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At least 595 records · Page 33Linked to original sources

PubMed1998

Partial left ventriculectomy and mitral valve repair for end-stage congestive heart failure.

OBJECTIVE: Partial left ventriculectomy (PLV), pioneered by Batista, has been proposed as an alternative treatment strategy in patients with refractory congestive heart failure. In order to analyze the midterm outcome of PLV and mitral valve (MV) repair and stratify patients according to risk, we prospectively studied 57 consecutive patients who underwent this procedure at the Cleveland Clinic Foundation (CCF). METHODS: Patients had a mean age of 53 years and were predominantly males (74%). In 95% the etiology of heart failure was idiopathic dilated cardiomyopathy. All patients had a left ventricular end diastolic diameter of >7cm and were in New York Heart Association (NYHA) functional classes III and IV. A total of 54 patients (95%) were awaiting heart transplantation. Preoperatively, requirements included inotropes in 23 (40%), intraaortic balloon pump counterpulsation in 3 (5.3%), and left ventricular assist device placement (LVAD) in 1 (1.8%). Concomitant procedures included MV repair (55 patients), MV replacement (2), tricuspid valve repair (34 patients), coronary artery bypass graft (CABG) (5), and aortic valve repair or replacement (1 patient each). RESULTS: Measurements preoperatively and at 3 months demonstrated improvement in left ventricular ejection fraction (14.4 +/- 7.7-23.2 +/- 10.7%, P < 0.001), left ventricular end diastolic volume (254 +/- 85-179 +/- 73 ml, P < 0.001) and left ventricular end diastolic diameter (8.4 +/- 1.1-6.3 +/- 0.9 cm, P < 0.001). Peak oxygen consumption (MVO2) increased from 10.6 +/- 3.9 to 15.3 +/- 4.5 ml/kg per min (P < 0.001). Cardiac index did not change (2.2 l/min per m2), although 40% had been on inotropes preoperatively and none were on inotropes at 3 months. NYHA functional class improved from 3.6 +/- 0.5 preoperatively to 2.2 +/- 0.9 at 3 months (P < 0.001). LVAD support was required as rescue therapy in 11 patients (17%). Actuarial freedom from procedure failure, defined as death or relisting for transplant, was 58% at 1 year. Hospital mortality was 3.5% (n = 2). On follow-up, there were 7 late deaths (including 3 sudden deaths) giving an actuarial survival of 82% at 1 year. Multivariate risk factor analysis revealed that age less than 40 years was associated with failure (P = 0.02). CONCLUSIONS: Although PLV with MV repair is now a surgical option in the treatment of end-stage congestive heart failure, caution is advised as early failures are unpredictable and mechanical support may be required as rescue therapy. Better risk stratification and patient selection may improve outcome. Further study is required to determine the procedure's exact role in the treatment of congestive heart failure.

Adolescent↗

PubMed2002

Detecting early clinical deterioration in chronic heart failure patients post-acute hospitalisation-a critical component of multidisciplinary, home-based intervention?

AIMS: To firstly describe the prevalence, characteristics and consequences of early clinical deterioration (ECD) in chronic heart failure (CHF) patients discharged from acute hospital care and, secondly, to examine the potential benefits of a multidisciplinary, home-based intervention (HBI) in limiting the common sequelae of such deterioration. METHODS: This phenomenon was studied in 90 CHF patients assigned to the intervention arm of a randomised study of HBI. ECD was defined as death, unplanned re-admission or clinical instability (detected at a home visit) within 14 days of hospital discharge. Multivariate analysis was used to determine the independent correlates of ECD. Using these data, a 1:1 case-control ratio of patients assigned to the usual care arm of the study was selected to match those patients exhibiting non-fatal ECD and subject to HBI. Subsequent morbidity and mortality rates were then compared on the basis of the presence or absence of non-fatal ECD and/or HBI. RESULTS: Of the 90 patients assigned to HBI, two died suddenly, five required an unplanned re-admission to hospital and 28 were found to be clinically unstable at a planned home visit, within 14 days of discharge from the index admission. The combined prevalence of ECD this cohort was therefore 39% (35 of 90 patients) and was independently correlated with greater age (OR=1.1 per yearly increment; P<0.001) and comorbidity (OR=2.0 per incremental Charlson index of comorbidity score; P<0.001). Patients who exhibited clinical instability at the home visit were significantly more likely to be non-adherent to prescribed treatment (10 of 28 vs. 9 of 55; P<0.05). Compared to the remainder of the cohort also subject to HBI, despite remedial intervention, patients who exhibited non-fatal ECD had reduced event-free survival (11 of 33 vs. 38 of 55; P<0.001), more frequent unplanned re-admission (0.2 vs. 0.1 admissions/patient/month; P<0.01), and more prolonged hospital stay (1.6 vs. 0.5 days/patient/month; P<0.001) in the subsequent 6-month period. However, compared to case-controls, these patients (n=33 in both groups) had fewer days of hospitalisation (1.6 vs. 3.6 days/patient/month; P=0.05) and, most significantly, were more likely to survive to 6 months (6 vs. 13 died; P<0.05). CONCLUSION: ECD is a common phenomenon in older CHF patients discharged from acute hospital care and is associated with poorer health outcomes in the longer-term. Post-discharge HBI is an important means for identifying and addressing ECD. Although HBI conveys benefits incremental to usual care, these data also provide a sound basis for increasing its effectiveness by applying earlier home visits in selected 'high-risk' patients.

Acute Disease↗

PubMed2006

Effects of the implementation of a telemedical stroke network: the Telemedic Pilot Project for Integrative Stroke Care (TEMPiS) in Bavaria, Germany.

BACKGROUND: Telemedical networks are a new approach to improve stroke care in community settings. We aimed to assess the effects of a stroke network with telemedical support in Germany on quality of care, according to acute processes and long-term outcome. METHODS: Five community hospitals without pre-existing specialised stroke care were included in a network with telemedical support by two academic hospitals. In a non-randomised, open intervention study, five community hospitals without specialised stroke care served as the control group, matched individually to the network hospitals by predefined characteristics. Stroke patients admitted consecutively to one of the participating hospitals between July 7, 2003, and March 31, 2005, were included in the study. Patients in network and control hospitals were assessed in the same manner and were followed up for vital status, living situation, and disability at 3 months. Poor outcome was defined by death, institutional care, or disability (Barthel index <60 or modified Rankin scale >3). Predefined indicators for quality of acute stroke care were achieved. FINDINGS: A total of 5696 patients with a sudden, non-convulsive loss of neurological function who were diagnosed with having suspected stroke were admitted to the ten hospitals participating in the study. After exclusion, 3122 were included in the final analysis, of whom 1971 (63%) were treated in the network hospitals. All indicators related to quality of acute stroke care were more commonly met in the network than in the control hospitals. After 3 months, 44% of patients treated in network hospitals versus 54% treated in control hospitals had a poor outcome (p<0.0001). In multivariate regression analysis, treatment in network hospitals independently reduced the probability of a poor outcome (odds ratio 0.62, 95% CI 0.52-0.74; p<0.0001). INTERPRETATION: Telemedical networks with academic stroke centres offer new and innovative approaches to improve acute stroke care at community level for stroke patients living in non-urban areas.

Academic Medical Centers↗

PubMedDate not supplied

Visual assessment of procedural results following treatment with Sr-90 beta-radiation for instent restenosis.

BACKGROUND: Visual assessment (VA) of postprocedural % diameter stenosis (DS) is used routinely in clinical practice to determine the adequacy of coronary intervention. Although VA has been shown to underestimate final %DS after balloon angioplasty compared to quantitative coronary angiography (QCA), the impact of this effect on clinical outcomes following treatment with intracoronary radiation therapy (IRT) with Sr-90 for instent restenosis (ISR) is unknown. METHODS: To determine the effect of VA on the rate of major adverse cardiac events (MACEs) after IRT for ISR, we compared the clinical outcomes of 102 consecutive patients based on postprocedural %DS by QCA vs. %DS by VA. MACE was defined as death, M1 or need for target vessel revascularization (TVR). RESULTS: MACE rates for the 102 consecutive patients grouped according to postprocedural %DS by QCA and VA were compared. The mean %DS by QCA was 30.7%, while the mean %DS by VA was 12.5%. The mean %DS by VA across the QCA subgroups were 13.67%, 10.71% and 13.37%, respectively (P = .244). Fifty-two patients (51.0%) had %DS > 30% by QCA with the highest MACE percentage occurring in this subgroup. CONCLUSION: VA underestimated the %DS compared to QCA, and it was associated with worse MACE following treatment with Sr-90 for ISR.

Beta Particles↗

PubMedDate not supplied

Predictors of late cardiac events following treatment with Sr-90 beta-irradiation for instent restenosis.

BACKGROUND: Intracoronary radiation therapy (IRT) with Sr-90 using the Novoste Beta-Cath system has been shown to be an effective therapy for instent restenosis (ISR), but the temporal occurrence of cardiac events and the predictors of late complications require further investigation. METHODS: We analyzed the demographics, lesion characteristics and clinical outcomes of 138 consecutive patients with ISR treated with IRT from September 1998 to March 2002. Major adverse cardiac events (MACE) were defined as death, myocardial infarction (MI) or target vessel revascularization (TVR). Characteristics of early (< or =8 months) and late (>8 months) failures were analyzed. RESULTS: Thirty-two (23.1%) of 138 patients had MACE on follow-up; 25% (8/32) of failures occurred late after treatment with IRT. A comparison of the clinical and angiographic profile of early and late failures using univariate analysis indicates no correlations to late failure following IRT. Duration to failure after IRT was 14.25+/-3.69 months in the late group compared to 4.63+/-2.86 months in the early group (P<.001). CONCLUSIONS: Late MACE after IRT with Sr-90 for ISR occur beyond the traditional period for clinical restenosis in 25% of cases and are difficult to predict. Further study is warranted to identify patients at risk for the development of late complications after IRT.

Aged↗

PubMed2005

[Lung transplantation in cystic fibrosis: perioperative mortality].

OBJECTIVE: To determine the incidence and causes of perioperative mortality following lung transplant for cystic fibrosis. PATIENTS AND METHODS: We analyzed the cases of 57 patients. Fifty-five patients received double lung transplants, 1 received a heart-double lung transplant, and 1 received a combined double lung and liver transplant. Information related to the organ donor, recipient, lung graft, and early postoperative period was gathered. Perioperative mortality was defined as death resulting from anesthesia or surgery regardless of how many days had passed. The Kaplan-Meier method was used to analyze survival. A Cox logistic regression model was used to determine variables affecting mortality. RESULTS: Survival was 83.7% at 1 year after transplantation, 77.3% at 2 years, and 66.9% at 5 years. Five (8.7%) patients died as a result of anesthesia or surgery. A ratio of PaO2 to inspired oxygen fraction (FiO2) less than 200 mm Hg in the early postoperative period was observed in 8 (14%) patients. Primary graft failure occurred in 4 patients, due to pneumonia in 2 and to biventricular dysfunction in 2. Three of those patients died. Two patients with PaO2/FiO2 greater than 200 mm Hg died after surgery, one from septic shock due to Pseudomonas cepacia and the other from massive cerebral infarction. PaO2/FiO2 upon admission to the recovery care unit was the only variable significantly associated with perioperative mortality in the logistic regression model (P=.0034). CONCLUSIONS: The only factor significantly related to perioperative mortality in patients receiving transplants for cystic fibrosis was PaO2/FiO2 upon admission to the recovery unit.

Adolescent↗

PubMed1999

Relation between proton magnetic resonance spectroscopy within 18 hours of birth asphyxia and neurodevelopment at 1 year of age.

The aim of the study was to test the hypotheses that elevated cerebral lactate, detected by proton spectroscopy performed within 18 hours of suspected birth asphyxia, is associated with adverse outcome, and that increased lactate can be used to predict adverse outcome. Thirty-one term infants suspected of having had birth asphyxia and seven control infants underwent proton magnetic resonance spectroscopy, using three-dimensional chemical shift imaging, within 18 hours of birth. Adverse outcome was defined as death or neurodevelopmental impairment at 1 year of age or more. Nine infants had an adverse outcome. The other 22 and all of the control infants remained normal. Median (range) lactate/creatine plus phosphocreatine (lactate/creatine) ratios in the abnormal, the normal, and the control group were 1.14 (0.17 to 3.81), 0.33 (0 to 1.51), and 0.05 (0 to 0.6) respectively (P=0.003). Lactate/creatine >1.0 predicted neurodevelopmental impairment at 1 year of age with sensitivity of 66% and specificity of 95%, positive and negative predictive values of 86% and 88%, and a likelihood ratio of 13.2. Elevated cerebral lactate/creatine within 18 hours of birth asphyxia predicts adverse outcome.

Asphyxia Neonatorum↗

PubMed2000

Predictors of poor outcome in patients with a spontaneous cerebellar hematoma.

BACKGROUND AND PURPOSE: The authors studied the clinical and neuroimaging features of cerebellar hematomas to predict poor outcome using comprehensive statistical models. METHODS: We retrospectively reviewed clinical and neuroimaging features in 94 patients with spontaneous cerebellar hematomas to identify predictive features for a poor neurologic outcome, defined as death or dismissal to long-term care facility. Data were analyzed using chi square and Fisher's exact test with calculation of odd's ratios together with 95% confidence intervals. RESULTS: Clinical and neuroradiologic predictors for a poor outcome at p < 0.05 were admission systolic blood pressure > 200 mm Hg, hematoma size > 3 cm, visible brain stem distortion, and acute hydrocephalus. Presenting findings predicting subsequent death at p < 0.05 were abnormal corneal and oculocephalic responses, Glasgow coma sum score less than 8, motor response less than localization to pain, acute hydrocephalus and intraventricular hemorrhage. CONCLUSION: A tree-based analysis model using binary recursive partitioning showed that cornea reflex, hydrocephalus, doll's eyes, age, and size were the most important discriminating factors. Absent corneal reflexes on admission highly predicts poor outcome (86 percent, confidence limits 67-96 percent). When a cornea reflex is present, acute hydrocephalus predicts poor outcome but only when doll's eyes are additionally absent.

Adult↗

PubMed1997

Giardiasis in HIV: a possible role in patients with severe immune deficiency.

We report the epidemiological, clinical and therapeutic characteristics of giardiasis in a population of HIV-infected patients with diarrhoic syndrome. During the period between 1988 and 1995, 720 HIV-patients with diarrhoic syndrome were evaluated. Fecal specimens were submitted to parasitological examination according to the Ritchie formalin-ethil acetate centrifugal sedimentation method and stained with iodine. Samples also underwent modified Ziehl-Neelsen staining and standard bacteriologic testing. Cystis of G. intestinalis were identified in stool sample of 25 patients. Two patients were classified as in stage A2 and 23 in C3. Mean CD4 values of patients with giardiasis (26.9 cells/mmc) were compared with those of 65 patients from whom, during the study, was isolated Cryptosporidium parvum (63.12, cells/mmc): the difference resulted highly significant (p < 0.001). Among the patients with full-blown AIDS, giardiasis occurred following a single previous AIDS-defining event in 13 inividuals, in seven and in five subjects giardiasis was the 3rd and, respectively, the 4th relevant AIDS-defining condition. Death occurred within the following 2 months in nine patients and within 6, 12 and 24 months in seven, six and two patients, respectively; at present only three AIDS patients are still alive. In general, G. intestinalis in HIV+, is not considered a major cause of enteritis; nevertheless, in our experience enteritis due to G intestinalis is a frequent event among AIDS patients, especially in the most advanced stage of disease, irrespectively of the risk factor. The increase in mean survival of AIDS patients will probably lead to a progressive emergence of this pathogen which could determine a severe diarroic syndrome with hydro-electrolytic impairments.

AIDS-Related Opportunistic Infections↗

PubMed2000

Corpse clearance defines the meaning of cell death.

While philosophers seek the meaning of life, cell biologists are becoming ever more interested in the meaning of death. Apoptosis marks unwanted cells with 'eat me' signals that direct recognition, engulfment and degradation by phagocytes. Far from being the end of the story, these clearance events allow scavenger cells to confer meaning upon cell death. But if the phagocytic 'spin doctors' receive or transmit the wrong messages, trouble ensues.

Animals↗

PubMed2006

Increasing incidence of proteinuria and declining incidence of end-stage renal disease in diabetic Pima Indians.

The introduction of more efficacious treatments for diabetic kidney disease may slow its progression, but evidence for their effectiveness in populations is sparse. We examined trends in the incidence of clinical proteinuria, defined as a urinary protein-to-creatinine ratio >0.5 g/g, and diabetic end-stage renal disease (ESRD), defined as death from diabetic nephropathy or onset of dialysis, in Pima Indians with type 2 diabetes between 1967 and 2002. The study included 2189 diabetic subjects >/=25 years old. During follow-up, 366 incident cases of proteinuria occurred in the subset of 1715 subjects without proteinuria at baseline. The age-sex-adjusted incidence rate of proteinuria increased from 24.3 cases/1000 person-years (pyrs) (95% confidence interval (CI) 18.7-30.0) in 1967-1978 to 35.4 cases/1000 pyrs (95% CI 28.1-42.8) in 1979-1990 and 38.9 cases/1000 pyrs (95% CI 31.2-46.5) in 1991-2002 (P(trend)<0.0002). In each period, the age-sex-adjusted incidence of proteinuria increased with diabetes duration, but diabetes duration-specific incidence was stable throughout the study period (P=0.8). The age-sex-adjusted incidence of ESRD increased between 1967 and 1990 and declined thereafter. The incidence of proteinuria increased over 36 years in Pima Indians as the proportion of people with diabetes of long duration increased. On the other hand, the incidence of ESRD declined after 1990, coinciding with improved control of blood pressure, hyperglycemia, and perhaps other risk factors.

Adult↗

PubMed2002

Prognostic significance of tumour angiogenesis in schistosoma-associated adenocarcinoma of the urinary bladder.

OBJECTIVE: To report on tumour angiogenesis and its relationship with morphological variables and prognosis in adenocarcinoma of the urinary bladder associated with schistosomiasis. PATIENTS AND METHODS: Fifty-five vesical adenocarcinomas were evaluated from 30 men and 25 women (mean age 47.2 years, sd 8.7, range 30-65) who were followed up after radical cystectomy and urinary diversion for a mean (sd, range) of 61 (43.5, 2.7-159.5) months. Vessels were stained immunohistochemically using an antibody to the platelet endothelial cell-adhesion molecule CD31. Microvessels were counted in active areas of angiogenesis within the tumours (at x250) and the microvessel density (MVD) quantified using the mean of three counts. Treatment failure was defined as death from cancer or the development of local recurrence or distant metastasis. Kaplan-Meier survival curves and Cox's proportional hazard model were used to assess survival. RESULTS: The overall 5- and 10-year survival rates were 57% and 51%, respectively. The presence of lymph node metastasis and high mean vascular density (> 26) were significantly associated with a poor prognosis. The 5-year survival for patients with negative lymph nodes was 66% while no patients with positive nodes survived for 5 years (P < 0.001); the survival was 72% for patients with a low MVD and 33% for those with a high MVD (P = 0.0016). From individual results plotted against vascularity in lymph node-negative patients, there was a significantly better outcome for those with a low MVD (< or = 26; P = 0.0099); this significance was maintained on multivariate analysis. However, there was no significant relationship between angiogenesis and the different clinicopathological factors apart from the grade (P = 0.03); tumour stage, grade and DNA profile had no significant effect on survival in these patients. CONCLUSIONS: These findings suggest that assessing angiogenesis using the MVD provides an independent predictor of survival in patients with adenocarcinoma of the urinary bladder.

Adenocarcinoma↗

PubMed2003

The risk of stillbirth in pregnancies before and after the onset of diabetes.

AIMS: There is significant controversy as to whether or not stillbirth is increased in pregnancies prior to the onset of diabetes. An observed increase may be indicative of risks associated with untreated gestational diabetes. It is generally accepted that the risk of stillbirth in pregnancies that occur after the onset of diabetes has been diminished by modern obstetric care. However, the degree of residual risk is not well quantified. This study sought to examine the rates of stillbirth before and after the onset of diabetes compared with the general population. METHODS: Retrospective cohort and nested case-control study. The study population was drawn from the UK-based General Practice Research Database, comprising some 300 practices, with data collection from the late 1980s until September 1999. From the base population, 913 diabetic women who had had a pregnancy were identified and 10,000 subjects without diabetes were randomly chosen as controls. Stillbirth was defined as death in utero after 20 weeks or with birth weight >500 g. RESULTS: The stillbirth rates were higher in prediabetic pregnancies (19.7/1000), and in those occurring after the diagnosis of diabetes (33.7/1000), compared with the non-diabetic population (5.5/1000). Stillbirths were matched to four live births by maternal age and year of birth. Prediabetic pregnancy and pregnancy after the onset of diabetes were strongly associated with stillbirth: odds ratio (OR)=4.68 (1.67, 13.08) and OR=4.39 (2.22, 8.64), respectively. CONCLUSIONS: The risk of stillbirth was increased in both prediabetic and post-diabetic pregnancy.

Case-Control Studies↗

PubMed2000

Long-term effects of angiotensin-converting enzyme inhibition and metabolic control in hypertensive type 2 diabetic patients.

UNLABELLED: Long-term effects of angiotensin-converting enzyme inhibition and metabolic control in hypertensive type 2 diabetic patients. BACKGROUND: In hypertensive type 2 diabetic patients, treatment with angiotensin-converting enzyme (ACE) inhibitors is associated with a lower incidence of cardiovascular events than those treated with calcium channel-blocking agents. However, the long-term renal effects of ACE inhibitors in these patients remain inconclusive. In 1989, we commenced a placebo-controlled, double-blind, randomized study to examine the anti-albuminuric effects of enalapril versus nifedipine (slow release) in 102 hypertensive, type 2 diabetic patients. These patients have been followed up for a mean trial duration of 5.5 +/- 2.2 years. We examined the determinants, including the effect of ACE inhibition on clinical outcomes in these patients. METHODS: After a six-week placebo-controlled, run-in period, 52 patients were randomized double-blind to receive nifedipine (slow release) and 50 patients to receive enalapril. After the one-year analysis, which confirmed the superior anti-albuminuric effects of enalapril (-54%) over nifedipine (+11%), all patients were continued on their previously assigned treatment with informed consent. They were subdivided into normoalbuminuric (N = 43), microalbuminuric (N = 34), and macroalbuminuric (N = 25) groups based on two of three 24-hour urinary albumin excretion (UAE) measurements during the run-in period. Renal function was shown by the 24-hour UAE, creatinine clearance (CCr), and the regression coefficient of the yearly plasma creatinine reciprocal (beta-1/Cr). Clinical endpoints were defined as death, cardiovascular events, and/or renal events (need for renal replacement therapy or doubling of baseline plasma creatinine). RESULTS: In the whole group, patients treated with enalapril were more likely to revert to being normoalbuminuric (23.8 vs. 15.4%), and fewer of them developed macroalbuminuria (19.1 vs. 30.8%) compared with the nifedipine-treated patients (P < 0.05). In the microalbuminuric group, treatment with enalapril (N = 21) was associated with a 13.0% (P < 0.01) reduction in 24-hour UAE compared with a 17.3% increase in the nifedipine group (N = 13). In the macroalbuminuric patients, enalapril treatment (N = 11) was associated with stabilization compared with a decline in renal function in the nifedipine group, as shown by the beta-1/Cr (0.65 +/- 4.29 vs. -1.93 +/- 2.35 1/micromol x 10-3, P < 0.05) after adjustment for baseline values. Compared with the normoalbuminuric and microalbuminuric patients, those with macroalbuminuria had the lowest mean CCr (75.5 +/- 24.1 vs. 63.5 +/- 21.3 vs. 41.9 +/- 18.5 mL/min, P < 0.001) and the highest frequency of clinical events (4.7 vs. 5.9 vs. 52%, P < 0. 001). On multivariate analysis, beta-1/Cr (R2 = 0.195, P < 0.001) was independently associated with baseline HbA1c (beta = -0.285, P = 0.004), whereas clinical outcomes (R2 = 0.176, P < 0.001) were independently related to the mean low-density lipoprotein cholesterol (beta = 2.426, P = 0.018), high-density lipoprotein cholesterol (beta = -8.797, P = 0.03), baseline UAE (beta = 0.002, P = 0.04), and mean CCr during treatment (beta = -0.211, P = 0.006). CONCLUSION: In this prospective cohort analysis involving 102 hypertensive, type 2 diabetic patients with varying degrees of albuminuria followed up for a mean duration of five years, we observed the importance of good metabolic and blood pressure control on the progression of albuminuria and renal function. Treatment with enalapril was associated with a greater reduction in albuminuria than with nifedipine in the entire patient group, and especially in those with microalbuminuria. In the macroalbuminuric patients, the rate of deterioration in renal function was also attenuated by treatment with enalapril.

Aged↗

PubMed2002

Predicting a life-threatening disease and death among ambulance-transported patients with chest pain or other symptoms raising suspicion of an acute coronary syndrome.

The purpose of this study was to evaluate the possibility to predict in the prehospital phase the occurrence of a life-threatening disease or death among ambulance transported patients with acute chest pain or other symptoms raising any suspicion of an acute coronary syndrome. All patients transported by ambulance during 3 months in the community of Göteborg because of symptoms raising any suspicion of an acute coronary syndrome were included in the study. In all, 930 transports (of 859 patients) fulfilled the inclusion criteria, of which 235 (25.3%) fulfilled the criteria for a life-threatening disease. The overall 30-day mortality was 8.8%, and the 1-year mortality was 18.0%. Independent predictors for a life-threatening disease were a low oxygen saturation on admission of the ambulance crew, patient being clammy on admission of the ambulance crew, a history of myocardial infarction and ST elevation and T-wave inversion on admission to the emergency department. Independent predictors for 30-day mortality were age greater than 70 years, symptoms of dyspnoea, a low oxygen saturation, hypotension and decreased consciousness on admission of the ambulance crew, and ST-depression on electrocardiogram (ECG) on admission to the emergency department. Predictors of 1 year mortality were age greater than 70 years, a history of myocardial infarction, symptoms of dyspnoea, a low oxygen saturation on admission of the ambulance crew and ST-depression, and no sinus rhythm on admission to the emergency department. Among patients with acute chest pain or other symptoms raising any suspicion of an acute coronary syndrome, factors associated with a life-threatening disease and death could be defined. Predictors for the risk of death during the first 30 days were age greater than 70 years, symptoms of dyspnoea, a low oxygen saturation, hypotension and decreased consciousness on admission of the ambulance crew, and ST-depression on ECG on admission to the emergency department.

Age Factors↗

PubMed1998

Impact of restenosis 10 years after coronary angioplasty.

AIMS: The aim of the study was to compare the 10-year follow-up results of patients with or without restenosis following single-vessel percutaneous transluminal coronary angioplasty (PTCA). METHODS AND RESULTS: A total of 313 patients with successful PTCA (> or = 20% reduction in luminal diameter narrowing without acute complications) and a control angiography 6 months after PTCA were included in the study. Events during the follow-up period were defined as death, myocardial infarction, bypass surgery, or repeat PTCA. Statistical evaluation was performed by the Fisher test, logistic regression, and life-table analysis. Restenosis (loss of > 50% of the initial gain and diameter stenosis of 50%) was found in 87 (28%) patients. During follow-up, 11 patients (5%) without restenosis (group A) and 11 (13%) patients with restenosis (group B) died (P < 0.05). In group A, 17 (8%) patients and in group B, 11 (13%) patients suffered myocardial infarction (ns); 17 group A (8%) patients and 25 (29%) group B patients had bypass surgery (P < 0.0001), and 34 (15%) group A patients and 55 (63%) group B patients underwent repeat PTCA (P < 0.0001). Logistic regression analysis identified restenosis as an independent risk factor that increases the risk of death 2.8-fold (P = 0.02), bypass surgery 5.6-fold (P < 0.0001), and repeat PTCA 10-fold (P < 0.0001). CONCLUSION: We conclude that patients with restenosis had a poorer long-term outcome than patients without restenosis. Although most patients with restenosis underwent repeat PTCA, the survival rate without any serious adverse events was only 59%, compared with 83% in patients without restenosis (P < 0.0001).

Adult↗

PubMed2001

Clinical characteristics, aetiological factors and long-term prognosis of myocardial infarction with an absolutely normal coronary angiogram; a 3-year follow-up study of 91 patients.

OBJECTIVES: The purpose of this study was to evaluate the clinical outcome of a large cohort of patients who suffered an acute myocardial infarction with absolutely normal epicardial coronary arteries at the post-myocardial infarction coronary angiogram. The aetiological and prognostic factors in this population were also analysed. BACKGROUND: Few data exist concerning the outcome, and aetiological and prognostic factors, of patients with myocardial infarction and angiographically absolutely normal coronary arteries. METHODS: Ninety-one patients (34 females/57 males; mean age 50+/-13 years, range 24--78 years) admitted with an acute myocardial infarction had absolutely normal coronary arteries at the angiogram performed 6.2+/-4 days (range 1--15 days) after the myocardial infarction, defined by smooth contours and no focal reduction (NC). Of the 91 NC patients, 71 were evaluated prospectively, alongside a systematic search of all aetiological factors reported in the literature. The NC patients were matched for age, sex, and the same period of myocardial infarction onset with a group of 91 patients with coronary artery stenosis (>50% diameter stenosis) at the angiogram performed 7.3+/-4 days (range 1--15 days) after the myocardial infarction (SC). RESULTS: The percent of smokers was similar between the two groups; higher prevalence rates of coronary heart disease family history, obesity, hypertension, hypercholesterolaemia and diabetes mellitus were found in SC (P=0.043 to 0.0001). In NC, coronary spasm was found in 15.5%, congenital coagulation disorders in 12.8%, collagen tissue disorders in 2.2%, embolization in 2.2%, and oral contraceptive use in 1.1%. Left ventricular ejection fraction at hospital discharge was higher in NC (60%+/-13%) than in SC (55%+/-13%, P=0.04). The mean follow-up was 35 months (range 1--100 months). Kaplan-Meier event-free survival, with the combined end-point defined as death, reinfarction, heart failure and stroke was 75% in NC vs 50% in SC (P<0.0001). Survival rate was 94.5% in NC compared to 92% in SC (ns). Univariate predictors of events in NC were left ventricular ejection fraction (P=0.03), age (P=0.02), diabetes (P=0.01), and smoking (P=0.03). Using Cox multivariate analysis, independent predictors of long-term outcome in NC patients were left ventricular ejection fraction (P=0.003) and diabetes (P=0.004). CONCLUSION: Aetiological factors, predominantly coronary spasm and inherited coagulation disorder, can be detected in only one third of the patients with myocardial infarction and absolutely normal coronary angiograms despite a systematic search in a prospective population. Mortality rates are similar but morbidity is lower in myocardial infarction patients with absolutely normal coronary angiography compared with those with coronary artery stenosis. The only two independent factors predictive of poor outcome in myocardial infarction patients with normal coronary arteries are left ventricular function and diabetes.

Adult↗

PubMed2006

Thirty-year analysis of a colonoscopic surveillance program for neoplasia in ulcerative colitis.

BACKGROUND & AIMS: The value of colonoscopic surveillance for neoplasia in long-standing extensive ulcerative colitis remains controversial. This study reports on prospectively collected data from a surveillance program over a 30-year period. METHODS: Data were obtained from the prospective surveillance database, medical records, colonoscopy, and histology reports. The primary end point was defined as death, colectomy, withdrawal from surveillance, or census date (January 1, 2001). Follow-up information was obtained for patients who left the program. RESULTS: Six hundred patients underwent 2627 colonoscopies during 5932 patient-years of follow-up. The cecal intubation rate was 98.7%, with no significant complications. Seventy-four patients (12.3%) developed neoplasia, including 30 colorectal cancers (CRCs). There was no difference in median age at onset of colitis for those with or without CRC (P = .8, Mann-Whitney). The cumulative incidence of CRC by colitis duration was 2.5% at 20 years, 7.6% at 30 years, and 10.8% at 40 years. The 5-year survival rate was 73.3%. Sixteen of 30 cancers were interval cancers. CRC incidence decreased over time (r = -.40, P = .04; linear regression). CONCLUSIONS: Colonoscopic surveillance is safe and allows the vast majority of patients to retain their colon. Although two thirds of patients with potentially life-threatening neoplasia benefited from surveillance, the program was not wholly effective in cancer prevention. The cancer incidence, however, was considerably lower than in the majority of other studies, and was constant for up to 40 years of colitis duration, suggesting there is no need to intensify surveillance over time.

Adenoma↗