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PubMed2026

Bempedoic Acid and First and Recurrent Limb Outcomes in Statin-Intolerant Patients With Peripheral Artery Disease: Insights From the CLEAR Outcomes Trial.

BACKGROUND: Patients with peripheral artery disease (PAD) are at high risk of major adverse limb events (MALE) and major adverse cardiovascular events (MACE). Recently, bempedoic acid was shown to reduce MACE in primary and secondary prevention patients. Whether bempedoic acid reduces the risk of MALE in patients with PAD is unknown. METHODS: CLEAR Outcomes (Cholesterol Lowering via Bempedoic Acid [ETC1002], an ACL-Inhibiting Regimen) randomized 13 970 patients to bempedoic acid 180 mg or placebo from December 22, 2016, to August 14, 2019. The trial primary end point was MACE-4, defined as death resulting from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, or coronary revascularization. A clinical history of PAD was reported by investigators at baseline. Two blinded vascular medicine specialists independently adjudicated MALE, including adverse events indicating worsening PAD symptoms leading to revascularization, chronic limb-threatening ischemia, and acute limb ischemia. Outcomes were assessed as time to first event and total (including recurrent) events with a negative binomial approach. RESULTS: A total of 1624 of the enrolled patients (mean±SD age, 63.9±9.9 years; 915 [56.3%] female) had PAD at baseline. In patients with PAD in the placebo group, 69 (8.3%) had MALE over a median of 40.6 months, with rate of recurrent events of 4.0%/y. Bempedoic acid reduced the risk of MALE by 36% (hazard ratio, 0.64 [95% CI, 0.44-0.93]; P=0.018). Bempedoic acid reduced total MALE by 45% (relative risk, 0.55 [95% CI, 0.35-0.85]; P=0.007). First MACE-4 or MALE was reduced overall by 13% (hazard ratio, 0.87 [95% CI, 0.80-0.95]) with consistent effects with PAD (hazard ratio, 0.82 [95% CI, 0.64-1.04]) and without PAD (hazard ratio, 0.87 [95% CI, 0.79-0.86]; Pinteraction=NS) but not statistically significant within the PAD subgroup alone. Total MACE-4 or MALE was reduced (relative risk, 0.81 [95% CI, 0.73-0.90]) overall with consistent effects in PAD (relative risk, 0.71 [95% CI, 0.54-0.95]) and without PAD (relative risk, 0.82 [95% CI, 0.73-0.92]; Pinteraction=NS). CONCLUSIONS: Patients with PAD are at high risk of MALE and MACE. Bempedoic acid reduces both MACE and MALE in patients with atherosclerotic vascular disease, with notable absolute benefits in patients with PAD. These findings support (1) the importance of lowering low-density lipoprotein cholesterol in patients with PAD to reduce overall vascular risk and (2) the benefits of bempedoic acid in this population.

Humans↗

PubMed2000

Relation of FEV(1) to clinical outcomes during exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group.

FEV(1) is an objective measure of airflow obstruction used in clinical practice and in therapeutic trials. The precise relationship of FEV(1) to clinical outcomes is generally uncertain. As part of a randomized trial to assess systemic corticosteroid efficacy, we obtained serial FEV(1) measurements in patients hospitalized for exacerbations of chronic obstructive pulmonary disease (COPD). Over the first 14 Study Days at least one FEV(1) value was obtained in 261 subjects. Sixty-four of these subjects experienced treatment failure, defined as death, intubation, readmission for COPD, or intensification of drug therapy, by Study Day 30. After adjustment, both FEV(1) at entry into the study (odds ratio [OR] for a 100-ml increase, 0.87; 95% confidence interval [CI], 0.79 to 0.96) and change in FEV(1) over the first two Study Days (OR for a 100 ml increase, 0.80; 95% CI, 0.69 to 0.92) predicted treatment failure. We identified no baseline characteristic that was significantly related to FEV(1) at entry into the study. Assignment to the systemic corticosteroid treatment arm was associated with a significantly larger FEV(1) at Study Day two (p = 0.01). We conclude that FEV(1) measurements at admission and over the first several days of hospitalization are highly predictive of clinical outcomes during exacerbations of COPD.

Adrenergic beta-Agonists↗

PubMed2004

Procalcitonin kinetics as a prognostic marker of ventilator-associated pneumonia.

We investigated the value of procalcitonin kinetics as a prognostic marker during ventilator-associated pneumonia (VAP). This prospective, observational study was conducted in a medical intensive care unit in a university hospital. All consecutive patients with microbiologically proven VAP who survived 3 days after its diagnosis were included and grouped according to clinical outcome: favorable or unfavorable, defined as death, VAP recurrence, or extrapulmonary infection requiring antibiotics before Day 28. Serum procalcitonin levels were measured on Days 1, 3, and 7 for all patients. Among the 63 patients included, 38 had unfavorable outcomes. On Day 1, they were more critically ill than patients with a favorable outcome. Serum procalcitonin levels decreased during the clinical course of VAP but were significantly higher from Day 1 to Day 7 in patients with unfavorable outcomes. Multivariate analyses retained serum procalcitonin levels on Days 1, 3, and 7 as strong predictors of unfavorable outcome. Based on these data, procalcitonin could be a prognostic marker of outcome during VAP.

Biomarkers↗

PubMed1998

The Ile164 beta2-adrenergic receptor polymorphism adversely affects the outcome of congestive heart failure.

The beta2-adrenergic receptor (beta2AR), an important modulator of cardiac inotropy and chronotropy, has significant genetic heterogeneity in the population. Because dysfunctional betaARs play a role in the pathogenesis of the failing ventricle, we tested the hypothesis that beta2AR polymorphisms alter the outcome of congestive heart failure. 259 patients with NYHA functional class II-IV heart failure due to ischemic or dilated cardiomyopathy were genotyped and prospectively followed, with the endpoint defined as death or cardiac transplantation. The allele frequencies between this group and those of 212 healthy controls also were compared and did not differ between the groups. However, those with the Ile164 polymorphism displayed a striking difference in survival with a relative risk of death or cardiac transplant of 4.81 (P < 0.001) compared with those with the wild-type Thr at this position. Age, race, gender, functional class, etiology, ejection fraction, and medication use did not differ between these individuals and those with the wild-type beta2AR, and thus the beta2AR genotype at position 164 was the only clear distinguishing feature between the two groups. The 1-yr survival for Ile164 patients was 42% compared with 76% for patients harboring wild-type beta2AR. In contrast, polymorphisms at amino acid positions 16 (Arg or Gly) or 27 (Gln or Glu), which also alter receptor phenotype, did not appear to have an influence on the course of heart failure. Taken together with cell-based and transgenic mouse results, this study establishes a paradigm whereby genetic variants of key signaling elements can have pathophysiologic consequences within the context of a disease. Furthermore, patients with the Ile164 polymorphism and heart failure may be candidates for earlier aggressive intervention or cardiac transplantation.

Adult↗

PubMed2004

When caregiving ends: the course of depressive symptoms after bereavement.

This study describes depressive symptoms among caregivers following bereavement and connects these trajectories to earlier features of caregiving using life course and stress process theory. Data are from a six-wave longitudinal survey (five years) of spouses and adult children caring for someone with Alzheimer's Disease. The analytic subsample (N = 291) is defined by death of the care-recipient after the baseline interview. A latent class mixture model is used to identify distinctive clusters of depressive symptoms over time. Of the four trajectories identified, three represent stable symptom levels over time, with two-thirds being repeatedly symptomatic (medium symptom levels), compared to two smaller groups of repeatedly asymptomatic (effectively absent of symptoms) and repeatedly distressed (severe symptoms). In contrast, about one in five caregivers experiences improved emotional well-being over time, the temporarily distressed, who progress from severe to moderate symptom levels. Caregivers with few symptoms before bereavement tend to maintain these states afterwards, but emotionally distressed caregivers tend to become more distressed. Role overload before bereavement substantially increases the odds of following an unfavorable trajectory afterwards, whereas self-esteem and socioemotional support play protective roles. These results demonstrate that caregivers are not uniform in their emotional responses to bereavement, but follow several distinct trajectories. These trajectories are linked to their previous experiences as caregivers, in particular exposure to stressors and access to resources. These findings suggest that intervention during caregiving may facilitate adaptation following death of a loved one.

Aged↗

PubMed2006

Measurement of quality of life in pulmonary hypertension and its significance.

Until recently, assessment of patients with pulmonary hypertension has mainly relied on functional and haemodynamic parameters. Health-related quality of life (HRQOL), however, has become increasingly important in defining overall health status. The present study investigated the performance and clinical relevance of the Minnesota Living with Heart Failure (MLHF) questionnaire by prospectively studying 48 patients with either pulmonary arterial hypertension (n = 26) or chronic thromboembolic pulmonary hypertension (n = 22). The MLHF scores were correlated to various clinical and haemodynamic parameters. Prognostic outcome was evaluated by calculating the time taken to reach an adverse clinical event defined as death, lung transplantation or pulmonary endarterectomy. The reliability of test-re-test and internal consistency of this HRQOL tool was high. The MLHF score and its physical subscore correlated moderately to well with functional and haemodynamic parameters, except in the case of pulmonary artery pressures. Both scores significantly improved during vasodilator therapy. This figure was surpassed only by the New York Heart Association/World Health Organization functional class. A multivariate analysis of all variables revealed that the MLHF score was the sole factor predicting subsequent outcome. The Minnesota Living with Heart Failure questionnaire is highly reproducible, consistent, and a moderately valid and responsive tool in assessing health-related quality of life in pulmonary hypertension. Moreover, it is a significant predictor of outcome in these patients.

Female↗

PubMed2002

Treatment with atorvastatin to the National Cholesterol Educational Program goal versus 'usual' care in secondary coronary heart disease prevention. The GREek Atorvastatin and Coronary-heart-disease Evaluation (GREACE) study.

BACKGROUND: Atorvastatin is very effective in reducing plasma low-density lipoprotein cholesterol (LDL-C) levels. However, there is no long-term survival study that evaluated this statin. PATIENTS-METHODS: To assess the effect of atorvastatin on morbidity and mortality (total and coronary) of patients with established coronary heart disease (CHD), 1600 consecutive patients were randomised either to atorvastatin or to 'usual' medical care. The dose of atorvastatin was titrated from 10 to 80 mg/day, in order to reach the National Cholesterol Education Program (NCEP) goal of LDL-C <100 mg/dl (2.6 mmol/l). All patients were followed up for a mean period of 3 years. MAIN OUTCOME MEASURES: Primary endpoints of the study were defined as death, non-fatal myocardial infarction, unstable angina, congestive heart failure, revascularisation (coronary morbidity) and stroke. Secondary endpoints were the safety and efficacy of the hypolipidaemic drugs as well as the cost-effectiveness of atorvastatin. RESULTS: The mean dosage of atorvastatin was 24 mg/day. This statin reduced total chlesterol by 36%, LDL-C by 46%, triglycerides by 31%, and non-high-density lipoprotein cholesterol (non-HDL-C) by 44%, while it increased HDL-C by 7%; all these changes were significant. The NCEP LDL-C and non-HDL-C treatment goals were reached by 95% (n = 759) and 97% (n = 776), respectively, of patients on atorvastatin. Only 14% of the 'usual' care patients received any hypolipidaemic drugs throughout the study and 3% of them reached the NCEP LDL-C treatment goal. The cost per quaility-adjusted life-year gained with atorvastatin was estimated at $US 8350. During this study 196 (24.5%) CHD patients on 'usual' care had a CHD recurrent event or died vs. 96 (12%) CHD patients on atorvastatin; risk ratio (RR) 0.49, confidence interval (CI) 0.27-0.73, p < 0.0001. In detail, atorvastatin reduced, in comparison to 'usual' care, total mortality (RR 0.57, CI 0.39-0.78, p = 0.0021), coronary mortality (RR 0.53, CI 0.29-0.74, p = 0.0017), coronary morbidity (RR 0.46, CI 0.25-0.71, p < 0.0001), and stroke (RR 0.53, CI 0.30-0.82, p = 0.034). All subgroups of patients (women, those with diabetes mellitus, arterial hypertension, age 60 to 75 years, congestive heart failure, recent unstable angina or prior revascularisation) benefited from treatment with atorvastatin. Withdrawal of patients because of side-effects from the atorvastatin group was low (0.75%) and similar to that of the 'usual' care group (0.4%). CONCLUSIONS: Long-term treatment of CHD patients with atorvastatin to achieve NCEP lipid targets significantly reduces total and coronary mortality, coronary morbidity and stroke, in comparison to patients receiving 'usual' medical care. Treatment with atorvastatin is well tolerated and cost-effective.

Adult↗

PubMed2005

Postoperative mortality after cancer surgery in octogenarians and nonagenarians: results from a series of 5,390 patients.

BACKGROUND: To support decisions about surgical treatment of elderly patients with cancer, population-based estimates of postoperative mortality (POM) rates are required. METHODS: Electronic records from the Rotterdam Cancer Registry were retrieved for octogenarians and nonagenarians who underwent resection in the period 1987-2000. POM was defined as death within 30 days of resection and both elective and emergency operations were included. RESULTS: In a series of 5.390 operated patients aged 80 years and older, POM rates were 0.5% for breast cancer, 1.7% for endometrial cancer and 4.2% for renal cancer. For patients with colorectal cancer, POM increased from 8% for the age group 80-84 to 13% for those 85-89 to 20% in nonagenarians. For stomach cancer, the respective figures were 11%, 20% and 44%. CONCLUSION: These results show that resections can be performed at acceptable risk in selected elderly patients with cancer.

Journal Article↗

PubMed2006

The impact of altitude on early outcome following the Fontan operation.

BACKGROUND: The success of a Fontan circulation depends on several factors including low pulmonary vascular resistance. Pulmonary vascular resistance rises in response to hypoxia. Hypoxia is associated with altitude. Therefore, we wondered whether altitude is a risk factor for early failure after the Fontan operation. The aim was to test this hypothesis. METHODS: Data were obtained from all published series of 'total cavopulmonary' Fontan operations since 1990. The early failure rate from each series and the altitude of the respective cities were recorded. Early failure was defined as death, takedown of Fontan, or transplantation during the same hospital admission. The association between altitude and failure rate was investigated by rank correlation and logistic regression. RESULTS: 24 series were identified from centres situated at altitudes ranging from sea level to 520 metres. The plot of failure rate versus altitude suggests that failure rate increases with altitude. Logistic regression did not fit the data adequately. This was possibly due to the influence of unmeasured and unknown factors affecting the results, as well as the fact that centres were not randomly chosen but were self-selected by virtue of publishing their results. However, Spearman's rank correlation was 0.74 (p = 0.001). CONCLUSION: The early outcome of the Fontan circulation appears to be adversely affected by altitude.

Altitude↗

PubMed2006

Multimarker panel to rule out acute coronary syndromes in low-risk patients.

OBJECTIVES: To test novel markers of acute coronary syndrome (ACS), monocyte chemoattractant protein-1 (MCP), myeloperoxidase (MPO), C-reactive protein (CRP), and brain natriuretic peptide (BNP) in low-risk emergency department (ED) patients who were evaluated for ACS in a chest pain unit (CPU). METHODS: A convenience sample of 414 patients underwent CPU evaluation, including provocative testing, and were followed prospectively for 45 days for ACS, which was defined as death, myocardial infarction (MI), revascularization, or >60% coronary artery stenosis prompting new medical treatment, adjudicated by three blinded reviewers. Published diagnostic thresholds were used to calculate diagnostic indices for each marker and for the multimarker panel. RESULTS: The prevalence of ACS was 7 in 414 (1.7%; 95% CI = 0.7% to 3.5%). Only MCP demonstrated a negative likelihood ratio [LR(-)] of less than 0.5, with a sensitivity of 85% (95% CI = 42% to 99%), specificity of 72% (95% CI = 67% to 76%), and LR(-) of 0.20 (95% CI = 0.04 to 0.71). For MPO, CRP, and BNP, LR(-) was 0.89 (95% CI = 0.26 to 2.05), 0.79 (95% CI = 0.40 to 1.01), and 0.90 (95% CI = 0.51 to 1.03), respectively. The sensitivity, specificity, and LR(-) of an abnormal multimarker panel were 86% (95% CI = 42% to 100%), 17% (95% CI = 13% to 21%), and 0.84 (95% CI = 0.15 to 3.12), respectively. CONCLUSIONS: The prevalence of ACS was very low but was similar to reports from other CPUs. BNP and CRP had high specificities, but had limited sensitivities, whereas MPO had a low specificity. Only MCP had a low LR(-) and should be studied further. The combined multimarker panel had an unexpectedly low sensitivity and specificity, yielding an LR(-) of 0.84, suggesting that the panel would not be an efficient screening test to decrease unnecessary CPU testing.

Acute Disease↗

PubMed2006

Risk of cardiovascular mortality in prostate cancer patients in the Rotterdam randomized screening trial.

PURPOSE: To estimate the risk of cardiovascular disease (CVD) mortality in prostate cancer patients in the Rotterdam section of European Randomized Study of Screening for Prostate Cancer, in both arms, and to compare this with the risk in the general population. METHODS: Standardized mortality ratios (SMRs) of cardiovascular mortality for 2,211 prostate cancer patients were calculated including analyses for treatment subgroups (surgery, radiotherapy, watchful waiting, and hormone therapy). Cardiovascular mortality was defined as death as a result of all CVD and as a result of coronary heart disease, acute myocardial infarction, other diseases of the heart, and cerebrovascular accidents. The prevalence of self-reported comorbidities at entry of the trial was evaluated as well. RESULTS: After a mean follow-up of 5.5 years, 258 prostate cancer patients (12%) had died. The SMR of all-cause mortality was 0.90 (95% CI, 0.79 to 1.01). The risk for cardiovascular mortality was low compared with that in the general population; the SMRs varied between 0.37 and 0.49. Low cardiovascular mortality risks were also seen within each treatment subgroup. CVD was the most frequently self-reported comorbidity at entry and prostate cancer patients undergoing radical prostatectomy reported the lowest rates (24%) compared with those receiving other therapies (40% to 42%). CONCLUSION: Although some self-selection has occurred, prostate cancer treatment did not increase the risk of dying as a result of cardiovascular causes in our cohort. The risk was significantly lower for all primary treatment modalities, suggesting that less emphasis should be put on CVD as a contraindication for aggressive (surgical) treatment for prostate cancer patients.

Aged↗

PubMed2006

An increased coronary risk is paradoxically associated with common cholesteryl ester transfer protein gene variations that relate to higher high-density lipoprotein cholesterol: a population-based study.

BACKGROUND: Several cholesteryl ester transfer protein (CETP) polymorphisms affect high-density lipoprotein (HDL) cholesterol, but the impact of CETP gene variants on incident coronary disease in the general population is uncertain after correction for their effect on HDL cholesterol. DESIGN: We determined relationships between the CETP -629C-->A promoter (n = 8141), the TaqIB (n = 8289), and the I405V (n = 8265) polymorphisms, serum lipids, C-reactive protein, and clinical factors with incident coronary heart disease (defined as death from or hospitalization for myocardial infarction, ischemic heart disease, or coronary intervention) during a median of 4.94 yr follow-up. SUBJECTS: A predominantly Caucasian general population was studied. RESULTS: HDL cholesterol was 0.08 mmol/liter higher in -629A carriers than in -629CC homozygotes (P < 0.001). The unadjusted coronary hazard was 1.26 [95% confidence interval (CI), 0.95-1.68; P = 0.11] in A carriers compared with CC homozygotes and increased to 1.46 (95% CI, 1.10-1.95; P = 0.01) after adjustment for HDL cholesterol. This effect remained after additional adjustment for apolipoprotein A-I, triglycerides, C-reactive protein, age, and gender. Likewise, the HDL-cholesterol-adjusted hazard ratio was also higher in AA than in CC homozygotes (hazard ratio, 1.72; 95% CI, 1.22-2.42; P < 0.01). Similar findings were obtained with the TaqIB polymorphism. The 405V allele was weakly associated with incident coronary heart disease after HDL cholesterol adjustment (P = 0.09). CONCLUSIONS: A common CETP promoter polymorphism, which beneficially contributes to higher HDL cholesterol, is paradoxically associated with increased incidence of coronary disease in the general population. Thus, CETP gene variation may affect coronary risk apart from the level of HDL cholesterol.

Apolipoprotein A-I↗

PubMed2006

Serum adiponectin is a predictor of coronary heart disease: a population-based 10-year follow-up study in elderly men.

CONTEXT: Cross-sectional and nested case-control studies indicate a relationship between adiponectin, obesity, and coronary heart disease (CHD). OBJECTIVE: Our objective was to investigate whether adiponectin could predict CHD in a population-based cohort of elderly men. DESIGN AND SETTING: From 1991-1995 a baseline investigation was carried out in 832 healthy men aged 70 yr in the Uppsala Longitudinal Study of Adult Men (ULSAM study). They were followed up to 10.4 yr using Swedish national registry data. The baseline investigation included anthropometry, blood pressure, smoking, serum lipids, a euglycemic insulin clamp, and fasting serum adiponectin. MAIN OUTCOME MEASURES: Main outcome measures were defined as death or first-time hospitalization for CHD (n = 116), recorded in the Cause of Death Registry or in the Hospital-Discharge Registry of the National Board of Health and Welfare, Sweden. Associations were analyzed using Cox's proportional hazards regression, presented as hazard ratios (HR) with 95% confidence intervals (CI) for 1 sd increase in the predictor variable. RESULTS: In a multivariable analysis including total cholesterol (HR, 1.24; CI, 1.02-1.50), high-density lipoprotein cholesterol (HR, 0.72; CI, 0.58-0.89), smoking (HR, 1.39; CI, 0.91-2.14), and systolic blood pressure (HR, 1.26; CI, 1.05-1.52), serum adiponectin was associated with lower risk for CHD (HR, 0.81; CI, 0.66-0.99). The association was independent of BMI and remained significant after adjustment for insulin sensitivity index. CONCLUSIONS: In this population-based cohort of healthy men, elevated serum levels of adiponectin were associated with a lower risk for CHD. Importantly, the association between adiponectin and CHD was independent of other well-known risk factors.

Adiponectin↗

PubMed2006

Recurrent stroke and cardiac risks after first ischemic stroke: the Northern Manhattan Study.

BACKGROUND: Few population-based studies with long-term follow-up have compared risk of recurrent stroke and cardiac events after first ischemic stroke. The relative risk of these two outcomes may inform treatment decisions. METHODS: In the population-based Northern Manhattan Study, first ischemic stroke patients age 40 or older were prospectively followed for recurrent stroke, myocardial infarction (MI), and cause-specific mortality. Fatal cardiac events were defined as death secondary to MI, congestive heart failure, sudden death/arrhythmia, and cardiopulmonary arrest. Risk of events (with 95% CIs) was calculated using Kaplan-Meier survival analysis and adjusted for sex and age using Cox proportional hazard models. RESULTS: Mean age (n = 655; median follow-up 4.0 years) was 69.7 +/- 12.7 years. The risk of recurrent stroke was more than twice that of cardiac events (including nonfatal MI) at 30 days and approximately twice cardiac risk at 5 years. The age- and sex-adjusted 5-year risk of fatal or nonfatal recurrent stroke was 18.3% (14.8 to 21.7%), and the 5-year risk of MI or fatal cardiac event was 8.6% (6.0 to 11.2%). The adjusted 5-year risk of nonfatal stroke (14.8%, 11.6 to 17.9%) was approximately twice as high as fatal cardiac events (6.4%, 4.1 to 8.6%) and four times higher than risk of fatal stroke (3.7%, 2.1 to 5.4%). CONCLUSIONS: Cardiac mortality is nearly twice as high as mortality owing to recurrent stroke, but long-term risk of all stroke, fatal or nonfatal, is approximately twice the risk of all cardiac events. The high risk of nonfatal recurrent stroke reinforces the importance of therapies aimed at preventing stroke recurrence in addition to preventing cardiac events.

Adult↗

PubMed2006

SSEPs and prognosis in postanoxic coma: only short or also long latency responses?

BACKGROUND: Short latency somatosensory evoked potential (SSEP) (N20) is a good predictor of poor outcome in postanoxic coma. It has been suggested that the long latency response (N70) may increase the sensitivity of SSEPs for predicting poor outcome. METHODS: As part of a prospective cohort study in 407 adult patients unconscious 24 hours after cardiopulmonary resuscitation (CPR), N20 was recorded 24, 48, and 72 hours after CPR, and N70 was recorded at least once in 319 patients. Poor outcome was defined as death or persistent vegetative state 1 month after CPR. RESULTS: Absent N20 had a 0% false positive test rate at all time intervals, with prevalence of poor test result varying from 37 to 48%. Addition of abnormal N70 (absent or delayed > 130 msec) with present N20 as poor test result added 21 to 28% to this prevalence, but at the cost of a false positive test rate of 4 to 15%. Good outcome could not be predicted reliably with either of the tests, as only 28% of patients with normal N20 and N70 had a good outcome. CONCLUSION: Determination of presence or absence of the N70 in patients with postanoxic coma gives additional information about the likelihood of poor outcome, but it is not precise enough to base treatment decisions solely on its absence.

Cohort Studies↗

PubMed2005

Meningioma resection in the elderly: nationwide inpatient sample, 1998-2002.

OBJECTIVE: Morbidity and mortality rates reported for meningioma resection in the elderly vary widely. Thus, it is difficult for neurosurgeons to compare the risks and benefits of operating on elderly patients against opting for radiosurgery or watchful waiting. To address this issue, we studied the effect of advanced age on outcome after meningioma resection using the Nationwide Inpatient Sample. METHODS: We identified all patients over the age of 20 in the Nationwide Inpatient Sample database who underwent surgical resection of a meningioma between 1998 and 2002 and were admitted from home. Primary outcomes were in-hospital mortality, adverse outcome (defined as death or discharge to a facility other than home), and length of hospitalization. Multivariate models were constructed to assess the effect of elderly age on the primary outcomes, adjusting for patient demographics, comorbid medical conditions, and hospital surgical volume. RESULTS: There were 8861 patients in the Nationwide Inpatient Sample database who underwent resection of meningioma during the study period; 26.0% were age 70 or older. Each of the primary outcomes demonstrated a marked effect of advancing age. The in-hospital mortality rate was higher in the elderly than in the nonelderly (4.0% versus 1.1%, P < 0.001), as was the rate of discharge to a facility other than home (53.2% versus 16.6%, P < 0.001). Elderly patients also had a longer mean length of stay (7.2 versus 5.1 d P < 0.001). CONCLUSION: The association between elderly age and adverse outcome after meningioma resection suggests a note of caution before proceeding to surgery with these patients.

Adult↗

PubMed2001

Long-term prognosis of acute aortic dissection with medical treatment: a survey of 263 unoperated patients.

Between 1973 and 1998, 263 patients with acute aortic dissection were medically treated only. They were divided into 4 groups: Stanford type A and B with open false lumen (open) or with early thrombosed false lumen (thrombosed). An event was defined as death by dissection or re-dissection. Gender, age, maximum diameter of dissected aorta and presence of shock at onset were examined as risk factors. In the open false lumen group, the presence of shock was associated with the event. During the chronic period, the diameter of the aorta was associated with prognosis in open type B dissection. The rate of event was higher in the open type A and B groups than in the thrombosed type A and B groups; however, there was no difference in the event-free rate between types A and B in patients surviving the acute period. The prognosis of medically treated dissecting aorta was not poor in patients with type B or with early thrombosed false lumen. The presence of shock at onset with open false lumen and the diameter of the aorta (> or =40 mm) in type B were significantly correlated with a poor prognosis.

Aged↗

PubMed1992

Concurrent bacterial lung infection in patients with AIDS, PCP, and respiratory failure.

STUDY OBJECTIVES: To determine and compare the incidence of concurrent bacterial lung infection in intubated and nonintubated patients with the acquired immunodeficiency syndrome (AIDS) and Pneumocystis carinii pneumonia (PCP) requiring medical intensive care unit (MICU) admission for support of their respiratory function. DESIGN: Retrospective review of medical records. SETTING: A large university hospital and AIDS treatment center. PATIENTS: All AIDS/PCP patients admitted to the MICU for support of oxygenation and/or ventilation between 1985 and 1989. Survival was defined as discharge from the hospital; nonsurvival was defined as death any time during the hospitalization. Patients with acute spinal cord injury (SCI) were used as controls to determine the incidence of nosocomial pneumonia in ICU patients of similar age without AIDS. MEASUREMENTS AND RESULTS: Twenty-nine AIDS/PCP patients met study criteria; eight (28 percent) were survivors and 21 (72 percent) were nonsurvivors. There was no significant difference in duration of intubation or duration of ICU stay between survivors and nonsurvivors with or without intubation. The incidence of bacterial concurrent lung infection (CLI) in AIDS/PCP patients overall was 7 percent and in intubated AIDS/PCP patients it was 10 percent. There was no statistically significant difference in the incidence of bacterial CLI between the survivors and nonsurvivors or between intubated and nonintubated patients with AIDS/PCP. The incidence of nosocomial pneumonia in SCI overall was 17 percent and in intubated SCI patients it was 30 percent. CONCLUSIONS: The incidence of bacterial lung infections in our retrospective study of AIDS patients with PCP is remarkably less than in the general ICU population with respiratory failure and in our control patients with SCI, although the differences did not attain statistical significance. This finding may be related to antimicrobial therapy directed against P carinii. Endotracheal intubation in patients with AIDS and PCP, who were undergoing appropriate antimicrobial therapy, did not result in a significantly higher incidence of bacterial lung infections than in those who were not intubated. There was no significant difference in the incidence of bacterial lung infections between those AIDS/PCP patients who survived episodes of severe respiratory failure and those who did not. Endotracheal intubation should not be delayed or withheld from this patient population due to concerns of pulmonary bacterial superinfection.

Acquired Immunodeficiency Syndrome↗