Biomedical subjects
Publications and source records attributed to W Feinberg.
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A number of pharmacologic interventions are now recommended for the prevention of cardiovascular disease, based on the results of randomized controlled trials. These include antihypertensive drugs, lipid-lowering agents, antiplatelet and anticoagulant drugs, estrogen replacement therapy, beta-blockers, and angiotensin converting enzyme (ACE) inhibitors. It is likely that additional pharmacologic interactions will soon be proven efficacious. Despite the strength of this evidence and the development of clinical guidelines incorporating their use, a surprisingly low proportion of patients are actively treated with these agents. There may be a variety of explanations for this, including barriers at the level of the patient, health care provider, and health care institution. Finally, a number of questions remain as to the optimal combination of interventions, both behavioral and pharmacologic, which will yield maximal reduction in risk. The description of factors which reduce the effectiveness of pharmacologic interventions below the efficacy demonstrated in randomized clinical trials should be a fertile area for epidemiologic and behavioral research.
There is mounting epidemiologic evidence to support the relationship of lipids as a risk factor for ischemic stroke. We review epidemiologic and pathophysiologic evidence for such a link. Treatment of hyperlipidemia is addressed within the context of overall cardiovascular disease risk but also for stroke prevention.
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PURPOSE: Recent reports suggest that 80% to 90% of patients can safely undergo carotid endarterectomy on the basis of duplex scanning alone without cerebral angiography. Other investigators have recommended that a complementary imaging study such as magnetic resonance angiography (MRA) also be obtained. METHODS: We prospectively evaluated 103 consecutive patients with carotid occlusive disease. Eighty percent of patients were symptomatic. All 103 patients underwent duplex scanning and arteriography. Additional noninvasive tests included computed tomography, magnetic resonance imaging, and MRA in 50%, 56%, and 48% of patients, respectively. At a multispecialty conference all studies except angiograms were reviewed, and a treatment decision was made by a panel of attending vascular surgeons, neurosurgeons, and neurologists. The cerebral angiograms then were reviewed and changes made to final treatment plans were noted. RESULTS: After review of noninvasive studies, 30 of 103 of patients (29%) were believed to require arteriography because of diagnostic uncertainty of carotid occlusion in three patients, suggestion of nonatherosclerotic disease in four, suggestion of proximal disease in two, suboptimal noninvasive studies in one, and uncertainty of therapy despite good-quality noninvasive studies in 20 patients primarily with borderline stenoses and unclear symptoms. In 10 of these 30 patients (33%) management decisions were changed on the basis of angiogram results. Of the remaining 73 patients (71%) in whom the panel felt comfortable proceeding with operative or medical therapy without angiography, only one patient (1.4%) would have had management altered by results of angiography. MRA results concurred with duplex findings in 92% of studies, but did not alter management in any patient. CONCLUSIONS: In patients with good-quality duplex images, focal atherosclerotic bifurcation disease, and clear clinical presentation, treatment decisions can be made without arteriography. In 30% of patients angiography is useful in clarifying decisionmaking. MRA is unlikely to influence management decisions and is thus rarely indicated.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.
Explore the source record for details and available documents.
BACKGROUND AND PURPOSE: In a group of patients with high-grade asymptomatic carotid artery stenosis, we prospectively determined the prevalence and radiological characteristics of clinically asymptomatic brain infarction evident on computed tomography. Risk factors and extent of carotid disease were also determined. METHODS: Patients randomized into the Asymptomatic Carotid Atherosclerosis Study (ACAS) underwent a neurological history, a detailed stroke/transient ischemic attack questionnaire, and a detailed neurological examination. Computed tomography scans were examined by standardized criteria developed as part of a quality-control program supervised by a neuroradiologist. The presence, location, and size of all cerebral infarctions evident by computed tomography were determined. RESULTS: Among 1132 patients, 848 had no history of stroke or transient ischemic attack. One hundred twenty-six patients (15%) had a silent infarct; 95 (11%) had one, 24 (3%) had two, and 7 (1%) had three or more infarcts. The infarct size was small and deep for 117 patients (72%), less than one-half lobe for 45 (28%), and one-half to less than one lobe for 1 (0.5%). The silent infarcts were evenly distributed ipsilaterally and contralaterally to the study artery but were significantly more frequent in the right hemisphere (P < .05). Factors associated with silent infarction were abnormal gait (P < .001), abnormal deep tendon reflexes or plantar responses (P = .038), but not degree of carotid stenosis. Silent infarction was less frequent among this totally asymptomatic cohort (15%) compared with those with transient ischemic attacks (34/139, 25%; P < .001). CONCLUSIONS: Silent infarction in the setting of asymptomatic carotid stenosis is not uncommon, but silent infarctions are rarely sizable. The clinical significance of silent cerebral infarction in patients with asymptomatic carotid artery stenosis has yet to be established.
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Approximately 85 percent of strokes are caused by infarction, with the remainder due to subarachnoid or intracerebral hemorrhage. Eighty percent of ischemic strokes are attributed to cerebrovascular disease, 15 percent to cardiogenic embolism and 5 percent to more unusual causes. Risk factors for stroke include hypertension and lifestyle choices. Recommendations for anticoagulant prophylaxis, treatment and dosage are provided.
The first two cases of Legionnaires' disease in heart transplant patients are reported. Of interest in these cases were culture of the organism from sputum, diagnosis by percutaneous lung aspiration, bronchopleural fistula formation in the first case, which was then successfully treated with multiple-tube thoracostomies, early cavitation of lesions in both cases after the start of antibiotic therapy, positive direct fluorescent antibody staining from transtracheal aspirate 42 days after starting appropriate antibiotic therapy in the first case, apparent superiority of intravenous erythromycin therapy in the first case, and survival of both patients. Our laboratory isolated and identified the organism in both cases.