality-of-life measures and times there was no difference between randomized groups. Immediate repair resulted in a higher prevalence of impotence more than 1 year after randomization, but was also associated with improved perception of general health in the first 2 years.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Disfunción Eréctil/etiología , Complicaciones Posoperatorias , Calidad de Vida , Anciano , Estudios de Seguimiento , Estado de Salud , Humanos , Masculino , Persona de Mediana EdadRESUMEN
PURPOSE: The purpose of this investigation was to evaluate the efficacy of PoleStriding exercise (a form of walking that uses muscles of the upper and lower body in a continuous movement similar to cross-country skiing) and vitamin E (alpha-tocopherol) to improve walking ability and perceived quality of life (QOL) of patients with claudication pain secondary to peripheral arterial disease (PAD). METHODS: Fifty-two subjects were randomized into four groups: PoleStriding with vitamin E (N = 13), PoleStriding with placebo (N= 14), vitamin E without exercise (N= 13), and placebo without exercise (N = 12). The dose of vitamin E was 400 IU daily. Only the PoleStriding with vitamin E and PoleStriding with placebo groups received PoleStriding instruction and training. Assignment to vitamin E or placebo was double blind. Subjects trained three times weekly for 30-45 min (rest time excluded). Individuals in vitamin E and placebo groups came to the laboratory biweekly for ankle blood-pressure measurements. RESULTS: Results of this randomized clinical trial provide strong evidence that PoleStriding significantly (P< 0.001) improved exercise tolerance on the constant work-rate and incremental treadmill tests. Ratings of perceived claudication pain were significantly less after the PoleStriding training program (P= 0.02). In contrast, vitamin E did not have a statistically significant effect on the subjects' ratings of perceived leg pain (P= 0.35) or treadmill walking duration ( P= 0.36). Perceived distance and walking speed (Walking Impairment Questionnaire) and perceived physical function (Rand Short Form-36) improved in the PoleStriding trained group only (P< 0.001, 0.022 and 0.003, respectively). CONCLUSION: PoleStriding effectively improved the exercise tolerance and perceived QOL of patients with PAD. Little additional benefit to exercise capacity was realized from vitamin E supplementation.
Asunto(s)
Terapia por Ejercicio , Pierna/irrigación sanguínea , Pierna/patología , Enfermedades Vasculares Periféricas/fisiopatología , Enfermedades Vasculares Periféricas/terapia , Vitamina E/uso terapéutico , Actividades Cotidianas/psicología , Anciano , Manejo de la Enfermedad , Método Doble Ciego , Prueba de Esfuerzo , Tolerancia al Ejercicio/efectos de los fármacos , Tolerancia al Ejercicio/fisiología , Femenino , Estudios de Seguimiento , Humanos , Illinois , Claudicación Intermitente/fisiopatología , Claudicación Intermitente/terapia , Masculino , Persona de Mediana Edad , Consumo de Oxígeno/efectos de los fármacos , Consumo de Oxígeno/fisiología , Cooperación del Paciente , Resistencia Física/efectos de los fármacos , Resistencia Física/fisiología , Estudios Prospectivos , Calidad de Vida/psicología , Ensayos Clínicos Controlados Aleatorios como Asunto , Flujo Sanguíneo Regional/efectos de los fármacos , Flujo Sanguíneo Regional/fisiología , Encuestas y Cuestionarios , Factores de Tiempo , Resultado del Tratamiento , Caminata/fisiologíaRESUMEN
BACKGROUND: Stroke after carotid endarterectomy (CEA) may be a result of intraoperative ischemia, embolism, or thrombosis at the operative site. Intraoperative duplex should eliminate the occurrence of a severe internal carotid artery (ICA) thrombosis and, thus, negate the benefit of reoperation. This article will detail the results of our evolving treatment algorithm for immediate versus delayed post-CEA neurologic deficit (ND). METHODS: We studied patients who had an ND after CEA from 1988 to 2000. Results. Thirty-two patients (3.2%) had a post-CEA ND (26 related stroke or transient ischemic attack, 6 other); 31 had a satisfactory intraoperative duplex post-CEA, 1 was not tested. Fifteen patients awoke from operation with a related deficit, 5 of whom were re-explored and all had a patent ICA. One patient without lateralizing signs who was not re-explored had extensive thrombosis at postmortem. The remaining 9 all had a duplex-proven patent ICA. Ten patients had a lucid interval before their related ND. Six patients were re-explored and all had thrombosed ICAs; 5 of the 6 improved postthrombectomy. Four patients were not re-explored for various reasons; a carotid thrombosis was not later diagnosed in any of these patients. CONCLUSIONS: Intraoperative and postoperative duplex has modified our treatment of post-CEA stroke. No longer are all patients re-explored. Patients with a normal intraoperative duplex who awaken with an immediate stroke do not usually have occlusive thrombus and routine re-exploration does not benefit these patients. Patients who have an ND develop after a lucid period may have a thrombosed ICA despite a normal intraoperative duplex, and unless there is a timely normal duplex, re-exploration is recommended and appears to benefit these patients.
Asunto(s)
Endarterectomía Carotidea/efectos adversos , Complicaciones Posoperatorias/terapia , Periodo Posoperatorio , Accidente Cerebrovascular/terapia , Endarterectomía Carotidea/métodos , Humanos , ReoperaciónRESUMEN
PURPOSE: The purpose of this study was to determine the outcome of nonoperative management (NOM) of asymptomatic high-grade (80% to 99%) carotid stenosis. METHODS: From April 1994 to December 2000, asymptomatic high-grade (80% to 99%) carotid stenosis was identified in 196 carotid arteries in 180 male veterans. Of the original number identified, 137 carotid endarterectomies (CEs) were performed in 123 patients (OP group) and 59 carotid arteries in 57 patients were managed nonoperatively (NOM group.) The NOM group was further subdivided into those patients who refused care (NOM-R group; n = 21; 36.8%) versus those who were not offered CE on the basis of comorbid conditions (NOM-C group; n = 36; 63.2%). Clinical follow-up was obtained to determine rates of neurologic events, patient survival, and progression to occlusion. RESULTS: During the follow-up period, a total of 13 ipsilateral neurologic events occurred: two amaurosis fugax (15.4%), two transient ischemic attacks (15.4%), and nine strokes (69.2%). The NOM-R group had a significantly lower ipsilateral neurologic event-free rate when compared with the OP group at both 18 months (81% +/- 9.8% versus 96% +/- 1.8%; P <.02) and 2 years (81% +/- 10.6% versus 95% +/- 2.1%; P <.04.) However, the NOM-C group and the OP group had no significant difference in their ipsilateral neurologic event-free rate out to 3 years (96% +/- 6.8% versus 95% +/- 2.7%). As would be expected, the NOM-C group had a much lower patient survival rate when compared with either the OP group (59% +/- 9.2% versus 84% +/- 3.6% at 2 years; P <.002) or the NOM-R group (59% +/- 9.2% versus 100% at 2 years; p <.0001). The cumulative patency rate of carotid arteries in the NOM group was 86% +/- 7.6% at 3 years. Progression to occlusion was associated with a neurologic event in two of five occurrences. No carotid artery progressed to occlusion in the OP froup. CONCLUSION: Although CE is the preferred treatment for asymptomatic high-grade carotid stenosis, NOM is an acceptable alternative in selected patients at high risk with diminished life expectancy.
Asunto(s)
Estenosis Carotídea/mortalidad , Estenosis Carotídea/terapia , Evaluación de Resultado en la Atención de Salud , Anciano , Estenosis Carotídea/complicaciones , Endarterectomía Carotidea , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Enfermedades del Sistema Nervioso/etiología , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Tasa de Supervivencia , Factores de Tiempo , Negativa del Paciente al TratamientoRESUMEN
BACKGROUND: The primary purpose of this study was to evaluate compliance, side effects, and safety associated with prolonged administration of doxycycline in patients with small asymptomatic abdominal aortic aneurysms (AAAs). A secondary goal was to determine how treatment with doxycycline influences circulating levels of matrix metalloproteinase-9 (MMP-9) in this patient population. METHODS: Thirty-six patients with AAAs (30 men and 6 women; mean age, 69 +/- 1 years) were enrolled into a 6-month phase II study to evaluate treatment with doxycycline (100 mg orally twice a day). Aneurysm size was measured before and after treatment, and compliance and side effects were monitored. Plasma levels of doxycycline were measured midway through the study, and plasma MMP-9 concentrations were measured at baseline, 3 months, and 6 months. RESULTS: Thirty-three of the 36 patients (92%) completed 6 months of doxycycline treatment. Significant treatment-related side effects occurred in five patients (13.9%), including three with cutaneous photosensitivity reactions (8.3%), one with tooth discoloration (2.8%), and one with yeast infection (2.8%). A high rate of compliance with treatment was seen, despite minor but frequent side effects, including nonspecific gastrointestinal symptoms (25%), easily managed episodes of photosensitivity (22.2%), and reversible tooth discoloration (5.5%). The mean plasma doxycycline level after 3 months was 4.62 +/- 0.68 ug/mL (median, 3.64 microg/mL; range, 1.31 to 14.39 microg/mL; n = 23 patients). No significant change was seen in AAA diameter (42.7 +/- 1.3 mm at 6 months versus 41.0 +/- 0.9 mm at baseline), and the overall rate of AAA expansion was 0.63% +/- 0.25% per month. The mean plasma MMP-9 level (n = 19 patients) was elevated at baseline (118.9 +/- 37.9 ng/mL; upper limit of normal, 85 ng/mL) but subsequently decreased to 83.8 +/- 32.9 ng/mL at 3 months (not significant versus baseline) and to 66.4 +/- 24.2 ng/mL at 6 months (P =.022 versus baseline). Only 21% of patients had an elevated level of plasma MMP-9 after 6 months of treatment compared with 47% at baseline (P <.05). CONCLUSION: Prolonged administration of doxycycline is safe and well tolerated by patients with small asymptomatic AAAs and is associated with a gradual reduction in plasma MMP-9 levels. Further studies are needed to evaluate the long-term effects of doxycycline on the rate and extent of aneurysm growth and the potential use of plasma MMP-9 levels as a biomarker of aneurysm disease progression.
Asunto(s)
Antibacterianos/administración & dosificación , Aneurisma de la Aorta Abdominal/tratamiento farmacológico , Doxiciclina/administración & dosificación , Anciano , Anciano de 80 o más Años , Antibacterianos/efectos adversos , Antibacterianos/sangre , Biomarcadores/sangre , Progresión de la Enfermedad , Doxiciclina/efectos adversos , Doxiciclina/sangre , Femenino , Estudios de Seguimiento , Humanos , Masculino , Metaloproteinasa 9 de la Matriz/sangre , Metaloproteinasa 9 de la Matriz/efectos de los fármacos , Persona de Mediana Edad , Cooperación del Paciente , Estudios Prospectivos , Estadística como Asunto , Factores de Tiempo , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
CONTEXT: Among patients with abdominal aortic aneurysm (AAA) who have high operative risk, repair is usually deferred until the AAA reaches a diameter at which rupture risk is thought to outweigh operative risk, but few data exist on rupture risk of large AAA. OBJECTIVE: To determine the incidence of rupture in patients with large AAA. DESIGN AND SETTING: Prospective cohort study in 47 Veterans Affairs medical centers. PATIENTS: Veterans (n = 198) with AAA of at least 5.5 cm for whom elective AAA repair was not planned because of medical contraindication or patient refusal. Patients were enrolled between April 1995 and April 2000 and followed up through July 2000 (mean, 1.52 years). MAIN OUTCOME MEASURE: Incidence of AAA rupture by strata of initial and attained diameter. RESULTS: Outcome ascertainment was complete for all patients. There were 112 deaths (57%) and the autopsy rate was 46%. Forty-five patients had probable AAA rupture. The 1-year incidence of probable rupture by initial AAA diameter was 9.4% for AAA of 5.5 to 5.9 cm, 10.2% for AAA of 6.0 to 6.9 cm (19.1% for the subgroup of 6.5-6.9 cm), and 32.5% for AAA of 7.0 cm or more. Much of the increased risk of rupture associated with initial AAA diameters of 6.5-7.9 cm was related to the likelihood that the AAA diameter would reach 8.0 cm during follow-up, after which 25.7% ruptured within 6 months. CONCLUSION: The rupture rate is substantial in high-operative-risk patients with AAA of at least 5.5 cm in diameter and increases with larger diameter.
Asunto(s)
Aneurisma de la Aorta Abdominal/fisiopatología , Rotura de la Aorta/epidemiología , Evaluación de Resultado en la Atención de Salud , Anciano , Aneurisma de la Aorta Abdominal/patología , Estudios de Cohortes , Contraindicaciones , Humanos , Incidencia , Masculino , Modelos de Riesgos Proporcionales , Riesgo , Procedimientos Quirúrgicos VascularesRESUMEN
BACKGROUND: Whether elective surgical repair of small abdominal aortic aneurysms improves survival remains controversial. METHODS: We randomly assigned patients 50 to 79 years old with abdominal aortic aneurysms of 4.0 to 5.4 cm in diameter who did not have high surgical risk to undergo immediate open surgical repair of the aneurysm or to undergo surveillance by means of ultrasonography or computed tomography every six months with repair reserved for aneurysms that became symptomatic or enlarged to 5.5 cm. Follow-up ranged from 3.5 to 8.0 years (mean, 4.9). RESULTS: A total of 569 patients were randomly assigned to immediate repair and 567 to surveillance. By the end of the study, aneurysm repair had been performed in 92.6 percent of the patients in the immediate-repair group and 61.6 percent of those in the surveillance group. The rate of death from any cause, the primary outcome, was not significantly different in the two groups (relative risk in the immediate-repair group as compared with the surveillance group, 1.21; 95 percent confidence interval, 0.95 to 1.54). Trends in survival did not favor immediate repair in any of the prespecified subgroups defined by age or diameter of aneurysm at entry. These findings were obtained despite a low total operative mortality of 2.7 percent in the immediate-repair group. There was also no reduction in the rate of death related to abdominal aortic aneurysm in the immediate-repair group (3.0 percent) as compared with the surveillance group (2.6 percent). Eleven patients in the surveillance group had rupture of abdominal aortic aneurysms (0.6 percent per year), resulting in seven deaths. The rate of hospitalization related to abdominal aortic aneurysm was 39 percent lower in the surveillance group. CONCLUSIONS: Survival is not improved by elective repair of abdominal aortic aneurysms smaller than 5.5 cm, even when operative mortality is low.
Asunto(s)
Aneurisma de la Aorta Abdominal/cirugía , Anciano , Aneurisma de la Aorta Abdominal/diagnóstico por imagen , Aneurisma de la Aorta Abdominal/mortalidad , Rotura de la Aorta/etiología , Rotura de la Aorta/mortalidad , Procedimientos Quirúrgicos Electivos/mortalidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Análisis de Supervivencia , Tomografía Computarizada por Rayos X , UltrasonografíaRESUMEN
OBJECTIVE: The efficacy of polestriding exercise (walking with modified ski poles with a movement pattern similar to cross-country skiing) to increase exercise tolerance of persons with intermittent claudication pain caused by peripheral arterial disease was tested in this 24-week prospective randomized clinical trial. METHODS: The study was conducted in a Department of Veterans Affairs Hospital with 52 individuals who gave written informed consent and were randomized into either a polestriding exercise (n = 27; age, 65.5 +/- 7.0 years; ankle brachial index, 0.64 +/- 0.25) or nonexercise control (n = 25; age, 68.6 +/- 8.9 years; ankle brachial index, 0.69 +/- 0.14) group (P >.05 for all comparisons). The polestriding exercise program consisted of supervised training three times per week for 4 weeks, two times per week for 8 weeks, one time per week for 4 weeks, biweekly for 4 weeks and unsupervised training for 4 weeks. Starting in week 5, subjects took their poles home with instructions to repeat the most recent supervised training walk at an appropriate and convenient location near their residence. This was referred to as unsupervised but directed exercise. Subjects were provided with a personal log book for documenting unsupervised exercise sessions. With both supervised and unsupervised exercise, subjects were expected to complete a total of four 30-minute to 45-minute polestriding exercise sessions per week. The main outcome measures were exercise duration on symptom-limited incremental treadmill test, Walking Impairment Questionnaire, rating of perceived leg pain at baseline, 4, 8, 12, 16, and 24 weeks, and constant work-rate treadmill exercise tests at baseline and at 4, 12, and 24 weeks. RESULTS: Polestriding significantly (P <.001) improved exercise tolerance on the constant work-rate and incremental treadmill tests. Ratings of perceived claudication pain were significantly less after the polestriding training program. Subject perceived distance and walking speed scores on the Walking Impairment Questionnaire improved in the polestriding trained group only (P <.001 and.022, respectively). CONCLUSION: This randomized clinical trial provides empirical evidence that 24 weeks of polestriding training significantly improves quantitative and qualitative measures of the exercise tolerance of persons limited by intermittent claudication pain.
Asunto(s)
Terapia por Ejercicio , Tolerancia al Ejercicio/fisiología , Claudicación Intermitente/fisiopatología , Claudicación Intermitente/terapia , Enfermedades Vasculares Periféricas/complicaciones , Anciano , Prueba de Esfuerzo , Femenino , Humanos , Pierna/irrigación sanguínea , Pierna/fisiopatología , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Enfermedades Vasculares Periféricas/fisiopatología , Estudios Prospectivos , Factores de TiempoRESUMEN
OBJECTIVE: This study was performed for the determination of the expansion rates and outcomes and for recommendations for the surveillance of the 3.0-cm to 3.9-cm abdominal aortic aneurysm (AAA). DESIGN: The study was observational with data from patients screened with ultrasound scanning for AAA at five Veterans Affairs Medical Centers for enrollment in the Aneurysm Detection and Management Trial. The eligibility requirements included: AAA from 3.0 cm to 3.9 cm in diameter and at least one repeat ultrasound scan more than 90 days after the initial screening. Patients also completed a questionnaire for demographic data and the determination of the presence of risk factors associated with AAA. The study endpoints included: 1, both mean and median expansion rates; 2, moderate expansion (>4 mm/year); 3, no expansion; 4, all causes of death; 5, AAA rupture; 6, expansion to 4 cm or more; 7, expansion to 5.0 cm or more; and 8, operative repair. RESULTS: Ultrasound scan screening results identified 1445 patients with 3.0-cm to 3.9-cm AAAs. Seven hundred ninety men met the ultrasound scan criterion of having at least two ultrasound scan studies during the study period, and these 790 men were used for this study. Mean AAA size was 3.3 cm, with an average follow-up period of 3.89 +/- 1.93 years. The median expansion rate was 0.11 cm/year. Expansion rates were significantly different (P <.001) between 3.0-cm and 3.4-cm cm AAA and 3.5-cm and 3.9-cm AAA. There were no reported AAA ruptures during the study period, although cause of death data were available in only 43% of the patients. Few 3.0-cm to 3.9-cm AAAs expanded to 5.0 cm or more during the study period. The patients with 3.0-cm to 3.9-cm AAAs who underwent operative repair during the study period were younger, had larger initial AAA diameters, and had more rapid expansion rates. CONCLUSION: AAAs of 3.0 cm to 3.9 cm expanded slowly, did not rupture, and rarely had operative repair or expanded to more than 5.0 cm in our study of male patients. Expansion rates and the incidence rate of operative repair are more common in the 3.5-cm to 3.9-cm AAA when compared with the 3.0-cm to 3.4-cm AAA.