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Rinnert, S., Scalea, T. and Sinert, R. (1996), Management of nontraumatic subarachnoid
  hemorrhage in a patient with sickle-cell disease: A case report. Academic Emergency
  Medicine, 3 (9), 859-863.
Abstract: Subarachnoid hemorrhage (SAH) due to sickle-cell anemia is rare, but
  potentially devastating. However, with early recognition of SAH, aggressive support
  with exchange transfusion, cerebral angiography, and neurosurgical intervention, a
  positive outcome may be achieved. A case report of SAH managed in this fashion is
  reported. Based on similar cases in the literature, a suggested treatment protocol is
  provided for the management of nontraumatic SAH in sickle-cell patients presenting
  to the ED
Keywords:        ABNORMALITIES/ANEMIA/ANEURYSMS/case                        report/cerebral
  aneurysm/COMPLICATIONS/CULTURED                                            VASCULAR
  ENDOTHELIUM/ERYTHROCYTES/exchange                                transfusion/intracranial
  hemorrhage/MASSIVE                                                    INTRACRANIAL
  HEMORRHAGE/SECONDARY/sickle-cell disease/stroke/STROKE/subarachnoid
Weiss, S.J., Kulik, J.P. and Calloway, E. (1997), Bioimpedance cardiac output
  measurements in patients with presumed congestive heart failure. Academic
  Emergency Medicine, 4 (6), 568-573.
Abstract: Objective: To describe preliminary ED experience with thoracic electrical
  bioimpedance (TEB) for evaluation of patients with complaints suggestive of
  congestive heart failure (CHF). Methods: A 6-month, prospective, observational
  study was performed using a convenience sample of patients with signs and
  symptoms consistent with CHE Patients were excluded if they had received
  medication prior to arrival in the ED, if they were obese, and if they had unstable
  vital signs. They also were excluded if they were combative, refused to sign consent,
  or had invasive lines that did not allow for TEE lead placement, Patients also were
  excluded if the study could not be completed because the patient was taken from the
  department for a diagnostic test, or if there were no good follow-up records available
  6-12 months after the patient's visit, The patient's physician was blinded to the output
  of the TEE monitor. Cardiac output (CO), stroke volume (SV), end-diastolic volume
  (EDV), thoracic fluid index (TFI), and acceleration index (ACI) were recorded at
  5-minute intervals, Results were evaluated for the time intervals 0-5 minutes, 30-35
  minutes, and 60-65 minutes. Results: Seven patients were included in the study. The
  echocardiographic diagnoses were hypertrophic cardiomyopathy (2 cases), dilated
  cardiomyopathy (2 cases), ischemic cardiomyopathy (1 case), right ventricular
  hypertrophy (1 case), and pericardial effusion (1 case), Significant changes were seen
  in all cardiac parameters, with variance from individual to individual. Conclusions:
  Significant differences in TEE variables exist between patients who appear similar
  on initial examination in the ED. Changes noted on TEE may help to further
  elucidate physiologic differences, The clinical use of TEE-based hemodynamic
  measurements to guide presumed CHF patient management remains speculative
Keywords: cardiac output/cardiography/cardiomyopathy/congestive heart failure/critical
  care/EMERGENCY/emergency                                       services/evaluation/heart
  volume/THERMODILUTION/THORACIC                                           ELECTRICAL
Showalter, W., Esekogwu, V., Newton, K.I. and Henderson, S.O. (1997), Vertebral
  artery dissection. Academic Emergency Medicine, 4 (10), 991-995.
Abstract: Vertebral artery dissections (VADs) following a variety of minor traumatic
  mechanisms have been previously reported, This article reports 2 cases of VAD with
  delayed recognition following motor vehicle collisions (MVCs), The first VAD
  patient developed major neurologic abnormalities 28 hours after an MVC. The
  second VAD patient presented with 3 weeks of neck and head pain beginning 8
  weeks after an MVC and subsequent chiropractic manipulation. The anatomy and
  pathophysiology of VAD are reviewed. Early ED recognition prior to the onset of
  major neurologic deficits (e.g., paresis, dysarthria, ataxia, or altered mental status) is
  emphasized. An algorithm for the ED management of the entity is suggested
Keywords:                                                                               case
  trauma/pain/PATIENT/stroke/vertebral artery dissection
Rosamond, W.D., Gorton, R.A., Hinn, A.R., Hohenhaus, S.M. and Morris, D.L. (1998),
  Rapid response to stroke symptoms: The Delay in Accessing Stroke Healthcare
  (DASH) study. Academic Emergency Medicine, 5 (1), 45-51.
Abstract: Objective: To assess the determinants of prehospital delay for patients with
  presumed acute cerebral ischemia (ACI) in order to provide the background
  necessary to develop interventions to shorten such delays. Methods: A prospective
  registry of patients presenting to the ED with signs and symptoms of stroke was
  established at a university hospital from July 1995 to March 1996. Trained nurses
  performed a structured ED interview, which assessed prehospital delay and potential
  confounders. Results: The median delay (interquartile range) from symptom onset to
  ED arrival for all patients seeking care for stroke- like symptoms (n = 152) was 3.0
  hours (1.5-7.8 hr). The median delay from symptom onset to ED arrival was less in
  cases where a witness first recognized that there was a serious problem than it was
  when the patient first identified the problem. A heightened sense of urgency by the
  patient about his or her symptoms, and use of 911/emergency medical services (EMS)
  transport were also associated with rapid arrival in the ED within 3 hours of
  symptom onset, After adjusting for all predictor variables in a multivariable logistic
  regression model, only recognition of symptoms by a witness and calling 911/EMS
  transport remained statistically significant. Conclusions: These data suggest that
  future efforts to intervene on prolonged prehospital delay for patients with ACI
  should include strategies for the community as a whole as well as persons at risk for
  stroke and should reinforce the use of 911 and EMS transport
Keywords:        access       to     care/acute/cerebral/cerebral        infarction/cerebral
  ischemia/emergency                   medicine/EMS/epidemiology/hospital/HOSPITAL
Pepe, P.E., Zachariah, B.S., Sayre, M.R. and Floccare, D. (1998), Ensuring the chain of
  recovery for stroke in your community. Academic Emergency Medicine, 5 (4),
Abstract: Until recently, the prehospital and ED management of nonhemorrhagic stroke
  was largely supportive care, Studies have now demonstrated the potential of certain
  therapeutic interventions to reverse the debilitating consequences of such strokes,
  The clinical benefit for such interventions and the risk of significant therapeutic
  complications are highly time- dependent, To optimize the chances of a better
  outcome fan, the patient with stroke, each community must establish and continue to
  refine a chain of recovery for stroke patients, The chain of recovery is a metaphor
  that describes a series of sequential actions that must take place in a timely fashion to
  optimize the chances of recovery from stroke, Each of these sequential actions forms
  an individual link in the chain, and each link must be intact. The links include:
  identification of the onset of stroke symptoms by the patient or bystanders; dispatch
  life support services, which preferably include enhanced 9-1-1 and medically
  supervised and trained dispatchers who can rapidly deploy the closest responders and
  transport units; emergency medical services (EMS) personnel who can rapidly assess
  and transport the stroke patient to the closest appropriate center capable of providing
  advanced stroke diagnostics and interventions; en route notification of the receiving
  facility so that appropriate personnel can be readied for rapid diagnosis and
  intervention; and receiving facilities capable of providing rapid diagnosis and
  advanced treatment of stroke, including the availability of specialists who can
  evaluate underlying etiologies as well as plan future therapies and rehabilitation. To
  ensure that the chain of recovery is in place, aggressive public education campaigns
  should be implemented to increase the probability that stroke symptoms and signs
  will be recognized as soon as possible by patients and bystanders, In addition,
  because most of the current training programs for EMS dispatchers and EMS
  personnel are lacking with regard to stroke, it is recommended that such personnel
  and their EMS system managers be updated on current management and treatment
  strategies for stroke
Keywords:                            9-1-1/ACUTE                              ISCHEMIC
  vascular                                                           accident/community
  intervention/complications/diagnosis/education/EMERGENCY/emergency medical
  services/emergency                        medicine/EMS/MANAGEMENT/neurologic
Baraff, L.J., Lee, T.J., Kader, S. and Della Penna, R. (1999), Effect of a practice
  guideline on the process of emergency department care of falls in elder patients.
  Academic Emergency Medicine, 6 (12), 1216-1223.
Abstract: Objective: To determine the effect of a practice guideline on the process of
  ED care in a health maintenance organization. Methods: A pre- post-intervention
  comparison with a one-year pre-intervention phase followed by a one-year
  post-educational intervention phase was used to study the effect of the guideline on
  ED care. Emergency physicians and nurses were provided the details of the guideline
  during a two-week interval between the two periods. Results: During the two years
  of the study, 1,140 preintervention and 759 post-intervention patients met study
  eligibility criteria. More patients were diagnosed as having had falls due to loss of
  consciousness, stroke, and seizures during the post-intervention period (pre-
  intervention 3.8% vs post-intervention 8.4%, p < 0.001). There was a significant
  improvement in documentation of six of ten history items: cause of fall (64.5% vs
  72.9%), location of fall (54.7% vs 60.5%), ability to get up unassisted (5.4% vs
  12.5%), long lie after fall (1.5% vs 10.1%), prescription medications (79.0% vs
  92.2%), and Pneumovax immunization status (20.8% vs 43.0%); and two of the four
  physical examination items: visual acuity (1.5% vs 3.2%) and the "get up and go
  test" (1.3% vs 11.2%). Prescribing of calcium and vitamin D increased from 0% to
  6.6%. Conclusions: The educational intervention to the practice guideline for the ED
  management of falls in elders led to small but significant improvements in the
  documentation of selected history and physical examination items and the
  prescribing of calcium and vitamin D, and to a greater consideration of the causes of
Keywords: accidental falls-prevention and control/aged/calcium/CLINICAL
  department/emergency         medicine/geriatric     assessment/guideline/health/health
  maintenance/HOME/loss                                                                of
  actice guidelines/RANDOMIZED TRIAL/RISK-FACTORS/seizures/stroke
Smith, R.W., Scott, P.A., Grant, R.J., Chudnofsky, C.R. and Frederiksen, S.M. (1999),
  Emergency physician treatment of acute stroke with recombinant tissue plasminogen
  activator: A retrospective analysis. Academic Emergency Medicine, 6 (6), 618-625.
Abstract: Stroke teams are advocated for the rapid treatment of patients who have acute
  ischemic stroke (AIS) with recombinant tissue plasminogen activator (rt-PA). An
  alternate model uses existing ED resources with specialist consultation as needed..
  Objectives: To evaluate the treatment of AIS with rt-PA in this alternate ED model.
  Methods: A retrospective observational review was performed of consecutive
  patients with AIS treated with rt-PA at four hospitals affiliated with an emergency
  medicine residency. Emergency physicians (EPs) were. directly responsible for the
  treatment of all patients according to predefined guidelines. Records were evaluated
  from the implementation of the guidelines through December 15, 1997. Results: 37
  patients with AIS received rt-PA. Mean age +/- SD was 63 +/- 16 years (range
  22-87), with 25 (68%) male. Patients presented 67 +/- 29 minutes after stroke onset.
  After ED- arrival, they were seen by the EP in 14 +/- 13 minutes, had CT in 46 +/-
  22 minutes, and were treated in 97 +/- 35 minutes. Neurologist consultation occurred
  in the department for nine patients (24.3%), and by telephone for 14 (37.8%).
  Symptomatic intracerebral hemorrhage (ICH) occurred in four (10.8%, 95% CI =
  0.8% to 20.8%). There were two deaths, neither associated with ICH. Neurologic
  outcome at discharge compared with presentation in survivors was normal for four
  patients (11.4%), improved for 16 (45.7%), unchanged for ten (28.6%), and worse
  for five (14.3%). Conclusions: In this analysis, EPs, with specialty consultation as
  required, successfully identified patients with AIS and delivered rt-PA with
  satisfactory outcomes. Important elements of this model include early patient
  identification, preestablished protocols, and rapid access to CT scanning and
Keywords:         ACCURACY/acute/ACUTE                ISCHEMIC            STROKE/acute
  stroke/age/cerebral infarction/cerebral ischemia/CT/DELAYS/emergency/emergency
  medicine/guidelines/hemorrhage/intracerebral            hemorrhage/ischemic/ischemic
  activator/recombinant       tissue     plasminogen       activator/review/stroke/stroke
  onset/thrombolytic therapy/THROMBOLYTIC THERAPY/tissue plasminogen
Nasisi, D., Bruns, J., Baumlin, K., Wilets, I. and Jagoda, A. (2000), Out-of-hospital
  management of stroke: Surveying local practice with implication for change.
  Academic Emergency Medicine, 7 (4), 402-405
Keywords: education/emergency medical technicians/management/management of
  stroke/paramedics/prehospital care/stroke/thrombolytics
Casebeer, L.L., Klapow, J.C., Centor, R.M., Stafford, M.A., Renkl, L.A., Mallinger,
  A.P. and Kristofco, R.E. (1999), An intervention to increase physicians' use of
  adherence- enhancing strategies in managing hypercholesterolemic patients.
  Academic Medicine, 74 (12), 1334-1339.
Abstract: Purpose. Patients' lack of adherence to medical regimens frustrates many
  practicing physicians. This study was conducted to determine the effectiveness of a
  combined continuing medical education intervention in increasing physicians'
  adherence- enhancing skills and improving hypercholesterolemic patients' health.
  Method. A prospective, randomized, controlled trial was designed using a nested
  cohort of 28 community physicians throughout Alabama and 222 of their
  hypercholesterolemic outpatients, The intervention, carried out in 1998, consisted of
  three interactive case audio-conferences plus chart reminders. Physicians' learning
  was measured by unannounced standardized patients, and patients' health by serum
  cholesterol levels, weight, knowledge of hypercholesterolemia, self-reported dietary
  habits, and health status. Results. No significant difference was found in the numbers
  of physician adherence-enhancing strategies, although the number did increase
  within the treatment group. There were significant differences in the intervention
  group's patients' knowledge of cholesterol management (p =.008) and significant
  reductions in their self-reported consumption of dietary fats (p =.002). A significant
  difference was found in the serum cholesterol level of men in the intervention group
  nine months after the intervention (p =.02), Conclusion. Combining a series of
  interactive case audio-conferences with charr reminders shows promise in increasing
  physicians' adherence-enhancing strategies. In chronic disease management, the
  problem of enhancing adherence remains complex
Keywords:        cholesterol/chronic        disease/combined/community/disease/disease
Levi, R. (1993), Therapies for Perioperative Hypertension - Pharmacodynamic
  Considerations. Acta Anaesthesiologica Scandinavica, 37 16-19.
Abstract: Cardiac output (CO) and peripheral resistance (PR), the two major
  determinants of systemic arterial blood pressure (BP), are regulated principally by
  the adrenergic (ADR) and renin- angiotensin-aldosterone (RAA) systems.
  Antihypertensive medications ultimately decrease CO, PR, or both, by acting at
  various sites in the ADR and RAA pathways or affecting cardiovascular functions
  directly. Beta-ADR-receptor blockers decrease heart rate (HR) and stroke volume
  (SV) by preventing the cardiostimulating effects of catecholamines and inhibiting
  renin release. Alpha-ADR-receptor blockers prevent the vasoconstricting effects of
  catecholamines and reduce PR (afterload). Angiotensin-converting enzyme inhibitors
  (ACEI) block the formation of angiotensin, a potent peripheral vasoconstrictor and
  aldosterone releaser. Hence, ACEI cause a decrease in both PR and CO, the tatter by
  preventing salt and water retention by aldosterone, thereby reducing plasma volume
  and venous return. Direct vasorelaxation and, thus, a fall in PR can be achieved by
  vasodilators. These include drugs (e.g. calcium antagonists) that prevent the entry of
  calcium ions into vascular smooth muscle cells, and others (e.g. nitrovasodilators)
  that boost the intracellular levels of vasodilating second messengers (e.g. cyclic
  GMP). Antihypertensives from different classes are often combined to improve the
  ratio between therapeutic and adverse effects
  SYSTEMS/ALPHA-                                            ADRENERGIC-RECEPTOR
  BLOCKERS/ANGIOTENSIN-CONVERTING                                              ENZYME
  OUTPUT                                 AND                              PERIPHERAL
Tuz, M., Erodlu, F., Dodru, H., Uygur, K. and Yavuz, L. (2003), Transient locked-in
  syndrome resulting from stellate ganglion block in the treatment of patients with
  sudden hearing loss. Acta Anaesthesiologica Scandinavica, 47 (4), 485-487.
Abstract: Stellate ganglion blockage (SGB) is a local anesthetic procedure intended to
  block the lower cervical and upper thoracic sympathetic chain and is one of the
  treatment modalities for a wide range of disorders such as sudden hearing loss,
  Menier's disease, stroke, sudden blindness, shoulder/hand syndrome and vascular
  headache. The complications of SGB are recurrent laryngeal or phrenic nerve block,
  pneumothorax, unconsciousness, respiratory paralysis, convulsions and sometimes
  severe arterial hypotension. We present a case with transient locked-in syndrome
  following SGB for the management of sudden hearing loss. The risk of an
  intra-arterial injection can be eliminated by rotating the needle, as is described in this
  he/hearing loss/hypotension/management/risk/stellate ganglion block/stroke/sudden
  hearing loss/transient/transient locked-in syndrome/treatment
VanDamme, H., Gillain, D., Desiron, Q., Detry, O., Albert, A. and Limet, R. (1996),
  Kinking of the internal carotid artery: Clinical significance and surgical management.
  Acta Chirurgica Belgica, 96 (1), 15-22.
Abstract: The authors report on 62 surgical corrections for kinking of the internal
  carotid artery during a 13-year period (1980- 1993). This represents 2.8% of all
  carotid operative procedures (n = 2188) in the same period. It always concerned a
  significant (< 60 degrees) angulation of a redundant internal carotid artery, that in all
  but 3 cases was associated with atherosclerotic involvement of the carotid bifurcation.
  The indication to surgery included transient hemispheric or ocular ischaemia in
  25.5% of cases, a regressive neurologic deficit in 8%, a minor stroke in 3%, a stroke
  in evolution in 11%, and non-lateralized cerebral ischaemia in 21%. In 19 patients
  (31%) it concerned an asymptomatic high degree stenosis. The surgical technique
  consisted in carotid transposition-reimplantation after eversion endarterectomy in 37
  cases, in posterior transverse plication with patch angioplasty in 20 cases, and in
  segmental excision with venous interposition graft in 5 cases. There was one
  postoperative death. The morbidity include one ipsilateral non-fatal stroke and 3
  transient ischaemic attacks. A complete long-term follow-up (mean duration 3.4
  years) is available for 57 patients. The late incidence of stroke is 1.5% per year. The
  5-year survival attains 67%. These long-term results are comparable to the outcome
  of standard endarterectomy in the same institution. The authors discuss the indication,
  techniques, and outcome of surgical correction of kinked internal carotid artery. They
  recommend a shortening procedure, often associated with endarterectomy for
  severely kinked vessels (angulation 60 degrees or less), symptomatic or not
Keywords:       atherosclerosis/carotid     artery/carotid      artery     diseases/cerebral
  ischaemia/ELONGATION/internal/internal                   carotid/internal          carotid
  artery/outcome/postoperative          complications/prognosis/stroke/transient/vascular
Van Damme, H., Sakalihasan, N. and Limet, R. (1999), Fibromuscular dysplasia of the
  internal carotid artery. Personal experience with 13 cases and literature review. Acta
  Chirurgica Belgica, 99 (4), 163-168.
Abstract: From January 1990 to December 1997, the authors observed 13 cases of
  fibromuscular dysplasia of the internal carotid artery. Four patients presented
  transient ischemic attacks, one amaurosis fugax, two suffered from a minor stroke,
  four had non-focalized ischemic cerebral symptoms and two were asymptomatic. At
  angiography, all patients showed a typical image of "string of beads". Seven patients
  were operated on. Six had endoluminal graduated dilatation, with rigid dilators up to
  4.5 mm, associated with thrombendarterectomy of the bifurcation in three and to
  correction of a kink in one case. In one case a venous interposition graft was done to
  exclude a saccular microaneurysm of the dysplasic internal carotid artery. In another
  case, backflow was insufficient after endoluminal dilatation, and a long venous patch
  allowed to restitute a normal vascular lumen. There was neither postoperative
  mortality nor stroke. Six patients, asymptomatic or with non focalized symptoms,
  were treated medically. During a mean follow-up of 47 months, only one of the 13
  patients developed a transient ischemic attack; the patient had not been operated on
  and received only medical treatment. Prevalence, etiopathology, diagnosis and
  management of fibromuscular dysplasia of the internal carotid artery are discussed.
  Fibromuscular dysplasia is a rare cause of cerebral ischemia. For asymptomatic
  lesions, a conservative approach seems appropriate. Surgery is only to be considered
  for symptomatic lesions. Surgical graduated endoluminal dilatation, where necessary
  combined with standard endarterectomy of the carotid bifurcation, is a safe, efficient
  and durable operation. Some complex cases of fibromuscular dysplasia may
  necessitate patch insertion or excision and graft interposition
Keywords:                 ANEURYSMS/angiography/angioplasty/artery/carotid/carotid
  artery/cerebral/cerebral                                       ischemia/cerebrovascular
  dysplasia/internal/internal                   carotid/internal                   carotid
  artery/ischemia/ischemic/management/mortality/OPERATIVE                     BALLOON
  ANGIOPLASTY/review/stroke/transient/transient ischemic attack/transient ischemic
Chelala, E., Paraskevas, N., Chahidi, N., Poortmans, M., Andre, R. and Alle, J.L. (2002),
  Primary mechanical stapled anastomosis in surgery for colorectal emergencies. Acta
  Chirurgica Belgica, 102 (1), 30-32.
Abstract: From May 91 to March 99 a consecutive series of 100 acute obstructions or
  perforations of the left colon or rectum were treated by primary resection with
  mechanical anastomosis using a double or triple stapling technique without proximal
  colostomy. There were 8 postoperative deaths (8%) due to sepsis, acute respiratory
  distress syndrome, pulmonary embolism, stroke, and cachexy. Complications
  occurred in 29% of surviving patients. Clinical anastomotic leaks were observed in
  7%, respiratory infection in 8%, wound infection in 8% and major cardiovascular
  problems in 4% of patients. The median hospital stay was 19 days. The morbidity
  and mortality of this series did not exceed the cumulative morbidity and mortality
  that can be expected after staged surgery. Compared with staged surgery, immediate
  resection and anastomosis using an entirely mechanical suture, thereby avoiding the
  problems of colostomy and reducing the length of hospital stay, has significant
  advantages for patients
Keywords:              acute/anastomosis/CANCER/CARCINOMA/cardiovascular/colic
  ction/large                                                                       bowel
  BSTRUCTION/one             stage      colectomy/postoperative/primary         colorectal
  anastomosis/pulmonary embolism/RESECTION/sepsis/stroke/surgery
De Keyser, J., Sulter, G., Langedijk, M., Elting, J.W. and van der Naalt, J. (1999),
  Management of acute ischaemic stroke. Acta Clinica Belgica, 54 (5), 302-305
Keywords: acute/acute ischaemic stroke/ACUTE ISCHEMIC STROKE/ECASS/focal
  brain      ischaemia/HOSPITAL/INTRAVENOUS                THROMBOLYSIS/ischaemic
  stroke/STREPTOKINASE/stroke/stroke                                      treatment/stroke
Ogawa, A., Yoshimoto, T. and Sakurai, Y. (1991), Treatment of Proximal Vertebral
  Artery-Stenosis - Vertebral to Subclavian Transposition. Acta Neurochirurgica, 112
  (1-2), 13-18.
Abstract: For vascular reconstruction in cases of atherosclerotic stenosis at the origin of
  the vertebral artery, we use vertebral to subclavian artery transposition. We discuss
  the advantages and effectiveness of such treatment based on a study of 32 cases. We
  have experienced neither surgical mortality nor morbidity and the outcome at the
  time of discharge has been favourable. Follow-up revealed no deaths, however, three
  cases exhibited symptoms of cerebral ischaemia. One had a supratentorial completed
  stroke, and the other two hat TIA or RIND, but without any notable lesion in the
  angiograms. There were no cases of cerebral infarction of the posterior fossa. We
  believe that this method should be the first choice for treatment of cases without
  lesions of the subclavian artery for the following reasons: serious operative
  complications have not been encountered, surgical invasion is minimal, temporary
  occlusion of the common carotid artery is unneccessary, the operation can be done
  by occluding only the vertebral artery, and unlike various bypass operations,
  anastomosis is required at only one location and is consequently technically
  uncomplicated. Following anastomosis the cerebral blood pathway is physiological
Keywords:                                        ANASTOMOSIS/BRAIN/CEREBRAL
  RECONSTRUCTION/TIA/VERTEBRAL                                                   ARTERY
  RECONSTRUCTION/VERTEBRAL                              TO                SUBCLAVIAN
Deruty, R., Mottolese, C., Pelissouguyotat, I. and Lapras, C. (1991), The Carotid
  Endarterectomy - Experience with 260 Cases and Discussion of the Indications. Acta
  Neurochirurgica, 112 (1-2), 1-7.
Abstract: During 1978 to 1989, 235 patients were operated upon with 260 procedures
  for cervical carotid endarterectomy. The patients were classified according to the
  presence or absence of ischaemic symptomatology, and for symptomatic patients,
  according to the reversibility or persistance of ischaemic symptoms. So the selection
  of patients was: reversible ischaemia 46%, stroke 29%, asymptomatic patients 25%.
  In the stroke group, no patient was operated on as an emergency, the endarterectomy
  was only performed after stabilization of the clinical state. Three subgroups were
  included in patients operated on for asymptomatic carotid stenosis: casual discovery
  40%, treatment of the second carotid artery (previous endarterectomy for
  symptomatic contralateral stenosis) 34%, and treatment of the second carotid artery
  (previous ECIC by-pass for contralateral carotid occlusion) 26%. All patients were
  operated upon after angiographic exploration (femoral catheterisation in most cases),
  and after cerebral CT scan. The surgical technique included general anaesthesia,
  systematic shunting, endarterectomy after longitudinal arteriotomy, closure without
  patch. The operating microscope has been used since 1985. The surgical results were
  studied in terms of uneventful postoperative course (87%), reversible complications
  (8%) and long lasting complications (5%). The long lasting complications were of
  local origin (1%), of neurological origin (2%), of general origin (1%). Overall the
  operative outcome at 6 months was: return to previous clinical state 95%,
  neurological sequelae 2%, death 3%. In the patients operated on for asymptomatic
  carotid stenosis the overall outcome was: previous clinical state 97%, death 3%. The
  legitimacy of carotid endarterectomy procedure is discussed in relation to some
  recent pertinent literature
Keywords:                   ARTERIAL-DISEASE/CAROTID                           ARTERY
Kawamura, S., Yasui, N., Shirasawa, M. and Fukasawa, H. (1991), Rat Middle
  Cerebral-Artery Occlusion Using An Intraluminal Thread Technique. Acta
  Neurochirurgica, 109 (3-4), 126-132.
Abstract: A modification of the previous methods of producing cerebral ischaemia in
  rats (Koizumi et al., Longa et al.), using an intraluminal thread technique, is
  described. The middle cerebral artery is occluded by introducing a simple 3-0 nylon
  thread (0.20-0.249 mm in diameter) through the internal carotid artery in the neck. It
  has been proven that with this method reproducible focal cerebral ischaemia can be
  achieved which resembles human stroke. Therefore this simple and relatively
  non-invasive model is suitable for the pathophysiological investigation of ischaemic
  stroke and the testing of potential therapies
Hamann, G.F., Strittmatter, N., Hoffmann, K.H., Holzer, G., Stoll, M., Keshevar, T.,
  Moili, R., Wein, K. and Schimrigk, K. (1995), Pattern of Elevation of Urine
  Catecholamines in Intracerebral Hemorrhage. Acta Neurochirurgica, 132 (1-3),
Abstract: Autonomic nervous system dysfunction is a common complication of severe
  intracranial disease. The aim of this study was to reveal the autonomic changes in
  patients suffering from acute intracerebral haemorrhage (ICH). 25 patients with
  spontaneous ICH within 24 hours of onset of symptoms were included. All patients
  were treated with standardised medical management and the meta- and
  normetanephrines were detected by high performance liquid chromatography (HPLC)
  in 24-hour urine every day. The mean level of normetanephrine (709 +/- 579 mu
  g/day) and me tanephrine (244 +/- 161 mg/day) were significantly elevated in
  comparison with a control group, p less than or equal to 0,01. The norepinephrine
  elevation was of greater diagnostic and prognostic importance. Maximum urinary
  catecholamine metabolite levels occurred between day 3 to 10 after the bleeding.
  Normetanephrines correlated with the prognosis and the complications of ICH:
  intraventricular involvement resulted in significantly elevated normetanephrine
  levels (896 +/- 520 mu g/day versus 311 +/- 78 mu g/day) p less than or equal to 0,01.
  Patients with a great volume of haematoma developed severe autonomic
  dysregulation (normetanephrines 1114 +/- 493 mu g/day), whereas patients with
  smaller haematoma did not (339 +/- 125 mu g/day) p less than or equal to 0,0001;
  patients with bad out come (1014 +/- 620 mg/day) had higher levels of
  normetanephrines than those with a good prognosis (322 +/- 110 mu g/day)p less
  than or equal to 0,001. A close relationship to elevated intracranial pressure was
  established. This study demonstrated the feasibility of detecting autonomic nervous
  system dysfunction in neurological intensive care patients by means of examination
  of the metabolites of the catecholamines in the urine. The pattern of elevation in ICH
  and the relation to the clinical situation is presented. Norepinephrine offers the
   chance of simple and feasible monitoring of autonomic dysfunction
Keywords:                                        acute/complications/INTRACEREBRAL
Steiger, H.J. (1995), Carotid endarterectomy - When to do it, how to do it? Acta
   Neurochirurgica, 137 (3-4), 121-127.
Abstract: With the completion of the major carotid endarterectomy trials the indications
   for this procedure can be defined. The procedure, if done by experienced teams, has
   been shown to improve the chance of stroke free survival in symptomatic and
   asymptomatic patients with a high-grade stenosis of the internal carotid artery. In
   asymptomatic patients the risk reduction gained by prophylactic carotid
   endarterectomy may be small in relation to the risk of coincident factors particularly
   coronary artery disease. The benefit gained by carotid endarterectomy depends
   closely on the risk of the procedure itself, and a single little flaw during the
   management can annulate the benefit of the operation in asymptomatic patients.
   There are still considerable controversies with regard to peri-operative management
   and surgical technique, e.g., the necessity of routine pre- operative arteriography has
   recently been questioned. Quality control programmes become a requirement with
   the publication of performance standards for carotid endarterectomy. According to a
   consensus of the American Heart Association, the surgical morbidity/mortality must
   be less than 6% for symptomatic carotid lesions and less than 3% for asymptomatic
   lesions. The present review discusses the steps of the pre-operative work- up, the
   procedure itself and the post-operative management with the aim to identify accepted
   safety standards as well as areas of uncertainty
Keywords:                       BIFURCATION/carotid                          artery/carotid
   endarterectomy/CEREBRAL-ISCHEMIA/cerebrovascular disease/coronary artery
   SURGERY/DISEASE/endarterectomy/internal/internal             carotid/internal    carotid
   DEFICITS/OPERATIONS/quality                                                      control
   programme/STENOSIS/STROKE/surgical technique/VEIN PATCH
Holmes, B., Sekhar, L., Sofaer, S., Holmes, K.L. and Wright, D.C. (1995), Outcomes
   Analysis in Cranial Base Surgery - Preliminary-Results. Acta Neurochirurgica, 134
   (3-4), 136-138.
Abstract: A system of analysis addressing predictors of management outcomes in
   Cranial Base Surgery has yet to be published. We therefore report data on
   seventy-nine consecutive patients undergoing surgery for tumors involving thr
   cranial base, excluding patients with the diagnosis of pituitary microadenoma.
   Outcomes were defined prospectively in terms of completeness of tumor resection,
   complications of treatment with emphasis on neurological morbidity, and return tn
   work or independent living. Also, preoperative features are analyzed as influencing
   cost of treatment, estimated in terms of the number of surgical procedures required,
   duration of hospital and Intensive Care Unit stay, and time taken to return to work.
   Preliminary analysis of data reveals that severe brainstem compression, large tumor
   size (average diameter > 3 cm), high cavernous sinus grade, and tumor encasement
   of major cerebral arteries are associated with incomplete tumor resection (p < 0.05).
   Patient age greater than 65, preoperative Karnofsky Performance Score (KPS) less
   than 80, and severe brainstem compression are associated with increased risk of
   stroke (p < 0.05). Age greater than 65 and preoperative KPS less than 80 are
  associated with an increased length of stay (p < 0.05). Other untoward events did not
  occur with sufficient frequency to reach statistical significance. A model of outcomes
  analysis in Cranial Base Surgery is proposed utilizing a database to incorporate a
  group of non-operated patients and include quality of life measurements in long-term
  patient follow-up
Keywords:        36-ITEM/age/arteries/complications/DATABASE/diagnosis/HEALTH
Schick, U., Zimmermann, M. and Stolke, D. (1996), Long-term evaluation of EG-IC
  bypass patency. Acta Neurochirurgica, 138 (8), 938-942.
Abstract: The EC-IC Bypass Study Group could not detect any benefit from surgery
  compared to medical management in the prevention of strokes in 1985 [15]. During
  the past years surgical revascularization was re-evaluated and considered as an
  appropriate treatment for a small subgroup of patients with recurrent focal cerebral
  ischaemia and impaired haemodynamics. This retrospective study examines the
  long-term benefit and patency rats of bypass. We present a follow-up of 5.6 years of
  47 patients, all of whom underwent bypass surgery after 1985. Forty patients
  suffered recurring transient ischaemic attacks due to uni- or bilateral internal carotid
  artery occlusion. Examination included neurologic status, TCD with CO2 or Diamox
  challenge, angiography, CT and SPECT scans. Neurological improvement was seen
  in 23% of patients with better results after early surgery, a worsening in 22%
  suffering further ischaemic events on a postoperative average of 2.8 years. Patency
  rate for vein graft material was 50%, for the STA-MCA procedure 91%. Occlusion
  of the vein graft occurred on an average after 1.4 years, other anastomosis after 2.7
  years. We conclude that only few patients derived long-term benefit from EC-IC
  bypasses. Functioning of the bypass worsens over time, suggesting a role for surgery
  predominantly in the first year of ischaemic events due to insufficient collateral
  supply. Actual indications for bypass surgery may be patients with failure of
  maximal medical therapy and progressive ischaemia and haemodynamic compromise
Keywords: ACETAZOLAMIDE/bypass/bypass function/bypass grafting/carotid artery
  occlusion/CEREBRAL                  BLOOD-FLOW/cerebrovascular                   reserve
Mori, K., Ishimaru, S. and Maeda, M. (1998), Unco-parahippocampectomy for direct
  surgical treatment of downward transtentorial herniation. Acta Neurochirurgica, 140
  (12), 1239-1244.
Abstract: Downward transtentorial herniation is a major cause of death and disability
  caused by acute supratentorial mass lesions. Thirteen patients, 7 men and 6 women
  aged from 23 to 75 years old, with progressive transtentorial herniation caused by
  cerebral contusion with acute subdural haematoma, acute brain swelling after
  aneurysmal subarachnoid haemorrhage, or massive cerebral infarction were treated
  by direct surgery using selective removal of the uncus and parahippocampal gyrus
  (unco- parahippocampectomy). All patients showed progressive deterioration of
  transtentorial herniation (late third nerve stage or midbrain stage) with unilateral
  pupillary dilation and absent light reflex, Preoperative Glasgow Coma Scale scores
  ranged from 4 to 8. Unco-parahippocampectomy was performed via the middle
  temporal gyrus under the operating microscope. The oculomotor nerve, posterior
  cerebral artery, and midbrain were directly decompressed. Incision of the arachnoid
   membrane in the tentorial incisura allowed free communication of the cerebrospinal
   fluid between the supra- and infra-cranial fossae to reduce the pressure gradient. Two
   of the 13 patients died (15%). Two of the 11 survivors (18%) were functionally
   independent and 1 (9%) required minimal assistance but was independent at home.
   This series suggests the lifesaving nature of unco-parahippocampectomy in patients
   with deteriorating clinical condition because of transtentorial herniation
   d/subarachnoid haemorrhage/SURGERY/surgical treatment/TEMPORAL-LOBE
   EPILEPSY/transtentorial herniation/treatment/unco-parahippocampectomy
Tamasauskas, A., Tamasauskas, J., Bernotas, G., Inao, S. and Yoshida, J. (2000),
   Management of patients with ruptured cerebral aneurysms in hospital population of
   Lithuania. Acta Neurochirurgica, 142 (1), 51-59.
Abstract: A retrospective analysis of ruptured cerebral aneurysms among the hospital
   population of Lithuania was performed. A total of 507 patients were enrolled in the
   study during a 5 year period. The unadjusted annual incidence of ruptured cerebral
   aneurysms was found to be 2.7/100,000 in the hospital population of Lithuania and
   3.9/100,000 in the hospital population of the defined area of the city of Kaunas.
   Overall management results showed a 45.6% good recovery and 31.6% death rate in
   this group of patients. Surgical results showed a 52.1% good outcome and 20.9%
   death rate. Despite the fact that the death rate according to the timing of surgery after
   the initial subarachnoid haemorrhage did not differ significantly (p > 0.05) among
   early (0-3 days post SAH), moderate (4-7 days post SAH) and late (more than 7 days
   post SAH) surgery groups, it was found that 75 (14.8%) patients deteriorated while
   awaiting surgery. Initial bleeding together with rebleeding, medical complications
   and vasospasm were the main causes of death, constituting 61.3%, 18.1% and 9.4%
   of all deaths, respectively. The results of this study showed that the annual incidence
   of ruptured cerebral aneurysms in Lithuania is similar to that in other European
   countries except for Finland. Overall management results in the Lithuanian hospital
   population indicated only a slight improvement compared to management results of
   previous population-based studies in other countries
Keywords:              aneurysms/bleeding/CASE               FATALITY/cerebral/cerebral
   aneurysms/complications/COOPERATIVE                        ANEURYSM/death/EARLY
   population/incidence/INTRACRANIAL                               ANEURYSMS/IZUMO
   VE                   ANALYSIS/SHIMANE                         PREFECTURE/STROKE
   INCIDENCE/studies/subarachnoid/subarachnoid haemorrhage/SUBARACHNOID
Liu, J.K., Tenner, M.S., Oestreich, H.M. and Couldwell, W.T. (2001), Reversal of
   radiographically impending stroke with multiple intraarterial papaverine infusions in
   severe diffuse cerebral vasospasm induced by subarachnoid hemorrhage. Acta
   Neurochirurgica, 143 (12), 1249-1256.
Abstract: Background. Selective intraarterial infusion of papaverine is used in the
   treatment of symptomatic cerebral vasospasm induced by aneurysmal subarachnoid
   hemorrhage (SAH). Delays in instituting therapy for vasospasm can lead to
   irreversible cerebral infarction and a devastating outcome. Endovascular papaverine
   treatment of vasospasm in the presence of low- attenuation lesions on computed
  tomography (CT) is controversial, because of the fear of reperfusion hemorrhage in
  completed infarcts. Method Two patients with aneurysmal SAH who subsequently
  developed severe diffuse vasospasm were identified. In both patients, large areas of
  low-attenuation change suggesting impending cerebral infarction were seen on CT
  scans. The patients received multiple infusions of intraarterial papaverine in an effort
  to treat vasospasm refractory to medical management. Findings. After multiple
  intermittent administrations of papaverine, which initially appeared to increase the
  low-attenuation changes, there was dramatic reversal of the radiographic findings.
  There was also improvement in circulation time, transcranial Doppler velocities, and
  clinical outcome. Interpretation. These findings suggest that in some patients,
  intraarterial infusions of papaverine initiated in the earliest stages of ischemia may
  exacerbate the radiographic appearance of low-attenuation changes, but may
  ultimately reverse the evolution of cerebral infarction
Keywords: aneurysmal subarachnoid hemorrhage/ARTERIES/cerebral/cerebral
  infarction/cerebral      vasospasm/computed          tomography/CT/CT         hypodense
  cal management/outcome/papaverine/reperfusion/stroke/subarachnoid/subarachnoid
  Doppler/TRANSLUMINAL ANGIOPLASTY/treatment/vasospasm
Benes, V. and Mohapl, M. (2001), Alternative surgery for the kinked internal carotid
  artery. Acta Neurochirurgica, 143 (12), 1267-1272.
Abstract: Background. Carotid kinking can either be a source of emboli or it may cause
  cerebral ischemia during head/neck rotation. Surgical techniques to correct the kink
  usually employ carotid cross-clamping and kink resection. In selected cases the
  authors used simple kink straigthening and fixation. The patients treated by this
  method were evaluated. Method. Total of 42 operations in 40 patients were
  performed from 1984 through 1998. Mean age was 56 years, male: female ratio 1:1.
  Patients presented with either TIAs (n = 26), minor stroke (n = 13) or were
  asymptomatic (n = 3). There were 2 distinct groups of patients. Group I. were the
  patients with kinking only (n = 28), Group II. the patients in whom the kink was seen
  at the end of regular carotid stenosis. In all patients the kink was dissected free,
  straigthened and fixed by several stitches. In the Group II. this manoeuvre followed
  standard carotid micro- endarterectomy. Findings. Mean follow-up is 4,8 years
  (1-15). There was no morbidity, no mortality. Only 1 patient suffered several TIAs in
  the 6 months period after surgery. All patients are alive and symptom free.
  Interpretation. In lesser kinks the simple surgical technique without cross-clamping is
  elective, easy and complication free
Keywords:               age/artery/asymptomatic/carotid/carotid              artery/carotid
  carotid/internal                                                                  carotid
  roke/surgery/surgical technique
Kaminogo, M. and Yonekura, M. (2002), Trends in subarachnoid haemorrhage in
  elderly persons from Nagasaki, Japan: Analysis of the Nagasaki SAH Data Bank for
  cerebral aneurysm, 1989-1998. Acta Neurochirurgica, 144 (11), 1133-1139.
Abstract: Background. Many industrialized countries are facing a volumetric growth of
  the senior population. We studied the trends in the incidence and outcome of
  subarachnoid haemorrhage (SAH) in patients aged greater than or equal to70 years.
  Method. We retrospectively reviewed the cases of 1030 patients registered in the
  Nagasaki SAH Data Bank from 1989 to 1993 and 1274 patients registered from 1994
  to 1998. Findings. The annual age-adjusted incidence of SAH per 100,000 increased
  only in women, from 15.4 in the 1989-1993 period to 19.7 in the 1994-1998 period.
  The average annual incidence of SAH per 100,000 women in the elderly aged greater
  than or equal to70 years increased significantly from 44.3 in the first period to 58.2
  in the second period. In patients aged :70 years, the proportion of high-grade SAH
  (Hunt & Kosnik Grade IV and V) significantly increased from 27.2% in the first 5
  years to 38.2% in the second 5 years. In patients aged <70 years, it increased slightly
  from 23.4% to 26.7%. The rate of favorable outcomes significantly fell from 43.9%
  (first period) to 30.9% (second period) in patients aged greater than or equal to70
  years but was stable in patients aged <70 years. Interpretation. Although the
  incidence of elderly patients with SAH in our study is compatible with or higher than
  that of other reports, we believe that elderly patients (especially women) with
  highgrade SAH may not have all been identified. When we discuss the management
  of ruptured and unruptured aneurysms in the elderly, we should bear these trends of
  SAH in mind
Keywords:         aged/aneurysm/aneurysms/CASE-           FATALITY/cerebral/cerebral
  aneurysm/COMMUNITY/elderly/elderly patients/haemorrhage/incidence/incidence
  rate/INTRACEREBRAL                                HEMORRHAGE/INTRACRANIAL
  haemorrhage/subarachnoid hemorrhage/trends/unruptured aneurysms/women
Vuorinen, V., Hinkka, S., Farkkila, M. and Jaaskelainen, J. (2003), Debulking or biopsy
  of malignant glioma in elderly people - a randomised study. Acta Neurochirurgica,
  145 (1), 5-10.
Abstract: Background. Patients with radiologically (MRI and/or CT images) suspected
  malignant glioma is referred to radiotherapy after craniotomy and resection of the
  tumour or after diagnostic biopsy. Patients with poor preoperative status and elderly
  patients are diagnosed more often by biopsy and treated by radiotherapy rather than
  by craniotomy and tumour resection. However, based on previous retrospective
  studies it is not possible to conclude which procedure is better for elderly patients.
  Thus a prospective study comparing these two procedures with elderly patients was
  planned. Methods. 30 patients older than 65 years with radiologically (CT and/or
  MRI) obvious malignant glioma were randomised into two groups: I) stereotactic
  biopsy and II) open craniotomy and resection of the tumour. Nineteen patients were
  diagnosed to have grade IV glioma and four patients grade III glioma. Seven out of
  30 (23%) were followed in the "intention-to-treat" group with diagnosis of stroke (n
  = 3), metastasis (n = 2), malignant lymphoma (n = 1) and one with out histological
  diagnosis. Patients with histologically verified malignant glioma (grade III-IV) were
  diagnosed by stereotactic biopsy (n = 13) or by open craniotomy and resection (n =
  10) and all the patients were referred to radiotherapy. Survival and time of
  deterioration were followed. Findings. The overall median survival time was 146
  (95%, CI 89-175) days after the procedure. The estimated median survival time was
  171 (95%, CI 146-278) days after the craniotomy versus 85 (95% CI 55-157) days
  after the biopsy (p = 0.035). The estimated survival time was 2.757 times longer
  (95% CI 1.004-7.568, p = 0.049) after craniotomy. However, there was no significant
  difference in the time of deterioration between these two treatments (p = 0.057).
  Amount of radiotherapy given had a significant effect on survival (p = 0.001).
  Interpretation. Longer survival time is achieved after open craniotomy and resection
  of tumour. However, overall benefit of open surgery to patient seems to be modest.
  while time of deterioration did not differ between two treatment groups. Our results
  support previous studies on the benefit of radiotherapy in the treatment of malignant
  derly       patients/Finland/GLIAL        NEOPLASMS/GLIOBLASTOMA/malignant
Desfontaines, P. and Despland, P.A. (1995), Dissection of the internal carotid artery:
  Aetiology, symptomatology, clinical and neurosonological follow-up, and treatment
  in 60 consecutive cases. Acta Neurologica Belgica, 95 (4), 226-234.
Abstract: We reviewed the medical records of 60 consecutive patients (28 men and 32
  women; aged from 13 to 63 years) with the diagnosis of dissection of the internal
  carotid artery (ICA) and with available clinical and neurosonological follow-up. Ten
  cases occurred after trauma and 50 cases were spontaneous. Angiographic evidence
  of fibromuscular dysplasia of the ICA was found in 23% of the cases. Unilateral
  headaches or neck pain associated with focal cerebral ischemic symptoms or
  oculosympathetic palsy were the most common findings. Less frequent symptoms
  such as isolated cranial nerve palsies and pulsating bruits were also observed
  Follow-up ranged from 3 to 144 months (mean, 37.5 months). A favorable outcome
  occurred in 73.7% of the cases with a follow-up of 6 months or more, and seemed to
  depend on the severity of the ischemic cerebral deficit associated with the ICA
  dissection. 68% (41/60 cases) of our patients developed stroke and 18% (11/60 cases)
  experienced a transient ischemic attack, which occurred as the initial manifestation
  of the ICA dissection in 28.8% (15/52 cases) of the cases, and with a delay (more
  than 24 hours) in the other cases. Evidence of embolization in the cerebral arteries
  Mm found in 36% of the cases with stroke (15/41 cases). Anticoagulant therapy,
  given in 34 of our patients, seems to be justified by the fact that a considerable risk
  exists for cerebral emboli in association with ICA dissections; no serious
  neurological complications were observed in our series as a result of this
  anticoagulant therapy Doppler sonography follow-rtp diagnosed a recanalization in
  67.8% of the stenotic or occlusive dissections, most of them beeing completed within
  the first 6 months (92%). Recurrence of ICA dissection is exceptional but occurred in
  one of our 60 cases, 2.5 years after the first event
Keywords: ANEURYSMS/arteries/carotid artery/complications/CONSERVATIVE
  MANAGEMENT/CRANIAL                                                             NERVE
  llow-up/HORNERS SYNDROME/ICA/internal/internal carotid/internal carotid
Gokcil, Z., Odabasi, Z., Vural, O. and Yardim, M. (1998), Cerebral venous thrombosis
  in pregnancy: the role of protein S deficiency. Acta Neurologica Belgica, 98 (1),
Abstract: We report a 20 year-old, 28 week-pregnant woman, who developed superior
  sagittal sinus thrombosis, associated with a decreased free protein S level. Hel father;
  who had been a stroke victim, had also significantly lower level of protein S. In very
  rare cases, a congenital or acquired protein S deficiency leads to cerebral venous
  thrombosis. The detection of such abnormalities has major practical consequences
   for the long-term management of patients to prevent further thrombotic episodes
Keywords: cerebral/cerebral venous thrombosis/management/pregnancy/protein
   S/protein S deficiency/SINUS THROMBOSIS/stroke/thrombosis/venous thrombosis
Detrembleur, C., Renders, A., Willemart, T. and van den Hecke, A. (2000), Usefulness
   of gait analysis combined with motor point block in a stroke patient. Acta
   Neurologica Belgica, 100 (2), 107-110.
Abstract: This clinical note describes a typical case of dynamic varus deformity of the
   rearfoot in a stroke patient. An overactive Tibialis Posterior muscle seemed mainly
   responsible for the varus deformity. However this hypothesis was not confirmed by a
   motor point block of this muscle. It appeared that the Tibialis Posterior and Extensor
   Hallucis Longus muscles were both involved in the varus deformity. A double motor
   point block of both the Tibialis Posterior and Extensor Hallucis Longus muscles was
   performed Kinematic and kinetic data showed improvement. This case report
   illustrates the usefulness of gait analysis combined with motor point block in the
   diagnosis and management of gait disturbance
Keywords: case report/combined/diagnosis/gait/gait analysis/management/motor point
Canavero, S., Bonicalzi, V., Lacerenza, M., Narcisi, P., Garabello, D., Marchettini, P.
   and Perozzo, P. (2001), Disappearance of central pain following iatrogenic stroke.
   Acta Neurologica Belgica, 101 (4), 221-223.
Abstract: An exceptional case of long-standing central pain temporarily relieved by a
   focal stroke in the primary, somatosensory, area is reported. This case highlights the
   focal nature of central pain mechanisms and the possible value of selective
   subparietal leukotomies in the management of central pain
Keywords:                                                                            central
Peeters, A. and Cras, P. (2002), Proposal of guidelines for acute stroke treatment and
   management. Acta Neurologica Belgica, 102 (2), 46-48
Keywords:                   acute/acute                  stroke/acute                 stroke
   troke treatment/THROMBOLYTIC THERAPY/treatment
Franke, C.L., Palm, R., Dalby, M., Schoonderwaldt, H.C., Hantson, L., Eriksson, B.,
   LangJenssen, L. and Smakman, J. (1996), Flunarizine in stroke treatment (FIST): A
   double-blind, placebo-controlled trial in Scandinavia and the Netherlands. Acta
   Neurologica Scandinavica, 93 (1), 56-60.
Abstract: Introduction - An international, multicenter trial was conducted in 331
   patients to determine the effect of a large dose of flunarizine (a calcium entry blocker)
   in the treatment of acute ischemic stroke in the territory of the Middle cerebral artery.
   Methods - The administration of the trial medication should start within 24 h after
   the initial symptoms of stroke. According to a random schedule, the patients were
   assigned to a 4-weeks double-blind treatment with either flunarizine (n = 166) or
   placebo (n = 165): one week intravenous administration (50 mg daily), followed by 3
   weeks oral treatment (week 2, 21 mg daily; week 3-4, 7 mg daily). All patients had to
   be investigated by computerized tomography (CT) within 7 days after stroke onset;
   36 patients were secundarily excluded because the CT showed another pathology.
   During the treatment period, other ''stroke therapies'' were not allowed. Patients were
   followed up for 24 weeks, Results - After the 24 weeks trial period, the percentage of
   patients who were dead or pendent (modified Rankin score 3-5) was similar in both
   treatment groups (flunarizine 67%, placebo 65%). During the trial, the scores for
   handicap severity (modified Rankin scale), neurological status (Orgogozo) and
   activities of daily living (modified Barthel index) strongly improved in both
   treatment groups, but no differences were found between the treatment groups. In
   this trial, the administration of trial treatment started relatively late after stroke onset
   (flunarizine group: mean time interval 13.5 h; placebo 12.3 h), A subgroup of
   patients received trial medication within 6 h after stroke onset (flunarizine n = 31;
   placebo n = 29). Also in this subgroup, no differences were found between the
   flunarizine and placebo group. Conclusion - Flunarizine did not improve neurologic
   and functional outcome in patients with acute ischemic stroke
Keywords: activities of daily living/acute/CALCIUM/calcium entry blocker/clinical
   trial/CT/double- blind/flunarizine/ischemic stroke/outcome/severity/stroke/stroke
Giaquinto, S., Buzzelli, S., Di Francesco, L., Lottarini, A., Montenero, P., Tonin, P. and
   Nolfe, G. (1999), On the prognosis of outcome after stroke. Acta Neurologica
   Scandinavica, 100 (3), 202-208.
Abstract: Objectives - The study was aimed at improving the accuracy of prognosis for
   recovery of function in patients suffering a first stroke. Materials and methods -
   Two-hundred and forty- eight patients were enrolled. The mean interval since the
   stroke was 23 days. Patients entered a rehabilitation program lasting 60 days. The
   predictive value of 12 factors were analysed, namely motor, cognitive and sphincter
   subitems of Functional Independence Measure at admission (FIM-a), age, sex,
   education, body mass index (BMI), depression, neglect, aphasia, ideomotor and
   constructive apraxia. FIM score at discharge was the dependent variable. Results - A
   multiple regression revealed that only age, cognitive and sphincter subitems of
   FIM-a, neglect and ideomotor apraxia were significantly associated with outcome.
   Moreover, these factors accounted for only 72% of the variance in outcome scores. A
   decision of unfavourable prognosis on the basis of a FIM-a value lower than 40 was
   incorrect in 2.8% of the patients in this study and in 8.2% of those having a FIM
   score lower than 40. Conclusions - The use of statistical methods to examine the
   outcome after stroke is useful for expressing probability on a group basis but is
   unsuitable for determining the prognosis of individual patients. Such data should not
   be used for fiscal management. A significant minority of patients presenting with a
   FIM lower than 40 can regain a useful measure of independence. The errors in
   prognosis based upon available methods, although small, have unacceptable effects
   in human terms if they lead to the clinical decisions which deny patients
   rehabilitation. All of the patients should therefore be admitted for rehabilitation after
   their first stroke. Severe comorbidity requires special attention
Keywords:                                              age/aphasia/attention/cerebrovascular
   AL                     INDEPENDENCE                          MEASURE/HEMISPHERIC
Silvestrini, M., Vernieri, F., Troisi, E., Passarelli, F., Matteis, M., Pasqualetti, P.,
   Rossini, P.M. and Caltagirone, C. (1999), Cerebrovascular reactivity in carotid artery
   occlusion: possible implications for surgical management of selected groups of
   patients. Acta Neurologica Scandinavica, 99 (3), 187-191.
Abstract: Objectives - The aim of this study was to use transcranial Doppler
   ultrasonography to investigate cerebrovascular reactivity to hypercapnia in the
   middle cerebral arteries of patients with carotid occlusion with different outcomes.
  Patients and methods - Cerebrovascular reactivity to hypercapnia was calculated with
  the breath-holding index (BHI). Patients with unilateral carotid occlusion were
  divided as follows: asymptomatic (20 patients), transient ischemic attack (TIA) (20
  patients), minor (20 patients) and major stroke (14 patients). Values of BHI
  homolateral to the carotid occlusion were compared with those of 25 healthy subjects
  and 34 stroke patients without significant carotid stenosis. Results - BHI values were
  comparable in healthy controls, non stenotic stroke patients and asymptomatic
  occluded patients. BHI values of patients with symptomatic occlusion were
  significantly lower than those of the above-mentioned groups (P<0.0001). Moreover,
  the reduction of BHI was significantly associated with the extent of the neurological
  impairment. In fact, BHI Values were significantly higher in TIA than in minor and
  major stroke (P<0.0001) and in minor than in major stroke patients (P<0.02). Finally,
  we found that a BHI value homolateral to carotid occlusion of 0.69 can be considered
  the cut-point for distinguishing between symptomatic and asymptomatic patients.
  Conclusion - Prospective studies are needed to demonstrate if the presence of this
  threshold value may help in selecting a subset of patients with asymptomatic carotid
  occlusion or with transient or mild neurological deficit with the highest probability of
  benefiting from surgical therapy
Keywords: arteries/artery/carotid/carotid artery/carotid artery occlusion/carotid
  occlusion/carotid            stenosis/cerebral/cerebral             arteries/CEREBRAL
  L DOPPLER/transcranial Doppler ultrasonography/transient/transient ischemic
Camerlingo, M., Casto, L., Censori, B., Ferraro, B., Caverni, L., Manara, O., Finazzi, G.,
  Radice, E., Drago, G., De Tommasi, S.M., Gotti, E., Barbui, T. and Mamoli, A.
  (2000), Recurrence after first cerebral infarction in young adults. Acta Neurologica
  Scandinavica, 102 (2), 87-93.
Abstract: Objective - We have investigated recurrence of stroke in a consecutive series
  of young adults, aged 16 to 45 years, after a first cerebral infarction. Methods - From
  January 1, 1988 to December 31, 1996 we submitted those patients to a diagnostic
  protocol including angiographic, cardiological, and haematological investigations.
  The patients were followed at 6 month intervals up to December 31, 1998, Results
  We have evaluated and followed-up 135 patients, 71 men and 64 women, who were
  3.99% of all the admitted stroke patients. At 12 months after stroke, 83 patients had
  returned to work, 40 patients were mildly to moderately handicapped, 4 were using a
  wheel-chair, and 8 had died. Follow-up was 26 to 123 months (mean 68.8).
  Recurrence of stroke, always of ischaemic nature, was seen in 15 patients (11.1%), 3
  to 76 months after the first stroke (mean 27.4), for an annual incidence of 2.26%.
  Recurrence was significantly associated with Partial Anterior Circulation Syndrome
  and Haematological subtype of first stroke (respectively, P = 0.0209 and P = 0.0135,
  chi(2) test), bur not with age (less than or equal to or >35 years) or risk factors.
  Repetition of stroke was never fatal, but it caused heavy disability in 13 patients, 8 of
  whom had completely or nearly completely recovered after the first event.
  Conclusions - Our data suggest that recurrence of stroke is a major clinical problem
  also for the patients aged less than 45 years and that it might be more frequent with
  specific clinical syndromes and etiologic subtypes of first stroke
Keywords:       age/aged/ANTIBODIES/cerebral/cerebral           infarction/cerebrovascular
   REGISTRY/ISCHEMIC                                            STROKE/LONG-TERM
   PROGNOSIS/MANAGEMENT/PROTEIN-C                                     DEFICIENCY/risk
   factors/RISK-FACTORS/stroke/SUBTYPES/women/young adults
Jespersen, H.F., Jorgensen, H.S., Nakayama, H., Reith, J. and Olsen, T.S. (2002),
   Carotid Doppler - costs and need after stroke or TIA. Acta Neurologica
   Scandinavica, 105 (1), 1-4.
Abstract: Objectives - To estimate the need for and the costs of carotid Doppler and
   carotid endarterectomy after stroke or TIA in non- selected hospitalized patients.
   Material and methods - During 25 months hospitalized patients with stroke or TIA,
   in whom carotid endarterectomy could be relevant, were examined with carotid
   Doppler. If a significant stenosis was found, they were further evaluated for surgery.
   Based on our results, the requirement for future carotid endarterectomy and Doppler
   screening was estimated, and the costs of the procedures calculated. Results - Among
   1351 patients 703 were screened with carotid Doppler. Forty-five had severe
   (70-99%) stenosis of the relevant carotid artery. Only 3 were operated on. The future
   costs of screening were estimated under different assumptions. Conclusion - Carotid
   endarterectomy is expensive due to the large number of patients screened with
   carotid Doppler per operated patient. A careful clinical selection of patients for
   screening is necessary
Keywords: artery/carotid/carotid arteries ultrasonography/carotid artery/carotid
Haapaniemi, E., Tatlisumak, T., Soinne, L., Syrjala, M. and Kaste, M. (2002), Natural
   anticoagulants (antithrombin III, protein C, and protein S) in patients with mild to
   moderate ischemic stroke. Acta Neurologica Scandinavica, 105 (2), 107-114.
Abstract: Background and purpose - The role of the natural anticoagulants, antithrombin
   III (AT III), protein C (PC), and protein S (PS), in patients with mild to moderate
   ischemic stroke remains uncertain. We aimed to find out whether their levels in
   peripheral blood correlated with the severity of neurological deficit or can predict
   clinical outcome and recurrence. Methods - We studied AT III, PC, and free PS
   levels in 55 consecutive patients likely to survive the study period on admission, 1
   week, 1 month and 3 months after a first-ever ischemic stroke. Sex- and age-matched
   controls were studied once. All patients underwent a full neurological examination
   and blood sampling at each study time point; comprehensive stroke risk factors were
   recorded, and the etiology of the ischemic stroke was determined. All patients were
   contacted 3 years later for possible recurrent ischemic events. Results - AT III level
   was found to be significantly lower at all time points after stroke; PC level was
   significantly increased on admission and normal at subsequent measurements, and
   PS level was normal on admission but significantly decreased later. The levels of the
   natural anticoagulants did not correlate with the etiology of stroke, any stroke risk
   factor, or neurological scores, except that the AT III level on admission showed
   significant correlation with stroke severity and disability at 3 months. Natural
   anticoagulant levels did not predict recurrence of ischemic stroke. Conclusions - The
   measurements of the level of AT III, PC, or PS did not deliver useful information for
   management of patients with mild or moderate ischemic stroke, expect that AT III
   level on admission might predict outcome
  schemic/ischemic         stroke/management/natural         anticoagulants/neurological
  protein                        S/recurrence/risk/risk                       factor/risk
  factors/RISK-FACTORS/severity/stroke/stroke severity/THROMBOSIS
Hong, K.S., Kang, D.W., Cho, Y.J., Hwang, Y.J. and Hur, G. (2002),
  Diffusion-weighted magnetic resonance imaging in Wernicke's encephalopathy. Acta
  Neurologica Scandinavica, 105 (2), 132-134.
Abstract: Objective - To report diffusion-weighted imaging (DWI) findings and
  postulate the pathogenic mechanism of Wernicke's encephalopathy (WE). Patient - A
  47-year-old-woman presented with altered consciousness. ophthalmoplegia, and
  ataxia. DWI revealed the abnormal signal changes in periaqueductal gray matter.
  mamillary bodies and bilateral medial thalami. Apparent diffusion coefficient (ADC)
  map revealed the high signal intensity lesions in bilateral medial thalami. suggestive
  of vasogenic edema. The abnormal signal intensity lesions disappeared on follow-up
  imaging with clinical improvement. Conclusions - Vasogenic edema plays an
  important role in the pathogenesis of WE and can be reversed by proper management.
  DWI findings in the early stage of WE may provide useful information about the
  eighted/diffusion-weighted                  imaging/edema/encephalopathy/HUMAN
  STROKE/imaging/information/magnetic              resonance/magnetic          resonance
  edema/Wernicke's encephalopathy
Soriano, D., Carp, H., Seidman, D.S., Schiff, E., Langevitz, P., Mashiach, S. and
  Dulitzky, M. (2002), Management and outcome of pregnancy in women with
  thrombophylic disorders and past cerebrovascular events. Acta Obstetricia et
  Gynecologica Scandinavica, 81 (3), 204-207.
Abstract: Objective. To evaluate the maternal and fetal outcome in a cohort of women
  undergoing a subsequent pregnancy after a previous cerebrovascular event in the
  presence of thrombophilia. Patients. Fifteen pregnancies were followed up in 12
  women with past cerebrovascular events and thrombophilic disorders. The
  cerebrovascular events occurred during a previous pregnancy in five patients. Six
  patients had a bad obstetric history including intrauterine fetal death in four cases,
  early onset of severe preeclampsia in two cases and one infant that was small for
  gestational age. The thrombophilic disorders included: anti-phospholipid syndrome,
  protein C, S or antithrombin III deficiencies, mutations of the methyltetrahydrofolate
  reductase (MTHFR). All patients received prophylactic treatment with low molecular
  weight heparin and low dose aspirin. Results. Thromboembolic complications
  occurred in four pregnancies. Postpartum complications occurred in one patient, deep
  vein thrombosis and pulmonary emboli after stopping anticoagulation treatment. No
  patient had long-term neurologic damage. All pregnancies except one resulted in live
  births. (mean gestational age at delivery 36 +/- 3.7 weeks, mean birth weight 2656
  811 g). The one remaining pregnancy was electively terminated. There was one
    neonatal death due to the complications of severe prematurity in a woman with
    severe HELLP syndrome. Conclusion. This preliminary data suggests that women
    with a history of cerebrovascular events and thrombophilic disorders receiving
    prophylactic treatment, have a relatively favorable pregnancy outcome, however,
    they remain at significant risk during pregnancy further studies are necessary to
    determine the optimal prophylactic treatment
Keywords:                                      age/anticoagulation/ANTIPHOSPHOLIPID
    ath/deep             vein            thrombosis/delivery/DENMARK/emboli/HELLP
    syndrome/HEPARIN/infant/low/low dose/low molecular weight heparin/molecular
Linnet, J., Hegedus, L. and Bjerre, P. (2001), Results of a neurosurgical two-wall orbital
    decompression in the treatment of severe thyroid associated ophthalmopathy. Acta
    Ophthalmologica Scandinavica, 79 (1), 49-+.
Abstract: Purpose: Follow-up of patients with severe thyroid associated ophthalmopathy
    treated with a transcranial two-wall orbital decompression and reconstruction,
    Methods: A two-wall transcranial orbital decompression was performed in 30 such
    patients (50 eyes), The patients were evaluated one month postoperatively, and
    long-term evaluation (median 14 months, range 2-54 months) was carried out. The
    main outcome measures were visual acuity, proptosis measured by Hertel
    ophthalmometry, soft tissue involvement, and restriction of eye motility, Result:
    Visual acuity improved rapidly in 28 of 32 affected eyes with normalization in 19
    eyes (p<0.001), Worsening was not seen, Median proptosis was reduced by 4.0 mm,
    range 0-10.0 (p<0.001). Double vision was present in 24 patients before operation 14
    of whom achieved binocular vision (p<0.001), Three patients had unchanged
    complaints and the double vision worsened in one patient, Seventeen of 20 patients
    on preoperative corticosteroid treatment discontinued this medication in relation to
    surgery Complications included one case of perioperative minor stroke and two cases
    of facial nerve frontal branch palsy, Conclusion: The transcranial two- wall
    decompression is a simple, an efficient and a low-risk procedure for treatment of
    patients with severe thyroid associated ophthalmopathy
Keywords:                                                                       CORONAL
    EYE             DISEASE/FAT/GRAVES                     OPHTHALMOPATHY/Graves'
    ke/surgery/thyroid diseases/transcranial/treatment
Ji, X.Y., Tan, B.K.H. and Zhu, Y.Z. (2000), Salvia miltiorrhiza and ischemic diseases.
    Acta Pharmacologica Sinica, 21 (12), 1089-1094.
Abstract: The demonstration of beneficial effects of salvia miltiorrhiza (DanShen) on
    ischemic diseases has revolutionized the management of angina pectoris, myocardial
    infarction (MI) or stroke in Chinese society. Experimental studies have shown that
    DanShen dilated coronary arteries, increased coronary blood flow, and scavenged
    free radicals in ischemic diseases, so that it reduced the cellular damage from
    ischemia and improved heart functions. Clinical trials also indicated that DanShen
    was an effective medicine for angina pectoris, MI, and stroke. This review will focus
    on DanShen's effects in angina pectoris, MI and stroke
Keywords:                  angina/angina                pectoris/antioxidants/arteries/blood
   flow/CAPTOPRIL/cardiovascular                                  system/cerebrovascular
   disorders/coronary/DAMAGE/free                                             radicals/free
   USION INJURY/review/Salvia miltiorrhiza/stroke/studies/SURVIVAL/trials
Singh, K. and Chye, G.C. (1998), Adverse effects associated with contraceptive
   implants: incidence, prevention and management. Advances in Contraception, 14 (1),
Abstract: Contraceptive implants are increasingly being used for fertility regulation all
   over the world. Reversible long-term use is their most appealing feature for many
   users. They have the practical advantage of overcoming the risks of user failure and
   low continuation rates associated with other methods that require continuous
   attention or motivation. Disruption of menstruation, complications of insertion and
   removal, and infection at implant site, constitute the majority of adverse effects
   associated with contraceptive implants. This article reviews these various common
   adverse effects associated with contraceptive implants and their possible
   management and prevention. In addition, we also discuss very rare events, like
   psychiatric disorders, pseudotumor cerebri, thrombotic, thrombocytopenic purpura
   and thrombocytopenia, that have been reported by some researchers. Further
   surveillance and research is necessary to determine if these rare adverse events are
   causally related to contraceptive implants. Until such a time, providers of
   contraceptive implants should be more selective in prescribing the contraceptive
   implants, especially in women with a history of and/or risk factors for stroke,
   cerebral and coronary heart disease, thrombocytopenia and pseudotumor cerebri
Keywords:            adverse         effects/adverse         events/attention/BLEEDING
   RY/complications/coronary                                                          heart
   IMPLANTS/prevention/risk                     factors/stroke/SYSTEM/THROMBOTIC
Davis, L.L. and Grant, J.S. (1994), Constructing the Reality of Recovery - Family
   Home Care Management Strategies. Advances in Nursing Science, 17 (2), 66-76.
Abstract: Development of home health care programs for family caregivers is
   predicated on an understanding of problems caregivers encounter and ways in which
   they manage those problems. This article describes home care management strategies
   of family caregivers of stroke survivors. Qualitative analysis of the interviews with a
   purposive sample of family caregivers indicated that caregivers of stroke survivors
   practice situational vigilance for the stroke survivor, create solutions for problems
   associated with functional losses of a stroke, construct the reality of recovery for
   themselves and the stroke survivor, and seek to find personal meaning in the
   caregiving experience. Implications for practice and future research are proposed
Stone, S.P. (1987), The Mount-Vernon-Stroke-Service - A Feasibility Study to
   Determine Whether It Is Possible to Apply the Principles of Stroke Unit
   Management to Patients and Their Families on General Medical Wards. Age and
   Ageing, 16 (2), 81-88
Bonita, R., Anderson, A. and North, J.D.K. (1987), The Pattern of Management After
  Stroke. Age and Ageing, 16 (1), 29-34
Brown, G., Warren, M., Williams, J.E., Adam, E.J. and Coles, J.A. (1993), Cranial
  Computed-Tomography of Elderly Patients - An Evaluation of Its Use in Acute
  Neurological Presentations. Age and Ageing, 22 (4), 240-243.
Abstract: We assessed the use of cranial computed tomography (CT) in elderly patients
  with acute neurological deficit and its influence on patient management. Clinical
  notes from 100 consecutive CT referrals from geriatric admissions presenting with
  acute neurological deficit were reviewed and categorized according to clinical
  presentation. CT results and subsequent therapy were recorded. Twenty of the
  patients had treatable lesions (in 6 out of 14 patients with signs atypical of stroke and
  7 out of 19 patients with acute confusion). These two groups contained 68% of all
  treatable lesions found. Forty-four scans yielded no new diagnostic information;
  these included all scans for transient ischaemic attacks and for progression of stroke.
  The remaining scans yielded information regarding pathology but did not alter
  patient management. CT is a valuable first-line investigation in elderly patients
  presenting with signs atypical of stroke and unexplained confusion but may be less
  useful in patients with other presentations
Kalra, L., Dale, P. and Crome, P. (1994), Evaluation of A Clinical Score for Prognostic
  Stratification of Elderly Stroke Patients. Age and Ageing, 23 (6), 492-498.
Abstract: Orpington Prognostic Score (OPS) is a clinically derived score which
  incorporates measures of motor deficit, proprioception, balance and cognition. OPS
  and urinary continence were measured prospectively in 217 stroke survivors over 75
  years of age at 1, 2 and 4 weeks after stroke and were correlated with dependence at
  discharge. Three levels of dependence were defined based on personal self-care
  abilities. OPS ranged from 2.0 to 3.2 (median 2.8) at 2 weeks after stroke in patients
  independent at discharge (n = 54). Their initial median Barthel index of 4 improved
  by a median of 12. Urinary continence was achieved in 95% of these patients by 2
  weeks. All patients were discharged home, 39 (72%) within 4 weeks. Patients with
  limited dependence at discharge (n = 129) had OPS of 3.2-4.8 (median 4.0) at 2
  weeks. Two-thirds were continent at 2 weeks. Their initial median Barthel index was
  2 and changed by a median of 12. Seventy-one (55%) of these patients went home.
  OPS ranged from 5.2 to 6.8 (median 6.0) at 2 weeks in patients dependent at
  discharge (n = 34). About 20% of these patients were continent. Their initial median
  Barthel index of 2 improved by a median of 6 at discharge. Only five (15%) patients
  in this group went home. OPS was comparable with urinary incontinence for
  sensitivity (96% vs. 90%), specificity (36% vs. 39%) and accuracy (75% vs. 66%) in
  identifying stroke patients achieving independent living. OPS had a greater
  predictive value than urinary incontinence in identifying patients requiring
  institutional care (82% vs. 57%). OPS is a simple objective predictor of outcome in
  elderly stroke patients, suitable for everyday clinical use. It also can facilitate stroke
  research by identifying a 'middle group' of patients who would be most sensitive to
  changes in therapy or organization of stroke services
Gladman, J.R.F. and Lincoln, N.B. (1994), Follow-Up of A Controlled Trial of
  Domiciliary Stroke Rehabilitation (Domino Study). Age and Ageing, 23 (1), 9-13.
Abstract: The DOMINO study compared domiciliary and hospital-based rehabilitation
  services for stroke discharge from hospital, stratified by the hospital ward at
  discharge. No difference between the services had been found at 6 months, but home
  therapy was better than outpatient department therapy at improving household ability
  and leisure activity in the patients discharged from the Stroke Unit (SU), and
  attendance at a day hospital may have been better than a domiciliary service at
  preventing death or institutionalization for patients discharged from Health Care of
  the Elderly (HCE) wards. We report the follow-up of the patients between 6 months
  and 1 year after discharge, during which time few patients received further treatment
  and little change in health or function occurred. Over this period the benefits of
  domiciliary rehabilitation in the SU group were lost, largely because the patients who
  had been treated in outpatient departments continued to improve. Between 6 months
  and 1 year the numbers of HCE patients in the two treatment groups who died or
  were institutionalized were similar, but the advantage of day hospital attendance was
  still evident at 1 year
Wellwood, I., Dennis, M. and Warlow, C. (1995), Patients and Carers Satisfaction with
  Acute Stroke Management. Age and Ageing, 24 (6), 519-524.
Abstract: We set out to discover how satisfied patients and carers were with existing
  stroke services. We prospectively identified 164 consecutive patients admitted to a
  department of general medicine with acute stroke and collected data using a
  satisfaction questionnaire in a semi-structured interview. Of the 110 (67%) survivors,
  65 (59%) patients and 80 (73%) carers completed an interview. We also interviewed
  34 bereaved carers. Most patients (97%), carers (92%) and bereaved carers (94%)
  were satisfied with overall care. However, 30 (46%) of our patients, 53 (66%) carers
  and 18 (53%) bereaved carers who were satisfied with care overall expressed
  dissatisfaction with at least one component. Carers of patients were significantly
  more dissatisfied than the patients themselves with the amount of information given
  and with social work intervention. Carers of patients who were unable to respond to
  the questionnaire themselves, usually because of cognitive difficulties, were the most
  dissatisfied group even when compared with bereaved carers. Measuring satisfaction
  can alert one to deficiencies within a service, aiding service development, but
  purchasers and providers of stroke services should be aware of the difficulties and
  pitfalls in measuring and interpreting patients' and carers' overall satisfaction. Efforts
  to improve communication, discharge planning and follow-up, aimed at carers as
  well as the patients themselves, are likely to be rewarded with improved satisfaction
  with stroke services
Keywords: acute/AGE/ENGLAND/stroke
Davenport, R.J., Dennis, M.S. and Warlow, C.P. (1995), Improving the Recording of
  the Clinical-Assessment of Stroke Patients Using A Clerking Pro Forma. Age and
  Ageing, 24 (1), 43-48.
Abstract: In this study we examine whether the introduction of a clerking pro forma
  improves the completeness of the recording of the management of stroke patients and
  we review methodological issues important in this type of audit. We prospectively
  identified 244 consecutive stroke patients before and after the introduction of the pro
  forma. Patient case notes were traced and audited using a specifically designed form.
  Following the introduction of the pro forma, there was a significant improvement in
  the completeness of the recording of patient management; no change was observed
  for those items not included in the pro forma, suggesting a causal effect. We
  conclude that a stroke clerking pro forma improves the completeness of the recording
  of the assessment of hospitalized stroke patients; this has implications for clinical
  practice and future audit and may be applicable to other common conditions. We
  emphasize that methodological problems associated with a case note audit must be
  addressed if it is to produce useful, comparative data
Keywords: AGE/audit/ENGLAND/management/stroke
McNamee, P., Christensen, J., Soutter, J., Rodgers, H., Craig, N., Pearson, P. and Bond,
  J. (1998), Cost analysis of early supported hospital discharge for stroke. Age and
  Ageing, 27 (3), 345-351.
Abstract: Objective: to measure the net costs to the health and personal social services
  of an early supported discharge policy for stroke. Design and setting: cost analysis,
  using data from a pragmatic randomized controlled trial conducted in three hospitals
  in Newcastle upon Tyne, UK. Subjects: 92 people admitted with acute stroke within
  72 h of onset from their own homes with no co-morbidity likely to affect
  rehabilitation. Main outcome measures: health and personal social service costs.
  Results: early supported discharge reduced median length of hospital by almost half
  (14 days vs 26 days, P = 0.02). The costs of the service were pound 7155 per patient
  compared with pound 7480 for conventional hospital care. Sensitivity analysis
  demonstrated that this result was robust to changes in values of bed days and
  exclusion of particular resource use items. Sub-group analysis suggested that costs
  were related to physical dependency. Conclusions: early supported discharge
  provided a cost-effective alternative in the management of stroke care. However, a
  larger study is required to assess the generalisability of the results and long-term cost
Keywords: acute/AGE/cost analysis/cost-effectiveness/costs/early supported hospital
[Anon]. (1998), Royal College of Physicians of Edinburgh Consensus Conference on
  Medical Management of Stroke, 26-27 May 1998. Age and Ageing, 27 (6), 665-666
Orme, S., Ralph, S.G., Birchall, A., Lawson-Matthew, P., McLean, K. and Channer,
  K.S. (1999), The normal range for inter-arm differences in blood pressure. Age and
  Ageing, 28 (6), 537-542.
Abstract: Objective: to establish the mean and normal range for the difference in
  simultaneous systolic and diastolic blood pressure measurements between the right
  and left arm. Subjects: 462 subjects, age range 20-89 years, in sinus rhythm and with
  no history of stroke, 98 of whom had a history of cardiovascular disease or were
  taking vasoactive medication. Methods: four simultaneous recordings of blood
  pressure in both arms were made using two automated sphygmomanometers with the
  subject supine after resting for 10 min. Results: inter-arm systolic and diastolic blood
  pressure differences show a near normal distribution of values. Some individuals had
  clinically important differences in systolic and diastolic blood pressure between their
  arms. The magnitude of these differences was not related to the mean baseline blood
  pressure. Linear regression analysis did not demonstrate any significant relationship
  between inter-arm systolic or diastolic blood pressure difference and age in patients
  of either sex. For systolic blood pressure the mean difference between the right and
  left arm was 1.1 mmHg and the normal range was -9 mmHg to 11 mmHg. For
  diastolic blood pressure the mean difference was 0 mmHg and the normal range -10
  mmHg to 10 mmHg. Conclusion: the frequency of significant inter-arm systolic and
  diastolic blood pressure differences suggests that the blood pressure should be taken
  in both arms at the initial consultation. At subsequent visits, the arm in which
  measurements are taken should be recorded in the case notes. The higher of the two
  readings should be used to guide further management decisions
Keywords: ACCURACY/AGE/aortic dissection/blood pressure/blood pressure
Mead, G.E., Wardlaw, J.M., Lewis, S.C., McDowall, M. and Dennis, M.S. (1999), The
  influence of randomized trials on the use of anticoagulants for atrial fibrillation. Age
  and Ageing, 28 (5), 441-446.
Abstract: Introduction: anticoagulants and anti-platelet drugs have been shown in
  randomized trials to reduce the risk of stroke in patients with atrial fibrillation (AF).
  We therefore investigated their use in patients known to be in AF before a stroke,
  transient ischaemic attack (either cerebral or ocular) or retinal artery occlusion to
  assess the influence of trials on clinical practice. Methods: inpatients and outpatients
  with acute stroke, transient ischaemic attack or retinal artery occlusion were
  prospectively identified by a stroke physician from 1990 to 1997. The presence or
  absence of AF before the vascular event, and prior use of anticoagulant and anti-
  platelet drugs were recorded at the time of the assessment and verified using
  information from general practitioner and hospital case notes. Results: of 1934
  patients with stroke or retinal artery occlusion, 191 (10%) were in AF before their
  ischaemic event. Anticoagulants had been used in 40 (21%) of these, but only in 32
  (2%) of the 1743 patients in sinus rhythm [odds ratio (OR) 14.2, 95% confidence
  interval (CI) 8.6-23.2]. Anti-platelet drugs had been used in 62 (32%) of those with
  AF compared with 500 (30%) of those in sinus rhythm (OR 1.2, 95% CI 0.9-1.64).
  Of the 161 patients in AF without contraindications to anticoagulants, only 36 (22%)
  were taking them. Although there was a statistically significant increase in
  anticoagulant use from 8% in 1990 to 23% in 1996, this could be explained solely by
  a fall in the age of the patients referred to our hospital. Conclusion: anticoagulation is
  probably under-used in AE We found no conclusive evidence that anticoagulation
  trials have influenced clinical practice. This raises issues about the dissemination and
  implementation of trial results
Keywords:                                                                        acute/acute
  ospital/inpatients/MANAGEMENT/PREVENTION/randomized                      trials/risk    of
  stroke/sinus             rhythm/STROKE/stroke/transient/transient                ischaemic
Duggan, S., Eccles, M.P., Steen, N., Jones, S. and Ford, G.A. (2001), Management of
  older patients with hypertension in primary care: improvement on the rule of halves.
  Age and Ageing, 30 (1), 73-76.
Abstract: Objectives: the benefits of treatment of hypertension in older people are
  well-established but implementation of this knowledge may be sub-optimal. We have
  determined recent primary care management of older people with hypertension.
  Methods: we examined health records (n = 6986) of a 1 in 7 sample of patients aged
  65-80 years from a random sample of practices (n = 51) in the former Northern
  Region of the UK, stratified by health authority, for the previous 6 years. We
  recorded documented risk factors, diagnosis of hypertension, three most recent blood
  pressure readings, current drug therapy and previous blood pressure lowering therapy
  and presence of coexistent pathology. Results: blood pressure was defined as
  hypertensive (greater than or equal to 160/greater than or equal to 90 mmHg; one or
  both values above these limits), normotensive or undetermined using a validated
  algorithm. In 30% of patients, blood pressure status was undetermined. Thirty-five
  percent of subjects were found to be hypertensive. Of these, 70% were receiving
  anti-hypertensive treatment but only 30% of treated patients had controlled (< 150
  and 90 mmHg) and 13% well controlled (< 140 and 85 mmHg) blood pressure. In all,
  14% of older hypertensive patients were detected, treated and had their hypertension
  controlled. There were significant differences between practices in the proportion of
  hypertensive patients treated (P < 0.001) and in the proportion of hypertensive
  patients whose blood pressure was controlled (P < 0.01). Conclusions: treatment of
  hypertension in older people in primary care has improved in terms of detection and
  treatment but in only one-third of patients is high blood pressure controlled. There
  remain important opportunities for prevention of stroke and myocardial infarction in
  this age group through achieving improved blood pressure control
Keywords:              AGE/aged/anti-hypertensive             treatment/antihypertensive
  treatment/audit/blood        pressure/blood     pressure    control/blood      pressure
  dial                infarction/PEOPLE/prevention/primary                  care/risk/risk
Bhalla, A., Dundas, R., Rudd, A.G. and Wolfe, C.D.A. (2001), Does admission to
  hospital improve the outcome for stroke patients? Age and Ageing, 30 (3), 197-203.
Abstract: Objectives: to identify the factors associated with hospital admission and the
  differences in management and outcome of stroke patients between hospital and
  home. Design: a prospective community stroke register (1995-8) with multiple
  notification sources. Setting: an inner city multi-ethnic population of 234 533 in
  South London, UK. Participants: 975 subjects with first in a lifetime strokes, whether
  or not they were admitted to hospital. Patients dying suddenly and those already
  hospitalized at the time of stroke were excluded. Main outcome Measures: factors
  associated with hospital admission; differences in management in the acute phase of
  stroke; mortality and dependency assessed by the Barthel index 3 months post-stroke.
  Results: 812 patients were admitted to hospital for stroke; 163 were managed in the
  community. Factors independently associated with hospital admission included
  stroke severity, pre-stroke independence, atrial fibrillation, having an intracranial
  haemorrhage and having a non-lacunar infarction. Computed tomography scan rates
  were higher in admitted (78%) than non-admitted patients (63%; P=0.001). By 3
  months, 285 (35%) of the admitted patients had died compared with 13 (8%) of
  non-admitted patients (P<0.001). Of the admitted patients, 241 (47%) had a Barthel
  index >18 compared with 106 (72%) of those who were not admitted (P<0.001).
  After adjusting for case-mix variables, the odds ratios for death and dependency
  (Barthel index<18) in admitted and non-admitted patients were 2.21 (0.96-5.12) and
  2.39 (1.35-4.22) respectively. Conclusion: patients with clinical indicators for a more
  severe stroke were more likely to be admitted to hospital. Hospitalized stroke
  patients may have poorer survival and disability rates than those who remain at home,
  even after adjustment for case mix. There may be some aspects of acute hospital care
  that may be detrimental to outcome in certain groups of stroke patients. This requires
  further investigation
Keywords:                                                               acute/AGE/atrial
Sulch, D., Evans, A., Melbourn, A. and Kalra, L. (2002), Does an integrated care
  pathway improve processes of care in stroke rehabilitation? A randomized controlled
  trial. Age and Ageing, 31 (3), 175-179.
Abstract: Objective: to evaluate whether integrated care pathways improve the
  processes of care in stroke rehabilitation. Design: comparison of processes of care
  data collected in a randomized controlled trial. Participants: acute stroke patients
  undergoing rehabilitation randomized to receive integrated care pathways
  management (n=76) or conventional multidisciplinary care (n=76). Measurements:
  proportion of patients meeting recommended standards for processes of care using a
  validated stroke audit tool. Results: integrated care pathways methodology was
  associated with higher frequency of stroke specific assessments, notably testing for
  inattention (84% versus 60%; P=0.015) and nutritional assessment (74% versus 22%,
  P<0.001). Documentation of provision of certain information to patients/carers (89%
  versus 70%; P=0.024) and early discharge notification to general practitioners (80%
  versus 45%; P<0.001) were also more common in this group. There were no
  significant differences in the processes of interdisciplinary co-ordination and patient
  management between the integrated care pathways group and the control group.
  Conclusion: integrated care pathways may improve assessment and communication,
  even in specialist stroke settings
Keywords:                  acute/acute                 stroke/AGE/assessment/AUDIT/care
  practitioners/INFORMATION/integrated/integrated                                    care
  andomized          controlled         trial/rehabilitation/SATISFACTION/stroke/stroke
Lowery, K., Ballard, C., Rodgers, H., McLaren, A., O'Brien, J., Rowan, E. and Stephens,
  S. (2002), Cognitive decline in a prospectively studied group of stroke survivors,
  with a particular emphasis on the > 75's. Age and Ageing, 31 24-27.
Abstract: Background: although cognitive decline is frequent after stroke, there has been
  very little work focussing upon older age groups, in whom the majority of strokes
  occur. Objective: to determine whether cognitive decline is more common in older
  (>75) compared to younger (<75) stroke survivors. Method: a cohort of 360 stroke
  survivors of all ages from a stroke register in Newcastle, UK, were assessed
  prospectively at 3 time points over 1 year with a standardized battery. Dementia was
  diagnosed according to Diagnostic and Statistical Manual of Mental Disorders,
  fourth edition criteria. Results: the overall one year prevalence of dementia was 23%,
  but rose from 7% in the under 65's to 53% in over 85's. People over 75 were
  significantly more likely to have dementia (Odds Ratio 8.9, 95% Confidence
  Intervals 4.1-19.1). Conclusion: the striking age related increase in the prevalence of
  dementia has important implications for service planning and clinical management
Keywords:                AGE/BASE-LINE                       FREQUENCY/cerebrovascular
  allocation/RISK-FACTORS/stroke/thrombolytic therapy/UK
Langhorne, P. and Pollock, A. (2002), What are the components of effective stroke unit
  care? Age and Ageing, 31 (5), 365-371.
Abstract: Background: the effectiveness of organized inpatient (stroke unit) care has
  been demonstrated in systematic reviews of clinical trials. However, the key
  components of stroke unit care are poorly understood. Methods: we conducted a
  survey of recent trials (published 1985-2000) of a stroke unit/ward which had
   demonstrated a beneficial effect consistent with the stroke unit systematic review.
   Results: we identified 11 eligible stroke unit trials of which the majority described
   similar approaches to i) assessment procedures (medical, nursing and therapy
   assessments), ii) early management policies (e.g. early mobilization; avoidance of
   urinary catheterization; treatment of hypoxia, hyperglycaemia and suspected
   infection), iii) ongoing rehabilitation policies (e.g. co-ordinated multidisciplinary
   team care, early assessment for discharge). Conclusions: this survey provides a
   description of stroke unit care which can serve as a benchmark for general stroke
   patient care and future clinical research
Keywords:               AGE/assessment/care               pathway/catheterization/clinical
   DOMIZED                         CONTROLLED                          TRIAL/randomized
   unit/systematic review/therapy/treatment/trials/WARDS
Price, C.I.M. (2002), Shoulder pain after stroke: a research challenge. Age and Ageing,
   31 36-38.
Abstract: Background: an evidence-based approach to the management of shoulder pain
   after stroke is required, but systematic reviews have highlighted the small number of
   studies suitable for use in developing clinical guidelines. Design: this brief overview
   summarises obstacles to shoulder pain research that systematic reviews have
   identified, and compares their therapeutic recommendations to the Royal College of
   Physicians National Clinical Guidelines for Stroke. Conclusion: clinicians treating
   shoulder pain after stroke can refer to guidelines and systematic reviews, but there
   are differences in their conclusions regarding the use of steroid injections and
   electrical stimulation. There is unanimous agreement that further efforts are required
   to examine interventions singly and in combination
Keywords:                            AGE/combination/England/guidelines/HEMIPLEGIC
Harwood, R.H., Kempson, R., Burke, N.J. and Morrant, J.D. (2002), Specialist nurses to
   evaluate elderly in-patients referred to a department of geriatric medicine. Age and
   Ageing, 31 (5), 401-404.
Abstract: Background: increasing numbers of elderly patients are admitted to hospital.
   Ensuring that they are given appropriate and timely access to the range of hospital
   and community medical, rehabilitation and social care facilities has become more
   difficult due to the complexity of management options now available, and limited
   senior medical staff time. Methods: we established a scheme in which specialist
   nurses made first assessments of all inter-departmental referrals to a hospital
   department of geriatric medicine. We evaluated the scheme prospectively using
   process and outcome data. Results: 2825 new patients were seen by two nurses in the
   first two years, an average of 5.4 per weekday (range 0-17). Mean time from
   admission to referral was 9 days. Most referrals were seen within 1 day. Mean total
   length of hospital stay was 43 days (range 1-351). Seven percent died on the
   referring ward, and 31% were discharged directly from the referring ward. Almost
   half were accepted for in-patient rehabilitation. Sixty percent of these were
   discharged home. Thirteen percent were transferred to an acute geriatric medical or
   stroke ward. One- quarter of these died. Senior medical review was requested in 8%
   of cases. Conclusions: nurses could select patients suitable for rehabilitation, identify
   those requiring on-going acute in- patient care, and make arrangements for supported
   direct discharges where appropriate. This model facilitated access to a wide array of
   discharge and community support schemes, and supported the efficient use of
   consultant time
Keywords:                                      acute/AGE/aged/community/elderly/elderly
   patients/England/home/hospital/inpatient rehabilitation/inpatients/management/nurse
Malone, M., Hill, A. and Smith, G. (2002), Three-month follow up of patients
   discharged from a geriatric day hospital. Age and Ageing, 31 (6), 471-475.
Abstract: Objective: to determine if mobility and functional status of patients attending
   a geriatric day hospital are maintained three months after discharge. Design:
   prospective, before- after, quasi-experimental design. Participants: community-
   dwelling elderly referred for comprehensive geriatric assessment and
   multidisciplinary management. Methods: all patients who attended a geriatric day
   hospital for at least 5 visits and discharged between 1 August, 1999 and 1 March,
   2000 were eligible (n = 41). Measurements were performed at admission, discharge
   and three months post-discharge. Data were analyzed using one way repeated
   measures ANOVA for parametric data and the Friedman-Chi square test for
   non-parametric data. Outcome measures: Barthel Index, Timed Up and Go Test,
   Berg Balance Scale, Mini-Mental Status Examination, Geriatric Depression Scale.
   Results: from admission to discharge, significant improvements were seen in Timed
   Up and Go Test, Berg Balance Scale, and Geriatric Depression Scale (all Pless than
   or equal to0.002). From discharge to 3 months post- discharge, the Timed Up and Go
   Test, Berg Balance Scale and Mini-Mental Status Examination declined (all P<0.001)
   with no significant change in Barthel Index or Geriatric Depression Scale. From
   admission to 3 months post-discharge, Mini-Mental Status Examination scores
   declined (p=0.002) and Geriatric Depression Scale scores improved (p=0.007), with
   all other outcomes unchanged. Conclusion: no sustained improvements in mobility or
   functional status were seen at 3 months following discharge from a geriatric day
   hospital. Further studies exploring methods to delay progressive deterioration in
   multiple domains are necessary
Keywords: AGE/assessment/Barthel Index/Canada/community/comprehensive geriatric
   assessment/day hospital/delay/design/elderly/ENGLAND/functional status/geriatric
   management/outcomes/progressive/RANDOMIZED                             CONTROLLED
Elliott, R.A., Woodward, M.C. and Oborne, C.A. (2002), Antithrombotic prescribing in
   atrial fibrillation: application of a prescribing indicator and multidisciplinary
   feedback to improve prescribing. Age and Ageing, 31 (5), 391-396.
Abstract: Background: atrial fibrillation is common in older people, and is associated
   with an increased risk of ischaemic stroke. Antithrombotic therapy reduces
   stroke-risk, but is known to be under-prescribed. Objectives: to use an
   evidence-based indicator to audit antithrombotic prescribing for older hospital
   inpatients with atrial fibrillation, and to assess whether feedback of audit results to
   hospital staff increases antithrombotic use. Design: cross-sectional notes-based audits,
   before and after feedback. Setting: six Aged Care and three General Medicine units
   at nine Australian public teaching hospitals between September 1998 and May 1999.
   Subjects: 1416 hospital inpatients aged 65 years and over (median age 81). Methods:
   medication charts were reviewed to identify patients prescribed digoxin or
   amiodarone. Presence of atrial fibrillation was confirmed by review of the patients'
   medical notes. To be considered appropriate, patients with atrial fibrillation had to be
  receiving either warfarin or aspirin (or both), or have documented contraindications
  to both agents. Feedback of audit results was provided to medical, pharmacy and
  nursing staff at multidisciplinary meetings. Changes in antithrombotic prescribing
  4-8 weeks and 6 months after feedback were assessed. Prescribing 8 weeks prior to
  feedback was assessed retrospectively. Results: appropriateness of the decision to
  prescribe (or not prescribe) antithrombotic therapy increased from 81/112 (72%)
  immediately prior to feedback to 97/105 (92%) 4-8 weeks later (P<0.0001). Six
  months after feedback, appropriateness of prescribing declined slightly, to 85%
  (p=0.36). Over the 8 weeks prior to feedback, appropriateness of prescribing did not
  change (74% versus 77%, p=0.80). Increased aspirin prescribing accounted for most
  of the improvement in antithrombotic use after feedback, while warfarin continued to
  be under-used. Conclusions: antithrombotics were under-prescribed for older patients
  with atrial fibrillation. Audit and multidisciplinary feedback resulted in increased
  antithrombotic prescribing. The intervention had a greater impact on aspirin
  prescribing compared with warfarin
Keywords:                                                                ADDITIONAL
  assurance/RECEIVING                         WARFARIN/review/risk/stroke/STROKE
Adunsky, A., Levenkron, S., Fleissig, Y., Blumstein, Z. and Chetrit, A. (2001),
  In-hospital referral source and rehabilitation outcome of elderly stroke patients.
  Aging Clinical and Experimental Research, 13 (6), 430-436.
Abstract: To date,, there is no data regarding the association of patient in-hospital
  referral source and stroke rehabilitation outcomes. The objective of the present study
  was to investigate the possible relation between in-hospital referring source, whether
  directly from an emergency ward (EW) or indirectly through a general medical ward
  (GMW), and the functional outcomes achieved during rehabilitation of such stroke
  patients. This retrospective observational study included 315 consecutive patients,
  admitted for rehabilitation following the onset of acute stroke. We compared those
  referred directly to us from the EW, with others referred from GMWs. Functional
  status was assessed by Functional Independence Measure method (FIM). Functional
  outcome was determined by total FIM gain (efficacy) and daily FIM gain
  (efficiency), both absolute and relative (to potential). The two study groups were
  similar in terms of age, gender, and diagnosis. FIM admission scores were higher at
  admission in patients admitted directly from the EW, compared with those referred
  from GMWs (72.5 +/- 27.5 and 62.7 +/- 25.6, respectively) but similar at discharge
  (77.4 +/- 28.8 and 80.7 +/- 32,5, respectively). Length of stay (LOS) in the GMW
  group was longer as compared to the EW group. Efficacy was significantly
  associated with being married, younger age, hemiplegia, and admission scores
  between 40-60. Both absolute and relative efficacy and efficiency rates of
  rehabilitation were significantly lower among patients referred from the EW. We
  conclude that in-hospital referral source is associated with different rehabilitation
  outcomes in stroke patients. Direct admission of stroke patients from the EW is
  associated with lower rehabilitation efficacy and efficiency rates, compared with
  those admitted from GMWs. The findings support the implementation of different
  selection methods, underscoring the need of both clinicians and administrators to
  consider the in- hospital referral source as a potential factor associated with stroke
  rehabilitation outcome. (C) 2001, Editrice Kurtis
Keywords:                                                                       acute/acute
  ehabilitation/stroke/stroke rehabilitation/TEAM/TRIAL
Baily, G.G. and Mandal, B.K. (1995), Recurrent Transient Neurological Deficits in
  Advanced Hiv- Infection. Aids, 9 (7), 709-712.
Abstract: Objectives: To report the occurrence of a syndrome of recurrent neurological
  deficits in advanced HIV disease and to discuss its management and prognosis.
  Design: Retrospective case study. Setting: A regional treatment centre for
  HIV-infected individuals in northwest England. Main outcome measures: Transient
  neurological deficit was defined as a focal neurological deficit of rapid onset which
  resolved completely within 24 h. Frequency, character and duration of episodes were
  recorded. Prior illnesses, CD4 count, changes in drug therapy and brain imaging
  investigations were also documented. Results: Seven cases with recurrent transient
  neurological deficits were identified among 748 patients over a 10-year period. Six
  had a CD4 cell count < 50 x 10(6)/l. The episodes lasted between 1 and 12 h and
  resolved completely without lasting sequelae. Dysphasia and hermiparesis were the
  most common presentations. Recurrent episodes for each patient tended to follow a
  similar pattern. None had computed tomographic evidence of cerebral infarction or
  clinical evidence of completed stroke. Prognosis was varied and not evidently altered
  by the episodes of neurological deficit. Three patients may have benefited from
  treatment with migraine prophylactics. Conclusion: A syndrome of recurrent
  transient neurological deficits may occur tn advanced HIV disease. We believe that
  in some cases this may be due to local cerebral vasospasm, comparable to a classic
  migraine aura
Keywords: AIDS/brain/cerebral infarction/CEREBROVASCULAR DISORDERS/drug
  deficit/outcome/prognosis/stroke/therapy/transient/TRANSIENT               CEREBRAL
Spranger, M., Hund, E. and Hacke, W. (1994), Disturbances in Cerebral Blood-Flow.
  Aktuelle Neurologie, 21 (1), 32-37.
Abstract: New therapeutic approaches have become possible thanks to progress in
  understanding pathophysiological processes. New therapies - which are at present
  still in the experimental stage - are due to the discovery of the neurotoxicity mediated
  by glutamat and the role of the leucocytes as generators of free oxygen radicals.
  Improved diagnostic possibilities allow ever more often than before the aetiological
  identification of a cerebral blood flow disturbance. Topical studies basing on this -
  taking into consideration the short therapeutic time window - are promising pointers
  to the efficacy of old and new therapeutic methods. Thrombolysis achieved by drugs
  to enable early recanalisation of intracranial vascular occlusions and surgical brain
  pressure therapy in case of space-occupying infarcts of the mesencephalon and
  cerebellum are examples of a highly promising and more aggressive approach in
  patients suffering from ischaemic stroke
Keywords:           ACUTE             ISCHEMIC            STROKE/ASPIRIN/EMBOLIC
Reul, J. and Thron, A. (1996), New developments in neuroradiology. Aktuelle
  Neurologie, 23 (5), 181-188.
Abstract: New developments can be observed in CT and MRI as well as in the
  interventional therapy of cerebral and spinal diseases. The spiral-CT technique offers
  wide opportunities for the non- invasive diagnostic management of cerebral
  aneurysms and extracranial brain-supplying arteries. Magnetic Resonance
  Angiography (MRA) can be used routinely for special indications (e.g. cerebral sinus
  thrombosis). The progress of functional MRI (fMRI) has increased the value of this
  method for several clinical and scientific questions. The actual results of perfusion
  and diffusion imaging suggest that these techniques will be important in future for
  early diagnosis and therapy of ischaemic strokes. In the interventional field,
  endovascular occlusion with detachable coils is supposed to be an alternative to
  surgical clipping; however, the long-term results have to be studied. The results of
  preliminary trials of percutaneous treatment of carotid artery stenoses with dilatation
  and stents should encourage a randomised trial comparing endovascular to surgical
Volles, E. (1997), Guidelines for the implementation of stroke units from the
  Committee on Stroke Units of the Deutsche Gesellschaft fur Neurologie. Aktuelle
  Neurologie, 24 (6), AR25-AR30.
Abstract: Stroke Units are hospital-based special wards aiming at an optimal care by a
  specialised team with an integrated concept for patients with acute strokes.
  Following the initial neurological and neuroradiological evaluation, early treatment
  will be initiated based on the assumed pathophysiology of the stroke. The acute
  management includes monitoring of physiological parameters, care by specialised
  nurses and early implementation of physiotherapists, speech therapy and
  occupational therapy, Despite the increased initial costs, the long-term burden for the
  health system is decreased by shorter hospital stay and reduced morbidity and
  ional therapy/REHABILITATION/stroke/stroke units/therapy/treatment
Weimar, C., Glahn, J., Neumaier, S., Wimmer, M., Busse, O., Haass, A., Haberl, R. and
  Diener, H.C. (1999), Pretesting the medical database: Comparison of stroke
  treatment in four neurological departments with stroke units. Aktuelle Neurologie, 26
  (8), 366-374.
Abstract: We present data of 708 patients with stroke or transient ischemia within one
  week prior to admission to compare the management of stroke in four Neurology
  Departments with an acute stroke unit. Four months' data on risk factors, concurrent
  vascular illnesses, neurological deficits, radiological findings, acute therapy, course
  of recovery, complications, secondary prevention, length of stay, discharge and
  outcome at 3 and 12 months were prospectively collected in a joint data base. 70% of
  all patients were admitted within 24 h, 47% within 6 h. 38% of all patients were
  referred by ambulance, 31% by a general practitioner and 23% by other hospitals or
  departments within the same hospital. There was a good correlation between the
  severity of stroke and the kind of referral. The mean length of stay of all stroke
  patients on the acute stroke unit varied between 3.4 and 6.3 days and between 10.4
  and 72.7 days in the Neurology department, depending on the type of care after
  discharge. 5.4% of all patients with ischemic stroke and 16.1% of all patients with
  intracerebral hemorrhage died during the acute hospital stay. The cumulated lethality
  of all patients with ischemic stroke not lost to follow-up at one year was 18.8%. 79%
  of all surviving patients with ischemic stroke had a Barthel index of >70. The
  method of data collection in this pretest proved to be apt for a multicenter study
  presently being conducted in 23 Neurology departments with an acute stroke unit
Keywords:                   acute/acute                 stroke/acute                stroke
  hemorrhage/ischemia/ischemic/ISCHEMIC                     STROKE/length               of
  stay/management/management                                                            of
  OGRAMS/recovery/REGISTRY/risk/risk                                    factors/secondary
  prevention/severity/stroke/stroke               treatment/stroke             unit/stroke
Ringelstein, E.B., Berlit, P., Busse, O., Diener, H.C., Grotemeyer, K.H., Haberl, R.,
  Hacke, W., Harms, L., Kaps, M. and Kessler, C. (2000), Concepts of supraregional
  and regional care for stroke patients in Germany. Aktuelle Neurologie, 27 (3),
Abstract: In the mid nineties, a national concept of stroke-specialised wards (,,stroke
  units") had been developed by an expert committee of the German Neurological
  Society. based on elements of the anglosaxon stroke units. The German stroke
  unit-concept, however, goes beyond the angosaxon one in that it aims at a
  pathogenetically oriented hyperacute diagnostic wark-up and treatment. This paper
  describes the further development of the present stroke concept towards an
  exhaustive management of acute stroke patients in Germany. This is why two
  different levels of supply are suggested, the Supraregional stroke unit and the
  Regional stroke unit. The Supraregional stroke unit constitutes a competence center
  and is the core of a stroke care network located at the top hospitals
  (,,Maximalversorgung"), and, as a rule, at the neurological department. It requires
  several structural, technical and staff resources. By contrast, the Regional stroke unit
  has less technical and staff requirements and is located at middle-level hospitals
  either in the neurological or internal departments. Good procedural quality in these
  Regional stroke units will be guaranteed by a stroke-specific high qualification of
  physicians and other medical staff. By means of this concept, high-level management
  of acute stroke patients, nation-wide within a stroke unit network will become reality.
  Regional Stroke Associations are encouraged to further refine stroke management
Keywords:      acute/acute     stroke/internal/management/quality/regional/stroke/stroke
  management/stroke unit/stroke units/treatment
Misselwitz, B. (2001), Inpatient rehabilitation after stroke: Results of the stroke
  database of Hesse. Aktuelle Neurologie, 28 (9), 413-420.
Abstract: Background: The stroke database of Hesse is designed as an external quality
  management tool. The database contains two sets of data: acute care and
  rehabilitation. This is the first paper dealing with the rehabilitation part. Methods:
  Admission severity of disability, type and intensity of therapy, complications and
  discharge location was collected using a standardised form. Results: Data from 5644
  patients for the period 1.1.1998-31.12.2000 were collected from 20 rehabilitation
  institutions (neurology or geriatric). 26.8% of patients had severe disability (Barthel
  Index [BI] < 30), 29.3% showed moderate (BI 30-70) and 43.9% had minor
  disability. Median age in the group of minor disability was 67 years (moderate 72,
  severe 71). The prevalence of the functional relevant disorders neglect, volition,
  memory and depression were high in the severe (BI < 30) group at 65.3%, 81.3%,
  81.1%, 62.3% respectively. The frequency of physiotherapy varied with the severity
  of disability (BI < 30: 8.2 u/week, BI > 70 6.7 u/week), mean length of stay was 42.8
  d (median 35.0 d). Changes of BI per month are described. Most frequent
  complication was urinary infection (19.4%), followed by painful shoulder (8.0%) and
  severe pneumonia (6.1%). A total of 17% of patients were transferred to an acute
  care hospital, 9.6% to a nursing home. 70.8% of patients went home, of whom 33.9%
  no longer had a need for professional or family help. 2.0% died during rehabilitation.
  Conclusions: This comprehensive study yields data about present structures and
  process quality of specialised units including those for the most disabled patients.
  Differentiation of results in relation to the initial degree of disability is possible
Keywords:                                                                   acute/age/Barthel
  ome/hospital/infection/length         of       stay/management/memory/neglect/nursing
Hamann, G.F. and Diener, H.C. (2001), Intravenous heparin therapy in acute ischaemic
  cerebral infarct: Contra. Aktuelle Neurologie, 28 (3), 122-127
Keywords:                              acute/ACUTE                                 ISCHEMIC
  STROKE/ATRIAL-FIBRILLATION/cerebral/cerebral                                 infarct/EARLY
Barth, H., Buhl, R., Schrader, B. and Mehdorn, H.M. (2002), Treatment of spontaneous
  intracerebral hematomas - Results in 661 patients. Aktuelle Neurologie, 29 (7),
Abstract: During a time period of 84 months 661 patients (380 male and 281 female
  patients between 4 months and 94 years of age) with a spontaneous intracerebral
  hematoma were treated in our department. Hypertension was found in 499 patients,
  ischemic heart disease in 287 patients and diabetes mellitus in 117 patients. 243
  patients were 70 years or older. In 47 patients an intratumoral hemorrhage was found;
  99 patients developed a hematoma on anticoagulating therapy. A cerebral amyloid
  angiopathy was proven histologically in 44 patients. A vascular malformation was
  found in 50 patients (arteriovenous malformation: 27, cavernoma: 20, microangioma:
  3). Operative treatment was performed in 424 patients, conservative management in
  237 patients. The 30-day mortality rate in all patients was 23.7%. The mortality rate
  for the patients, who were initially in a GCS between 3 and 8 was 46%, for the
  patients with a GCS of 9 to 15 was 5.1%. Patients with anticoagulating therapy had
  the highest mortality rate with 33.3%. The mortality rate in patients over 69 years
  (31.3%) compared to the younger patients below 69 years (19.4%) is related to the
  concomitant diseases in the elderly patients. The time spent in the hospital was 11.5
  days on average. The group of patients, who were treated operatively stayed on
  average 15.7 days with a mortality rate of 22.2%. The conservatively treated patients
  stayed 3.8 days on average with a mortality rate of 26.6%
Keywords:                                               age/ANGIOGRAPHY/arteriovenous
  malformation/BRAIN/cerebral/CEREBRAL                                             AMYLOID
Weimar, C., Lungen, M., Wagner, M., Kraywinkel, K., Evers, T., Busse, O., Haberl,
   R.L., Laaser, U., Lauterbach, K.W. and Diener, H.C. (2002), Cost of stroke care in
   Germany - An analysis of the stroke data bank of the German foundation stroke-aid.
   Aktuelle Neurologie, 29 (4), 181-190.
Abstract: The cost of stroke in Germany have so far not been investigated in terms of
   unselected and prospectively collected data. It is furthermore unknown how direct
   and indirect cost of stroke are affected by different types of stroke care. This study
   therefore compares the cost of stroke up to the first year in 15 departments of
   Neurology with an Acute Stroke Unit (ASU), 9 departments of General Neurology
   (GN) and 6 departments of internal Medicine (IM). 5192 patients were prospectively
   documented according to an extensive manual during a one year period between
   1998 and 1999 and collected in a common data bank. The patients were centrally
   followed-up via telephone interview after 3 and 12 months to assess further acute
   hospital and rehabilitation stays, out-patient resource utilization and indirect cost
   through loss of work force. The hospital cost were calculated via per-day and ward
   charges (proceeds) provided by each hospital. Mean overall cost for hospital
   treatment (including rehabilitation) amounted to 16320 DEM for ASU, 14069 DEM
   for GN and 14023 DEM for IM. After discharge, especially nursing care and
   out-patient therapies were cost-relevant, while secondary preventive medication, out-
   patient physician care and out-patient diagnostic work-ups were less important. Mean
   cost for loss of work force in patients with paid work prior to stroke amounted to
   34583 DEM. Without accounting for case-mix variations, the overall cost for in-
   patient treatment in ASU - based on higher per day charges with shorter length of
   stay - were in the range of 9-16% above GN or IM. However, the comorbidity as
   well as the higher diagnostic and therapeutic effort in younger patients also need to
   be considered for future resource allocation in Germany
   nal/ISCHEMIC        STROKE/length        of    stay/NETHERLANDS/nursing/nursing
Liepert, J. (2003), New therapies in neurorehabilitation. Aktuelle Neurologie, 30 (5),
Abstract: Even years after a stroke a large number of patients still suffer from motor
   impairment. In recent years some new motor rehabilitation techniques have emerged.
   This review focusses on forced use treatments, bilateral arm training, robot-assisted
   sensorimotor therapies, modulations of afferent input and drugs that might promote
   motor rehabilitation
Bazner, H. and Hennerici, M. (2003), Should asymptomatic carotid stenosis be operated
   on? Aktuelle Neurologie, 30 (2), 76-86.
Abstract: In contrast to the proven benefit of carotid endarterectomy (CEA) in patients
  with middle- and high-grade symptomatic stenoses of the internal carotid artery,
  there exist controversies about the use of this procedure in asymptomatic patients
  which is not supported by study data. Recent metaanalyses compared all completed
  randomized studies which analysed the effect of CEA in comparison to conservative
  management, and concluded that there is a certain evidence in favour of the surgical
  procedure in the treatment of asymptomatic internal carotid stenosis, which, however,
  is not significant with regard to absolute risk reduction. In this review, we report on
  the original data and the results of metaanalyses and discuss the controversial
  recommendations. Accordingly, an individual decision for an experimental surgical
  therapy after a thorough risk-modelling analysis may be justified, which, apart from
  measurable parameters (e.g. in an algorithm as it is used in symptomatic carotid
  stenosis patients), has to consider individual patient's attitudes towards medical vs.
  surgical management. In conclusion, on the basis of outdated original data a
  reasonable argument in favour or against the procedure is no longer possible. This
  points to a need of new large studies with intelligent designs and low individual risks
Keywords:                             absolute                        risk/artery/ARTERY
  STENOSIS/asymptomatic/attitudes/carotid/carotid                             artery/carotid
  endarterectomy/carotid                 stenosis/CEREBRAL                  VASOMOTOR
  mental/GERMANY/internal/internal carotid/internal carotid artery/ISCHEMIC
  ON/review/risk/stenosis/studies/therapy/treatment/VASCULAR EVENTS
Schmidt, W.A. (2001), Emergencies in vasculitides. Aktuelle Rheumatologie, 26 (2),
Abstract: Most complications in vasculitides are caused by ischemia. The clinical image
  depends on the size of the vessels involved. In Takayasu's arteritis the aorta and its
  branches are inflamed. Thus strokes, limb ischemia, renovascular arterial
  hypertension and mesenteric ischemia occur as well as pulmonary hypertension due
  to vasculitis of the pulmonary arteries and myocardial infarction due to involvement
  of the ascending aorta. Established therapies in acute complications of Takayasu's
  arteriitis are 50 mg/d prednisolone, angioplasty, and bypass- surgery. In 71
  consecutive patients with acute temporal arteritis we found 39% with
  ophthalmological complications such as anterior ischemic optic neuropathy (14
  patients), amaurosis fugax (8 patients), paralysis of ocular muscles (2 patients), and
  cotton-wool exudates (2 patients). One patient had an occlusion of the central retinal
  artery, another one an occlusion of a ramus. Two of 71 patients with acute temporal
  arteritis had myocardial infarction, stroke, thoracal aortic aneurysm, and occlusion of
  the brachial/axillary artery, respectively. If temporal arteritis is suspected,
  corticosteroid therapy should be started immediately. A daily dose of 70 mg for
  patients without complications and 200 to 1000 mg for patients with complications is
  recommended. Kawasaki's syndrome is an acute vasculitis occurring predominantly
  in children. It is treated with high doses of acetylsalicylic acid and a single high dose
  of immunoglobulins. Small-vessel vasculitides (Wegener's granulomatosis, mPAN,
  Churg-Strauss syndrome, Henoch-Schonlein purpura, and mixed cryoglobulinemia)
  are complicated by alveolitis, glomerulonephritis, intestinal ischemia, and
  neuropathy. Early treatment with 2 to 15 mg/kg/d prednisolone combined with 2
  mg/kg/d cyclosporine is essentially required
Keywords:             acetylsalicylic          acid/acute/aneurysm/angioplasty/aorta/aortic
  aneurysm/arterial          hypertension/arteries/artery/ascending         aorta/B-MODE
  ULTRASONOGRAPHY/bypass/children/CLASSIFICATION/COLOR                          DUPLEX
  porine/GERMANY/GIANT-                                                             CELL
  ocardial infarction/optic neuropathy/POLYARTERITIS-NODOSA/PROGNOSTIC
  FACTORS/size/stroke/surgery/TAKAYASU ARTERITIS/temporal arteritis/TERM
Fujishima, M. and Kiyohara, Y. (2002), Incidence and risk factors of dementia in a
  defined elderly Japanese population - The Hisayama Study. Alzheimer'S Disease:
  Vascular Etiology and Pathology, 977 1-8.
Abstract: Vascular dementia (VaD) is more common than Alzheimer's disease (AD) in
  Japan, while AD is much more frequent in Western countries. The Hisayama study,
  an epidemiological study on dementia in a Japanese elderly population aged 65 years
  or older, has shown that the prevalence of VaD decreased for men, while AD
  remained unchanged in both sexes during a 7-year follow-up period (1985-1992).
  Decreased prevalence of VaD seems to be due to decreased incidence of stroke in
  recent years, resulting from the management of hypertension. The age-adjusted
  incidence of total dementia was approximately 20 per 1000 person-years in either sex;
  VaD was more frequent for men and AD for women. Risk factors for VaD were age,
  hypertension, previous stroke, and alcohol consumption, while age was only a
  significant risk factor for AD. Although the Hisayama study failed to demonstrate the
  relationship of vascular factors to AD, the previously reported studies suggest that
  either hypertension per se or blood pressure changes appear to partially participate in
  the pathogenesis of AD
Keywords:          age/aged/Alzheimer's         disease/ALZHEIMERS-DISEASE/blood
  y/epidemiological                                                      study/Hisayama
  athogenesis/population/prevalence/PREVALENCE/risk/risk                        factor/risk
  factors/ROTTERDAM/sex/stroke/studies/USA/VASCULAR DEMENTIA/women
Kuller, L.H. (1996), Potential prevention of Alzheimer disease and dementia. Alzheimer
  Disease & Associated Disorders, 10 13-16.
Abstract: The prevention of dementia is of critical importance. The increasing
  population of high-risk older individuals will result in an increasing prevalence of
  dementia. Primary prevention of dementia and Alzheimer disease can take either a
  public health or high-risk preventive medicine approach. At the present time, there is
  little evidence to support a specific primary public health approach such as a specific
  nutrient. The possible association of vascular disease with dementia may offer the
  best preventive high-risk approach. The identification of individuals with clinical and
  subclinical vascular disease is possible. There is a very high prevalence of subclinical
  cerebral infarction in older individuals. Specific treatments can prevent clinical
  disease such as stroke and coronary heart disease. Whether therapies will prevent
  some dementia can be determined
Keywords: ALLELE/ASSOCIATION/cerebral infarction/clinical trials/COGNITIVE
  FUNCTION/coronary              heart       disease/dementia/EDUCATION/ELDERLY
Scherokman, B.J. and Hallenbeck, J.M. (1985), Management of Acute Stroke.
  American Family Physician, 31 (3), 190-199
Rothrock, J., Taft, B.J. and Lyden, P.D. (1987), A New Approach to Stroke
  Management. American Family Physician, 36 (4), 189-197
Paspa, P.A. and Movahed, A. (1992), Thrombolytic Therapy in Acute
  Myocardial-Infarction. American Family Physician, 45 (2), 640-648.
Abstract: Multiple clinical trials have demonstrated that thrombolytic treatment early in
  the course of acute myocardial infarction significantly reduces mortality. Patients
  under 75 years of age who have had chest pain for no longer than six hours and who
  demonstrate ST-segment elevation on electrocardiogram are the best candidates for
  this therapy. Recent studies suggest that there is little difference in effectiveness
  among streptokinase, alteplase and anistreplase. However, streptokinase is 10 times
  less expensive than the other agents and causes fewer intracranial bleeds, the major
  serious adverse effect of thrombolytic therapy. An advantage of anistreplase is that it
  can be given in a five-minute bolus injection, compared with a one-hour infusion for
  streptokinase and a three-hour infusion for alteplase. Thrombolytic therapy is
  contraindicated in patients with known pregnancy, active internal bleeding,
  uncontrolled hypertension, aortic dissection, intracranial neoplasm or a history of
  hemorrhagic stroke. Heparin should be administered with both alteplase and
  streptokinase. Aspirin, beta blockers, nitrates and lidocaine are useful adjunctive
  therapies in the setting of an acute myocardial infarction
Neville, R.F. and Calcagno, D. (1993), Symptomatic Carotid-Artery Disease - Current
  Management Recommendations. American Family Physician, 48 (6), 1059-1066.
Abstract: Proper management of symptomatic carotid artery disease requires prompt
  diagnosis and therapy based on both the patient's symptoms and the nature of the
  carotid lesion. Duplex ultrasonography is the preferred diagnostic modality for
  evaluating symptomatic patients for the presence of a hemodynamically significant
  carotid lesion. Arteriography can confirm severe carotid stenosis or delineate a
  nonstenotic, ulcerated plaque before surgery. Antiplatelet and anticoagulant agents
  administered after transient ischemic attacks or completed stroke have shown
  questionable benefit in stroke reduction as an independent variable. Results of
  randomized clinical trials support the use of carotid endarterectomy for symptomatic
  patients with ipsilateral carotid stenosis greater than 70 percent. The operation should
  be performed for appropriate indications by surgeons whose perioperative morbidity
  and mortality rates meet established guidelines
Keywords: WARD
Havranek, E.P. (1994), The Management of Atrial-Fibrillation - Current Perspectives.
  American Family Physician, 50 (5), 959-968.
Abstract: The management of atrial fibrillation is evolving in response to recently
  published data. Low-risk patients with new-onset atrial fibrillation may not need to
  be hospitalized. Beta blockers may be the most effective drugs for controlling the
  heart rate. When a patient does not respond to drug therapy, it is still appropriate to
  search for the cause of the arrhythmia and to use direct-current cardioversion. Clear
  evidence now exists that patients with chronic atrial fibrillation should be given
  anticoagulant drugs to reduce the risk of stroke. Antiarrhythmic drugs should be used
  cautiously, because they may cause life-threatening arrhythmias
Coletta, E.M. and Murphy, J.B. (1994), Physical and Functional Assessment of the
  Elderly Stroke Patient. American Family Physician, 49 (8), 1777-1785.
Abstract: A functionally oriented approach to acute stroke care should take place in
  parallel with traditional medical management, since the medical care provided during
   the first days and weeks after a stroke affects the patient's ultimate disability status.
   The components of the functionally oriented approach include a comprehensive
   history and physical examination, through which information is obtained on current
   disabilities and abilities, risk factors for common poststroke complications,
   psychologic and social resources, and environmental barriers that preclude maximal
Smucker, W.D., Disabato, J.A. and Krishen, A.E. (1995), Systematic-Approach to
   Diagnosis and Initial Management of Stroke. American Family Physician, 52 (1),
Abstract: Stroke is a medical emergency with high rates of mortality and morbidity.
   Ischemic, stroke should be distinguished from hemorrhagic stroke. Indicators of
   hemorrhagic stroke include coma, vomiting, severe headache, a systolic blood
   pressure greater than 220 mm Hg and a blood glucose level of 170 mg per dL (9.4
   mmol per L). Essential elements of the physical examination Include assessment of
   level of consciousness, speech, cognitive abilities, visual fields, extraocular muscle
   function, motor function and gait. Computed tomography or magnetic resonance
   imaging should be performed. The main goal of treatment is to maximize physical
   and cognitive function by limiting acute complications and facilitating rehabilitation.
   The role of the family physician is to stabilize the patient's condition, coordinate a
   multidisciplinary team and guide the patient, as well as the patient's family, through
   the process of recovery
Keywords:           acute/blood           pressure/complications/FAMILIES/hemorrhagic
   stroke/magnetic                                                               resonance
Kerle, K.K. and Nishimura, K.D. (1996), Exertional collapse and sudden death
   associated with sickle cell trait. American Family Physician, 54 (1), 237-240.
Abstract: Although rare, exertional collapse and sudden death are the most serious
   potential complications of sickle cell trait. Studies suggest that this condition may
   occur in susceptible persons when poor physical conditioning, dehydration, heat
   stress or hypoxic states precipitate sickling of the abnormal erythrocytes. Sickling
   leads to endothelial damage, which can cause vasoconstriction, disseminated
   intravascular coagulation and local tissue damage. Cardiac effects include acute
   ischemia and arrhythmias. Muscle damage results in acute compartment syndromes
   and release of myoglobin into the circulation. Acute renal failure is possible.
   Diagnosis is based on a high index of suspicion, and characteristic presentation and
   laboratory findings, including myoglobinuria, hyperkalemia, hypocalcemia,
   hyperphosphatemia and elevated creatine kinase levels. The differential diagnosis
   includes pulmonary embolism, acute cardiac events, anaphylaxis and heat stroke.
   Management is based on stabilization, rehydration, and the treatment and prevention
   of complications
   emia/prevention/RHABDOMYOLYSIS/RISK FACTOR/stroke/WARD
Ferrera, P.C. and Chan, L. (1997), Initial management of the patient with altered mental
   status. American Family Physician, 55 (5), 1773-1780.
Abstract: Primary care physicians may encounter patients with altered mental status or
   neurologic deficit. Because the differential diagnosis for altered mental status
   includes conditions with significant morbidity and mortality care of these patients
   must be rapid and thorough. The resources required to ensure and maintain
   cardiopulmonary stabilization and to perform the initial workup are often unavailable
  in the primary care office setting. Therefore, these patients often require immediate
  referral to an emergency department. Proper evaluation and initial management
  include evaluation of metabolic factors, assessment for toxic ingestions and a
  thorough neurologic assessment
Akhtar, W., Reeves, W.C. and Movahed, A. (1998), Indications for anticoagulation in
  atrial fibrillation. American Family Physician, 58 (1), 130-136.
Abstract: Factors associated with an increased risk of thromboembolic events in patients
  with atrial fibrillation (AF) include increasing age, rheumatic heart disease poor left
  ventricular function, previous myocardial infarction, hypertension and a past history
  of a thromboembolic event. Patients with AF should be considered for
  anticoagulation or antiplatelet therapy based on the patient's age, the presence of
  other risk factors for stroke and the risk of complications from anticoagulation. In
  general, Patients with risk factors for stroke should receive warfarin anticoagulation,
  regardless of their age. In patients who are tinder age 65 and have no other risk
  factors for stroke, either aspirin therapy or no therapy at all is recommended Aspirin
  or warfarin is recommended for use in patients between 65 and 75 years of age with
  no other risk factors, and warfarin is recommended for use in patients without risk
  factors who are older than 75 years of age
Keywords:                                    age/anticoagulation/antiplatelet/aspirin/atrial
Barrow, M.W. and Clark, K.A. (1998), Heat-related illnesses. American Family
  Physician, 58 (3), 749-756.
Abstract: Heat-related illnesses cause 240 deaths annually. Although common in
  athletes, heat-related illnesses also affect the elderly persons with predisposing
  medical conditions and those taking a variety of medications. Symptoms range from
  mim weakness, dizziness and fatigue in cases of heat edema, to syncope, exhaustion
  and multisystem complications, including coma and death, in cases of heat stroke.
  Milder heat-related symptoms can be treated with hydration, rest and removal from
  the hot environment. Hear stroke, a life-threatening problem, must he treated
  emergently. Prompt recognition is critical since rapid cooling is the cornerstone of
  treatment and must not be delayed. Fluid resuscitation with dextrose and normal or
  half-normal saline is also important. These therapies should be instituted while the
  patient is being stabilized. Heat illness may be prevented by recognizing which
  individuals are at risk, using appropriate hydration and paying attention to
  acclimatization and environmental conditions. Preventive care should include
  drinking plenty of fluids before, during and after activities, gradually increasing the
  time spent working in the heat and avoiding exertion during the hottest part of the
Keywords:                           attention/complications/death/elderly/EXERTIONAL
Benavente, O. and Hart, R.G. (1999), Stroke: Part II. Management of acute ischemic
  stroke. American Family Physician, 59 (10), 2828-2834.
Abstract: Optimal treatment of the patient who has sustained an acute ischemic stroke
  requires rapid assessment and early intervention. The leisurely approach to acute
  stroke management sometimes taken in the past should be replaced by an approach
  that treats stroke as a true medical emergency, Thrombolysis with tissue plasminogen
  activator has been labeled for the treatment of acute ischemic stroke, but it must be
  given within three hours of stroke onset. However, fibrinolytic therapy can be given
  safely to only a fraction of patients with acute stroke, and more broadly applicable
  therapies are needed. Recent evidence does not support the routine use of heparin in
  patients with acute stroke, and early use of aspirin offers only modest benefit.
  Neuroprotective therapies designed to interfere with cytotoxic events initiated by
  ischemia are undergoing clinical trials that should be completed within the next year.
  At present, only tissue plasminogen activator has been labeled for acute stroke
  treatment; however, other agents are on the horizon, and much can be done
  supportively to improve neurologic outcome. Because of the unique susceptibility of
  neurons to ischemia, minutes count. Thus, hospitals providing care for patients with
  acute stroke should organize clinical protocols and pathways for effective
  implementation of therapies
Keywords:                    acute/acute               stroke/acute               stroke
  activator/SPECIAL              WRITING            GROUP/STATEMENT/stroke/stroke
  management/stroke             onset/stroke       treatment/therapy/THROMBOLYTIC
  THERAPY/tissue plasminogen activator/treatment/trials/WARD
Bouknight, D.P. and O'Rourke, R.A. (2000), Current management of mitral valve
  prolapse. American Family Physician, 61 (11), 3343-3350.
Abstract: Mitral valve prolapse is a pathologic anatomic and physiologic abnormality of
  the mitral valve apparatus affecting mitral leaflet motion. "Mitral valve prolapse
  syndrome" is a term often used to describe a constellation of mitral valve prolapse
  and associated symptoms or other physical abnormalities such as autonomic
  dysfunction, palpitations and pectus excavatum, The importance of rc cognizing that
  mitral valve prolapse may occur as an isolated disorder or with other coincident
  findings has led to the use of both terms. "Mitral valve prolapse syndrome, which
  occurs in 3 to 6 percent of Americans, is caused by a systolic billowing of one or
  both mitral leaflets into the left atrium, with or without mitral regurgitation. It is
  often discovered during routine cardiac auscultation or when echocardiography is
  performed for another reason. Most patients with mitral valve prolapse are
  asymptomatic. Those who have symptoms commonly report chest discomfort,
  anxiety, fatigue! and dyspnea, but whether these are actually due to mitral valve
  prolapse is not certain. The principal physical finding is a midsystolic click, which
  frequently is followed by a late systolic murmur. Although echocardiography is the
  most useful mode for identifying mitral valve prolapse, it is not recommended as a
  screening tool for mitral valve prolapse in patients who have no systolic click or
  murmur on careful auscultation. Mitral valve prolapse has a benign prognosis and a
  complication rate of 2 percent per year. The Progression of mitral regurgitation may
  cause dilation of the left-sided heart chambers. Infective endocarditis is a potential
  complication. Patients with mitral valve prolapse syndrome who have murmurs
  and/or thickened redundant leaflet!; seen on echocardiography should receive
  antibiotic prophylaxis against endocarditis
Keywords:           ABNORMALITIES/asymptomatic/CEREBRAL                         ISCHEMIC
King, D.E., Dickerson, L.M. and Sack, J.L. (2002), Acute management of atrial
  fibrillation: Part II. Prevention of thromboembolic complications. American Family
  Physician, 66 (2), 261-264.
Abstract: Family physicians should be familiar with the acute management of atrial
  fibrillation and the initiation of chronic therapy for this common arrhythmia. Initial
  management should include hemodynamic stabilization, rate control, restoration of
  sinus rhythm, and initiation of antithrombotic therapy. Part 11 of this two-part article
  focuses on the prevention of thromboembolic complications using anticoagulation.
  Heparin is routinely administered before medical or electrical cardioversion.
  Warfarin is used in patients with persistent atrial fibrillation who are at higher risk
  for thromboembolic complications because of advanced age, history of coronary
  artery disease or stroke, or presence of left-sided heart failure. Aspirin is preferred in
  patients at low risk for thromboembolic complications and patients with a high risk
  for falls, a history of noncompliance, active bleeding, or poorly controlled
  hypertension. The recommendations provided in this article are consistent with
  guidelines published by the American Heart Association and the Agency for
  Healthcare Research and Quality
Keywords:                              acute/age/American                             Heart
  /rate             control/risk/sinus             rhythm/stroke/therapy/thromboembolic
Vega, C., Kwoon, J.V. and Lavine, S.D. (2002), Intracranial aneurysms: Current
  evidence and clinical practice. American Family Physician, 66 (4), 601-608.
Abstract: Unruptured intracranial aneurysms occur in up to 6 percent of the general
  population. Most persons with these aneurysms remain asymptomatic and are usually
  unaware of their presence. Risk factors foe the formation of aneurysms include a
  family,history of aneurysm, various inherited disorders, age,greater than 50 years,
  female gender, current cigarette smoking, and cocaine use. Because of the morbidity
  and mortality associated with surgical intervention, screening for aneurysms remains
  controversial. Two groups of patients may benefit from early detection: Those with
  autosomal dominant polycystic kidney disease and those with a: history,of
  aneurysmal subarachnoid hemorrhage. These patients should undergo magnetic
  resonance angiography, followed by neurosurgical referral if an aneurysm is detected.
  Screening of patients who have two or more family members with intracranial
  aneurysms is controversial. Screening of,patients who have one first-degree relative
  with an aneurysm does not,appear to be beneficial
Keywords: AMERICAN-HEART-ASSOCIATION/aneurysm/aneurysmal subarachnoid
  LTH-CARE          PROFESSIONALS/hemorrhage/intervention/intracranial/intracranial
  aneurysms/magnetic                     resonance/magnetic                    resonance
Colucci, W.S. (1991), Cardiovascular Effects of Milrinone. American Heart Journal,
  121 (6), 1945-1947.
Abstract: The myocardial effects of milrinone are mediated through inhibition of
  myocardial phosphodiesterase ill. This inhibition results in accumulation of cyclic
  adenosine monophosphate and consequently increased calcium influx through
  voltage-dependent channels. The vascular effects also result from increased cyclic
  adenosine monophosphate. Direct coronary artery infusion of milrinone causes a
  concentration-related increase in left ventricular +dP/dt and substantial improvement
  in pump function as indicated by increased stroke work at lower left ventricular
  end-diastolic pressures. Subsequent intravenous administration of milrinone
  produces additional hemodynamic improvement, which is associated with a further
  reduction in systemic vascular resistance and left and right heart filling pressures.
  There is also a downward displacement of the left ventricular pressure- volume curve
  and acceleration of isovolumic relaxation, findings which indicate improved diastolic
  filling and accelerated isovolumic myocardial relaxation, respectively. The former
  action may reflect unloading of the right ventricle, whereas the latter may be due to
  improved calcium reuptake in the myocardium. Myocardial oxygen demand is
  unaltered because peripheral vasodilatation reduces wall stress and counteracts the
  increased oxygen requirement necessary to support enhanced contractility. This
  therapeutic profile differs from that of inotropic agents such as dobutamine and
  vasodilators such as nitroprusside, and contributes significantly to the usefulness of
  phosphodiesterase ill inhibitors such as milrinone in the short-term management of
  patients with heart failure
Keywords:             CONGESTIVE                 HEART-FAILURE/DOSE-RESPONSE
Yarzebski, J., Col, N., Pagley, P., Savageau, J., Gore, J. and Goldberg, R. (1996),
  Gender differences and factors associated with the receipt of thrombolytic therapy in
  patients with acute myocardial infarction: A community-wide perspective. American
  Heart Journal, 131 (1), 43-50.
Abstract: In spite of national interest in gender differences in the presentation and
  management of chronic disease, limited information is available about possible
  gender differences in the receipt of thrombolytic therapy after acute myocardial
  infarction (AMI). As part of an ongoing community-based study of AMI, we
  examined gender differences in the receipt of thrombolytic therapy among 2885
  patients with confirmed AMI. The study sample consisted of 1680 males and 1205
  females with validated AMI who were admitted to 16 hospitals in the Worcester,
  Massachusetts, metropolitan area in four study periods between 1986 and 1991.
  During the years under study, 24.4% of men and 14.4% of women received
  thrombolytic therapy. Increases over time in the use of thrombolytic therapy were
  seen in both men (13.9% in 1986; 31.6% in 1991) and women (3.2% in 1986; 19.0%
  in 1991). After controlling for a variety of factors that might affect use of
  thrombolytic agents, younger age, absence of a history of either congestive heart
  failure or stroke, and experiencing a Q-wave AMI were associated with receipt of
  thrombolytic therapy in both men and women; having an anterior AMI also was
  associated with use of thrombolytic agents in men. Women without as compared
  with those with a history of angina pectoris were significantly more likely to receive
  thrombolytics. Men who had Medicare insurance were significantly less likely to
  receive thrombolytics than were men with other types of health insurance. When this
  analysis was restricted to patients who were seen in area-wide hospitals within 6
  hours of the onset of symptoms suggestive of AMI, similar factors were associated
  with the receipt of thrombolytic agents in men and women. The results of this
  community-wide study suggest a marked increase over the 5-year study period in the
  use of thrombolytic therapy in both men and women, with a greater relative increase
  observed in women. A relatively similar profile of patients likely to receive
  thrombolytic therapy was seen in both men and women
Keywords:                               acute/acute                             myocardial
Nendaz, M.R., Sarasin, F.P., Junod, A.F. and Bogousslavsky, J. (1998), Preventing
  stroke recurrence in patients with patent foramen ovale: Antithrombotic therapy,
  foramen closure, or therapeutic abstention? A decision analytic perspective.
  American Heart Journal, 135 (3), 532-541.
Abstract: Emphasis on the role of patent foramen ovale as a potential risk factor for
  ischemic paradoxical stroke has recently increased. Current therapeutic options for
  secondary stroke prevention include long-term antithrombotic therapies and invasive
  closure of the defect, but selective indications have not been evaluated. Therefore we
  developed a Markov-based decision analysis model for a hypothetical cohort of
  patients 55 years of age with presumed paradoxical embolism, measuring for each
  therapy the risks of stroke recurrence, treatment- related complications, and death
  after 5 years and the quality- adjusted life-years. Over a wide range of stroke risk
  recurrence (0.8% per year to 7% per year), the gain provided by closure of the defect
  exceeded the one obtained by other therapeutic options. When the risk exceeded
  0.8% per year and 1.4% per year, respectively, this was also verified for
  anticoagulation and antiplatelet therapies compared with therapeutic abstention.
  Therapeutic abstention was the preferred strategy under 0.8% per year. Sensitivity
  analyses identified key parameters influencing the choice of therapy. These included
  estimates of stroke recurrence, bleeding rates, surgery-related case fatality rates, and
  age. Considering the risks of treatment and the devastating consequences of a
  recurrent stroke, our model suggests that if the estimated risk of paradoxical stroke
  recurrence is >0.8% per year, therapeutic abstention becomes the worst option.
  Above this threshold secondary stroke prevention with anticoagulation therapy or
  surgical closure of the defect is the preferred strategy, and assessment of both the risk
  of stroke recurrence and the risk related to therapeutic options should guide
  individual therapeutic decision making
Keywords:                                      age/anticoagulation/antiplatelet/antiplatelet
  therapies/antithrombotic/ATRIAL                                 SEPTAL-DEFECT/case
  fatality/complications/CRYPTOGENIC STROKE/death/decision analysis/decision
  EMBOLISM/patent/patent              foramen         ovale/prevention/RISK/risk          of
  stroke/stroke/stroke                                             prevention/SURGICAL
Becker, R.C., Burns, M., Gore, J.M., Spencer, F.A., Ball, S.P., French, W., Lambrew,
  C., Bowlby, L., Hilbe, J. and Rogers, W.J. (1998), Early assessment and in-hospital
  management of patients with acute myocardial infarction at increased risk for
  adverse outcomes: A nationwide perspective of current clinical practice. American
  Heart Journal, 135 (5), 786-796.
Abstract: Background Therapeutic decision making in critically ill patients requires
  both prompt and comprehensive analysis of available information. Data derived from
  randomized clinical trials provide a powerful tool for risk assessment in the setting of
  acute myocardial infarction (MI); however, timely and appropriate use of existing
  therapies and resources are the key determinants of outcome among high-risk
  patients. Methods Demographic, procedural, and outcome data from patients with MI
  were collected at 1073 U.S, hospitals collaborating in the National Registry of MI
  (NRMI 2). Patients were classified on hospital arrival as either "low risk" or "high
  risk" according to a modified Thrombolysis in Myocardial Infarction II Risk Scale
  based on predetermined demographic, electrocardiographic, and clinical features.
  Results Among the 170,143 patients enrolled, 115,222 (67.5%) were classified as
  low risk and 55,521 (32.5%) as high risk for in-hospital death, recurrent ischemia,
  recurrent MI, congestive heart failure, and stroke. Using a composite unsatisfactory
  outcome measure, in-hospital adverse events were had by a greater proportion of
  patients initially classified as high risk compared with those classified as low risk. By
  multivariate analysis, age >70 years, prior MI, Killip class >1, anterior site of
  infarction, and the combination of hypotension and tachycardia were independent
  predictions of poor outcome in patients with or without ST-segment elevation on the
  presenting electrocardiogram. High-risk patients with ST-segment elevation were
  treated with thrombolytics (47.5%) or alternative forms of reperfusion therapy (9.3%)
  within 62 minutes and 226 minutes of hospital arrival, respectively. High-risk
  patients offered reperfusion therapy were also more likely to receive aspirin,
  P-blockers (intravenous, oral) and angiotensin-converting enzyme inhibitors within
  24 hours of infarction (all p < 0.0001), survive their event (8.4% versus 21.4% p <
  0.0001), and leave the hospital sooner than those not reperfused. Conclusions This
  large registry experience included more than 150,000 nonselected patients with MI
  and suggests that high- risk patients can be identified on initial hospital presentation.
  The current use of reperfusion and adjunctive therapies among high-risk patients is
  suboptimal and may directly influence outcome. Randomized trials designed to test
  the impact of specific management strategies on outcome according to initial risk
  classification are warranted
Keywords: acute/acute myocardial infarction/adverse events/age/aspirin/CARE/clinical
  trials/congestive        heart      failure/critically   ill     patients/death/decision
  making/decision-making/ELDERLY PATIENTS/GUSTO TRIAL/HEART/heart
McInnes, G.T. (1999), Integrated approaches to management of hypertension:
  Promoting treatment acceptance. American Heart Journal, 138 (3), S252-S255.
Abstract: Overwhelming trial evidence indicates that the treatment of hypertension is
  beneficial, but in practice, less than 50% of treated hypertensive subjects have blood
  pressure well controlled. The success of treatment relies on acceptance by the patient.
  Treatment acceptance may be affected by the efficacy and tolerability of drug
  therapy, its effects on quality of life, and other important but less well-recognized
  influences such as the expectations and preconceived ideas of the physician and the
  patient. This report briefly reviews the factors affecting patient concordance with
  antihypertensive treatment and the role these Factors play in the development of an
  integrated treatment plan. Nonconcordance with drug therapy is common: Only one
  third of patients always lake treatment, one third take it sometimes, and one third
  never take their prescribed medication. With poor concordance, control of blood
  pressure and the consequent benefits are less likely to be realized. The factors that
  influence concordance are ill understood. Although drug side effects and
  convenience of dosing regimens are contributors, the attitudes of patients, physicians,
  and their interactions are likely to be of considerable importance. Concordance may
  be improved by involving the patient in the treatment plan, setting explicit targets,
  following a clear treatment pion, motivating the patient to comply with treatment,
  paying attention to the concerns and particular needs of the individual patient, and by
  ensuring frequent contacts between patients and health care professions. Successful
  integrated approaches to the management of hypertension must address all the factors
  that affect treatment acceptance
Keywords:            ANTIHYPERTENSIVE                  DRUGS/attention/attitudes/blood
  pressure/BLOOD-PRESSURE/control/CORONARY                      HEART-DISEASE/drug
  of life/STROKE/THERAPY/treatment
Smolensky, M.H. and Portaluppi, F. (1999), Chronopharmacology and chronotherapy of
  cardiovascular medications: Relevance to prevention and treatment of coronary heart
  disease. American Heart Journal, 137 (4), S14-S24.
Abstract: Biological functions and processes, including cardiovascular ones, exhibit
  significant circadian (24-hour) and other period rhythms. Ambulatory blood pressure
  assessment reveals marked circadian rhythms in blood pressure both in normotensive
  persons and hypertensive patients, whereas Holter monitoring substantiates day-night
  patterns in electrocardiographic events of patients with ischemic heart disease. The
  concept of homeostasis, that is, constancy of the milieu interna which has dominated
  the teaching, research, and practice of medicine during the 20th century, is now
  being challenged by emerging concepts from the field of chronobiology-the science
  of biological rhythms. Epidemiologic studies document the heightened morning-time
  risk of angina, myocardial infarction, and stroke. Circadian rhythms in coronary tone
  and reactivity, plasma volume, blood pressure, heart rate, myocardial oxygen
  demand, blood coagulation, and neuroendocrine Function plus day-night patterns in
  the nature and strength of environmental triggers all contribute to this morning
  vulnerability Homeostatically devised pharmacotherapies, that is, medications
  formulated to ensure a near-constant drug concentration, may not be optimal to
  adequately control diseases that vary in risk and severity during the 24 hours.
  Moreover, circadian rhythms in the physiology of the gastrointestinal tract, vital
  organs, and body tissues may give rise to administration-time differences in the
  pharmacokinetics and effects of therapies. Thus the same medication consumed in
  the same dose under identical conditions in the evening and morning may not exhibit
  comparable pharmacokinetics and dynamics. New technology makes possible
  chronotherapy, that is, increase of the efficiency and safety of medications by
  proportioning their concentrations during the 24 hours in synchrony with biological
  rhythm determinants of disease. The chronotherapy of peptic ulcer disease achieved
  by the evening dosing of H-2-receptor antagonists and of asthma by the evening
  dosing of special drug delivery forms of theophylline and morning
  methylprednisolone administration has proven to be beneficial. Controlled-onset
  extended-release verapamil constitutes the first chronotherapy of essential
  hypertension and ischemic heart disease; once-a- day bedtime dosing results in a
  high drug concentration in the morning and afternoon and a reduced one overnight.
  Studies demonstrate effective 24-hour control of blood pressure, including the
  attenuation of its rapid rise in the morning, without induction of nighttime
  hypotension. Moreover, this formulation effectively controls angina, especially in the
  morning when the risk of ischemia is greatest. Determination of the role of verapamil
  chronotherapy in the primary prevention of cardiovascular morbidity and mortality
  awaits the results of the CONVINCE trial now in progress
Keywords: administration/angina/ANGINA-PECTORIS/assessment/BETA-BLOCKER
  THERAPY/blood              pressure/CHRONIC-         RENAL-FAILURE/CIRCADIAN
  VARIATION/coagulation/control/CONTROLLED-ONSET/coronary/coronary heart
  rate/hypertension/hypotension/infarction/ischemia/ischemic/ischemic                 heart
  prevention/safety/severity/STABLE ANGINA/stroke/studies/treatment
Hennekens, C.H. (1999), Update on aspirin in the treatment and prevention of
  cardiovascular disease. American Heart Journal, 137 (4), S9-S13.
Abstract: The effects of low-dose aspirin on cardiovascular disease have been tested in
  randomized trials in 3 types of populations: (1) patients with a history of
  cardiovascular disease; (2) patients with evolving acute myocardial infarction (MI),
  and (3) apparently healthy subjects. In a very wide range of patients with prior
  occlusive cardiovascular disease, aspirin reduces the risks of nonfatal MI, nonfatal
  stroke, and vascular death. Initiating aspirin therapy within 24 hours after the onset
  of symptoms of an acute MI also confers conclusive reductions in the risk of nonfatal
  reinfarction, nonfatal stroke, and total cardiovascular death. In primary prevention
  trials, aspirin has been shown to reduce the risk of a first MI in men, but the data on
  stroke and total cardiovascular death are not sufficient to allow firm conclusions to
  be drawn; randomized data from studies in women are not yet available. The
  Women's Health Study an ongoing large-scale trial in Female health core
  professionals, will provide the data necessary to assess the balance of benefits and
  risks of aspirin in primary prevention. Until then, the decision to use aspirin in
  primary prevention should be based on the clinical judgment of the physician and
  considered as an adjunct in the management of other cardiovascular disease risk
Keywords:           acute/acute        myocardial        infarction/aspirin/cardiovascular
  rdial        infarction/prevention/primary      prevention/randomized          trials/risk
  factors/stroke/studies/THERAPEUTIC AGENT/therapy/treatment/trials
Connolly, S.J. (2000), Appropriate outcome measures in trials evaluating treatment of
  atrial fibrillation. American Heart Journal, 139 (5), 752-760.
Abstract: Background Atrial fibrillation [AF] is a widespread disease chat has only
  recently received the focused attention of arrhythmia specialists despite being the
  most frequently occurring significant cardiac arrhythmia. Methods and Results The
  wide variety of trial designs used to evaluate AF treatment is a reflection of the
   diverse outcomes associated with this condition. The best trials assess the impact of
   treatment on a clearly measured outcome that is of clinical relevance to patients. This
   review discusses the different designs of AF treatment trials and analyzes the utility
   of the various outcomes that can be assessed. Conclusions A sensible goal of AF
   treatment is to reduce the frequency of recurrences and to prolong the time between
   them. The most appropriate trials focus on AF recurrences that are symptomatic and
   therefore relevant to the patient. We still do not know if there is value in AF
   prevention, beyond preventing symptoms. However, ongoing and future studies will
   show whether AF suppression reduces the longer-term risks of stroke or death and
   improves patient quality of life. Cost of care will increasingly be studied in future
   trials of AF management
Keywords:                 arrhythmia/ARTERY                  BYPASS-SURGERY/atrial
   fibrillation/ATRIOVENTRICULAR                                             JUNCTION
   ND              CROSSOVER/fibrillation/HEART/III                ANTIARRHYTHMIC
   AMIODARONE/management/outcome/outcomes/PLACEBO-                      CONTROLLED
   TRIAL/prevention/quality/quality of life/QUALITY-OF-LIFE/RANDOMIZED
   CONTROL TRIALS/review/SINUS RHYTHM/stroke/studies/treatment/trials
Miele, P.S., Kogulan, P.K., Levy, C.S., Goldstein, S., Marcus, K.A., Smith, M.A.,
   Rosenthal, J., Croxton, M., Gill, V.J. and Lucey, D.R. (2001), Seven cases of
   surgical native valve endocarditis caused by coagulase-negative staphylococci: An
   underappreciated disease. American Heart Journal, 142 (4), 571-576.
Abstract: Background Native valve endocarditis caused by coagulase- negative
   staphylococci is uncommon and the diagnosis is infrequently considered. The disease,
   however, appears to be increasing in frequency and can pursue an aggressive clinical
   course. We report the clinical features of 7 cases of coagulase-negative
   staphylococcal native valve endocarditis (CNS-NVE) seen at 1 institution with a
   large cardiovascular referral base over a 10-month period. All cases required valve
   replacement surgery. Methods Clinical history, echocardiograms, and microbiologic
   and histopathologic data were reviewed for 7 patients with surgical CNS-NVE.
   Results Four patients had intravenous central catheters, and 1 had recent surgery,
   whereas the remaining 2 had no identifiable risk factors. Presentations ranged from
   subacute (4 cases) to acute with complications (3 cases). Complications included
   congestive heart failure, stroke, and heart block. Echocardiography demonstrated
   valvular lesions in all 7 cases. Valve pathologic study demonstrated gram-positive
   cocci in all 7 cases; blood cultures grew coagulase-negative staphylococci in 6 cases
   and valve cultures grew Staphylococcus epidermidis in 5 cases. Conclusions
   Coagulase-negative staphylococci, including S epidermidis, can cause severe native
   valve endocarditis requiring valve replacement. The increasing use of intravascular
   access devices in the community may herald an increase in the incidence of
   CNS-NVE. A high index of diagnostic suspicion in the appropriate clinical setting Is
   critical for optimal management
Keywords:                  acute/community/complications/congestive                  heart
   factors/stroke/surgery/THERAPY/valve replacement
Fathi, R. and Marwick, T.H. (2001), Noninvasive tests of vascular function and
   structure: Why and how to perform them. American Heart Journal, 141 (5), 694-703.
Abstract: Background Early atherosclerosis involves the endothelium of many arteries.
  Information about peripheral arterial anatomy and function derived from vascular
  imaging studies such as brachial artery reactivity (BAR) and carotid intima media
  thickness (IMT) may be pertinent to the coronary circulation. The prevention and
  early treatment of atherosclerosis is gaining more attention, and these tests might be
  used as indications or perhaps guides to the effectiveness of therapy, but their
  application in clinical practice has been limited. This review seeks to define the
  anatomy and pathophysiology underlying these investigations, their methodology,
  the significance of their Findings, and the issues that must be resolved before their
  application. Methods The literature on BAR and IMT is extensively reviewed,
  especially in relation to clinical use. Results Abnormal flow-mediated dilation is
  present in atherosclerotic vessels, is associated with cardiovascular risk factors, and
  may be a marker of preclinical disease. Treatment of known atherosclerotic risk
  Factors has been shown to improve flow-mediated dilation, and some data suggest
  that vascular responsiveness is related to outcome. Carotid IMT is associated with
  cardiovascular risk factors, and increased levels can predict myocardial infarction
  and stroke. Aggressive risk factor management can decrease IMT. Conclusions BAR
  and IMT ate functional and structural markers of the atherosclerotic process. The
  clinical use of BAR has been limited by varying reproducibility and the influence by
  exogenous factors, but IMT exhibits less variability. A desirable next step in the
  development of BAR and IMT as useful clinical tools would be to show an
  association of improvement in response to treatment with improvement in prognosis
Keywords:          arteries/artery/atherosclerosis/attention/cardiovascular/cardiovascular
  risk/cardiovascular risk factors/carotid/CAROTID- ARTERY/coronary/coronary
  circulation/CORONARY-ARTERY                                    DISEASE/DEPENDENT
  OVES             ENDOTHELIAL                  FUNCTION/infarction/INTIMA-MEDIA
  WOMEN/prevention/prognosis/review/risk/risk                                   factor/risk
Levy, S. (2001), Pharmacologic management of atrial fibrillation: Current therapeutic
  strategies. American Heart Journal, 141 (2), S15-S21.
Abstract: Background Atrial fibrillation (AF), the most common form of sustained
  arrhythmia, is associated with a frightening risk of embolic complications,
  tachycardia-related ventricular dysfunction, and often disabling symptoms.
  Pharmacologic therapy is the treatment used most commonly to restore and maintain
  sinus rhythm, to prevent recurrences, or to control ventricular response rate. Methods
  This article reviews published data on pharmacologic treatment and discusses
  alternative systems to classify AF and to choose appropriate pharmacologic therapy.
  Results AF is either paroxysmal or chronic. Attacks of paroxysmal AF can differ in
  duration, frequency, and functional tolerance. In the new classification system
  described, 3 clinical aspects of paroxysmal AF are distinguished on the basis of their
  implications For therapy. Chronic AF usually occurs in association with clinical
  conditions that cause atrial distention. The risk of chronic AF is significantly
  increased by the presence of congestive heart failure or rheumatic heart disease.
  Mortality rate is greater among patients with chronic AF regardless of the presence
  of coexisting cardiac disease. The various options available for the treatment of
  chronic AF include restoration of sinus rhythm or control of ventricular rate.
  Cardioversion may be accomplished with pharmacologic or electrical treatment. For
  patients in whom cardioversion is not indicated or who have not responded to this
  therapy, antiarrhythmic agents used to control ventricular response rate include
  nondihydropyridine calcium antagonists, digoxin, or beta -blockers. For patients who
  are successfully cardioverted, sodium channel blockers or potassium channel
  blockers such as sotalol, amiodarone, or a pure class III agent such as dofetilide, a
  selective potassium channel blocker, may be used to prevent recurrent AF to
  maintain normal sinus rhythm. Conclusions The ultimate choice of the
  antiarrhythmic drug will depend on the presence or absence of structural heart
  disease. An additional concern with chronic AF is the risk of arterial embolization
  resulting from atrial stasis and the formation of thrombi. In patients with chronic AF
  the risk of embolic stroke is increased 6-fold. Therefore anticoagulant therapy should
  be considered in patients at high risk for embolization. Selection of the appropriate
  treatment should be based on the concepts recently developed by the Sicilian Gambit
  Group (based on the specific channels blocked by the antiarrhythmic agent) and on
  clinical experience gained over the years with antiarrhythmic agents. For example,
  termination of AF is best accomplished with either a sodium channel blocker (class I
  agent) or a potassium channel blocker (class III agent). In contrast ventricular
  response rate is readily controlled by a beta -blocker (propranolol) or a calcium
  channel blocker (verapamil). Alternatively, antiarrhythmic drug therapy may be
  chosen based on the Vaughan- Williams classification, which identifies the cellular
  electrophysiologic effects of the drug
  DRUGS/anticoagulant/anticoagulant                               therapy/arrhythmia/atrial
  fibrillation/calcium/calcium                antagonists/calcium                 channel
  tive                    heart                   failure/control/DIGOXIN/disease/drug
  failure/HEART-DISEASE/management/ORAL                     PROPAFENONE/risk/SINUS
Labovitz, A.J. and Bransford, T.L. (2001), Evolving role of echocardiography in the
  management of atrial fibrillation. American Heart Journal, 141 (4), 518-527.
Abstract: The most common cardiovascular arrhythmia is atrial fibrillation (AF), with
  an estimated prevalence of 2.5 million in 1994. The extent of this public health
  problem is enormous, particularly in its stroke sequelae. Routine management of this
  public health problem includes anticoagulation as the primary stroke-preventive
  measure. Echocardiography has been an important adjunctive tool in the evaluation
  of AF. More innovative and controversial is the putative role of transesophageal
  echocardiography in the treatment strategy of AF cardioversion to sinus rhythm. The
  standard of care for AF of less than 1-year duration is to attempt cardioversion to
  sinus rhythm. An alternative strategy is to utilize the assets of transesophageal
  echocardiography to visually screen the left atrium for thrombus, thereby playing an
  active role in the treatment strategy of AF. This review will discuss the role of
  echocardiography in AF as it was initially used as a diagnostic tool with weak
  prognostic features, and, more recently, as it can be used today as on adjunctive tool
  to guide therapy with excellent stroke risk-stratification features
Keywords:                                      ANTICOAGULATION/arrhythmia/atrial
  FUNCTION/PREDICTORS/prevalence/public                         health/review/RISK/risk
Voros, S., Nanda, N.C., Samal, A.K., Gomez, C.R., Liu, M.W., Puri, V.K., Jindal, A.,
  Terry, J.B., Tulyapronchote, R. and Thakur, A.C. (2001), Transesophageal
  echocardiography in patients with ischemic stroke accurately detects significant
  coronary artery stenosis and often changes management. American Heart Journal,
  142 (5), 916-922.
Abstract: Objectives TEE is performed in many patients with ischemic stroke, and it is
  possible to examine the proximal coronaries by TEE in these patients. Our purpose
  was to (1) determine the accuracy of transesophageal echocardiography (TEE) in the
  diagnosis of proximal coronary stenosis in patients with ischemic stroke and (2)
  show that TEE detection of proximal coronary stenosis changed management in a
  substantial number of patients. Methods Thirty-two patients with ischemic stroke
  undergoing TEE, in whom the proximal coronaries were examined and who had
  angiographic results available, were studied. Results Proximal coronaries were
  visualized as follows: left main (LM) in 31 (97%), left anterior descending (LAD) in
  32 (100%), left circumflex (LCx) in 30 (94%) and right coronary artery (RCA) in 21
  (66%). The sensitivity and specificity of TEE in diagnosing significant coronary
  stenosis in visualized vessels were as follows: LM 100% and 100%, LAD 100% and
  95%, LCx 100% and 96%, and RCA 100% and 100%, respectively. When visualized
  and nonvisualized segments were considered, TEE detected significant stenosis as
  follows: 4 of 5 in the LM (80%), 13 of 13 in the LAD (100%), 2 of 3 in the LCx
  (66%), and 2 of 8 in the RCA (25%). Of the 32 patients, TEE results changed
  management in 17 patients (53%). Angiographic findings resulted in 10 of the 17
  patients (59%) undergoing revascularization. Conclusions TEE was very accurate in
  diagnosing significant coexisting coronary artery disease in patients with ischemic
  stroke. TEE diagnosis of these lesions prompted coronary angiography and
  subsequent revascularization in a substantial number of patients
Keywords: angiography/artery/BLOOD-FLOW/COLOR DOPPLER/coronary/coronary
  artery disease/coronary artery stenosis/detection/DIAGNOSIS/disease/DOPPLER
  l echocardiography
Mukherjee, D., Mahaffey, K.W., Moliterno, D.J., Harrington, R.A., Yadav, J.S., Pieper,
  K.S., Gallup, D., Dyke, C., Roe, M.T., Berdan, L., Lauer, M.S., Manttari, M., White,
  H.D., Califf, R.M. and Topol, E.J. (2002), Promise of combined
  low-molecular-weight heparin and platelet glycoprotein IIb/IIIa inhibition: Results
  from platelet IIb/IIIa antagonist for the reduction of Acute Coronary Syndrome
  Events in a Global Organization Network B (PARAGON b). American Heart
  Journal, 144 (6), 995-1002.
Abstract: Background Low-molecular-weight heparin (LMWH) has a more predictable
  anticoagulant effect than unfractionated heparin (UFH), is easier to administer, and
  does not require monitoring. Minimal data are available on LMWH combined with
  platelet glycoprotein (GP) III/IIIa inhibitors. Methods In the Platelet IIb/IIIa
  Antagonist for the Reduction of Acute Coronary Syndrome Events in a Global
  Organization Network B (PARAGON B) trial, patients with an acute coronary
  syndrome were randomized to receive the IIb/IIIa inhibitor lamifiban or a placebo.
  To rigorously explore the potential benefits of LWMH and GP IIb/IIIa inhibition, we
  analyzed the rates of ischemic complications and safety outcomes in PARAGON B.
  Results Approximately one fifth of the patients received LMWH (805 vs 4395 UFH).
  For the overall cohort, the incidence of death/myocardial infarction (Ml)/severe
  recurrent ischemia (SRI) was 12.2%, and this composite end point was numerically
  lowest in the lamifiban with LMWH group (10.2%). Similarly, the incidence of
  death/MI was 11.0% for the entire cohort and lowest in the lamifiban and LMWH
  group (9.0%). The lower event rate for patients taking LMWH in the lamifiban group
  was sustained at 6 months, with a lower revascularization rate (51.5% vs 42.8%) and
  a lower composite of death/MI (13.8% vs 11.9%). Bleeding was comparable in the 2
  heperin groups (1.4% with UFH vs 0.9% with LMWH). The propensity adjusted
  odds ratio for 30-day revascularization was significantly lower with LMWH (odds
  ratio 0.67, 95% CI 0.57-0.79, P <.001). There were no significant differences in
  death/MI/SRI at 30 days (P =.465), death/Ml at 30 days (P =.264), and stroke at 30
  days with the type of heparin use (P.201) after propensity risk adjustment.
  Conclusions In the PARAGON B trial, use of LMWH in conjunction with a GP
  IIb/IIIa inhibitor was safe and associated with a lower revascularization rate. These
  findings support the rationale and promise for combining GP IIb/IIIa blockers and
  LMWH for future management of acute coronary syndrome
Keywords:               acute/anticoagulant/ARTERY                 DISEASE/CLINICAL
  cidence/infarction/ischemia/ischemic/low                 molecular                weight
Avanzini, F., Corsetti, A., Maglione, T., Alli, C., Colombo, F., Torri, V., Floriani, I. and
  Tognoni, G. (2002), Simple, shared guidelines raise the quality of antihypertensive
  treatment in routine care. American Heart Journal, 144 (4), 726-732.
Abstract: Aims To assess the impact of simple, collectively produced, evidence-based
  guidelines on optimizing the choice of antihypertensive drugs in routine care.
  Methods and Results Forty-eight physicians agreed to produce and test these
  guidelines for 1 year in their daily practice on a random sample of 1049 treated
  hypertensive patients (intervention group). A control group of 42 general
  practitioners recruited and followed up for, I year a parallel nonintervention cohort of
  722 treated hypertensive patients. After I year of follow- up, the patients in the
  nonintervention group had no changes in any of the predefined end points. In the
  intervention group, the use of diuretics and beta-blockers-drugs with documented
  preventive efficacy-increased, respectively, from 48.3% to 57.6% and from 22.0% to
  29.7%; and the proportion of hypertensive patients receiving indicated drugs.(with
  no contraindications) rose from 66.1% to 73.0%. The prescription of, poorly
  tolerated drugs decreased from 12.4% to 7.2%, and noncompliance, with the anti
  hypertensive therapy decreased from 5.2% to 3.8%. In the intervention group, both
  systolic and diastolic blood pressure control improved (systolic pressure <140 mm
  Hg, from 23.3% to 89.5%; diastolic pressure <90 mm,Hg, from 65.4% to 87.4%).
  Conclusions An intervention strategy based on the collaborative production of simple
  evidence-based. guidelines appears to be effective in raising the quality of anti
  hypertensive therapy in routine care
Keywords: antihypertensive drugs/antihypertensive treatment/blood pressure/blood
  pressure                           control/BLOOD-PRESSURE/control/CORONARY
Guo, Y.F. and Stein, P.K. (2003), Circadian rhythm in the cardiovascular system:
   Chronocardiology. American Heart Journal, 145 (5), 779-786.
Abstract: Background We reviewed recent progress in the study of the chronobiological
   aspects of the cardiovascular system. Methods Medline was used as the main search
   tool, and the full texts of selected papers were obtained. Results More than 300
   references were found, and 52 of them, representing the major findings in this field,
   were included in the reference list. Results of these studies confirm that most
   cardiovascular physiological parameters (such as heart rate, blood pressure,
   electrocardiogram indices) and pathophysiological events (myocardial
   ischemia/infarction, sudden cardiac death) show circadian rhythms. Results also
   suggest that consideration of these rhythms is important for the diagnosis and
   treatment of cardiovascular disorders and that restoration of normal circadian
   rhythms may be associated with clinical improvement. Conclusion The study of
   circadian rhythms in the cardiovascular system is emerging as an important area of
   investigation because of its potential implications for patient management
Keywords:                                                ATRIAL-FIBRILLATION/blood
   SION/HEART/heart                     rate/HEART-RATE-VARIABILITY/ISCHEMIC
   INCREASE/RENIN-ANGIOTENSIN/studies/SUDDEN                                    CARDIAC
Treiman, R.L., Cossman, D.V., Cohen, J.L., Foran, R.F. and Levin, P.M. (1981),
   Management of Postoperative Stroke After Carotid Endarterectomy. American
   Journal of Surgery, 142 (2), 236-238
Ram, C.V.S. (1990), Antiatherosclerotic and Vasculo-Protective Actions of Calcium-
   Antagonists. American Journal of Cardiology, 66 (21), I29-I32.
Abstract: Treatment of hypertension may prevent many of the complications
   attributable to blood pressure elevation, particularly those that are "pressure-related,"
   such as stroke. However, the atherosclerotic complications of hypertension, e.g.,
   coronary artery disease manifested as coronary morbidity and mortality, have not
   been reduced significantly with antihypertensive therapy. This disappointing
   outcome may reflect the adverse metabolic effects of the traditional therapies,
   diuretics and beta blockers, and their lack of specific vasoprotective properties.
   Increasing attention is thus being paid to the newer antihypertensive agents, which
   typically have fewer adverse effects and perhaps more physiologic mechanisms of
   antihypertensive action. Since calcium plays a key role in the genesis of
   atherosclerosis, calcium antagonists may positively affect the course of vascular
   disease. Investigators have observed that calcium antagonists display clear
   antiatherosclerotic properties in experimental as well as clinical studies. In one
   recently published clinical study, coronary artery disease was shown to develop more
   slowly, with a slower progression of individual stenoses, higher regression rate and
   less frequent occurrence of new lesions in patients treated chronically with verapamil
   compared to those receiving conventional therapies. Other similar investigations are
   currently under way to evaluate the antiatherogenic properties of calcium anatgonists,
   including the Frankfurt Isoptin Progression Study (FIPS), the Multicenter Isradipine
  Diuretic Atherosclerosis Study (MIDAS), the International Nifedipine Trial on
  Atherosclerosis Coronary Therapy (INTACT), and the large-scale Montreal Heart
  Institute Study. Results of these studies, which use precise end points such as
  myocardial infraction, cerebral infarction and peripheral vascular disease, may
  revolutionize the treatment of hypertension by identifying therapeutic approaches
  that control both the pressure-related and atherosclerotic complications of the disease
Nayler, W.G. (1991), Vascular Injury - Mechanisms and Manifestations. American
  Journal of Medicine, 90 S8-S13.
Abstract: Abnormalities in regulatory mechanisms for calcium handling play a key role
  in cell death and tissue necrosis. In the cardiovascular system this applies to the
  vasculature and the myocardium alike. In the aged population, where hypertension is
  a known risk factor, manifestations of vascular injury include atherogenesis and
  stroke. The newly developed dihydropyridine-based calcium antagonist amlodipine
  was used in investigations to determine whether calcium antagonists with sustained
  activity, in addition to lowering blood pressure, slow the development of
  atherogenesis in rabbits receiving high cholesterol diets, or reduce mortality in
  stroke-prone hypertensive rats. To establish whether this drug protects the
  vasculature against excessive atheroma formation in the presence of high cholesterol
  intake, rabbits were given 2% cholesterol in addition to their normal food intake and
  either 0, 1, or 5 mg/kg/day amlodipine orally for either 8 or 12 weeks. One day after
  the conclusion of the treatment protocol, the thoracic aorta was excised, assayed for
  calcium or cholesterol concentrations, and stained to identify sudanophilic-positive
  lesions. Amlodipine caused a time- and dose-dependent reduction in lesion formation,
  calcium overload, and cholesterol level. In the second series of experiments,
  amlodipine (5 mg/kg/day) was added to the diets of stroke-prone hypertensive rats.
  Treatment was initiated at age 5 weeks and continued for 30 weeks. During the
  treatment period, systolic blood pressure was reduced in the amlodipine-treated rats
  (166 +/- 9 mm Hg) versus those treated with placebo (248 +/- 12 mm Hg) (p < 0.001).
  A significant reduction in mortality was observed in the amlodipine-treated rats (p <
  0.001), with 93% surviving versus only 26% in the placebo group at the end of the
  30-week treatment period. Concomitantly, cardiac hypertrophy was attenuated in the
  treated group compared with the placebo group (heart-to-body weight ratios of 4.5
  +/- 0.01 vs 5.8 +/- 0.6, respectively [p < 0.01]). These results extend the evidence
  that calcium antagonists provide vascular protection in animal models. This finding
  may become increasingly important in the management of an aging hypertensive
Hansson, L. (1991), Shortcomings of Current Antihypertensive Therapy. American
  Journal of Hypertension, 4 (2), S84-S87.
Abstract: Effective antihypertensive agents have been available for the last four decades.
  Their use in the treatment of hypertension has resulted in a marked decline in
  hypertension-induced morbidity and mortality. There are, however, some notable
  short-comings with the currently available antihypertensive therapies, including
  disappointing effects against coronary artery disease and the fact that, even with
  treatment, hypertensive patients still have considerably higher cardiovascular
  morbidity and mortality than matched normotensives. This may be due to insufficient
  lowering of the elevated arterial pressure in hypertensive patients. In theory,
  overtreatment may also constitute a risk, considering the J-curve phenomenon. Other
  factors which may play a role are the different pathophysiological mechanisms in
  stroke and myocardial infarction, the potentially negative metabolic effects induced
  by some antihypertensive drugs, the importance of cardiovascular hypertrophy (in
  particular, left ventricular hypertrophy), and the inability of some antihypertensive
  agents to reverse such changes. To rectify some of these shortcomings, a more
  effective antihypertensive therapy is required. Ideally, an antihypertensive agent
  should provide effective lowering of blood pressure, in most patients to
  normotensive levels, while being devoid of potentially negative metabolic effects. It
  should also induce reversal of the changes of cardiovascular hypertrophy and, if
  possible, limit tissue damage if and when a vascular complication occurs
Dawson, D.L., Zierler, R.E. and Kohler, T.R. (1991), Role of Arteriography in the
  Preoperative Evaluation of Carotid-Artery Disease. American Journal of Surgery,
  161 (5), 619-624.
Abstract: This retrospective study was undertaken to determine the role of arteriography
  in the treatment of patients being considered for carotid endarterectomy. The results
  of preoperative classification of disease severity by duplex ultrasound and
  arteriography were compared, and the impact of arteriography on patient
  management was ascertained. We reviewed the records of 83 patients who had
  carotid surgery planned on the basis of their clinical history and duplex scan results
  and who then underwent arteriography. Duplex scan results agreed with the
  classification of stenosis by arteriography in 87% of evaluated sides and were within
  one category in 98%. In 87% of the cases reviewed, the clinical presentation and
  duplex scan findings were sufficient for appropriate patient management. In the
  instances that arteriography was useful (13%), the need for arteriography was evident
  when the duplex scan (1) was technically inadequate or equivocal; (2) showed an
  unusual distribution of disease, atypical anatomy, or a recurrent lesion; or (3)
  demonstrated an internal carotid artery with diameter-reducing stenosis of less than
  50% in a patient with hemispheric neurologic symptoms despite antiplatelet therapy
Keywords:                   ANGIOGRAPHY/CATHETER                           CEREBRAL
Asaph, J.W., Janoff, K., Wayson, K., Kilberg, L. and Graham, M. (1991), Carotid
  Endarterectomy in A Community-Hospital - A Change in Physicians Practice
  Patterns. American Journal of Surgery, 161 (5), 616-618.
Abstract: A total of 243 consecutive carotid endarterectomies (CEA) performed at
  Providence Medical Center in Portland, Oregon, were retrospectively reviewed over
  a 22-month period. Of these, 137 patients (56%) underwent CEA for asymptomatic
  disease, 52 (37%) of whom had stenotic lesions of 79% or less. There were 6 deaths
  (3%) and 12 strokes (5%). Four strokes were in asymptomatic patients. These data
  prompted development of criteria for CEA: (1) hemisphere-specific transient
  ischemic attacks, reversible ischemic neurologic deficits, or amaurosis fugax with an
  appropriate carotid lesion; (2) completed stroke with major recovery and significant
  carotid stenosis; (3) asymptomatic lesion with greater than 80% stenosis (D+) either
  by carotid arteriogram or non-invasive lab evaluation; and (4) other indications only
  with a supporting second opinion from a disinterested vascular surgeon,
  neurosurgeon or neurologist. A prospective review followed institution of the
  guidelines. In 21 months, 148 operations were performed, a 36% reduction over the
  initial study period. Of these, 46 (31%) were for asymptomatic lesions. Two patients
  (4%) did not fulfill the guideline criteria. There were six strokes (4%) and no deaths.
  The reduction of CEAs appears to be related to a significant decrease in
  "inappropriate" operations being performed. Surgeons' familiarity with the data
  rather than external pressures seems to be the major factor in changing practice
  patterns. The decrease in stroke/death rate is not statistically significant
Keywords:                                                                        ARTERY
Wall, C.A., Long, J.B., Lampert, N.R., Clarke, J.C. and Murray, R.E. (1991), Impact of
  Changing Attitudes in Carotid Surgery on Community- Hospital Practice. American
  Journal of Surgery, 162 (2), 190-193.
Abstract: In 1985, institutional guidelines for the evaluation and performance of carotid
  surgery were established in our community hospital. During the 5-year period from
  1985 through 1989, 159 carotid reconstructions were done. There were four major
  strokes (3%), one eventually resulting in death, with the second death in this series
  from a myocardial infarction (mortality 1%). The combined mortality/major stroke
  morbidity incidence was 3%. Three transient ischemic attacks (2%) postoperatively
  cleared promptly without residua. During the latter 1980s, an increasing number of
  vascular surgeons were doing less carotid surgery. Monitoring institutional quality
  assurance and individual surgeon performance within the community hospital is
  becoming a reality. Our experience with institutional guidelines for the evaluation
  and conduct of carotid surgery, together with an assessment of results and ongoing
  individual surgeon performance, is presented. Maintaining acceptable morbidity and
  mortality statistics can be enhanced by having a plan for assessment, management,
  and concurrent review
Califf, R.M., Fortin, D.F., Tenaglia, A.N. and Sane, D.C. (1992), Clinical Risks of
  Thrombolytic Therapy. American Journal of Cardiology, 69 (2), A12-A20.
Abstract: Understanding the clinical risks of intravenous thrombolytic therapy is critical
  to appropriate patient selection. The major risks can be classified into 5 major
  categories: intracranial hemorrhage, systemic hemorrhage, immunologic
  complications, hypotension, and myocardial rupture. Although theoretical concern
  exists about thromboembolic complications, they rarely occur. Although cardiac
  rhythm disturbances are somewhat more likely to occur at the time of reperfusion,
  the clinical significance of "reperfusion arrhythmias" is minimal. Intracranial
  hemorrhage, the most devastating complication, occurs in 0.2-1% of patients treated
  with thrombolytic therapy. Factors associated with incremental risk are now being
  identified from large clinical trials. Systemic hemorrhage is uncommon in patients
  without major vascular punctures and seldom leads to serious adverse outcomes.
  Immunologic complications-including anaphylaxis, which is rare, and immune
  complex disease, which is more common-occur only with streptokinase or agents
  with      a    streptokinase      moiety,     including      anistreplase    (anisoylated
  plasminogen-streptokinase activator complex, APSAC). Hypotension, which can be
  managed easily in most patients, is also observed much more frequently with
  streptokinase and anistreplase. Myocardial rupture is increasingly being recognized
  as a possible complication of late thrombolysis. A proper perspective on clinical risk
  can only be gained in the context of potential benefit of therapy. In many cases
  individual patients considered to be at highest risk for complications also stand to
  gain the most from treatment. Many of the questions raised by currently available
  data about bleeding risk are being addressed in the ongoing Global Utilization of
  t-PA and Streptokinase (GUSTO) Trial. A paradigm for considering this decision
  making problem is presented
Odell, M.W. and Sasson, N.L. (1992), Hemiparesis in Hiv-Infection - Rehabilitation
  Approach. American Journal of Physical Medicine & Rehabilitation, 71 (5),
Abstract: Persons with acquired immunodeficiency syndrome (AIDS) and human
  immunodeficiency virus (HIV) infection demonstrate a wide array of central nervous
  system impairments and may be at a significantly increased risk for cerebrovascular
  disease. Cerebrovascular disease can be the first manifestation of HIV infection and
  may be associated with a treatable etiology. Anticipating more referrals for
  HIV-related physical disability, we detail the rehabilitation management of three
  persons with HIV infection and hemiparesis. Onset of hemiparesis ranged from just
  before to 24 months after an AIDS- defining illness. No specific underlying etiology
  was identified in two of three patients, consistent with previous observations.
  Rehabilitation interventions included lower and upper extremity orthoses, assistive
  devices to aid gait and activities of daily living, therapeutic exercise and use of
  antispasticity medication. All patients made at least mild, temporary gains in
  functional status. Survival ranged from 3 to >6 months from initial contact with
  rehabilitation services. Neurologic and nonneurologic considerations in the
  rehabilitation of persons with HIV infection are discussed. We conclude that selected
  individuals with HIV infection and hemiparesis can benefit from rehabilitation
  intervention. HIV infection should be considered in any young adult presenting with
Harris, E.J., Moneta, G.L., Yeager, R.A., Taylor, L.M. and Porter, J.M. (1992),
  Neurologic Deficits Following Noncarotid Vascular-Surgery. American Journal of
  Surgery, 163 (5), 537-540.
Abstract: Neurologic events, following noncarotid vascular surgery (NCVS) are
  considered unpredictable. To test this hypothesis, we reviewed our vascular registry
  for a 3-year period and identified all patients with new postoperative focal neurologic
  events (stroke, hemispheric transient ischemic attack [TIA]) within 2 weeks of a
  category I or II vascular procedure as defined by the American Board of Surgery,
  exclusive of carotid surgery and arterial trauma. Thirteen of 1,390 NCVS procedures
  (0.9%) in 13 patients were associated with focal neurologic events. There were 2
  TIAs, 10 anterior circulation strokes, and 1 posterior circulation stroke.
  Twenty-seven percent of strokes were fatal. The neurologic deficit developed in the
  immediate postoperative period in 31%, more than 4 hours but less than 72 hours
  postoperatively in 54%, and within 3 to 14 days postoperatively in 15%. Patients
  with anterior circulation events (group A, n = 12) were compared for variables
   potentially influencing postoperative stroke with care controls who were selected
   using a table of random numbers (group B, n = 12). Controls were derived from a
   pool of all category I or II NCVS procedures recorded in our vascular registry
   sequentially during the same time period and who were without new neurologic
   deficits postoperatively. Using Fisher's exact test, comparisons between groups A
   and B revealed that new anterior circulation neurologic events in vascular surgical
   patients tended to be associated with intra-abdominal procedures (p < 0.05),
   perioperative hypotension (p < 0.05), and the presence of a greater than or equal to
   50% internal carotid artery stenosis ipsilateral to the neurologic event (p < 0.001).
   Such information may prove useful in the management of selected patients prior to
   arterial reconstruction and in operated NCVS patients with postoperative neurologic
   POSTOPERATIVE                                                 CEREBROVASCULAR
Urbinati, S., Dipasquale, G., Andreoli, A., Lusa, A.M., Ruffini, M., Lanzino, G. and
   Pinelli, G. (1992), Frequency and Prognostic-Significance of Silent Coronary-Artery
   Disease in Patients with Cerebral-Ischemia Undergoing Carotid Endarterectomy.
   American Journal of Cardiology, 69 (14), 1166-1170.
Abstract: To evaluate the prevalence and prognostic role of silent coronary artery
   disease (CAD) in patients with symptomatic high-grade carotid stenosis (70 to 99%)
   undergoing carotid endarterectomy, and with neither history nor symptoms of CAD,
   106 patients (76 men, 30 women, mean age 58.7 years [range 42 to 71]) with recent
   cerebral ischemia were prospectively studied. Patients were stratified as to the
   presence (n = 27, 25%) or absence (n = 79, 75%) of silent CAD defined by
   concordant abnormal exercise electrocardiographic testing and thallium-201
   myocardial scintigraphy. The male sex, the severity of the symptomatic carotid
   lesion ( > 90%), and the coexistence of contralateral carotid disease identified
   patients with higher probability of coexisting CAD. The 106 patients underwent 121
   operations (bilateral in IS). In the perioperative period, no deaths or cardiac events
   occurred, 1 patient suffered a recurrent stroke and 3 had a transient ischemic attack.
   During a mean follow-up period of 5.4 years, 9 patients died (1.7%/year): fatal
   myocardial infarction occurred in 5 (all in the silent CAD group), cancer in 3 and
   vertebrobasilar stroke in 1. Nonfatal events occurred in 9 patients: myocardial
   infarction in 1 (without silent CAD), unstable angina in 3 (with silent CAD), and
   cerebral ischemic attacks in 5. After 7 years, the Kaplan-Meier estimated survival
   free from coronary events was 5l% in patients with silent CAD, and 98% in patients
   without CAD (p < 0.01). In conclusion, among patients with symptomatic high-grade
   carotid stenosis undergoing carotid endarterectomy, even in absence of history or
   symptoms of CAD, a silent CAD is detectable in one fourth of the patients. Silent
   CAD did not affect the perioperative outcome, but strongly influenced the long-term
   prognosis. These results suggest the need for routine screening of silent CAD in
   patients with severe carotid stenosis to identify those at high long-term risk of
   cardiac events, for whom a more aggressive management should be warranted
Sleight, P. (1992), After the Diagnosis of Systemic Hypertension, Is Risk Factor
   Management Important. American Journal of Cardiology, 70 (12), D9-D13.
Abstract: In the hypertensive patient, the presence of other cardiovascular risk factors,
   particularly smoking, hypercholesterolemia, obesity, and diabetes, greatly influences
   the prognosis. In many patients, these other risk factors are linked, perhaps by
   adverse effects of pressure on endothelial function. The newer antihypertensive
   agents may have better effects on prognosis by ameliorating these other risk factors,
   as well as lowering pressure. We await trials to see if this promise is fulfilled
Keywords:                                                        BENEFITS/CORONARY
Sloan, M.A. and Gore, J.M. (1992), Ischemic Stroke and Intracranial Hemorrhage
   Following Thrombolytic Therapy for Acute Myocardial-Infarction - A Risk Benefit
   Analysis. American Journal of Cardiology, 69 (2), A21-A38.
Abstract: Stroke is a potentially serious complication of acute myocardial infarction
   (AMI). In the prethrombolytic era, most strokes were attributed to cerebral embolism.
   On the basis of available information, the occurrence of stroke in the thrombolytic
   era appears to be less than in the prethrombolytic era. In the thrombolytic era, the
   occurrence of various forms of intracranial hemorrhage has increasingly been
   documented in addition to cerebral embolism, with intriguing features. In general,
   however, the delineation of specific stroke subtypes has been imprecise and must
   take into account factors that are unique to this setting. Age is a risk factor for both
   ischemic and hemorrhagic stroke. Potential risk factors for intracranial hemorrhage
   include hypertension, dosage of fibrinolytic agents, and prior neurologic disease.
   Potential causes of intracranial hemorrhage include combined fibrinolytic/adjunctive
   therapies, various cerebrovascular lesions, and head trauma. Existing data suggest
   that mortality related to stroke complicating AMI is on the decline as well. More
   research is needed in order to quantify precisely the occurrence and proportions of
   stroke subtypes, risk factors, and causes in order to define mechanisms and
   preventive measures
Laragh, J.H. (1992), A Decade of Angiotensin-Converting Enzyme (Ace) Inhibition.
   American Journal of Medicine, 92 S3-S7.
Abstract: The renin system plays a critical role in hypertension as well as in the
   edematous states of heart failure, cirrhosis, and nephrosis. Properly performed
   measurements of plasma renin, with techniques now widely available, can be used as
   indicators of risk and of therapeutic strategies. The results of the plasma renin
   measurements are equally relevant whether they are high or low. The renin profile
   should be part of the routine workup of the patient with hypertension of any type or
   of the patient with an edematous disorder. Once the renin component of hypertension
   is established, management with angiotensin- converting enzyme (ACE) inhibitors,
   such as perindopril, follows, for ACE inhibitors attack the pathophysiologic source,
   thus providing adequate perfusion and protection of vital organs. The role of renin's
   involvement in hypertensive states is elaborated, as well as that of the ACE inhibitors
Chen, A. (1993), Effective Acupuncture Therapy for Stroke and Cerebrovascular
  Diseases .2. American Journal of Acupuncture, 21 (3), 205-218.
Abstract: In Part II the author reviews the contemporary therapies of Scalp acupuncture
  and Eye (Orbit) acupuncture, their application and supporting research in the
  treatment of post- stroke hemiplegia, and illustrates how each therapy is derived from
  traditional acupuncture. As such, both share points of the clinically significant
  ''Central System of Yang Meridians'' and the ''Eye System of Collaterals'' (described
  in Part I) which the author notes are frequently overlooked in traditional meridian
  theory. Part Ill will review acupuncture prescriptions for prevention of transient
  ischemic attack, hypertension, cerebral arteriosclerosis, hyperlipidemia,
  hyperlipoproteinemia and stress, as well as emergency treatments for coma and
Bower, T.C., Merrell, S.W., Cherry, K.J., Toomey, B.J., Hallett, J.W., Gloviczki, P.,
  Naessens, J.M. and Pairolero, P.C. (1993), Advanced Carotid Disease in Patients
  Requiring Aortic Reconstruction. American Journal of Surgery, 166 (2), 146-151.
Abstract: Perioperative stroke is a devastating complication of abdominal aortic
  operations. Patients requiring aortic reconstruction with advanced carotid occlusive
  disease pose a particularly challenging management problem regarding timing of
  operations. All patients (n = 121) undergoing both carotid artery endarterectomy
  (CEA) and abdominal aortic reconstruction (AAR) within 1 year of each other
  between 1979 and 1989 were reviewed. The sequence of operation was analyzed to
  determine its effect on early and late outcome. CEA was the first operation in 99
  patients (group I); AAR was performed first in 22 patients (group II). Age, gender,
  number, types of risk factors, and associated medical problems were similar in both
  groups. Indications for CEA were: transient ischemic attacks (TIAs), recent
  ipsilateral stroke, or high-grade asymptomatic carotid artery stenosis exceeding 80%.
  Indications for aortic operation included: abdominal aortic aneurysm, aortoiliac
  occlusive disease, and combined aortic and renovascular disease. There were five
  perioperative strokes, two in group 1 (2%) and three in group II (14%) (p <0.04). All
  strokes occurred after AAR. There were five perioperative deaths (4%), four in group
  I (4%) and one in group II (5%). Overall survival was significantly greater in group I
  compared to group II (p <0.04); 5-year survival was 77% and 51%, respectively.
  Multivariate analysis demonstrated age, hypertension, and diabetes to adversely
  affect survival; CEA as the first procedure, however, had a protective effect.
  Importantly, eight strokes occurred in group I in late follow-up, but only one was
  ipsilateral to the CEA. We conclude that CEA in selected patients who require AAR
  is safe, and, when performed prior to abdominal aortic repair, reduces perioperative
  stroke and may improve long-term survival
Synn, A.Y., Chalmers, R.T.A., Sharp, W.J., Hoballah, J.J., Kresowik, T.F. and Corson,
  J.D. (1993), Is There A Conduit of Preference for A Bypass Between the Carotid and
  Subclavian Arteries. American Journal of Surgery, 166 (2), 157-162.
Abstract: The conduit of choice for a bypass between the carotid and subclavian arteries
  remains controversial. We retrospectively evaluated 32 patients who underwent
  bypass between the carotid and subclavian arteries. Perioperative mortality was
  limited to a single patient who sustained a myocardial infarction. Long- term
  follow-up (mean: 46 months) revealed an 87% stroke-free survival rate, a 74%
  neurologic symptom-free survival rate, and a 77% primary patency rate at 5 years.
  No overall difference was discerned between a prosthetic or an autogenous vein
  conduit. However, in bypasses constructed from the subclavian artery to the level of
  the carotid bifurcation, 100% (nine of nine) of vein bypasses remained primarily
  patent compared with 40% (two of five) of prosthetic grafts (p <0.05). No distinct
  patency difference was identified between a short vein or a prosthetic bypass
  constructed between the proximal common carotid artery and subclavian artery. A
  vein bypass results in superior patency compared with a prosthetic graft for longer
  bypasses constructed from the subclavian artery to the and artery bifurcation
Hata, J.S., Ayres, R.W., Biller, J., Adams, H.P., Stuhmuller, J.E., Burns, T.L., Kerber,
  R.E. and Vandenberg, B.F. (1993), Impact of Transesophageal Echocardiography on
  the Anticoagulation Management of Patients Admitted with Focal Cerebral-Ischemia.
  American Journal of Cardiology, 72 (9), 707-710.
Abstract: Transesophageal echocardiography (TEE) improves the diagnostic accuracy
  of transthoracic echocardiography in the identification of potential cardiac sources of
  embolus. However, there are few studies of the impact of TEE on the medical
  management of patients with focal cerebral ischemia. The records of 52 consecutive,
  hospitalized patients undergoing both TEE and transthoracic echocardiography for
  suspected cardiac source of embolus were reviewed to determine the influence of
  TEE on the decision to anticoagulate patients. Of 52 patients, 39 had focal cerebral
  ischemia (transient ischemic attack, n = 9, acute cerebral infarction, n = 30). In 4 of
  these 39 patients (10%), the TEE results changed the management of anticoagulation.
  In 19 of 39 patients (49%). the TEE results helped confirm anticoagulation decisions,
  and in 16 (41%), the results had no effect on anticoagulation decisions, because of
  overriding clinical information. Ten of the latter 16 patients had TEE evidence for a
  possible source of an embolus, but were not anticoagulated; 5 of these were poor
  candidates for long- term anticoagulation, and the others had right-to-left shunting
  across a patent foramen ovale or an interatrial septal aneurysm. Clinical variables
  (atrial fibrillation, TEE findings and pre-TEE anticoagulation status) were considered
  as possible predictors of post-TEE anticoagulation status using logistic regression
  analysis; the strongest predictor of post-TEE anticoagulation status was pre-TEE
  anticoagulation status (p < 0.0005). Despite the selection of patients presumed to
  receive maximal benefit from TEE. this study suggests that TEE findings are not
  predictive of subsequent anticoagulation management However, TEE is at least
  confirmatory of anticoagulation decisions in most cases
Keywords:               ATRIAL             SEPTAL              ANEURYSM/CARDIAC
Maynard, C., Weaver, W.D., Litwin, P.E., Martin, J.S., Kudenchuk, P.J., Dewhurst,
  T.A., Eisenberg, M.S., Hallstrom, A.P. and Chambers, J. (1993), Hospital Mortality
  in Acute Myocardial-Infarction in the Era of Reperfusion Therapy (the
  Myocardial-Infarction Triage and Intervention Project). American Journal of
   Cardiology, 72 (12), 877-882.
Abstract: This study was conducted in 19 hospitals in the metropolitan Seattle area and
   included 6,270 unselected patients who had acute myocardial infarction (AMI)
   between January 1988 and April 1991. Hospital mortality was determined and
   related to patient demographic and clinical characteristics, the use of reperfusion
   therapies, and to complications after AMI. Thrombolytic therapy or direct coronary
   angioplasty <6 hours from symptom onset was used to treat 1,185 (19%) and 524
   (9%) patients, respectively. There were 629 (10%) hospital deaths; most occurred
   during the first 3 days of hospitalization. Factors affecting mortality after admission
   included: recurrent chest pain, recurrent AMI, development of heart failure, and the
   occurrence of stroke. After adjustment for age, treatment with thrombolytic therapy
   or direct angioplasty had no independent effect on reducing the overall mortality rate.
   Hospital mortality rates for AMI have improved considerably since 1970, although
   recurrent myocardial ischemic events continue to have an adverse effect on outcome.
   The current use of reperfusion treatments has had minimal causal impact on overall
   mortality rates, principally because less than one third of patients, who are relatively
   ''low risk,'' are eligible and receive these treatments
Keywords:                                                    ANGIOPLASTY/ELDERLY
Hillegass, W.B., Jollis, J.G., Granger, C.B., Ohman, E.M., Califf, R.M. and Mark, D.B.
   (1994), Intracranial Hemorrhage Risk and New Thrombolytic Therapies in Acute
   Myocardial-Infarction. American Journal of Cardiology, 73 (7), 444-449.
Abstract: Thrombolytic therapy for acute myocardial infarction (AMI) has reduced
   mortality at the expense of additional intracranial hemorrhages. To determine
   whether this trade-off has been optimized, a decision analysis was performed using
   pooled data to determine the further reductions in mortality required to justify
   increased intracranial hemorrhage rates from more potent thrombolytic and
   adjunctive antithrombotic regimens than intravenous streptokinase. Pooled data from
   large clinical trials suggest that streptokinase has a 0.07% nonfatal intracranial
   hemorrhage rate. Approximately 54% of these result in major/moderate disability
   and 46% in recovery or minor residual. The early mortality rate in all AMI patients
   treated with thrombolytic therapy is 9.8%; it is 6.8% in patients with inferior wall
   AMI and 17.9% in elderly patients. If a new thrombolytic regimen provides a 1%
   absolute reduction in early mortality compared with streptokinase therapy,
   approximately a greater than or equal to 3.2% nonfatal intracranial hemorrhage rate
   is justified to obtain this survival benefit. For a 10% relative reduction in mortality
   risk, the maximal acceptable nonfatal intracranial hemorrhage rates are 2.2% for
   inferior wall AMI, 3.2% for all patients and 5.9% for elderly patients. Whereas
   intracranial hemorrhage is a catastrophic complication of thrombolytic therapy in the
   treatment of patients with AMI, thrombolytic regimens that result in significantly
   higher rates of intracranial hemorrhage than those observed with streptokinase may
   be preferable at surprisingly smaller additional reductions in mortality. In addition to
   evaluating new thrombolytic and antithrombotic regimens, this analysis, in
   conjunction with models that predict patient-specific intracranial hemorrhage risks
   and mortality benefits from thrombolytic therapy, can Provide a framework for
   matching AMI patients with optimal thrombolytic regimens
Keywords:                                              AGE/BENEFIT/INTRACEREBRAL
Jones, E.F., Calafiore, P., Donnan, G.A. and Tonkin, A.M. (1994), Evidence That
   Patent Foramen Ovale Is Not A Risk Factor for Cerebral-Ischemia in the Elderly.
   American Journal of Cardiology, 74 (6), 596-599.
Abstract: Patent foramen ovale (PFO) may be a risk factor for ischemic stroke in young
   patients. The aim of this study was to assess the importance of PFO in subjects with a
   wider age range using patient-control methodology. Transesophageal contrast
   echocardiography and carotid imaging were performed in 220 consecutive patients
   with cerebral ischemia (mean age 66 +/- 13 years) and in 202 community-based
   control subjects (mean age 64 +/- 11 years). Of patients with stroke, 35 (16%) had
   PFO compared with 31 control subjects (15%) (p = 0.98). Analysis of PFO
   prevalence by age did not show a significant difference between patients and control
   subjects in the age groups <50 years (27% vs 11%; p = 0.33), 50 to 69 years (17% vs
   15%; p = 0.78), and greater than or equal to 70 years (12%. vs 17%; p = 0.43).
   However, the group aged <50 years was relatively small (26 cases, 19 controls). No
   significant difference in PFO prevalence was detected between patients with
   cryptogenic stroke (20%), noncryptogenic stroke (14%), and control subjects (15%).
   These results suggest that PFO is not a risk factor for cerebral ischemia in subjects
   aged >50 years, which would have major implications for the investigation and
   management of stroke patients in this age group. Longitudinal studies are now
   required to assess the incidence of stroke in sympton-free patients with PFO
Cannon, R.O., Tripodi, D., Dilsizian, V., Panza, J.A. and Fananapazir, L. (1994),
   Results of Permanent Dual-Chamber Pacing in Symptomatic Nonobstructive
   Hypertrophic Cardiomyopathy. American Journal of Cardiology, 73 (8), 571-576.
Abstract: Because dual-chamber (DDD) pacing has been shown to be of benefit
   regarding symptoms, rest and pacing hemodynamics, and exercise duration in
   patients with obstructive hypertrophic cardiomyopathy (HC), the effect of DDD
   pacing was assessed in patients with nonobstructive HC who were significantly
   symptomatic despite medical management. Echocardiography, treadmill exercise
   testing, thallium-201 scintigraphy, radionuclide angiography, and invasive
   measurement of rest and semi-erect bicycle exercise hemodynamics were performed
   in 12 patients before and approximately 4 months after permanent DDD pacing. One
   patient died 3 months after pacemaker implantation, because of worsening diastolic
   heart failure. Of the remaining 11 patients, 10 improved regarding symptoms, and
   treadmill exercise duration was longer during DDD pacing than during the baseline
   study in sinus rhythm (6.8 +/- 2.8 to 8.5 +/- 2.8 minutes; p <0.01), with a significant
   increase in the peak double product achieved (28.9 +/- 6.1 to 31.0 +/- 6.8 x 10(3); p
   <0.05). However, there were significant reductions in cardiac (3.7 +/- 0.9 to 3.1
   +/-0.5 ml/min/m2; p <0.01) and stroke volume (47.4 +/- 11.4 to 38.7 +/- 6.5
   ml/beat/m2; p <0.01) indexes, and a trend toward reduction in submaximal stroke
   volume index during DDD pacing as compared with the baseline study in sinus
   rhythm (44.7 +/- 13.5 to 40.9 +/- 10.9 ml/beat/m2; p = 0.097). No change in peak
   heart rate, cardiac or stroke volume index, mean blood pressure, or pulmonary artery
   or pulmonary capillary wedge pressure occurred with peak exercise during DDD
   pacing as compared with the initial exercise study in sinus rhythm. Furthermore,
   repeat exercise thallium-201 scintigraphy during DDD pacing in 9 patients showed
   no consistent change due to pacing. Of 10 patients >1 year after pacemaker
   implantation, cardiac medications have been reinitiated in 6, and DDD pacing was
   discontinued in 1, because of persistent or worsening symptoms. Thus, although
  DDD pacing in patients with nonobstructive HC was associated with improvement in
  symptoms and effort tolerance, there was absence of objective evidence of
  hemodynamic benefit, and a common need for reinitiation of medical therapy.
  Currently, chronic DDD pacing cannot be recommended for routine use in the
  management of patients with nonobstructive HC who are symptomatic despite
  medical management
Keywords:                                                                     CLINICAL
  PERFUSION                                            ABNORMALITIES/OUTFLOW
Mentzer, W.C., Heller, S., Pearle, P.R., Hackney, E. and Vichinsky, E. (1994),
  Availability of Related Donors for Bone-Marrow Transplantation in
  Sickle-Cell-Anemia. American Journal of Pediatric Hematology Oncology, 16 (1),
Abstract: Purpose: To determine who might qualify for allogeneic bone marrow
  transplantation (BMT), we reviewed the medical records of all 143 patients with
  sickle cell anemia under the age of 16 years who were registered at our center.
  Patients and Methods: A total of 135 records were complete and were used to
  estimate donor availability and disease severity. The mean number of siblings per
  patient was two, but this number decreased to 0.73 if half-siblings and siblings who
  had sickle cell anemia were excluded. Probability calculations indicated that a human
  leukocyte antigen (HLA)-matched sibling donor would be available for only 18% of
  patients with sickle cell disease. Results: With regard to clinical severity, if only
  stroke and chronic debilitating pain are considered criteria for bone marrow
  transplantation, only 16% of sickle cell patients would qualify, but with use of the
  broader criteria of the National Collaborative Study, 38% of patients would qualify.
  However, not all parents will consent to have bone marrow transplantation for their
  child, and only a minority of patients (18%) will have an HLA-matched sibling
  donor. Thus, as few as 1-2% of the total population of children with sickle cell
  anemia will ultimately qualify for marrow transplantation. Increasing the number
  who can undergo transplantation will require increasing the size of the donor pool.
  Conclusions: Search for other therapies not based on marrow transplantation should
  continue. For the majority of patients with sickle cell disease, these nontransplant
  treatments offer the best chance for enabling patients to achieve greater longevity
  and a better quality of life
Keywords:                                                            BONE-MARROW
Grinstead, W.C., Francis, M.J., Marks, G.F., Tawa, C.B., Zoghbi, W.A. and Young, J.B.
  (1994),      Discontinuation    of    Chronic     Diuretic     Therapy     in   Stable
  Congestive-Heart-Failure Secondary to Coronary-Artery Disease Or to Idiopathic
  Dilated Cardiomyopathy. American Journal of Cardiology, 73 (12), 881-886.
Abstract: To assess the feasibility of diuretic discontinuation In patients with stable
  congestive heart failure (CHF) and to identify risk factors for subsequent
  development of congestion, a prospective, 12-week clinical trial of unmasked
  diuretic withdrawal was conducted with continuation of background CHF therapy
  and double-blind randomization to placebo or lisinopril. Forty-one patients with a
  history of CHF and continuous diuretic use for greater than or equal to 3 months had
  all diuretic therapy discontinued, and therapy with lisinopril 5 mg (target 20 mg)/day
  (n = 20) or placebo (n = 21) begun the next day. A diuretic was restarted if new or
  worsening CHF symptoms and signs developed. Twelve patients (29%) did not
  require diuretic reinitiation at any time during follow-up, whereas 29 (71%) restarted
  diuretic therapy after a median of 15 days (range 2 to 42). Fourteen patients taking
  lisinopril and 15 taking placebo required diuretic drugs (p = NS). The baseline daily
  furosemide dose of >40 mg a left ventricular ejection fraction less than or equal to
  0.27, and history of systemic hypertension were independently predictive of early
  diuretic reinitiation by Cox proportional-hazards analysis. The probability of
  remaining diuretic-free after 6 weeks was 71% if none of these criteria were present.
  This trial demonstrates the feasibility of discontinuing diuretic drugs in certain
  patients with stable CHF and predicts those patients likely to require reinitiation of
  therapy. Diuretic withdrawal may be warranted when the furosemide dose is less
  than or equal to 40 mg/day, left ventricular ejection fraction is >0.27 and when no
  history of systemic hypertension is present
Belfort, M.A., Rokey, R., Saade, G.R. and Moise, K.J. (1994), Rapid Echocardiographic
  Assessment of Left and Right Heart Hemodynamics in Critically Ill Obstetric
  Patients. American Journal of Obstetrics and Gynecology, 171 (4), 884-892.
Abstract: OBJECTIVE: Our purpose was to compare noninvasive two- dimensional and
  Doppler echocardiography and right heart catheterization with a pulmonary artery
  catheter in the estimation of stroke volume, cardiac output, cardiac index, left
  ventricular filling pressure, pulmonary artery systolic pressure, and right atrial
  pressure in a heterogeneous group of critically ill obstetric patients. STUDY
  DESIGN: Eleven critically ill obstetric patients requiring invasive monitoring for
  clinical management were prospectively studied. Simultaneous Doppler and
  pulmonary artery catheter readings of stroke volume, cardiac output, cardiac index,
  left ventricular filling pressure, pulmonary artery systolic pressure, and right atrial
  pressure were acquired. Mean +/- SD or median and range, as appropriate, of each
  parameter were compared, and data for all parameters were subjected to regression
  analysis. A two- tailed p value < 0.05 was regarded as significant. RESULTS: There
  was no significant difference between the two techniques in the estimation of cardiac
  index, intracardiac pressures, or pulmonary artery systolic pressure. There was a
  good correlation between the two methods for stroke volume (R(2) = 0.98), cardiac
  output (R(2) = 0.98), cardiac index (R(2) = 0.96), left ventricular filling pressure
  (R(2) = 0.79), pulmonary artery systolic pressure (R(2) = 0.85), and right atrial
  pressure (R(2) = 0.86). CONCLUSION: Two-dimensional and Doppler
  echocardiography allow rapid, reliable, noninvasive assessment of hemodynamic
  parameters in critically ill obstetric patients and may give the clinician valuable
  information that may influence therapeutic and clinical management
  ECHOCARDIOGRAPHY/STROKE                                       VOLUME/TRICUSPID
Chang, B.B., Darling, R.C., Shah, D.M., Paty, P.S.K. and Leather, R.P. (1994), Carotid
  Endarterectomy Can be Safely Performed with Acceptable Mortality and Morbidity
  in Patients Requiring Coronary-Artery Bypass Grafts. American Journal of Surgery,
  168 (2), 94-96.
Abstract: BACKGROUND: Patients undergoing the placement of coronary artery
  bypass grafts (CABG) with hemodynamically significant carotid artery lesions pose
  a difficult problem for both cardiac and vascular surgeons. Despite numerous studies,
  there has been no consensus of opinion as to the proper management of these patients.
  In numerous series, the combined mortality and perioperative stroke rates in
  concomitant carotid endarterectomy and CABG procedures have ranged from 8% to
  40%. This has made many surgeons consider staging these procedures. METHODS:
  Retrospective analysis of patients undergoing combined carotid endarterectomies and
  CABG from 1980 to 1993 were reviewed. Two hundred six procedures were
  performed in 189 patients. Seventeen patients had bilateral carotid endarterectomy
  performed with CABG. The average age of our patient population was 66 years, with
  123 being male and 66 being female. Seventy-five percent of the patients were
  asymptomatic with the remainder having transient ischemic attacks, amaurosis fugax,
  or Drier stroke. RESULTS: Operative mortality was 2%, with three of four patients
  dying of cardiac failure and one of a stroke. A temporary neurologic deficit was seen
  in 2% of patients, and a permanent neurologic deficit was seen in 2 of 206, or 1%.
  Thirty shunts were used inn this series, mostly in patients with contralateral carotid
  occlusion. Ah procedures were performed under general anesthesia with full invasive
  monitoring. One patient was re- explored for bleeding, and one patient had a
  temporary hypoglossal palsy. A total of 203 cases had the arteriotomies closed
  primarily, and 3 required patches. CONCLUSION: In our experience, simultaneous
  carotid endarterectomy and CABG can he performed with an acceptable mortality
  and morbidity and does not appear to put the patient at an increased risk. Staging of
  these procedures may not be necessary in most cages
Heinemann, A.W., Hamilton, B., Linacre, J.M., Wright, B.D. and Granger, C. (1995),
  Functional Status and Therapeutic Intensity During Inpatient Rehabilitation.
  American Journal of Physical Medicine & Rehabilitation, 74 (4), 315-326.
Abstract: The objective of this study was to describe the relationships between
  functional status at discharge and intensity of therapies received during inpatient
  medical rehabilitation. The sample was comprised of 140 patients with traumatic
  brain injury and 106 patients with spinal cord injury at eight hospitals that subscribe
  to the Uniform Data System for Medical Rehabilitation. Data included linear
  measures of motor and cognitive ability derived from the Functional Independence
  Measure at admission to and discharge from rehabilitation. Multiple regression was
  used to predict intensity of therapies, discharge motor and cognitive function, the
  extent to which potential functional gains were achieved, and the efficiency of gains.
  Intensities of occupational, physical, and speech therapies were not significant
  predictors of outcomes for either group, controlling linearly for admission function,
  psychology intensity, length of stay, onset to admission interval, age, and interrupted
  stays. Only intensity of psychology services seemed to have any relation to
  functional gain (in cognition for patients with traumatic brain injury). The apparent
  lack of benefit related to intensity of therapies may be due to factors such as
  spontaneous recovery, goals not measured by the Functional Independence Measure,
  limited modulation of therapy intensity according to likely patient responsiveness, or
  therapies focused on impairment or other goals rather than disability. We suggest that
  efficiently staged rehabilitation should vary the intensity and nature of services
  according to patients' functional status, impairments, comorbid conditions, and other
  clinical factors
Keywords:                age/brain/CONTROLLED                     TRIAL/FUNCTIONAL
  STATUS/INDEPENDENCE                                             MEASURE/MEDICAL
  RTHRITIS/SPINAL                            CORD                     INJURY/STROKE
Cate, Y., Baker, S.S. and Gilbert, M.P. (1995), Occupational-Therapy and the Person
  with Diabetes and Vision Impairment. American Journal of Occupational Therapy,
  49 (9), 905-911.
Abstract: Diabetes affects 5.2% of the population; many of those persons experience
  loss of vision as one complication of the disease. Occupational therapists are treating
  these persons often for other resulting complications (such as stroke or amputations),
  or are being ask ed to adapt techniques or equipment (such as insulin-drawing
  devices) needed for diabetes management. Because no guidelines exist for
  occupational therapy with persons with diabetes or vision loss or both, occupational
  therapists may be unsure of appropriate treatment approaches. Among the
  approaches described in the occupational therapy literature, common ones include
  collaboration with other professionals and incorporation of one or more aspects of
  the diabetes regimen into the person's life-style. When addressing persons who have
  both diabetes and vision loss, therapists consider their own knowledge base as well
  as the persons' needs in managing their diabetes. Treatment ideas include enhancing
  the visual environment or incorporating tactile and auditory feedback with
  self-management tasks such as testing blood glucose let,els. Collaboration with and
  referral to diabetes and low-vision professionals are adjuncts to therapy and ensure a
  comprehensive and ongoing diabetes management program
Keywords:                    ACTIVITIES                      OF                   DAILY
Mathis, J.M., Barr, J.D., Jungreis, C.A., Yonas, H., Sekhar, L.N., Vincent, D., Pentheny,
  S.L. and Horton, J.A. (1995), Temporary Balloon Test Occlusion of the Internal
  Carotid-Artery - Experience in 500 Cases. American Journal of Neuroradiology, 16
  (4), 749-754.
Abstract: PURPOSE: To describe experience with 500 temporary balloon occlusions of
  the internal carotid artery, with particular emphasis on the techniques and
  complications. METHODS: Temporary occlusion of the internal carotid artery was
  accomplished endovascularly using various balloon-catheter combinations. These
  temporary balloon occlusions were combined, when possible, with cerebral blood
  flow analysis with stable xenon-enhanced CT. RESULTS: Complications related to
  this procedure occurred in 16 (3.2%) patients. Eight (1.6%) patients had
  asymptomatic complications. There were 8 who experienced neurologic changes. Six
  (1.2%) of these were transient; two (0.4%) were permanent. There were no deaths.
  CONCLUSIONS: Temporary balloon occlusion of the internal carotid artery,
  believed helpful in identifying patients at risk of stroke during abrupt carotid artery
  sacrifice, can be performed with an acceptably low complication rate
Keywords: ANEURYSMS/ARTERIES/CAROTID/carotid artery/CBF/cerebral blood
  flow/CEREBRAL                  BLOOD-FLOW/complications/CT/INTERNAL/internal
  carotid/internal                   carotid                 artery/INTERVENTIONAL
  TESTING/stroke/SURGERY/TC-99M-HMPAO                           SPECT/THERAPEUTIC
Dabaghi, S.F., Rokey, R., Rivera, J.M., Saliba, W.I. and Majid, P.A. (1995),
  Comparison of Echocardiographic Assessment of Cardiac Hemodynamics in the
  Intensive-Care Unit with Right-Sided Cardiac-Catheterization. American Journal of
  Cardiology, 76 (5), 392-395.
Abstract: Estimation of left ventricular filling pressure and cardiac index is important in
  the management of patients requiring right heart catheterization. Doppler
  echocardiography can provide a noninvasive measure of these parameters, but its
  accuracy in individual measurements, predicting hemodynamic subgroups, and in
  tracking serial changes in critically ill patients remains to be elucidated. Left
  ventricular filling pressure and cardiac index were assessed in 49 critically ill
  patients requiring right heart catheterization and Doppler echocardiographic studies.
  Two or more serial studies were performed in 18 of these subjects, patients were
  placed into 1 of 4 hemodynamic subgroups for each technique based on the acquired
  hemodynamic parameters. Left ventricular filling pressure and cardiac index by
  Doppler echocardiography and right heart catheterization were similar (21 +/- 8 vs
  20 +/- 8 mm Hg; 3.0 +/- 1.2 vs 2.9 +/- 1.2 L/min/m(2), respectively) and correlated
  well with each other (left ventricular filling pressure, r = 0.88; cardiac index, r =
  0.92). The Doppler technique accurately placed 73 of 76 studies into the correct
  hemodynamic subgroup. The noninvasive technique also reliably tracked serial
  hemodynamic measurements, We conclude that Doppler echocardiography
  accurately assesses left heart hemodynamics in critically ill patients. Since this
  technique can be readily acquired, it can be ideal for the rapid assessment of
  hemodynamic parameters in critically ill patients, especially when right heart
  catheterization is delayed or is problematic
  DIASTOLIC                                                          PRESSURE/HEART-
Heesch, C.M., Marcoux, L., Hatfield, B. and Eichhorn, E.J. (1995), Hemodynamic and
  Energetic Comparison of Bucindolol and Metoprolol for the Treatment of
  Congestive-Heart-Failure. American Journal of Cardiology, 75 (5), 360-364.
Abstract: Although beta blockers have demonstrated a salutary effect on ventricular
  function in patients with heart failure, it is unclear whether a nonselective
  third-generation beta blocker produces different hemodynamic and energetic effects
  than a second-generation beta(1) selective agent. In 30 male patients with heart
  failure, we retrospectively analyzed hemodynamic data from 2 protocols examining
  the effects of a nonselective beta antagonist bucindolol (n = 15), and a highly
  selective beta(1) antagonist metoprolol (n = 15). Both studies were conducted in a
  similar fashion with patients undergoing cardiac catheterization before and after
  receiving 3 months of beta blockade. Both groups were matched at baseline in terms
  of ventricular function. beta blockade resulted in similar reductions in heart rate and
  similar improvements in ejection fraction, ventricular volumes, stroke and minute
  work, peak +dP/dt, and isovolumic relaxation in both groups. Only patients taking
  bucindolol had a significant within-group decrease in resting left ventricular
  end-diastolic pressure. The metoprolol group had a greater decrease in coronary
  sinus flow and myocardial oxygen consumption. Bucindolol increased cardiac index
  more than metoprolol, but did not increase stroke volume index more than
  metoprolol. The bucindolol group had an increase in systolic elastance, whereas the
  metoprolol group had a parallel left shift in this relation. Thus, metoprolol reduces
   coronary blood flow and myocardial oxygen consumption more than bucindolol,
   whereas bucindolol produces slightly more favorable improvements in resting
   cardiac index and end- diastolic pressure. Otherwise, these 2 agents produced similar
   hemodynamic changes
Keywords: BETA-ADRENERGIC-BLOCKADE/heart failure/heart rate/IDIOPATHIC
   ATION/stroke/stroke volume/VOLUME RELATION
Flaker, G.C., Fletcher, K.A., Rothbart, R.M., Halperin, J.L. and Hart, R.G. (1995),
   Clinical and Echocardiographic Features of Intermittent Atrial- Fibrillation That
   Predict Recurrent Atrial-Fibrillation. American Journal of Cardiology, 76 (5),
Abstract: In addition to antithrombotic therapy, 2 treatment strategies for intermittent
   atrial fibrillation (AF) are evolving: suppression of AF or control of the ventricular
   response during AF. Clinical and echocardiographic features that predict recurrent
   AF may influence the choice of management. In this study, clinical,
   echocardiographic, and electrocardiographic data from 486 patients with intermittent
   AF in the Stroke Prevention in Atrial Fibrillation studies were analyzed. Patients
   with intermittent AF were younger (p <0.001), had fewer incidences of systemic
   hypertension (p <0.007) and heart failure (p <0.001), and had more recent-onset AF
   than patients with constant AF. They also had a smaller mean left atrial diameter, a
   lower prevalence of a large (>5 cm) left atrium, better left ventricular performance
   by echo, and less mitral regurgitation. After a mean follow-up of 26 months, 51% of
   patients remained in sinus rhythm and 49% of patients developed recurrent AF,
   including 12% who had AF, as seen on all follow- up electrocardiograms. Clinical
   factors predicting recurrent AF were age, heart failure, and myocardial infarction. An
   enlarged left atrium was associated with recurrent intermittent AF; an enlarged left
   ventricle predicted conversion to constant AF. Thus, clinical and echocardiographic
   parameters predict recurrent AF in patients with intermittent nonvalvular AF
Keywords:              age/atrial         fibrillation/CARDIOVERSION/DISEASE/heart
   infarction/SINUS RHYTHM/strategies/THERAPY
Francis, G.S., Mcdonald, K., Chu, C.X. and Cohn, J.N. (1995), Pathophysiologic
   Aspects of End-Stage Heart-Failure. American Journal of Cardiology, 75 (3),
Abstract: Heart failure is not a distinct disease, but rather a complex clinical syndrome
   that can result from virtually any form of heart disease. The so-called ''end stages'' of
   heart failure do not respect etiologic boundaries. Patients are characterized clinically
   by extreme cardiomegaly, breathlessness, and fluid retention. Despite recent ad
   vances in the pharmacologic management of congestive heart failure, it remains a
   highly lethal and disabling disorder. Only through an improved understanding of the
   basic biology of the early stages of the syndrome can heart failure be prevented or at
   least forestalled. There is now intense interest in understanding the mechanisms
   operative in early left ventricular remodeling, which has the potential to culminate in
   end-stage heart failure. The study of animal models has been particularly useful in
   this card, as have clinical studies performed in the early stages of acute myocardial
   infarction. The remodeling process is characterized by myocyte loss and segmental
   scarring, interstitial fibrosis, myocardial slippage, and myocyte hypertrophy.
   Although the mechanisms responsible for these topographic changes are as yet
   unclear, the net result is progressive enlargement of the heart, culminating in severe
   left ventricular dysfunction. A long-held view that cardiomegaly is a necessary
   adaptive process that maintains stroke volume in the presence of a falling ejection
   fraction has been challenged, although undoubtedly the early responses to
   myocardial injury In the form of myocyte hypertrophy and maintenance of wall
   stress are useful adaptations. However, as the left ventricle continues to dilate and
   hypertrophy over time, a form of overadjustment occurs that perhaps is an important
   contributory factor toward end-stage failure. Current therapeutic strategies designed
   to modify this process include the use of pharmacologic agents designed to optimize
   loading conditions and reduce myocyte hypertrophy. Although we are only now
   beginning to understand the underpinnings of progressive left ventricular remodeling,
   it is apparent that this is a potentially modifiable process
Keywords:                acute/acute              myocardial             infarction/ACUTE
   Y/DILATATION/FIBRILLAR                     COLLAGEN/heart            failure/ISCHEMIC
   infarction/strategies/stroke/stroke volume/UNITED-STATES
Tsuji, T., Sonoda, S., Domen, K., Saitoh, E., Liu, M. and Chino, N. (1995), ADL
   structure for stroke patients in Japan based on the functional independence measure.
   American Journal of Physical Medicine & Rehabilitation, 74 (6), 432-438.
Abstract: The difficulty patterns of FIM (Functional Independence Measure) in Japan
   were determined and compared with patterns found in the United States to assess
   whether FIM can be used for worldwide comparisons of ADL (the activities of daily
   living). The FIM was measured for 190 stroke patients in several hospitals
   throughout Japan. The scores at admission and discharge were converted to an
   interval scale by Rasch analysis. Right and left brain lesion patients were analyzed
   separately. The FIM items were divided into two groups: motor items and cognitive
   items to minimize misfit, A degree of misfit was acceptable, except for bowel and
   bladder management, stairs, bathing, and expression. Motor items, eating, and bowel
   and bladder management were the easiest stairs, bathing and tub/shower transfers
   were the most difficult. The difficulty patterns of patients with left and right
   hemisphere lesions were almost identical. Bathing and tub/shower transfer were
   more difficult for Japanese patients than for those studied in the United States.
   Concerning the cognitive items, expression was easiest for patients with right
   hemisphere lesions but most difficult for those with left hemisphere lesions. Social
   interaction was easier for Japanese patients with left hemisphere lesions than the
   other patients. The item difficulty patterns in Japan differs slightly from those in the
   United States because of cultural differences. As countries show different patterns of
   difficulty, we must be careful when making international comparisons of FlM data
   converted by Rasch analysis
Keywords: activities of daily living/brain/cerebrovascular disorders/disability
Psaty, B.M., Siscovick, D.S., Weiss, N.S., Koepsell, T.D., Rosendaal, F.R., Lin, D.Y.,
   Heckbert, S.R., Wagner, E.H. and Furberg, C.D. (1996), Hypertension and outcomes
   research - From clinical trials to clinical epidemiology. American Journal of
   Hypertension, 9 (2), 178-183.
Abstract: Outcomes research seeks to identify effective evidence-based methods of
   providing the best medical care. While randomized clinical trials (RCT) usually
   provide the dearest answers, they are often not done or not practicable. More than a
   decade after the introduction of calcium channel blockers and angiotensin converting
   enzyme (ACE) inhibitors, clinical trial data about their effect on major disease
   endpoints in patients with hypertension are still not available. The primary
   alternatives are the use of randomized trials that include surrogate endpoints, such as
   level of blood pressure or extent of carotid atherosclerosis, and the use of
   observational studies that include major disease endpoints. Both approaches, their
   strengths and limitations, are discussed in detail. The possibility of residual
   confounding limits the strength of inferences that can be drawn from observational
   studies. Similarly, the possibility of important drug effects, other than those
   involving the surrogate endpoint, limits the inferences that can be drawn from
   randomized trials that rely solely on surrogate outcomes as guides to therapy. In the
   absence of evidence from large clinical trials that include major disease endpoints,
   treatment decisions and guidelines need to synthesize the best available information
   from a variety of sources. Consistency of findings across various study designs,
   outcomes, and populations is critical to the practice of evidence-based medicine and
   the effort to maximize the health benefits of antihypertensive therapies
Keywords:            atherosclerosis/blood         pressure/BLOOD-PRESSURE/clinical
   trials/confounding           variables/CORONARY                HEART-DISEASE/drug
   MORTALITY/observational studies/ORAL MILRINONE/outcomes/PRIMARY
Jackson, M.R., Daddio, V.J., Gillespie, D.L. and ODonnell, S.D. (1996), The fate of
   residual defects following carotid endarterectomy detected by early postoperative
   duplex ultrasound. American Journal of Surgery, 172 (2), 184-187.
Abstract: BACKGROUND: The purpose of this study is to evaluate the results of
   color-flow duplex ultrasound (CFB) soon after carotid endarterectomy (CEA) to
   determine the incidence of residual abnormalities and their effect on subsequent
   outcome and management. METHODS: We reviewed 318 consecutive CEAs
   performed over a 48 month-period, Of these, 206 were followed up with CFD, 195
   prior to discharge and 11 at first follow-up (within 9 weeks). Patients (43) followed
   up with only oculoplethysmography (OPG) car those with no OPG or CFD (69) were
   excluded from the study, All CEAs were performed under general anesthesia with
   routine shunting and patch angioplasty. RESULTS: Twelve of the 206 studies (5.8%)
   were abnormal, Two patients with an abnormal CFD sustained perioperative stroke,
   both of whom had distal intimal lesions of >60% diameter stenosis by velocity
   criteria, Four patients had >60% stenosis and were reoperated upon to correct
   technical errors, The remaining 6 patients are asymptomatic, Four had residual
   lesions of <60% stenosis, three of which have returned to normal on subsequent CFD,
   Two residual lesions had >60% stenosis; one returned to normal by CFD and the
   other remains abnormal at 10 months, In the group of 192 normal postoperative CFD
   studies, there were no strokes, deaths, or redo procedures (0%, 95% confidence
   interval 0% to 1.54%) compared with a combined 50% rate (6 of 12) of either stroke
   (2 of 12) or redo procedure (4 of 12) when the postoperative CFD was abnormal
   (95% confidence interval 22.3% to 77.7%, P < 0.0001), During the study period the
   CEA stroke rate was 0.9% (3 of 318), with a combined stroke-mortality rate of 1.3%
   (4 of 318). CONCLUSIONS: Early postoperative CFD identified residual
   abnormalities in 5.8% of carotid endarterectomies despite a low overall stroke
   mortality rate, One half of these abnormalities resulted in stroke or required operative
   correction, Color-flow duplex ultrasound is useful in identifying residual
   abnormalities following CEA and should be considered for intraoperative use
Keywords:                                                          ANGIOGRAPHY/carotid
Morley, J., Marinchak, R., Rials, S.J. and Kowey, P. (1996), Atrial fibrillation,
  anticoagulation, and stroke. American Journal of Cardiology, 77 (3), A38-A44.
Abstract: There is a demonstrated statistical association between atrial fibrillation,
  rheumatic valvular disease, and embolic stroke. This article assesses the results of 6
  major clinical trials (AFASAK, BAATAF, SPINAF, SPAF [parts I and II], CAFA
  and EAFTA- see text for trial names). Multivariate analysis revealed 4 independent
  clinical features that identified patients with atrial fibrillation at an increased risk for
  stroke: hypertension, increasing age, previous transient ischemic attack, and diabetes
  mellitus. Without anticoagulation therapy, patients with any of these risk factors had
  a 4% annual risk of stroke. Patients with cardiac disorders such as congestive heart
  failure and coronary artery disease have a stroke rate 3 times higher than patients
  without any risk factors; patients with atrial fibrillation but no concomitant risk
  factors or structural heart disease seemed to have little concomitant risk for stroke.
  Meta-analysis revealed a 64% reduction of risk for stroke in patients treated with
  warfarin, as compared with placebo. The value of warfarin therapy in patients >75
  years old is less clear because of a high risk of hemorrhagic complications
Keywords: age/atrial fibrillation/clinical trials/COMPLICATIONS/coronary artery
  disease/diabetes                                                              mellitus/heart
Armstrong, L.E., Crago, A.E., Adams, R., Roberts, W.O. and Maresh, C.M. (1996),
  Whole-body cooling of hyperthermic runners: Comparison of two field therapies.
  American Journal of Emergency Medicine, 14 (4), 355-358.
Abstract: Severe exercise induced hyperthermia requires rapid cooling. Of the many
  cooling modalities available, there is disagreement over which is the most effective.
  The purpose of this field study was to compare two cooling therapies for
  hyperthermic distance runners who had completed an 11.5-km summer foot race.
  Twenty-one distance runners (mean [+/- SE] initial rectal temperature 41.2 +/- 0.2
  degrees C) were treated either by ice water immersion (1 to 3 degrees C, n = 14) or
  by air exposure while wrapped in wet towels (24.4 degrees C ambient, n = 7). Ice
  water immersion versus air exposure resulted in significantly different (P <.005)
  pretherapy to posttherapy changes in rectal temperature (-3.0 +/- 0.3 v -1.4 +/- 0.3
  degrees C) and mean cooling rate(0.20 +/- 0.02 v 0.11 +/- 0.02 degrees C/min). Ice
  water immersion cooled approximately twice as fast as air exposure. These data
  refute the theory that ice water immersion is an inefficient cooling modality.
  Copyright (C) 1996 by W.B. Saunders Company
Keywords: blood pressure/body temperature/CANINE MODEL/COMPARATIVE
  rate/heat exhaustion/heat injuries/HEAT-STROKE/hyperthermia/ICED GASTRIC
Alderman, M.H. (1996), Absolute cardiovascular risk: The basis for deciding to treat.
  American Journal of Nephrology, 16 (3), 182-189.
Abstract: It has been convincingly demonstrated that raised blood pressure is a risk
  factor for cardiovascular disease and that its reduction saves lives. It seems logical to
  suggest that the whole population's blood pressure distribution should be displaced
  downwards, since the reduction of blood pressure by only a few millimeters of
  mercury, if easily and safely achieved, would produce more disease prevention than
  could be attained by any other conceivable clinical strategy. Physicians already have
  powerful tools to lower blood pressure in individual patients, but must make
  challenging decisions as to when and how to use them. Blood pressure level is a
  reflection of relative risk and one of many risk factors that determine absolute risk.
  Reduction of blood pressure therefore does not cure cardiovascular disease, but
  reduces the risk of developing disease. The need for hypotensive therapy should be
  determined by absolute risk and the opportunity for successful prevention, rather
  than by a threshold level of blood pressure. The task of the physician is to assist the
  patient in assessing the balance between the potential for benefit and the burden of
  intervention, and to provide the best possible care to implement the therapeutic
  choice that is made
Keywords:             absolute           risk/blood        pressure/BLOOD-PRESSURE
  REDUCTION/cardiovascular                                           disease/CORONARY
  sive                        therapy/MANAGEMENT/MORTALITY/MYOCARDIAL-
  INFARCTION/prevention/PROFILE/relative risk/risk factors/STROKE
Roubin, G.S., Yadav, S., Iyer, S.S. and Vitek, J. (1996), Carotid stent-supported
  angioplasty: A neurovascular intervention to prevent stroke. American Journal of
  Cardiology, 78 8-12.
Abstract: Obstructive carotid artery disease is responsible for 60% of strokes in the
  United States and is the third major cause of death. Stent-supported carotid artery
  angioplasty has the potential to prevent stroke in thousands of patients and offers a
  number of potential advantages over surgical revascularization (carotid
  endarterectomy). Results of the prospective observational study at the University of
  Alabama at Birmingham indicate that carotid stent-supported angioplasty is safe and
  probably effective in reducing stroke in patients with high-risk cerebrovascular
  disease. Technical success was achieved in 99% of 146 procedures; 210 stents were
  placed in 152 vessels, with only 1 instance of stent thrombosis. The rate of major
  in-hospital complications was unexpectedly low-only 1 death and 2 major strokes.
  Seven patients suffered minor strokes, but only 2 were left with minor weakness.
  When compared with a projected complication rate of 6% had these patients
  undergone carotid endarterectomy, stenting resulted in fewer major events. At
  6-month follow-up, 69 of 74 patients were evaluated by angiography or ultrasound,
  which detected 8 cases of stent deformation and a restenosis rate of <5%. Because of
  these instances of stent deformation, use of the Palmaz (biliary) stent was
  discontinued. Although 1 patient had a transient ischemic attack, no strokes occurred
  during follow- vp. To date, carotid stenting is an investigational procedure.
  Cardiovascular interventionalists, industry, and the FDA are encouraged to validate
  this approach through clinical testing. However, Improvements in technique, devices,
  and adjunctive therapies are needed before the method can be tested in randomized
Keywords: angiography/angioplasty/carotid artery/carotid artery disease/carotid
  trials/stents/stroke/thrombosis/transient/transient ischemic attack/United States
Wilcox, R.G. (1996), Clinical trials in thrombolytic therapy: What do they tell us?
  INJECT 6-month outcomes data. American Journal of Cardiology, 78 20-23.
Abstract: Numerous controlled clinical trials have documented the efficacy of
  thrombolytic agents in reducing the risk of mortality after myocardial infarction (MI),
  As a result, it is no longer ethical to test a new thrombolytic regimen against placebo,
  Rather, promising new therapies must be compared with proven treatments, This has
  been the direction taken in trials of reteplase, a new recombinant plasminogen
  activator. Initial studies of double-bolus reteplase demonstrated its superior ability to
  produce TIMI grade 2 or 3 flow at 90 minutes when compared with accelerated
  alteplase, A subsequent randomized, double-blind, 9-country study, the international
  Joint Efficacy Comparison of Thrombolytics (INJECT) trial was designed to
  determine whether the efficacy of reteplase is at least equivalent to that of
  streptokinase, The 2 treatments were associated with similar frequencies of
  in-hospital cardiac events, bleeding, and strokes, Likewise, no significant difference
  was apparent between the reteplase and streptokinase groups with regard to 35-day
  mortality (the primary endpoint), the combined endpoint of 35-day mortality plus
  continuing disability from in-hospital stroke, or 6-month mortality, Unadjusted data
  from the 3 countries that contributed the majority of patients seemed to indicate a
  survival benefit, irrespective of treatment allocation, among patients who underwent
  interventional procedures. However, no such benefit was apparent when the data
  were adjusted far differences in the baseline characteristics of the patients enrolled in
  the different countries. Rather, intervention within the first 3 days post-MI was found
  to place patients at a substantially higher risk of 35-day mortality, Further insights
  into the relative efficacy of reteplase should emerge from the ongoing third Global
  Utilization of Strategies to Open Occluded Coronary Arteries (GUSTO-III) trial. (C)
  1996 by Excerpta Medica, Inc
Keywords:         cardiac        events/clinical      trials/disability/mortality/myocardial
Antman, E.M. (1996), Maintaining sinus rhythm with antifibrillatory drugs in atrial
  fibrillation. American Journal of Cardiology, 78 67-72.
Abstract: Management of atrial fibrillation is a common and complex clinical problem,
  Two major treatment strategies have emerged: suppression of recurrences versus
  control of ventricular rate and anticoagulation to reduce the risk of stroke.
  Maintaining sinus rhythm offers the hemodynamic benefits of improving ventricular
  performance and exercise capacity but may expose the patient to the risk of
  proarrhythmia/sudden death and drug- related morbidity, Controlling ventricular rate
  helps decrease symptomatic palpitations and improve exercise capacity but
  necessitates long-term anticoagulation (which may also be needed despite the use of
  antiarrhythmics to suppress recurrences of atrial fibrillation) with some risk of
  bleeding, Randomized trials are now needed to define the relative benefits of these 2
  treatment strategies, Such trials should be designed to provide information on the
  impact of the 2 approaches on symptoms, exercise capacity, quality of life, and
  mortality rate in patients with atrial fibrillation
Keywords:                                            AMIODARONE/anticoagulation/atrial
  CE/morbidity/mortality/PREVENTION/QUINIDINE                      THERAPY/risk           of
Childers, M.K., Stacy, M., Cooke, D.L. and Stonnington, H.H. (1996), Comparison of
  two injection techniques using botulinum toxin in spastic hemiplegia. American
  Journal of Physical Medicine & Rehabilitation, 75 (6), 462-469.
Abstract: This study sought to test the hypothesis that injections of botulinum toxin type
  A (BTX-A) at the mid belly of the gastrocnemius muscle in spastic hemiplegic adults
  produce superior clinical results to proximal injections directed toward the muscular
  origin. We designed a randomized, double- blind, placebo-controlled intervention
  study at a university tertiary care setting. Seventeen subjects with chronic spastic
  hemiplegic gait were enrolled from a volunteer community sample; time range from
  acute neurologic insult was 0.75 to 31 yr; age range was 19 to 71 yr; gender
  consisted of 11 men and 4 women; diagnoses were 12 patients with stroke, 2 with
  traumatic brain injuries, and 1 with a brain tumor, Two subjects were withdrawn
  from the study because of (1) acute vascular occlusion before intervention and (2)
  noncompliance with follow-up visits. After baseline measurements, subjects were
  injected with 50 units of BTX-A (volume, 0.5 cc) into the medial or lateral
  gastrocnemius: (1) proximally at one site near the muscular origin; (2) distally at
  three sites along the mid belly. We measured outcome using the Fugl-Meyer score,
  Ashworth scale, ankle range of motion, and a timed 50-ft fastest walk. No outcome
  measures showed a significant effect attributable to site of injections. Confounding
  variables included physical therapy and varying duration of illness in the study
  cohort. We conclude that the results failed to support the hypothesis that BTX-A
  injections at the mid belly of the gastrocnemius produced superior functional
  improvements to injections located near the muscular origin using localization
  techniques described. Additional research comparing more precise localization
  methods for BTX-A injections might Further establish the importance of
  electromyographic guidance using BTX-A in management of spasticity
Keywords: A TOXIN/acute/age/botulinum toxin/brain/CEREBRAL-PALSY/double-
Rockman, C.B., Riles, T.S., Fisher, F.S., Adelman, M.A. and Lamparello, P.J. (1996),
  The surgical management of carotid artery stenosis in patients with previous neck
  irradiation. American Journal of Surgery, 172 (2), 191-195.
Abstract: BACKGROUND: A history of therapeutic irradiation to the neck complicates
  the management of carotid artery occlusive disease, Serious surgical concerns are
  raised regarding alternative incisions, difficult dissections, and adequate wound
  closure. Pathology may be typical atherosclerotic occlusive disease or
  radiation-induced arteritis, In order to establish guidelines for the treatment of these
  patients, we have reviewed our operative experience. PATIENTS AND METHODS:
  A review of our operative experience over the past 15 years revealed 10 patients with
  a history of prior irradiation to the neck who underwent 14 carotid operations.
  RESULTS: The indications for radiation included laryngeal carcinoma and
  lymphoma, Five patients had undergone previous radical neck dissections, and four
  patients had permanent tracheostomies. The surgical indications were asymptomatic
  high-grade stenosis in 7 cases, transient ischemic attack in 4 cases, stroke in 2 cases,
  and a pseudoaneurysm in 1 case, Conventional carotid endarterectomy with patch
  angioplasty was used in 10 of the 14 operations, In the remaining four operations,
  saphenous vein interposition grafting was utilized to replace the diseased segment of
  carotid artery secondary to a panarteritis, Wound closure required dermal grafting in
  two of five cases where surgery was performed ipsilateral to a prior radical neck
  dissection, One perioperative cerebral infarction occurred; there were no other
  neurologic or non-neurologic complications, All patients are doing well in one- to
  five-year follow-up, with serial postoperative duplex scans demonstrating no signs of
  recurrent stenosis. CONCLUSIONS: Patients with a history of irradiation to the neck
  should be screened for the presence of carotid disease. Carotid occlusive disease
  should be treated surgically in these patients with the usual indications.
  Intraoperative surgical management is similar to that of non-irradiated patients.
  Concerns about difficulty in achieving an adequate endarterectomy plane and about
   problems with wound closure have generally been unfounded
Keywords:               ATHEROSCLEROSIS/carotid                   endarterectomy/cerebral
   CERVICAL                                                IRRADIATION/OCCLUSIVE
Weber, B.E. and Kapoor, W.N. (1996), Evaluation and outcomes of patients with
   palpitations. American Journal of Medicine, 100 (2), 138-148.
Abstract: PURPOSE: To determine: (1) the etiologies of palpitations, (2) the usefulness
   of diagnostic tests in determining the etiologies of palpitations, and (3) the outcomes
   of patients with palpitations. PATIENTS AND METHODS: One hundred and ninety
   consecutive patients presenting with a complaint of palpitations at a university
   medical center were enrolled in this prospective cohort study. Patients underwent a
   structured clinical interview and psychiatric screening. The charts were abstracted for
   results of the physical exam and tests ordered by the primary physician. Assignment
   of an etiology of palpitations was based on strict adherence to predetermined criteria
   and achieved by consensus of the two physician investigators. One-year followup
   was obtained in 96% of the patients. RESULTS: An etiology of palpitations was
   determined in 84% of the patients. The etiology of palpitations was cardiac in 43%,
   psychiatric in 31%, miscellaneous in 10%, and unknown in 16%. Forty percent of the
   etiologies could be determined with the history and physical examination, an
   electrocardiogram, and/or laboratory data. The 1-year mortality rate was 1.6% (95%
   confidence interval [CI] 0% to 3.4%) and the 1-year stroke rate was 1.1% (95% CI
   0% to 2.6%). Within the first year, 75% of the patients experienced recurrent
   palpitations. At 1-year follow-up, 89% reported that their health was the same or
   improved compared to that at enrollment, 19% reported that their work performance
   was impaired, 12% reported that workdays were missed, and 33% reported
   accomplishing less than usual work at home. CONCLUSIONS: The etiology of
   palpitations can often be diagnosed with a simple initial evaluation. Psychiatric
   illness accounts for the etiology in nearly one third of all patients. The short-term
   prognosis of patients with palpitations is excellent with low rates of death and stroke
   at 1 year, but there is a high rate of recurrence of symptoms and a moderate impact
   on productivity
   tests/etiology/evaluation/GENERAL                                              HEALTH
Gilligan, D.M., Ellenbogen, K.A. and Epstein, A.E. (1996), The management of atrial
   fibrillation. American Journal of Medicine, 101 (4), 413-421.
Abstract: Atrial fibrillation affects approximately one million persons in the United
   States, making it the most,common cardiac arrhythmia seen in clinical practice. Its
   prevalence increases with age, and occurs in up to 10% of the population in the
   eighth decade of life. Unlike coronary heart disease, atrial fibrillation affects men
   and women approximately equally and, in an increasingly elderly population, will
   become an increasing burden to the health care system. The management of atrial
   fibrillation has undergone significant change in recent years. Large randomized
   controlled trials have shown that anticoagulation markedly reduces the risk of stroke,
   and a number of new antiarrhythmic agents are available for the restoration and
   maintenance of sinus rhythm. Furthermore, physicians have become more aware of
   the potential proarrhythmic side effects of all antiarrythmic drugs. Finally, new
   procedures such as radiofrequency ablation of the atrioventricular junction and
   permanent pacing are playing increasing roles in the management of this arrhythmia.
   In this review, the identification of underlying causes and/or precipitating factors of
   atrial fibrillation, methods to control the ventricular response with atrioventricular
   nodal blocking drugs, the questions of whether restoration of sinus rhythm is a
   possible or desirable goal and how best to maintain sinus rhythm, should sinus
   rhythm be restored, and the importance of long-term anticoagulation with warfarin or
   antiplatelet therapy with aspirin are discussed
Werner, R.A. and Kessler, S. (1996), Effectiveness of an intensive outpatient
   rehabilitation program for postacute stroke patients. American Journal of Physical
   Medicine & Rehabilitation, 75 (2), 114-120.
Abstract: The effectiveness of ongoing rehabilitation services for postacute strike
   survivors is poorly documented. We designed a randomized control, single-blinded
   study to demonstrate the effectiveness of intensive outpatient therapy. The treatment
   intervention consisted of 1 hr each of physical and occupational therapy, four times
   per week, for 12 wk; therapy focused on neuromuscular facilitation and functional
   tasks. All subjects were screened before the therapies and after 3 mo and 9 mo.
   Forty-nine stroke survivors, who were at least 1 yr (mean, 2.9 yr) poststroke, were
   randomized with two treated patients to each control (no treatment supplied). All
   patients had received inpatient rehabilitation at the time of their acute stroke, but no
   patient had any ongoing therapy within the last 6 mo. The outcome measures
   included the Functional Independence Measure (FIM), Brunnstrom stages of motor
   recovery, timed mobility tasks, and the Jebson hand evaluation. We also evaluated
   the level of depression, self-esteem, and socialization. The treated patients
   demonstrated an improvement of 6.6 points over the 3 mo of therapy compared with
   only 1.5 points in the control group in the FIM motor score transformed using Rasch
   analysis. The change from time 0 to 3 mo was significant in the treated group but not
   in the controls. Treated patients maintained their gains at the 9-mo follow-up, and
   controls lost ground. The treated group improved in terms of socialization and
   self-esteem as evidenced by a lower Sickness Impact Profile, whereas the controls
   tended to get worse. There was a trend toward less depression, but this did not reach
   a P = 0.05 level of significance. This study demonstrates that significant functional
   gains can still be attained in the postacute stroke survivor, despite prior inpatient
   rehabilitation services
Keywords: cerebral vascular disease/DISABILITY/functional status/FUNCTIONAL
   STATUS/occupational                                therapy/outcome/outcomes/physical
Paty, P.S.K., Darling, R.C., Cordero, J.A., Shah, D.M., Chang, B.B. and Leather, R.P.
   (1996), Carotid artery bypass in acute postendarterectomy thrombosis. American
   Journal of Surgery, 172 (2), 181-183.
Abstract: BACKGROUND: Carotid endarterectomy has demonstrated excellent results
   over the past 2 decades with combined stroke mortality of <4% in most active
   centers, However, the optimal technique for surgical reconstruction for patients with
   acute postoperative deficits is more controversial. PATIENTS AND METHODS: In
   the last 10 years (1985 to 1995), we performed 1,267 carotid endarterectomies, with
   17 strokes (1.3%) and 16 deaths (1.2%), Twenty-four patients developed acute
  (within 72 hours) postoperative neurologic deficits, In 10 patients, the carotid artery
  was confirmed patent by duplex scan or angiography, and the neurologic deficit
  resolved without further therapy, Early reexploration was performed in 14 cases for
  suspected thrombosis associated with a new neurologic deficit, In each case,
  resection of the endarterectomy site and an interposition bypass was performed with
  greater saphenous vein (11), jugular vein (2), or polytetrafluoroethylene (2) grafts,
  (One patient required a new bypass for acute occlusion of the initial vein bypass.)
  Postoperatively, 8 patients had complete resolution of their deficit, 3 had minimal
  residual deficits, and 3 suffered permanent stroke, However, 2 of these patients died.
  RESULTS: Carotid artery bypass with exclusion of the endarterectomy site resulted
  in improvement in symptoms in 79% (11 of 14) of the patients and complete
  resolution in 57% (8 of 14), In long-term follow up (1 to 41 months), there have been
  no occlusions and one restenosis requiring revision at 11 months. CONCLUSIONS:
  Carotid artery bypass can be performed safely with acceptable results, The use of
  autogenous venous conduits allows reconstruction with an endothelial lined conduit
  that may improve results in patients with acute postoperative neurologic deficit
  secondary to thrombosis of the endarterectomized carotid artery
Keywords:                           ACUTE                           POSTOPERATIVE
Zarnke, K.B., Feagan, B.G., Mahon, J.L. and Feldman, R.D. (1997), A randomized
  study comparing a patient directed hypertension management strategy with usual
  office-based care. American Journal of Hypertension, 10 (1), 58-67.
Abstract: This study aimed to compare the efficacy of a patient-directed management
  strategy with office-based management in maintaining blood pressure control in
  patients with chronic stable hypertension using a randomized trial of two months
  duration. The subjects had chronic stable essential hypertension without secondary
  causes or unstable cardiovascular disease and were selected through the offices of 11
  family physicians and a tertiary care hypertension research unit. Patients were
  randomly assigned (2:1 ratio) to either a patient-directed management strategy using
  home blood pressure monitoring to adjust drug therapy if readings consistently
  exceeded defined limits, or office-based management through physician visits. The
  primary endpoint was the change from baseline in mean arterial pressure as
  determined by automatic ambulatory blood pressure monitoring. Secondary
  endpoints were changes in compliance, quality of life, and health care resource use.
  Ninety-one potential subjects were screened and 31 were randomized. Subjects in the
  patient-directed management group employed the drug adjustment protocols
  appropriately without complications. A significant difference in change in mean
  blood pressure was observed, favoring the patient-directed management (-0.95 mm
  Hg and +1.90 mm Hg, respectively, for patient- directed management and
  office-based management, P = .039). Compliance rates and quality of life scores
  were not significantly different between groups. Physician visits were more frequent
  in the patient-directed management group (1.05 v 0.20 visits/8 weeks, respectively,
  for patient-directed management and office-based management groups, P = .045). A
  patient-directed hypertensive management strategy may be feasible for patients with
  chronic stable hypertension. Such a strategy may improve blood pressure control
  compared with usual office-based care. However, physician visits may be increased
  using this strategy, at least in the short term. (C) 1997 American Journal of
  Hypertension, Ltd
Keywords:        ACCURACY/ambulatory              blood      pressure/AMBULATORY
  BLOOD-PRESSURE/blood                 pressure/cardiovascular       disease/CLINICAL-
  TRIALS/complications/CORONARY                       HEART-DISEASE/DEVICES/drug
  therapy/home/home                               blood                          pressure
Hunter, G.C. (1997), The clinical and pathologic spectrum of recurrent carotid stenosis.
  American Journal of Surgery, 174 (6), 583-588.
Abstract: BACKGROUND: Hemodynamically significant (greater than or equal to 50%)
  carotid restenosis occurs in approximately 10% to 12% of individuals undergoing
  carotid endarterectomy. The underlying pathology is usually neointimal thickening
  within 3 years and recurrent atherosclerosis thereafter. Although a number of
  etiologic factors have been implicated in the development of restenosis, the etiology
  remains unclear and preventative measures relatively ineffective. METHODS: A
  review of the English literature was undertaken to determine the incidence, clinical
  presentation, and pathologic features of carotid restenosis. CONCLUSIONS: Carotid
  restenosis is the major factor limiting long-term patency after carotid endarterectomy.
  Although drug therapy has been shown to be effective in preventing restenosis in
  animal models, the results of clinical human trials have been disappointing.
  Delineation of the biochemical and molecular mechanisms contributing to the
  development of restenosis is essential if effective therapeutic interventions are to be
  developed. (C) 1997 by Excerpta Medica, Inc
Keywords: animal/ARTERY STENOSIS/atherosclerosis/carotid endarterectomy/carotid
  stenosis/CORONARY                                     ANGIOPLASTY/DISEASE/drug
  RM FOLLOW-UP/therapy
Campbell, B.H., Tuominen, T.C. and Toohill, R.J. (1997), The risk and complications
  of aspiration following cricopharyngeal myotomy. American Journal of Medicine,
  103 61S-63S.
Abstract: This article reviews a series of patients undergoing cricopharyngeal myotomy
  and determines whether clinically dangerous aspiration is seen postoperatively. A
  total of 23 patients underwent myotomy. Indications included Zenker's diverticulum
  (14), anticipated or real dysphagia from skull base lesions (5), dysphagia from stroke
  (2), and dysphagia from glossectomy and radiation therapy (2). Surgical procedures,
  complications, and effectiveness were reviewed. Of patients with Zenker's
  diverticula, 13 of 14 had clinically useful improvement in dysphagia. Of patients
  with skull base lesions, all 5 had improvement (4 of these also had thyroplasites and
  cervical plexus-to-superior laryngeal nerve anastomoses). Of the patients with
  strokes, neither had significant improvement. Of the patients with glossectomy and
  radiation, 1 had useful improvement. Complications were seen in 5 patients: 2 had
  self- limiting pharyngeal leaks, and 3 had pneumonia 1-4 months postoperatively.
  One patient also had a postoperative ipsilateral recurrent laryngeal nerve injury.
  There were no postoperative deaths. In conclusion, cricopharyngeal myotomy has
  definite utility in the management of cervical dysphagia, even though the etiology of
  the dysphagia can be multifactorial. Risks directly attributable to the procedure are
  usually self-limiting; serious complications are usually associated with the
  underlying disease. The addition of adjunctive procedures, such as thyroplasty and
  superior laryngeal nerve reinnervation, may be of additional benefit to patients with
  high extracranial vagal injuries. (C) 1997 by Excerpta Medica, Inc
  nagement/radiation therapy/skull base/stroke/therapy
Wyse, D.G., Anderson, J.L., Antman, E.M., Cooper, E.S., Dalquist, J.E., Davis, K.B.,
  Greene, H.L., Mickel, M.C., DiMarco, J.P., Domanski, M.J., Rosenberg, Y., Schron,
  E.B., Shih, J.H., Epstein, A.E., Gersh, B.J., Jenkins, L.S., Saksena, S., Sherman, D.G.,
  Steinberg, J.S. and Waldo, A.L. (1997), Atrial fibrillation follow-up investigation of
  rhythm management - The AFFIRM study design. American Journal of Cardiology,
  79 (9), 1198-1202.
Abstract: The Atrial Fibrillation Follow-vp Investigation of Rhythm Management
  (AFFIRM) Study is a randomized evaluation of treatment of atrial fibrillation by 1 of
  2 strategies: ventricular rate control and anticoagulation versus rhythm control and
  anticoagulation. The primary end point is total mortality, analyzed by
  intention-to-treat. Secondary end points are composite end points (total mortality,
  disabling intracranial bleed [subdural and/or subarachnoid hemorrhage], stroke
  [embolus, thrombosis, hemorrhage], disabling anoxic encephalopathy, cardiac arrest,
  major noncentral nervous system bleed), cost of therapy, and quality of life,
  AFFIRM will randomize therapy and follow 5,300 patients for an average of 3.5
  years (minimum 2 years) at 200 sites in the United States and Canada. (C) 1997 by
  Excerpta Medica, Inc
Keywords:                                                            anticoagulation/atrial
Maxwell, J.G., Rutledge, R., Covington, D.L., Churchill, M.P. and Clancy, T.V. (1997),
  A statewide, hospital-based analysis of frequency and outcomes in carotid
  endarterectomy. American Journal of Surgery , 174 (6), 655-661.
Abstract: BACKGROUND: For more than 40 years carotid endarterectomy (CE) has
  been used in the treatment of extracranial carotid disease for the prevention of stroke,
  Recent prospective clinical trials have confirmed the benefit of CE for both
  symptomatic and asymptomatic patients, Our purpose was to examine statewide
  trends in the numbers of CE over a 6-year time period and to evaluate outcomes,
  METHODS: Using data from the North Carolina Medical Database Commission
  (NCMDC) all CE procedures from 1988 to 1993 were identified, Numbers of CE
  were compared with the population and hospital admissions, Variables of length of
  stay, hospital charges, discharge disposition, and occurrence of stroke and death were
  analyzed. RESULTS: A total of 11,973 CE were performed in 6 years, Compared by
  admissions, population, and the proportion of elderly, the number of CE increased
  yearly, The stroke rate was 1.7% and the death rate 1.2% for an overall in-hospital
  stroke plus mortality rate of only 2.7%. CONCLUSIONS: From a diverse group of
  hospitals and a large number of surgeons and patients, this hospital-based study
  documents the acceptance and safety of CE in the treatment of extracranial carotid
  disease. (C) 1997 by Excerpta Medica, Inc
  endarterectomy/clinical               trials/elderly/endarterectomy/EXTRACRANIAL
Witlin, A.G., Friedman, S.A., Egerman, R.S., Frangieh, A.Y. and Sibai, B.M. (1997),
  Cerebrovascular disorders complicating pregnancy - Beyond eclampsia. American
  Journal of Obstetrics and Gynecology, 176 (6), 1139-1145.
Abstract: OBJECTIVE: Our purpose was to investigate the problems encountered in the
  diagnosis and management of cerebrovascular disorders associated with pregnancy
  and the puerperium. STUDY DESIGN: Pregnancies complicated by cerebrovascular
  disorders were identified by retrospective chart review (1985 to 1995). Events
  associated with trauma, neoplasm, drug ingestion, and infection were excluded.
  RESULTS: The study population comprised 24 women with a variety of
  cerebrovascular disorders: 14 with infraction (5 arterial, 9 venous), 6 with
  intracranial hemorrhage (3 anatomic malformation, 3 unknown etiology), 3 with
  hypertensive encephalopathy, and 1 with an unruptured aneurysm. Blood pressure
  reflected physical condition at presentation and did not predict diagnosis or outcome
  except in the 3 women with hypertensive encephalopathy. Only 4 of 14 women with
  infarction and 1 of 6 with intracranial hemorrhage had a diastolic blood pressure
  greater than or equal to 110 mm Hg. Presumption of eclampsia delayed the diagnosis
  in 10 women (41.7%). In addition, patient delay in seeking medical attention
  complicated 10 cases. After review, none of the adverse maternal outcomes were
  deemed preventable by earlier physician intervention. Seven maternal deaths
  occurred (29.2%). Neonatal outcome was related to the gestational age and the
  maternal condition at presentation. CONCLUSION: Cerebrovascular disorders are an
  uncommon and unpredictable complication of pregnancy that are associated with
  substantial maternal and fetal mortality. Suspected eclampsia unresponsive to
  magnesium sulfate therapy warrants an immediate neuroimaging study. Interestingly,
  in women with intracranial hemorrhage, severe hypertension was not an associated
  predictive factor
Keywords: age/aneurysm/ARTERIOVENOUS-MALFORMATIONS/attention/blood
  PERTENSIVE                                 ENCEPHALOPATHY/infection/intracranial
Yee, H.C., Nwosu, J.E., Lii, A.D., Velasco, M. and Millman, A. (1997),
  Echocardographic features of papillary fibroelastoma and their consequences and
  management. American Journal of Cardiology, 80 (6), 811-&.
Abstract: Thirty-five percent of patients (5 of 15) were diagnosed with ischemic stroke
  from left-sided papillary fibroelastomas, by diagnosis of exclusion, whereas 40% of
  patients (6 of 15) did not have ischemic stroke
Keywords:                            diagnosis/EXCRESCENCES/INTERNAL/ischemic
Alberts, M.J. (1997), Hyperacute stroke therapy with tissue plasminogen activator.
  American Journal of Cardiology, 80 (4C), D29-D34.
Abstract: The past year has seen tremendous progress in developing new therapies
  aimed at reversing the effects of acute stroke, Thrombolytic therapy with various
  agents has been extensively studied in stroke patients for the past 7 years, Tissue
  plasminogen activator (t-PA) received formal US Food and Drug Administration
  approval in June 1996 for use in patients within 3 hours of onset of an ischemic
  stroke, Treatment with t-PA improves neurologic outcome and functional disability
  to such a degree that, for every 100 stroke patients treated with t-PA, an additional
  11-13 will be normal or nearly normal 3 months after their stroke, The downside of
  t-PA therapy is a 6% rate of symptomatic intracerebral hemorrhage (ICH) and a 3%
  rate of fatal ICH, Studies are under way to determine whether t-PA can be
  administered with an acceptable margin of safety within 5 hours of stroke, to
  evaluate the therapeutic benefits of intraarterial pro-urokinase, and to assess the use
  of magnetic resonance spectroscopy to identify which patients are most likely to
  benefit from thrombolysis. Combination thrombolytic- neuroprotectant therapy is
  also being studied, In theory, patients could be given an initial dose of a
  neuroprotectant by paramedics and receive thrombolytic therapy in the hospital, We
  are now entering an era of proactive, not reactive, stroke therapies, These treatments
  may reverse some or all acute stroke symptoms and improve functional outcomes, (C)
  1997 by Excerpta Medica, Inc
Keywords: acute/ACUTE ISCHEMIC STROKE/intracerebral hemorrhage/ischemic
  therapy/therapy/thrombolysis/thrombolytic therapy/tissue plasminogen activator/US
Giardina, E.G.V. (1997), Atrial fibrillation and stroke: Elucidating a newly discovered
  risk factor. American Journal of Cardiology, 80 (4C), D11-D18.
Abstract: Atrial fibrillation is the most common sustained arrhythmia reported in the
  United States; an estimated 1-2 million Americans have chronic nonvalvular atrial
  fibrillation. This disorder is associated with a substantial risk of stroke. Several
  recent studies provide evidence that anticoagulation therapy is indicated for stroke
  prevention in patients with nonvalvular atrial fibrillation after recovery from a minor
  stroke. Clinical and echocardiographic criteria help to identify those patients who are
  at especially high risk for thromboembolic stroke and are candidates for carefully
  controlled anticoagulation. In an effort to reduce the possibility of thromboembolic
  events following either chemical or electrical cardioversion, the American College of
  Chest Physicians has recently prepared guidelines for the use of anticoagulation in
  the conversion of atrial fibrillation. The efficacy of antiar-rhythmic drug therapy for
  cardioversion is often difficult to assess. Furthermore, it is associated with major
  risks, including heart failure and exacerbation of arrhythmia, and minor risks,
  including systemic intolerance. A new National Institutes of Health trial, Atrial
  Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM), will clarify
  the true risks and benefits of antiarrhythmic therapy for conversion of atrial
  fibrillation to sinus rhythm. Patients who cannot tolerate drug therapy may benefit
  from interruption of conduction in the bundle of His, followed by implantation of a
  permanent pacemaker, the use of radiofrequency energy ablation, or the implantation
  of an atrial defibrillator. Some patients may benefit from surgical procedures, such as
  left atrial isolation, the corridor operation, and the maze operation. (C) 1997 by
  Excerpta Medica, Inc
Keywords:        ANTICOAGULATION/atrial              fibrillation/CARDIOVERSION/drug
  THERAPY/SINUS RHYTHM/stroke/stroke prevention/therapy
Arko, F., Buckley, C., Baisden, C. and Manning, L. (1997), Mobile atheroma of the
  aortic arch is an underestimated source of embolization. American Journal of
  Surgery, 174 (6), 737-740.
Abstract: BACKGROUND: Mobile atheroma are associated with increased
  perioperative strokes in patients undergoing coronary artery bypass surgery.
  Peripheral embolization is an additional risk. Transesophageal echocardiography
  (TEE) accurately identifies mobile atheroma. Recent reports have discussed the
  possible influence of anticoagulant therapy in promoting peripheral cholesterol
  embolization. METHODS: Fourteen patients with mobile atheroma were treated with
  anticoagulation. A review of literature reporting results and complications of
  anticoagulation in the treatment of this condition was compared with our recent
  experience. RESULTS: Between 1994 and 1996, 14 patients with peripheral
  embolization and mobile atheroma confirmed by TEE were anticoagulated. Clinical
  follow-up between 6 to 30 months has demonstrated no further evidence of systemic
  embolization since anticoagulation. Furthermore, repeat TEE in 3 of 14 patients no
  longer visualized mobile atheroma. CONCLUSIONS: Mobile atheroma are
  recognized sources for embolization. Patients with generalized atherosclerosis should
  be screened for this condition in cases of systemic embolization. Anticoagulation
  may have therapeutic considerations in the management of this condition. (C) 1997
  by Excerpta Medica, Inc
Kallmes, D.F. and Kallmes, M.H. (1997), Cost-effectiveness of angiography performed
  during surgery for ruptured intracranial aneurysms.             American Journal of
  Neuroradiology, 18 (8), 1453-1462.
Abstract: PURPOSE: To calculate the incremental cost-utility ratio for routine
  angiography performed during surgery for ruptured cerebral aneurysms. METHODS:
  Decision-tree and Markov analyses based on a cohort simulation were used to
  determine the incremental cost-utility ratio of routine intraoperative angiography
  versus no angiography. Input data from the literature were estimated for the
  following variables: frequency of unexpected aneurysmal rests and branch artery
  occlusions; annual rate of rehemorrhage of partially clipped aneurysms; prevalence
  of clinically relevant infarction resulting from branch artery occlusion; efficacy of
  clip repositioning; morbidity associated with intraoperative angiography; morbidity
  and mortality associated with aneurysmal rehemorrhage; sensitivity of intraoperative
  angiography for aneurysmal rests; and costs of intraoperative angiography, added
  duration of surgery, ischemic cerebral infarction, aneurysmal rehemorrhage, and
  rehabilitation. Sensitivity analyses were performed for all relevant input variables. A
  societal perspective was used, and cost-utility ratios less than $50
  000/quality-adjusted life years (QALY) gained were considered acceptable.
  RESULTS: Baseline input variables resulted in an acceptable cost-utility ratio for
  routine intraoperative angiography ($19 000/QALY). The input variables with
  greatest influence on the cost-utility ratio were frequency of branch artery occlusions,
  angiographic morbidity, and cost of angiography. However, the cost-utility ratio
  remained acceptable even over wide ranges of these input variables. Frequency of
  unexpected partially clipped aneurysms, efficacy of clip repositioning, and costs of
  stroke, rehemorrhage, and rehabilitation had relatively little impact on the analysis.
  CONCLUSION: Routine intraoperative angiography is cost-effective if performed in
  a manner consistent with low morbidity in a patient cohort harboring at least some
  unexpected branch artery occlusions that, if uncorrected, would result in clinically
  relevant cerebral infarctions
Keywords:          aneurysm/angiography/cerebral/cerebral           angiography/cerebral
  infarction/DECISION-ANALYSIS/DIGITAL                                  SUBTRACTION
Manning, W.J. (1997), Role of transesophageal echocardiography in the management of
  thromboembolic stroke. American Journal of Cardiology, 80 (4C), D19-D28.
Abstract: Cardiac causes of stroke account for approximately 20% of strokes occurring
  in the United States, Transthoracic echocardiography (TTE) remains the cornerstone
  of noninvasive cardiac imaging, but transesophageal echocardiography (TEE) is
  superior for identifying potential cardiac sources of emboli, including left atrial
  thrombi, valvular vegetations, thoracic aortic plague, patent foramen ovale, and
  spontaneous left atrial echocardiographic contrast, The diagnostic yield of TEE for
  potential cardiac causes of thromboembolism exceeds 50%. The impact of TEE on
  the clinical management of this group, however, remains undefined for most
  TEE-specific diagnoses, Thus, routine use of TEE in these patients has been
  questioned. The diagnostic yield is highest if the clinical history/physical
  examination suggests a cardiac source, However, the clinical scenario often dictates
  patient management, and TEE data are used to ''validate'' the clinical impression.
  Data from large, prospective, randomized (aspirin/warfarin) studies, in which TEE
  data are obtained from patients with suspected cardiac thromboembolism, are needed,
  IF specific TEE diagnoses can be identified in which defined therapies are beneficial,
  ''source of embolism'' will continue to be the most common indication for TEE
  referral, In this paradigm, TEE (without initial TTE) will probably become a more
  direct diagnostic pathway, However, if these studies demonstrate that all patients
  with suspected cardiac source benefit from one (or no) therapy, independent of TEE
  data, referrals for TEE will decline, Results of ongoing randomized trials to evaluate
  the efficacy of TEE in patients with cryptogenic stroke or transient ischemic attack
  are awaited, (C) 1997 by Excerpta Medico, Inc
Keywords:             APPENDAGE                THROMBUS/ATRIAL                  SEPTAL
  ANEURYSM/emboli/foramen                                 ovale/LEFT-VENTRICULAR
  FORAMEN                      OVALE/randomized                     trials/RHEUMATIC
Lewis, C.W., Atkins, B.Z., Hutcheson, K.A., Gillen, C.T., Reedy, M.C., Glower, D.D.
  and Taylor, D.A. (1998), A load-independent in vivo model for evaluating
  therapeutic interventions in injured myocardium. American Journal of
  Physiology-Heart and Circulatory Physiology, 44 (5), H1834-H1844.
Abstract: Although cardiomyocyte damage is normally irreversible, gene therapy and
  somatic cell transfer offer potential for improving function in damaged regions of the
  heart;. However, in ischemic models of injury, variability in depth, size, and location
  of damage compromises statistical evaluation of in vivo function. We have adapted
  cryoablation to create a reproducible, posterior, transmural lesion within rabbit
  myocardium in which small changes in function are measurable in vivo. Before and
  at 2 and 6 wk postinjury, in vivo left ventricular intracavitary pressure and
  myocardial segment length were measured. Regional indexes of performance,
  segmental stroke work (SW), and percent systolic shortening (SS) were significantly
  decreased (P < 0.001) postcryoinjury as was the slope (M-w) of the linear preload
  recruitable SW relationship between SW and end- diastolic segment length (P =
  0.0001). Decreased SW, SS, and M- w correlated with wall. thinning, loss of
  myocytes, presence of fibroblasts, and transmural scar formation. Reproducible
  changes in regional myocardial performance in vivo postcryoinjury suggest that this
  is a reasonable model for evaluating novel therapies for cardiovascular disease
Keywords:                          cardiovascular                         disease/cellular
  cardiomyoplasty/contractility/cryoinjury/evaluation/Frank-Starling relationship/gene
   infarction/NECROSIS/PERFORMANCE/PHYSIOLOGICAL/preload                        recruitable
   stroke                  work/preload                  recruitable                  work
   area/QUANTIFICATION/RABBITS/regional/regional                                    cardiac
Endo, S., Kuwayama, N., Hirashima, Y., Akai, T., Nishijima, M. and Takaku, A. (1998),
   Results of urgent thrombolysis in patients with major stroke and atherothrombotic
   occlusion of the cervical internal carotid artery. American Journal of Neuroradiology,
   19 (6), 1169-1175.
Abstract: PURPOSE: Atherothrombotic occlusion of the cervical internal carotid artery
   (ICA) without collateral flow is one of the most critical forms of acute ischemia. We
   report the results of urgent thrombolytic treatment of patients with major stroke in
   this clinical category. METHODS: Clinical findings and outcome in 33 patients were
   investigated. All patients had suffered a major stroke, with a score of 24 or higher on
   the NIH Stroke Scale on admission. Ischemic abnormalities were not detected on
   initial CT studies. Diagnoses were made at angiography, and patients were treated by
   intravenous or intraarterial local thrombolysis within 6 hours of stroke onset.
   RESULTS: Recanalization was accomplished in eight patients with intraarterial local
   thrombolysis; four of these patients had a good clinical outcome. Two factors
   characteristic of those whose treatment was successful were dramatic improvement
   of symptoms after partial recanalization achieved within 3 hours of onset and
   stabilized improvement after subsequent percutaneous transluminal angioplasty or
   carotid endarterectomy for residual atherosclerotic stenosis at the ICA origin.
   CONCLUSION: The results of this study suggest that urgent intraarterial local
   thrombolysis may be a successful treatment method for some patients in this critical
   clinical category if the treatment can be accomplished within 3 hours of ictus and
   followed by either angioplasty or endarterectomy for residual stenosis
Keywords:                             acute/ACUTE                              ISCHEMIC
   STROKE/angiography/angioplasty/carotid/carotid                            artery/carotid
   STROKE/ENDARTERECTOMY/ICA/internal/internal carotid/internal                     carotid
   transluminal angioplasty/PHASE- III TRIAL/recanalization/stenosis/stroke/stroke
   TOR/TRANS-LUMINAL ANGIOPLASTY/transluminal/treatment
Hilleman, D.E. (1998), Management of peripheral arterial disease. American Journal of
   Health-System Pharmacy, 55 S21-S27.
Abstract: The risk factors, epidemiology, diagnosis, and treatment of peripheral arterial
   disease are reviewed. Peripheral arterial disease is characterized by a gradual
   reduction in blood flow to one or more limbs secondary to atherosclerosis. Risk
   factors include smoking, diabetes mellitus, hyperlipidemia, and hypertension. The
   most common clinical manifestation is intermittent claudication. The prevalence of
   intermittent claudication in people over the age of 50 is 2-7% for men and 1-2% for
   women. The ankle:brachial pressure index (ABPI) is a useful measure of disease
   severity; an ABPI of 0.5-0.9 is common in intermittent claudication. The goals of
   therapy are to relieve or reduce ischemic symptoms, alleviate disability, improve
   functional capacity, prevent progression that may result in gangrene and limb loss,
   and prevent cardiovascular and cerebrovascular events. Treatment includes
   risk-factor modification, drug therapy (primarily with antiplatelet agents), and
   revascularization procedures. Aspirin has been shown to be effective in reducing the
   associated risk of myocardial infarction and stroke. Ticlopidine appears to be a
  reasonable alternative for patients who are hypersensitive to aspirin. Clopidogrel has
  been shown to be more effective than aspirin in patients with recent myocardial
  infarction, recent stroke, or established peripheral arterial disease. There is
  controversy over the appropriate treatment for acute arterial occlusions. Risk-factor
  modification and antiplatelet drugs are the mainstays of therapy for patients with
  intermittent claudication, the most common manifestation of peripheral arterial
Keywords:                              acute/age/antiplatelet/aspirin/atherosclerosis/blood
  flow/CARDIOVASCULAR EVENTS/cerebrovascular/clopidogrel/diabetes/diabetes
  mellitus/diagnosis/disability/DOUBLE-BLIND                                  TRIAL/drug
  CLAUDICATION/ischemic/ISCHEMIC                  ULCERS/LOWER-LIMBS/myocardial
  vascular diseases/platelet aggregation inhibitors/prevalence/RANDOMIZED
  TRIAL/risk factors/severity/stroke/therapy/ticlopidine/treatment
Thompson, D., Edelsberg, J., Kinsey, K.L. and Oster, G. (1998), Estimated economic
  costs of obesity to US business. American Journal of Health Promotion, 13 (2),
Abstract: Objective. To Estimate the economic costs of obesity to U.S. business.
  Methods. Standard epidemiologic methods for risk attribution and techniques for
  ascertaining cost of illness were used to estimate obesity-attributable expenditures on
  selected employee benefits, including health, life, and disability insurance and paid
  sick leave by private-sector firms in the U.S. in 1994. Data were obtained from a
  variety of secondary sources, including the National Health Interview Survey, reports
  from the Bureau of Labor Statistics and other federal agencies, and the published
  literature. Attention was focused on employees between the ages of 25 and 64 years
  who were classified according to body mass index (BMI) as "nonobese" (BMI < 25
  Kg/m(2)), "mildly obese" (BMI = 25-28.9 kg/m(2)), or "moderately to severely
  obese" (BMI greater than or equal to 29 kg/m(2)). Results. The cost of obesity to U.S.
  business in 1994 was estimated to total $12.7 billion including $2.6 billion as a result
  of mild obesity and $10.1 billion due to moderate to severe obesity. Health insurance
  expenditures constituted $7.7 billion of the total amount, representing 43% of all
  spending by U.S. business on, coronary heart disease, hypertension type 2 diabetes,
  hypercholesterolemia, stroke, gallbladder disease, osteoarthritis of the Knee, and
  endometrial cancer Obesity-attributable business expenditures on paid sick leave, life
  insurance, and disability insurance amounted to $2.4 billion, $1.8 billion, and $800
  million, respectively. Conclusions. The health-related economic cost of obesity, to
  U.S. business is substantial representing approximately 5% of total medical care
  costs. Further research is needed to determine the cost-effectiveness of worksite
  weight management programs and of other efforts to reduce the prevalence of
  obesity in the U.S. workforce
Keywords: BODY-WEIGHT/cancer/coronary heart disease/cost-effectiveness/costs and
  cost analysis/diabetes/DIABETES-MELLITUS/disability/employee benefits/FAT
Ley, E.I., Scarrow, A.M., Kanal, E., Rubin, G., Yonas, H. and Kirby, L. (1998),
  Reversible ischemia determined by xenon-enhanced CT after 90 minutes of complete
  basilar artery occlusion. American Journal of Neuroradiology, 19 (10), 1943-1946.
Abstract: Intraarterial thrombolytic therapy decreases mortality in the treatment of acute
   basilar artery occlusion, An acute decrease in cerebral blood flow (CBF) (<12
   mL/100 g per minute) has been reported to invariably result in infarction, We report
   a case of acute basilar artery occlusion, recanalized within 90 minutes, with reversal
   of CBF of less than 6 mL/100 g per minute, After reperfusion, areas with persistent
   CBF of 6 mL/100 g per minute resulted in infarctions on subsequent CT studies.
   Parenchymal viability is possible after 90 minutes of posterior CBF of 6 mL/100 g
   per minute
Keywords: acute/artery/basilar artery/blood flow/CBF/cerebral/cerebral blood
Black, H.R. (1998), Antihypertensive therapy and cardiovascular disease - Impact of
   effective therapy on disease progression. American Journal of Hypertension, 11 (1),
Abstract: Hypertension is the most ubiquitous risk factor for developing cardiovascular
   disease, which is the leading cause of death in the United States. Results from
   clinical trials have established the benefit of antihypertensive therapy in preventing
   the morbidity and mortality associated with high blood pressure, including stroke,
   coronary heart disease, and heart failure. Treatment is effective in the elderly, a
   significant consideration because the percentage of the elderly population is growing
   rapidly. This article reviews the impact of antihypertensive treatment on
   cardiovascular disease and treatment endpoints. (C) 1998 American Journal of
   Hypertension, Ltd
Keywords:        beta-blocker/blood      pressure/BLOOD-      PRESSURE/cardiovascular
   disease/clinical        trials/CONGESTIVE-HEART-FAILURE/coronary                  heart
   py/treatment/TRIAL/trials/United States
Cooke-Ariel, H. (1998), Circadian variations in cardiovascular function and their
   relation to the occurrence and timing of cardiac events. American Journal of
   Health-System Pharmacy, 55 S5-S11.
Abstract: Circadian patterns of risk for cardiac events and their implications for
   prevention and treatment of cardiovascular conditions are discussed. Sympathovagal
   tone, a major biological determinant of circadian variation in cardiovascular function,
   is modulated through circadian patterns of sleep-wake activity. The influence of
   neurohumoral activity on cardiovascular function is manifested by 24-hour
   variability in heart rate, blood pressure, and vasomotor tone. Platelet aggregation and
   plasminogen-activator inhibitor-1 activity peak around the time of awakening.
   Conversely, endogenous plasminogen activator exhibits a nadir around the lime of
   awakening. Studies of patterns of occurrence of cardiac disorders such as acute
   myocardial infarction, sudden cardiac death, stroke, and ventricular arrhythmia show
   an increased occurrence during the period surrounding awakening. These patterns are
   consistent with observed circadian patterns in cardiovascular function. Diabetes, left
   ventricular dysfunction, and congestive heart failure may contribute to alterations in
   patterns of occurrence of cardiac events. Factors such as race, sex, and age may lead
   to alterations in circadian variation in cardiovascular function. Unusual physical
   exertion, stress, and anger may act as triggers of an event at any time of day. The
  circadian patterns of cardiac events follow the natural fluctuations in endogenous
  physiological processes, with a vulnerable period consistently observed in the early
  morning; dynamic assessment of markers of cardiovascular function may assist in
  determining the extent of disease progression and in selecting cardiovascular
Keywords:              acute/acute              myocardial             infarction/ACUTE
  drugs/cardiac      events/cardiovascular        diseases/chronopharmacology/circadian
  rhythm/congestive                                                                 heart
  PATIENTS/heart                  failure/heart              rate/LEFT-VENTRICULAR
  HYPERTROPHY/MORNING                                             INCREASE/myocardial
Maier, S.E., Gudbjartsson, H., Patz, S., Hsu, L., Lovblad, K.O., Edelman, R.R., Warach,
  S. and Jolesz, F.A. (1998), Line scan diffusion imaging: Characterization in healthy
  subjects and stroke patients. American Journal of Roentgenology, 171 (1), 85-93.
Abstract: OBJECTIVE, Our objective was to evaluate a new scanning method, MR line
  scan diffusion imaging, and assess the apparent diffusion coefficient in the brains of
  healthy subjects and stroke patients. SUBJECTS AND METHODS. Line scan
  diffusion imaging without cardiac gating or head restraints was implemented on low-
  (0.5 T) and medium- (1.5 T) field-strength scanners with conventional hardware.
  Diffusion-weighted images were obtained in six healthy subjects and eight stroke
  patients. Unidirectional diffusion encoding was used for fast localization of stroke
  lesions. For further characterization, orthogonal diffusion encoding was applied, and
  the trace of the apparent diffusion coefficient was calculated. Single-shot
  diffusion-weighted echoplanar imaging served as the reference standard. For healthy
  subjects, imaging was repeated four times on each scanner. Mean and relative
  precision of the apparent diffusion coefficient trace values were calculated for each
  pixel. In stroke lesions and adjacent normal tissue, apparent diffusion coefficient
  trace values were determined. RESULTS.In the 108 scans obtained, line scan
  diffusion imaging proved to be robust, virtually free of artifact (independent of slice
  location and orientation), reproducible, and rapid for localization of a stroke. Scan
  time for 14 slices at 7-mm thickness was 8 min at 0.5 T and 7 min at 1.5 T. Image
  qualities with line scan diffusion imaging and single-shot diffusion-weighted
  echoplanar imaging were comparable. At 1.5 T,precision was essentially the same
  for line scan diffusion imaging (4.3%) and echoplanar imaging (4.7%). With line
  scan diffusion imaging at 0.5 T and 1.5 T, normal paraventricular apparent diffusion
  coefficient trace values averaged 0.71 mu m(2)/msec, and with echoplanar imaging
  these values averaged 0.69 mu m(2)/msec. In acute lesions apparent diffusion
  coefficient trace values were low, and in chronic lesions these values were high.
  CONCLUSION. Line scan diffusion imaging on low- and medium-field-strength
  MR scanners equipped with conventional hardware was reliable and practical for
  measuring brain apparent diffusion values, which can be applied to the early
  diagnosis, and hence timely management, of stroke
Crane, V.S. (1998), Formulary and economic considerations in the selection of
  antiplatelet agents. American Journal of Health-System Pharmacy, 55 S28-S31.
Abstract: A pharmacoeconomic model for evaluating antiplatelet therapies is described.
  In order to conduct a pharmacoeconomic analysis, it is important to understand the
  course of the disease under study and the prevention and treatment options, identify
  the associated economic consequences, develop concomitant strategies, and target
  high-yield decisions. The steps of a pharmacoeconomics-based decision are defining
  the pharmacoeconomic problem, creating a crossfunctional team, determining the
  study's perspective, determining the treatment alternatives and outcomes, selecting
  the appropriate pharmacoeconomic method, placing a monetary value on outcomes,
  identifying resources and data sources, establishing probabilities of outcomes, using
  decision analysis, undertaking a cost or sensitivity analysis, presenting the results,
  developing and implementing a policy or clinical intervention based on the results,
  educating health care professionals about the new policy or intervention, and
  documenting the quality of care and potential cost savings through follow-up.
  Clopidogrel is given as an example. The composite endpoint of myocardial infarction,
  stroke, or vascular death has been shown to be 8.7% lower with clopidogrel than
  with aspirin in patients with recent myocardial infarction, recent ischemic stroke, or
  symptomatic peripheral arterial disease. Clopidogrel costs more than aspirin but may
  be considered as first-line therapy for high-risk patients, patients who are allergic to
  aspirin, or patients who cannot tolerate the gastrointestinal effects of aspirin.
  Cost-effectiveness analyses can be used to support formulary decisions about which
  antiplatelet agent should be used; the use of a particular agent ultimately also
  depends on efficacy, safety, pharmacodynamics, patient-specific factors, and relative
  direct and indirect costs
Keywords:                                          administration/antiplatelet/antiplatelet
  infarction/outcomes/pharmacoeconomics/pharmacy/platelet                     aggregation
Kallmes, D.F., Kallmes, M.H., Cloft, H.J. and Dion, J.E. (1998), Guglielmi detachable
  coil embolization for unruptured aneurysms in nonsurgical candidates: A
  cost-effectiveness exploration. American Journal of Neuroradiology, 19 (1),
Abstract: PURPOSE: We calculated the incremental cost-utility ratio for Guglielmi
  detachable coil (GDC) embolization versus no therapy for unruptured intracranial
  aneurysms considered inappropriate for surgical clipping procedures. METHODS:
  Decision tree and Markov analyses that employ cohort simulation were applied to
  determine the incremental cost-utility ratio of GDC embolization versus no therapy
  for unruptured cerebral aneurysms. Clinical values required as input data were
  estimated from the literature for the following variables: relative frequencies of
  complete aneurysmal occlusion, partial aneurysmal occlusion, and attempted coiling
  (no coils detached); morbidity and mortality of GDC embolization; frequency,
  morbidity, and mortality of spontaneous aneurysmal rupture in untreated and
  GDC-embolized aneurysms; annual rate of recanalization of GDC-embolized
  aneurysms; quality of life when knowingly living with untreated or GDG-embolized
  aneurysms and of living with fixed neurologic deficit; costs of GDC embolization,
  spontaneous aneurysmal rupture, stroke, and rehabilitation; and discount rate.
  Cost-utility ratios below $50 000 per quality-adjusted life year saved were
  considered acceptable. Sensitivity analyses were performed for all relevant input
  variables. RESULTS: Baseline input values resulted in acceptable cost-utility ratios
  for GDC embolization of unruptured intracranial aneurysms. These ratios remained
  within acceptable limits across wide ranges of various input parameters.
  Cost-effectiveness was markedly affected by the natural course of unruptured,
  untreated aneurysms; rates of spontaneous rupture greater than 2% per year resulted
  in favorable cost-utility ratios that were relatively unaffected by variation in GDC
  efficacy, while rates of rupture less than 1% per year resulted in unfavorable ratios
  that were highly dependent on GDC efficacy. Many of the GDC efficacy indexes,
  such as rate of failed coiling, early recanalization, and progressive aneurysmal
  thrombosis, have mild effects on the cost-utility ratios. GDC complication rate as
  well as life expectancy had moderate effects on the analysis. The influence of late
  aneurysmal recanalization was mild unless high rates of rupture for partially coiled
  aneurysms were applied. Suboptimal clip placement resulting from the presence of
  GDC coils within a ruptured aneurysm had no demonstrable consequence on cost-
  utility ratios. CONCLUSIONS: The single most influential variable determining the
  cost-effectiveness of GDC embolization in our analysis was the natural course of
  untreated aneurysms. Other important variables included GDC-related morbidity and
  life expectancy at the time of GDC embolization
Keywords:                                            aneurysm/cerebral/complication/cost
  S/FOLLOW-UP/Guglielmi                   detachable            coil/INTRA-CRANICAL
  ANEURYSMS/intracranial/INTRACRANIAL                                       SACCULAR
  RORADIOLOGY/quality                                                                  of
  ptured aneurysms
Shiran, A., Goldstein, S.A., Zafar, S., Ellahham, S., Sears-Rogan, P., Pinnow, E. and
  Lindsay, J. (1998), Determination of pretest probability for detection of a
  cardiovascular source of emboli by transesophageal echocardiography using clinical
  and transthoracic echocardiographic data. American Journal of Cardiology, 81 (12),
Abstract: Transesophageal echocardiographic findings and their effect on disease
  management were evaluated in 216 patients with suspected cardiovascular source of
  emboli. Clinical and transesophageal echocardiographic findings were useful in
  defining pretest probability for finding a probable cardiovascular source of emboli on
  transesophageal echocardiography
Keywords:                                             ANTICOAGULATION/CARDIAC
  EMBOLISM/PATENT                                                            FORAMEN
  OVALE/STROKE/transesophageal/transesophageal echocardiography
Akpunonu, B.E., Mutgi, A.B., Lee, L., Khuder, S., Federman, D.J. and Roberts, C.
  (1998), Can a clinical score aid in early diagnosis and treatment of various stroke
  syndromes? American Journal of the Medical Sciences, 315 (3), 194-198.
Abstract: Background: Accurate and timely diagnosis of hemorrhagic and
  nonhemorrhagic strokes helps in patient management. Neuroimaging studies are
  useful in diagnosis and distinction of hemorrhagic (HS) and nonhemorrhagic (NHS)
  strokes. The use of clinical variables, such as Siriraj stroke scores (SSS), has shown
  good sensitivity, specificity and predictive values (distinguishing stroke types). The
   aim of our study was to evaluate the use of SSS in a U.S. population and assess
   whether it could aid to expedite treatment decisions. Methods: Levels of
   consciousness, vomiting, headache and atheroma markers used in SSS were applied
   to patients who met the criteria for stroke. Results: Of the 302 patients identified, the
   SSS classified 254 with sensitivity of 36% (HS) and 90% (NHS) and positive
   predictive values of 77% and 61%, respectively. Conclusion: Our results suggest that
   SSS is not reliable in distinguishing stroke types (in a US population). Definite
   neuroimaging studies are needed prior to thrombolytic therapy
Keywords:                                             diagnosis/hemorrhagic/hemorrhagic
   HEMORRHAGE/management/nonhemorrhagic                                stroke/stroke/stroke
   scores/therapy/thrombolytic therapy/treatment/US
Atlas, S.W. and Thulborn, K.R. (1998), MR detection of hyperacute parenchymal
   hemorrhage of the brain. American Journal of Neuroradiology, 19 (8), 1471-1477.
Abstract: BACKGROUND AND PURPOSE: The detection of hemorrhage in acutely ill
   patients is crucial to clinical management, The MR features that allow diagnosis of
   intracerebral hematomas of less than 24 hours' duration are described and the
   mechanistic basis of these features is investigated. METHODS: The clinical MR
   features of seven confirmed hyperacute intracerebral hematomas were compared
   with those of experimentally induced hematomas in a rat model in which detailed
   analyses of iron metabolism and morphometry were performed. RESULTS: In all
   patients and all animals, a hypointense rim on T2-weighted spin-echo images that
   was less marked on T1-weighted spin-echo images was seen surrounding a central
   isointense or heterogeneous region of hyperacute hematoma, Histologically, the clot
   showed interdigitation of intact erythrocytes and tissue at the hematoma-tissue
   interface without significant hemosiderin, ferritin, or phagocytic activity,
   Biochemically, the iron from the extravasated blood was present only as heme
   proteins within the first 24 hours, CONCLUSION: The hypointense rim on T2-
   weighted images, and to a lesser extent on T1-weighted images, is a distinctive
   feature of hyperacute hematoma, This pattern is consistent with magnetic
   susceptibility variations of paramagnetic deoxygenated hemoglobin within intact
   erythrocytes at a microscopically irregular tissue-clot interface. The detection of
   hemorrhage is important in the management of patients with acute stroke
Keywords:                          acute/ACUTE                          INTRACRANIAL
Biousse, V., Touboul, P.J., D'Anglejan-Chatillon, J., Levy, C., Schaison, M. and
   Bousser, M.G. (1998), Ophthalmologic manifestions of internal carotid artery
   dissection. American Journal of Ophthalmology, 126 (4), 565-577.
Abstract: PURPOSE: To report the ophthalmologic symptoms and signs associated with
   extracranial internal carotid artery dissection. METHODS: One hundred forty-six
   consecutive patients with extracranial internal carotid artery dissection were evaluted;
   29 were studied retrospectively from 1972 to 1984 and 117 prospectively from 1985
   to 1997. RESULTS: Sixty two percent of patients (91/146) with extracranial internal
   carotid artery dissection had ophthalmologic symptoms or signs that were the
   presenting symptoms or signs of dissection in 52% (76/146). Forty-four percent
   (65/146) had painful Horner syndrome, which remained isolated in half the cases
   (32/65). Twenty eight percent (41/146) had transient monocular visual loss, which
   was painful in 31 cases, associated with Horner syn drome in 13 cases, and described
   as "scintillations" or "flashing lights"- often related to postural changes or exposure
   to bright lights- suggesting acute choroidal hypoperfusion in 23 cases, Four patients
   had ischemic optic neuropathy; one had diplopia. Among the 76 patients with
   ophthalmologic symptoms or signs as the presenting features of carotid dissection, a
   nonreversible ocular or hemispheric stroke later occurred in 27, within a mean of 6.2
   days (range, 1 hour to 31 days). Eighteen patients had a stroke within the first week
   after the onset of neuro- ophthalmic symptoms and signs, and 24 had a stroke within
   the first 2 weeks. CONCLUSION: Ophthalmologic symptoms or signs are frequently
   associated with and are often the presenting features in internal carotid artery
   dissection. Painful Horner syndrome or transient monocular visual loss should
   prompt investigations to diagnose carotid artery dissection and begin early treatment
   to prevent a devastating ocular or hemispheric stroke. (Am J Ophthalmol
   1998;126:565-577. (C) 1998 by Elsevier Science Inc. All rights reserved.)
Keywords:                acute/carotid/carotid              artery/carotid            artery
   SYNDROME/internal/internal                        carotid/internal                carotid
Stoddard, M.F., Longaker, R., Klein, A.L., Vaughn, S., Porter, T.R., Silver, M.,
   Chartrand, M., Smith, R.H., Lazar, J., Bilodeau, S., Trehan, N., Kasliwal, R.R.,
   Singh, S., Acquatella, H., Benitez, J., Mendoza, I., Mathias, W., Borowski, L., Small,
   R.S., Soucier, D.J., Hollywood, L., Erbel, R., Muller, S., Madkour, M.A., Melman,
   P., Pasteuning, W.H., Katz, W.E., Obarski, T.P., Mayer, C., Eichelberger, J.P.,
   Opladen, J., Redberg, R.F., Bosco, V., Pape, L.A., Aurigemma, G., Rofino, K.A.,
   Barbosa, M.M., Fattal, P.G., Harris, M., Blanchard, D.G., Sobel, J., Schwartz, S.L.,
   Garcia, M.J., Henck, T., Hoit, B.D., Kraft, L., Baruch, L., Patacsil, P., Arrowood,
   J.A., Nixon, J.V., Shapiro, S.M., Wang, S.J., Mele, D., Gruppioni, G., Lang, R.M.,
   Spencer, K., Furlong, K., Grayburn, P.A., Abraham, T., Black, I.W., Smith, A.,
   Walsh, W., Davidson, T., Rosen, S.E., Chepurko, L., Figueredo, E., Quinones, M.A.,
   Wilansky, S., Harlan, M., Shively, B.K., Gelgand, E., Haichin, R., Feldman, B.T.,
   Rodgers, G.P., Ducote, V., Orsinelli, D.A., Sagar, K.B., Bambulas, D., Coulis, L.,
   Sommers, T., Langholz, D., Johnson, E., Phillips, P.L., Wahl, S.A., Nagelhout, D.,
   Farley, R., Miller, K., Nye, G.C., Barackman, K., Pai, R.G., Daggubatti, R., Tyler, D.,
   Briller, J., McNally, B., Pollack, P.S., Whitley, D., Lengyel, M., Kancz, S., Davidoff,
   R., Manning, W.J., Mansur, J., Carneiro, M., Sorrell, V.L., Corbett, C., Gillam, L.D.,
   Mangion, J., Fisher, M., Schlesinger, R.B., Palazzo, D., LaVoie, J., Krasnow, N.,
   Sherrid, M., Tan, E., Abi-Samra, M., Grant, A., Khalighi, K., Mezei, L.E., Hamilton,
   W.P., Riggio, S., Markarian, M., Ring, M., Fein, S., Megas-Nowak, I., Goldberger,
   M.H., Wilson, D.B., DeVore, D., Weiss, R.J., Chandler, D., Arheart, K.L., Klein,
   A.L., Grimm, R.A., Murray, R.D., Garcia, M.J., Chung, M.K., Vaughn, S.E., Becker,
   E.R., Culler, S.D., Ellis, S.G., Elson, P.J., Olin, J., Furlan, A.J., Lauer, M., Asinger,
   R.W., Black, I.W., Davidoff, R., Erbel, R., Halperin, J.L., Orsinelli, D.A., Porter,
   T.R., Stoddard, M.F., Arheart, K.L., Black, I.W., Grimm, R.A., Klein, A.L., Murray,
   R.D., Orsinelli, D.A., Porter, T.R. and Stoddard, M.F. (1998), Design of a clinical
   trial for the assessment cardioversion using Transesophageal Echocardiography (The
   ACUTE Multicenter Study). American Journal of Cardiology, 81 (7), 877-883.
Abstract: Patients with atrial fibrillation (AF) undergoing cardioversion are at an
   increased risk of cardioembolic stroke and require anticoagulation, The Assessment
   of Cardioversion Using Transesophageal Echocardiography (ACUTE) Multicenter
  Study is a randomized clinical trial of patients undergoing electrical cardioversion of
  AF of >2 days' duration comparing a transesophageal-guided strategy (TEE) with
  brief anticoagulation to the conventional anticoagulation strategy. patients randomly
  assigned to the TEE-guided strategy receive therapeutic anticoagulation before TEE
  and cardioversion, followed by 4 weeks of anticoagulation, Patients with thrombus
  imaged by TEE have postponement of cardioversion, continue anticoagulation for 3
  weeks, and undergo a repeat TEE, Conventional strategy patients receive 3 weeks of
  anticoagulation before cardioversion, followed by 4 weeks of anticoagulation after
  cardioversion, The primary end point events are ischemic stroke, transient ischemic
  attack, and systemic embolization for an 8-week period from enrollment, Secondary
  end points are major and minor bleeding, all-cause mortality, successful return to and
  maintenance of sinus rhythm, and cost effectiveness, Analysis is based on the
  intention-to-treat principle. The anticipated rates of embolism of 2.9% for
  conventional strategy and 1.2% for the TEE-guided strategy are based on published
  research and the completed pilot study, The ACUTE Multicenter Study will
  randomize therapy and follow an estimated 3,000 patients from 65 study sites to
  determine the relative efficacy of the TEE-guided and conventional approaches to
  electrical cardioversion for patients in AF, The results of this investigation will have
  important clinical implications for the management of patients with AF undergoing
  electrical cardioversion. (C) 1998 by Excerpta Medica, Inc
Keywords:          ACUTE/anticoagulation/ANTITHROMBOTIC                    THERAPY/atrial
  fibrillation/clinical               trial/cost-effectiveness/effectiveness/ELECTRICAL
  stroke/LEFT               ATRIAL             THROMBI/management/MITRAL-VALVE
  DISEASE/mortality/SPONTANEOUS                                                       ECHO
  CONTRAST/stroke/therapy/thrombus/transient/transient                              ischemic
Keane, D., Zou, L. and Ruskin, J. (1998), Nonpharmacologic therapies for atrial
  fibrillation. American Journal of Cardiology , 81 (5A), 41C-45C.
Abstract: The limited efficacy and proarrhythmic risks of antiarrhythmic drug therapies
  for atrial fibrillation have led to the exploration of a wide spectrum of alternative
  therapeutic approaches. The diversity of the approaches is warranted by the current
  absence of a single procedure that can safety and effectively cure atrial fibrillation.
  The interventional therapies that are currently under most active development
  include implantable atrial defibrillator therapy, prophylactic atrial pacing in
  combination with drug therapy, multisite regional pace-entrainment of atrial
  fibrillation by rapid pacing, atrial surgery, and catheter ablation for atrial fibrillation.
  The current limitations of these procedures include: (1) for the implantable atrial
  defibrillator-patient tolerance of low energy shocks and early recurrence of atrial
  fibrillation; (2) for prophylactic pacing-limited efficacy in a small proportion of the
  total atrial fibrillation population; (3) for multisite regional pace-entrainment-lack of
  proved efficacy and difficulty in the expansion and merging of the entrained regions;
  (4) for atrial surgery-highly invasive as a stand-alone procedure; and (5) for catheter
  ablation-lack of proved long-term efficacy, shortcomings of currently available
  technology, and risk of thromboembolic stroke. It is evident that more basic and
  clinical research as well as technologic innovation are needed. However, it is likely
  that some of these new therapies, possibly in combination with antiarrhythmic drug
  therapy, will offer considerable clinical benefit to selected patients with symptomatic
  atrial fibrillation. (C) 1998 by Excerpta Medica, Inc
Keywords:            ARRHYTHMIAS/atrial                fibrillation/DEFIBRILLATION/drug
   therapy/HUMANS/implantable                   atrial            defibrillator/INTERNAL
   RHYTHM/stroke/surgery/therapy/VENTRICULAR                                        CYCLE
Kostis, J.B., Espeland, M.A., Appel, L., Johnson, K.C., Pierce, J. and Wofford, J.L.
   (1998), Does withdrawal of antihypertensive medication increase the risk of
   cardiovascular events? American Journal of Cardiology, 82 (12), 1501-1508.
Abstract: The Fifth Report of the Joint National Committee on Detection, Evaluation,
   and Treatment of High Blood Pressure recommends that attempts to discontinue
   antihypertensive drug therapy be considered after blood pressure (BP) has been
   controlled for 1 year. However, discontinuation of drug therapy could unmask
   underlying conditions and precipitate clinical cardiovascular events. The Trial of
   Nonpharmacologic Interventions in the Elderly (TONE) was a clinical trial of the
   efficacy of weight loss and/or sodium reduction in controlling BP after withdrawal of
   drug therapy in patients with a BP<145/85 mm Hg on 1 antihypertensive medication.
   Of 975 participants, 886 entered the drug withdrawal phase of the trial and 774 were
   successfully withdrawn from their medications. Thirty-three events (stroke, transient
   ischemic attack, myocardial infarction, arrhythmia, congestive heart failure, angina,
   other) occurred between randomization and the onset of drug withdrawal (median
   time 3.6 months), 57 events occurred either during or after drug withdrawal (14.0
   months), and 36 events occurred after resumption of antihypertensive therapy (15.9
   months). Event rates per 100 person-years were 5.5, 5.5, and 6.8 for the 3 time
   periods (p = 0.84) in the nonoverweight group and 7.2, 5.2, and 5.6 (p = 0.08) in the
   overweight group. The study shows that antihypertensive medication can be safely
   withdrawn in older persons without clinical evidence of cardiovascular disease who
   do not have diastolic pressure greater than or equal to 150/90 mm Hg at withdrawal,
   providing that good BP control can be maintained with nonpharmacologic therapy.
   (C) 1998 by Excerpta Medica, Inc
Keywords: angina/antihypertensive therapy/arrhythmia/blood pressure/cardiovascular
   disease/clinical        trial/congestive       heart        failure/control/disease/drug
   /myocardial         infarction/stroke/therapy/TONE/transient/transient          ischemic
Black, H.R. and Crocitto, M.T. (1998), Number needed to treat: Solid science or a path
   to pernicious rationing? American Journal of Hypertension, 11 (8), 128S-134S.
Abstract: Basing clinical practice decisions on currently available evidence from clinical
   trials may result in suboptimal care in the real-world practice of medicine. The
   problem stems from both the quality of data and the means by which the data have
   been interpreted. In an attempt to remedy the situation, a term based on an
   assessment of all risk factors and comorbidity has been suggested and made more
   easily translatable to clinical decision making. This term, the reciprocal of absolute
   risk reduction, is the number needed to treat (NNT), an idea that has gained wide
   acceptance. There are, however, risks that the simplicity of the NNT will be misused
   to guide reimbursement decisions and potentially prevent patients from receiving
   optimal care. This seemingly objective measure may be seriously flawed if the data
   on which this measure is based do not necessarily reflect the results that real world
   doctors achieve in practice. These problems could lead to the misguided allocation of
   health care resources. It is therefore incumbent upon us to closely evaluate the data
  on which NNTs are based and, if necessary, to arrive at more accurate NNTs. In our
  view, such data should be gleaned from effectiveness trials done by real world
  doctors in real world settings with real world volunteers. Large simple trials, as have
  already been performed in a number of therapeutic areas, especially for acute
  management of myocardial infarction and in acquired immune deficiency syndrome,
  offer the best likelihood of yielding this crucial information. We need to be sure that
  future trials of chronic conditions such as hypertension are done with this trial
  paradigm, so that those who pay for care have the accurate knowledge needed to
  spend their money wisely. Am J Hypertens 1998;11:128S-134S (C) 1998 American
  Journal of Hypertension, Ltd
Keywords:       absolute     risk/acute/blood      pressure/BLOOD-PRESSURE/clinical
  trials/CLINICAL-TRIALS/CORONARY                             HEART-DISEASE/decision
  DITY/MORTALITY/myocardial                   infarction/number           needed          to
  treat/PRAVASTATIN/risk factors/STROKE/trials
Weber, M.A. (1998), Translating data on antihypertensive drugs into clinical practice.
  American Journal of Hypertension, 11 (6), 89S-94S.
Abstract: Two problems in the treatment of hypertension continue to be largely
  unsolved. The first, and more simple,, is our inability to adequately control blood
  pressure in the majority of hypertensive patients. This not only reflects the difficulty
  of retaining patients in effective treatment programs, but also of convincing
  physicians to strive for optimal blood pressure levels. There is a continuing need for
  new antihypertensive drugs and combinations to help accomplish these goals. The
  second major problem is that the major clinical endpoints, including coronary events
  and renal failure, have not been adequately reduced by traditional therapies. Standard
  regimens, particularly those including diuretics, have protected against strokes and
  heart failure. Our improved understanding of vascular biology in hypertension has
  directed interest to the mechanisms in hypertensive patients that might accelerate
  atherosclerosis and vascular events in these individuals. This involves addressing the
  concomitant metabolic risk factors that comprise the "Hypertension Syndrome," and,
  perhaps of equal importance, finding therapies that directly inhibit unwanted types of
  growth and proliferative activities within the walls of critical arteries. Many
  substances within the endothelium and the vascular wall may participate as initiators
  or mediators of pathology, but most information thus far has focused on the
  renin-angiotensin system. Angiotensin converting enzyme inhibitors (and potentially
  angiotensin receptor blockers) have provided coronary and renal protection in
  various cardiovascular conditions, though not yet in formal hypertension trials.
  Calcium channel blockers have also shown promise, including recent stroke and
  cardiovascular benefits in patients with isolated systolic hypertension, but, again,
  definitive coronary data in hypertension are awaited. Unless concomitant conditions
  mandate the selection of a particular antihypertensive drug class, physicians currently
  have a dilemma: should they choose drugs from older classes that have not provided
  full protection? Or, should they prescribe newer agents with exciting potential but
  with, as yet, unproved endpoint benefits in hypertension? Until currently ongoing
  prospective trials of antihypertensive therapy are completed, physicians must be
  guided by their own interpretations of the available data. (C) 1998 American Journal
  of Hypertension, Ltd
Keywords:               antihypertensive               drugs/arteries/atherosclerosis/blood
  pressure/CAPTOPRIL/concomitant/coronary                             events/diuretics/heart
Farnier, M. and Davignon, J. (1998), Current and future treatment of hyperlipidemia:
   The role of statins. American Journal of Cardiology, 82 (4B), 3J-10J.
Abstract: Hyperlipidemia is recognized as one of the major risk factors for the
   development of coronary artery disease and progression of atherosclerotic lesions.
   Dietary therapy together with hypolipidemic drugs are central to the management of
   hyperlipidemia, which aims to prevent atherosclerotic plaque progression, induce
   regression, and so decrease the risk of acute coronary events in patients with
   pre-existing coronary or peripheral vascular disease. In patients at high risk of
   coronary artery disease but without evidence of atherosclerosis, treatment is designed
   to prevent the premature development of coronary artery disease, whereas in those
   with hypertriglyceridemia, treatment aims to prevent the development of
   hepatomegaly, splenomegaly, and pancreatitis. The 3-hydroxy- 3-methylglutaryl
   coenzyme A (HMG-CoA) reductase inhibitors, or statins, are the most potent
   lipid-lowering agents currently available, and their use in the treatment of
   hyperlipidemia provides the focus for this review. Particular emphasis is given to
   cerivastatin, a new HMG-CoA reductase inhibitor that combines potent
   cholesterol-lowering properties with significant triglyceride-reducing effects.
   Recently completed primary and secondary intervention trials have shown that the
   significant reductions in low-density lipoprotein (LDL) cholesterol achieved with
   statins result in significant reductions in morbidity and mortality associated with
   coronary artery disease as well as reductions in the incidence of stroke and total
   mortality. Such benefits occur early in the course of statin therapy and have led to
   suggestions that these drugs may possess antiatherogenic effects over and above their
   capacity to lower atherogenic lipids and lipoproteins. Experimental studies have also
   shown statin-induced improvements in endothelial function, decreased platelet
   thrombus formation, improvements in fibrinolytic activity, and reductions in the
   frequency of transient myocardial ischemia. (C) 1998 by Excerpta Medica, Inc
   UCTASE               INHIBITORS/coronary              artery          disease/coronary
   events/CORONARY-ARTERY                                             DISEASE/HEART-
   TION/PRIMARY                                            PREVENTION/regression/risk
   /vascular disease
Maeda, M., Yuh, W.T.C., Ueda, T., Maley, J.E., Crosby, D.L., Zhu, M.W. and
   Magnotta, V.A. (1999), Severe occlusive carotid artery disease: Hemodynamic
   assessment by MR perfusion imaging in symptomatic patients. American Journal of
   Neuroradiology, 20 (1), 43-51.
Abstract: BACKGROUND AND PURPOSE: Cerebral hemodynamic status has been
   reported to influence the occurrence and outcome of acute stroke. The purpose of this
   study was to assess hemodynamic compromise in symptomatic patients with severe
   occlusive disease of the carotid artery by the use of echo-planar perfusion imaging.
   METHODS: Spin-echo echo-planar perfusion imaging was performed in 11 patients
   (two Bad bilateral disease) with severe stenosis or occlusion of the carotid artery who
   had experienced either a recent transient ischemic attack or minor stroke, Relative
   cerebral blood volume (rCBV) maps and relative mean transit time (rMTT) maps
   were generated from the time-concentration curve. Findings on T2-weighted images,
   angiograms, rCBV maps, and rMTT maps were compared and assessed qualitatively
   and quantitatively, RESULTS: Although the abnormalities on T2-weighted images
   were absent, minimal, and/or unrelated to the degree of stenosis or collateral
   circulation, rMTT maps showed much larger and more distinct perfusion
   abnormalities along the vascular distribution of the affected vessels in all 13 vascular
   territories of the 11 patients, Despite obvious abnormalities on rMTT maps, none of
   the patients had evidence of decreased rCBV in the affected brain tissue (increased in
   three, normal in eight), A statistically significant difference in rMTT values was
   found between the affected and unaffected brain tissue, whereas no significant
   difference was seen in rCBV values. CONCLUSION: Echo-planar perfusion
   imaging is a noninvasive and rapid method for evaluating the hemodynamics in
   severe occlusive carotid artery disease and the compensatory vascular changes, and it
   may be useful in patient management
Keywords:                   acute/ACUTE                   CEREBRAL-ISCHEMIA/acute
   stroke/artery/assessment/BLOOD-FLOW/brain/carotid/carotid artery/carotid artery
   /GRADE/hemodynamics/imaging/ischemic/management/mean                              transit
   imaging/REACTIVITY/STENOSIS/STROKE/transient/transient ischemic attack
Stergiou, G.S., Thomopoulou, G.C., Skeva, I.I. and Mountokalakis, T.D. (1999),
   Prevalence, awareness, treatment, and control of hypertension in Greece - The
   Didima study. American Journal of Hypertension, 12 (10), 959-965.
Abstract: To assess the prevalence and the levels of awareness, treatment, and control of
   hypertension in the rural population of Greece, a cross-sectional survey of the total
   population age greater than or equal to 18 years of the village Didima was conducted.
   The survey included an interview and blood pressure (BP) measurement on two
   clinic visits. Hypertension was defined as systolic BP greater than or equal to 140
   mm Hg and or diastolic BP greater than or equal to 90 mm Hg or current treatment
   with antihypertensive drugs. The same BP threshold was used for the assessment of
   hypertension control. A total of 694 inhabitants participated (response rate 76.4%),
   and 665 were analyzed. The prevalence of hypertension was 28.4% (men 30.2%,
   women 27.1%). Of the subjects age greater than or equal to 65 years, 50% had
   hypertension. Although 73% of participants were measuring their BP at least once a
   year, overall, 39.2% of hypertensives were unaware of the diagnosis (men 50%,
   women 30.5%), 6.3% were aware but not treated (men 4.8%, women 7.6%), 27.5%
   were treated but not controlled (men 22.6%, women 31.4%), and 27% were treated
   and controlled (men 22.6%, women 30.5%). These results suggest that, in the rural
   population of Greece, hypertension is a common risk factor with considerable
   potential for improvement in levels of control. (C) 1999 American Journal of
   Hypertension, Ltd
Keywords:               age/antihypertensive           drugs/assessment/awareness/blood
   pressure/BLOOD-PRESSURE/control/control             of      hypertension/CORONARY
Piegas, L.S., Flather, M., Pogue, J., Hunt, D., Varigos, J., Avezum, A., Anderson, J.,
   Keltai, M., Budaj, A., Fox, K., Ceremuzynski, L. and Yusuf, S. (1999), The
   Organization to Assess Strategies for Ischemic Syndromes (OASIS) registry in
  patients with unstable angina. American Journal of Cardiology, 84 (5A), 7M-12M.
Abstract: Clinical approaches to the prevention of the potentially catastrophic
  consequences of coronary ischemic phenomena such as unstable angina and
  suspected non-Q-wave myocardial infarction (MI) differ across the world. in addition
  to prevailing physician beliefs in different societies, the level of access to
  catheterization laboratories largely determines whether an interventionist or
  conservative strategy is adopted. The Organization to Assess Strategies for Ischemic
  Syndromes (OASIS)-a prospective registry of approximately 8,000 patients with
  acute myocardial ischemia with no ST elevation, treated in 95 hospitals across 6
  countries-furnished a unique window into regional differences in clinical
  management and the frequency and timing of invasive procedures (i.e., angiography,
  percutaneous transluminal coronary angioplasty [PTCA], and coronary artery bypass
  graft [CABG] surgery), as well as the outcomes of these trends. At 6 months after
  symptom onset, patients in the United States and Brazil, where the catheterization
  laboratory facilities are more accessible, underwent significantly (p <0.001) more
  angiography (69.4%), PTCA (23.6%), and CABG (25.2%) than in Canada and
  Australia, where the corresponding rates were 48.4%, 17.0%, and 16.8% (p <0.001),
  respectively; and in Hungary and Poland, where the respective rates were 23.5%,
  5.8%, and 10.9% (p <0.001). This relatively aggressive approach led at 6 months to a
  more substantial decrease in refractory angina in the United States and Brazil than in
  Canada and Australia (20.4% vs 13.9%; p <0.001), but no improvement in rates of
  cardiovascular mortality and MI (10.5% versus 10.5%; p = 0.36). There was a
  significant (p less than or equal to 0.012) increase in stroke, (1.9% vs 1.3%; p =
  0.010) and major bleeding (1.9% vs 1.1%; p = 0.009) events. Furthermore, an inverse
  correlation emerged between baseline cardiovascular risk status and frequency of
  angiography and PTCA interventions preferentially for low-risk compared with
  high-risk patients. In concert with findings from other recent randomized trials, the
  OASIS Registry data suggest that although there are fewer hospital readmissions for
  unstable angina, there is a trend toward increased rates of death, MI, and stroke.
  These data urge a cautious approach to the use of invasive procedures in patients
  with unstable angina unless future trials demonstrate a clear benefit with on
  aggressive approach. (C) 1999 by Excerpta Medico, Inc
  risk/catheterization/CONSERVATIVE STRATEGIES/coronary/coronary artery
  al         infarction/OUTCOMES/percutaneous               transluminal       coronary
  RIAL/trials/United States/unstable angina/WAVE MYOCARDIAL-INFARCTION
Arko, F.R., Fritcher, S., Mettauer, M., Patterson, D.E., Buckley, C.J. and Manning, L.G.
  (1999), Mobile atheroma of the aortic arch and the risk of carotid artery disease.
  American Journal of Surgery, 178 (3), 206-208.
Abstract: BACKGROUND: Mobile atheromas of the aortic arch are associated with
  otherwise unexplained strokes and transient ischemic attacks (TIA). They are
  associated with increased perioperative strokes in patients undergoing coronary
  artery bypass surgery. Peripheral embolization is an additional risk. Transesophageal
  echocardiography (TEE) accurately identifies mobile atheroma. Anticoagulant
  therapy may have therapeutic considerations In the management of this condition.
  However, the risk of significant carotid artery disease associated with mobile
  atheromas is unknown. METHODS: Between March 1994 and July 1998, 40 patients
  with mobile atheromas by TEE and evidence of embolization were studied. Ail
  patients were captured prospectively in a vascular registry and were retrospectively
  reviewed. Carotid artery disease was evaluated using carotid duplex imaging in an
  accredited vascular laboratory. Ail patients with significant carotid disease, 70% or
  greater stenosis, underwent arteriography. Patients with significant carotid artery
  stenosis then underwent carotid endarterectomy. All patients with mobile atheromas
  were maintained on anticoagulation. RESULTS: Forty patients with mobile
  atheromas of the aortic arch were diagnosed with TEE. All 40 patients had evidence
  of embolization. Patient age ranged from 57 to 73 years (mean 68.4). There were 22
  men and 18 women. Twenty of 40 (50%) patients presented with symptoms of TIA.
  Eleven of 40 (28%) patients presented with diffuse atheroembolization (lower
  extremity embolization and renal insufficiency), Six of 40 (15%) patients presented
  with a completed stroke. Three of 20 (7%) patients presented with acute extremity
  ischemia secondary to a peripheral embolus, Twenty-three of 40 (58%) of patients
  had significant carotid artery stenosis, 70% or greater stenosis. These 23 patients
  underwent both arteriography and carotid endarterectomy without complication. All
  patients were treated with anticoagulation and have remained anticoagulated.
  Clinical follow-up between 2 to 48 months (mean 18) has demonstrated no further
  evidence of systemic embolization in these 40 patients. Repeat TEE was performed
  in 6 of 40 patients. These follow-up studies no longer visualized mobile atheromas.
  CONCLUSIONS: Mobile atheromas are recognized sources for embolization.
  Routine carotid duplex imaging should be performed in patients found to have
  mobile atheromas of the aortic arch. Carotid endarterectomy appears to be safe in
  patients who have combined carotid artery stenosis and mobile atheromas.
  Anticoagulation may have therapeutic considerations in the management of this
  condition. (C) 1999 by Excerpta Medica, Inc
Keywords:              acute/age/anticoagulation/artery/atheroma/bypass/carotid/carotid
  artery/carotid                         artery                          disease/carotid
  endarterectomy/combined/complication/coronary/coronary                          artery
  ECHOCARDIOGRAPHY/transient/transient ischemic attacks
Sheps, S.G. (1999), Overview of JNC VI: New directions in the management of
  hypertension and cardiovascular risk. American Journal of Hypertension, 12 (8),
Abstract: Treatment recommendations for hypertension as outlined in the Sixth Report
  of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment
  of High Blood Pressure (JNC VI) are constantly evolving and being refined as new
  information on the disease becomes evident. Uncontrolled hypertension is a major
  antecedent of stroke, heart failure, coronary heart disease, and end-stage renal
  disease. The increasing incidences of both cardiovascular and renal diseases fuel the
  need for improved control of hypertension. In fact, according to the National Health
  and Nutrition Examination Survey (NHANES), about 69% of Americans whose
  blood pressure is greater than 140/90 mm Hg are aware of it, about half are getting
  treatment for it, and only about one-quarter are adequately controlled. These
  observations fuel the need for improved patient management guidelines. JNC VI
  makes several changes from the previous JNC V to assist physicians in the diagnosis,
  treatment, and improved management of patients with hypertension. These changes
  include reporting adult blood pressure in two new ways, via staging and risk factor
  classification. A high-normal classification (systolic: 130 to 139 mm Hg, or diastolic:
  85 to 89 mm Hg) is included in JNC VI because of the clinical importance of such
  blood pressure contributing to cardiovascular disease. Additionally, clinicians are
  advised to assign a patient to one of three risk categories that, in addition to
  hypertension stage, influence the decision to select antihypertensive drug therapy.
  Lifestyle modification is an important component at each stage. These and other
  changes and highlights of recent studies supporting the need for more intensive blood
  pressure control are discussed in this paper. Am J Hypertens 1999; 12:65S-72S (C)
  1999 American Journal of Hypertension, Ltd
Keywords: antihypertensive therapy/AWARENESS/blood pressure/blood pressure
  control/cardiovascular        disease/cardiovascular        risk/cardiovascular      risk
  factors/control/control         of        hypertension/coronary/coronary            heart
  disease/diagnosis/disease/drug                       therapy/guidelines/HEALTH/heart
Rouleau, P.A., Huston, J., Gilbertson, J., Brown, R.D., Meyer, F.B. and Bower, T.C.
  (1999), Carotid artery tandem lesions: Frequency of angiographic detection and
  consequences for endarterectomy. American Journal of Neuroradiology, 20 (4),
Abstract: BACKGROUND AND PURPOSE: Several prospective trials have shown that
  ischemic stroke can be prevented by performing an endarterectomy in patients with
  high-grade carotid stenosis, Our purpose was to ascertain the frequency of carotid
  artery tandem lesions and to determine whether their presence alters the surgeon's
  decision to perform an endarterectomy, METHODS: We retrospectively reviewed
  the cerebral angiograms obtained between January 1994 and June 1996 in 853
  patients with carotid occlusive disease, Studies were analyzed for the presence of
  internal carotid artery (ICA) stenosis as well as for tandem lesions (defined as greater
  than or equal to 50% diameter stenosis) within the common carotid artery, carotid
  siphon, or proximal intracranial arteries. The frequency of intracranial saccular
  aneurysms was determined, RESULTS: Six hundred seventy-two of the 853 patients
  had a carotid bifurcation stenosis of 70% or greater or underwent an endarterectomy,
  Of these, a carotid siphon stenosis of 50% or greater was noted in 65 patients (9.7%)
  and was ipsilateral to an ICA stenosis in 37 patients (5.5%), A common carotid
  stenosis was present in 29 patients (4.3%), ipsilateral to an ICA stenosis in 14
  patients (2.1%), A stenosis of 50% or greater within the proximal intracranial
  circulation was present in 28 patients (4.2%), ipsilateral to an ICA stenosis in 15
  patients (2.2%), Flour patients had tandem stenoses at more than one site. Tandem
  stenoses in the siphon or intracranial segments were noted in 13.5% with a
  bifurcation stenosis and in 8.8% of those with no bifurcation stenosis,
  Endarterectomy was performed in 48 of the 66 patients with tandem stenotic lesions.
  CONCLUSION: The presence of a tandem lesion infrequently alters the surgeon's
  decision to perform an endarterectomy. However, the importance of detecting
  tandem stenoses cannot be underestimated, since they may have important
  implications for long-term medical management in symptomatic patients
Keywords: arteries/artery/carotid/carotid artery/carotid occlusive disease/carotid
  carotid/internal              carotid              artery/intracranial/ischemic/ischemic
Economopoulos, K.J., Gentile, A.T. and Berman, S.S. (1999), Comparison of carotid
   endarterectomy using primary closure, patch closure, and eversion techniques.
   American Journal of Surgery, 178 (6), 505-509.
Abstract: BACKGROUND: This Study was undertaken to evaluate the role of eversion
   endarterectomy in the management of extracranial carotid occlusive disease.
   METHODS: A retrospective review was performed of all patients undergoing carotid
   endarterectomy between July 1994 and July 1998. After reviewing the records,
   patients were assigned to one of three groups: eversion (ECEA); open with primary
   closure (CEA degrees); or open with patch closure (CEAP). Statistical comparisons
   were made. RESULTS: The 190 index cases comprised 33 ECEA (17%), 15 CEA
   degrees (8%), and 142 CEAP (75%). Both ECEA and CEA degrees were more likely
   to be done on males versus females compared with CEAP (P = 0.01), For the entire
   190 cases, stroke occurred in 1 patient (0.5%); and myocardial infarction in 2
   patients (1%), resulting in death in both. Two patients (1.4%) in the CEAP group
   have undergone redo surgery at 8 and 24 months, CONCLUSIONS: This study
   demonstrates that eversion endarterectomy achieves early results similar to open
   endarterectomy with and without patch closure. Am J Surg. 1999;178:505-510, (C)
   1999 by Excerpta Medica, Inc
Keywords:         ARTERY/carotid/carotid          endarterectomy/carotid        occlusive
Jones, D., Basile, J., Cushman, W., Egan, B., Ferrario, C., Hill, M., Lackland, D.,
   Mensah, G., Moore, M., Ofili, E., Roccella, E.J., Smith, R. and Taylor, H. (1999),
   Managing hypertension in the southeastern United States: Applying the guidelines
   from the Sixth Report of the Joint National Committee on Prevention, Detection,
   Evaluation, and Treatment of High Blood Pressure (JNC VI). American Journal of
   the Medical Sciences, 318 (6), 357-364.
Abstract: The southeastern United States has the highest occurrence of heart disease and
   stroke and among the highest rates of congestive heart failure and renal failure in the
   country. The Consortium for Southeastern Hypertension Control (COSEHC) is
   cooperating with other organizations in implementing initiatives to reduce morbidity
   and mortality from hypertension-related conditions in the southeastern United States.
   This article outlines for clinicians special consideration for implementation of the
   Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation,
   and Treatment of High Blood Pressure ONC VI in the southeastern United States.
   Clinicians are encouraged to adapt the recommendations of JNC VI to their own
   patient groups, paying attention to these specific areas: (1) Ensure screening for
   hypertension in your practice and community. (2) Evaluate all patients for
   accompanying risk factors and target organ damage. (3) Promote lifestyle
   management for individual patients and populations for prevention and treatment of
   hypertension. (4) Set a goal blood pressure for each patient, and monitor progress
   toward that goal. (5) Recognize that many patients will be candidates for blood
   pressure goals of <130/85 mm Hg. (6) Pay attention to compelling and special
   indications such as diabetes, congestive heart failure, and renal dysfunction. (7)
   Consider combination therapy. (8) Maximize staff contributions to enhance patient
   adherence. (9) Encourage patient, family, and community activities to promote
   healthy lifestyles and blood pressure control
Keywords:                attention/blood                pressure/blood             pressure
   control/combination/community/congestive                                            heart
   POTASSIUM/disease/DISEASE                           MORTALITY/guidelines/heart/heart
   TRIAL/REDUCTION/renal/renal                                             failure/risk/risk
   factors/screening/southeast/STROKE/stroke belt/therapy/treatment/United States
Johnson, C.A., Tollefson, D.F.J., Olsen, S.B., Andersen, C.A. and McKee-Johnson, J.
   (1999), The natural history of early recurrent carotid artery stenosis. American
   Journal of Surgery, 177 (5), 433-436.
Abstract: BACKGROUND: Early recurrent carotid stenosis, defined as greater than
   50% stenosis within 2 years of a carotid endarterectomy (CEA), occurs in 4% to 19%
   of patients. These lesions are secondary to myointimal hyperplasia (MH). The natural
   history of these lesions has been examined prospectively, but the appropriate
   management of these lesions has not been clearly defined. The vascular surgery
   service at Madigan Army Medical Center (MAMC) has prospectively collected a
   cohort of patients with recurrent high-grade carotid stenoses following CEA to
   determine their natural history and define the ideal therapeutic approach for those
   lesions. METHODS: Patients undergoing CEA between January 1, 1993, and
   January 1, 1997, at a single tertiary care institution were followed prospectively with
   postoperative carotid duplexes at 3-month intervals for the first year and then every 6
   months for a year and then annually thereafter. Data were collected regarding patient
   demographics, type of carotid closure, neurologic morbidity, and death. These results
   were compared with accepted rates in the literature. Discrete variables were tested
   for significance by chi-square analysis and Fisher's exact test. A P value less than or
   equal to 0.05 was considered significant. RESULTS: One hundred and seventy-four
   (174) patients with 181 operative sites were evaluated. Fourteen patients with 17
   sites (9%) had recurrent stenosis, Twelve patients with 14 sites (7%) had stenoses of
   50% to 79%. All were asymptomatic, Two patients with 3 sites (2%) had stenoses
   greater than 80%. Two sites were managed operatively because of neurologic
   symptoms or preocclusive nature and one remains asymptomatic and stable on serial
   duplex imaging. All lesions were present at 6 months and those in the 50% to 79%
   category did not progress in follow-up. Recurrent carotid stenosis occurred to a
   significantly higher degree in women (women 11 of 60 18.3% versus men 6 of 114
   5.3%; P = 0.25), primary closure versus patch angioplasty (primary 6 of 22 27.3%
   versus patch 11 of 159 6.9%; P = 0.01), and dacron versus polytetrafluoroethylene
   (PTFE) patch angioplasty (dacron 7 of 36 19.4% versus PTFE 2 of 100 2.0%; P =
   0.02), CONCLUSION: Early recurrent stenosis (50% to 79%) is a benign lesion.
   Patch angioplasty is preferred over primary closure, Dacron patches had a
   significantly higher rate of recurrent stenosis when compared with PTFE patches.
   Women undergoing CEA are move prone to recurrent stenosis. Postoperative duplex
   at 3 and 6 months will identify recurrent carotid stenosis (given a normal duplex
   prior to discharge following CEA), Moderate high-grade (50% to 79%) stenoses are
   benign. High-grade (80% to 99%) stenoses require individual management. Am J
   Surg, 1999;177:433-436, (C) 1999 by Excerpta Medica, Inc
Keywords: angioplasty/artery/carotid/carotid artery/carotid artery stenosis/carotid
  FOLLOW-UP/vascular surgery
Chen, L., Keane, A.T. and Every, N.R. (1999), The food and drug administration and
  atrial defibrillation devices. American Journal of Managed Care, 5 (7), 899-909.
Abstract: Context: Atrial fibrillation is a common arrhythmia. It leads to significant
  morbidity and mortality, primarily from the increased incidence of stroke. The
  implantable atrial defibrillator, a new therapeutic option for the management of atrial
  fibrillation, is currently undergoing Food and Drug Administration (FDA) scrutiny
  for approval to market in the United States. Data Sources: A review of the basic
  epidemiology of atrial fibrillation, as well as the current status of accepted treatment
  options in light of the development of the implantable atrial defibrillator, was
  conducted. A literature search using the terms atrial fibrillation, implantable
  defibrillator, Food and Drug Administration, medical devices, and medical device
  regulatory law was conducted using the MEDLINE and Current Contents databases.
  Results: Currently, there is no consensus on the optimal treatment of atrial fibrillation.
  Despite the lack of definitive studies showing overall benefit associated with
  maintaining sinus rhythm in patients in atrial fibrillation, the implantable atrial
  defibrillator may soon reach the general market. We examine the FDA process for
  the evaluation of this new medical device and discuss implications for the patient,
  physician, industry, and health insurers. Conclusions: Current FDA approval
  processes for new devices are a compromise between (a) the needs for expediency
  and encouraging innovation by the medical device industry and (b) the need to
  ensure that new devices will contribute to improved patient outcomes. We suggest
  alternative FDA- approval processes that address these issues
Keywords:                administration/atrial            fibrillation/CARE/CATHETER
  ABLATION/CORRIDOR                   OPERATION/epidemiology/evaluation/EXERCISE
  CAPACITY/FIBRILLATION/general/implantable                                           atrial
  TACHYCARDIA/treatment/United States
Cahan, M.A., Killewich, L.A., Kolodner, L., Powell, C.C., Metz, M., Sawyer, R., Lilly,
  M.P., Benjamin, M.E. and Flinn, W.R. (1999), The prevalence of carotid artery
  stenosis in patients undergoing aortic reconstruction. American Journal of Surgery,
  178 (3), 194-196.
Abstract: BACKGROUND: Coronary artery disease occurs frequently in patients
  undergoing aortic reconstruction, and it has been presumed that internal carotid
  artery occlusive disease is also common. This has led to the practice of screening for
  and repairing significant carotid lesions in asymptomatic patients prior to aortic
  reconstruction. The purpose of this study was to determine the true prevalence of
  internal carotid artery disease in these patients, METHODS: The records of 240
  patients who underwent duplex ultrasound screening for carotid artery disease prior
  to aortic reconstruction were reviewed, Surgery was performed for aortic aneurysm
  (AA) or aorto-iliac occlusive disease (AO). The prevalence of hyperlipidemia and
  coronary artery disease was similar between the two groups, but tobacco use,
  hypertension, and diabetes mellitus differed. RESULTS: Internal carotid artery
  stenosis greater than or equal to 50% occurred in 26.7% of the total group (64 of 240
  cases). Stenosis greater than or equal to 50% was move common in the AO group
  (40 of 101 cases, 39.60%) than the AA group (24 of 139 cases, 17.3%, P = 0.0001).
  Severe disease (70% to 99%) was also more common in the AO group than the AA
   group (9.9% versus 3.6%, P = 0.0464). CONCLUSION: internal carotid artery
   disease occurs commonly in patients undergoing aortic reconstruction, and screening
   is worthwhile. Significant disease is more common in patients with aorto-iliac
   occlusive disease than in those with aortic aneursym, although atherosclerotic risk
   factors occur with varying frequency in the two groups. These findings suggest that
   additional factors may contribute to the higher prevalence of internal carotid artery
   stenosis in aorto-iliac occlusive disease. (C) 1999 by Excerpta Medica, Inc
Keywords:                       aneurysm/ANEURYSM                           REPAIR/aortic
   aneurysm/artery/CARDIAC-SURGERY/carotid/carotid                artery/carotid      artery
   disease/coronary/coronary                  artery              disease/diabetes/diabetes
   mellitus/DISEASE/duplex/duplex                  ultrasound/hypertension/internal/internal
   carotid/internal carotid artery/LESIONS/MANAGEMENT/prevalence/RISK/risk
Dillavou, E.D., Kahn, M.B., Carabasi, R.A., Smullens, S.N. and DiMuzio, P.J. (1999),
   Long-term follow up of reoperative carotid surgery. American Journal of Surgery,
   178 (3), 197-200.
Abstract: BACKGROUND: We examined our long-term results of carotid reoperation
   to identify risk factors far morbidity and secondary recurrence. METHODS: Medical
   record review revealed 27 patients had reoperative surgery for recurrent stenosis.
   Demographics, operative details, pathology, clinical outcome, and follow-up imaging
   results were reviewed. RESULTS: No neurologic deficits and no mortalities were
   noted perioperatively. Long-term follow-up (average 54 months) revealed an 85%
   5-year and 29% 10-year estimated survival. The 5- and 10-year estimated neurologic
   event rates were 15% and 35%, respectively. These included 3 ipsilateral strokes and
   1 ipsilateral TIA; only the TIA involved secondary restenosis. Follow-up imaging
   revealed a 21% incidence of secondary restenosis, occurring more frequently in
   patients with hyperlipidemia (P < 0.05) and previous contralateral endarterectomy (P
   < 0.05). CONCLUSIONS: (1) Reoperation provides long-term protection from
   stroke due to recurrent stenosis. (2) Secondary restenosis rates appear higher than
   those for primary surgery. (3) Hyperlipidemia and contralateral endarterectomy are
   risk factors for secondary restenosis. (C) 1999 by Excerpta Medica, Inc
White, R.H., McBurnie, M.A., Manolio, T., Furberg, C.D., Gardin, J.M., Kittner, S.J.,
   Bovill, E. and Knepper, L. (1999), Oral anticoagulation in patients with atrial
   fibrillation: Adherence with guidelines in an elderly cohort. American Journal of
   Medicine, 106 (2), 165-171.
Abstract: PURPOSE: To determine adherence with practice guidelines in a
   population-based cohort of elderly persons aged 70 years or older with atrial
   fibrillation. SUBJECTS AND METHODS: This was a cross-sectional analysis of a
   subgroup of participants in the Cardiovascular Health Study, a prospective
   observational study involving four communities in the United States. Subjects were
   participants with atrial fibrillation on electrocardiogram at one or more yearly
   examinations from 1993 to 1995. The outcome measure was self-reported use of
   warfarin in 1995. RESULTS: In 1995, 172 (4.1%) participants had atrial fibrillation
   together with information regarding warfarin use and no preexisting indication for its
   use, Warfarin was used by 63 (37%) of these participants. Of the 109 participants not
   reporting warfarin use, 92 (84%) had at least one of the clinical risk factors (aside
  from age) associated with stroke in patients with atrial fibrillation. Among
  participants not taking warfarin, 47% were taking aspirin. Several characteristics
  were independently associated with warfarin use, including age [odds ratio (OR) =
  0.6 per 5-year increment, 95% CI 0.5-0.9], a modified mini- mental examination
  score <85 points [OR = 0.3, 95% confidence interval (CI) 0.1-0.9], and among
  patients without prior stroke, female sex (OR = 0.5, 95% CI 0.2-1.0).
  CONCLUSIONS: Despite widely publicized practice guidelines to treat patients who
  have atrial fibrillation with warfarin, most participants who had atrial fibrillation
  were at high risk for stroke but were not treated with warfarin. More studies are
  needed to determine wily elderly patients with atrial fibrillation are not being treated
  with warfarin. Am J Med. 1999;106: 165-171. (C) 1999 by Excerpta Medica, Inc
Keywords:                                                                        ACUTE
  factors/sex/stroke/STROKE                  PREVENTION/studies/THERAPY/United
Fox, K.A.A. (1999), Implications of the Organization to Assess Strategies for Ischemic
  Syndromes-2 (OASIS-2) study and the results in the context of other trials. American
  Journal of Cardiology, 84 (5A), 26M-31M.
Abstract: Although unfractionated heparin is widely used for thrombin inhibition in the
  management of unstable coronary artery disease, clinical and experimental evidence
  suggests that it is suboptimal. Recent pharmaceutical strategies to improve upon
  unfractionated heparin's efficacy profile have centered on the development of 2
  major classifications of thrombin inhibition medications: the naturally occurring
  leech protein hirudin (and synthetic analogs) and low-molecular-weight (LMW)
  heparins. In the Organisation to Assess Strategies for Ischaemic Syndromes-2
  (OASIS-2) trial, hirudin was demonstrably more effective than heparin in
  diminishing rates of death, myocardial infarction (MI), and angina at both 72 hours
  and 7 days after unstable coronary artery disease index events, with risk ratios on the
  order of 0.8. Similarly, in the Efficacy and Safety of Subcutaneous Enoxaparin in
  Nan-Q-Wave Coronary Events (ESSENCE) study, the LMW heparin enoxaparin
  emerged superior to unfractionated heparin in attenuating rates of unstable coronary
  artery disease at 14 days, 30 days, and 1 year. On the other hand, findings involving
  other LMW heparins (dalteparin sodium, Fragmin, and fraxaparin) are equivocal,
  Although the Fragmin During Instability in Coronary Artery Disease (FRISC) study
  demonstrated statistically significant superiority of this LMW heparin over
  aspirin/placebo in driving down death/ Ml/revascularization rates, the Fragmin in
  Unstable Coronary Artery Disease (FRIC) trial showed no such superiority, but had
  wide confidence intervals. Similarly, the Fraxaparin Versus Unfractionated Heparin
  in Acute Coronary Syndromes (FRAXIS) trial with fraxaparin failed to show
  superiority over unfractionated heparin. The favorable efficacy findings associated
  with hirudin and enoxaparin regimens, compared with unfractionated heparin,
  accrued without significant increases in the incidences of life-threatening bleeding
  events (e.g., hemorrhagic stroke), but did include more frequent lesser bleeding
  events. In summary, both hirudin and enoxaparin have demonstrated clinically
  important improvements in outcome compared with standard treatments in unstable
  coronary artery disease. (C) 1999 by Excerpta Medico, Inc
Keywords:                 angina/artery/ASPIRIN/coronary/coronary                   artery
  HEPARIN/myocardial                                          infarction/MYOCARDIAL-
Ness, J. and Aronow, W.S. (1999), Prevalence of coronary artery disease, ischemic
  stroke, peripheral arterial disease, and coronary revascularization in older
  African-Americans, Asians, Hispanics, whites, men, and women. American Journal
  of Cardiology, 84 (8), 932-+.
Abstract: The prevalence of coronary artery disease and of peripheral arterial disease
  was similar in older African-Americans, Asians, Hispanics, and whites, and the
  prevalence of ischemic stroke was lower in older whites than in older African-
  Americans and Hispanics. The prevalence of coronary revascularization in older
  persons with coronary artery disease was lower in African-Americans than in whites
  and Hispanics and was lower in women than in men
Keywords:         African       Americans/artery/BLACKS/coronary/coronary              artery
  disease/coronary            revascularization/disease/INFARCTION/ischemic/ischemic
Oparil, S. (1999), Treating multiple-risk hypertensive populations. American Journal of
  Hypertension, 12 (11), 121S-129S.
Abstract: The majority of patients with hypertension have one or more additional risk
  factors for cardiovascular disease. In planning an appropriate treatment program, it is
  useful to identify and stratify hypertensive patients according to their risk of
  developing cardiovascular, cerebrovascular, or renal disease. At particular risk are
  the elderly, patients with diabetes, and those with target-organ damage manifested by
  impaired renal function. Evidence supports increased risk in these patients, and
  clinical trial results demonstrate the considerable benefits realized through aggressive
  blood pressure (BP) control. The number of elderly individuals continues to increase
  in the United States and other industrialized countries. The prevalence of isolated
  systolic hypertension (ISH) is higher in the elderly than in younger individuals. ISH
  is associated with significant morbidity and mortality and should not be considered a
  physiologic manifestation of the normal aging process. Type 2 diabetes is also
  increasing in prevalence. Patients with diabetes are at increased risk for coronary
  heart disease, stroke, renal failure, and other cardiovascular complications.
  Aggressive treatment of elevated BP can produce dramatic decreases in the
  cardiovascular complications of diabetes. The incidence of end-stage renal disease
  has increased 2.5-fold in the past two decades, and poorly controlled BP is a major
  contributor to the increase. Lowering BP to levels well below the traditional goal of
  140/90 mm Hg is needed to slow the progression of renal dysfunction and prevent
  renal failure in hypertensive patients with renal disease, whether related to diabetes
  or to another etiology. Aggressive treatment of hypertension in multiple-risk
  populations (to the goals of JNC VI and the recent WHO-ISM Guidelines for the
  Management of Hypertension) can be expected to produce significant reductions in
  the incidence and prevalence of stroke, heart failure, coronary heart disease, chronic
  renal failure, and total cardiovascular mortality. Am J Hypertens 1999;
  12:121S-129S (C) 1999 American Journal of Hypertension, Ltd
Keywords:                 blood             pressure/BLOOD-PRESSURE/cardiovascular
  disease/cerebrovascular/chronic                    renal                   failure/clinical
  trial/complications/control/coronary            heart           disease/diabetes/diabetes
   mellitus/disease/elderly/etiology/heart     failure/hypertension/incidence/ISOLATED
   SYSTOLIC HYPERTENSION/morbidity/mortality/prevalence/renal/risk factors/risk
   stratification/stroke/treatment/TRIAL/United States
Stone, J.H., Amend, W.J.C. and Criswell, L.A. (1999), Antiphospholipid antibody
   syndrome in renal transplantation: Occurrence of clinical events in 96 consecutive
   patients with systemic lupus erythematosus. American Journal of Kidney Diseases,
   34 (6), 1040-1047.
Abstract: We report the results of a detailed examination of clinical events associated
   with the antiphospholipid antibody (aPL) syndrome in 96 consecutive patients with
   systemic lupus erythematosus (SLE) who underwent renal transplantation between
   January 1, 1984, and September 1, 1996, Because of the retrospective nature of our
   study, we developed strict definitions of clinical events considered to be associated
   with the aPL syndrome. We reviewed all available hospital, clinic, and outside
   records of the patients with SLE who underwent transplantation at our center during
   this time period and noted the results of three standard serological tests for aPLs,
   when available. Mean follow-up of the 96 patients was 62.6 months. Eighty-five of
   the 96 patients (88.5%) had at least one test for aPLs performed, and 25 patients
   (29.4%) had at least one abnormal test result. Among these 25 patients, 15 patients
   (60%) had clinical events associated with aPL syndrome. Ten patients (10.4%) either
   died of the aPL syndrome or had an aPL- associated clinical event within 3 months
   of transplantation. Other morbidity from the aPL syndrome in these 15 patients
   included: thrombotic arteriolar microangiopathy (2 patients), stroke (4 patients),
   ocular ischemia (7 patients), deep vein thrombosis or pulmonary embolism (6
   patients), renal artery or vein thrombosis (4 patients), peripheral ischemia (1 patient),
   and fetal wastage (3 patients). By comparison, among the 60 patients with normal
   aPL test results, only 5 patients had clinical events compatible with the aPL
   syndrome (P < 0.0001 by chi-squared test). aPLs may be associated with significant
   morbidity and mortality in patients with SLE undergoing renal transplantation. This
   study is the first attempt to quantify the impact of aPLs on renal transplantation in a
   large population of patients with SLE, Further investigation of aPLs in SLE patients
   with end-stage renal disease is required to clarify the risks, benefits, and optimal
   clinical management of renal transplantation for these patients. (C) 1999 by the
   National Kidney Foundation, Inc
Keywords:                ALLOGRAFT                  THROMBOSIS/ANTICARDIOLIPIN
   ANTIBODIES/ANTICOAGULANT/antiphospholipid                                     antibodies
   orbidity/mortality/outcome/pulmonary            embolism/renal/renal         artery/renal
   transplantation/SLE/stroke/systemic lupus erythematosus (SLE)/thrombosis
Olney, R.S. (1999), Preventing morbidity and mortality from sickle cell disease - A
   public health perspective. American Journal of Preventive Medicine, 16 (2),
Abstract: Context: Sickle cell disease is a group of conditions characterized by
   production of abnormal hemoglobin, with clinical manifestations that vary by
   genotype and age. Objective: To discuss current public health issues associated with
   sickle cell disease, and approaches to preventing complications from these conditions
   in die United States. Design: Literature review. Results: Most clinical interventions
   for people with sickle cell disease discussed in the medical literature can be classified
   as tertiary prevention: for example, therapy to ameliorate anemia, reduce the
   frequency of pain crises, or prevent stroke I recurrences. A form of secondary
   prevention, newborn screening, has emerged as an important public health approach
  to identifying affected children before they develop complications. Newborn
  screening is the starting point, for simple public health strategies such as parental
  education, immunization, and penicillin prophylaxis. Identification of affected
  families by newborn or community screening programs has also been an entry point
  for genetic counseling, although utilization of prenatal testing has varied by factors
  such as geographic location. Public health agencies have had significant involvement
  with funding, policy making, and formulation of laboratory and clinical guidelines
  for sickle cell disease. Since the introduction of penicillin prophylaxis policies,
  newborn screening, new immunizations, and comprehensive medical care centers,
  the survival of young children with sickle cell disease has improved. Conclusions:
  Although the efforts of preventive medicine providers in public health programs are
  not solely responsible for the improved survival of children with sickle cell disease,
  such programs remain an important component in preventing sickle cell
Keywords:                        age/ANEMIA/anemia/child                          health
  health/review/secondary prevention/sickle cell disease/sickle cell prevention and
  control/strategies/stroke/survival/therapy/TRIAL/United States/utilization
Ford, R.F., Barton, J.R., O'Brien, J.M. and Hollingsworth, P.W. (2000), Demographics,
  management, and outcome of peripartum cardiomyopathy in a community hospital.
  American Journal of Obstetrics and Gynecology, 182 (5), 1036-1038.
Abstract: OBJECTIVE: The purpose of this study was to describe the outcome of
  peripartum cardiomyopathy in patients cared for in a community hospital. STUDY
  DESIGN: The cases of peripartum cardiomyopathy treated at Central Baptist
  Hospital in Lexington, Kentucky, from January 1, 1992, to December 31, 1998, were
  reviewed. RESULTS: Eleven patients with peripartum cardiomyopathy were
  identified. The patient population was 91% white and 9% African American.
  Seventy-two percent of patients were nulliparous, and the prevalence of chronic
  hypertension was 27%. All patients were examined with echocardiography and met
  diagnostic criteria for the disease when this modality was used. The mean ejection
  fraction was 32% +/- 10%. Invasive techniques used to assist in diagnosis included
  left ventricular catheterization (63%), right ventricular catheterization (54%), and
  cardiac biopsy (54%). One patient required cardiac transplantation. This patient also
  had an embolic stroke from a confirmed mural thrombus. No study patient died of
  the disease, and no other major complications were observed. CONCLUSIONS: The
  patient profile of peripartum cardiomyopathy in this study differed remarkably from
  profiles in published reports. Nulliparous white women have better outcomes than
  indicated by previous reports, probably because of the low frequency of coexisting
  chronic disease and a younger age at diagnosis
Keywords: age/cardiomyopathy/catheterization/chronic disease/community/community
Sprecher, D.L. (2000), Raising high-density lipoprotein cholesterol with niacin and
  fibrates: A comparative review. American Journal of Cardiology, 86 (12A),
Abstract: A growing number of trials that used fibrates and niacin alone or in
   combination with other lipid-altering agents have shown that both these drugs are
   effective for reducing total cholesterol, low-density lipoprotein cholesterol (LDL-C)
   and triglycerides, and for increasing high-density lipoprotein cholesterol (HDL-C)
   levels. These lipid changes are associated with a reduction in events such as fatal and
   nonfatal myocardial infarction, stroke, and transient ischemic attack. In angiographic
   trials, they are associated with disease regression, increased minimal luminal
   diameter, and protection from risk of new lesions. In a head-to-head comparison
   study, niacin 2,000 mg/day increased HDL-C more than gemfibrozil 1,200 mg/day,
   and decreased the total cholesterol-to-HDL-C ratio, lipoprotein (a) (Lp[a]), and
   fibrinogen levels significantly more. Combination therapies of niacin plus a resin or
   statin are effective, well tolerated, and (C) 2000 by Excerpta Medica, Inc
Keywords:                                           cholesterol/combination/CORONARY
   DL                        CHOLESTEROL/high-density                            lipoprotein
   cholesterol/HYPERLIPIDEMIA/infarction/ischemic/low-density                    lipoprotein
   /transient ischemic attack/trials/triglycerides/VEIN-GRAFT ATHEROSCLEROSIS
Prystowsky, E.N. (2000), Management of atrial fibrillation: Therapeutic options and
   clinical decisions. American Journal of Cardiology, 85 (10A), 3D-11D.
Abstract: Atrial fibrillation (AF) is the most common, sustained tachyarrhythmia seen in
   clinical practice. Although it is not immediately life threatening, AF can cause
   troublesome symptoms and poses a risk of stroke. The patient's clinical status is often
   complicated by the presence of other cardiovascular or concomitant diseases. As a
   result, management of the patient with AF involves many questions and choices, all
   of which must be individualized. There ore 3 general strategies for the management
   of patients with AF, including (1) restoration and maintenance of sinus rhythm, (2)
   control of ventricular rate, and (3) prevention of stroke. More than 1 strategy may be
   appropriate in some patients, Furthermore, either pharmacologic or
   nonpharmacologic options can be chosen in certain situations. Although some data
   from randomized clinical trials are available to aid in clinical decision-making, only
   the benefits of anticoagulation are supported by substantial evidence. This article
   explores practical approaches to several management issues and scenarios for which
   there ore limited relevant clinical date. These include: (1) patient selection for
   ventricular rate control and assessment of treatment, (2) choice of antiarrhythmic
   drug for maintenance of sinus rhythm, (3) inpatient versus outpatient initiation of
   therapy, (4) definition of antiarrhythmic drug success, (5) methods of transthoracic
   direct cardioversion, and (6) prediction and prevention of AF after cardiac surgery.
   (C) 2000 by Excerpta Medica, Inc
Keywords:        AMIODARONE/anticoagulation/assessment/atrial           fibrillation/cardiac
   FT-VENTRICULAR                                   DYSFUNCTION/management/patient
   selection/prediction/prevention/RADIOFREQUENCY                 ABLATION/risk           of
   stroke/sinus rhythm/strategies/stroke/surgery/therapy/treatment/TRIAL/trials
Crary, M.A. and Groher, M.E. (2000), Basic concepts of surface electromyographic
   biofeedback in the treatment of dysphagia: A tutorial. American Journal of
   Speech-Language Pathology, 9 (2), 116-125.
Abstract: Surface electromyographic (sEMG) biofeedback has been used to enhance
  behavioral treatment interventions in a variety of movement disorders involving the
  head and neck musculature. These include, but are not limited to, voice disorders
  (Andrews, Warner, & Stewart, 1986), dysarthria (Gentil, Aucouturier, Delong, &
  Sambuis, 1994), hemifacial spasm (Rubow, Rosenbek, Collins, & Celesia, 1984),
  mandibular closure (Nemec & Cohen, 1984), and dysphagia (Bryant, 1991; Crary,
  1995). Despite the potential for widespread application of sEMG
  biofeedback-assisted treatments in motor disorders of the head and neck musculature,
  speech-language pathologists generally are not aware of these techniques or of their
  potential application to speech, voice, or swallowing disorders. The intent of this
  tutorial is to provide a general introduction to surface electromyographic biofeedback
  techniques as they may apply to the rehabilitation of dysphagia in adults. Specific
  examples are provided based on clinical management of patients with dysphagia
  following brainstem stroke
Keywords:                                  adults/biofeedback/dysarthria/dysphagia/EMG
Chen, L., Chen, M.H., Larson, M.G., Evans, J., Benjamin, E.J. and Levy, D. (2000),
  Risk factors for syncope in a community-based sample (The Framingham Heart
  Study). American Journal of Cardiology, 85 (10), 1189-1193.
Abstract: The epidemiology of syncope has not been well described. Prior studies have
  examined risk factors for syncope in hospital- based or other acute or long-term core
  settings. To determine risk factors for syncope in a community-based sample, we
  performed a nested case-control study. We examined reports of syncope in
  Framingham Heart Study participants who underwent routine clinic visits from 1971
  to 1990. For each syncope case (n = 543) 2 controls were matched for age, sex, and
  examination period. Mean age of subjects was 67 years (range 25 to 95); 59% were
  women. History of stroke or transient ischemic attack, history of myocardial
  infarction, high blood pressure, use of antihypertensive medication, use of other
  cardiac medication, smoking, alcohol intake, body moss index, systolic blood
  pressure, diastolic blood pressure, heart rate, atrial fibrillation, PR interval
  prolongation, interventricular block, and diabetes or elevated glucose level were
  examined as potential predictors. Using conditional logistic regression analysis, the
  predictors of syncope included a history of stroke or transient ischemic attack (odds
  ratio [OR] 2.56, 95% confidence interval [CI] 1.62 to 4.04), use of cardiac
  medication (OR 1.67, 95% CI 1.21 to 2.30), and high blood pressure (OR 1.46, 95%
  CI 1.14 to 1.88). Lower body mass index was marginally associated with syncope
  (OR per 4 kg/m(2) decrement 1.10, 95% CI 0.99 to 1.22), as were increased alcohol
  intake (OR per 5 oz/week 1.11, 95% CI 0.99 to 1.26), and diabetes or on elevated
  glucose level (OR 1.29, 95% CI 0.96 to 1.75). To our knowledge, this study
  represents the first community-based study of risk factors for syncope. (C) 2000 by
  Excerpta Medica, Inc
Keywords:           acute/age/atrial       fibrillation/blood       pressure/case-control
  factors/sex/smoking/stroke/studies/SUDDEN-DEATH/transient/transient ischemic
Murray, R.D., Goodman, A.S., Lieber, E.A., Jasper, S.E., Grimm, R.A., Garcia, M.J.,
  Miller, D.M. and Klein, A.L. (2000), National use of the transesophageal
  echocardiographic-guided approach to cardioversion for patients in atrial fibrillation.
  American Journal of Cardiology, 85 (2), 239-244.
Abstract: Transesophageal echocardiographic (TEE)-guided cardioversion of patients in
  atrial fibrillation (AF) of >2 days' duration is used as an alternative to conventional
  therapy. The purpose of this study was to investigate practice patterns employed for
  stroke prophylaxis in patients with AF who underwent cardioversion, and to
  determine the relative use of conventional and TEE-guided management strategies.
  We forwarded regionally stratified survey questionnaires to 947 clinical practices
  within the United States. The 10-question questionnaire queried demographic and
  clinical practice volumes and practices for managing patients with AF who
  underwent cardioversion. In addition, we used historical data to determine
  longitudinal use patterns of the TEE-guided approach for a large institution over 7
  years. The 197 completed and returned surveys yielded a return rate of 20.8%. The
  TEE-guided approach was employed in approximately 12% of total cardioversions,
  but 75% of practices indicated that they employed transesophageal echocardiography
  only occasionally. The TEE-guided approach was associated with community size (r
  = 0.19; p <0.008), type of practice (r = 0.26; p = 0.001), total use of transesophageal
  echocardiography (r = 0.48; p <0.001), and volume of cardioversions (r = 0.28; p
  <0.001). Importantly, there was little consensus on the most appropriate clinical
  indications for TEE-guided cardioversions, and the proportions of TEE-guided
  cardioversion to total number of electrical cardioversions remained stable over 7
  years. Practice volume and physician training may be the most important variables in
  the adoption of the TEE approach. (C) 2000 by Excerpta Medica, Inc
Keywords:                                                   ANTICOAGULATION/atrial
  eal echocardiography/United States
Munger, M.A., Gradman, A.H., Lee, T.H. and Steinberg, E.P. (2000), Critical overview
  of antihypertensive therapies: What is preventing us from getting there? American
  Journal of Managed Care, 6 (4), S211-S221.
Abstract: Hypertension is by far the most prevalent form of cardiovascular disease in
  the United States, affecting between 43 million and 50 million adults. Although
  uncontrolled hypertension is well recognized as a modifiable risk factor associated
  with long-term target-organ damage, many are unaware they have hypertension, as
  many as 50% are not receiving treatment, and an estimated 70% of those being
  treated do not achieve adequate blood pressure control. Why? Despite the
  effectiveness of antihypertensive therapy and considerable evidence that morbidity
  and coronary disease have decreased between 1950 and 1990, it appears that the
  progress made during those decades has not continued into the 1990s. Age-adjusted
  stroke rates for 1990 to 1994 rose slightly, and the rate of decline in coronary disease
  during this same period has leveled off. Moreover, both the rate of end-stage renal
  disease and the prevalence of heart failure increased during the early 1990s. The
  reasons for inadequate blood pressure control are numerous, including the
  multifactorial nature of hypertension; the presence of environmental factors such as
  diet, smoking, and concomitant drug therapy; poor adherence to therapy; insufficient
  therapeutic effort on the part of the treating physician; and adverse side effects of
  hypertensive agents
Keywords:          antihypertensive     therapy/blood        pressure/blood       pressure
  disease/CARE/concomitant/control/coronary/coronary                  disease/disease/drug
  disease/risk/risk factor/smoking/stroke/therapy/treatment/TRENDS/United States
Wang, R.Y., Chan, R.C. and Tsai, M.W. (2000), Functional electrical stimulation on
  chronic and acute hemiplegic shoulder subluxation. American Journal of Physical
  Medicine & Rehabilitation, 79 (4), 385-390.
Abstract: Objective: The present study investigated and assessed the effectiveness of a
  functional electrical stimulation (FES) program in the management of acute and
  chronic shoulder subluxation. Design: By their postonset duration, hemiplegic
  subjects with subluxation participating in the study were placed into a short-duration
  group and a long-duration group. Subjects in each group were further assigned
  randomly to either a control subgroup or an experimental subgroup. The
  experimental subgroups of both short and long duration received FES therapy in
  which supraspinatus and posterior deltoid were induced to contract repetitively up to
  6 hr/day for 6 wk. The duration of the FES session and muscle contraction/relaxation
  ratio were progressively increased as performance improved. Results: The
  experimental subgroup of short duration showed significant improvements in
  reducing subluxation as indicated by x-ray compared with the control subgroup of
  short duration after the first FES treatment. The same effect was not shown for the
  experimental subgroup of long duration. The second FES treatment program only
  resulted in an insignificant change of shoulder subluxation for both the short- and
  long-duration subgroups. Conclusions: The present study suggests that hemiplegic
  subjects with short postonset duration are effectively trained for shoulder subluxation
  by the first FES treatment program. The same FES showed not to be effective when
  applied to the subjects with subluxation of >1 yr
Keywords:        acute/control/effectiveness/experimental/FES/functional         electrical
Lagalla, G., Danni, M., Reiter, F., Ceravolo, M.G. and Provinciali, L. (2000),
  Post-stroke spasticity management with repeated botulinum toxin injections in the
  upper limb. American Journal of Physical Medicine & Rehabilitation, 79 (4),
Abstract: Objective: Although the botulinum toxin A (BTX-A) treatment has proved
  effective in spasticity management, no information is available with regard to the
  effects of repeated injections over time. Design: To evaluate the effects of BTX-A on
  moderate or severe upper limb spasticity, an exploratory investigation was performed
  on 28 stroke patients treated for 2 yr or longer and observed for 3 yr. Every 3 to 5 mo,
  each patient received BTX-A injections in upper limb muscles. The assessment,
  performed before and 1 mo after each injection for a median of 28 mo, included
  technical and functional objectives and the burden of care. The former were
  evaluated by using the modified Ashworth Scale for spasticity and the goniometric
  measurement of rest position and range of motion; functional objectives were
  evaluated by means of the Frenchay Arm Test and a patient/caregiver goals
  assessment scale. Results: BTX-A treatment was followed by an improvement in all
  technical outcome measures. Motor dexterity scores improved in only 8 of 28
  patients, vs. daily living activities, which increased in all subjects, Although the
  average dosage injected per session did not change, intervals between injections
  became longer. No relationship between either spasticity onset or residual motoricity
  and response to treatment could be found. Conclusions: This investigation is relevant
  clinically because repeated BTX-A injections show unchanging effectiveness in the
  management of focal spasticity after stroke
Keywords:              assessment/botulinum               toxin/botulinum             toxin
  ment/upper limb spasticity
Chertow, G.M., Normand, S.L.T., Silva, L.R. and Mcneil, B.J. (2000), Survival after
  acute myocardial infarction in patients with end-stage renal disease: Results from the
  Cooperative Cardiovascular Project. American Journal of Kidney Diseases, 35 (6),
Abstract: Cardiovascular disease (CVD) is the most common cause of death in patients
  with end-stage renal disease (ESRD), The optimal management strategy in this
  population is unknown. We studied 640 patients with ESRD and acute myocardial
  infarction during 1994 to 1995 as part of the Health Care Financing Administration's
  Cooperative Cardiovascular Project. The majority of patients were treated with
  medical therapy alone, 46 patients (7%) were treated with percutaneous transluminal
  coronary angioplasty (PTCA), and 29 patients (5%) underwent coronary artery
  bypass grafting (CABG). Patient characteristics and comorbid conditions were
  similar among the three groups. The overall 1-year mortality rate was 53%,
  Advanced age, low or high body mass index, history of peripheral vascular disease or
  stroke, the inability to walk independently, and several indicators of cardiac
  dysfunction were associated with an increased relative risk (RR) for death. Survival
  curves differed significantly by treatment modality, with 1-year survival rates of 45%,
  54%, and 69% in the medical therapy alone, PTCA, and CABG groups, respectively
  (P = 0.03). After adjustment for confounding variables, the RR for death was less
  (but not significantly so) in the CABG group (RR, 0.6; 95% confidence interval, 0.3
  to 1.1), There are no randomized clinical trial data to guide therapy of CVD in
  patients with ESRD, On the basis of these and other available data, CABG may be
  the optimal therapy for CVD in ESRD, In light of the exceptionally poor outcomes
  observed for patients treated with medical therapy alone, it may be premature to
  dismiss PTCA as a therapeutic option in this population. (C) 2000 by the National
  Kidney Foundation, Inc
Keywords:      acute/acute     myocardial      infarction/age/angioplasty/artery/ARTERY
  BYPASS-SURGERY/bypass/bypass grafting/CABG/cardiac dysfunction/CHRONIC
  PATIENTS/clinical trial/cohort study/confounding variables/coronary/coronary
  artery                  bypass/coronary                    artery                  bypass
  infarction/OUTCOMES/percutaneous transluminal coronary angioplasty/peripheral
  vascular      disease/PTCA/relative       risk/renal/renal     disease/REPLACEMENT
  analysis/therapy/transluminal/TRANSLUMINAL                                 CORONARY
  ANGIOPLASTY/treatment/vascular disease
Schellinger, P.D., Jansen, O., Fiebach, J.B., Pohlers, O., Ryssel, H., Heiland, S., Steiner,
  T., Hacke, W. and Sartor, K. (2000), Feasibility and practicality of MR imaging of
  stroke in the management of hyperacute cerebral ischemia. American Journal of
  Neuroradiology, 21 (7), 1184-1189.
Abstract: BACKGROUND AND PURPOSE: Neuroimaging techniques such as
  diffusion- and perfusion-weighted MR imaging have been proposed as tools for
  advanced diagnosis in hyperacute ischemic stroke. There is, however, substantial
  doubt regarding the feasibility and practicality of applying MR imaging for the
  diagnosis of stroke on a routine basis, especially with respect to possible delay for
  specific treatment such as thrombolysis. In this study, we tested whether MR
  imaging of stroke is safe, fast, and accurate, and whether the gain in additional
  information can be used in the daily routine without a loss of time and a risk of
  suboptimal treatment for the patient with stroke. METHODS: Between September
  1997 and August 1999, 64 patients with acute ischemic stroke were recruited for MR
  imaging (ie, diffusion-weighted imaging, perfusion-weighted imaging, MR
  angiography, T2-weighted imaging) after a baseline CT was performed. We
  evaluated practicality and feasibility of MR imaging of stroke by analyzing the
  intervals between symptom onset, arrival, CT, and MR imaging. RESULTS:
  Sixty-four patients (mean age, 60.9 years) underwent routine CT and MR imaging
  within 12 hours after stroke onset (n = 25, less than or equal to3 hr; n = 26, 3-6 hr; n
  = 13, 6-12 hr). Median times to arrival, start of CT, MR imaging, and between CT
  and MR imaging were 1.625 hours, 2 hours, 3.875 hours, and 1 hour, respectively.
  Intervals between symptom onset and MR imaging (P < .005), arrival and MR
  imaging (P < .002), and CT and MR imaging (P = .0007) differed significantly
  between the early phase of the study and after November 1998, whereas the intervals
  between symptom onset and arrival, symptom onset and CT, and arrival and CT did
  not. Hemorrhage could be excluded in all; a perfusion/diffusion match or mismatch
  could be shown in 63 of 64 patients. CONCLUSION: Practice and experience with
  MR imaging in a stroke team significantly reduce the time and effort required to
  perform this technique and thus make 24-hour availability for MR imaging of stroke
  practical. Assessment of patients with hyperacute stroke is rapid and comprehensive.
  Image quality can be substantially improved by head immobilization and by mild
  sedation, if necessary
Keywords:        acute/age/angiography/cerebral/cerebral        ischemia/CONTROLLED
  TRIAL/CT/delay/diagnosis/diffusion-weighted imaging/DIFFUSION-WEIGHTED
  PERFUSION/REPERFUSION/stroke/stroke                 onset/stroke     team/SYMPTOM
  ONSET/thrombolysis/THROMBOLYTIC THERAPY/treatment
Malek, A.M., Higashida, R.T., Phatouros, C.C., Lempert, T.E., Meyers, P.M., Smith,
  W.S., Dowd, C.F. and Halbach, V.V. (2000), Endovascular management of
  extracranial carotid artery dissection achieved using stent angioplasty. American
  Journal of Neuroradiology, 21 (7), 1280-1292.
Abstract: Background and purpose: Dissection of the carotid artery can, in certain cases,
  lead to significant stenosis, occlusion, or pseudoaneurysm formation, with
  subsequent hemodynamic and embolic infarcts, despite anticoagulant therapy, we
  sought to determine the therapeutic value of stent-supported angioplasty
  retrospectively in this subset of patients who are poor candidates for medical therapy.
  Methods: Five men and five women (Age range, 37-83 years; Mean age, 51.2 Years)
  With dissection of the internal (N=9) And common (N=1) Carotid artery were
  successfully treated with percutaneous endovascular balloon angioplasty and stent
  placement, the etiology was spontaneous in five, iatrogenic in three, and traumatic in
  two, seven of the treated lesions were left-sided and three were right-sided. Results:
  The treatment significantly improved dissection-related stenosis from 74+/-5.5% To
  5.5+/-2.8%, Two occlusive dissections were successfully recanalized using
  microcatheter techniques during the acute phase. Multiple overlapping stents were
  needed in four patients to eliminate the inflow zone and false lumen and establish an
  angiographically smooth outline within the true lumen. There was one case of
  retroperitoneal hemorrhage, but there were no procedural transient ischemic attacks
  (Tias), Minor or major strokes, or deaths (0%). Clinical outcome at latest follow-up
  (16.5+/-1.9 Months) Showed significant improvements compared with pretreatment
  modified rankin score (0.7+/-0.3 Vs 1.8+/- 0.44) And barthel index (99.5+/-0.5 Vs
  80.5+/-8.9), One delayed stroke occurred in a treated patient with contralateral
  carotid occlusion following a hypotensive uterine hemorrhage at 8 months; The
  remaining nine patients have remained free of tia or stroke. Conclusion: In select
  cases of carotid dissection associated with critical hemodynamic insufficiency or
  thromboembolic events that occur despite medical therapy, endovascular stent
  placement appears to be a safe and effective method of restoring vessel lumen
  integrity, with good clinical outcome
Keywords:              acute/age/ANEURYSM/angioplasty/anticoagulant/anticoagulant
  therapy/artery/balloon/balloon angioplasty/carotid/carotid artery/carotid artery
  herapy/transient/transient ischemic attacks/treatment/women
Glass, T.A., Dym, B., Greenberg, S., Rintell, D., Roesch, C. and Berkman, L.F. (2000),
  Psychosocial intervention in stroke: Families in recovery from stroke trial (FIRST).
  American Journal of Orthopsychiatry, 70 (2), 169-181.
Abstract: A family-focused psychosocial intervention fbr stroke survivors is described
  and illustrated with case studies. If is designed to improve functional recovery
  through four specific pathways: increased knowledge, efficacy, and control through
  stroke education; optimized social support; increased network cohesion; and
  improved problem-solving abilities. Rationales for these pathways ave presented and
  methods of implementing them discussed
Keywords:                ARTHRITIS                  SELF-MANAGEMENT/CARDIAC
  ARCTION/NETWORK                                           THERAPY/POSTSTROKE
  DEPRESSION/RANDOMIZED                 CONTROLLED           TRIAL/recovery/SOCIAL
Winkley, J.M. and Adams, H.P. (2000), Potential role of abciximab in ischemic
  cerebrovascular disease. American Journal of Cardiology, 85 (8A), 47C-51C.
Abstract: Abciximab is an intravenously administered antiplatelet agent that could be
  used alone or in conjunction with thrombolytic therapy to treat patients with acute
  ischemic stroke. However, experience with medication for treatment of patients with
  stroke is limited. Symptomatic intracranial bleeding is the most common serious
  complication of therapies that aim at restoring or improving blood flow to the brain
  after stroke and it is the most likely potential serious complication of the use of
  abciximab in this setting, Preliminary data suggest that abciximab is not associated
  with a prohibitively high rate of symptomatic intracranial hemorrhage, Further
  research is needed to determine the safety and potential efficacy of abciximab For
  treatment of ischemic stroke. (C) 2000 by Excerpta Medica, Inc
Keywords:       abciximab/acute/ALTEPLASE/antiplatelet/bleeding/BLOCKADE/blood
  ED                                                                     CONTROLLED
Hammond, C.B., Rackley, C.E., Fiorica, J., Morrison, A. and Wysocki, S. (2000),
  Consequences of estrogen deprivation and the rationale for hormone replacement
  therapy. American Journal of Managed Care, 6 (14), S746-S760.
Abstract: Menopause results in a fairly precipitous decline in estrogen levels. This
  estrogen deprivation is probably associated with a number of consequences,
  including osteoporosis, tooth loss, cardiovascular disease, stroke, age-related macular
  degeneration, colon cancer, diabetes mellitus, Alzheimer's disease, and Parkinson's
  disease. Coronary artery disease is the most frequent cause of death in women age 50
  years and older, yet most women report a fear of dying from breast cancer. Current
  data suggest that women who take some form of hormone replacement therapy (HRT)
  after menopause can reduce their cardiovascular mortality approximately 50%, yet
  many stop taking HRT-or never start-because of this fear. Although use of estrogen
  replacement therapy and HRT (after a diagnosis of breast cancer) currently is
  contraindicated for at least 5 years by the US Food and Drug Administration, 3
  studies have found that women who took hormones had no greater incidence of
  breast cancer recurrence than the general breast cancer population. Evidence suggests
  HRT has a beneficial effect on the central nervous system, including on
  neurotransmitter systems within the brain that are implicated in mood disorders and
  depression; learning, memory, and Alzheimer's disease; and movement disorders
  such as Parkinson's disease. When women are counseled about the benefits and risks
  of HRT and alternative therapies, it may help for physicians to keep in mind that
  women are more than a sum of their estrogen receptors: their emotions and beliefs
  will influence how they view menopause and their receptivity to available
  therapeutic options
Keywords:                                                                         ACUTE
  DAM                             EYE/brain/BREAST-CANCER/cancer/cardiovascular
  disease/CARDIOVASCULAR-DISEASE/CARE/central                                     nervous
  system/CORONARY                 HEART-DISEASE/death/depression/diabetes/diabetes
  OSTMENOPAUSAL                        WOMEN/RISK-FACTORS/stroke/studies/TERM
Becker, D.M., Tuggle, M.B. and Prentice, M.F. (2001), Building a gateway to promote
  cardiovascular health research in African-American communities: Lessons and
  findings from the field. American Journal of the Medical Sciences, 322 (5), 288-293.
Abstract: African American communities traditionally mistrust academic research. This
  forms a significant barrier to understanding cardiovascular risk factors in this
  population, which bears an excess risk of cardiovascular disease and stroke. A
  clergy/academic partnership was established to build a gateway for salient research
  and for improving resources for reducing cardiovascular disease risk in the
  community. From this partnership emanated the African American Family Heart
  Study. People with a family history of premature coronary heart disease (CHD) have
  an increased risk for the disease-as high as 12 times that of the general population, if
  among siblings. Considerably less is known about the actual remediable risk factors
  in African American families with premature CHD. We initiated the Family Heart
  Study with a full characterization of 161 apparently healthy, unaffected 30- to
  59-year-old African Americans whose siblings were 85 African American index
  cases with documented premature CHD prior to 60 years of age. We compared their
  risk factor values to population reference norms obtained in the Third National
  Health and Nutrition Examination Survey (NHANES III) and the National Health
  Interview Survey (NHIS) for cigarette smoking. Only 13% of African American
  male siblings and 14% of female siblings from these families were without any major
  remediable risk factors. The fact that so many siblings were at extremely high risk
  calls into question the current applications by provider systems of national guidelines
  in high-risk African American families. This is an easily identifiable population that
  would be likely to benefit greatly from targeted screening and culturally sensitive
  and appropriate treatment
Keywords:       African     American/African       Americans/age/ATTITUDES/BLOOD
  CHOLESTEROL/cardiovascular             disease/cardiovascular    health/cardiovascular
  risk/cardiovascular risk factors/community/coronary/coronary disease/coronary heart
  disease/CORONARY                   HEART-DISEASE/disease/Family                   Heart
  POPULATIONS/PHYSICIANS/prevention/risk/risk                                  factor/risk
Sunshine, J.L., Bambakidis, N., Tarr, R.W., Lanzieri, C.F., Zaidat, O.O., Suarez, J.I.,
  Landis, D.M.D. and Selman, W.R. (2001), Benefits of perfusion MR imaging
  relative to diffusion MR imaging in the diagnosis and treatment of hyperacute stroke.
  American Journal of Neuroradiology, 22 (5), 915-921.
Abstract: BACKGROUND: The development of thrombolytic agents for use with
  compromised cerebral blood flow has made it critical to quickly identify those
  patients to best treat. We hypothesized that combined diffusion and perfusion MR
  imaging adds vital diagnostic value for patients for whom the greatest potential
  benefits exist and far exceeds the diagnostic value of diffusion MR imaging alone.
  METHODS: The cases of patients with neurologic symptoms of acute ischemic
  stroke who underwent ultra-fast emergent MR imaging within 6 hours were reviewed,
  In all cases, automatic processing yielded isotropic diffusion images and perfusion
  time-to-peak maps. Images with large vessel distribution ischemia and with
  mismatched perfusion abnormalities were correlated with patient records. All follow-
  up images were reviewed and compared with outcomes resulting from hyperacute
  therapies. RESULTS: For 16 (26%) of 62 patients, hypoperfusisn was the best MR
  imaging evidence of disease distribution, and for 15 of the 16, hypoperfusion (not
  abnormal diffusion) comprised the only imaging evidence for disease involving large
  vessels, For seven patients, diffusion imaging findings mere entirely normal, and for
  nine, diffusion imaging delineated abnormal signal in either small vessel
  distributions or in a notably smaller cortical branch in one case. III all cases,
  perfusion maps were predictive of eventual lesions, as confirmed by angiography CT,
  or subsequent MR imaging. CONCLUSION: If only diffusion MR imaging is used in
  assessing patients with hyperacute stroke, nearly one quarter of the cases may be
  incorrectly categorized with respect to the distribution of ischemic at-risk tissue.
  Addition of perfusion information further enables better categorizing of vascular
  distribution to allow the best selection among therapeutic options and to improve
  patient outcomes
Keywords: abnormalities/acute/ACUTE ISCHEMIC STROKE/angiography/blood
   flow/BRAIN/cerebral/cerebral                    blood               flow/CEREBRAL
   BLOOD-FLOW/combined/CONTRAST                          AGENTS/CT/diagnosis/diffusion
   imaging/diffusion                                                                  MR
   stroke/MR/NEURORADIOLOGY/outcomes/PENUMBRA/perfusion/perfusion MR
   imaging/stroke/thrombolytic/thrombolytic              agents/TIME/treatment/WATER
Cross, D.T., Derdeyn, C.P. and Moran, C.J. (2001), Bleeding complications after basilar
   artery fibrinolysis with tissue plasminogen activator. American Journal of
   Neuroradiology, 22 (3), 521-525.
Abstract: BACKGROUND AND PURPOSE: Fibrinolysis with local intraarterial
   urokinase infusion for basilar artery thrombosis has been associated with a low rate
   of spontaneous symptomatic cerebral hemorrhage, even when patients have been
   treated late in the course of symptoms. Because urokinase is presently unavailable in
   the United States, this study was undertaken to determine the frequency of
   spontaneous cerebral hemorrhage in basilar artery fibrinolysis performed with tissue
   plasminogen activator (tPA). METHODS: In a retrospective review of our initial
   experience with cerebral fibrinolysis for acute stroke using intraarterial tPA, four
   cases of basilar thrombosis were identified. Doses of the fibrinolytic agent and
   heparin, angiographic findings, clinical courses, and bleeding complications for these
   patients were determined. These results were compared with those from a prior study
   of 20 similar consecutive patients treated with urokinase. RESULTS: Symptom
   duration before treatment was unlimited. Intraarterial doses of tPA were 20 to 50 mg,
   Patients received full systemic anticoagulation with heparin. Complete basilar artery
   recanalization was achieved in 75% of patients. Two patients treated with tPA had
   angioplasty and stent placement for related high-grade stenosis. Spontaneous
   symptomatic cerebral hemorrhage occurred in three (75%) of the four tPA-treated
   patients and in three (15%) of the 20 urokinase-treated patients. CONCLUSION: The
   cerebral hemorrhage complication rate for intraarterial fibrinolysis with tPA was
   very high in cases of basilar artery thrombosis at the doses we used. Protocol
   adjustments should be considered
Keywords:                acute/ACUTE               ISCHEMIC                STROKE/acute
   stroke/angioplasty/anticoagulation/artery/basilar         artery/bleeding/CARDIAC-
   sminogen/plasminogen           activator/R-TPA/RANDOMIZED             CONTROLLED
   THERAPY/thrombosis/tissue                plasminogen        activator/treatment/United
Elliott, P.J. and Ross, J.S. (2001), The proteasome - A new target for novel drug
   therapies. American Journal of Clinical Pathology, 116 (5), 637-646.
Abstract: The proteasome is an enzyme present in all cells, from yeast to human, and
   has a central role in the proteolytic degradation of the vast majority of intracellular
   proteins. Among the key proteins modulated by the proteasome are those involved in
   controlling inflammatory processes, cell cycle regulation, and gene expression. As
   such, agents that inhibit the proteasome have been. shown to be active in numerous
   animal models of inflammation and cancer Two proteasome inhibitors are under
   clinical evaluation. PS-519 is being studied for the treatment of reperfusion injury
  that occurs following cerebral ischemia and myocardial infarction. The other; PS-341,
  has recently entered multiple phase 2 clinical trials for the treatment of multiple
  myeloma, chronic lymphocytic leukemia, and a variety of solid tumors. The
  proteasome may have an important role in the evolution of HIV-related disorders
  including AIDS and inflammatory disorders. Therapeutic strategies using proteasome
  inhibitors for the treatment of these conditions have now entered preclinical
  ischemia/CHYMOTRYPSIN-                         LIKE                  ACTIVITY/clinical
  PS-341/injury/ischemia/models/MULTICATALYTIC                             PROTEINASE
  COMPLEX/multiple               sclerosis/myocardial         infarction/NF        kappa
Peach, R.K. (2001), Further thoughts regarding management of acute aphasia following
  stroke. American Journal of Speech-Language Pathology, 10 (1), 29-36
Keywords: acute/acute aphasia/ADULTS/aphasia/EFFICACY/management/MELODIC
Hollenberg, S.M., Dumasius, A., Easington, C., Colilla, S.A., Neumann, A. and Parrillo,
  J.E. (2001), Characterization of a hyperdynamic murine model of resuscitated sepsis
  using echocardiography. American Journal of Respiratory and Critical Care
  Medicine, 164 (5), 891-895.
Abstract: A small animal model of sepsis that reproduces the vasodilation, hypotension,
  increased cardiac output, and response to treatment seen in patients with septic shock
  would be useful for studies of pathophysiology and treatment, but no current models
  replicate all of these features. Mice were made septic by cecal ligation and puncture
  and resuscitated with fluids and antibiotics every 6 h. Blood pressure was measured
  in anesthetized mice with manometric catheters, and echocardiography was
  performed in these animals every 6 h. Survival in treated septic mice was improved
  compared with untreated mice (44% versus 0%, p < 0.01). In control mice, heart rate
  (HR, 420 +/- 31 beats/min), mean arterial pressure ((Pa) over bar, 100 +/- 8 mm Hg),
  stroke volume (SV, 26 +/- 4 mul), and cardiac output (12.5 +/- 6.6 ml/min) were
  unchanged over 48 h. In septic mice (Pa) over bar was significantly decreased (102
  +/- 14 to 65 +/- 19 mm Hg, p < 0.02), starting at 12 h. HR and cardiac output
  increased significantly (HR, 407 +/- 70 to 524 +/- 76 beats/min, cardiac output, 11.6
  +/- 2.0 to 17.1 +/- 1.5 ml/min, p < 0.01). SV (24 +/- 5 mul) remained constant. This
  fluid-resuscitated, antibiotic-treated model replicates the mortality, hypotension, and
  hyperdynamic state seen in clinical sepsis. Precise determination of serial
  hemodynamics in this model may be useful to elucidate pathophysiologic
  mechanisms and to evaluate new therapies for septic shock
Keywords: animal/animal model/ANIMAL-MODELS/CANINE MODEL/cardiac
  resuscitation/heart/heart             rate/hemodynamics/HUMAN                  SEPTIC
  SHOCK/hyperdynamic                             state/hypotension/MICROVASCULAR
   shock/shock/stroke/stroke volume/studies/treatment/vasodilation
Fridriksson, J. and Holland, A. (2001), Final thoughts on management of aphasia in the
   early phases of recovery following stroke. American Journal of Speech-Language
   Pathology, 10 (1), 37-39
Keywords:                                  aphasia/counseling/DIFFUSION-WEIGHTED
Michel, E., Liu, H.Y., Remley, K.B., Martin, A.J., Madison, M.T., Kucharczyk, J. and
   Truwit, C.L. (2001), Perfusion MR neuroimaging in patients undergoing balloon test
   occlusion of the internal carotid artery. American Journal of Neuroradiology, 22 (8),
Abstract: Background and purpose: We sought to investigate whether the combination
   of conventional, diffusion-weighted, and perfusion- weighted mr imaging increases
   the diagnostic accuracy of balloon test occlusion of the internal carotid artery. We
   describe perfusion anomalies and patterns of enhancement seen in areas of altered
   brain perfusion during mr-monitored temporary balloon occlusion of the internal
   carotid artery. Methods: Nine patients underwent balloon occlusion testing under
   standard angiographic conditions with continuous clinical and eeg monitoring. One
   patient who failed the test by clinical criteria underwent an external carotid to
   internal carotid bypass operation, followed by a repeat balloon test occlusion, thereby
   bringing the total number of procedures to 10. Patients were further imaged at 1.5 T
   with perfusion- and diffusion- weighted imaging as well as with conventional
   noncontrast and contrast-enhanced turbo fluid-attenuated inversion recovery (Flair)
   And ti-weighted sequences. Results: Seven of 10 patients who tolerated unilateral
   carotid test occlusion without adverse clinical neurologic or eeg changes exhibited
   delayed first-pass transit of contrast material through the affected cerebral
   hemisphere, indicative of altered perfusion without significant concurrent cerebral
   blood flow or blood volume changes. Four of these patients and both symptomatic
   patients showed pial or subarachnoid contrast staining in areas of altered perfusion
   without abnormalities on diffusion- weighted images. Conclusion: Our findings
   indicate that mr perfusion-weighted imaging is safe and easily accomplished in a
   high-field-strength magnet and that contrast-enhanced turboflair imaging may
   provide clinically useful mr imaging evidence of abnormal cerebral blood flow and
   subclinical ischemia
Keywords: 1.5 T/ANEURYSMS/artery/balloon/blood flow/brain/bypass/carotid/carotid
   artery/cerebral/cerebral                    blood                    flow/CEREBRAL
   STROKE/IMAGES/imaging/internal/internal                carotid/internal          carotid
   artery/ISCHEMIA/MANAGEMENT/MIMICKING                               SUBARACHNOID
   erfusion-weighted imaging/recovery/subarachnoid/THERAPY
Derex, L., Tomsick, T.A., Brott, T.G., Lewandowski, C.A., Frankel, M.R., Clark, W.,
   Starkman, S., Spilker, J., Udsten, G.J., Khoury, J., Grotta, J.C. and Broderick, J.P.
   (2001), Outcome of stroke patients without angiographically revealed arterial
   occlusion within four hours of symptom onset. American Journal of Neuroradiology,
   22 (4), 685-690.
Abstract: Background and purpose: Follow-up imaging data from stroke patients
   without angiographically apparent arterial occlusions at symptom onset are lacking,
   we reviewed our emergency management of stroke (Ems) Trial experience to
   determine the clinical and imaging outcomes of patients with ischemic stroke who
  showed no arterial occlusion on angiograms obtained within 4 hours of symptom
  onset. Methods: All patients in this report were participants in the ems trial that was
  designed to address the safety and potential efficacy of combined iv and intraarterial
  thrombolytic therapy with recombinant tissue plasminogen activator (Rt-pa) In
  patients with acute ischemic stroke. Results: Thirty-five patients were randomized to
  receive either iv rt-pa (N = 17) Or placebo (N = 18), Followed by cerebral
  angiography. No symptomatic arterial occlusion was evident in 10 (29%) Of the 34
  patients, eight (80%) Of 10 patients without angiographically apparent clot within 4
  hours of symptom onset had a new cerebral infarction confirmed on follow-up brain
  imaging. The median 72-hour infarction volume was 2.4 Cc (Range, 1-30 cc). Four
  of the 10 "No-clot" Patients had a favorable 3-month outcome as assessed by barthel
  index (Score, 95 or 100) And modified rankin scale (Score, 0 or 1). The six
  remaining patients had 3-month rankin scale scores of 1 (Barthel of 90), 2, 3, 4, Or 5,
  conclusion: Acute ischemic stroke patients with a neurologic deficit but a negative
  angiogram during the first 4 hours after symptom onset usually develop
  image-documented cerebral infarction, and approximately half suffer from long-term
  functional disability, the two most likely explanations for negative angiograms are
  very early irreversible ischemic damage despite recanalization or ongoing ischemia
  secondary to clot in non-visible penetrating arterioles or in the microvasculature
Keywords: acute/ACUTE ISCHEMIC STROKE/angiography/arterial occlusion/barthel
  index/brain/cerebral/cerebral                                       angiography/cerebral
  stroke/management/management                    of                stroke/MRI/neurologic
  activator/recanalization/recombinant                  tissue                plasminogen
  therapy/tissue                     plasminogen                         activator/TISSUE
Holland, A. and Fridriksson, J. (2001), Aphasia management during the early phases of
  recovery following stroke. American Journal of Speech-Language Pathology, 10 (1),
Keywords:            acute           aphasia/counseling/early              communication
  ation team communication/spontaneous recovery/stroke/THERAPY
Wintermark, M., Thiran, J.P., Maeder, P., Schnyder, P. and Meuli, R. (2001),
  Simultaneous measurement of regional cerebral blood flow by perfusion CT and
  stable xenon CT: A validation study. American Journal of Neuroradiology, 22 (5),
Abstract: BACKGROUND AND PURPOSE: Knowledge of cerebral blood how (CBF)
  alterations in cases of acute stroke could be valuable in the early management of
  these cases. Among imaging techniques affording evaluation of cerebral perfusion,
  perfusion CT studies involve sequential acquisition of cerebral CT sections obtained
  in an axial mode during the IV administration of iodinated contrast material. They
  are thus very easy to perform in emergency settings, Perfusion CT values of CBF
  hare proved to be accurate in animals, and perfusion CT affords plausible values in
  humans, The purpose of this study was to validate perfusion CT studies of CBF by
  comparison with the results provided by stable xenon CT, which have been reported
  to be accurate, and to evaluate acquisition and processing modalities of CT data,
  notably the possible deconvolution methods and the selection of the reference artery.
   METHODS: Twelve stable xenon CT and perfusion CT cerebral examinations were
   performed within an interval of a few minutes in patients with various
   cerebrovascular diseases, CBF maps were obtained from perfusion CT data by
   deconvolution using singular value decomposition and least mean square methods.
   The CBF were compared with the stable xenon CT results in multiple regions of
   interest through linear regression analysis and bilateral t tests for matched variables.
   RESULTS: Linear regression analysis showed good correlation between perfusion
   CT and stable xenon CT CBF values (singular value decomposition method: R-2 =
   0.79, slope = 0.87; least mean square method: R-2 = 0.67, slope = 0.83). Bilateral t
   tests for matched variables did not identify a significant difference between the two
   imaging methods (P > .1), Both deconvolution methods were equivalent (P > .1). The
   choice of the reference artery is a major concern and has a strong influence on the
   final perfusion CT CBF map. CONCLUSION: Perfusion CT studies of CBF
   achieved with adequate acquisition parameters and processing lead to accurate and
   reliable results
Keywords:          acute/acute        stroke/administration/artery/blood     flow/BOLUS
   GEOMETRY/BRAIN/CBF/cerebral/cerebral                       blood           flow/cerebral
Sarasin, F.P., Louis-Simonet, M., Carballo, D., Slama, S., Rajeswaran, A., Metzger, J.T.,
   Lovis, C., Unger, P.F. and Junod, A.F. (2001), Prospective evaluation of patients
   with syncope: A population- based study. American Journal of Medicine, 111 (3),
Abstract: PURPOSE: To determine the diagnostic yield of a standardized sequential
   evaluation of patients with syncope in a primary care teaching hospital. PATIENTS
   AND METHODS: All consecutive patients who presented to the emergency
   department with syncope as a chief complaint were enrolled. Their evaluation
   included initial and routine clinical examination, including carotid sinus massage, as
   well as electrocardiography and basic laboratory testing. Targeted tests, such as echo
   cardiography, were used when a specific entity was suspected clinically. Other
   cardiovascular tests (24-hour Holter monitoring, ambulatory loop recorder ECG,
   upright tilt test, and signal- averaged electrocardiography) were performed in patients
   with unexplained syncope after the initial steps. Electro physiologic studies were
   performed in selected patients only as clinically appropriate. Follow-up information
   on recurrence and mortality were obtained every 6 months for as long as 18 months
   for 94% (n = 611) of the patients. RESULTS: After the initial clinical evaluation, a
   suspected cause of syncope was found in 69% (n = 446) of the 650 patients,
   including neurocardiogenic syncope (n = 234, 36%), orthostatic hypotension (n =
   156, 24%), arrhythmia (n = 24, 4%), and other diseases (n = 32, 5%). Of the 67
   patients who underwent targeted tests, suspected diagnoses were confirmed in 49
   (73%) patients: aortic stenosis (n = 8, 1%), pulmonary embolism (n = 8, 1%),
   seizures/stroke (n = 30, 5%), and other diseases (n = 3). Extensive cardiovascular
   workups, which were performed in 122 of the 155 patients in whom syncope
   remained unexplained after clinical assessment, provided a suspected cause of
   syncope in only 30 (25%) patients, including arrhythmias in 18 (60%), all of whom
  had abnormal baseline ECGs. The 18-month mortality was 9% (n = 55, including 8
  patients with sudden death); syncope recurred in 15% (n = 95) of the patients.
  CONCLUSION: The diagnostic yield of a standardized clinical evaluation of
  syncope was 76%, greater than reported previously in unselected patients.
  Electrocardiogram-based risk stratification was useful in guiding the use of
  specialized cardiovascular tests. (C) 2001 by Excerpta Medica, Inc
Keywords:                                                               ambulatory/aortic
  NT/monitoring/mortality/NEW-YORK/orthostatic hypotension/PATIENT/primary
  care/pulmonary                                                       embolism/risk/risk
  stratification/stenosis/studies/Switzerland/TRENDS/UNEXPLAINED SYNCOPE
Callahan, A. (2001), Cerebrovascular disease and statins: A potential addition to the
  therapeutic armamentarium for stroke prevention. American Journal of Cardiology,
  88 (7B), 33J-37J.
Abstract: Cerebrovascular disease is the leading cause of disability in Western societies.
  In the United States, it has been estimated that a stroke occurs every 53 seconds.
  Consequently, the societal costs attributable to cerebrovascular disease are immense
  and encourage the medical community to seek new therapies that can reduce stroke's
  frequency and impact. Although serum lipid levels have not been shown to act as a
  surrogate marker for stroke, in landmark lipid-lowering trials, statin therapy has been
  associated with reductions in the incidence of ischemic stroke in patient populations
  with manifest ischemic heart disease. This observation is supported by a recently
  published meta-analysis of statin trials that reported an average reduction of about
  30% in the incidence of cerebrovascular disease. However, to date, statin studies
  have only been conducted in patients with, or at high risk for coronary artery disease,
  who are not truly representative of the overall stroke population. The ongoing Stroke
  Prevention by Aggressive Reduction of Cholesterol Levels (SPARCL) trial has been
  designed to prospectively evaluate the benefits of aggressive lipid-lowering therapy
  on cerebrovascular events in patients who have had a previous stroke or transient
  ischemic attack, but who have no prior history of coronary artery disease. (C) 2001
  by Excerpta Medica, Inc
Keywords:                                         artery/cerebrovascular/cerebrovascular
  disease/CHOLESTEROL/community/coronary/coronary                                   artery
  disease/costs/disability/disease/heart/incidence/ischemic/ischemic                 heart
  disease/ischemic                                              stroke/meta-analysis/new
  prevention/studies/therapy/transient/transient ischemic attack/trials/United States
Chinnery, P.F. and Turnbull, D.M. (2001), Epidemiology and treatment of
  mitochondrial disorders. American Journal of Medical Genetics, 106 (1), 94-101.
Abstract: The last ten years have seen a huge increase in the number of different genetic
  defects found in patients with mitochondrial disorders, but the true impact of
  mitochondrial disease is only just becoming apparent. Mitochondrial diseases are far
  more common than was anticipated. Although there have also been major advances
  in our understanding of mitochondrial pathology, the clinical management of patients
  with mitochondrial disease is largely supportive. In this article, we focus on primary
  disorders of the mitochondrial respiratory chain and mtDNA defects. We review the
  available epidemiological data, outline current strategies for the management of
  mitochondrial disease, and highlight new therapeutic approaches that may prove
  useful in the future, (C) 2001 Wiley-Liss, Inc
  MUTATIONS/England/FRENCH-CANADIAN FAMILIES/gene therapy/genetic
  epidemiology/HEREDITARY                                                           OPTIC
  RESONANCE             SPECTROSCOPY/management/MELAS/MERRF/mitochondrial
Berman, M.F., Stapf, C., Sciacca, R.R. and Young, W.L. (2002), Use of ICD-9 coding
  for estimating the occurrence of cerebrovascular malformations. American Journal of
  Neuroradiology, 23 (4), 700-705.
Abstract: BACKGROUND AND PURPOSE: Accurate epidemiologic data concerning
  cerebrovascular malformations are scarce. Our goals were to determine the
  distribution of lesions in the International Classification of Diseases, Ninth Revision,
  (ICD-9) code for cerebrovascular malformations and to evaluate the use of state
  discharge registries for estimating their detection rate. METHODS: We reviewed
  records of all patients discharged from our center between January 1, 1992, and June
  30, 1999, whose diagnoses included the ICD-9 code for cerebrovascular anomaly
  (code 747.81) to determine the accuracy of the coding. Hospital admission rates for
  cerebrovascular anomaly were calculated by using the 1995-1999 state discharge
  databases of California and New York. RESULTS: Of 804 patients with this code,
  706 (88%) had a lesion consistent with the diagnosis. Five lesions accounted for 99%
  of the diagnoses; the two most common were AVM (66%) and cavernous
  malformation (13%). The ratio of AVMs to all cerebrovascular anomalies was
  similar to that in a prior population-based study. The sensitivity of identifying a
  patient with cerebrovascular malformation by using ICD-9 coding was 94%; the
  false-positive rate was 1.7 cases per 100,000 person-years. For California and New
  York, rates of first hospital admission for cerebrovascular malformation were 1.5 and
  1.8 cases per 100,000 person-years, respectively. CONCLUSION: Rates of
  admission for cerebrovascular malformations calculated from state discharge
  databases are consistent with disease detection rates in the range of 1 case per
  100,000 person-years. However, the false-positive rate for coding is in the same
  range as the disease detection rate. Thus, current state discharge registries cannot
  serve as sources of detailed epidemiologic data
Keywords:                                                          ANEURYSMS/BRAIN
Ergeletzis, D., Kevorkian, C.G. and Rintala, D. (2002), Rehabilitation of the older
  stroke patient - Functional outcome and comparison with younger patients. American
  Journal of Physical Medicine & Rehabilitation, 81 (12), 881-889.
Abstract: Objective: To evaluate the inpatient rehabilitation progress and functional
  outcome of stroke patients aged 80 yr and over and make comparisons with a
  younger (< 80 yr) stroke population receiving similar comprehensive rehabilitation
  therapies. Design: A case series of 223 stroke patients consecutively admitted to the
  inpatient rehabilitation unit of a tertiary acute general hospital. A total of 44 patients
  with a first- time stroke were at least 80 yr old and over and 179 initial stroke
  patients were < 80 yr old. The main outcome measures included admission and
  discharge scores of the FIM(TM) instrument, FIM gain and efficiency, and discharge
  disposition. Results: The majority (72.7%) of the older stroke group (mean age, 84 yr;
  standard deviation, 3.7 yr; range, 80-94 yr) was able to return home, although to a
  lesser extent than the younger segment (90.5%). No continuous or categorical
  variable studied was related to discharge disposition in the older stroke patients.
  Admission FIM total was the most significant predictor of discharge FIM total and
  discharge FIM motor. The older group did have a lower FIM efficiency and made
  smaller FIM total and motor gains. In comparison with the younger stroke patients,
  the older stroke group was statistically more likely to be women (P < 0.001),
  unmarried (P < 0.001), living alone prestroke (P < 0.05), and unemployed (P <
  0.001). Conclusion: Most older stroke patients can successfully complete a
  rehabilitation program and return to the community. Demographic, functional, and
  outcome differences were found when comparing this population with younger
Keywords:         acute/AGE/aged/community/DISABILITY/disposition/FIM/functional
Tesio, L., Granger, C.V., Perucca, L., Franchignoni, F.P., Battaglia, M.A. and Russell,
  C.F. (2002), The FIMTM instrument in the United States and Italy - A comparative
  study. American Journal of Physical Medicine & Rehabilitation, 81 (3), 168-176.
Abstract: Objective: To compare FIMTM instrument ratings between Italy and the
  United States. Design: This study utilized 169,835 United States and 4,536 Italian
  FIM instrument records for stroke with the left side of the body affected, stroke with
  the right side of the body affected, and orthopedic conditions. Results: Case-mix,
  patient age, and admission and discharge FIM instrument scores were similar. The
  delays between onset of disability and admission to rehabilitation and lengths of stay
  in rehabilitation were 2-4 times longer in Italy. In Italy, some 88-95% of the subjects
  were discharged to the community vs. 74-88% in the United States. Hierarchies of
  FIM instrument ratings across the motor and cognitive items were similar, but there
  were interesting differences. The hierarchical patterns showed that dressing, bathing,
  perineal hygiene, and tub or shower transfer were relatively more difficult in Italy
  compared with the Unites States, whereas walking was easier in Italy compared to
  the United States. Conclusion: The Italian health care payment system offers less
  incentive for early discharges from acute care and rehabilitation. In Italy, nursing
  homes are less accessible, whereas family support is more available. Apparently less
  intensive treatment is applied in Italy, where a minimum time per day for
  rehabilitation services is not mandatory for payment. Occupational therapy is not
  used in Italy and the focus is more on physical therapy
Keywords:                   acute/acute                care/age/community/cross-cultural
  comparison/disability/FIM/FIM instrument/FUNCTIONAL INDEPENDENCE
  MEASURE/health/health            care/Healthcare      management/nursing/PA/physical
  INPATIENTS/stroke/therapy/treatment/United States/validity
Lew, H.L., Lee, E., Date, E.S. and Zeiner, H. (2002), Influence of medical
  comorbidities and complications on FIM (TM) change and length of stay during
  inpatient rehabilitation. American Journal of Physical Medicine & Rehabilitation, 81
  (11), 830-837.
Abstract: Objective: This study was performed to evaluate the influence of medical
  problems on functional outcome measures of patients admitted for comprehensive
  inpatient rehabilitation. Design: In this retrospective database review of patients,
  demographic information, length of stay, FIM scores at admission and discharge, and
  FIM efficiency were collected and analyzed. Preexisting comorbidities and acute
  medical complications of all patients were identified, tabulated, and analyzed.
  Results: A total of 175 patients were categorized into three major groups. In the
  postorthopedic surgery group, the presence of preexisting medical comorbidities did
  not significantly affect admission or discharge FIM scores. In contrast, traumatic
  brain injury patients with preexisting medical comorbidities had a tendency to be
  admitted and discharged with lower FIM scores. However, traumatic brain injury
  patients with acute medical complications still made reasonable functional
  improvement during their extended stay, so that their FIM efficiency was adequately
  maintained. In the cerebrovascular accident group, almost all patients had preexisting
  medical issues. Conclusions: The rehabilitation population is diverse, and functional
  outcome measures for distinct disease entities may be differentially affected by
  factors such as preexisting medical comorbidities and acute medical complications.
  Except for life-threatening medical emergencies, rehabilitation patients may benefit
  by staying on the acute rehabilitation unit, where both medical management and a
  comprehensive rehabilitation program are provided with continuity
Keywords:               acute/brain/brain          injury/cerebrovascular/cerebrovascular
  accident/complications/disease/FIM/FIM                               efficiency/functional
  outcome/information/injury/inpatient                 rehabilitation/length              of
  stay/management/medical              comorbidities/medical         complications/medical
  REHABILITATION/surgery/traumatic brain injury
Matchar, D.B., Samsa, G.P., Cohen, S.J., Oddone, E.Z. and Jurgelski, A.E. (2002),
  Improving the quality of anticoagulation of patients with atrial fibrillation in
  managed care organizations: Results of the Managing Anticoagulation Services Trial.
  American Journal of Medicine, 113 (1), 42-51.
Abstract: PURPOSE: Randomized trials have indicated that well-managed
  anticoagulation with warfarin could prevent more than half of the strokes related to
  atrial fibrillation. However, many patients with atrial fibrillation who are eligible for
  this therapy either do not receive it or are not maintained within an optimal
  prothrombin time-international normalized ratio (INR) range. We sought to
  determine whether an anticoagulation service within a managed care organization
  would be a feasible alternative for providing anticoagulation care. SUBJECTS AND
  METHODS: We performed a multi-site randomized trial in six large managed care
  organizations in the United States. Subjects were aged 65 years or older and had
  nonvalvular atrial fibrillation. At each site, physician practices were divided into two
  geographically defined practice clusters; each site was randomly assigned to have
  one intervention and one control cluster. The intervention cluster received an
  anti-coagulation service that satisfied specifications for high-quality anticoagulation
  care and was coordinated through the managed care organization. Control clusters
  continued with their usual provider-based care. We measured the proportion of time
  that warfarin-treated patients in each of the clusters (intervention and control) were
  in the target range for the INR at baseline, and again during a follow-up period.
  RESULTS: Five of the Six Selected Site, succeeded at developing air anticoagulation
  service. Patients in the intervention and control Clusters had Similar demographic
  characteristics, contrain-dications to warfarin, and risk factors for stroke. Among
  patient, (n = 144 in the intervention clusters; n = 118 in the control clusters) for
  whom data were available during the baseline and follow-up periods, the changes in
  percentages of time in the target range were similar for those in the intervention
  clusters (baseline: 47.7%; follow-up: 55.6%) and in the control clusters (baseline:
  49.1%; follow-up: 52.3%; intervention effect: 5%; 95% confidence interval: -5% to
  14%; P = 0.32). CONCLUSION: Although it was feasible in a managed care
  organization to implement anticoagulation services that were tailored to local
  circumstances, provision of this service did not improve anticoagulation care
  compared With usual care. The effect of the anticoagulation service was limited by
  the utilization of the service, the degree to which the referring physician supports
  Strict adherence to recommended target ranges for the INR, and the ability of the
  anticoagulation service to identify and to respond to out-of-range Values promptly.
  (C) 2002 by Excerpta Medica, Inc
Keywords: aged/anticoagulation/anticoagulation service/atrial fibrillation/BLEEDING
  care/managed                                                                            care
  IN                         TIME/quality/randomized                            trial/risk/risk
  PREVENTION/THERAPY/trials/United                  States/utilization/warfarin/WARFARIN
Lew, H.L., Lee, E.H., Date, E.S. and Melnik, I. (2002), Rehabilitation of a patient with
  heat stroke - A case report. American Journal of Physical Medicine & Rehabilitation,
  81 (8), 629-632.
Abstract: The recent death of a famous football player raised public awareness of the
  fatal nature of heat stroke, which is actually the third leading cause of death among
  American athletes. We present a typical case of heat stroke to illustrate its clinical
  manifestation and recovery process; risk factors, treatment options, and the
  importance of prevention are also discussed. Although heat stroke is not a common
  admission diagnosis for inpatient rehabilitation, physiatrists need to be aware of its
  pathophysiology, rehabilitation management, and prevention
Keywords:          awareness/case           report/cause          of       death/CLINICAL
  CHARACTERISTICS/death/diagnosis/heat                      stroke/HEATSTROKE/inpatient
  /rehabilitation/risk/risk factors/stroke/treatment
Rader, D.J. (2002), Future outlook: Changing perspectives on best practice. American
  Journal of Managed Care, 8 (2), S40-S44.
Abstract: The guidelines recently released by the National Cholesterol Education
  Program call for more aggressive lowering of the level of low-density lipoprotein
  (LDL) cholesterol and a significant increase in the number of patients eligible for
  therapy that lowers the level of LDL. Despite the efficacy of statins in lowering the
  LDL level and in reducing the risk of a coronary event or stroke, other
  cholesterol-lowering therapies are needed. Some patients are unable to tolerate
  statins or are not candidates for statin therapy because of liver enzyme abnormalities,
  age, a preference for nonsystemic therapy, or a modestly elevated LDL level. For
  those patients, bile acid sequestrants, intestinal bile acid transport inhibitors, acyl
  coenzyme A:cholesterol acyltransferase inhibitors, and a number of nonselective
  cholesterol absorption inhibitors are alternative treatments. However, those agents
  vary in their effectiveness in reducing the level of LDL. Their use often does not
  reduce the LDL level to the extent desired or is compromised by patients' poor
  compliance with therapy because of inconvenient dosing or unpleasant side effects.
  Ezetimibe, the first selective inhibitor of intestinal cholesterol absorption, is a
   promising alternative to the agents listed above. When ezetimibe is used either as
   monotherapy or in combination with a statin, once-daily dosing reduces the level of
   LDL by an average of 18%
Kamal, A.K., Segal, A.Z. and Ulug, A.M. (2002), Quantitative diffusion-weighted MR
   imaging in transient ischemic attacks. American Journal of Neuroradiology, 23 (9),
Abstract: Background and purpose: The risk of stroke after a transient ischemic attack
   (Tia) Is high. Appropriately directed therapies may reduce this risk. However,
   sensitive means of detecting the presence of subtle neuronal ischemia are lacking.
   We investigated the potential use of quantitative diffusion- weighted (Dw) Mr
   imaging in the detection of deficits produced by transient cerebral ischemia. Methods:
   Twenty-eight patients who came to the stroke service from the emergency room of a
   tertiary teaching hospital with the final diagnosis of transient cerebral ischemia
   underwent conventional mr imaging, mr angiography, and dw mr imaging within 24
   hours of presentation. Fifteen patients had normal conventional dw images confirmed
   by a staff neuroradiologist and neurologist. For these patients, absolute quantitative
   diffusion values were subsequently calculated for the clinically relevant brain region
   and were compared with the values calculated for the corresponding contralateral
   unaffected brain region. Thirteen patients had conventional dw images positive for
   lesions and were not studied. Results: Quantitative dw imaging enabled detection of
   abnormal decreases (9-26%, P < .05) In the diffusion constant in brain regions
   suspected to be clinically involved by ischemia, when compared with the
   contralateral clinically unaffected brain tissue as well as with two other internal
   controls. Conclusion. Quantitative dw imaging depicts diffusion deficit in patients
   with tia. Quantitative dw imaging may have better sensitivity compared with
   conventional dw imaging in detecting transient cerebral ischemia
Keywords:                                           angiography/BRAIN/cerebral/cerebral
   Y/risk/risk of stroke/stroke/transient/transient ischemic attack/transient ischemic
Al Mubarak, N., Vitek, J.J., Mousa, I., Iyer, S.S., Mgaieth, S., Moses, J. and Roubin,
   G.S. (2002), Immediate catheter-based neurovascular rescue for acute stroke
   complicating coronary procedures. American Journal of Cardiology, 90 (2), 173-+.
Abstract: Immediate catheter-based revascularization was attempted in 8 patients who
   developed dramatic neurologic events during invasive coronary procedures.
   Successful recanalization was achieved in 7 patients, complete neurologic
   improvement occurred immediately after intervention in 3 patients, significant
   recovery was observed in an additional 3 patients, and 2 had no clinical improvement
   (1 died from a massive intracerebral hemorrhage)
Keywords:                  acute/acute               stroke/ANGIOPLASTY/CARDIAC-
Petrella, R.J., Overend, T. and Chesworth, B. (2002), FIM (TM) after hip fracture - Is
  telephone administration valid and sensitive to change? American Journal of
  Physical Medicine & Rehabilitation, 81 (9), 639-644.
Abstract: Objectives: It has been reported recently that follow-up FIM(TM) scores have
  been obtained from stroke patients via telephone interviews with either the former
  patient or proxy caregivers. We studied the validity and sensitivity of change of a
  "phone FIM" score in a sample of hip fracture patients after rehabilitation. Design:
  We compared FIM scores among hip fracture patients in a specialized
  musculoskeletal rehabilitation program. Sample size estimate of 27 was determined
  before the study. Patients included those with hip fracture returning to independent
  living in their own home. Results: Twenty-nine patients were identified as a
  convenience Sample of admitted patients. The phone FIM score at 8 wk was a valid
  predictor of the discharge FIM score and the observed FIM and phone FIM scores at
  8 wk were similar. The sensitivity to change over 8 wk was similar between observed
  and phone FIM scores compared with the discharge FIM score. Conclusions: The
  phone FIM instrument presents a useful clinical instrument to monitor patient
  functional status in the community, showing excellent psychometric properties. Ease
  of use and low cost should encourage greater use in clinical management of these
Keywords:                                                   administration/ASSESSMENT
  SCALES/Canada/caregivers/community/cost/FIM/FIM                                    (TM)
  instrument/FUNCTIONAL INDEPENDENCE MEASURE/functional status/hip
  TY/size/stroke/telephone administration
Kendall, D.M. and Harmel, A.P. (2002), The metabolic syndrome, type 2 diabetes, and
  cardiovascular disease: Understanding the role of insulin resistance. American
  Journal of Managed Care, 8 (20), S635-S653.
Abstract: The most common and clinically important complication in adults with
  diabetes is cardiovascular disease (CVD), which includes coronary heart disease,
  peripheral vascular disease, and stroke. Both type 2 diabetes and the insulin
  resistance syndrome are associated with a marked increase in the risk for CVD. The
  metabolic syndrome and the closely related insulin resistance syndrome have
  recently been recognized as important disorders, each being associated with an
  increase in CVD risk even in the absence of glucose intolerance. Given the
  significant public health burden of CVD, risk reduction has emerged as a significant
  clinical challenge for most practitioners. Diabetes and the insulin resistance
  syndrome are closely related disorders, with insulin resistance being more than a key
  pathogenic defect in type 2 diabetes. Even in the absence of glucose intolerance,
  these 2 disorders are both associated with a number of distinct pathologic findings,
  including hypertension, atherogenic dyslipidemia, a prothrombotic environment, and
  significant vascular and hemodynamic abnormalities that result from endothelial cell
  dysfunction. Insulin resistance is now recognized to be closely associated with the
  development of each of these risk factors. This article uses a case-based approach to
  discuss the unique features of insulin resistance and type 2 diabetes considered to be
  key contributors to CVD risk. A systematic approach to both evaluation and
  management is proposed, with priority given to therapies of demonstrated clinical
  benefit. Because of its critical and central role in the development of many CVD risk
  factors, targeted treatment of insulin resistance will also be discussed as such therapy
  may prove to be a critical component of care in years to come
Keywords:                             abnormalities/adults/ARTERIAL-WALL/BLOOD-
  disease/CARE/CHOLESTEROL/complication/coronary/coronary                          heart
  disease/CORONARY                        HEART-DISEASE/CVD                         risk
  etabolic                   syndrome/peripheral/peripheral                    vascular
  disease/PIOGLITAZONE/practitioners/public                             health/risk/risk
  factors/RISK-FACTORS/stroke/therapy/treatment/USA/vascular disease
Carhuapoma, J.R., Barker, P.B., Hanley, D.F., Wang, P. and Beauchamp, N.J. (2002),
  Human brain hemorrhage: Quantification of perihematoma edema by use of
  diffusion-weighted MR imaging. American Journal of Neuroradiology, 23 (8),
Abstract: BACKGROUND AND PURPOSE: Animal models have clearly shown a
  critical role for extravascular blood in the initiation of the vasogenic edema
  associated with intracerebral hemorrhage (ICH). Nevertheless, the relevance of these
  observations to the human disease process has not been evaluated. With a
  prospectively collected cohort of nine patients, we report the relation between
  intraparenchymal blood clot volume and elevation of perihematoma brain tissue (and
  homologous contralateral brain tissue) apparent diffusion coefficient (ADC).
  METHODS: Patients with acute and subacute supratentorial ICH were prospectively
  evaluated by using diffusion-weighted imaging. ADC was measured in
  perihematoma tissue and in homologous contralateral regions. The relationship
  between ADC and volume of hematoma was determined by using linear regression
  analysis. RESULTS: Nine patients were enrolled in the study. The mean hematoma
  volume was 30.8 cc (range, 2.6-74 cc). The ADC in the perihematoma regions was
  172.5 x 10(-5) mm(2)/s (range, 120.1-302.5 x 10(-5) mm(2)/s) and in the
  contralateral corresponding regions of interest was 87.6 x 10(-5) mm(2)/s (range,
  76.5-102.1 x 10(-5) mm(2)/s) (P =.02). The Pearson correlation coefficient for the
  ADC in surrounding edema and hematoma volume was 0.7 (P =.04). The correlation
  coefficient between hematoma volume and contralateral hemisphere ADC was 0.8 (P
  =.02). CONCLUSION. We report a significant direct correlation between ICH
  volume and degree of ADC elevation in perihematoma and ADC values in
  contralateral corresponding brain tissue. These findings suggest a dose-effect
  interaction between volume and concentration of blood products and intensity of
  response that brain tissue exhibits in blood-mediated edema. Prospective natural
  history and interventional studies are required to confirm this biologically
  meaningful correlation in patients with ICH
Keywords:                                               acute/ASPIRATION/brain/brain
  ebral                     hemorrhage/MANAGEMENT/MODEL/models/MR/natural
  AL                                                               INTRACEREBRAL
Avegliano, G., Evangelista, A., Elorz, C., Gonzalez-Alujas, T., del Castillo, H.G. and
  Soler-Soler, J. (2002), Acute peripheral arterial ischemia and suspected aortic
  dissection: Usefulness of transesophageal echocardiography in differential diagnosis
  with aortic thrombosis. American Journal of Cardiology, 90 (6), 674-+.
Abstract: Acute peripheral arterial ischemia may be the first manifestation of acute
  aortic dissection.(1-4) Aortic thrombosis, particularly when the thrombus is mobile,
  is a rare process frequently associated with peripheral arterial embohsm(5-9) and
  may be mistaken for aortic dissection by some imaging techniques.(10) Correct
  diagnosis is crucial because management differs in both entities.(2,5,7,8) This study
  assesses the usefulness of trans esophageal echocardiography (TEE) in patients with
  acute peripheral ischemia and aortic dissection diagnosed by computed tomography
Keywords: acute/aortic dissection/ARCH/ATRIAL SEPTAL ANEURYSM/computed
  ombus/tomography/transesophageal/transesophageal echocardiography
Biousse, V., Suh, D.Y., Newman, N.J., Davis, P.C., Mapstone, T. and Lambert, S.R.
  (2002), Diffusion-weighted magnetic resonance imaging in shaken baby syndrome.
  American Journal of Ophthalmology, 133 (2), 249-255.
Abstract: PURPOSE: To evaluate the role of diffusion weighted magnetic resonance
  imaging (DWIMRI) in the diagnosis and management of children with suspected or
  confirmed Shaken Baby Syndrome (SBS). METHODS: This was a retrospective
  interventional case series of all infants and children younger than 2 years of age
  admitted to a children's hospital. We retrospectively reviewed medical records and
  neuroimaging findings of all children younger than 2 years of age with confirmed or
  suspected SBS admitted to a children's hospital. Inclusion criteria were documented
  ocular examination by an ophthalmologist and a brain MRI with DWI. Twenty-six
  infants and children were included. Other children were excluded. Children with
  proven SBS were diagnosed with "confirmed SBS," while children in whom the
  diagnosis of SBS remained uncertain were diagnosed with "suspected SBS."
  RESULTS: Twenty-six infants and children with mean age of 7.1 months (range, 6
  weeks-24 months) were included, 18 with confirmed SBS. All 26 patients had a
  subdural hematoma, 10 had associated occult bone fractures, and 18 had retinal
  hemorrhages. Seven of the eight cases without retinal hemorrhages had isolated
  subdural hematoma without parenchymal brain lesions on both conventional MRI
  and DWIMRI. SBS was confirmed in only one case with a normal fundus. Among
  the 18 patients with retinal hemorrhages, SBS was confirmed in all but one case. All
  18 patients with confirmed SBS had an abnormal DWIMRI. In 13 patients, DWI
  showed lesions that were larger than on conventional MRI. In patients with brain
  parenchymal lesions, the DWIMRI characteristics suggested cerebral ischemia,
  which appears to play a major role in SBS. CONCLUSIONS: In all patients with
  confirmed SBS, DWIMRI was abnormal and suggested diffuse or posterior cerebral
  ischemia, in addition to subdural hematomas in the pathogenesis of this disorder.
  (Am J Ophthalmol 2002;133:249-255. (C) 2002 by Elsevier Science Inc. All rights
Keywords:                                            ABUSE/age/brain/cerebral/cerebral
  g/INFANTS/ischemia/magnetic                 resonance/magnetic              resonance
Oelschlager, B.K., Barreca, M., Chang, L. and Pellegrini, C.A. (2003), The use of small
  intestine submucosa in the repair of paraesophageal hernias: Initial observations of a
  new technique. American Journal of Surgery, 186 (1), 4-8.
Abstract: Background: Recent reports suggest that when laparoscopy is used to repair
  paraesophageal hernias recurrence rates reach 20% to 40%. Tension-free hernia
  closure with synthetic mesh reduces recurrence but occasionally results in
  esophageal injury-We hypothesized that reinforcement of the hiatal closure with
  small intestine submucosa (SIS) mesh, in some unusually large hernias, might reduce
  recurrence rates without causing injury to the esophagus. Methods: From January
  2001 to March 2002 we treated 18 large paraesophageal hernias via a laparoscopic
  approach. In 9 of the largest hernias (one type II and 8 type III, of which 1 was
  recurrent) the repair was reinforced with SIS mesh (Surgisis, Cook Surgical) and
  represent the subjects of this study. Nissen fundoplication with gastropexy was
  performed in all patients. Clinical follow- up ranged from 3 to 16 months (median 8).
  Every patient was evaluated with barium esophagram or endoscopy or both 1 to 8
  months (median 2) postoperatively. Results: The presenting symptoms were
  postprandial pain/fullness (9 of 9), heartburn (4 of 9), anemia (4 of 9), dysphagia Q
  of 9), regurgitation Q of 9), and chest pain Q of 9). One patient died of a
  hemorrhagic stroke within 30 days,of the operation. Postoperatively, presenting
  symptoms resolved (83%) or improved (17%) in each of the remaining 8 patients.
  One patient required endoscopic dilation for mild dysphagia. Seven of 8 patients had
  a normal barium esophagram without evidence of hernia. One morbidly obese (body
  mass index = 47) patient had a small (2 cm.) sliding hiatal hernia postoperatively.
  There were no other complications, and specifically no perforations or mesh erosions.
  Conclusions: These observations suggest that the use of SIS in the repair of
  paraesophageal hernias is safe and may reduce recurrence. Longer follow-up and a
  randomized study are needed to validate these results. (C) 2003 Excerpta Medica, Inc.
  All rights reserved
  stroke/hiatal                   hernia/HIATAL-HERNIA/injury/INTRATHORACIC
  fundoplication/pain/paraesophageal              hernia/paraesophageal             hernia
  repair/prosthesis/recurrence/small intestinal submucosa/stroke
Wong, A.M.K., Leong, C.P., Su, T.Y., Yu, S.W., Tsai, W.C. and Chen, C.P.C. (2003),
  Clinical trial of acupuncture for patients with spinal cord injuries. American Journal
  of Physical Medicine & Rehabilitation, 82 (1), 21-27.
Abstract: Objective: To examine whether electrical acupuncture therapy through
  adhesive surface electrodes and concomitant auricular acupuncture therapy could
  improve the neurologic or functional recovery in acute traumatic spinal cord injury
  patients. Design: A total of 100 acute traumatic spinal cord injury patients with
  American Spinal Injury Association (ASIA) impairment grading of A and B were
  recruited into this study. They were randomly divided into the acupuncture and
  control groups. In the acupuncture group, electrical acupuncture therapy via the
  adhesive surface electrodes were applied to the bilateral Hou Hsi (SI3) and Shen Mo
  (B62) acupoints. In auricular acupuncture, four acupoints related to the spinal cord
  were selected for stimulation at the antihelix, helix, and lower portion of the ear-back
  areas. Acupuncture therapy was initiated early in the emergency room setting or soon
  after spinal surgical intervention. Rehabilitation therapy was also provided to the
  patients during acupuncture therapy. In the control group, only rehabilitation therapy
  was provided to the patients. Neurologic and functional scores were assessed during
  the time of admission, hospital discharge, and 1-yr postinjury follow-up. Results:
  There were significant improvements in neurologic (sensory and motor), functional,
  and FIM(TM) scores in the acupuncture group compared with the initial admission
  period when assessed during the time of hospital discharge and the 1-yr postinjury
  follow-up. A greater percentage of patients in the acupuncture group recovered to a
  higher ASIA impairment grading. Conclusion: The use of concomitant auricular and
  electrical acupuncture therapies, when implemented early in acute spinal cord injury,
  can contribute to significant neurologic and functional recoveries
Keywords:      acupuncture/acute/American Spinal          Injury Association/auricular
  y/rehabilitation/spinal       cord/spinal       cord       injury/stimulation/STROKE
Gable, D.R., Bergamini, T., Garrett, W.V., Hise, J., Smith, B.L., Shutze, W.P., Pearl, G.
  and Grimsley, B.R. (2003), Intermediate follow-up of carotid artery stent placement.
  American Journal of Surgery, 185 (3), 183-187.
Abstract: Background: Carotid artery stent placement (CAS) is becoming more popular
  among various specialties for the treatment of primary and recurrent carotid artery
  disease. The morbidity associated with this procedure is improving but the
  intermediate- and long-term follow-up remains unknown. We report our restenosis
  rates and follow-up associated with CAS. Methods: Thirty-one interventions on 29
  patients from May 1998 to January 2002 were reviewed. All patients have undergone
  serial follow-up using Doppler ultrasound at 3 and 6 months and every 6 months
  thereafter. Ten interventions (32%) were performed on patients with recurrent carotid
  artery disease and 21 (68%) on patients with primary disease. Results: Five
  periprocedural complications occurred (transient ischemic attack, n = 3; major stroke,
  n = 1; immediate intrastent restenosis requiring lysis, n 1) for a total immediate
  complication rate of 16%. No deaths occurred. Follow-up was achieved in all 29
  patients (mean 28 months; range 20 to 46). Twenty-seven patients (29 vessels; 94%)
  remain asymptomatic with less than 50% stenosis. Two vessels (6%) have been
  found to have a critical restenosis of greater than 90%. Both patients were
  symptomatic from their recurrence (transient ischemic attack, n = 1; acute stroke, n =
  1). Cumulative major stroke and death rate including all follow-up was 6%.
  Conclusions: CAS can be performed with an acceptable stroke/death rate (3%) in a
  properly selected patient population. In our small series of patients, the restenosis
  rate at a mean of 28 months after CAS is 6%. (C) 2003 Excerpta Medica Inc. All
  rights reserved
Keywords:        acute/acute      stroke/angioplasty/artery/asymptomatic/carotid/carotid
  artery/carotid                          artery                           disease/carotid
  sient/transient ischemic attack/treatment/ultrasound/USA
Lesley, W.S., Chaloupka, J.C. and Weigele, J.B. (2003), Preliminary experience with
  endovascular reconstruction for the management of carotid blowout syndrome.
  American Journal of Neuroradiology, 24 (5), 975-981.
Abstract: PURPOSE. Permanent balloon occlusion (PBO) of the carotid artery has been
  previously shown to be an effective means to treat carotid blowout syndrome (CBS).
  However, despite the effectiveness of this endovascular technique, concern remains
  regarding its potential for producing delayed cerebral ischemic complications in 15%
  to 20% of patients. This significant limitation of carotid PBO led our group to
  evaluate an alternative management strategy, consisting of endovascular
  reconstruction of the carotid artery (ERCA) in patients thought to be at particularly
  high risk for carotid occlusion (ie, provocative balloon test occlusion, angiographic
  documented incomplete circle of Willis, or contralateral carotid artery occlusion).
  METHODS: We reviewed all cases of CBS referred to our service, in which ERCA
  was chosen as a management strategy for patients thought to be at high risk for PBO,
  based on previously defined criteria. RESULTS: Sixteen carotid blowout events
  occurred in 12 patients with CBS who were deemed to be at high risk for cerebral
  ischemic complications, which were managed with ERCA by using a variety of stent
  devices and techniques. Adjunctive embolization of carotid pseudoaneurysms was
  performed in five of these patients by using platinum coils or acrylic glue.
  Hemostasis was achieved in all cases, although one patient with traumatic CBS and
  three patients with aggressive head and neck cancer-related CBS, required
  retreatment with ERCA. Recurrent CBS rates were similar to those reported in other
  studies using PBO. Overall, no treatment-related strokes or deaths occurred.
  CONCLUSION: CBS managed with ERCA can be performed safely and with
  efficacy of outcomes at least equivalent to those previously reported in association
  with conventional carotid PBO, therefore representing an excellent alternative
  endovascular technique for patients who are at increased risk of stroke after PBO
  OCCLUSION/carotid/carotid             artery/carotid     artery      occlusion/carotid
  URYSM/risk/risk of stroke/RUPTURE/stent/stroke/studies/TECHNICAL CASE-
Smith, W.S., Roberts, H.C., Chuang, N.A., Ong, K.C., Lee, T.J., Johnston, S.C. and
  Dillon, W.P. (2003), Safety and feasibility of a CT protocol for acute stroke:
  Combined CT, CT angiography, and CT perfusion imaging in 53 consecutive
  patients. American Journal of Neuroradiology, 24 (4), 688-690.
Abstract: By combining non-contrast-enhanced CT imaging, CT perfusion imaging, and
  cranial-to-chest CT angiography (CTA), the entire cerebrovascular axis can be
  imaged during acute stroke. To our knowledge, the safety and feasibility of this
  technique have not been previously reported. In a consecutive series of 53 patients
  with suspected acute stroke, renal failure was not observed. Median imaging time
  was 27 minutes (range, 9-67 minutes). Image quality was degraded by motion in
  1.3% of vessels studied. Dynamic CT perfusion data were successfully obtained in
  52 patients (98% of patients). High-speed, multisection, helical CT scanners allow
  rapid, safe imaging of the entire neurovascular axis in patients with acute stroke by
  use of combined CT imaging, CT perfusion imaging, and CTA
Keywords:                                                                     acute/acute
  ADIOLOGY/perfusion/perfusion                                imaging/quality/renal/renal
Kowey, P.R., Yan, G.X., Winkel, E. and Kao, W. (2003), Pharmacologic and
  nonpharmacologic options to maintain sinus rhythm: Guideline-based and new
  approaches. American Journal of Cardiology, 91 (6A), 33D-38D.
Abstract: Atrial fibrillation is a common arrhythmia in patients with heart failure and is
  responsible for substantial morbidity and mortality. Restoration and preservation of
  sinus rhythm, therefore, has a premium. Of the numerous treatment options available,
  many must be avoided because of their potential for adverse effects or because of
  limited proof of efficacy in defined populations. Published guidelines provide help
  by synthesizing clinical trial data into a recommended approach. This article
  summarizes current information regarding the best methods applicable to patients
  with left ventricular dysfunction for rate control, sinus rhythm restoration and
  maintenance, and stroke prevention. New and evolving therapies and how they might
  fit into the evolving treatment paradigm are also briefly reviewed. (C) 2003 by
  Excerpta Medica, Inc
Keywords:       adverse     effects/arrhythmia/CATHETER           ABLATION/CHRONIC
  failure/information/INTRAVENOUS                 AMIODARONE/left              ventricular
  control/sinus rhythm/stroke/stroke prevention/treatment/USA
Healey, J.S. and Connolly, S.J. (2003), Atrial fibrillation: Hypertension as a causative
  agent, risk factor for complications, and potential therapeutic target. American
  Journal of Cardiology, 91 (10), 9G-14G.
Abstract: Atrial fibrillation and hypertension are 2 prevalent, and often coexistent,
  conditions in the North American population. Their incidence increases with
  advancing age, and they are responsible for considerable morbidity and mortality.
  Although the relation between the 2 conditions has long been known, the treatment
  of hypertension is not currently a focus in the clinical management of atrial
  fibrillation. Hypertension is associated with left ventricular hypertrophy, impaired
  ventricular filling, left atrial enlargement, and slowing of atrial conduction
  velocity.,These changes in cardiac structure and physiology favor the development of
  atrial fibrillation, and they increase the risk of thromboembolic complications.
  Conventional therapy of atrial fibrillation has focused on interventions to control
  heart rate and rhythm and the prevention of stroke through the use of anticoagulant
  medications. In patients with atrial fibrillation, aggressive treatment of hypertension
  may reverse the structural changes in the heart, reduce thromboembolic
  complications, and retard or prevent the occurrence of atrial fibrillation. Specific
  pharmocotherapy could potentially play a major role in the primary and secondary
  prevention of atrial fibrillation and its complications. (C) 2003 by Excerpta Medica,
Keywords:          age/anticoagulant/ANTIHYPERTENSIVE                TREATMENT/atrial
  rate/HEART-FAILURE/hypertension/hypertrophy/incidence/left                   ventricular
  ation/prevention/RANDOMIZED             TRIAL/risk/risk     factor/secondary/secondary
  prevention/SINUS                                    RHYTHM/SIZE/stroke/SYSTEMIC
  HYPERTENSION/therapy/thromboembolic complications/treatment/USA
Saxonhouse, S.J. and Curtis, A.B. (2003), Risks and benefits of rate control versus
  maintenance of sinus rhythm. American Journal of Cardiology, 91 (6A), 27D-32D.
Abstract: There are 2 fundamental approaches to managing patients with recurrent atrial
  fibrillation (AF): to restore and maintain sinus rhythm with cardioversion and/or
  antiarrhythmic drugs, or to control the ventricular rate only. Over the past few years,
  there have been several important prospective clinical trials comparing rate control
   with rhythm control in patients with recurrent AF. The Pharmacological Intervention
   in Atrial Fibrillation (PIAF) trial was the first prospective randomized study to test
   the hypothesis of equivalency between the 2 management strategies for AF. The trial
   demonstrated that rate control was not inferior to rhythm control with respect to
   symptoms, quality of life, or number of hospitalizations in patients with persistent
   AF. The Strategies of Treatment in Atrial Fibrillation (STAF) trial was a pilot study
   that enrolled approximately 200 patients with AF who were randomized to either
   ventricular rate control or cardioversion and maintenance of sinus rhythm. The
   results, showed that over a 1- year period there was little difference in outcome in
   terms of morbidity or symptoms. In the Atrial Fibrillation Follow-up Investigation of
   Rhythm Management (AFFIRM) trial, patients with AF and risk factors for stroke
   were randomized to either rhythm control or, rate control, with both groups receiving
   anticoagulation with warfarin. There was no difference in the composite end point of
   death, disabling stroke or anoxic encephalopathy, major bleeding, or cardiac arrest
   between the 2 arms. In addition, no major differences were noted in functional status
   or quality of life. The Rate Control Versus Electrical Cardioversion (RACE) trial
   also reached a similar conclusion. Thus, rate control is an acceptable primary
   strategy for management of patients with recurrent AF. (C) 2003 by Excerpta Medica,
Keywords:            AMIODARONE/antiarrhythmic                  drugs/anticoagulation/atrial
   fibrillation/ATRIAL-           FIBRILLATION/bleeding/CARDIOVERSION/clinical
   lation/functional status/HIGHLIGHTS/IMPLANTATION/maintenance of sinus
   PACEMAKER/quality/quality of life/QUINIDINE/RACE/rate control/risk/risk
   factors/SCIENTIFIC SESSIONS/sinus rhythm/strategies/stroke/trials/USA/warfarin
Brien, H.W., Yellin, A.E., Weaver, F.A. and Carroll, B.F. (1991), A Review of Carotid
   Endarterectomy at A Large Teaching Hospital. American Surgeon, 57 (12), 756-762.
Abstract: Before 1981, the neurologic morbidity and mortality associated with carotid
   endarterectomy (CEA) in the Los Angeles County/USC Medical Center public
   teaching institution was 20 per cent, similar to results from other hospitals. In 1981, a
   standardized protocol was adopted in an attempt to improve surgical outcome
   following CEA. Between 1981 through 1990, 89 patients with a mean age of 60.9
   years (range 38 to 80 yrs) had 100 consecutive CEAs. Atherosclerotic risk factors
   included hypertension in 57 patients (61.8%), tobacco use in 57 (64.0%), and
   diabetes mellitus in 28 (31.5%). Forty-nine patients had a history of ischemic heart
   disease. Indications for CEA were stroke in 40 cases, transient ischemic attack in 33
   cases, and asymptomatic, high-grade stenosis of the internal carotid artery (greater
   than 85 per cent) in 19. Perioperative and surgical management are detailed in the
   authors' protocol. Intraluminal shunts were routinely used (99 cases) and 24
   arteriotomies were patched. Completion arteriograms were performed in 99 cases,
   four of which were revised because of arteriographic abnormalities. Three patients
   sustained postoperative ipsilateral neurologic events. Ten patients had cranial nerve
   palsies, six of which were transient. Two patients had nonfatal postoperative
   myocardial infarctions. There were no deaths. The combined stroke and transien
   ischemic attack (TIA) mortality rate was 3 per cent. In conclusion, the audit and
   quality assurance process identified unacceptable results following CEA. A protocol
   was developed that addressed pre, intra, and postoperative details of patient selection,
   operative technique, and postoperative care. By adhering to the protocol, the major
   neurologic morbidity and mortality rate has been reduced to 3 per cent
Keywords:                                      BRUITS/COMMUNITY/CONSECUTIVE
Cirocco, W.C. and Brown, A.C. (1993), Anterior Resection for the Treatment of Rectal
   Prolapse - A 20- Year Experience. American Surgeon, 59 (4), 265-269.
Abstract: Between 1971 and 1991, 41 patients underwent anterior resection for the
   treatment of complete rectal prolapse. Anterior resection was performed after full
   rectal mobilization to the levator ani muscles with reanastomosis (39 hand-sewn and
   two stapled) carried out to peritonealized distal rectum. The 41 patients comprised 35
   women and six men with an average age of 56 years (range, 7-88 years).
   Postoperative follow-up averaged 6 years (range, 6 months to 18 years). Three
   patients (7%) suffered recurrent prolapse in 2, 2.5, and 5.5 years, respectively.
   Mortality was 0 per cent; morbidity was 15 per cent including three incisional
   herniae, two small bowel obstructions, and one stroke. No pelvic sepsis, abscess, or
   anastomotic dehiscence occurred. Anal incontinence was a preoperative finding in 21
   patients (51%) with rectal prolapse. Nineteen of these patients (90%) noted either
   improvement or no change in postoperative continence. Anterior resection is a
   familiar, frequently performed operation that does not require a foreign body or
   rectal suspension. We believe this to be the procedure of choice for patients with
   complete rectal prolapse. Anterior resection withstands long-term scrutiny both in
   terms of recurrence rate and associated complications
Abouljoud, M.S., Obeid, F.N., Horst, H.M., Sorensen, V.J., Fath, J.J. and Chung, S.K.
   (1993), Arterial Injuries of the Thoracic Outlet - A 10-Year Experience. American
   Surgeon, 59 (9), 590-595.
Abstract: Arterial injuries of the thoracic outlet are complex and require a precise plan
   for adequate management and prompt exposure of injured vessels. Our 10-year
   experience with 28 such injuries is reviewed. Arteriography was performed
   whenever possible in stable patients (15) and aided in planning the operative
   approach. Unstable patients with active bleeding, pulsatile or expanding hematoma,
   or pulse deficit were taken to the operating room without delay. A thoracic approach
   was required in 15 patients, and the exposure was extrathoracic in 12 patients.
   Airway was secured with liberal use of emergency endotracheal intubation (16
   patients). Primary repair was possible in 16 patients, with grafting performed in eight
   and ligation in three. One vertebral artery injury was successfully controlled with
   embolization. Venous injuries were repaired in six patients and ligation was
   necessary in eight; there was no significant morbidity. Two patients died in this
   series from complications of severe hemorrhage. Significant morbidity was
   encountered from associated neurologic injuries in 15 patients. Stroke was evident in
   two patients, both of whom were moribund preoperatively. Proximal subclavian
   artery injuries were particularly more problematic and frequently required an interim
   anterior thoracotomy for early control of exsanguinating hemorrhage. Our
   philosophy in the management of these injuries and choices of exposure are
   discussed in detail
Ranger, W.R., Glover, J.L. and Bendick, P.J. (1995), Carotid Endarterectomy Based on
   Preoperative Duplex Ultrasound. American Surgeon, 61 (7), 548-555.
Abstract: Recent studies have suggested that carotid endarterectomy can be performed
  safely based solely on the noninvasive duplex ultrasound evaluation in selected
  patients. We have prospectively evaluated 60 consecutive patients who underwent 65
  carotid endarterectomies, 48 patients without preoperative angiography and 12 with
  angiography. Forty-two patients were operated on for symptomatic disease, and 23
  procedures were done for critical, asymptomatic stenoses. Long term followup
  consisted of physical examination and serial duplex scans every 3-6 months
  postoperatively over a mean followup period of 2.4 years. Clinical management
  indicated by duplex ultrasound was altered in only one of the 12 patients who had
  preoperative angiography, a change in the timing of the endarterectomy in a
  symptomatic patient with an ulcerated lesion seen at angiography. At operation the
  severity of disease predicted by duplex ultrasound was confirmed in all cases (100
  per cent sensitivity), including one >80% diameter stenosis interpreted by
  angiography as occluded; no unsuspected anatomic anomalies were found at surgery.
  The duplex scan also correlated well with intraoperative findings of surface
  ulceration and gross intraplaque hemorrhage. There was one intraoperative stroke
  with good recovery in a patient with preoperative angiography; and there were no
  deaths, for a combined morbidity and mortality of 1.6 per cent. During long term
  followup, 97 per cent of patients have remained symptom-free. We conclude that
  clinical assessment with a preoperative duplex ultrasound scan of good technical
  quality and interpreted in collaboration with the vascular surgeon provides
  appropriate information on which to base carotid endarterectomy and allows a safe
  alternative to the routine use of preoperative angiography. The minority of patients
  for whom angiography is indicated can be identified by technically inadequate or
  equivocal duplex scans or minimal disease seen by the duplex examination in a
  symptomatic patient
Keywords:                                ANGIOGRAPHY/ARTERIOGRAPHY/carotid
Mitchell, R.O., Richardson, J.D. and Lambert, G.E. (1996), Characteristics, surgical
  management, and outcome in 17 carotid body tumors. American Surgeon, 62 (12),
Abstract: Tumors of the carotid body are relatively rare and may pose a difficult
  surgical problem because of their vascularity and compression of cranial nerves in
  the neck. This article reviews the physiology of the carotid body, its surgical history,
  and retrospectively reviews the management and outcome of 17 carotid body tumors
  occurring in 14 patients over an 18-year period at the University of Louisville
  Hospitals. The average age at presentation was 54.4 years, Three patients had
  bilateral tumors. Two patients (12%) had postoperative cranial nerve paralysis lasting
  greater than 6 months. One patient had a postoperative stroke after discharge from
  the hospital and subsequently died 2 months later from a pulmonary embolus, One
  patient had a malignant carotid body tumor and pulmonary metastasis and died 11
  years after her original operation during an attempted embolization of recurrent
  carotid lesion. Early operation for the tumor is indicated to prevent nerve dysfunction
  due to compression and stretch injury as the lesion increases in size
Arnell, T.D., DeVirgilio, C., Donayre, C., Grant, E., Baker, J.D. and White, R. (1996),
  Abdominal aortic aneurysm screening in elderly males with atherosclerosis: The
  value of physical exam. American Surgeon, 62 (10), 861-864.
Abstract: The purpose was 1) To assess the prevalence of abdominal aortic aneurysms
  (AAA) in elderly males with atherosclerosis and 2) to evaluate the value of physical
  exam (PE) by a vascular surgeon in detecting AAA. A total of ninety-six males older
  than 55 years referred to vascular surgery clinic with atherosclerotic disease were
  screened prospectively with PE by a vascular surgeon, followed by ultrasonography
  (US). Atherosclerosis was documented by ankle brachial index and duplex US.
  Patients who had recently undergone a vascular procedure, aortography, laparotomy,
  abdominal computed tomography, or US were excluded. Mean age was 67 years.
  Patients were 67 per cent Caucasian, 32 per cent black, and 1 per cent Hispanic.
  Presenting complaints were related to claudication (83%), carotid disease (19%),
  both (3%), and subclavian stenosis (1%). Patient characteristics included cigarette
  smoking (85%), hypertension (67%), cardiac disease (51%), diabetes (45%), stroke
  (18%), and chronic obstructive pulmonary disease (8%). One (1%) 3.7 cm AAA was
  detected by US. Sensitivity of PE was 100 per cent and specificity 92 per cent.
  Twenty-two (23%) patients were too obese for us to feel the aortic pulse. Screening
  cost was $14,250. The prevalence of AAA in this population is very low. AAA
  screening should be reserved for patients with a positive PE or who are too obese for
  the examiner to feel the aortic pulse
Taylor, S.M., Langan, E.M., Snyder, B.A., Cull, D.L. and Crane, M.M. (1999),
  Nonendarterectomy procedures of the carotid artery: A five-year review. American
  Surgeon, 65 (4), 323-327.
Abstract: Although the efficacy of carotid endarterectomy has been well established,
  nonendarterectomy procedures of the carotid bifurcation have only sporadically been
  reported. Of 334 consecutive nontraumatic carotid procedures performed on 321
  patients from July 1992 until May 1997, 306 (91.6%) were carotid endarterectomies,
  14 (4.2%) were carotid-subclavian bypasses/transpositions, and 14 (4.2%) were
  nonendarterectomy procedures of the carotid artery. These latter 14 cases (nine
  females and five males; mean age, 63 years) were all symptomatic (neurological or
  painful mass) and included carotid kink/coil resection (n = 3; 0.9%), endarterectomy
  and vertebral transposition (n = 2; 0.6%), carotid aneurysm resection (n = 2; 0.6%),
  carotid body tumor resection (n = 2; 0.6%), carotid stump ligation/external
  endarterectomy (n 1; 0.3%), infected/bleeding carotid patch removal with vein graft
  replacement (n = 1; 0.3%), saphenous vein graft replacement (n = 1; 0.3%), carotid
  dilatation for fibromuscular dysplasia (n = 1; 0.3%), and descending aorta to carotid
  bypass (n = 1; 0.3%). With 30 day follow-up complete for all 334 carotid operations,
  10 perioperative strokes (2.9%) and five deaths (1.5%) occurred for a combined
  stroke/death rate of 3.3 per cent. Of the 14 nonendarterectomy carotid artery
  operations, there were no strokes or deaths; with mean follow-up of 13 months, 13
  patients (92.9%) are asymptomatic, patent, and disease-free. Three severe transient
  cranial nerve (CN) neuropraxias (21.4%), one myocardial infarction (7.1%), and one
  late death (mesenteric ischemia at 2 months), however, occurred. Although no
  statistical differences in stroke, death, and stroke/death occurred between the
  endarterectomy versus the nonendarterectomy group, transient CN injury was more
  common in the nonendarterectomy group (21.4% versus 4.1%; P = 0.027). Although
  nonendarterectomy procedures of the carotid bifurcation are infrequently needed,
  they seem safe, effective, and indicated in selected patients, despite a higher
  incidence of transient CN injury
Keywords: age/aneurysm/aorta/artery/BODY/bypass/carotid/carotid artery/carotid body
Johna, S., Gaw, F., Berten, R. and Miro, J. (2000), Carotid endarterectomy far severe
   asymptomatic carotid stenosis: A perioperative experience at a community hospital.
   American Surgeon, 66 (11), 1046-1048.
Abstract: The purpose of this study was to evaluate the safety and feasibility of carotid
   endarterectomy (CEA) for severe asymptomatic carotid stenosis in a community
   setting with direct surgical resident participation. The medical records of ail patients
   who had undergone CEA for severe asymptomatic carotid stenosis between 1989 and
   1997 were retrospectively reviewed to ascertain perioperative morbidity and
   mortality. One hundred forty-seven CEAs were performed on 131 patients over the
   8-year interval, Perioperative stroke and death rate was 0 per cent, However, one
   patient had a postoperative transient ischemic attack, and one patient: had vocal cord
   dysfunction due to vague nerve injury (1.3%), Three other patients had perioperative
   complications not directly related to CEA (2.1%). Therefore the total perioperative
   complication rate of (3.4%) compares favorably with results reported by several
   large tertiary referral centers, CEA for severe asymptomatic carotid stenosis can be
   safely performed in a community hospital setting with direct surgical resident
Keywords: ARTERY/ATHEROSCLEROSIS/carotid/carotid endarterectomy/carotid
   complications/safety/stenosis/stroke/SURGEON           SELECTION/transient/transient
   ischemic attack
Mariano, M.C., Gutierrez, C.J., Alexander, J., Roth, F., Katz, S. and Kohl, R.D. (2000),
   The utility of transesophageal echocardiography in determining the source of arterial
   embolization. American Surgeon, 66 (9), 901-904.
Abstract: Arterial embolism is frequently of a cardiac source. arterial- arterial and
   paradoxical embolization also occurs. Failure to identify the origin may subject the
   patient to an important series of events. Herein we describe seven cases in which
   transesophageal echocardiography (TEE) was uniquely valuable in identifying the
   source or mechanism and in which conventional echocardiography and aortography
   were nondiagnostic. We conducted a chart review of patients with arterial emboli
   definitively diagnosed after undergoing TEE. Seven patients (mean age 68 years)
   were included in the study. Peripheral embolization occurred in four patients,
   visceral embolization occurred in one, and two experienced cerebrovascular events.
   Five patients had transthoracic echocardiography and six had aortography; none of
   these identified the source of embolization. All were diagnosed by TEE. Mobile
   aortic thrombus was the primary source in three patients, paradoxical embolization
   occurred in two, and two others had a combination of findings. Two patients received
   operative management with one mortality, and five received nonoperative
   management. The source of arterial emboli remains obscure in some patients. TEE
   can be valuable in identifying sources or mechanisms of embolization when
   angiography and conventional echocardiography are negative
Keywords:                                   age/angiography/AORTIC-ARCH/CARDIAC
   OLISM/embolization/ISCHEMIC             STROKE/management/mortality/nonoperative
  echocardiography/transthoracic echocardiography
Hughes, K.M., Collier, B., Greene, K.A. and Kurek, S. (2000), Traumatic carotid artery
  dissection: a significant incidental finding. American Surgeon, 66 (11), 1023-1027.
Abstract: Blunt traumatic carotid artery dissection remains controversial in terms of
  diagnostic screening, reported incidence, and management. Treatment options
  include observation, anticoagulation and endovascular stenting, and aggressive
  surgical repair of the carotid artery injury. Blunt traumatic carotid artery dissections
  were reviewed through a retrospective study of trauma registry records. Seven
  patients were identified from 3342 patients over 3 years. Six patients were identified
  incidentally during magnetic resonance imaging (MRI) cervical spine/brain
  screening and one patient during angiographic evaluation for possible penetrating
  neck injury without MRI/magnetic resonance angiography (MRA). A total of 189
  patients underwent MRI screening over this 3-year period, demonstrating a relative
  incidence of 3.7 per cent, contrasting with the reported incidence of 0.08 to 0.4 per
  cent for all trauma patients. All seven patients suffered severe head injuries (mean
  Glasgow Coma Score = 4.7) requiring mean intensive care unit and hospital stays of
  15.6 and 23.7 days, respectively. None of the patients showed evidence of stroke
  with CT scanning on presentation. None of the patients demonstrated clinical focal
  neurologic signs or symptoms indicating carotid injury or stroke. Six patients
  survived their acute trauma and were discharged to rehabilitation after initiation of
  observation tone patient) or anticoagulation (five patients). All six patients showed
  neurological improvement without deterioration clinically or radiographically. In
  conclusion we propose early aggressive screening through MRI/MRA of severely
  injured patients to detect occult carotid artery dissections. Conservative medical
  treatment for this occult injury has been effective in this series of patients
Keywords:                         acute/ANGIOGRAPHY/anticoagulation/artery/BLUNT
  INJURY/carotid/carotid                         artery/carotid                      artery
  /imaging/incidence/injuries/injury/magnetic         resonance/magnetic         resonance
Ross, C.B., Naslund, T.C. and Ranval, T.J. (2002), Carotid stent-assisted angioplasty:
  The newest addition to the surgeons' armamentarium in the management of carotid
  occlusive disease. American Surgeon, 68 (11), 967-975.
Abstract: Carotid artery angioplasty and stenting (CAS) has been accomplished in
  multiple centers with short-term and midterm results similar to carotid
  endarterectomy (CEA). Until completion of multicentered prospective evaluation of
  the benefit of CAS versus established therapy (CEA) clinical judgment must be used
  to determine whether an individual patient with unusual technical challenges and/or
  risks might be best suited for CEA or CAS. We report our experience with 41 CAS
  procedures in 39 patients treated from November 1996 through November 2001. Six
  patients had primary lesions (three symptomatic and three asymptomatic).
  Thirty-three patients had 35 procedures for recurrent carotid stenosis (11
  symptomatic and 24 asymptomatic). Technical success was achieved in 40 of 41
  procedures. No deaths occurred. The 30-day major stroke rate was one in 41 (2.4%),
  and the overall 30-day stroke/transient ischemic attack rate was three in 41 (7.3%).
  No recurrence or late neurologic events were seen in patients treated for primary
  carotid stenosis. A 23 per cent recurrence rate was observed in patients treated for
  recurrent carotid stenosis, after one or more CEAs, with mean follow-up of 18 +/- 14
  months. Recurrence requiring operative correction with carotid resection and
  interposition grafts occurred in three patients treated with CAS in this group. Late
  deaths occurred in six patients; one of these was due to stroke. Overall freedom from
  late stroke and/or need for reintervention (by Kaplan-Meier analysis) was 64 13 per
  cent at 48 months in the group treated by CAS for post-CEA recurrence. CAS
  represents a technically simplistic means of providing carotid revascularization.
  However, its role remains undefined and benefits unproven. Surgical
  revascularization remains appropriate for patients with operable carotid lesions.
  However, surgical revascularization is not always an ideal option when we are faced
  with difficult carotid lesions and risks. For this reason we advocate that all surgeons
  who intend to remain specialists in the management of carotid disease should attain,
  master, and maintain the skills necessary for CAS
Keywords: AGE/angioplasty/artery/ARTERY-STENOSIS/asymptomatic/BALLOON
  ANGIOPLASTY/carotid/carotid disease/carotid endarterectomy/carotid occlusive
Mariano, M.C., Gutierrez, C.J., Alexander, J.Q., Roth, F., Katz, S.G. and Kohl, R.D.
  (2002), Utility of transesophageal Echocardiography in determining the source of
  arterial embolization. American Surgeon, 68 (9), 765-768.
Abstract: Arterial embolism is frequently the product of a cardiac source.
  Arterial-arterial embolization and paradoxical embolization also occur. Failure to
  identify the point of origin may subject the patient to an important incidence of
  preventable events. Conventional echocardiography is insensitive in identifying a
  cardiac origin of emboli and is of little use in identifying sources of arterial-arterial
  emboli. Aortography is invasive and not as sensitive in detecting mobile aortic
  thrombus, which is a recently reported embolic source. Herein we describe seven
  cases in which transesophageal echocardiography was uniquely valuable in
  identifying the source or mechanism of arterial embolization. We performed chart
  reviews of patients with arterial emboli definitively diagnosed after utilizing
  transesophageal echocardiography. Four females and three males with a mean age of
  68 years were included in the study. Peripheral embolization occurred in four
  patients, visceral embolization occurred in one patient, and two patients experienced
  cerebrovascular events. Six patients had transthoracic echocardiography and six
  patients had aortography. None of these studies identified the source of embolization.
  All patients were diagnosed with transesophageal echocardiography. Mobile aortic
  thrombus was the primary embolic source in three patients, paradoxical embolization
  occurred in two patients, and two patients had a combination of findings including
  one patient with atrial thrombus. Two patients received operative repair of the aorta
  and five underwent nonoperative management. There was one mortality in the
  operative group. The source of arterial emboli remains obscure in some patients.
  Transesophageal ultrasound can be valuable in identifying the source or mechanism
  of embolization even when angiography and conventional echocardiography are
  operative management/operative/PLAQUES/RISK/STROKE/studies/THORACIC
  AORTA/thrombus/transesophageal/transesophageal echocardiography/transthoracic
Myles, P.S., Evans, A.B., Madder, H. and Weeks, A.M. (1997), Dynamic hyperinflation:
  Comparison of jet ventilation versus conventional ventilation in patients with severe
  end-stage obstructive lung disease. Anaesthesia and Intensive Care, 25 (5), 471-475.
Abstract: Positive pressure ventilation in patients with obstructive lung disease may
  result in over-inflation of the relatively compliant lungs, resulting in dynamic
  hyperinflation (DHI), Using a crossover trial design, we compared high-frequency jet
  ventilation (HFJV) versus ''optimal'' intermittent positive pressure ventilation (IPPV)
  in ten patients undergoing lung transplantation for severe, end-stage obstructive lung
  disease. We measured haemodynamics and the degree of DHI after both modes of
  ventilation, There were no significant differences between IPPV and HFJV, with
  respect to efficiency of ventilation (PalphaCO2), haemodynamic effects (stroke
  volume, blood pressure and cardiac output), or lung hyperinflation (trapped gas
  volume). This study suggests that HFJV, when compared with optimal IPPV, is no
  better at minimizing DHI in patients with severe, end-stage obstructive lung disease
Keywords:                  AIR-FLOW                     OBSTRUCTION/ANESTHETIC
  MANAGEMENT/ARREST/AUSTRALIA/AUTO-                               PEEP/barotrauma/blood
  ic          hyperinflation/gas         trapping/haemodynamics/HIGH-FREQUENCY
  VENTILATION/INTENSIVE-CARE/jet                                         ventilation/lung
  transplantation/PAIN/PRESSURE/stroke/stroke volume/ventilation
Pothmann, W., Fullekrug, B. and Schulte, J. (1992), Fiberoptic Assessment of the
  Laryngeal Mask Airway Position. Anaesthesist, 41 (12), 779-784.
Abstract: The laryngeal mask airway (LMA) provides a patent airway when placed
  'blindly' into the hypopharynx. At the laryngeal side it is supposed to form a seal
  surrounding the laryngeal inlet with the epiglottis lying outside the mask aperture.
  This study is designed to assess the prelaryngeal position of the mask by the
  fibreoptic technique. Methods. After approval by the local ethical committee and
  informed consent, 100 adult patients (ASA groups I and II) undergoing general
  anaesthesia for extracorporal stroke wave lithotripsy (ESWL, Lithotripter HM 3,
  Dornier) of the kidney were studied. Anaesthesia was induced with propofol (1.5-2.5
  mg . kg-1) and fentanyl (1-1.5 mug . kg- 1) and maintained with isoflurane and N2O
  (65% in O2) as clinically indicated. The LMA was left in situ until the patients
  opened their mouth on command. Monitoring consisted of an ECG (SMV 104-D,
  Dornier), a pulse oximeter (Nellcor 200, Draeger), and a non-invasive blood pressure
  monitor (BP 103 N, Hoyer). Clinical assessment of airway patency and fibreoptic
  laryngoscopy (BF Typ 10, Olympus) - immediately and 20 min following the
  insertion of the LMA - were performed by two observers. Results. The insertion of
  the LMA was successful on the first attempt in 89 patients while 5% required two,
  4% three and 2% four attempts. 'Blindly' inserted without neuromuscular blockade
  the LMA provided a clinically sufficient airway in all patients. A central position of
  the LMA was assessed in only 59% of the cases. In 4 patients the mask was riding on
  the vocal folds. Positioned at the posterior larynx the cuff produced a compression of
  the laryngeal orifice when insufflated. Oblique insertion of the LMA or oblique head
  position during insertion produced a misplacement of the LMA. In 5 cases the LMA
  followed lateral movements of the head without losing its central position. In 87%
  the epiglottis was within the lumen of the LMA. Secretions inside the mask lumen or
  at the anatomic structures were seen in 36%. During manual ventilation with high
  inspiratory pressure (> 25 cm H2O) the oesophagus opened in 10 cases. Conclusions.
  Previous studies have suggested that the LMA takes a 'perfect' position at the
  laryngeal side when a clinically patent airway is recognized. In contrast, our results
  demonstrated that a central position of the LMA is achieved in only 59% of the cases.
  Our results indicate that epiglottic downfolding or left/right side or anterior/posterior
  misplacement are common but generally provide a satisfactory patent airway. This is
  consistant with fibreoptic findings in children and radiological observations in adults.
  The LMA is an essential enrichment to conventional airway management. It provides
  a better seal than the face mask, especially in bearded or in old patients where the
  facial contours are often not suited to the mask. Ideal indications seem to be elective
  operations of intermediate duration (1-2 h). The LMA does not protect against
  aspiration. For patients who are at risk of regurgitation of gastric contents, use of the
  LMA is absolutely contraindicated. Relative contraindications are local pathology of
  the pharynx and situations with low pulmonary compliance and/or high airway
  resistance (massive obesity, asthma, etc.), especially during controlled ventilation.
  Further studies are necessary to establish definite indications for the application of
  the LMA
Keywords:                                  ANESTHESIA/ASPIRATION/LARYNGEAL
Hennes, H.J., Heid, F. and Steiner, T. (1999), Preclinical treatment of patients with
  acute stroke. Anaesthesist, 48 (12), 858-870.
Abstract: Stroke is the third leading cause of death and number one cause of disability
  in industrialised countries. Studies into the pathophysiology of acute ischaemic
  stroke have indicated that treatment options are likely to be optimized when early
  signs of stroke are recognized and treatment is initiated within 3 hours from
  symptom onset. Therefore, new conceptions heading towards early diagnosis, fast
  preclinical treatment, structured diagnostics, immediate initiation of acute therapy as
  well as early initiation of rehabilitation are required. It is well known that,for most
  patients, there is a long delay between the onset of symptoms and the sta rt of therapy.
  Many factors are responsible for the time delay:signs and symptoms often go
  unrecognized and/or are minimized by patients, relatives and bystanders. Unlike
  trauma or myocardial infarction, stroke is not given a high priority by medical staff
  and/or emergency medical services (EMS). Although a small number of stroke
  patients is treated as emergency and attended to by the emergency medical services
  within this time window, this number could easily be increased by intensified public
  and emergency personnel education. At present the standard of care by the EMS
  personnel includes adequate cerebral oxygenation, treatment of cardiac arrhythmia,
  management of hypertension as well as therapy of hyperglycemia and hyperthermia.
  For the future, we hope that emergency medical services will be able to initiate
  therapies which must be administered within the first few hours of acute stroke after
  onset of symptoms. Early notification of hospitals would enable a particular stroke
  team to be present at the patient's admission
Keywords: acute/acute ischaemic stroke/ACUTE ISCHEMIC STROKE/acute
  gency               medical            services/EMS/GUIDELINES/HEALTH-CARE-
  emic                                                    stroke/management/myocardial
  OUP/STATEMENT/stroke/stroke                           team/therapy/THROMBOLYTIC
Steiner, T., Hennes, H.J., Kretz, R. and Hacke, W. (2000), Treatment of acute clinical
   stroke. Anaesthesist, 49 (1), 2-8.
Abstract: Stroke is an emergency. Treatment must begin as soon as possible because
   significant sustained neurological improvement has been demonstrated when
   thrombolytic treatment, mainly with recombined tissue plasminogen activator (rtPA)
   is initiated within the first hours of stroke onset. On the other hand in the acute phase
   of stroke it is critical that patients get adequate management for the prevention of
   early complications. Management of the acute phase of stroke is the target of this
   article. Preclinically started treatment must be continued in the neurological
   emergency unit. Clinical examination is followed by technical investigations:
   cerebral computertomography (CCT) is the most useful radiological investigation in
   the acute phase. It allows to distinguish between ischemia and hemorrhagic lesions
   and also to rule out nonstroke brain conditions. Multimodal magnetic resonance
   imaging (mMRI) may provide data on viable versus irreversibly damaged tissue.
   Sufficient stroke treatment is based on well managed in-hospital infrastructure.
   Thrombolysis is the only causative treatment of stroke in selected patients.
   Complications of acute stroke comprise changes of blood pressure with
   hemodynamically relevant effects on cerebral perfusion pressure,acute postischemic
   brain edema,and intracerebral bleedings
Keywords:         acute/ACUTE           ISCHEMIC          STROKE/acute          stroke/blood
   pressure/ischemia/magnetic                   resonance/magnetic                 resonance
   activator/prevention/SONOGRAPHY/stroke/stroke onset/stroke treatment/stroke
   unit/thrombolysis/thrombolytic/THROMBOLYTIC                     THERAPY/thrombolytic
   treatment/tissue plasminogen activator/treatment/TRIAL/WINDOW
Himmelseher, S. and Pfenninger, E. (2000), Neuroprotection in neuroanesthesia:
   Results of a survey of current practices in Germany in 1997. Anaesthesist, 49 (5),
Abstract: This survey collected and analyzed data on the current practice of clinical
   neuroprotection in neuroanesthesia in Germany. Methods: The data were collected
   by a questionnaire sent to departments of anesthesiology in Germany in 1997 which
   provided care for neurosurgical patients on a routine basis, and which were registered
   members of the German Society of Anesthesiology and Intensive Care Medicine
   (DGAI). Since the questions concerning "neuroprotective therapy" were linked to a
   general survey on clinical neuroanesthesia performed by the scientific
   neuroanesthesia working group of the DGAI, the only departments that were
   assessed were those which had participated in an earlier study on neuroanesthesia in
   1991. Results: Of the completed questionnaires 63% could be included in the
   analysis. Approximately 75,000 cases were thus evaluated. Therapy varied
   considerably between departments. Following head trauma 69% of injured patients
   were managed with enhanced cerebral perfusion pressure (CPP) within the range of
   70-90 mmHg. If necessary, CPP increase was induced by vasopressors (exogenous
   supply of catecholamines in 100% of instances) and the administration of fluids
   (97% of instances). The most commonly used therapeutic approaches to treat
   intracranial hypertension were mannitol (95% of instances), hyperventilation (91%
   of instances), cerebrospinal fluid drainage (89% of instances), and barbiturates (86%
   of instances). Tris(hydroxymethyl)- aminomethane was administered in almost 49%,
  mild hypothermia in 37%, and hypertonic-hyperoncotic solutions in 28% of patients
  treated for an increase in intracranial pressure. Following intracranial aneurysm
  surgery "triple-H" therapy was used in 74% of patients, applied as hemodilution in
  94% and as hypervolemia and hypertension in 87% of instances. Mild hypothermia
  was employed as a method of neuroprotection in 54% of the departments involved. It
  was used in 83% of patients during perioperative care and in 52% of patients during
  intensive care therapy. Specific neuroprotective drugs were applied in 68% of
  departments, with barbiturates (38% of instances), nimodipine (23% of instances),
  and corticosteroids (10% of instances) as the ma in agents named. These brain-
  protective medications were administered especially in intracranial hypertension in
  30%, in intracranial aneurysms in 21%, and in subarachnoid hemorrhages subsequent
  to head trauma in 18% of instances described. Conclusion: These findings
  demonstrate that the neuroprotective therapy administered in anesthesiological
  departments in Germany is not yet standardized, i.e., there is a wide variation.
  Although outcome was not assessed with this survey, it is conceivable that
  algorithms based on logical approaches in the sense of evidence-based medicine
  could serve as tools to reduce morbidity and mortality
Keywords: "triple-H" therapy/administration/algorithms/aneurysm/ANEURYSMAL
  SUBARACHNOID HEMORRHAGE/aneurysms/brain/cerebral/cerebral perfusion
  pressure/CPP/DOSE          TIRILAZAD           MESYLATE/general/HEAD-INJURED
  cranial          aneurysm/INTRACRANIAL                  HYPERTENSION/intracranial
  MANAGEMENT/questionnaire/questionnaires/SPECIAL                              WRITING
Lapa, R.A.S., Lima, J.L.F.C., Reis, B.F., Santos, J.L.M. and Zagatto, E.A.G. (2002),
  Multi-pumping in flow analysis: concepts, instrumentation, potentialities. Analytica
  Chimica Acta, 466 (1), 125-132.
Abstract: A novel strategy for the implementation of flow-based analytical procedures
  using several micropumps is proposed. The pumps are switched individually or in
  combination, in order to create a pulsed flowing stream through the analytical path,
  and are the only active devices acting simultaneously as liquid propelling units,
  sample insertion ports and commuting elements. Configuration and control of the
  flow system are then greatly simplified. The micropumps produce distinct stroke
  volumes at distinct pulse frequencies with high reproducibility ensuring the
  attainment of very stable flow rates. This leads to an enhanced versatility that enables
  the utilisation of different approaches for sample management including step-wise
  variable sample volume, binary sampling and merging zones without reconfiguration
  of the system hardware. In contrast to the typical flow systems, the proposed one is
  characterised by a pulsed flow ensuring a fast sample/reagent mixing that contributes
  to improve the reaction development-thus sensitivity-even in situations of limited
  dispersion. The basic features and the performance of the proposed strategy are
  evaluated in the spectrophotometric determination of Cr(VI) in natural waters with
  1,5-diphenylcarbazide. (C) 2002 Elsevier Science B.V. All rights reserved
Keywords:          chromium(VI)/combination/control/flow            system/INJECTION
  DILUTION/PLANT/pulsed                                                     flow/solenoid
Carney, J.M., Landrum, W., Mayes, L., Zou, Y. and Lodder, R.A. (1993), Near-Infrared
  Spectrophotometric Monitoring of Stroke-Related Changes in the Protein and
  Lipid-Composition of Whole Gerbil Brains. Analytical Chemistry, 65 (10),
Abstract: Strokes are a critical problem in the U.S. that affect more than 500 000 people
  annually. Research into the causes of stroke and testing of drug therapies to reduce
  ischemic and postischemic damage to the brain is frustrated by an inability to
  continuously follow the physical and chemical events that occur during ischemia and
  reperfusion in vivo. Near-IR spectrometry is used in this paper to observe
  stroke-induced changes in the lipids and proteins of whole brain samples and in
  intact subjects. The examination of whole brains is made possible by a combination
  of hardware and software techniques designed to make the sample presentation to the
  spectrometer more reproducible. Near-IR spectrophotometry of brain tissue
  discriminates between adult (3-4 months of age) and aged (18-20 months of age)
  brains as well as between brains exposed to 5- and 10-min ischemia. The near-IR
  analytical method has many applications in aging and stroke research, including the
  noninvasive determination of age from brain spectra obtained transcranially,
  simultaneous multicomponent analysis of lipids and proteins, and quantification of
Koch, C., Luiz, T., Ellinger, K., van Ackern, K., Behrens, S. and Daffertshofer, M.
  (1999), Pre-clinical management of acute strokes. Anasthesiologie & Intensivmedizin,
  40 (10), 737-742.
Abstract: Cerebral infarction is the most common cause of disablement and dependancy
  on nursery among adults. Recently, it could be demonstrated that systemic
  thrombolysis with rt-PA is able to improve prognosis. Furthermore, according to a
  consensus agreement, stabilization of impaired vital functions of patients with acute
  cerebral ischemia has a significant influence on outcome. Up to now preclinical
  management of stroke (delayed EMS response by ambulance, insufficient
  stabilization of vital functions) often did not fulfil those requirements. In order to
  establish an optimized preclinical therapy we initiated a regional model of preclinical
  stroke management. Optimizing the process quality with existing EMS systems in
  acute stroke management is a cost-effective option to reduce prehospital delay in
  case of acute stroke
Keywords:         acute/ACUTE            ISCHEMIC             STROKE/acute           stroke
  management/ambulance/cerebral/cerebral                                infarction/cerebral
  management/therapy/thrombolysis/thrombolytic                 therapy/THROMBOLYTIC
Luiz, T., Moosmann, A., Koch, C., Behrens, S., Daffertshofer, M. and Ellinger, K.
  (2001), Optimized logistics in the prehospital management of acute stroke.
  Anasthesiologie Intensivmedizin Notfallmedizin Schmerztherapie, 36 (12), 735-741.
Abstract: Current management of acute stroke is characterised by an aggressive
  approach including specific therapy i.e. reperfusion therapy. However currently
  stroke patients often arrive too late in hospitals offering adequate treatment.
  Therefore optimized logistics play a predominant role in modern stroke management.
  Aims of the study: 1. Does teaching of EMS staff and the public result in reduced
  prehospital latencies 2. Will EMS personnel be able to effectively screen patients
  potentially suitable for thrombolysis? Methods: During a six week-period all EMS
  patients presenting with possible signs of an acute stroke were prospectively
  registered (period 1). Data of interest were age, mode of primary contact, prehospital
  latencies, mode of transportation, destination and final diagnosis. Next an algorithm
  was established allowing EMS personnel to transfer patients with an assumed stroke
  to the best suitable hospital. Teaching comprised clinical signs, indication of CT
  scanning, pathophysiology, specific therapeutic options (thrombolysis), and criteria
  to identify patients suitable for thrombolysis. in a second step the public was
  continuously taught about stroke symptoms and the necessity to instantly seek EMS
  assistance. After 12 months data were compared to baseline (period 2). Results:
  (period 2 vs. Period 1): Rate of patients transferred to a stroke center: 60% vs. 54%;
  rate of those transported to hospitals not offering CT scans: 17% vs. 26% (p<0.05).
  Percentage of patients primarily contacting the EMS system: 33% vs. 24%. Median
  interval between onset of symptoms and emergency call: 54 vs. 263 minutes Median
  interval between the emergency call and arrival at the emergency department: 44 vs.
  58 minutes (p<0.01). Rate of patients admitted with a diagnosis other than stroke:
  18% vs. 25% (n.s.). Median interval between onset of symptoms and hospital
  admission: 140 vs. 368 minutes (p<0.001). Median age: 69 vs. 75 years (p<0.01).
  Conclusion: This study demonstrates the efficacy of educational efforts in reducing
  latencies and in screening patients potentially suitable for thrombolysis. Future
  efforts will comprise more intense education of a high risk subpopulation
Keywords:              acute/ACUTE               ISCHEMIC                 STROKE/acute
  y           department/emergency             medical           services         system
  siology/prehospital treatment/reperfusion/risk/screening/stroke/stroke center/stroke
Thiel, A., Ritzka, M. and Saur, G. (2001), Anesthesia on patients with mitochondrial
  encephalopathy. Anasthesiologie Intensivmedizin Notfallmedizin Schmerztherapie,
  36 (7), 437-439.
Abstract: A 6-year-old boy with a rare mitochondrial disease (MELAS: mitochondrial
  encephalopathy, lactic acidosis, stroke-like episodes) was presented to undergo
  adenoid resection and bilateral paracentesis. ENT surgery was performed without
  complications under general anaesthesia using propofol, fentanyl, and ventilation
  with nitrous oxide and oxygen. Routine intraoperative monitoring (ECG, noninvasive
  blood pressure, oxymetry and capnometry) was supplemented by frequent body
  temperature measurements and repeated laboratory analysis of venous blood gases,
  lactate, and glucose. Clinically, the postoperative course was uneventful and the boy
  was discharged from hospital on the first postoperative day. Signs or symptoms of
  malignant hyperthermia never occurred. Laboratory analysis only showed a
  remarkable serum lactate elevation postoperatively (6 mmol/l) which decreased on
  the first postoperative day (3,7 mmol/l). The present anaesthesiologic experiences
  with MELAS-syndrome are limited, and recommendations are mainly based on case
  reports. Careful preoperative physical examination with special regard to all
  available medical records, and anaesthetic management comparable with that in
  malignant hyperthermia susceptibles resulted in an uneventful course in our patient.
  Pathogenetic aspects of mitochondrial diseases focussing on anaesthetic
  considerations are briefly discussed
Keywords:            acidosis/blood            pressure/body             temperature/case
Raffelsieper, B., Merten, C., Mennel, H.D., Hedde, H.P., Menzel, J. and Bewermeyer, H.
  (2002), Decompressive craniectomy for severe intracranial hypertension due to
  cerebral infarction or meningoencephalitis. Anasthesiologie Intensivmedizin
  Notfallmedizin Schmerztherapie, 37 (3), 157-162.
Abstract: We describe the clinical course and outcome following decompressive
  craniectomy in six patients. Five patients suffered from severe intracranial
  hypertension due to middle cerebral artery infarction. In one patient the cause was
  bacterial meningoencephalitis. Acute clinical and neuroradiological signs of
  intracranial hypertension were seen in all cases. Following ineffective conventional
  brain edema therapy, decompressive craniectomy was undertaken. In five cases
  intracranial pressure was sufficiently lowered. One patient developed transtentorial
  herniation with subsequent brain death. Four patients with middle artery infarction
  showed moderate neurological disorders and one patient with bacterial
  meningoencephalitis recovered completely after treatment. Craniectomy in malignant
  middle artery infarction should be taken into consideration if conventional brain
  edema therapy does not sufficiently reduce critically raised intracranial pressure.
  Craniectomy provides development of brain herniation. This treatment may reduce
  high lethality rate and high frequency of severe neurological disorders
Keywords: artery/ARTERY INFARCTION/brain/brain edema/cerebral/cerebral
  infarction/clinical                 course/craniectomy/death/EDEMA/FUNCTIONAL
  on/intracranial/intracranial                                   hypertension/intracranial
  pressure/MANAGEMENT/meningoencephalitis/middle                cerebral     artery/middle
  cerebral artery infunction/neurological disorders/outcome/PRESSURE/raised
  intracranial pressure/STROKE/therapy/transtentorial herniation/treatment
Hutchins, J.B. and Barger, S.W. (1998), Why neurons die: Cell death in the nervous
  system. Anatomical Record, 253 (3), 79-90.
Abstract: It is likely that humans are born with all of the nerve cells (neurons) that will
  serve them throughout life, For all practical purposes, when our neurons die, they are
  lost forever. During nervous system development, about one-and-a- half times the
  adult number of neurons are created. These "extra" neurons are then destroyed or
  commit suicide. This process of programmed cell death occurs through a series of
  events termed apoptosis and is an appropriate and essential event during brain
  development. Later in life, inappropriate neuronal cell death may result from
  pathological causes such as traumatic injury, environmental toxins, cardiovascular
  disorders, infectious agents, or genetic diseases, In some cases, the death occurs
  through apoptosis, In other cases, cell death is random, irreversible, and
  uncontrollable; to distinguish it from the controlled, planned cell death of apoptosis,
  we call this necrotic cell death, Understanding the difference between apoptotic and
  necrotic cell death is essential for designing therapies which will prevent or limit
  inappropriate cell death in the nervous system. Anat. Rec, (NewAnat.): 253:79-90
  1998. (C) 1998 Wiley-Liss, Inc
Keywords:                                                                       Alzheimer
  radicals/glutamate/Huntington disease/injury/necrosis/NEUROTOXICITY/Parkinson
Hartman, G.S., Yao, F.S.F., Bruefach, M., Barbut, D., Peterson, J.C., Purcell, M.H.,
  Charlson, M.E., Gold, J.P., Thomas, S.J. and Szatrowski, T.P. (1996), Severity of
  aortic atheromatous disease diagnosed by transesophageal echocardiography predicts
  stroke and other outcomes associated with coronary artery surgery: A prospective
  study. Anesthesia and Analgesia, 83 (4), 701-708.
Abstract: Advanced atheromatous disease of the thoracic aorta identified by
  transesophageal echocardiography (TEE) is a major risk factor for perioperative
  stroke. This study investigated whether varying degrees of atherosclerosis of the
  descending aorta, as assessed by TEE, are an independent predictor of cardiac and
  neurologic outcome in patients undergoing coronary artery bypass grafting (CABG).
  Intraoperative TEE of the descending aorta was performed on 189 of 248 patients
  participating in a randomized controlled trial of low (50-60 mm Hg) or high (80-100
  mm Hg) mean arterial pressure during cardiopulmonary bypass for elective CABG.
  Aortic atheromatous disease was graded from I to V in order of increasing severity
  by observers blinded to outcome. Measured outcomes were death, stroke, and major
  cardiac events assessed at 1 wk and 6 mo. Nine of the 189 patients with TEE
  examinations had perioperative strokes by 1 wk. At 1 wk, no strokes had occurred in
  the 123 patients with atheroma Grades I or II, while the l- wk stroke rate was 5.5%
  (2/36), 10.5% (2/19), and 45.5% (5/11) for Grades III, IV, and V, respectively
  (Fisher's exact test, P = 0.00001). For 6-mo outcome, advancing aortic atheroma
  grade was a univariate predictor of stroke (P = 0.00001) and death (P = 0.03). By 6
  mo there were one additional stroke, three additional deaths, and one additional
  major cardiac event. Atheromatous disease of the descending aorta was a strong
  predictor of stroke and death after CABG. TEE determination of atheroma grade is a
  critical element in the management of patients undergoing CABG surgery
Keywords:               aorta/ARCH/ATHEROSCLEROTIC                        ASCENDING
Sakamoto, T., Kawaguchi, M., Kurehara, K., Kitaguchi, K., Furuya, H. and Karasawa, J.
  (1997), Risk factors for neurologic deterioration after revascularization surgery in
  patient with moyamoya disease. Anesthesia and Analgesia, 85 (5), 1060-1065.
Abstract: To investigate the risk factors for postoperative neurological deterioration in
  patients with moyamoya disease, we retrospectively reviewed the perioperative
  course of 368 cases of revascularization surgery in 216 patients with this disease.
  Risk factors anecdotally associated with postoperative ischemic events were
  analyzed by comparing groups with or without a history of such events on the
  operative day. Ischemic events were noted in 14 cases (3.8%), 4 of which were
  defined as strokes and the others as transient ischemic attack (TIA). Postoperative
  neurological deterioration more of ten developed in patients who suffered fi om
  frequent TIAs, had precipitating factors for TIA, and underwent indirect
  nonanastomotic revascularization. The authors conclude that the incidence of
  postoperative ischemic events were related more to the severity of moyamoya
  disease and the type of surgical procedure than to other factors, including anesthetic
  management. Implications: Although preventing stroke is the major concern for
  patients with moyamoya disease, risk factors for perioperative cerebral ischemia
  have not been clarified. We retrospectively analyzed the perioperative course in 368
  cases with this disease and found that the severity of the disease and type of surgical
  procedure were major determinants of postoperative cerebral ischemia
Keywords:           ANESTHETIC                MANAGEMENT/BLOOD-FLOW/cerebral
  dence/ischemia/management/risk             factors/severity/stroke/surgery/SURGICAL-
Grigore, A.M., Grocott, H.P., Mathew, J.P., Phillips-Bute, B., Stanley, T.O., Butler, A.,
  Landolfo, K.P., Reves, J.G., Blumenthal, J.A. and Newman, M.F. (2002), The
  rewarming rate and increased peak temperature alter neurocognitive outcome after
  cardiac surgery. Anesthesia and Analgesia, 94 (1), 4-10.
Abstract: Neurocognitive dysfunction is a common complication after cardiac surgery.
  We evaluated in this prospective study the effect of rewarming rate on
  neurocognitive outcome after hypothermic cardiopulmonary bypass (CPB). After
  IRB approval and informed consent, 165 coronary artery bypass graft surgery
  patients were studied. Patients received similar surgical and anesthetic management
  until rewarming from hypothermic (28degrees-32degreesC) CIPB. Group 1 (control;
  n=100) was warmed in a conventional manner (4degrees-6degreesC gradient
  between nasopharyngeal and CPB perfusate temperature) whereas Group 2 (slow
  rewarm; n=65) was warmed at a slower rate, maintaining no more than 2degreesC
  difference between nasopharyngeal and CPB perfusate temperature. Neurocognitive
  function was assessed at baseline and 6 wk after coronary artery bypass graft surgery.
  Univariable analysis revealed no significant differences between the Control and
  Slow Rewarming groups in the stroke rate. Muitivariable linear regression analysis,
  examining treatment group, diabetes, baseline cognitive function, and cross-clamp
  time revealed a significant association between change in cognitive function and rate
  of rewarming (P=0.05)
Keywords:                  anesthetic                  management/artery/BRAIN/BULB
  OXYGEN-SATURATION/bypass/cardiac                               surgery/cardiopulmonary
  bypass/CEREBRAL BLOOD-FLOW/complication/control/coronary/coronary artery
  bypass/coronary           artery          bypass          graft/CORONARY-ARTERY
  BYPASS/INDEX/informed consent/management/METABOLISM/MYOCARDIAL
Davies, M.J., Mooney, P.H., Scott, D.A., Silbert, B.S. and Cook, R.J. (1993),
  Neurologic Changes During Carotid Endarterectomy Under Cervical Block Predict A
  High-Risk of Postoperative Stroke. Anesthesiology, 78 (5), 829-833.
Abstract: Background. This study was undertaken to confirm a previous report that
  patients having neurologic changes with carotid artery clamping were at greater risk
  of developing permanent postoperative neurologic complications after carotid
  endarterectomy. Methods:: Superficial and deep cervical plexus blocks were
  performed in 389 patients undergoing carotid endarterectomy. The patients were
  premedicated and sedated to a level that allowed awake neurologic assessment.
  Intraoperative neurologic changes were recorded and all patients were examined
  postoperatively by an independent anesthesiologist to record postoperative
  neurologic outcome. Results: Trial carotid artery cross clamping resulted in 24% of
  patients having neurologic changes that usually responded to declamping and shunt
  insertion. Postoperative permanent neurologic complications occurred in 2.6% of
  patients, but were more common in patients who had neurologic changes associated
  with carotid artery cross clamping (6.6% compared to 1.1%, P < 0.01). Thrombosis
  of the carotid artery was the most common finding in patients who underwent
  reexploration of the carotid artery after developing postoperative neurologic changes.
   Conclusions. This study confirms that patients undergoing carotid endarterectomy
   under cervical plexus block who have intraoperative neurologic changes have a
   sixfold increase in the chance of developing a postoperative stroke. This high-risk
   group may benefit from antithrombotic therapies to improve their outcome
   ENDARTERECTOMY/CERVICAL                                                      PLEXUS
Stone, J.G., Young, W.L., Marans, Z.S., Khambatta, H.J., Solomon, R.A., Smith, C.R.,
   Ostapkovich, N., Jamdar, S.C. and Diaz, J. (1993), Cardiac-Performance Preserved
   Despite Thiopental Loading. Anesthesiology, 79 (1), 36-41.
Abstract: Background: Some cerebral artery aneurysms require cardiopulmonary bypass
   and deep hypothermic circulatory arrest to be clipped safely. During bypass these
   neurosurgical patients often are given large doses of thiopental in the hope that
   additional cerebral protection will be provided. However, thiopental loading during
   bypass has been associated with subsequent cardiac dysfunction in patients with
   heart disease. This study was undertaken to determine how patients without
   concomitant heart disease would respond to thiopental loading. Methods:
   Twenty-four neurosurgical patients with giant cerebral aneurysms and little or no
   cardiac disease were anesthetized with fentanyl, nitrous oxide, and isoflurane.
   Thiopental was titrated to achieve electroencephalographic burst-suppression before
   bypass, and the infusion was continued until after separation. Prebypass
   hemodynamic and echocardiographic measurements were obtained during a stable
   baseline and 15 min after thiopental loading began. They were repeated after bypass.
   Results: Prebypass thiopental loading increased heart rate from 61 +/- 11 to 72 +/- 13
   beats/min and decreased stroke volume from 43 +/- 10 to 38 +/- 8 ml . beat-1 . m-2,
   but arterial and filling pressures, vascular resistance, cardiac index, and ejection
   fraction remained the same. Before bypass, thiopental plasma concentration
   measured 28 +/- 8 mug/ml. Loading continued for 2-3 h until after bypass was
   terminated, and the overall infusion rate was 18 +/- 5 mg . kg-1 . h-1. All patients
   were easily separated from bypass without inotropic support. Following bypass,
   vascular resistance was decreased; heart rate. filling pressures, and cardiac index
   were increased; stroke volume had returned to its baseline; and ejection fraction was
   unchanged. Conclusions: It was concluded that if preoperative ventricular function is
   good, thiopental loading to electroencephalographic burst-suppression causes
   negligible cardiac impairment and does not impede separation from cardiopulmonary
   ONARY                  BYPASS/CEREBRAL                    ANEURYSM/CEREBRAL
   CIRCULATORY                                                     ARREST/EJECTION
Hoeft, A., Schorn, B., Weyland, A., Scholz, M., Buhre, W., Stepanek, E., Allen, S.J.
   and Sonntag, H. (1994), Bedside Assessment of Intravascular Volume Status in
   Patients Undergoing Coronary-Bypass Surgery. Anesthesiology, 81 (1), 76-86.
Abstract: Background: Management of intravascular volume is crucial in patients after
   cardiopulmonary bypass as myocardial dysfunction is common. The purpose of this
  study was to validate a novel bedside technique for real-time assessment of
  intravascular volumes. Methods: Eleven patients undergoing cardiopulmonary
  bypass were studied. In addition to standard monitors, a fiberoptic thermistor catheter
  was placed in the descending aorta and central venous injections of 10 ml ice-cold
  indocyanine green dye were performed. Total blood volume was measured by a
  standard in vitro technique. Circulating and central blood volume were calculated by
  using cardiac output, mean transit times, and a newly developed recursive
  convolution algorithm that models recirculation. Measurements were performed after
  induction of anesthesia and at 1, 6, and 24 h after surgery. Results: A
  two-compartment model of the circulation was required for adequate fit of the data.
  We found a significant correlation between total and circulating blood volumes (r =
  0.87). One hour after surgery, central blood volume was decreased by 10% (P <
  0.05). At 6 and 24 h after surgery, circulating blood volumes were significantly
  increased by 29% and 20%, respectively (P < 0.01), although central blood volume
  was similar to control values. Before surgery stroke volume index correlated with
  circulating blood volume (r = 0.87) but not with pulmonary capillary wedge and
  central venous pressures. Conclusions: This study shows that bedside determinations
  of intravascular blood volumes are feasible and that these measurements are more
  indicative of intravascular volume status than are either pulmonary capillary wedge
  or central venous pressures in the post-cardiopulmonary bypass period. Our data also
  demonstrate that despite a normal central blood volume both circulating and total
  blood volume are significantly increased in the immediate post-cardiopulmonary
  bypass period
Keywords:              BLOOD/BLOOD                  VOLUME/CARDIOPULMONARY
  VENTRICULAR                                             PRELOAD/MEASUREMENT
Brooker, R.F., Butterworth, J.F., Kitzman, D.W., Berman, J.M., Kashtan, H.I. and
  McKinley, A.C. (1997), Treatment of hypotension after hyperbaric tetracaine spinal
  anesthesia - A randomized, double-blind, cross-over comparison of phenylephrine
  and epinephrine. Anesthesiology, 86 (4), 797-805.
Abstract: Background: Despite many advantages, spinal anesthesia often is followed by
  undesirable decreases in blood pressure, for which the ideal treatment remains
  controversial. Because spinal anesthesia-induced sympathectomy and management
  with a pure alpha-adrenergic agonist can separately lead to bradycardia, the authors
  hypothesized that epinephrine, a mixed alpha- and beta-adrenergic agonist, would
  more effectively restore arterial blood pressure and cardiac output after spinal
  anesthesia than phenylephrine, a pure alpha-adrenergic agonist Methods: Using a
  prospective, double-blind, randomized, cross- over study design, 13 Patients received
  sequential infusions of epinephrine and phenylephrine to manage hypotension after
  hyperbaric tetracaine (10 mg) spinal anesthesia Blood pressure, heart rate, and stroke
  volume (measured by Doppler echocardiography using the transmitral time-velocity
  integral) were recorded at baseline, 5 min after injection of tetracaine, and before and
  after management of hypotension with epinephrine and phenylephrine. Cardiac
  output was calculated by multiplying stroke volume x heart rate. Results: Five min
  after placement of a hyperbaric tetracaine spinal anesthesia, significant decrease in
  systolic (from 143 +/- 6 mmHg to 125 +/- 5 mmHg; P < 0.001), diastolic (from 81
  +/- 3 to 71 +/- 3; P < 0.001), and mean (from 102 +/- 4 to 89 +/- 3; P < 0.001) arterial
  pressures occurred. Heart rate (75 +/- 4 beats/ min to 76 +/- 4 beat/min; P = 0.9),
  stroke volume (115 +/- 17 to 113 +/- 13; P = 0.3), and cardiac output (8.0 +/- 1 l/m to
  8.0 +/- 1 l/m; P = 0.8) did not change significantly after spinal anesthesia.
  Phenylephrine was effective at restoring systolic blood pressure after spinal
  anesthesia (120 +/- 6 mmHg to 144 +/- 5 mmHg; P < 0.001) but was associated with
  a decrease in heart rate from 80 +/- 5 beats/min to 60 +/- 4 beats/min CP < 0.001)
  and in cardiac output from 8.6 +/- 0.7 l/m to 6.2 +/- 0.7 l/m (P < 0.003). Epinephrine
  was effective at restoring systolic blood pressure after spinal anesthesia (119 +/- 5
  mmHg to 139 +/- 6 mmHg; P < 0.001) and was associated with an increase in stroke
  volume from 114 +/- 12 ml to 142 +/- 17 (P < 0.001) and cardiac output from 7.8 +/-
  0.6 l/m to 10.8 +/- 1.1 l/m (P < 0.001). Conclusions: Epinephrine management of
  tetracaine spinal-induced hypotension increases heart rate and cardiac output and
  restores systolic arterial pressure but does not restore mean and diastolic blood
  pressure. Phenylephrine management of tetracaine spinal-induced hypotension
  decreases heart rate and cardiac output while restoring systolic, mean, and diastolic
  blood pressure
Keywords:      anesthesia/anesthetic    technique/blood     pressure/bradycardia/cardiac
  NE/heart                      rate/hypotension/INFUSION/management/measurement
  technique/phenylephrine/spinal anesthesia/stroke/stroke volume/treatment/VOLUME
Sungurtekin, H., Plochl, W. and Cook, D.J. (1999), Relationship between
  cardiopulmonary bypass flow rate and cerebral embolization in dogs. Anesthesiology,
  91 (5), 1387-1393.
Abstract: Background: Cerebral embolization is a primary cause of cardiac surgical
  neurologic morbidity. During cardiopulmonary bypass (CPB), there are well-defined
  periods of embolic risk. In theory, cerebral embolization might be reduced by an
  increase in pump flow during these periods. The purpose of this study was to
  determine the CPB flow-embolization relation in a canine model Methods: Twenty
  mongrel dogs underwent CPB at 35 degrees C with alpha-stat management and a
  fentanyl-midazolam anesthetic. In each animal, CPB flow was adjusted to achieve a
  mean arterial pressure of 65-75 mmHg. During CPB, an embolic load of 1.2 x 10(5)
  67 mu m fluorescent microspheres was injected into the arterial inflow Line. Before
  and after embolization, cerebral blood now was determined using 15-mu m
  microspheres. Tissue was taken from 12 brain regions and microspheres were
  recovered. The relation between pump flow and embolization/g of brain was
  determined. Results: The mean arterial pressure at embolization was 67 +/- 4 mmHg,
  and the range of pump flow was 0.9-3.5 l . min(-1) . m(-2). Cerebral blood now was
  independent of pump flow. At lower pump flow, the percentage of that flow
  delivered to the brain increased. There was a strong inverse relation between pump
  flow and cerebral embolization (r = -0.708, P < 0.000 by Spearman rank order
  correlation). Conclusions: Cerebral embolization is determined by the CPB flow. At
  an unchanged mean arterial pressure, as pump now is reduced, a progressively
  greater proportion of that how is delivered to the brain
  bypass/cerebral/cerebral blood flow/cerebral emboli/CORONARY-ARTERY
Grigore, A.M., Mathew, J., Grocott, H.P., Reves, J.G., Blumenthal, J.A., White, W.D.,
  Smith, P.K., Jones, R.H., Kirchner, J.L., Mark, D.B. and Newman, M.F. (2001),
  Prospective Randomized Trial of Normothermic versus Hypothermic
  Cardiopulmonary Bypass on Cognitive Function after Coronary Artery Bypass Graft
  Surgery. Anesthesiology, 95 (5), 1110-1119.
Abstract: Background: Despite significant advances in cardiopulmonary bypass (CPB)
  technology, surgical techniques, and anesthetic management, central nervous system
  complications occur in a large percentage of patients undergoing surgery requiring
  CPB. Many centers are switching to normothermic CPB because of shorter CPB and
  operating room times and improved myocardial protection. The authors hypothesized
  that, compared with normothermia, hypothermic CPB would result in superior
  neurologic and neurocognitive function after coronary artery bypass graft surgery.
  Methods: Three hundred patients undergoing elective coronary artery bypass graft
  surgery were prospectively enrolled and randomly assigned to either normothermic
  (35.5-36.5 degreesC) or hypothermic (28-30 degreesC) CPB. A battery of
  neurocognitive tests was performed preoperatively and at 6 weeks after surgery. Four
  distinct cognitive domains were identified and standardized using factor analysis and
  were then compared on a continuous scale. Results: Two hundred twenty-seven
  patients participated in 6-week follow-up testing. There were no differences in
  neurologic or neurocognitive outcomes between normothermic and hypothermic
  groups In multivariable models, adjusting for covariable effects of baseline cognitive
  function, age, and years of education, as well as interaction of these with temperature
  treatment. Conclusions: Hypothermic CPB does not provide additional central
  nervous system protection in adult cardiac surgical patients who were maintained at
  either 30 or 35 degreesC during CPB
Keywords:                         ACUTE                           STROKE/age/anesthetic
  management/artery/ASSOCIATION/BLOOD                          CARDIOPLEGIA/BRAIN
  TEMPERATURE/bypass/CARDIAC-SURGERY/cardiopulmonary bypass/central
  nervous system/CEREBRAL-ISCHEMIA/complications/coronary/coronary artery
Kollmar, R., Frietsch, T., Georgiadis, D., Schabitz, W.R., Waschke, K.F., Kuschinsky,
  W. and Schwab, S. (2002), Early effects of acid-base management during
  hypothermia on cerebral infarct volume, edema, and cerebral blood flow in acute
  focal cerebral ischemia in rats. Anesthesiology , 97 (4), 868-874.
Abstract: Background: Although the frequency for the use of moderate hypothermia in
  acute ischemic stroke is increasing, the optimal acid-base management during
  hypothermia remains unclear. This study investigates the effect of pH- and alpha-stat
  acid-base management on cerebral blood flow (CBF), infarct volume, and cerebral
  edema in a model of transient focal cerebral ischemia in rats. Methods: Twenty
  Sprague-Dawley rats were subjected to transient middle cerebral artery occlusion
  (MCAO) for 2 h during normothermic conditions followed by 5 h of reperfusion
  during hypothermia (33degreesC). Animals were artificially ventilated with either
  alpha- (n = 10) or pH-stat management (n = 10). CBF was analyzed 7 h after
  induction of MCAO by iodo[C- 14]antipyrine autoradiography. Cerebral infarct
  volume and cerebral edema were measured by high-contrast silver infarct staining
  (SIS). Results. Compared with the a-stat regimen, pH- stat management reduced
  cerebral infarct volume (98.3 +/- 33.2 nim 3 vs. 53.6 +/- 21.6 mm(3); p greater than
  or equal to 0.05 mean +/- SD) and cerebral edema (10.6 +/- 4.0% vs. 3.1 +/- 2.4%; P
  greater than or equal to 0.05). Global CBF during pH- stat management exceeded
  that of a-stat animals (69.5 +/- 12.3 ml (.) 100 g(-1) (.) min(-1) vs. 54.7 +/- 13.3 ml (.)
  100 g(-1) (.) min(-1); P greater than or equal to 0.05). The regional CBF of the
  ischendc hemisphere was 62.1 +/- 11.2 ml (.) 100 g(-1) (.) min(-1) in the pH-stat
  group versus 48.2 +/- 7.2 ml (.) 100 g(-1) (.) min(-1) in the alpha-stat group (P
  greater than or equal to 0.05). Conclusions. In the very early reperfusion period (5 h),
  pH-stat management significantly decreases cerebral infarct volume and edema as
  compared with a-stat during moderate hypothermia, probably by increasing CBF
Keywords: acute/acute ischemic stroke/ALPHA-STAT/alphastat/artery/ARTERY
  OCCLUSION/blood flow/CARDIOPULMONARY BYPASS/CBF/cerebral/cerebral
  blood flow/cerebral edema/cerebral infarct/cerebral ischemia/edema/focal/focal
  cerebral                            ischemia/GROWTH-FACTOR/hypothermia/infarct
  stroke/management/MCAO/METABOLISM/middle cerebral artery/middle cerebral
  artery                                        occlusion/MILD/MODEL/MODERATE
Burger, A.J., Peart, B., Jabi, H. and Touchon, R.C. (1991), The Role of 2-Dimensional
  Echocardiography in the Diagnosis of Ineffective Endocarditis. Angiology, 42 (7),
Abstract: Two-dimensional echocardiography has had a significant impact on and is
  considered the technique of choice for the diagnosis and management of infective
  endocarditis. Over a thirty-six month period, 106 patients were evaluated by
  echocardiography for the possibility of endocarditis. The diagnosis of endocarditis
  was determined by strict clinical and laboratory criteria. All clinical histories, blood
  cultures, echocardiograms, and autopsy results were reviewed. Five echocardiograms
  were technically inadequate, resulting in a study population of 101 patients. The age
  of the patients ranged from forty-five days to eighty-eight years (mean fifty- seven
  years). The clinical manifestations of endocarditis included fever (83%), chills (60%),
  congestive heart failure (25%), and splenomegaly (18%). Twelve patients had
  preexisting valvular or congenital heart disease. Gram-positive cocci were the most
  common microorganisms. Complications included mitral regurgitation, subarachnoid
  hemorrhage, renal infarction, stroke, and a pulmonary embolus. The patients were
  divided into two groups: Group I consisted of 36 patients with definite vegetations by
  echocardiography, and Group II had 65 patients with no vegetations. In Group I,
  acute infective endocarditis was present in 35 patients, whereas only 4 patients had
  endocarditis in Group II. The sensitivity of two-dimensional echocardiography for
  detecting endocarditis was 90%. The specificity was 98%. The predictive accuracy
  for a positive test was 97%, and the predictive accuracy for a negative test was 94%.
  Thus, two-dimensional echocardiography appears to have a high sensitivity,
  specificity, and predictive value in the evaluation of patients with suspected
Keywords:                               ACTIVE                               INFECTIVE
  ONS/OPIATE                                          ADDICTS/TWO-DIMENSIONAL
Sanguigni, V., Gallu, M. and Strano, A. (1993), Incidence of Carotid-Artery
  Atherosclerosis in Patients with Coronary-Artery Disease. Angiology, 44 (1), 34-38.
Abstract: The natural history of coronary artery disease (CAD) is often complicated by
  cerebrovascular accidents. The real incidence of atherosclerotic lesions of carotid
  arteries in coronary patients is not well established. In order to detect a high- risk
  group for stroke development, 184 patients affected by CAD, either partially
  symptomatic or asymptomatic for carotid artery stenosis, underwent Echo-Doppler
  ultrasonography (duplex scanning) of supra-aortic branches. Significant carotid
  stenosis (> 50%) was demonstrated in 51 subjects (27.7%); 21 subjects (41.2%) were
  partially symptomatic (dizziness, vertigo, lipothymia, etc), and 30 subjects (58.8%)
  were completely asymptomatic. The authors' data suggest that carotid disease can
  develop concurrently with coronary disease in a significant proportion of patients,
  even though completely asymptomatic. In order to obtain optimal long-term results,
  both coronary and carotid artery disease require appropriate evaluation and either
  medical or surgical management. For these reasons they recommend duplex scanning
  as a routine screening procedure in patients affected by CAD
Turgut, M., Ozcan, O.E., Erturk, O., Saribas, O. and Erbengi, A. (1996), Spontaneous
  cerebellar strokes clinical observations in 60 patients. Angiology, 47 (9), 841-848.
Abstract: This is a retrospective study carried out by clinical analysis of the authors'
  experience in 60 patients with cerebellar strokes-of which 39 were spontaneous
  cerebellar hemorrhage and 21 were cerebellar infarction-to compare the clinical
  presentation, course, and prognosis. Hypertension was found to be the most
  important etiologic factor. Clinical differentiation of cerebellar hemorrhage from
  infarction was not possible, but the management was similar in both entities.
  Computerized tomography was necessary to make diagnosis of the stroke mechanism,
  In evaluating outcome, the authors conclude that the most important single factor
  affecting the prognosis was the early correct diagnosis
Walzl, M., Walzl, B. and Haas, A. (1997), Heparin-induced extracorporeal
  fibrinogen/LDL precipitation (HELP): A promising regimen for the treatment of
  vascular diseases. Angiology, 48 (12), 1031-1036.
Abstract: Current management of atherosclerotic diseases consists primarily of medical
  therapy designed to increase oxygen supply to the heart, the brain, retinal vessels, or
  lower limbs. The development of these diseases is based on atherosclerotic changes
  induced by risk factors such as elevated levels of fibrinogen and lipoproteins. These
  risk factors are related to a dramatic deterioration of the hemorrheologic pattern,
  which reduces perfusion. Consequently, attempts are now being made to treat
  ischemia via hemorrheological intervention. A new treatment modality utilizing the
  heparin-induced extracorporeal low-density lipoprotein (LDL) precipitation (HELP),
  offers the possibility of obtaining therapeutic success not only in cases of severe
  hypercholesterolemia but also in the field of hemorrheology. With HELP a safe and
  rapid reduction of fibrinogen and lipid fractions has become feasible, thus providing
  acute improvements of red cell aggregation, of the filterability of blood cells, of
  whole-blood and plasma viscosity, and thereby of microcirculation. Because
  cerebrovascular diseases are known to be related to disturbances of the
  hemorrheological situation, the HELP system is used in the Department of
  Electrobiology of Graz for the treatment of acute stroke, cerebral multiinfarct disease,
  and occlusions of retinal arteries
Keywords: acute/ACUTE STROKE/arteries/brain/cerebrovascular/cerebrovascular
  REDUCTION/RISK FACTOR/risk factors/stroke/therapy
Babatasi, G., Theron, J., Massetti, M., Payelle, G., Rossi, A. and Khayat, A. (1996),
  Value of the percutaneous carotid angioplasty before cardiac surgery. Annales de
  Cardiologie et D Angeiologie, 45 (1), 24-29.
Abstract: Transluminal angioplasty (TLA) of asymptomatic carotid stenoses (> 85%) in
  patients candidates for coronary artery bypass graft for stable angina appears to be an
  interesting technique to evaluate in a population whose management is controversial.
  Between January 1993 and January 1995, 10 patients underwent Carotid TLA
  (CTLA) prior to coronary artery bypass grafts (mean: 17.4 days). The mean age was
  71 +/- 4.3 years. Eight patients were classified as NYHA class II and two were
  classified as class III. The mean number of bypass grafts per patient was 2.7. Four
  patients presented contralateral thrombosis of the internal carotid artery. CTLA was
  performed under cerebral protection by means of a triple coaxial catheter. Six CTLA
  required a Strecker stent. The mean follow- up was 11.4 months, with no mortality.
  One patient presented with transient hemianopsia. All patients were reviewed at 4
  months by follow-up angiography, followed by Doppler. Only one of the 10 patients
  reviewed required redilatation with complementary stenting and another patient
  required dilatation of the stent. Although the follow-up of this short series is brief,
  the results of CTLA are encouraging in this population with a high risk of morbidity
  and mortality (elderly patients, frequently bilateral carotid lesions, coronary bypass
  grafts with multiple arterial grafts)
Keywords: age/angina/angiography/ARTERY BYPASS-SURGERY/bypass/cerebral
  vascular         accident/CEREBROVASCULAR-DISEASE/CORONARY/coronary
  surgery/elderly/ENDARTERECTOMY/FOLLOW-UP/internal                       carotid/internal
  carotid angioplasty
Lardoux, H., Touboul, A., Thai, S.P., Payot, L., Jacq, L. and Pezzano, M. (1998), Does
  transoesophageal echocardiography modify the management of atrial fibrillation?
  Annales de Cardiologie et D Angeiologie, 47 (9), 676-682
Keywords:            ANTICOAGULATION/APPENDAGE                         FUNCTION/atrial
  accidents/management/RISK/SPONTANEOUS                                            ECHO
  ECHOCARDIOGRAPHY/transoesophageal echography
Benkerrou, M., Brahimi, L. and Vilmer, E. (1999), Anemia in pediatric sickle cell
  patients. Annales de Pediatrie, 46 (7), 479-485.
Abstract: Chronic hemolytic anemia is a consistent and early manifestation of sickle cell
  anemia that arises as a direct consequence of the hemoglobin abnormality. Genotype
  is the main determinant of steady-state hemoglobin levels and of the occurrence of
  acute anemic events, although considerable interindividual variability exists for a
  given genotype. Anemia develops at three months of age and exhibits a number of
  specific features in younger children. Thus, massive sequestration of blood in the
  spleen is a life-threatening event seen in about 30% of homozygotes before splenic
  atrophy occurs around six years of age. Acute anemia due to hemolysis or
  erythroblastopenia can occur in response to infections, some of which are fostered by
  the functional asplenia. Parvovirus B19 is the leading cause of acute
  erythroblastopenia in pediatric sickle cell anemia. The increased nutritional needs
  due to the conjunction of chronic: hemolysis and growth can result in
  rapidly-developing nutritional deficiencies. The management of anemia in sickle-cell
   patients requires early diagnosis and symptomatic therapy. Targeted neonatal
   screening on a nationwide scale is associated with a substantial reduction in mortality
   most marked in children younger than five years of age. This reduction is due in part
   to parental education. Red blood cell transfusions are reserved for severe acute
   complications and for the prevention of their recurrence. They are also used before
   some surgical procedures. Use of red blood cell transfusions to prevent stroke is
   controversial. Simple measures such as education, vitamin supplementation, and
   multidisciplinary follow-up have resulted in reductions in mortality and morbidity
   due to sickle cell disease. Because it is fairly well tolerated, sickle cell anemia is not
   in itself an indication for cumbersome treatments such as long-term blood transfusion
   programs, or bone marrow transplantation
Keywords: acute/acute hemolysis/ACUTE SPLENIC SEQUESTRATION/acute splenic
   rbidity/mortality/pediatric/prevention/sickle         cell       anemia/sickle        cell
de Montalembert, M. (1999), Blood transfusion therapy in hemoglobinopathies. Annales
   de Pediatrie, 46 (1), 40-44.
Abstract: Sickle cell anemia and thalassemia major are the main hemoglobin disorders
   responsible for anemia requiring blood transfusion therapy. Either simple transfusion
   or exchange transfusion can be used. Simple transfusion is indicated in patients
   whose chronic anemia worsens, for instance as a result of hyperhemolysis secondary
   to an infection or a vasoocclusive crisis, of erythroblastopenia due to parvovirus B19
   infection, or of sequestration crisis. To avoid excessive hyperviscosity, the goal
   should be to return the hemoglobin level to its usual value. Exchange transfusion,
   which allows to provide a large number of normal red blood cells without increasing
   the hematocrit, is recommended as acute therapy for severe manifestations of
   vasoocclusive crisis (e.g., stroke, pulmonary infarction, priapism) or in preparation
   for a long anesthesia. Maintenance exchange transfusion programs can also be used
   to keep the HbS level under 30% at all times, particularly in children with a history
   of stroke. Patients with thalassemia major require blood transfusions on a regular
   basis to keep the hemoglobin level above 10 g/dl. The indications for blood
   transfusion therapy are more complex in thalassemia intermedia, in which some
   hemoglobin is produced spontaneously
   e transfusion/hemoglobin/infarction/infection/MANAGEMENT/packed red blood
   cells/preparation/RECURRENT STROKE/RISK/sickle cell anemia/SICKLE-CELL
Melon, E. and Rimaniol, J.M. (1996), Vasospasm in subarachnoid haemorrhage:
   Pharmacological treatment. Annales Francaises D Anesthesie et de Reanimation, 15
   (3), 366-373.
Abstract: Pharmacological treatment of vasospasm in subarachnoid haemorrhage (SAH)
   is founded on prevention and treatment of arterial narrowing and delayed ischaemic
   deficits. Safety and efficacy of different agents have been studied and trials classified
   according to the level of evidence proposed by the ''Stroke Council'' of the American
   Heart Association. Early intracisternal fibrinolysis can prevent vasospasm (level III
   to V of evidence, grade C). Pharmacological treatment is based on few drugs.
   Nimodipine reduces poor outcome related to vasospasm, but does not affect
   angiographic vessel caliber (level of evidence I and II, grade A). Its use is strongly
   recommended. Nicardipine decreases symptomatic and angiographic vasospasm, but
   does not affect outcome (level of evidence I to V, grade B). Tirilazad associated with
   nimodipine prevents delayed ischaemic deficits due to vasospasm and improves
   outcome in male patients. Intra-arterial infusion of papaverine associated with
   transluminal angioplasty can improve symptomatic vasospasm, resistant to
   conventional therapy (level of evidence IV to V, grade C), Pharmacological
   treatment of vasospasm associated with specific management founded on
   pathophysiology of SAH has improved patients outcome
Keywords:        amino     steroids/calcium-channel      blocking     agents/CEREBRAL
   VASOSPASM/COOPERATIVE                       ANEURYSM/delayed                 ischaemic
Lieu, P.K., Chong, M.S. and Seshadri, R. (2001), The impact of swallowing disorders in
   the elderly. Annals Academy of Medicine Singapore, 30 (2), 148-154.
Abstract: Introduction: Swallowing disorders are common in the elderly but its
   prevalence is often underestimated. They can result in increased morbidity and
   mortality. Methods: This article summarises the findings of selected published papers
   in major international journals indexed oil Medline on swallowing using the key
   words-swallowing, dysphagia, aged, geriatrics and deglutition. Results: There are
   age-related changes in the oral, pharyngeal and oesophageal functions. In the elderly,
   central nervous system diseases such as stroke, parkinsonism, dementia, medications,
   local oral and oesophageal factors are common causes of swallowing dysfunction.
   Swallowing disorders in the elderly are associated with increased mortality and
   morbidity. Aspiration, dehydration, pneumonia, malnutrition, functional decline and
   institutionalisation are often encountered in the elderly with dysphagia. There is a
   choice of different interventions available to reduce morbidity and mortality arising
   from swallowing impairments, and improving their quality of life. Conclusion: The
   effective management of swallowing impairment in the elderly requires a
   multidisciplinary team approach
Keywords:                          aged/ageing/ALZHEIMERS-DISEASE/ASPIRATION
   PNEUMONIA/BRAIN-STEM                           STROKE/central                  nervous
   PHARYNGEAL/physiology/prevalence/quality/quality                                    of
Por, Y.C., Lim, D.T.H., Teoh, M.K. and Soo, K.C. (2002), Surgical management and
   outcome of carotid body tumours. Annals Academy of Medicine Singapore, 31 (2),
Abstract: Introduction: Carotid body tumours are rare but are interesting in their manner
   of presentation and challenging with respect to surgical extirpation. They may
   present as a neck mass from which a bloody aspirate is obtained on fine needle
   aspiration. They are occasionally diagnosed only at the time of surgery, when one
   encounters the vascular tumour mass. Methods: We re viewed the results of 8 cases
   operated in our department over a 10-year period from 1989 to 1999. We evaluated
   in-hospital mortality and morbidity, as well as the long-term outcome especially with
   regards to functional disability. Results: Preoperative evaluation included
   angiography, computed tomography (CT) or magnetic resonance angiography.
  Operative technique involves good exposure, vascular control, identification and
  preservation of neurovascular structures and subadventitial tumour dissection. In all
  cases the vagus nerve was preserved, except in I case who had a malignant tumour
  and resection of the vagus nerve together with the accessory nerve and sympathetic
  chain. Two patients had unexpected hoarseness of voice postoperatively, I was due to
  permanent vagus nerve palsy and the other to transient vagus nerve palsy. One of
  them needed vocal cord medialisation and long-term tube feeding. One patient had
  bilateral tumours and developed a stroke after an operation on the second tumour. No
  patients exhibited local or metastatic disease during follow-up. There was no
  mortality in all cases. Conclusion: Although resection of the carotid body tumour is
  safe in experienced hands, long-term morbidity is still a significant problem and can
  be debilitating to the patient
  mortality/magnetic                       resonance/magnetic                   resonance
  stroke/surgery/tomography/transient/tube feeding/TUMORS
Widjaja, L.S., Chan, B.P., Chen, H., Ong, B.K.C. and Pang, Y.T. (2002), Variance
  analysis applied to a stroke pathway: How this can improve efficiency of healthcare
  delivery. Annals Academy of Medicine Singapore, 31 (4), 425-430.
Abstract: Introduction: Stroke is a complicated disease that requires a multidisciplinary
  approach for its management. We postulated that variance analysis applied to a
  stroke pathway, by identifying major problem areas and encouraging timely
  corrective actions, would lead to more efficient healthcare delivery to hospitalised
  stroke patients. Materials and Methods: Prospectively collected variance data from
  consecutive stroke patients discharged from a tertiary hospital in Singapore during a
  3-month period in 2000 were used to identify the major variances causing increased
  length of stay. These were compared and contrasted to variance data collected during
  the same 3-month period in the subsequent year (2001), after the implementation of
  stroke pathway and the availability of monthly variance analysis reports. Patient
  characteristics and outcome measures were also compared between the two study
  periods. Results: The four major variances that accounted for increased length of stay
  were, in descending order of the number of patients affected, awaiting bed
  availability in step- down facilities, delay in head computed tomographic scan
  performance, awaiting family's decision on discharge plan and incomplete
  application submitted to step-down facilities. After implementation of the stroke
  pathway with ongoing variance analysis, all four variances showed different extent
  of improvements. There were no significant differences inpatient characteristics
  between the two study periods, whereas the average length of stay significantly
  diminished in the late study period with a trend for decreased in-hospital mortality,
  compared to the early study period. Conclusion: Variance analysis applied in the
  context of a stroke pathway was effective in identifying major variances causing
  increased length of stay. This allowed targeted intervention to improve efficiency of
  healthcare delivery to stroke patients
Keywords:          delay/delivery/discharge         planning/disease/hospital/HOSPITAL
  COSTS/hospitalisation          costs/in-hospital    mortality/intervention/length    of
Venketasubramanian, N., Chang, H.M. and Chan, B.P.L. (2002), Update in the
  management of stroke. Annals Academy of Medicine Singapore, 31 (6), 717-721.
Abstract: Recent advances have improved the outlook for patients with stroke,
  Singapore's fourth leading cause of death. Stroke unit care reduces death,
  dependency and institutionalisation, independent of age, gender and stroke severity.
  Neuroimaging is essential prior to initiation of specific therapies. While computed
  tomography (CT) Head remains the most widely used modality, magnetic resonance
  imaging (MRI), particularly diffusion weighted imaging (DWI) has enhanced the
  positive diagnosis of ischaemic stroke. General medical measures include close
  monitoring, adequate oxygenation, avoidance of excessive blood pressure lowering,
  reduction of hyperthermia, control of hyperglycaemia, adequate nutrition, prevention
  of complications and early rehabilitation. Despite the risk of fatal intracranial
  haemorrhage, thrombolysis may improve outcomes in appropriately selected patients
  with ischaemic stroke. No safe and effective neuroprotectant has been found. While
  suboccipital craniectomy is established for large cerebellar infarcts and haemorrhage,
  surgical evacuation of supratentorial haemorrhage has not been shown to be
  beneficial. Hemicraniectomy reduces mortality after massive hemispheric ischemic
  stroke. Early and sustained antiplatelet use after atherothrombotic stroke reduces
  stroke recurrence. Stroke recurrence is also reduced by sustained warfarin use for
  cardioembolic stroke, carotid endarterectomy for severe symptomatic internal carotid
  artery stenosis, blood pressure lowering starting after the acute phase of stroke and
  lipid lowering. On-going clinical trails are likely to provide better treatments in the
  near future
Keywords:                            acute/ACUTE                              ISCHEMIC
  pressure/cardioembolic stroke/carotid/carotid artery/carotid artery stenosis/carotid
  endarterectomy/cause          of        death/cerebral       infarction/cerebrovascular
  disease/cerebrovascular                          haemorrhage/complications/computed
  ARE PROFESSIONALS/hyperthermia/imaging/internal/internal carotid/internal
  carotid                                                     artery/INTRACEREBRAL
  HEMORRHAGE/intracranial/ischaemic/ischaemic                   stroke/ischemic/ischemic
  stroke/lipid-lowering/magnetic               resonance/magnetic               resonance
  imaging/management/management                                                        of
  n/recurrence/rehabilitation/risk/severity/SPECIAL                            WRITING
Tan, C.C. (2002), National disease management plans for key chronic non-
  communicable diseases in Singapore. Annals Academy of Medicine Singapore, 31 (4),
Abstract: in Singapore, chronic, non-communicable diseases, namely coronary heart
  disease, stroke and cancer, account for more than 60% of all deaths and a high
  burden of disability and healthcare expenditure. The burden of these diseases is
  likely to rise with our rapidly ageing population and changing lifestyles, and will
  present profound challenges to our healthcare delivery and financing systems over
  the next 20 to 30 years. The containment and optimal management of these
  conditions require a strong emphasis on patient education and the development of
  integrated models of healthcare delivery in place of the present uncoordinated,
  compartmentalised way of delivering healthcare. To meet these challenges, the
  Ministry of Health's major thrusts are disease control measures which focus mainly
  on primary prevention; and disease management, which coordinates the national
  effort to reduce the incidence of these key diseases and their predisposing factors and
  to ameliorate their long-term impact by optimising control to reduce mortality,
  morbidity and complications, and improving functional status through rehabilitation.
  The key initiatives include restructuring of the public sector healthcare institutions
  into two clusters, each comprising a network of primary health care polyclinics,
  regional hospitals and tertiary institutions. The functional integration of these
  healthcare elements within each cluster under a common senior administrative and
  professional management, and the development of common clinical IT systems will
  greatly facilitate the implementation of disease management programmes. Secondly,
  the Ministry is establishing National Disease Registries in coronary heart disease,
  cancer, stroke, myopia and kidney failure, which will be valuable sources of clinical
  and outcomes data. Thirdly, in partnership with expert groups, national committees
  and professional agencies, the Ministry will produce clinical practice guidelines
  which will assist doctors and healthcare professionals to better manage important
  aspects of the key diseases. Finally, the Ministry has committed funds to support
  selected National Disease Management programmes, illustrated by the disease
  management plan for asthma
Keywords:                     ASTHMA/burden/cancer/clinical                        practice
  guidelines/complications/control/coronary/coronary                                  heart
  disease/delivery/disability/disease/disease                               control/disease
  management/diseases/education/functional                  status/guidelines/health/health
  mortality/National       Disease      Registries/outcomes/patient     education/practice
  guidelines/prevention/primary                      health                   care/primary
Sherry, S. (1991), Thrombolytic Therapy for Noncoronary Diseases. Annals of
  Emergency Medicine, 20 (4), 396-404.
Abstract: Thrombolytic therapy has been used fairly extensively in the management of
  acute proximal deep-vein thrombophlebitis of the extremities, acute pulmonary
  embolism, and acute peripheral arterial thrombosis and embolism in addition to acute
  thrombotic coronary events. In the presence of acceptable indications and a favorable
  benefit to risk ratio, this form of therapy, when successful, has served as a useful
  adjunct in the management of these disorders. In deep-vein thrombophlebitis, lysis of
  the thrombus before permanent pathological changes (eg, organization, scarring)
  have occurred can prevent venous valvular dysfunction and postural venous
  hypertension and its complications, especially the postphlebitic syndrome. In the
  more severe forms of acute pulmonary embolism, thrombolytic therapy, when
  applied early after symptom onset, decreases morbidity and is likely to prevent a
  chronic increase in pulmonary vascular resistance and persistent pulmonary
  hypertension. In peripheral arterial thrombo-occlusive events, early restoration of
  flow through thrombolysis has been shown to limit ischemic damage and serve as a
  useful supplement to angioplasty or surgery. Thrombolytic therapy has been used
  less extensively in acute strokes. Here the danger of reperfusion causing bleeding
  into a softened area of brain undergoing infarction has slowed its evaluation for this
  disorder; its application to stroke remains experimental
Pollack, C.V., Torres, M.T. and Alexander, L. (1996), Feasibility study of the use of
  bilevel positive airway pressure for respiratory support in the emergency department.
  Annals of Emergency Medicine, 27 (2), 189-192.
Abstract: Study objective: To determine the feasibility of bilevel positive airway
  pressure (BiPAP) support for acute respiratory distress (ARD) in the emergency
  department. Methods: A convenience sample of patients in ARD as a result of any
  nontraumatic cause was recruited for a prospective, noncontrolled clinical trial in the
  ED of an urban tertiary care teaching hospital. Hemodynamically unstable patients
  and those requiring immediate endotracheal intubation were excluded. After an
  initial arterial blood gas (AGB) analysis was obtained, the patient was placed on
  BiPAP (Bi-PAP S/T noninvasive ventilator; Respironics, Incorporated) by nose mask
  or face mask to provide noninvasive pressure support at 5 cm H2O. Settings were
  titrated to patient tolerance and satisfactory pulse oximetry. After at least 30 minutes
  on a stable setting, arterial blood gases were remeasured. The cause of respiratory
  distress, vital signs, assessment of need for intubation, arterial blood gas results, and
  patient disposition were recorded. Success of noninvasive support was defined as the
  presence of (1) improvement in ABG parameters, (2) clinical improvement and
  decrease in evident dyspnea, and (3) avoidance of endotracheal intubation and
  mechanical ventilation. Results: Fifty patients were studied. Causes of ARD included
  acute congestive heart failure (CHF; n=16), exacerbation of chronic obstructive
  pulmonary disease (COPD; n=9), mixed COPD/CHF (n=3), pneumonia (n=10),
  status asthmaticus (n=6), and other causes of acute respiratory failure leg, stroke,
  overdose; n=6). Noninvasive management was successful in 43 patients (86%), with
  patients in all etiologic categories being equally likely to respond favorably to
  therapy. All patients were admitted to the hospital, but 52.5% of those who ordinarily
  would have required ICU beds were admitted to lower land less costly) levels of care.
  Three patients were eventually intubated, ail after admission to the ICU on BiPAP.
  Two patients did not tolerate BiPAP, and two others were considered ED treatment
  failures but were not intubated because of advance directives. Conclusion: As has
  been reported from other critical care set tings, use of BiPAP is feasible and has
  potential utility in the management of ARD in the ED
  MASK/FAILURE/heart                         failure/NASAL                   MASK/pulse
Love, J.N., Hanfling, D. and Howell, J.M. (1996), Hemodynamic effects of calcium
  chloride in a canine model of acute propranolol intoxication. Annals of Emergency
  Medicine, 28 (1), 1-6.
Abstract: Study objective: To evaluate the hemodynamic effects of calcium chloride in
  a canine model of acute propranolol toxicity. Methods: Two minutes after the
  completion of a propranolol infusion (10 mg/kg), a bolus of .125 mL/kg 10% CaCl
  solution followed by an infusion of .375 mL/kg over the next 30 minutes or a bolus
  and subsequent infusion of an equivalent volume of normal saline solution was
  administered to each dog. Results: CaCl yielded significant improvements in
  propranolol-induced decreases in cardiac index and stroke volume compared with
  saline solution-treated control animals (overall alpha=.05). Furthermore, CaCl
  administration resulted in earlier improvement in propranolol-induced alterations in
  mean arterial pressure, maximal left ventricular pressure change over time, and
  peripheral vascular resistance compared with saline solution (overall alpha=.05). We
  observed no difference between treatment groups In response to propranolol-induced
  bradycardia or QRS-interval prolongation. Conclusion: In this model of acute
  propranolol toxicity, CaCl therapy improved depressed hemodynamic status, mainly
  by a positive inotropic action
Keywords:                                             ACEBUTOLOL/BETA-BLOCKER
O'Connor, R.E., McGraw, P. and Edelsohn, L. (1999), Thrombolytic therapy for acute
  ischemic stroke: Why the majority of patients remain ineligible for treatment. Annals
  of Emergency Medicine, 33 (1), 9-14.
Abstract: Study objectives: Thrombolytic therapy has been advocated as an effective
  treatment for acute ischemic stroke. In an attempt to promote maximum benefit while
  reducing the risk of hemorrhagic complications, numerous exclusions to the use of
  thrombolytic therapy for acute ischemic stroke have been promulgated. This study
  was conducted to identify the number of acute ischemic stroke patients eligible for
  thrombolytic therapy and to determine the reasons those deemed ineligible were
  excluded. Methods: This observational study was conducted from September 15,
  1996, to May 1, 1997, at an emergency depart ment with an annual census of 70,000.
  Patients with a chief complaint suggestive of acute ischemic stroke were categorized
  as "eligible" if thrombolytic therapy was not contraindicated and could be initiated
  within 3 hours of symptom onset. Patients were deemed "ineligible" if the time to
  thrombolytic therapy would have exceeded 3 hours, or if other specific
  contraindications to thrombolytic therapy were present. For all categories, 95%
  confidence intervals (95% CI) were determined. Results: Of the 214 patients with
  acute ischemic stroke who were screened, 6 (2.8%+/-2.2%) were eligible.
  Ninety-five patients (44%+/-7%) were excluded solely on the basis of the time
  interval from onset of symptoms to eligibility for thrombolytic therapy exceeding 3
  hours. Other common reasons for exclusion included resolution of symptoms in 31
  patients (14%+/-4%), intracranial hemorrhage as determined by head computed
  tomography in 22 (10%+/-4%), and minor symptoms in 20 (9%+/-4%). Conclusion:
  The majority of acute ischemic stroke patients do not meet accepted criteria for
  thrombolytic therapy. Most are ineligible because of delays in obtaining treatment.
  Strategies should be devised to reduce the time to treatment if thrombolytic therapy
  is to achieve widespread use in the treatment of acute ischemic stroke
Keywords:                                         acute/CARE/complications/computed
  l/intracranial                                          hemorrhage/ischemic/ischemic
Neely, K.W. and Norton, R.L. (1999), Survey of health maintenance organization
  instructions to members concerning emergency department and 911 use. Annals of
  Emergency Medicine, 34 (1), 19-24.
Abstract: Study objective: Anecdotal concerns suggest that health management
  organization (HMO) membership instructions may deter members from calling 911
  or going to an emergency department far a perceived emergency. This study
  examines such instructions, specifically in regard to their definition of an emergency
  condition and associated instructions. Methods: Member instructions were requested
  from 28 HMOs in 3 large West Coast cities with HMO penetration exceeding 30%.
  Fifteen (54%) provided membership materials. Features examined included the
  definition of an emergency, instructions for calling 911, specific instructions
  regarding chest pain and stroke, and mention of costs associated with emergency care.
  Results: Instructions and definitions varied widely. Six HMOs (40%) included chest
  pain in their definition of an emergency; 2 (13%) included symptoms of stroke. Ten
  (67%) made mention of calling 911 or going to the ED somewhere within their
  instructions; 4 (27%) provided no options for calling 911 or seeking ED care. Three
  (30%) cited higher costs associated with ED care. Eleven (73%) indicated that claims
  would be denied for visits determined on retrospective review to be nonemergencies.
  Conclusion: Instructions varied considerably. Most did not include chest pain or
  symptoms of stroke in their definition of an emergency. Most did include directions
  to call 911 or go to an ED. Other instructions may lead members to call the HMO
  first during an emergency
Keywords:                 costs/emergency/emergency                    department/health
  maintenance/HMOs/MANAGED CARE/management/pain/review/stroke
Labiche, L.A., Chan, W.Y., Saldin, K.R. and Morgenstern, L.B. (2002), Sex and acute
  stroke presentation. Annals of Emergency Medicine, 40 (5), 453-460.
Abstract: Study objectives: We determine whether a sex difference exists for acute
  stroke emergency department presentation. Methods: The TILL Temple Foundation
  Stroke Project is a prospective observational study of acute stroke management that
  identified 1,189 validated strokes in nonurban community EDs from February 1998
  to March 2000. Structured interview of the patient and the person with the patient at
  symptom onset identified the symptom or symptoms that prompted the patient to
  seek medical attention. Interview data were available for 1,124 (94%) patients. A
  physician blinded to sex classified the reported symptoms into 14 categories. Results:
  Nontraditional stroke symptoms were reported by 28% of women and 19% of men
  (odds ratio 1.62; 95% confidence interval 1.2 to 2.2). Nontraditional stroke
  symptoms, pain (men 8%, women 12%) and change in level of consciousness (men
  12%, women 17%), were more often reported by women. Traditional stroke
  symptoms, imbalance (men 20%, women 15%) and hemiparesis (men 24%, women
  19%), were reported more frequently by men. Trends were also found for women to
  present with nonneurologic symptoms (men 17%, women 21%) and men to present
  with gait abnormalities (men 11%, women 8%). There was no sex difference in the
  mean number of symptoms reported by an individual patient. Conclusion: This study
  suggests that a sex difference exists in reporting of acute stroke symptoms. Women
  with validated strokes present more frequently with non-traditional stroke symptoms
  than men. Recognition of this difference might yield faster evaluation and
  management of female patients with acute stroke eligible for acute therapies
Keywords:             abnormalities/acute/acute            stroke/acute           stroke
Du, X.L., McNamee, R. and Cruickshank, K. (2000), Stroke risk from multiple risk
  factors combined with hypertension: A primary care based case control study in a
  defined population of northwest England. Annals of Epidemiology, 10 (6), 380-388.
Abstract: PURPOSE: To examine how hypertension interacts with ether known risk
  factors in affecting the rick of stroke in a primary care based setting. METHODS:
  Cases were patients with first-ever stroke identified from the community-based
  stroke register in 1994-95 in northwest England. Two controls per case wore
  randomly selected from the same primary care site and matched by age and sex.
  Information on predefined risk factors was extracted from medical records.
  RESULTS: 267 cases and 534 controls were included. Adjusted odds ratio (OR) for
  stroke from hypertension was 2.6 (95%, confidence interval: 1.7-3.9). In
  hypertensives who were current smokers, risk of stroke was increased 6 fold (OR =
  6.1 (2.7-13.7)) as compared to non- smokers without hypertension. Hypertensives
  who had a preexisting history of myocardial infarction or obesity or diabetes had 3
  fold higher risks of stroke. Subjects with hypertension and with a history of transient
  ischemic attack or atrial fibrillation had greater than or equal to 8 fold excess risk of
  stroke. Among them, the risk was greater in those with poorly controlled or untreated
  hypertension (OR = 13.2 (2.6- 67.0)) and in those with well or moderately controlled
  (OR = 5.2 (1.6-17.2)) as compared to subjects without both risk factors. There
  appeared to be a steady increase in rick of stroke according to the number of risk
  factors present, particularly in hypertensive subjects. CONCLUSIONS: Stroke risks
  in hypertensives associated with combinations of other risk factors appeared to
  follow an additive model. Subjects with multiple risk factors should he targeted in
  order to reduce the overall risk for stroke. Ann Epidemiol 2000;10:380- 388. (C)
  2000 Elsevier Science Inc. All rights reserved
Keywords:                                                            age/ALCOHOL/atrial
  infarction/obesity/PREVENTION/primary               care/risk       factors/risk       of
  stroke/sex/stroke/transient/transient ischemic attack/WEST ENGLAND
Yeh, S.P., Hsueh, E.J., Wu, H. and Wang, Y.C. (1998), Ticlopidine-associated aplastic
  anemia - A case report and review of literature. Annals of Hematology, 76 (2), 87-90.
Abstract: Serious hematologic complications associated with ticlopidine have been
  reported, including aplastic anemia. We report here an additional case of fatal
  aplastic anemia due to ticlopidine. A 66-year-old male patient developed fever and
  pancytopenia 2 months after ticlopidine was started. Despite the administration of
  granulocyte colony-stimulating factor (G-CSF) and broad-spectrum antibiotics, as
  well as aggressive red cell and platelet transfusions, the patient died 16 days after
  admission due to septic shock. Eighteen other cases of ticlopidine-induced aplastic
  anemia published in the English literature are also reviewed and presented here.
  Eight of the total 19 patients (including the one reported here) have died, mostly due
  to infection. Of the seven who received supportive treatment only, four had
  spontaneous recovery. Nine cases were treated with G-CSF or
  granulocyte-macrophage colony-stimulating factor (GM-CSF), and response was
  observed in only four of them. Several other cases were treated with high-dose
  corticosteroids or androgens; however, it was not possible to evaluate the efficacy of
  these treatments because of the limited number of cases. In the absence of
  satisfactory treatment for ticlopidine-induced aplastic anemia at present, it may be
  reasonable to try antilymphocyte globulin or cyclosporine. Also, great efforts should
  be made in the prevention and management of infection accompanying this disease
Keywords:        administration/antilymphocyte         globulin/aplastic       anemia/case
Kerr, G.S., Hallahan, C.W., Giordano, J., Leavitt, R.Y., Fauci, A.S., Rottem, M. and
  Hoffman, G.S. (1994), Takayasu Arteritis. Annals of Internal Medicine, 120 (11),
Abstract: Objective: To evaluate prospectively the clinical features, angiographic
  findings, and response to treatment of patients with Takayasu arteritis. Design: 60
  patients with Takayasu arteritis were studied at the National Institute of Allergy and
  Infectious Diseases between 1970 and 1990 and were followed for 6 months to 20
  years (median follow-up, 5.3 years). Measurements: Data on clinical features,
  angiographic and laboratory findings, disease course, and response to therapy were
  all recorded and stored in a computer-based retrieval system. Setting: The Warren
  Magnuson Clinical Center of the National Institutes of Health. Results: In our series
  of patients, Takayasu arteritis was more common in Asian persons compared with
  persons from other racial groups. Females (97%) were most frequently affected. The
  median age at disease onset was 25 years. Juveniles had a delay in diagnosis that was
  about four times that of adults. The clinical presentation ranged from asymptomatic
  to catastrophic with stroke. The most common clinical finding was a bruit.
  Hypertension was most often associated with renal artery stenosis. Only 33% of all
  patients had systemic symptoms on presentation. Sixty-eight percent of patients had
  extensive vascular disease; stenotic lesions were 3.6-fold more common than were
  aneurysms (98% compared with 27%). The erythrocyte sedimentation rate was not a
  consistently reliable surrogate marker of disease activity. Surgical bypass biopsy
  specimens from clinically inactive patients showed histologically active disease in
  44% of patients. Although clinically significant palliation usually occurred after
  angioplasty or bypass of severely stenotic vessels, restenosis was common. Medical
  therapy was required for 80% of patients, whereas 20% had monophasic self-limiting
  disease. Immunosuppressive treatment with glucocorticoids alone or in combination
  with a cytotoxic agent failed to induce remission in one fourth of patients; about half
  of those who achieved remission later relapsed. Conclusions: In North America,
  Takayasu arteritis is a rare disease. It is heterogeneous in presentation, progression,
  and response to therapy. Current laboratory markers of disease activity are
  insufficiently reliable to guide management. Most patients require repeated and, at
  times, prolonged courses of therapy. Although mortality was low, substantial
  morbidity occurred in most patients
Keywords:                                                              ANGIOGRAPHIC
Hoes, A.W., Grobbee, D.E., Lubsen, J., Tveld, A.J.M.I., Vanderdoes, E. and Hofman, A.
  (1995), Diuretics, Beta-Blockers, and the Risk for Sudden Cardiac Death in
  Hypertensive Patients. Annals of Internal Medicine, 123 (7), 481-&.
Abstract: Objective: To determine whether the use of non-potassium- sparing diuretics
  and beta-blockers is associated with an excess risk for sudden cardiac death in
  hypertensive patients. Design: Case-control study. Setting: Rotterdam, the
  Netherlands. Patients: 257 case-patients who had died suddenly while receiving drug
  therapy for hypertension and 257 living controls also receiving drug therapy for
  hypertension. Measurements: Detailed information on medication use and clinical
  characteristics of all case-patients and controls was collected from the files of general
  practitioners. Additional information on medication use was obtained from
  computerized pharmacy records. Results: Patients receiving non-potassium- sparing
  diuretics had an increased risk for sudden cardiac death (relative risk, 1.8 [95% CI,
  1.0 to 3.1]) compared with a reference group treated primarily with
  potassium-sparing diuretics. The corresponding relative risk for beta-blocker use was
  1.7 (CI, 1.1 to 2.6). The use of non-potassium-sparing diuretics without beta-blockers
  was associated with a higher risk for sudden death (relative risk, 2.2 [CI, 1.1 to 4.6])
  than was concomitant use of non-potassium-sparing diuretics and beta-blockers
  (relative risk, 1.4 [CI, 0.6 to 3.0]). The risk for sudden cardiac death among
  recipients of non-potassium- sparing diuretics was more pronounced in those who
  had been receiving the diuretic for less than 1 year and in those aged 75 years or
  younger. Conclusions: The use of non-potassium- sparing diuretics and beta-blockers
  is associated with an increased risk for sudden cardiac death. This association may
  offset part of the mortality benefit of these drugs in the treatment of hypertension
Keywords:                   ABNORMALITIES/ADRENERGIC                                BETA-
  Y                                        HEART-DISEASE/DEATH/DIURETICS/drug
  SSIUM/practitioners/relative risk/STROKE/SUDDEN/therapy
McNamara, R.L., Lima, J.A.C., Whelton, P.K. and Powe, N.R. (1997),
  Echocardiographic identification of cardiovascular sources of emboli to guide
  clinical management of stroke: A cost- effectiveness analysis. Annals of Internal
  Medicine, 127 (9), 775-&.
Abstract: Background: No consensus exists about the use of imaging strategies to
  identify potential cardiovascular sources of emboli in patients who have had strokes.
  Objective: To;determine the cost-effectiveness of various cardiac imaging strategies
  after stroke. Design: A Markov model decision analysis was used to evaluate the
  benefits and costs of nine diagnostic strategies, including transthoracic
  echocardiography, transesophageal echocardiography, sequential approaches,
  selective imaging, and no imaging. Setting: Simulated clinical practice in the United
  States. Patients: Hypothetical patients with a first stroke who were in normal sinus
  rhythm. Measurements: Echocardiographic detection rates of potential sources of
  emboli were ascertained by doing a systematic review of the literature. Values for
  event rates, anticoagulation effects, utilities, and costs were obtained from the
  literature and Medicare data. Results: When visualized left atrial thrombus was used
  as the only indication for anticoagulation, transesophageal echocardiography
  performed only in patients with a history of cardiac problems cost $9000 per
  quality-adjusted life-year; transesophageal echocardiography in all patients cost $13
  000 per quality- adjusted life-year. Cost savings and decreased morbidity and
  mortality rates associated with reduction in preventable recurrent strokes
  substantially offset examination costs and risks of anticoagulation. These results
  were moderately sensitive to efficacy of anticoagulation and incidence of intracranial
  bleeding during anticoagulation and were mildly sensitive to prevalence of left atrial
  thrombus, rate of recurrent stroke in patients with thrombus, quality of life after
  stroke, cost of transesophageal echocardiography, and specificity of transesophageal
  echocardiography. Transthoracic echocardiography, alone or in sequence with
  transesophageal echocardiography, was not cost-effective compared with
  transesophageal echocardiography. Conclusion: Physicians should consider doing
  transesophageal echocardiography in all patients with new; onset stroke
Keywords:      anticoagulation/ARTERY          DISEASE/BREAST-CANCER/CARDIAC
  SOURCE/CEREBRAL-ISCHEMIA/cerebrovascular                           disorders/cost-benefit
  analysis/DECISION-           ANALYSIS/echocardiography/emboli/embolism               and
  thrombosis/incidence/management/mortality/mortality                    rates/NATIONAL
  ECHOCARDIOGRAPHY/TRANSIENT                                                    ISCHEMIC
Dalakas, M.C. (1997), Intravenous immune globulin therapy for neurologic diseases.
  Annals of Internal Medicine, 126 (9), 721-730.
Abstract: High-dose intravenous immune globulin (IVIg) has emerged as an important
  therapy for various neurologic diseases. Different interpretations of clinical trial
  results; the expected benefit of IVIg compared with that of alternate therapies; and
  issues about IVIg's safety, cost, and mechanisms of action have raised concern and
  uncertainty among practitioners. To clarify these areas, this paper examines the
  clinical, serologic, and immunologic data on more than 110 patients with various
  autoimmune neurologic diseases who received IVIg during the past 6 years at the
  National Institute of Neurological Disorders and Stroke. It also reviews work by
  other investigators on the efficacy, risks, benefits, and mechanisms of the action of
  IVIg in these diseases. In controlled clinical trials, IVIg has been effective in treating
  the Guillain-Barre syndrome, multifocal motor neuropathy, chronic inflammatory
  demyelinating polyneuropathy, and dermatomyositis. In other controlled or
  open-label trials and case reports, IVIg produced improvement in several patients
  with the Lambert-Eaton myasthenic syndrome and myasthenia gravis but had a
  variable, mild, or unsubstantiated benefit in some patients with inclusion-body
  myositis, paraproteinemic IgM demyelinating polyneuropathy, certain intractable
  childhood epilepsies, polymyositis, multiple sclerosis, optic neuritis, and the
  stiff-man syndrome. The primary adverse reaction was headache; aseptic meningitis,
  skin reactions, thromboembolic events, and renal tubular necrosis occurred rarely.
  The most relevant immunomodulatory actions of IVIg, operating alone or in
  combination, are inhibition of complement deposition, neutralization of cytokines,
  modulation of Fc-receptor-mediated phagocytosis, and downregulation of
  autoantibody production. Therapy with IVIg is effective for certain autoimmune
  neurologic diseases, but its spectrum of efficacy has not been fully established.
  Additional controlled clinical trials are needed
Keywords:                            B-CELL/clinical                           trial/clinical
  RRE-SYNDROME/IMMUNOGLOBULIN                                    THERAPY/KAWASAKI
  SYNDROME/meningitis/MULTIFOCAL                                                   MOTOR
Kronzon, I. and Tunick, P.A. (1997), Atheromatous disease of the thoracic aorta:
  Pathologic and clinical implications. Annals of Internal Medicine, 126 (8), 629-637.
Abstract: Purpose: To review recent developments in the diagnosis, clinical
  epidemiology, pathology, and management of atherosclerosis of the thoracic aorta,
  especially atherosclerosis of the thoracic aorta as a source of embolization. Data
  Sources: MEDLINE searches, bibliographies of published papers, and consultation
  with experts in the field. Study Selection: English-language publications on
  atherosclerosis of the thoracic aorta were selected. Data Synthesis: During the last 6
  years, the increasing use of transesophageal echocardiography has shown that
  atherosclerotic plaque in the thoracic aorta is a source of otherwise unexplained
  embolic events, including stroke, transient ischemic attack, and peripheral emboli.
  Retrospective studies have documented a strong independent association between
  larger lesions (4 mm to 5 mm) and previous embolic disease, and prospective studies
  have shown that patients with these lesions have a high risk for future events (in one
  study, the risk for stroke was 12%; in another, the risk for cerebral or peripheral
  events was 33% in a follow-up period of just 14 months). These lesions also pose a
  serious risk for embolization caused by manipulation of the aorta during
  catheterization, intra-aortic balloon-pump placement, and cannulation of the aorta for
  heart surgery. Pathologic examination has shown atherosclerotic plaque, often with
  superimposed thrombi that account for the mobile components seen on
  transesophageal echocardiography. The management of patients who have
  atherosclerotic lesions in the thoracic aorta has not been determined prospectively.
  However, anticoagulation may help prevent emboli, as it does for patients who have
  thrombi in other locations, such as the left atrium and the left ventricle. Conclusions:
  Protruding atherosclerotic lesions in the thoracic aorta, often with superimposed
  mobile thrombi, are an important cause of embolic disease. Transesophageal
  echocardiography should be considered in the work-up of patients who have
  unexplained embolic events
Keywords:                                                       anticoagulation/aorta/ARCH
  ECHOCARDIOGRAPHIC                                          DETECTION/transesophageal
  echocardiography/transient/transient ischemic attack
Weigner, M.J., Caulfield, T.A., Danias, P.G., Silverman, D.I. and Manning, W.J. (1997),
  Risk for clinical thromboembolism associated with conversion to sinus rhythm in
  patients with atrial fibrillation lasting less than 48 hours. Annals of Internal Medicine,
  126 (8), 615-&.
Abstract: Background: It has been assumed that cardioversion in patients with atrial
  fibrillation lasting less than 48 hours is associated with a low risk for
  thromboembolism. However, no clinical data support this assumption. Objective: To
  determine the incidence of cardioversion-related clinical thromboembolism among
  patients presenting with atrial fibrillation lasting less than 48 hours. Design: Patients
  were prospectively identified on admission, and clinical data on the duration of atrial
  fibrillation were recorded. Data on cardioversion and thromboembolism were
  obtained retrospectively from hospital and outpatient records. Setting: Academic
  medical center. Patients: 1822 consecutive patients admitted to the hospital for atrial
  fibrillation were screened. Three hundred seventy-five adults (mean age +/- SD, 68
  +/- 16 years) with atrial fibrillation that had lasted less than 48 hours were identified.
  One hundred eighty-one patients (48.3%) had a history of atrial fibrillation; 23 (6.1%)
  had a history of thromboembolism. Results: 357 patients (95.2%) converted to sinus
  rhythm during the index admission; spontaneous conversion occurred in 250 patients
  (66.7%) and active pharmacologic or electrical conversion was done in 107 patients
  (28.5%). Three patients (0.8% [95% CI, 0.2% to 2.4%]), all of whom had converted
  spontaneously after ventricular rate control was begun, had a clinical
  thromboembolic event: One had a stroke, 1 had a transient ischemic attack, and 1 had
  a peripheral embolus. None of these 3 patients had a history of atrial fibrillation or
  thromboembolism, and all had normal left ventricular systolic function. Conclusion:
  Among patients presenting with atrial fibrillation that was clinically estimated to
  have lasted less than 48 hours, the likelihood of cardioversion-related clinical
  thromboembolism is low. These data support the current recommendation for early
  cardioversion in these patients
Keywords:       age/ANTICOAGULATION/ANTITHROMBOTIC                         THERAPY/atrial
  fibrillation/cardiac                    output/COMPLICATIONS/DIRECT-CURRENT
  factors/TRANSESOPHAGEAL                    ECHOCARDIOGRAPHY/transient/transient
  ischemic attack/TRIAL
Lewis, R.F., Abrahamowicz, M., Cote, R. and Battista, R.N. (1997), Predictive power of
  duplex ultrasonography in asymptomatic carotid disease. Annals of Internal
  Medicine, 127 (1), 13-&.
Abstract: Background: Duplex ultrasonography is considered a valid measure of
  stenosis of the carotid arteries, but the prognostic value of repeated ultrasonographic
  examinations is unknown. Objective: To determine the ability of serial
  ultrasonographic measurements to predict cerebrovascular events in patients with
  asymptomatic carotid disease. Design: Secondary analysis of data from a natural
  history study of asymptomatic carotid disease. Patients: Asymptomatic patients with
  cervical bruits. Measurements: Duplex ultrasonography of the carotid arteries was
  done at study enrollment and biannually thereafter. Multivariable Cox proportional
  hazards models with fixed and time-dependent covariates were used for analysis.
  Results: 61 transient ischemic attacks (TIAs) and 38 strokes occurred in 715
  participants over a mean follow-up period of 3.2 years; 4 strokes were disabling, and
  no deaths from stroke occurred. Sixty percent of strokes occurred in persons who did
  not have severe stenosis. One fifth of; participants had stenosis progression. Baseline
  carotid stenosis was a significant predictor of the outcome ''TIA or stroke'' (relative
  risk, 1.5 [95% CI, 1.2 to 1.7]) and retained its predictive ability for more than 3 years.
  Progression of stenosis to 80% or more significantly increased the risk for
  cerebrovascular events and death. The sensitivity and positive predictive Value of
  progression as an independent predictor of TIA or stroke were low. Conclusion:
  Severe carotid stenosis is associated with a higher risk for cerebrovascular events,
  but the power of repeated ultrasonography to predict ischemic events is limited by
  low incidence rates and low rates of progression. The evidence does not support the
  routine use of serial ultrasonography to determine the risk for stroke in unselected
  patients with asymptomatic carotid disease
Keywords: 5-YEAR FOLLOW-UP/arteries/ARTERY STENOSIS/BRUITS/carotid
  arteries/carotid      stenosis/cerebral       ischemia/cerebrovascular/cerebrovascular
  RISK/SURGICAL-TREATMENT/TIA/transient/transient                                 ischemic
Klein, A.L., Grimm, R.A., Black, I.W., Leung, D.Y., Chung, M.K., Vaughn, S.E.,
  Murray, R.D., Miller, D.P. and Arheart, K.L. (1997), Cardioversion guided by
  transesophageal echocardiography: The ACUTE pilot study - A randomized,
  controlled trial. Annals of Internal Medicine, 126 (3), 200-&.
Abstract: Background: Electrical cardioversion in patients with atrial fibrillation is
  associated with an increased risk for embolic stroke. Screening for atrial thrombi
  with transesophageal echocardiography (TEE) before cardioversion should, in many
  patients, safely permit cardioversion to be done earlier than would be possible with
  prolonged conventional, anticoagulation therapy. Objective: To compare the
  feasibility and safety of TEE-guided early cardioversion with those of conventional
  management of cardioversion in patients with atrial fibrillation. Design: Randomized,
  multicenter clinical trial. Setting: 10 hospitals in the United States, Europe, and
  Australia. Patients: 126 patients who had atrial fibrillation lasting longer than 2 days
  and were having electrical cardioversion. Intervention: Conventional therapy or early,
  TEE-guided cardioversion with short-term anticoagulation therapy. Outcome
  Measures: Feasibility outcome variables were frequency of cardioversion and times
  to cardioversion and sinus rhythm. Safety outcomes were ischemic stroke, transient
  ischemic attack, systemic embolization, bleeding, and detected episodes of clinical
  hemodynamic instability occurring as long as 4 weeks after cardioversion. Results:
  62 patients were randomly assigned to receive TEE-guided cardioversion; IEE was
  done in 56 (90%) of these patients. Atrial thrombi were detected in 7 patients (13%)
  and led to the postponement of cardioversion. Cardioversion was successful in 38 of
  45 patients (84%) who had early cardioversion. No embolization occurred with this
  strategy. Of the 64 patients receiving conventional therapy, 37 (58%) had
  cardioversion, which was successful in 28 patients (76%). One patient had a
  peripheral embolic event. The time to cardioversion was shorter in the TEE group
  (0.6 weeks [95% Cl, 0.3 to 0.9 weeks] compared with 4.8 weeks [Cl, 3.8 to 5.7
  weeks]; P < 0.01). The incidence of clinical hemodynamic instability and bleeding
  complications tended to be greater in the conventional therapy group. Conclusions:
  These results suggest that TEE-guided cardioversion with short-term anticoagulation
  therapy is feasible and safe. The use of TEE may allow cardioversion to be done
  earlier, may decrease the risk for embolism associated with cardioversion, and may
  be associated with less clinical instability than conventional therapy. A large
  multicenter study to confirm these findings is currently under way
Keywords:                                                         ACUTE/ANATOMIC
  CORRELATIONS/anticoagulants/anticoagulation/atrial                fibrillation/ATRIAL
  MECHANICAL                                                        FUNCTION/clinical
  ORIENTATION/incidence/ischemic                  stroke/management/MITRAL-VALVE
  DISEASE/outcome/outcomes/PHYSICIANS/SPONTANEOUS                                  ECHO
  echocardiography/transient/transient       ischemic     attack/TWO-DIMENSIONAL
Gurwitz, J.H., Gore, J.M., Goldberg, R.J., Barron, H.V., Breen, T., Rundle, A.C., Sloan,
  M.A., French, W. and Rogers, W.J. (1998), Risk for intracranial hemorrhage after
  tissue plasminogen activator treatment for acute myocardial infarction. Annals of
  Internal Medicine, 129 (8), 597-+.
Abstract: Background: The efficacy of thrombolytic therapy in reducing mortality from
  acute myocardial infarction has been unequivocally shown. However, thrombolysis
  is related to bleeding complications, including intracranial hemorrhage. Objective:
  To determine the frequency of and risk factors for intracranial hemorrhage after
  recombinant tissue-type plasminogen activator (tPA) given for acute myocardial
  infarction in patients receiving usual care. Design: Large national registry of patients
  who have had acute myocardial infarction. Setting: 1484 U.S. hospitals. Patients: 71
  073 patients who had had acute myocardial infarction from 1 June 1994 to 30
  September 1996, received tPA as the initial reperfusion strategy, and did not receive
  a second dose of any thrombolytic agent. Measurement: Intracranial hemorrhage
  confirmed by computed tomography or magnetic resonance imaging. Results: 673
  patients (0.95%) were reported to have had intracranial hemorrhage during
  hospitalization for acute myocardial infarction; 625 patients (0.88%) had the event
  confirmed by computed tomography or magnetic resonance imaging. Of the 625
  patients with confirmed intracranial hemorrhage, 331 (53%) died during
  hospitalization. An additional 158 patients (25.3%) who survived to hospital
  discharge had residual neurologic deficit. In multivariable models for the main
  effects of candidate risk factors, older age, female sex, black ethnicity, systolic blood
  pressure of 140 mm Hg or more, diastolic blood pressure of 100 mm Hg or more,
  history of stroke, tPA dose more than 1.5 mg/kg, and lower body weight were
  significantly associated with intracranial hemorrhage. Conclusions: Intracranial
  hemorrhage is a rare but serious complication of tPA in patients with acute
  myocardial infarction. Appropriate drug dosing may reduce the risk for this
  complication. Other therapies, such as primary coronary angioplasty, may be
  preferable in patients with acute myocardial infarction who have a history of stroke
Keywords:         acute/acute         myocardial         infarction/age/angioplasty/blood
  hemorrhage/magnetic                      resonance/magnetic                    resonance
  imaging/models/mortality/myocardial                             infarction/percutaneous
  factors/sex/STROKE/therapy/thrombolysis/THROMBOLYTIC                  THERAPY/tissue
  plasminogen                                                              activator/tissue
Smith, M.A., Doliszny, K.M., Shahar, E., McGovern, P.G., Arnett, D.K. and Luepker,
  R.V. (1998), Delayed hospital arrival for acute stroke: The Minnesota stroke survey.
  Annals of Internal Medicine, 129 (3), 190-+.
Abstract: Background: Although recent advances have been made in the treatment of
  acute stroke, patients often arrive at the hospital too late to receive the maximum
  benefit from these new therapies. Objective: To investigate characteristics that
  influence the time from symptom onset to hospital arrival (delay time) for patients
  with acute stroke. Design: Retrospective medical record review. Setting:
  Minneapolis-St. Paul metropolitan hospitals. Patients: A 50% random sample of all
  patients 30 to 79 years of age who were hospitalized with acute stroke from 1991 to
  1993. Measurements: Patients were identified through discharge diagnosis lists by
  using the International Classification of Diseases, 9th Revision. Trained nurses
  abstracted the medical records. Stroke events were validated by using neuroimaging
  reports and additional clinical criteria (1895 patients). An accelerated failure time
  model was used to identify patient characteristics that independently predicted delay
  time. For 70% of patients (n = 1334), delay time was calculated from the medical
  record by subtracting the recorded time of symptom onset from the admission time.
  For the remaining 30% of patients (n = 561), the time of symptom onset was not
  recorded, and an approximate delay time was estimated from all available
  information. Results: Among patients with a calculated delay time, half arrived
  within 3 hours of symptom onset and 90% arrived within 24 hours. Patients with
  approximated delay times tended to have longer delays, and less than 40% of these
  patients arrived within 24 hours of symptom onset. Some characteristics associated
  (P < 0.05) with longer delay included Asian/Pacific Islander ethnicity, dependence in
  any activities of daily living before stroke, and several symptoms at stroke onset.
  Characteristics associated (P < 0.05) with shorter delay included admission through
  the emergency department, presence of syncope or seizures at stroke onset, previous
  myocardial infarction, abnormal mental status, and greater disability at presentation
  (measured by the Rankin scale). Conclusions: Most patients arrive at the hospital too
  late to receive the maximum benefit from emerging stroke therapies. Efforts to
  reduce delays in hospital arrival after acute stroke can maximize the effectiveness of
  these thera pies by specifically targeting persons at risk for longer delay
Keywords: activities of daily living/acute/ACUTE ISCHEMIC STROKE/ACUTE
  SSIONALS/hospital/INTERVENTION/myocardial                               infarction/patient
  DELAY/RACE/seizures/SPECIAL-WRITING-                               GROUP/stroke/stroke
  onset/THROMBOLYSIS/TIME/time factors/treatment
Tonelli, M., Moye, L., Sacks, F.M., Kiberd, B. and Curhan, G. (2003), Pravastatin for
  secondary prevention of cardiovascular events in persons with mild chronic renal
  insufficiency. Annals of Internal Medicine, 138 (2), 98-104.
Abstract: Background: Cardiovascular disease is a common cause of morbidity and
  death in persons with renal insufficiency. Although 3-hydroxy-3methylglutaryl
  coenzyme A reductase inhibitors (statins) are effective for secondary prevention of
  cardiovascular events in the general population, they have not been specifically
  studied in chronic renal insufficiency. Objective: To determine whether pravastatin is
  effective and safe for secondary prevention of cardiovascular events in persons with
  chronic renal insufficiency. Design: Post hoc subgroup analysis of a randomized,
  double-blind, placebo- controlled trial. Setting: The Cholesterol and Recurrent
  Events (CARE) study, a randomized trial of pravastatin versus placebo in 4159
  participants with previous myocardial infarction and total plasma cholesterol levels
  less than 6.21 mmol/L (<240 mg/dL). Participants: 1711 participants with chronic
  renal insufficiency defined by creatinine clearance less than or equal to 75 mL/min,
  using the Cockcroft-Gault equation. Measurements: The primary outcome was death
  from coronary disease or symptomatic nonfatal myocardial infarction. Results: After
  a median follow-up of 58.9 months, the incidence of the primary end point was lower
  in participants receiving pravastatin than in those receiving placebo (adjusted hazard
  ratio, 0.72 [95% Cl, 0.55 to 0.95]; P = 0.02). Pravastatin was associated with lower
  adjusted hazard ratios for major coronary events (0.72 [Cl, 0.59 to 0.88]; P = 0.001)
  and coronary revascularization (0.65 [Cl, 0.50 to 0.83]; P = 0.001), but not total
  mortality (0.81 [Cl, 0.61 to 1.08]; P = 0.14) or stroke (0.62 [Cl, 0.39 to 1.00]; P =
  0.051). Tests for interaction suggested that the observed benefit was independent of
  the presence and severity of renal insufficiency. Incidence of side effects was similar
  in persons receiving pravastatin and those receiving placebo. Conclusions: These
  data suggest that pravastatin is effective and appears safe for secondary prevention of
  cardiovascular events in persons with mild chronic renal insufficiency. Since statins
  may be underused in this setting, physicians should consider prescribing them for
  patients with chronic renal insufficiency and known coronary disease
Keywords:                                           Canada/cardiovascular/cardiovascular
  events/CARE/cholesterol/CHOLESTEROL                     LEVELS/chronic              renal
  insufficiency/coronary/coronary              disease/coronary            events/coronary
   prevention/SERUM CREATININE/severity/statins/stroke/TRIAL/USA/WEST
Yao, H.S. and Fujishima, M. (2001), Cerebral blood flow and metabolism in silent brain
   infarction and related cerebrovascular disorders. Annals of Medicine, 33 (2), 98-102.
Abstract: The appropriate management of silent stroke requires better understanding of
   the haemodynamic status in the brain, However, only a few studies have examined
   cerebral blood flow and metabolism in subjects with silent stroke. Positron emission
   tomography demonstrated a slight decrease in cortical blood flow with an increase in
   oxygen extraction fraction (ie misery perfusion) in subjects with silent brain
   infarction, whereas both cerebral blood flow and oxygen metabolism decreased in
   patients with symptomatic brain infarction (matched hypoperfusion), These findings
   confirm that brain circulation is haemodynamically compromised in subjects with
   silent stroke. Another important point is that subcortical silent stroke may induce a
   reduction in cortical blood flow and metabolism by a disconnection mechanism (ie
   diaschisis) between the cortex and the subcortical structures, Silent infarction is not
   innocuous in terms of compromised cerebral circulation, which may lead to cognitive
   decline or subsequent clinical stroke, In the future, further developments in
   functional imaging will permit a more sophisticated analysis of brain circulation and
   metabolism in silent stroke
Keywords: ABNORMALITIES/ADULTS/asymptomatic stroke/blood flow/brain/brain
   infarction/cerebral/cerebral         blood        flow/cerebrovascular/cerebrovascular
   /MEDICINE/metabolism/misery perfusion/MRI/oxygen/oxygen extraction/oxygen
   metabolism/perfusion/positron                                                   emission
Ropper, A.H. (1992), Neurological Intensive-Care. Annals of Neurology, 32 (4),
Abstract: Neurological intensive care has evolved from the principles of respiratory care
   established during the poliomyelitis epidemics into a broad field encompassing all of
   the acute and serious aspects of neurological disease. The economic and political
   complexities of modern intensive care play a major role in organizing a unit and
   building a program. Central themes of practice in modern neurological intensive care
   units include the clinical physiology of intracranial pressure, cerebral blood flow, and
   brain electrical activity; the systemic abnormalities and medical complications of
   nervous system diseases; postoperative care; and management of neuromuscular
   respiratory failure. Treatment of severe stroke and cerebral hemorrhage, brain death,
   ethical dilemmas of severe neurological illnesses, and the neurological features of
   critically ill medical patients are also becoming neurological intensive care pursuits.
   The "neurointensivist" is trained to defragment medical care by combining
   knowledge of neurological diseases with the techniques of intensive care. Future
   directions include the clinical implementation of brain resuscitation and
   brain-sparing therapies, sophisticated monitoring of electrophysiological and
   intracranial physiological indices, and further understanding of the dysfunction of
   other organs that follows brain and nerve failure
Jiang, N., Moyle, M., Soule, H.R., Rote, W.E. and Chopp, M. (1995), Neutrophil
  inhibitory factor is neuroprotective after focal ischemia in rats. Annals of Neurology,
  38 (6), 935-942.
Abstract: We tested the neuroprotective potential of neutrophil inhibitory factor (rNIF),
  a novel 41-kd recombinant glycoprotein derived from a hookworm, in a model of
  focal cerebral ischemia in the rat. Male Wistar rats were assigned to treatment with
  rNIF and vehicle. Middle cerebral artery occlusion (MCAO) for 2 hours was induced
  by insertion of an intraluminal suture. Infusion of the drug was initiated at the onset
  of reperfusion. Infarct volume was determined 48 hours after reperfusion.
  Neutrophils were measured within the ischemic tissue by myeloperoxidase (MPG)
  staining. Treatment with rNIF resulted in a 48% reduction in cerebral infarction
  compared with control animals (P < 0.01). Neutrophil accumulation in the ischemic
  brains of rNIF-treated rats was reduced significantly (p < 0.01) compared with
  control animals. The number of neutrophils within the infaraed tissue correlated
  positively with the size of the area of infarction (p < 0.001, r = 0.6) within
  representative cerebral coronal sections. We demonstrated a significant
  neuroprotective effect of rNIF with continuous treatment for 48 hours following 2
  hours of MCAO. The neuroprotective effect was correlated with a reduced number of
  neutrophils within the ischemic tissue. These results demonstrate potential
  therapeutic properties of rNIF in the management of stroke
Keywords:       ADHESION           MOLECULE/CELL/cerebral              infarction/cerebral
  ischemia/CEREBRAL-ARTERY                                      OCCLUSION/focal/focal
Lutsep, H.L., Albers, G.W., DeCrespigny, A., Kamat, G.N., Marks, M.P. and Moseley,
  M.E. (1997), Clinical utility of diffusion-weighted magnetic resonance imaging in
  the assessment of ischemic stroke. Annals of Neurology, 41 (5), 574-580.
Abstract: Diffusion-weighted imaging (DWI) detects small changes in water diffusion
  that occur in ischemic brain. This study evaluated the clinical usefulness of a
  phase-navigated spin-echo DWI sequence compared with T2-weighted magnetic
  resonance imaging (T2W MRI) in patients with cerebral ischemia and assessed
  apparent diffusion coefficient (ADC) and T2-weighted imaging (T2WI) changes over
  time. ADC values and T2 ratios of image intensity were measured from the region of
  ischemia and from the corresponding contralateral brain region. The clinical histories
  of patients with DWI scans obtained over the course of I year were reviewed to
  ascertain whether DM aided in clinical diagnosis or management. Of 103 scans
  obtained a mean of 10.4 days after symptom onset, DWI detected six lesions not seen
  on T2WI and discriminated two new infarcts from old lesions. DWI was most useful
  within 48 hours of the ictus. The evolution of ADC values and T2 ratios was
  evaluated in 26 cases with known symptom onset times. ADC values were low at
  less than 1 week after stroke onset and became elevated at chronic time points. T2
  ratios were near normal acutely, increasing thereafter. DWI was superior to T2W
  MRI in detecting acute stroke, whereas both techniques assisted in determining
  lesion age
Keywords:                                             acute/age/BRAIN/cerebral/cerebral
  mic             stroke/magnetic              resonance/magnetic               resonance
  imaging/management/MRI/RATS/stroke/T2-WEIGHTED MRI
Lovblad, K.O., Baird, A.E., Schlaug, G., Benfield, A., Siewert, B., Voetsch, B., Connor,
  A., Burzynski, C., Edelman, R.R. and Warach, S. (1997), Ischemic lesion volumes in
  acute stroke by diffusion-weighted magnetic resonance imaging correlate with
  clinical outcome. Annals of Neurology, 42 (2), 164-170.
Abstract: Diffusion-weighted magnetic resonance imaging detects ischemic injury
  within minutes after onset, and has been used to demonstrate drug efficacy in animal
  models of stroke, In 50 patients diagnosed with acute ischemic stroke (<24-hour
  duration) within the middle cerebral artery territory, lesion volume was measured by
  diffusion-weighted imaging, Thirty-four patients also had volumes measured by
  T2-weighted imaging chronically (median time, 7.5 weeks; mean, 15.9 weeks),
  Clinical severity was measured by the National Institutes of Health Stroke Scale
  Score and the Barthel index, Acute lesion volumes correlated with the acute stroke
  scale score (r = 0.56), the chronic stroke scale score (r = 0.63), and chronic lesion
  volumes (r = 0.84). Chronic volumes correlated with the chronic stroke scale score (r
  = 0.86) and the Barthel index (r = -0.60). When only cortically based lesions were
  considered, the correlations relating acute lesion volume measured by
  diffusion-weighted imaging (r = 0.61) and chronic lesion volume measured by
  T2-weighted imaging (r = 0.90) to the chronic stroke scale score were higher, These
  results provide evidence that lesion volumes determined by diffusion-weighted
  imaging acutely may be predictive of clinical severity and outcome, and may support
  a role for diffusion-weighted imaging in the assessment of acute stroke therapies in
  clinical trials
Keywords: acute/ACUTE CEREBRAL INFARCTION/animal/cerebral/clinical
  trials/injury/ischemic stroke/magnetic resonance/magnetic resonance imaging/middle
Neumann-Haefelin, T., Moseley, M.E. and Albers, G.W. (2000), New magnetic
  resonance imaging methods for cerebrovascular disease: Emerging clinical
  applications. Annals of Neurology, 47 (5), 559-570.
Abstract: During the 1990s, novel magnetic resonance imaging (MRT) techniques have
  emerged that allow the noninvasive and rapid assessment of normal brain functioning
  and cerebral pathophysiology. Some of these techniques, including diffusion-
  weighted imaging and perfusion-weighted imaging, have already been used
  extensively in specialized centers for the evaluation of patients with cerebrovascular
  disease. Evidence is now rapidly accumulating that both diffision- and perfusion-
  weighted imaging, particularly when used in combination with high-speed MR
  angiography, will lead to improvements in the clinical management of acute stroke
  patients. Other novel MR techniques, such as spectroscopic imaging, diffusion tensor
  imaging, and blood oxygenation level-dependent functional MRI, have not yet
  assumed a definitive role in the diagnostic evaluation of cerebrovascular disease.
  However, they are promising research tools that provide noninvasive data about
  infarct evolution as well as mechanisms of stroke recovery. In this article, we review
  the basic principles underlying these novel MRI techniques and outline their current
  and anticipated future impact on the diagnosis and management of patients with
  cerebrovascular disease
Keywords:              acute/ACUTE               ISCHEMIC                STROKE/acute
  REBRAL                               BLOOD-FLOW/cerebrovascular/cerebrovascular
  disease/combination/diagnosis/diffusion              tensor/DIFFUSION-WEIGHTED
  MRI/disease/evaluation/HUMAN                     BRAIN/imaging/INTRACEREBRAL
  HEMORRHAGE/magnetic                        resonance/magnetic                resonance
   iew/SPIN-ECHO/stroke/TENSOR                    MRI/TRANSIENT                GLOBAL
Kirkham, F.J., Calamante, F., Bynevelt, M., Gadian, D.G., Evans, J.P.M., Cox, T.C. and
   Connelly, A. (2001), Perfusion magnetic resonance abnormalities in patients with
   sickle cell disease. Annals of Neurology, 49 (4), 477-485.
Abstract: Neurological complications are common in sickle cell disease (SCD).
   However, it is often difficult to relate the clinical presentation to conventional
   neuroimaging, because subclinical infarction is common and stroke has been
   described in the absence of large-vessel disease. We studied 48 patients with SCD
   aged 4-34 (median 13) years with T2-weighted, diffusion and perfusion magnetic
   resonance imaging (MRI) and with MR angiography. Forty-four underwent
   transcranial Doppler (TCD). Abnormalities on perfusion imaging were seen in 25
   cases, 24 of whom had been symptomatic. The remaining patient had evidence of
   executive dysfunction and reduced perfusion in the frontal lobes. The perfusion
   abnormality was larger than the area of infarction in 9 patients and was seen in an
   arterial distribution with no infarction in a further 9. In 3 patients with transient
   ischemic attacks, perfusion abnormalities were demonstrated in the absence of any
   other neuroimaging abnormalities, and perfusion changes were seen in 3 others
   despite normal MR angiography and TCD. Perfusion abnormalities are associated
   with neurological symptoms in patients with SCD, whether or not MRT, MR
   angiography, and TCD are abnormal. It is likely that this technique will guide
   management in individual patients
Keywords:                  abnormalities/aged/ANEMIA/ANGIOGRAPHY/CEREBRAL
   maging/infarction/ischemic/magnetic             resonance/magnetic          resonance
   n/perfusion                          imaging/RISK/sickle                           cell
   disease/STROKE/transcranial/TRANSCRANIAL                 DOPPLER/transient/transient
   ischemic attacks
Wintermark, M., Reichhart, M., Thiran, J.P., Maeder, P., Chalaron, M., Schnyder, P.,
   Bogousslavsky, J. and Meuli, R. (2002), Prognostic accuracy of cerebral blood flow
   measurement by perfusion computed tomography, at the time of emergency room
   admission, in acute stroke patients. Annals of Neurology, 51 (4), 417-432.
Abstract: The purpose of this study was to determine the prognostic accuracy of
   perfusion computed tomography (CT), performed at the time of emergency room
   admission, in acute stroke patients. Accuracy was determined by comparison of
   perfusion CT with delayed magnetic resonance (MR) and by monitoring the
   evolution of each patient's clinical condition. Twenty-two acute stroke patients
   underwent perfusion CT covering four contiguous 10mm slices on admission, as well
   as delayed MR, performed after a median interval of 3 days after emergency room
   admission. Eight were treated with thrombolytic agents. Infarct size on the admission
   perfusion CT was compared with that on the delayed diffusion-weighted (DWI)MR,
   chosen as the gold standard. Delayed magnetic resonance angiography and
   perfusion-weighted MR were used to detect recanalization. A potential recuperation
   ratio, defined as PRR = penumbra size/(penumbra size + infarct size) on the
   admission perfusion CT, was compared with the evolution in each patient's clinical
   condition, defined by the National Institutes of Health Stroke Scale (NIHSS). In the 8
   cases with arterial recanalization, the size of the cerebral infarct on the delayed
   DWI-MR was larger than or equal to that of the infarct on the admission perfusion
  CT, but smaller than or equal to that of the ischemic lesion on the admission
  perfusion CT; and the observed improvement in the NIHSS correlated with the PRR
  (correlation coefficient = 0.833). In the 14 cases with persistent arterial occlusion,
  infarct size on the delayed DWI-MR correlated with ischemic lesion size on the
  admission perfusion CT (r = 0.958). In all 22 patients, the admission NIHSS
  correlated with the size of the ischemic area on the admission perfusion CT (r =
  0.627). Based on these findings, we conclude that perfusion CT allows the accurate
  prediction of the final infarct size and the evaluation of clinical prognosis for acute
  stroke patients at the time of emergency evaluation. It may also provide information
  about the extent of the penumbra. Perfusion CT could therefore be a valuable tool in
  the early management of acute stroke patients
Keywords: acute/ACUTE ISCHEMIC STROKE/acute stroke/angiography/arterial
  occlusion/ARTERY/blood             flow/cerebral/cerebral     blood       flow/cerebral
  infarct/CIRCULATION/computed                                        tomography/CT/CT
  ACUTE STROKE/information/ischemic/magnetic resonance/magnetic resonance
Kidwell, C.S., Saver, J.L., Starkman, S., Duckwiler, G., Jahan, R., Vespa, P.,
  Villablanca, J.P., Liebeskind, D.S., Gobin, Y.P., Vinuela, F. and Alger, J.R. (2002),
  Late secondary ischemic injury in patients receiving intraarterial thrombolysis.
  Annals of Neurology, 52 (6), 698-703.
Abstract: Although animal models have demonstrated that late secondary cerebral
  injury after arterial occlusion and subsequent recanalization may limit the benefit of
  reperfusion therapy, this phenomenon has not been well characterized in humans.
  Diffusion-perfusion magnetic resonance imaging studies were performed before
  treatment, early after treatment, and at day 7 in patients undergoing vessel
  recanalization with intraarterial thrombolytics. Among 18 patients studied, mean age
  was 71 (range, 27-94), and median entry National Institutes of Health Stroke Scale
  score was 13 (range, 6-25). Early after recanalization, partial or complete
  normalization of diffusion imaging abnormalities occurred in 8 of 18 (44%) patients.
  Among the eight patients with early diffusion imaging reversal, late secondary injury
  by day 7 occurred in 5 (63%), and sustained normalization of all reversed tissue
  occurred in 3 (38%). Pretreatment apparent diffusion coefficient values were lowest
  in regions experiencing no reversal (mean apparent diffusion coefficient, 608
  mum(2)/sec), intermediate in regions with reversal and secondary decline (617
  mum(2)/sec), and highest in regions with sustained reversal (663 mum(2)/sec). There
  was a trend toward less improvement in neurological deficit in patients with
  secondary injury versus patients with sustained reversal. In the future, late secondary
  tissue injury may become an important therapeutic target for postreperfusion
  neuroprotective therapies, with treatment efficacy monitored by serial diffusion
  magnetic resonance imaging
Keywords:               abnormalities/age/animal/animal             models/APPARENT
  DIFFUSION-COEFFICIENT/arterial                      occlusion/BRAIN/cerebral/cerebral
  injury/CEREBRAL-ARTERY                 OCCLUSION/diffusion            imaging/EARLY
  ISCHEMIA/imaging/INFARCTION/injury/ischemic/magnetic resonance/magnetic
  resonance                                                 imaging/models/neurological
  deficit/NEW-YORK/RATS/recanalization/reperfusion/secondary/secondary cerebral
DeKosky, S.T., Ikonomovic, M.D., Styren, S.D., Beckett, L., Wisniewski, S., Bennett,
  D.A., Cochran, E.J., Kordower, J.H. and Mufson, E.J. (2002), Upregulation of
  choline acetyltransferase activity in hippocampus and frontal cortex of elderly
  subjects with mild cognitive impairment. Annals of Neurology, 51 (2), 145-155.
Abstract: In Alzheimer's disease (AD), loss of cortical and hippocampal choline
  acetyltransferase (ChAT) activity has been correlated with dementia severity and
  disease duration, and it forms the basis for current therapies. However, the extent to
  which reductions in ChAT activity are associated with early cognitive decline has not
  been well established. We quantified ChAT activity in the hippocampus and four
  cortical regions (superior frontal, inferior parietal, superior temporal, and anterior
  cingulate) of 58 individuals diagnosed with no cognitive impairment (NCI; n = 26;
  mean age 81.4 +/- 7.3 years), mild cognitive impairment (MCI; n = 18; mean age
  84.5 +/- 5.7), or mild AD (n = 14; mean age 86.3 +/- 6.6). Inferior parietal cortex
  ChAT activity was also assessed in 12 subjects with end- stage AD (mean age 81.4
  +/- 4.3 years) and compared to inferior parietal cortex ChAT levels of the other three
  groups. Only the end-stage AD group had ChAT levels reduced below normal. In
  individuals with MCI and mild AD, ChAT activity was unchanged in the inferior
  parietal, superior temporal, and anterior cingulate cortices compared to NCI. In
  contrast, ChAT activity in the superior frontal cortex was significantly elevated
  above normal controls in MCI subjects, whereas the mild AD group was not different
  from NCI or MCI. Hippocampal ChAT activity was significantly higher in MCI
  subjects than in either NCI or AD. Our results suggest that cognitive deficits in MCI
  and early AD are not associated with the loss of ChAT and occur despite regionally
  specific upregulation. Thus, the earliest cognitive deficits in AD involve brain
  changes other than simply cholinergic system loss. Of importance, the cholinergic
  system is capable of compensatory responses during the early stage of dementia. The
  upregulation in frontal cortex and hippocampal ChAT activity could be an important
  factor in preventing the transition of MCI subjects to AD
Keywords:           activity/age/Alzheimer's          disease/ALZHEIMERS-DISEASE
  CERAD/BASAL                  FOREBRAIN/brain/cognitive               decline/cognitive
Arvin, K.L., Han, B.H., Du, Y.S., Lin, S.Z., Paul, S.M. and Holtzman, D.M. (2002),
  Minocycline markedly protects the neonatal brain against hypoxic-ischemic injury.
  Annals of Neurology, 52 (1), 54-61.
Abstract: Hypoxic-ischemic brain injury in the perinatal period is a major cause of
  morbidity and mortality. Presently, there are no proven effective therapies with
  which to safeguard the human neonatal brain against this type of injury. Minocycline,
  a semisynthetic tetracycline, has been shown to be neuroprotective in certain adult
  ischemic injury/stroke and neurodegenerative disease models. However,
  minocycline's neuroprotective effects have not been assessed after insults to the
  neonatal brain. We now report that minocycline administered either immediately
  before or immediately after a hypoxic- ischemic insult substantially blocks tissue
  damage in a rodent model of neonatal hypoxic-ischemic brain injury. Minocycline
  treatment prevents the formation of activated caspase-3, a known effector of
  apoptosis, as well as the appearance of a calpain cleaved substrate, a marker of
   excitotoxic/necrotic cell death. To our knowledge, this is the first report of a systemic
   treatment that can be administered after a hypoxic- ischemic insult, which provides
   robust, nearly complete neuroprotection to the developing brain. Our data suggest
   that minocycline or a related neuroprotective tetracycline may be a candidate to
   consider in human clinical trials to protect the developing brain against
   hypoxic-ischemic-induced damage
Keywords: adult/apoptosis/brain/brain injury/calpain/CEREBRAL-PALSY/clinical
   DEATH/neuroprotection/NEW-YORK/NEWBORN                      PIGLETS/NITRIC-OXIDE
Fisher, M. and Ratan, R. (2003), New perspectives on developing acute stroke therapy.
   Annals of Neurology, 53 (1), 10-20.
Abstract: The development of additional acute stroke therapies to complement and
   supplement intravenous recombinant tissue-type plasminogen activator within the
   first 3 hours after stroke onset remains an important and pressing need. Much has
   been teamed about the presumed target of acute stroke therapy, the ischemic
   penumbra, and clinically available imaging modalities such as magnetic resonance
   imaging and computed tomography hold great promise for at least partially
   identifying this region of potentially salvageable ischemic tissue. Understanding the
   biology of ischemia-related cell injury has also evolved rapidly. New treatment
   approaches to improve outcome after focal brain ischemia will likely be derived by
   looking at naturally occurring adaptive mechanisms such as those related to ischemic
   preconditioning and hibernation. Many clinical trials previously performed with a
   variety of neuroprotective and thrombolytic drugs provide many lessons that will
   help to guide future acute stroke therapy trials and enhance the likelihood of success
   in future trials. Combining knowledge from these three areas provides optimism that
   additional acute stroke therapies can be developed to maximize beneficial functional
   outcome in the greatest proportion of acute stroke patients possible
Keywords: acute/ACUTE ISCHEMIC STROKE/acute stroke/acute stroke
   therapy/BRAIN/brain            ischemia/CEREBRAL               BLOOD-FLOW/clinical
   trials/computed         tomography/drugs/EFFICACY               TRIAL/focal/functional
   outcome/imaging/injury/ischemia/ischemic/ischemic penumbra/knowledge/magnetic
   resonance/magnetic                                                             resonance
   ED MRI/plasminogen/plasminogen activator/RANDOMIZED CONTROLLED
   TRIAL/RT-PA                       STROKE/stroke/stroke                       onset/stroke
   therapy/therapy/thrombolytic/THROMBOLYTIC                              THERAPY/tissue
Pototschnig, C.A., Schneider, I., Eckel, H.E. and Thumfart, W.F. (1996), Repeatedly
   successful closure of the larynx for the treatment of chronic aspiration with the use of
   botulinum toxin A. Annals of Otology Rhinology and Laryngology, 105 (7), 521-524.
Abstract: Botulinum toxin A was used preoperatively to temporarily paralyze the
   intrinsic laryngeal muscles to hinder movements during the healing period after
   operation. In addition, toxin was injected into the cricopharyngeal muscle to allow a
   better passive drainage of the saliva into the esophagus. We treated six patients.
   Three suffered from chronic aspiration problems after multiple lower cranial nerve
  lesions, and three patients were apallic (after stroke and major brain injury). Two
  weeks before scheduled operation, we injected the toxin into the posterior
  cricoarytenoid muscles, the aryepiglottic muscles, and the vocalis muscle on both
  sides, as well as the cricopharyngeal muscle. The amount of injected toxin varied
  between 1.0 and 1.4 mt, equal to 200 to 280 units of botulinum toxin A (Dysport).
  After a complete palsy of these muscles (controlled by direct electromyography), a
  closure of the larynx was performed. After laminotomy and exposure of the
  intralaryngeal structures, the false vocal cords were mobilized and adapted with
  sutures. Because involuntary movements of the intralaryngeal musculature were
  absent, primary healing without complications occurred in all cases. Aspiration and
  related complications disappeared in all patients. In addition, the intensity of patient
  care could be considerably reduced. Preoperative use of botulinum toxin A allows
  sufficient laryngeal closure. This procedure is especially useful in the treatment of
  children and young adults, preserving the ability of Inter speech rehabilitation
  because of the return of voluntary movements of the intrinsic laryngeal muscles 6
  months after the injection. Furthermore, this technique, as minimal surgical
  intervention, can be performed in high-risk patients
Keywords: botulinum toxin/botulinum toxin A/brain/BRAIN-STEM/chronic
  treatment/stroke/SURGICAL-TREATMENT/young adults
Kim, T., Goodhart, K., Aviv, J.E., Sacco, R.L., Diamond, B., Kaplan, S. and Close, L.G.
  (1998), FEESST: A new bedside endoscopic test of the motor and sensory
  components of swallowing. Annals of Otology Rhinology and Laryngology, 107 (5),
Abstract: We here introduce an office or bedside method of evaluating both the motor
  and sensory components of swallowing, called fiberoptic endoscopic evaluation of
  swallowing with sensory testing (FEESST). FEESST combines the established
  endoscopic evaluation of swallowing with a technique that determines
  laryngopharyngeal (LP) sensory discrimination thresholds by endoscopically
  delivering air pulse stimuli to the mucosa innervated by the superior laryngeal nerve.
  Endoscopic assessment of LP sensory capacity followed by endoscopic visualization
  of deglutition was prospectively performed 148 times on 133 patients with dysphagia
  over an 8-month period. The patients had a variety of underlying diagnoses, with
  stroke and chronic neurologic disease predominating (n = 94). Subsequent to LP
  sensory testing, a complete dysphagia evaluation was conducted. Various food and
  liquid consistencies were dyed green, and attention was paid to their management
  throughout the pharyngeal stage of swallowing. Evidence of latent swallow initiation,
  pharyngeal pooling and/or residue, laryngeal penetration, laryngeal aspiration, and/or
  reflux was noted. Recommendations for therapeutic intervention were based on
  information obtained during the FEESST and often involved the employment of
  compensatory swallowing strategies, modification of the diet or its presentation,
  placement on non- oral feeding status, and/or referral to other related specialists. All
  patients successfully completed the examination. In 111 of the evaluations (75%),
  severe (>6.0 mm Hg air pulse pressure [APP]) unilateral or bilateral LP sensory
  deficits were found. With puree consistencies, 31% of evaluations with severe
  deficits, compared to 5% of evaluations with either normal sensitivity or moderate
  (4.0 to 6.0 mm Hg APP) LP sensory deficits, displayed aspiration (p < .001, chi 2
  test). With puree consistencies, 69% of evaluations with severe deficits, compared to
  24% with normal or moderate deficits, displayed laryngeal penetration (p < .001,
  chi(2) test). FEESST allows the clinician to obtain a comprehensive bedside
  assessment of swallowing that is performed as the initial swallowing evaluation for
  the patient with dysphagia
Keywords:                  ACUTE                        STROKE/aspiration/ASPIRATION
Fagan, S.C., Zarowitz, B.J. and Robert, S. (1992), Brain Attack - An Indication for
  Thrombolysis. Annals of Pharmacotherapy, 26 (1), 73-80.
Abstract: OBJECTIVE: The primary objective of this article is to introduce the reader to
  the use of thrombolytics in the acute treatment of ischemic stroke. Theory and
  experimental evidence to support this approach are emphasized in addition to
  potential adverse effects of thrombolysis. DATA SOURCES: A MEDLINE search
  was used to identify pertinent literature, including reviews. STUDY SELECTION:
  Studies were selected for detailed review if they involved stroke patients and
  addressed possible toxicities of therapy. Any abstracts concerning ongoing clinical
  trials also were reviewed. DATA EXTRACTION: Data from animal investigations
  using tissue plasminogen activator for the acute treatment of several models of
  cerebral ischemia were used to support the importance of early treatment (within six
  hours of symptom onset). Also, studies performed in animal models of stroke
  revealed that thrombolysis could be accomplished safely in acute ischemic stroke.
  All human studies published to date are anecdotal case reports, but point to the safety
  of thrombolysis if administered early. Reviews of ongoing multicenter trials are
  taken from published abstracts and proceedings. DATA SYNTHESIS: Thrombolysis
  holds promise as a hyperacute therapy for acute stroke; however, the risk of
  intracerebral hemorrhage remains. Crucial to the success of this and any other
  therapy for acute stroke is the ability to treat patients within hours of symptom onset.
  Also, the importance of concomitant medications such as heparin and aspirin has not
  yet been addressed. CONCLUSIONS: Pharmacists need to be knowledgeable of new
  treatments of stroke and the risks associated with them. As patient educators,
  pharmacists can contribute to public awareness by promoting the early recognition of
  stroke symptoms. As pharmacotherapists, pharmacists need to understand the risks
  and the important monitoring parameters related to thrombolysis. The results of
  ongoing multicenter clinical trials are awaited before making a final judgement on
  the usefulness of thrombolysis in acute ischemic stroke
Keywords:             ACUTE                 MYOCARDIAL-INFARCTION/CEREBRAL
  INFARCTION/EMBOLIC                                           STROKE/INTRAVENOUS
Adubofour, K.O., Kajiwara, G.T., Goldberg, C.M. and KingAngell, J.L. (1996),
  Oxybutynin-induced heatstroke in an elderly patient. Annals of Pharmacotherapy, 30
  (2), 144-147.
Abstract: OBJECTIVE: TO report an elderly patient with oxybutynin-induced
  heatstroke and to remind clinicians of the possibility of drugs as an etiology of
  hyperthermia. CASE SUMMARY: An elderly man was admitted to the emergency
  department in a confused state. The day of admission was the hottest of the summer
  months in the San Francisco area. Because his rectal temperature was 40 degrees C
  and his skin was hot and dry, he was immediately packed in ice, given intravenous
  NaCl 0.9%, and a cooling fan was used to aid in external cooling. The patient was
   taking oxybutynin chloride, a drug with anticholinergic properties. The previous
   summer he had been admitted with a rectal temperature of 41.1 degrees C. No
   infectious etiology could be found. He was discharged in an improved state after a
   48-hour observation period. The drug was discontinued. DISCUSSION: It is
   important to recognize heatstroke and institute prompt management because of the
   high mortality associated with this thermoregulatory disorder. Prompt treatment
   should consist of rapid cooling and vigorous cardiopulmonary support.
   CONCLUSIONS: The possibility of drug-induced heatstroke should be investigated
   in all patients admitted during the summer months with unexplained hyperthermia,
   especially the elderly. To our knowledge this is the first reported case of heatstroke
   associated with the use of oxybutynin
Majid, A., Delanty, N. and Kantor, J. (2001), Antiplatelet agents for secondary
   prevention of ischemic stroke. Annals of Pharmacotherapy, 35 (10), 1241-1247.
Abstract: OBJECTIVE, To review and summarize the efficacy, mechanisms of action,
   and cost of the options available when choosing antiplatelet agents for secondary
   stroke prevention. DATA SOURCES: This article is based on a review of the
   literature found with MEDLINE, CINAHL, and Cochrane Reviews (1980-June 2000)
   and abstracts from relevant international scientific meetings. We searched for the
   terms aspirin, ticlopidine, dipyridamole, antiplatelet, and clopidogrel. STUDY
   SELECTION: English-language articles, both reviews and original studies, were
   evaluated, and all information considered relevant was included in this review. In
   addition, guidelines from the American Heart Association are Included. DATA
   SYNTHESIS; Aspirin is a relatively inexpensive and effective agent fbr secondary
   stroke prevention, and lower doses of aspirin appear as effective as higher doses.
   Ticlopidine has been used alone or in combination with aspirin, but serious adverse
   effects have limited its use. Clopidogrel has emerged as a safe and effective
   alternative to ticlopidine and lacks some of the serious adverse effects associated
   with ticlopidine, but is not superior to aspirin in secondary stroke prevention. Unlike
   previous studies, one recent trial showed that dipyridamole in combination with
   aspirin is superior to aspirin alone. CONCLUSIONS: Antiplatelet therapy is a key
   component of secondary prevention strategies in ischemic stroke. While aspirin has
   been the cornerstone in the management of stroke, other classes of antiplatelet drugs
   present new opportunities to optimize antiplatelet therapy
Keywords: adverse effects/American Heart Association/AMERICAN-HEART-
   ASSOCIATION/antiplatelet/antiplatelet                                 agents/antiplatelet
   emic                      stroke/MANAGEMENT/management                                 of
   prevention/secondary       stroke    prevention/SELECTION/STABLE             ANGINA-
   PECTORIS/strategies/stroke/stroke           prevention/studies/therapy/THROMBOTIC
Erstad, B.L. (2001), Antifibrinolytic agents and desmopressin as hemostatic agents in
   cardiac surgery. Annals of Pharmacotherapy, 35 (9), 1075-1084.
Abstract: OBJECTIVE: To review the use of systemic hemostatic medications for
   reducing bleeding and transfusion requirements with cardiac surgery. DATA
  SOURCES: Articles were obtained through computerized searches involving
  MEDLINE (from 1966 to September 2000). Additionally, several textbooks
  containing information on the diagnosis and management of bleeding associated with
  cardiac surgery were reviewed. The bibliographies of retrieved publications and
  textbooks were reviewed for additional references. STUDY SELECTION: Due to the
  large number of randomized investigations involving systemic hemostatic
  medications for reducing bleeding associated with cardiac surgery, the article
  selection process focused on recent randomized controlled trials, meta-analyses, and
  pharmacoeconomic evaluations. DATA EXTRACTION: The primary outcomes
  extracted from the literature were blood loss and associated transfusion requirements,
  although other outcome measures such as mortality were extracted when available.
  DATA SYNTHESIS: Although the majority of investigations for reducing cardiac
  bleeding and transfusion requirements have involved aprotinin, evidence from recent
  meta-analyses and randomized trials indicates that the synthetic antifibrinolytic
  agents, aminocaproic acid and tranexamic acid, have similar clinical efficacy.
  Additionally, aminocaproic acid (and to a lesser extent tranexamic acid) is much less
  costly. More comparative information of hemostatic agents is needed relative to
  other outcomes (e.g., reoperation rates, myocardial infarction, stroke). There is
  insufficient evidence to recommend the use of desmopressin for reducing bleeding
  and transfusion requirements in cardiac surgery, although certain subsets of patients
  may benefit from its use. CONCLUSIONS: Of the medications that have been used
  to reduce bleeding and transfusion requirements with cardiac surgery, the
  antifibrinolytic agents have the best evidence supporting their use. Aminocaproic
  acid is the least costly therapy based on medication costs and transfusion
Keywords: aminocaproic acid/aprotinin/ASPIRIN/bleeding/BLOOD-LOSS/cardiac
  surgery/CARDIOPULMONARY                                                BYPASS/clinical
  OIC                                        ACID/EXTRACTION/infarction/LOW-DOSE
  infarction/OPEN-HEART- SURGERY/outcome/outcomes/randomized controlled
  trials/randomized trials/review/SELECTION/stroke/surgery/therapy/TRANEXAMIC
  ACID/tranexamic acid/TRANSFUSION REQUIREMENTS/trials
Lackie, C.L., Garbarino, K.A. and Pruetz, J.A. (2002), Warfarin therapy for atrial
  fibrillation in the elderly. Annals of Pharmacotherapy, 36 (2), 200-204.
Abstract: OBJECTIVE: To evaluate a clinical practice model that addresses special
  needs for managing anticoagulation in a community- dwelling elderly population
  with atrial fibrillation and high risk of stroke. METHODS: Medical records of 18
  patients (mean age 82 y) followed by the Geriatric Ambulatory Program over 2 years,
  with a target international normalized ratio (INR) of 2.0-3.0, were reviewed. Risk
  factors for stroke, number and results of INR tests, suspected reasons for suboptimal
  response, and adverse events were analyzed. Patients were defined as having
  cognitive impairment if they had a Folstein Mini-Mental State Exam score less than
  or equal to26. Functional impairment was defined by greater than or equal to2
  disabilities in activities of daily living. RESULTS: Eighty- three percent (15/18) had
  greater than or equal to2 additional stroke risk factors. Fifty-one percent (273/541) of
  INR responses were therapeutic. Female gender (p = 0.015) and cognitive (p = 0.019)
  and functional impairment (p = 0.001) were associated with supratherapeutic INR
  response. All patients with cognitive impairment and 85% of those with functional
  impairment received caregiver support for medication administration. There were 4
  minor bleeding events and no thromboembolic events. The mean number of
  medications was 9.3 in those with bleeding versus 6.8 in those without bleeding (p =
  0.052). CONCLUSIONS: Elderly patients with high stroke risk achieved therapeutic
  INR responses. However, those with significant cognitive or functional impairment
  require caregiver support and special consideration for anticoagulation management
Keywords:           activities        of       daily        living/administration/adverse
  events/age/ANTICOAGULATION/anticoagulation                          management/atrial
  international/management/practice models/PREVALENCE/risk/risk factors/risk of
Ryan, M. and Johnson, M.S. (2002), Use of alternative medications in patients with
  neurologic disorders. Annals of Pharmacotherapy, 36 (10), 1540-1545.
Abstract: OBJECTIVE: To determine alternative medication use in a neurology clinic
  population and to predict patients likely to use alternative medications. DESIGN:
  Survey of 216 adults presenting to a university-affiliated neurology clinic.
  METHODS: Subjects were queried regarding diagnosis, medications, satisfaction
  with medications, alternative medications, and demographics. Alternative
  medications were defined as herbal therapies, holistic therapies, minerals, or vitamins
  other than multiple vitamins. Frequencies were tabulated for categorical data; means
  and standard deviations were calculated for continuous data. Logistic regression was
  performed to predict use of alternative therapies. RESULTS: The most frequent
  conditions seen in all subjects were headache, epilepsy, and stroke. Mean ratings of
  patients' satisfaction with their conventional medications and health were 6.8 +/- 2.64
  and 6.4 +/- 2.23 on a 10-point scale, respectively. Forty subjects were taking
  alternative therapies. Regression analysis suggests that patients with higher levels of
  education are more likely to use alternative therapies. CONCLUSIONS: Forty of 216
  subjects (18.5%) seen in the neurology clinic took alternative therapies. Increased
  educational level was associated with use of alternative therapies
Keywords:         adults/alternative     therapy/COMPLEMENTARY/ALTERNATIVE
  disorders/PERCEPTIONS/PREVALENCE/regression/stroke/THERAPY USE
Klungel, O.H., Heckbert, S.R., de Boer, A., Leufkens, H.G.M., Sullivan, S.D., Fishman,
  P.A., Veenstra, D.L. and Psaty, B.M. (2002), Lipid-lowering drug use and
  cardiovascular events after myocardial infarction. Annals of Pharmacotherapy, 36
  (5), 751-757.
Abstract: BACKGROUND: The benefits of lipid-lowering drug treatment for the
  secondary prevention of coronary heart disease have been well established by
  randomized, controlled trials. Nonetheless, the risk of events has not been compared
  directly for inhibitors of hydroxymethylglutaryl coenzyme A reductase (statins) and
  non-statin lipid-lowering drugs. Further, it remains uncertain whether patients in
  usual practice who are treated with lipid-lowering drugs after myocardial infarction
  (MI) gain a similar benefit with regard to the risk of cardiovascular events compared
  with patients in randomized, controlled trials. OBJECTIVE: To assess the
  association between lipid-lowering drug therapies in usual clinical practice and the
  risk of cardiovascular events in patients with a first MI who were discharged alive
  from the hospital. METHODS: An inception-cohort study was performed among
  1956 enrollees of Group Health Cooperative who sustained an incident MI between
  July 1986 and December 1996 and survived for at least 6 months after hospitalization.
  Subjects with untreated lowdensity- lipoprotein cholesterol concentrations >130
  mg/dL or untreated total cholesterol concentrations >200 mg/dL were included. The
  median duration of follow-up after the first MI was 3.3 years. Medical record review
  was used to collect information on cardiovascular risk factors. Computerized
  pharmacy records were used to assess antihyperlipidemic drug use during the first 6
  months after hospitalization. RESULTS: Compared with 1263 subjects who did not
  receive lipid-lowering drug treatment, 373 subjects who received statins had a lower
  risk of recurrent coronary events (relative risk [RR] 0.59; 95% Cl 0.39 to 0.89),
  stroke (RR 0.82; 95% Cl 0.35 to 1.95), atherosclerotic cardiovascular mortality (RR
  0.49; 95% Cl 0.21 to 1.13), and any atherosclerotic cardiovascular event (RR 0.63;
  95% Cl 0.40 to 0.98). Among 320 subjects who used non-statin drug therapies, the
  RRs were 0.66 (95% Cl 0.45 to 0.97) for recurrent coronary events, 0.95 (95% Cl
  0.46 to 1.95) for stroke, 0.68 (95% Cl 0.35 to 1.32) for cardiovascular mortality, and
  0.77 (95% Cl 0.53 to 1.11) for any atherosclerotic cardiovascular event, compared
  with untreated hyperlipidemic patients. CONCLUSIONS: In this study of MI
  survivors, the use of lipid-lowering drug therapies after hospitalization was
  associated with a reduced risk of cardiovascular events. These results emphasize the
  importance of lipid-lowering drug treatment in patients with hyperlipidemia who
  survive a first MI
Keywords:               cardiovascular/cardiovascular              events/cardiovascular
  mortality/cardiovascular                    risk/cardiovascular                    risk
  factors/cholesterol/coronary/coronary               events/coronary              heart
  risk/review/RISK/risk                                     factors/secondary/secondary
Yousuf, M., AlSaudi, D.A., Sheikh, R.A. and Lone, M.S. (1995), Pattern of medical
  problems among Haj pilgrims admitted to King Abdul Aziz Hospital, Madinah
  Al-Munawarah. Annals of Saudi Medicine, 15 (6), 619-621.
Abstract: This prospective epidemiological study was done at King Abdul Aziz Hospital,
  Madinah Al-Munawarah, during the 1993 Haj season, to identify the medical
  problems of pilgrims. Out of 23,806 pilgrims who attended this hospital during the
  study period, 773 (3.25%) were admitted as medical cases. Mean age of admitted
  cases was 60.4 +/- 11.4 years. Pneumonia(45.8%), diabetes mellitus (20.7%) and
  ischemic heart disease (15.3%) were the most common diseases among pilgrims.
  Respiratory, cardiovascular and metabolic diseases affected 74%, 57% and 23% of
  the pilgrims. There were 57 deaths, with a mortality rate of 7.4%. Myocardial
  infarction was the most common cause of death. A large number of cases (32.6%)
  discharged themselves against medical advice. Old a,ae, poor physical fitness,
  multiple diseases, neglect in continuous treatment of known chronic diseases and
  failure to seek early medical advice were the major factors responsible for morbidity
  and mortality
Keywords:                                                                   age/diabetes
Awada, A., Amene, P., AlRajeh, S. and Obeid, T. (1996), Carotid bruits and ischemic
  cerebrovascular disease. Annals of Saudi Medicine, 16 (2), 218-220
Keywords:                                                                    ARTERY
Best, T. (1999), Atrial fibrillation: A review of the management in the emergency
  department. Annals of Saudi Medicine, 19 (3), 232-235
  department/fibrillation/FLUTTER/INTRAVENOUS                        PROCAINAMIDE
Donaldson, M.C., Ivarsson, B.L., Mannick, J.A. and Whittemore, A.D. (1993), Impact
  of Completion Angiography on Operative Conduct and Results of Carotid
  Endarterectomy. Annals of Surgery, 217 (6), 682-687.
Abstract: Objective This study assessed the impact of operative completion angiography
  on conduct and results of carotid endarterectomy (CEA). Summary Background Data
  Completion imaging by angiography, ultrasound or angioscopy reveals occasional
  residual lesions after CEA. The importance and appropriate management of these
  lesions remain controversial with respect to operative morbidity and long-term
  restenosis. Methods Carotid endarterectomy was performed 410 times for transient
  ischemic attack (44%), amaurosis fugax (19%), prior stroke (10%), and
  asymptomatic carotid stenosis (27%). Routine intraoperative completion angiograms
  were obtained to exclude significant residual lesions. Postoperative ultrasound
  follow- up was obtained in 232 patients over a mean interval of 17.3 months. Results
  Angiography revealed 71 defects warranting correction in 66 cases (16.1%),
  including kinks (23), external carotid flaps (18), common carotid plaque (10),
  thrombus (10), distal internal carotid stenosis (8), intracranial occlusion (1), and
  spasm (1). Operative morbidity included seven ipsilateral strokes (1.7%) and
  operative mortality was 0.7%. During follow-up, restenosis > 80% was detected in
  17 (7.3%) of 232 arteries, 9 (3.9%) of which underwent reoperation. Rates of
  restenosis of > 80% were similar between sexes and patched versus unpatched
  arteries. Conclusions Routine completion angiography after CEA guides use of
  selective operative revision contributing to low rates of perioperative morbidity and
Kouchoukos, N.T., Daily, B.B., Wareing, T.H. and Murphy, S.F. (1994), Hypothermic
  Circulatory Arrest for Cerebral Protection During Combined Carotid and
  Cardiac-Surgery in Patients with Bilateral Carotid-Artery Disease. Annals of Surgery,
  219 (6), 699-706.
Abstract: Objective The authors evaluated the protective effect of hypothermic
  circulatory arrest for patients with bilateral carotid artery disease who underwent
  cardiac surgical procedures. Summary Background Data Severe bilateral carotid
  artery disease coexisting with cardiac disease that requires surgical treatment is
  associated with a substantial incidence of stroke after operations that require
  cardiopulmonary bypass. The optimal method of management of patients with these
  coexisting conditions is not established clearly. Because hypothermia has a
  protective effect on neural and myocardial tissue during cardiac operations, a
  protocol employing profound hypothermia and a period of circulatory arrest was
  evaluated in a group ct patients who underwent combined carotid and cardiac surgery
  who were considered to be at increased risk for the development of stroke. Methods
  Fifty patients with bilateral carotid artery disease, including 24 patients with
  high-grade unilateral stenosis and contralateral occlusion and 6 patients with 80% to
  99% bilateral stenosis, underwent combined carotid endarterectomy and cardiac
  surgery (coronary artery bypass grafting in all 50 patients and additional procedures
  in 8 patients). Profound systemic hypothermia (15 C) was instituted, and the carotid
  endarterectomy was performed during a period of circulatory arrest that averaged 30
  minutes. The cardiac procedure was performed during the periods of cooling and
  rewarming. Results The 30-day mortality rate was 6% (3 patients). There were no
  early postoperative strokes or reversible ischemic neurologic deficits. There have
  been seven late deaths in the postoperative period, which extends to 54 months. None
  of these deaths were caused by stroke. There has been one late stroke, which
  occurred in the distribution of the unoperated carotid artery. Conclusions This
  technique provides adequate protection of the brain and myocardium during
  combined carotid and cardiac surgical procedures and appears to reduce the
  frequency of stroke in the high-risk subgroup oi patients with bilateral carotid artery
Keywords:                            BLOOD-FLOW/BRAIN/CARDIOPULMONARY
Mason, R.J., Bremner, C.G., DeMeester, T.R., Crookes, P.F., Peters, J.H., Hagen, J.A.
  and DeMeester, S.R. (1998), Pharyngeal swallowing disorders - Selection for and
  outcome after myotomy. Annals of Surgery, 228 (4), 598-607.
Abstract: Objective To develop selection criteria based on the mechanical properties of
  pharyngoesophageal swallowing thai indicate when patients with pharyngeal
  dysphagia will benefit from a myotomy. Summary Background Data The
  pathophysiology of pharyngoesophageal swallowing disorders is complex. The
  disorder is of interest to several medical specialists (gastroenterologists,
  otorhinolaryngologists, general and thoracic surgeons), which contributes to
  confusion about the entity. The management is compounded because it is most
  frequently seen in the elderly, is often associated with generalized neuromuscular
  disease, and occurs with a high prevalence of concomitant disease. The selection of
  patients for myotomy is difficult and of major importance to the quality of life of the
  affected patients. Method One hundred seven patients without a Zenker diverticulum
  but with pharyngeal dysphagia underwent a detailed manometric assessment of the
  upper esophageal sphincter (UES). Cricopharyngeal opening was identified by the
  presence of a subatmospheric pressure drop before bolus arrival. Impaired
  pharyngoesophageal segment compliance resulting in a resistance to pharyngo
  esophageal flow was determined by measuring the intrabolus pressure generated by a
  5-ml liquid bolus, Results Thirty-one of 107 patients underwent a myotomy (29%).
  Both impaired sphincter opening and increased intrabolus pressure predicted a good
  outcome. Conclusion Myotomy is beneficial in patients with pharyngeal swallowing
  disorders and manometric evidence of defective sphincter opening and increased
  intrabolus pressure
Keywords:                                          concomitant/CRICOPHARYNGEAL
Biffl, W.L., Moore, E.E., Elliott, J.P., Ray, C., Offner, P.J., Franciose, R.J., Brega, K.E.
   and Burch, J.M. (2000), The devastating potential of blunt vertebral arterial injuries.
   Annals of Surgery, 231 (5), 672-680.
Abstract: Objective To formulate management guidelines for blunt vertebral arterial
   injury (BVI). Summary Background Data Compared with carotid arterial injuries,
   BVIs have been considered innocuous. Although screening for BVI has been
   advocated, particularly in patients with cervical spine injuries, the appropriate
   therapy of lesions is controversial. Methods In 1996 an aggressive arteriographic
   screening protocol for blunt cerebrovascular injuries was initiated. A prospective
   database of all screened patients has been maintained. Analysis of injury mechanisms
   and patterns, BVI grades, treatment, and outcomes was performed. Results
   Thirty-eight patients (0.53% of blunt trauma admissions) were diagnosed with 47
   BVIs during a 3.5-year period. Motor vehicle crash was the most common
   mechanism, and associated injuries were common. Cervical spine injuries were
   present in 71% of patients, but there was no predilection for cervical vertebral level
   or fracture pattern. The incidence of posterior circulation stroke was 24%, and the
   BVI-attributable death rate was 8%. Stroke incidence and neurologic outcome were
   independent of BVI injury grade. In patients treated with systemic heparin, fewer
   overall had a poor neurologic outcome, and fewer had a poor outcome after stroke.
   Trends associated with heparin therapy included fewer injuries progressing to a
   higher injury grade, fewer patients in whom stroke developed, and fewer patients
   deteriorating neurologically from diagnosis to discharge. Conclusions Blunt vertebral
   arterial injuries are more common than previously reported. Screening patients based
   on injury mechanisms and patterns will diagnose asymptomatic injuries, allowing the
   institution of therapy before stroke. Systemic anticoagulation appears to be effective
   therapy: it is associated with improved neurologic outcome in patients with and
   without stroke, and it appears to prevent progression to a higher injury grade, stroke,
   and deterioration in neurologic status
   CAL-SPINE                           TRAUMA/death/diagnosis/DISSECTION/EARLY
   ment                                                                     guidelines/MR-
Luketich, J.D., Raja, S., Fernando, H.C., Campbell, W., Christie, N.A., Buenaventura,
   P.O., Weigel, T.L., Keenan, R.J. and Schauer, P.R. (2000), Laparoscopic repair of
   giant paraesophageal hernia: 100 consecutive cases. Annals of Surgery, 232 (4),
Abstract: Objective To summarize the authors' laparoscopic experience for
   paraesophageal hernia (PEH). Summary Background Data Laparoscopic antireflux
   surgery and repair of small hiatal hernias are now routinely performed. Repair of a
   giant PEH is more complex and requires conventional surgery in most centers. Giant
   PEH accounts for approximately 5% of all hiatal hernias. Medical management may
   be associated with a 50% progression of symptoms and a significant death rate.
   Conventional open surgery has a low death rate, but complications are significant
   and return to routine activities is delayed in this frequently elderly population.
   Recently, short-term out come studies have reported that minimally invasive
   approaches to PEH may be associated with a lower complication rate, a shorter
   hospital stay, and faster recovery. Methods From July 1995 to February 2000, 100
   patients (median age 68) underwent laparoscopic repair of a giant PEH. Follow-up
   included heartburn scores and quality of life measurements using the SF-12 physical
   component and mental component summary scores. Results There were 8 type II
   hernias, 85 type III, and 7 type IV. Sac removal, crural repair, and antireflux
   procedures were performed (72 Nissen, 27 Collis-Nissen). The 30-day death rate was
   zero; there was one surgery-related death at 5 months from a perioperative stroke.
   Intraoperative complications included pneumothorax, esophageal perforation, and
   gastric perforation. There were three conversions to open surgery. Major
   postoperative complications included stroke, myocardial infarction, pulmonary
   emboli, adult respiratory distress syndrome, and repeat operations (two for abscess
   and one each for hematoma, repair leak, and recurrent hernia). Median length of stay
   was 2 days. Median follow-up at 12 months revealed resumption of proton pump
   inhibitors in 10 patients and one repeat operation for recurrence. The mean heartburn
   score was 2.3 (0, best; 45, worst); the satisfaction score was 91%; physical and
   mental component summary scores were 49 and 54, respectively (normal, 50).
   Conclusion This report represents the largest series to date of laparoscopic repair of
   giant PEH. In the authors' center with extensive experience in minimally invasive
   surgery, laparoscopic repair of giant PEH was successfully performed in 97% of
   patients, with a minimal complication rate, a 2-day length of stay, and good
   intermediate results
   L-HERNIAS/hospital/infarction/length of stay/low/MANAGEMENT/minimally
   invasive/minimally        invasive     surgery/myocardial      infarction/postoperative
   complications/quality of life/recovery/stroke/studies/surgery
Biffl, W.L., Ray, C.E., Moore, E.E., Franclose, R.J., Aly, S., Heyrosa, M.G., Johnson,
   J.L. and Burch, J.M. (2002), Treatment-related outcomes from blunt cerebrovascular
   injuries - Importance of routine follow-up arteriography. Annals of Surgery, 235 (5),
Abstract: Objective To assess the impact of routine follow-up arteriography on the
   management and outcome of patients with acute blunt cerebrovascular injuries
   (BCVI). Summary Background Data During the past 5 years there has been
   increasing recognition of BCVI, but the management of these lesions remains
   controversial. The authors previously proposed a grading system for BCVI, with
   grade-specific management guidelines. The authors have noted that a significant
   number of injuries evolve within 7 to 10 days, warranting alterations in therapy.
   Methods A prospective database of a regional trauma center's experience with BCVI
   has been maintained since 1990. A policy of arteriographic screening for BCVI
   based on injury mechanism (e.g., cervical hyperextension) and injury patterns (e.g.,
   cervical and facial fractures) was instituted in 1996. A grading system was devised to
   develop management            protocols:    I = intimal irregularity;          11 =
   dissection/flap/thrombus; III = pseudoaneurysm; IV = occlusion; V = transecticn.
   Results From June 1990 to October 2001, 171 patients (115 male, age 36 +/- 1 years)
   were diagnosed with BCVI. Mean injury severity score was 28 +/- 1; associated
   injuries included brain (57%), spine (44%), chest (43%), and face (34%). Mechanism
   was motor vehicle crash in 50%, fall in 11%, pedestrian struck in 11%, and other in
   29%. One hundred fourteen patients had 157 carotid artery injuries (43 bilateral), and
   79 patients had 97 vertebral artery Injuries (18 bilateral). The breakdown of injury
   grades was 137 grade 1, 52 grade 11, 32 grade 111, 25 grade IV, and 8 grade V. One
   hundred fourteen (73%) carotid and 65 (67%) vertebral arteries were restudied with
   arteriography 7 to 10 days after the injury. Eight-two percent of grade IV and 93% of
   grade III Injuries were unchanged. However, grade I and 11 lesions changed
   frequently. Fifty-seven percent of grade I and 8% of grade 11 injuries healed,
   allowing cessation of therapy, whereas 8% of grade I and 43% of grade 11 lesions
   progressed to pseudoaneurysm formation, prompting interventional treatment. There
   was no significant difference in healing or in progression of injuries whether treated
   with heparin or antiplatelet therapy or untreated. However, heparin may improve the
   neurologic outcome in patients with ischemic deficits and may prevent stroke in
   asymptomatic patients. Conclusions Routine follow-up arteriography is warranted in
   patients with grade I and II BCVIs because most of these patients (61% in this series)
   will require a change in management. A prospective randomized trial will be
   necessary to identify the optimal treatment of BCVI
Keywords:                                                  acute/age/antiplatelet/antiplatelet
   artery/CAROTID-                           ARTERY/cerebrovascular/CERVICAL-SPINE
Kumar, S., Osman, I.S., Woollard, C.J. and Cameron, A.E.P. (2000), 'Fast track' carotid
   duplex scanning in a district general hospital. Annals of the Royal College of
   Surgeons of England, 82 (3), 167-170.
Abstract: 'Fast track' carotid scanning is designed to rapidly identify patients with
   significant symptomatic carotid stenosis and, thereby, allow prompt surgery. We
   review the outcome of patients referred to our open-access scanning service over 3
   years and 6 months. A total of 807 cases (62% males and 38% females with a mean
   age of 64 years) were referred. The main presenting symptoms were TIA in 69%,
   amaurosis fugax in 11% and minor CVA in 8.3%. The mean time between referral
   and scan was 17 days. In 80% of the eases, the scan showed no significant disease
   and the patients were not seen in the clinic. Significant abnormality (stenosis > 70%
   or occlusion) was found in 20% of the patients. Of the total, 12% were reviewed in
   the out-patient clinic following which no action was taken, 2% had angiography but
   no surgery, while 5% had angiography and surgery. 1% were lost to follow-up. The
   mean delay from scan to operation was 36 days. Conclusion: Fast track scanning has
   led to early detection of surgically relevant carotid lesions and avoidance of delay in
   surgical intervention. It is an efficient and cost-effective practice
Keywords:          age/angiography/carotid/carotid            duplex        scanning/carotid
   prevention/surgery/TIA/transient ischaemic attack
Ting, W., Silverman, N. and Levitsky, S. (1991), Valve-Replacement in Patients with
   Endocarditis and Cerebral Septic Emboli. Annals of Thoracic Surgery, 51 (1), 18-22.
Abstract: Cerebral septic emboli complicate the cases in 20% to 40% of patients with
   left-sided endocarditis but the management of these patients who require a valvar
   operation remains unclear. From 1980 to 1988, the incidence of cerebral septic
   embolus was 42% (n = 45) among 106 patients with endocarditis who underwent
   valve replacement at the University of Illinois Hospital in Chicago. Of these 45
   patients, 69% (n = 31) had symptomatic cerebral septic infarctions, and 31% (n = 14)
   were asymptomatic. Findings on cerebral computed tomographic scans included
   ischemic infarcts (n = 36, 80%), hemorrhagic infarcts (n = 5, 11%), normal studies (n
   = 2, 4%), and unknown (n = 2, 4%). Neurological complications after valve
   replacement included postoperative strokes (n = 6, 6%), cerebral abscesses (n = 2,
   2%), and seizure (n = 1, 1%). The presence of a hemorrhagic infarct preoperatively
   predisposed to a perioperative stroke (p < 0.05). In conclusion, cerebral septic
   infarctions, both symptomatic and asymptomatic, are common among patients with
   endocarditis referred for valvar operation. In the absence of a hemorrhagic infarct,
   valve replacement can be performed with minimal risk of a perioperative stroke
Keywords: BRAIN
Weiss, S.J., Sutter, F.P., Shannon, T.O. and Goldman, S.M. (1992), Combined Cardiac
   Operation and Carotid Endarterectomy During Aortic Cross-Clamping. Annals of
   Thoracic Surgery, 53 (5), 813-816.
Abstract: We present a surgical technique that we believe provides superior cerebral
   protection for simultaneous correction of carotid and cardiac pathology with low
   operative mortality and stroke rate. Our study population consists of 23 consecutive
   patients undergoing cardiac operation between August 1989 and April 1991 who also
   had associated critical (> 85%) carotid artery stenosis. Using 20-degrees-C systemic
   hypothermia for cerebral protection, we performed simultaneous correction of both
   lesions during the aortic cross-clamp period, using continuous retrograde blood
   cardioplegia for myocardial protection. Mean patient age was 69.4 years; 83% were
   65 years or older. Eighty-seven percent had angina, 35% had recent myocardial
   infarctions (within 30 days), and 52% had congestive heart failure. Asymptomatic
   bruit was found in 39%, and 61% had previous strokes, neurologic symptoms, or
   both. All had 85% or greater luminal narrowing on cerebral angiography, with 65%
   having severe or critical contralateral disease as well. Sixty- one percent had
   associated other vascular pathology, including peripheral vascular occlusive disease,
   renal artery stenosis, or abdominal aortic aneurysm. There were no postoperative
   strokes or neurologic events. One early vein graft occlusion resulted in postoperative
   myocardial infarction and subsequent death (4.3%)
Keywords:                                      BLOOD-FLOW/CARDIOPULMONARY
Rizzo, R.J., Whittemore, A.D., Couper, G.S., Donaldson, M.C., Aranki, S.F., Collins,
   J.J., Mannick, J.A. and Cohn, L.H. (1992), Combined Carotid and Coronary
   Revascularization - the Preferred Approach to the Severe Vasculopathy. Annals of
   Thoracic Surgery, 54 (6), 1099-1109.
Abstract: The timing of carotid endarterectomy (CEA) and coronary revascularization
   (CABG) for concomitant disease is controversial. Results of combined CEA/CABG
   in 127 patients (age range, 46 to 82 years; mean age, 65 years; 61% male) from 1978
   to 1991 were reviewed. Ninety-five patients (75%) were in New York Heart
   Association functional class III or IV, 48 (38%) had left main coronary artery disease,
   and 32 (28%) had depressed ejection fraction (<0.50). Forty (32%) had
   asymptomatic bruits, 61 (48%) transient ischemic attacks, and 26 (20%) prior strokes.
   Seventy-five (59%) had bilateral carotid stenosis, including 20 (16%) with
   contralateral occlusions. Perioperative mortality was 7 of 127 (5.5%), and all deaths
   were cardiac related. Myocardial infarctions occurred in 6 of 127 patients (4.7%) and
   were nonfatal in 3 (2.3%). Permanent strokes occurred in 7 of 127 (5.5%) and were
  ipsilateral in 5 (3.9%). Perioperative stroke did not occur in the asymptomatic-group,
  but the risk was higher in those with prior stroke (19%) or with contralateral carotid
  occlusion (15%). The stroke risk for our patients with carotid disease having CABG
  without CEA is not known, but the literature reports rates as high as 14%. For our
  patients without known concomitant disease, the risk of permanent stroke was 1.0%
  (31/3012) for isolated CABG and 1.5% (7/482) for isolated CEA. The late results
  after CEA/CABG revealed a 5-year survival of 70% +/- 5%, which correlated with
  ejection fraction (greater- than-or-equal-to 0.50, 81% +/- 5%; < 0.50, 45% +/- 11%;
  p < 0.003). Freedom from late permanent ipsilateral stroke was 97% +/- 2% at 8
  years. Freedom from stroke at 5 years was lower among patients with a previous
  stroke (71% +/- 10%) compared with transiently symptomatic (90% +/- 4%) and
  asymptomatic (96% +/- 4%) patients (p < 0.03). Combined CEA/CABG is a useful
  option in this high-risk group of patients with extensive atherosclerosis; avoids a
  subsequent hospitalization, anesthetic, and delay period; and provides long-term
  protection from ipsilateral stroke
Weil, S.R., Russo, P.A., Heckman, J.L., Balsara, R.K., Pasiecki, V. and Dunn, J.M.
  (1993), Pressure Volume Relationship of the Fetal Lamb Heart. Annals of Thoracic
  Surgery, 55 (2), 470-475.
Abstract: In contrast to the adult heart, the fetal heart reportedly has little functional
  reserve. With increased clinical emphasis on fetal cardiac diagnosis, neonatal surgery,
  and the potential for future fetal cardiac intervention, it is essential that we better
  understand fetal cardiac function. Therefore, to demonstrate the extent of fetal
  cardiac preload reserve, we studied 10 fetal lambs using an isolated, isovolumic,
  blood- perfused heart preparation. We maintained constant afterload, inotropic state,
  coronary blood flow, heart rate, and perfusate blood gas values. As left ventricular
  (LV) volume (preload) was incrementally increased, LV end-diastolic pressure and
  LV peak systolic pressure were recorded. Linear regression analysis demonstrated
  that increases in LV developed pressures were predicted by the LV volume,
  demonstrating the presence of the Frank-Starling mechanism in each case. The
  plateau of the Starling pressure-volume curve occurred at an LV end-diastolic
  pressure of 12.5 +/- 4.79 mm Hg (95% confidence interval, 9.07 to 15.9 mm Hg),
  lower than the plateau expected in the adult heart. This implies that, in the
  management of fetal and immature neonatal hearts, preload reserve plays an
  important but limited role in cardiac reserve
Keywords:                                                                     ARTERIAL
Millner, R.W.J., Burrows, M., Pearson, I. and Pepper, J.R. (1993), Dynamic
  Cardiomyoplasty in Chronic Left-Ventricular Failure - An Experimental-Model.
  Annals of Thoracic Surgery, 55 (2), 493-501.
Abstract: Dynamic cardiomyoplasty continues to attract interest as a therapeutic option
  in the management of heart failure. In a large animal model of ischemic heart failure,
  we have compared dynamic cardiomyoplasty with both adynamic cardiomyoplasty
  and a control group. Heart failure was induced by coronary artery ligation in sheep,
  and under the same anesthetic dynamic cardiomyoplasty (n = 5), adynamic
  cardiomyoplasty (n = 4), or no further procedure was performed (n = 5). After
  recovery the animals were housed for a further 3 months. The dynamic
  cardiomyoplasty underwent a recognized muscle transformation protocol during this
  period. At terminal studies, the animals were hemodynamically assessed, both under
  baseline conditions and after colloid volume loading. The data at baseline were
  compared with unpaired t tests, and the function curves created by volume loading
  were compared by analysis of variance. Although the changes at baseline were small,
  there were highly significant improvements in the function curves in the dynamic
  cardiomyoplasty group when the stimulators were turned on compared with
  stimulators off (p = 0.005 for cardiac output; p = 0.035 for left ventricular
  end-diastolic pressure; p = 0.002 for pulmonary artery capillary wedge pressure; p =
  0.004 for stroke volume; and p = 0.003 for cardiac power). There were also
  significant improvements in indices of cardiac performance when the dynamic
  cardiomyoplasty group was compared with both the control and adynamic
  cardiomyoplasty groups. We conclude that there is experimental evidence that
  cardiomyoplasty augments cardiac function in a model of chronic left ventricular
Keywords:                                                                     DILATED
Mazzucotelli, J.P., Deleuze, P.H., Baufreton, C., Duval, A.M., Hillion, M.L., Loisance,
  D.Y. and Cachera, J.P. (1993), Preservation of the Aortic-Valve in Acute Aortic
  Dissection - Long-Term Echocardiographic Assessment and Clinical Outcome.
  Annals of Thoracic Surgery, 55 (6), 1513-1517.
Abstract: The aim of the present study was to determine the long-term status of the
  native aortic valve after surgical treatment of acute aortic dissection involving the
  ascending aorta. From 1972 to 1991, 93 patients underwent operation for type I or II
  aortic dissection. There were 76 men and 17 women. Mean age was 54 +/- 13 years.
  Eighty patients (86%) had a conservative procedure regarding the aortic root and
  aortic cusps: 74 had prosthetic replacement of the ascending aorta and 6, complete
  replacement of the aortic arch. Thirteen patients (14%) had simultaneous
  replacement of the aortic valve and the ascending aorta. The overall hospital
  mortality rate was 29% (27/93). The overall actuarial survival rate was 60.2% +/-
  5.2%, 49.7% +/- 6.1%, and 35.9% +/- 8.1% at 5, 10, and 15 years, respectively. The
  survival rates for patients who had an ascending aortic procedure only were 63% +/-
  5.5%, 54% +/- 6.5%, and 39% +/- 8.5% at 5, 10, and 15 years, respectively, and for
  patients who required aortic valve replacement, 45% +/- 14% and 22% +/- 17.5% at
  5 and 10 years, respectively. Fifty long-term survivors (94% follow-up) with
  preservation of the aortic valve and aortic root were studied. Among them, 9 (18%)
  died within a mean interval of 97 +/- 46 months after operation. Causes of death
  were ischemic cardiac failure (2), aortic rupture or extension of dissection (4), renal
  disease (1), stroke (1), and sudden death (1). Forty-one patients had long-term
  clinical and echocardiographic evaluation. Severe aortic insufficiency developed in 7
  patients in the years after operation, and 6 of them underwent reoperation for
  prosthetic valve replacement. Echocardiographic findings were judged to show no or
  mild residual aortic insufficiency in 22 patients and moderate aortic insufficiency
  with satisfactory left ventricular function in 12 (2 patients had aortic valve
  replacement because of concomitant mitral valve disease or coronary disease). In all,
  late aortic valve replacement was realized in 8 patients at a mean interval of 61.5 +/-
  51.2 months after the first operation. Actuarial freedom from aortic valve
  replacement was 83% +/- 6% at 5 years and 79% +/- 7% at 10 and 15 years. This
  study emphasizes the benefit of surgical procedures that preserve the aortic valve and
   aortic root in the repair of acute aortic dissection involving the ascending aorta,
   without additional risk of recurrent aortic insufficiency
Keywords:                                                     ANEURYSM/ASCENDING
Bonchek, L.I., Burlingame, M.W., Worley, S.J., Vazales, B.E. and Lundy, E.F. (1993),
   Cox Maze Procedure for Atrial Septal-Defect with Atrial- Fibrillation - Management
   Strategies. Annals of Thoracic Surgery, 55 (3), 607-610.
Abstract: Atrial fibrillation is found at late follow-up in approximately half of all adults
   who have had correction of atrial septal defect, even if it was not present
   preoperatively. These patients are thus exposed to the risks of stroke and chronic
   drug therapy even after a successful operation. Simultaneous surgical correction of
   atrial septal defect and atrial fibrillation was accomplished in a 52-year-old man by
   means of the Cox/maze procedure. The small added risk and the substantial benefit
   of eliminating atrial fibrillation suggest that this approach is warranted in selected
   adults with atrial septal defect
Wareing, T.H., Davilaroman, V.G., Daily, B.B., Murphy, S.F., Schechtman, K.B.,
   Barzilai, B. and Kouchoukos, N.T. (1993), Strategy for the Reduction of Stroke
   Incidence in Cardiac Surgical Patients. Annals of Thoracic Surgery, 55 (6),
Abstract: Atherosclerosis of the ascending aorta (AAA) and severe carotid artery
   disease are risk factors for stroke in cardiac surgical patients. Twelve hundred of a
   consecutive series of 1,334 patients 50 years of age or older having a cardiac
   operation were screened for the presence of AAA by intraoperative ultrasonographic
   scanning and for the presence of carotid artery occlusive disease (791 of 798 patients
   greater-than-or- equal-to 65 years of age and younger symptomatic patients) by
   carotid duplex scanning. Coronary artery disease was present in 88% of the patients.
   Patients with moderate or severe AAA (n = 231; 19.3% of the total) were treated by
   ascending aortic replacement (n = 27) or by modified, less extensive techniques (n =
   168) to avoid the atherosclerotic areas. Thirty-three patients had combined carotid
   endarterectomy and cardiac operation. Thirty-day mortality and stroke rates for the
   1,200 patients were 4.0% and 1.6%, respectively. The stroke rate was low (1.1%)
   among the 969 patients with no or mild AAA. It was zero among 27 patients with
   moderate or severe AAA who had ascending aortic replacement and among the 33
   patients who had carotid endarterectomy. The stroke rates were higher for 111
   patients with moderate or severe ascending aortic disease who had only minor
   interventions (6.3%) and for 16 patients with severe carotid artery disease who did
   not have carotid endarterectomy (18.7%). Screening for AAA and carotid artery
   disease and aggressive surgical treatment of moderate or severe AAA and severe or
   symptomatic carotid artery disease appears to reduce the frequency of stroke in older
   cardiac surgical patients
Keywords:                   ASCENDING                    AORTA/CORONARY-ARTERY
Liu, D.W., Lin, P.J. and Chang, C.H. (1994), Treatment of Acute Type-A Aortic
   Dissection with Intraluminal Sutureless Prosthesis. Annals of Thoracic Surgery, 57
   (4), 987-991.
Abstract: Sutureless intraluminal aortic graft has been used for substitution of aorta,
   with the advantages of decreasing the aortic cross-clamp time and decreased blood
  loss. From January 1991 to December 1992, 10 consecutive patients underwent
  emergency operations to repair acute type A aortic dissection in which sutureless
  intraluminal grafts were used for replacement of ascending aorta. There were 5 men
  and 5 women, with ages that ranged from 40 to 74 years (mean, 51 years). The
  inclusion method was used in all patients. Modified Cabrol shunts were created in 7
  patients. Dacron graft (Meadox Medicals, Inc, Oakland, NJ) was used to wrap the
  ascending aorta in 7 patients. The circulatory arrest time was 33 +/- 13 (mean +/-
  standard deviation) minutes, and the cardiac ischemic time was 64 +/- 17 minutes.
  Retrograde superior vena cava cerebral perfusion during circulatory arrest was
  performed on 4 patients. All patients survived. One patient had a minor stroke and
  pneumonia with complete recovery. There was no evidence of pseudoaneurysm
  formation, graft erosion, graft migration, or aortic bleeding in the postoperative
  period. No patients had permanent renal deficit. Follow-up (1 to 22 months; mean,
  9.6 months) of all patients revealed satisfactory graft function, with no device-related
  deaths and no known complications attributable to the prosthesis, such as thrombosis,
  erosion, pseudoaneurysm formation, or hemorrhage. Our experience suggests that
  grafting of the ascending aorta is less hazardous with the sutureless grafts than with
  the conventional sutured anastomosis technique. We are now using this method
  whenever possible in all substitutions of the aorta
Keywords:                                          ANEURYSMS/ARCH/ASCENDING
Aranki, S.F., Rizzo, R.J., Adams, D.H., Couper, G.S., Kinchla, N.M., Gildea, J.S. and
  Cohn, L.H. (1994), Single-Clamp Technique - An Important Adjunct to Myocardial
  and Cerebral Protection in Coronary Operations. Annals of Thoracic Surgery, 58 (2),
Abstract: To determine the myocardial and cerebral protective properties of the single
  cross-clamp (group I; n = 160) versus the partial occluding clamp (group II; n = 150)
  technique for construction of the proximal anastomoses, a retrospective analysis of
  310 patients op erated on by the same surgeon was performed. Group I patients were
  older (median age, 70 versus 64 years; p less than or equal to 0.0001), with 83 (52%),
  versus 41 (27%) in group II, 70 years and older (p less than or equal to 0.0001).
  More group I patients were in New York Heart Association functional class IV (42
  [26%] versus 22 [15%]; p = 0.008); more required preoperative balloon
  counterpulsation (35 [22%] versus 16 [11%]; p = 0.006); and more required
  emergent operation (20 [13%] versus 3 [2%]; p less than or equal to 0.0001).
  Antegrade crystalloid cardioplegia was used in both groups. The median cross-clamp
  time was 58 minutes for group I versus 44 minutes for group II (p less than or equal
  to 0.0001). However, there was no significant difference between the two groups in
  terms of the number of bypass grafts, the use of the mammary artery, or the bypass
  time. The operative mortality was 2.5% (n = 4) for group I versus 5.3% (n = 8) for
  group II (p = 0.16), and the perioperative myocardial infarction/low cardiac output
  state was seen in 6 patients (3.8%) in group I versus 18 patients (12%) in group II (p
  = 0.006). The median creatine kinase Mb release was 13 U/L for group I versus 19
  U/L for group II (p = 0.0029). A major stroke occurred in 1 patient (0.6%) in group I
  and in 3 patients (2%) in group II (p = 0.3). Multivariate logistic regression analysis
  for an adverse outcome (operative mortality, myocardial output/low cardiac output
  state, and stroke), with 11 events (6.9%) occurring in 10 patients in group I and 29
  events (19%) occurring in 24 patients in group II (p = 0.005), showed that use of the
  partial occluding clamp was a significant predictor for an adverse outcome (p =
  0.002; odds ratio, 3.6; +/-95%, confidence intervals, 1.6 and 8.0), along with diabetes,
  nonelective coronary artery bypass grafting, and weight of 65 kg or less. The
  improved results associated with the single cross-clamp method suggest that this
  technique plays an integral part in ensuring myocardial and cerebral protection,
  possibly due to better cardioplegia delivery and distribution, more uniform
  rewarming and revascularization, and reduced manipulation of and trauma to the
  ascending aorta
Keywords:          ARTERY              BYPASS/ASCENDING                 AORTA/BLOOD
Mills, S.A. (1995), Risk-Factors for Cerebral Injury and Cardiac-Surgery. Annals of
  Thoracic Surgery, 59 (5), 1296-1299.
Abstract: Cerebral complications represent the leading cause of morbidity after cardiac
  operations. With the growing awareness of their social and economic importance,
  increasing attention is being given to their prevention. In the coronary artery bypass
  population, advanced age (greater than or equal to 75 years) is associated with an
  8.9% neurologic deficit rate. Mortality is increased ninefold in the elderly patient
  with a neurologic deficit. Cardiopulmonary bypass has long been recognized as a
  cause of neuropsychologic deficits. Emboli are thought to be the causal agent.
  Retinal microvascular lesions during cardiopulmonary bypass as well as recent
  demonstration of widespread pathologic subcapillary arteriolar dilatations in the
  brain after cardiopulmonary bypass have been documented. Despite widespread
  interest in cerebral blood flow and neurologic deficits, there is no convincing
  evidence that defines a critically low or dangerously high level of flow. The
  ascending aorta represents a leading source of embolic neurologic injury. The use of
  intraoperative ultrasound to identify the diseased aorta may result in alternative
  operative strategies in an effort to minimize emboli and improve neurologic outcome.
  Existing literature offers conflicting views on optimal management of carotid artery
  stenosis in the coronary artery surgical patient. A trend that combined carotid
  endarterectomy and coronary artery bypass may often be appropriate will need
  confirmation through a multicenter clinical trial. Open cardiac surgical procedures,
  particularly in the aged population, carry a significant increased risk of adverse
  neurologic outcome. Postoperative arrhythmias may result in embolic neurologic
  deficit. A further understanding of risk factors for cerebral injury will be of value in
  developing therapeutic approaches to this major clinical problem
Keywords:                                                        age/aorta/ASCENDING
  BYPASS/carotid artery/carotid endarterectomy/cerebral blood flow/clinical
  SURGERY/outcome/prevention/risk factors/strategies/STROKE
Newman, M.F., Croughwell, N.D., Blumenthal, J.A., Lowry, E., White, W.D., Spillane,
  W., Davis, R.D., Glower, D.D., Smith, L.R., Mahanna, E.P. and Reves, J.G. (1995),
  Predictors of Cognitive Decline After Cardiac Operation. Annals of Thoracic Surgery,
  59 (5), 1326-1330.
Abstract: Despite major advances in cardiopulmonary bypass technology, surgical
  techniques, and anesthesia management, central nervous system complications
   remain a common problem after cardiopulmonary bypass. The etiology of
   neuropsychologic dysfunction after cardiopulmonary bypass remains unresolved and
   is probably multifactorial. Demographic predictors of cognitive decline include age
   and years of education; perioperative factors including number of cerebral emboli,
   temperature, mean arterial pressure, and jugular bulb oxygen saturation have varying
   predictive power. Recent data suggest a genetic predisposition for cognitive decline
   after cardiac surgery in patients possessing the apolipoprotein E epsilon-4 allele,
   known to be associated with late-onset and sporadic forms of Alzheimer's disease.
   Predicting patients at risk for cognitive decline allows the possibility of many
   important interventions. Predictive power and weapons to reduce cellular injury
   associated with neurologic insults lend hope of a future ability to markedly decrease
   the impact of cardiopulmonary bypass on short-term and long-term neurologic,
   cognitive, and quality-of-life outcomes
Keywords: age/BRAIN/bypass/CARDIOPULMONARY BYPASS/central nervous
   system/CEREBRAL                     ISCHEMIA/complications/CORONARY-BYPASS
Slater, J.P., Goldstein, D.J., Ashton, R.C., Levin, H.R., Spotnitz, H.M. and Oz, M.C.
   (1995), Right-To-Left Venoarterial Shunting for Right-Sided Circulatory Failure.
   Annals of Thoracic Surgery, 60 (4), 978-985.
Abstract: Background. Right-sided circulatory failure, a complication of heart
   transplantation and left ventricular assist device use, results in decreased cardiac
   output due to diminished flow across the pulmonary circuit. We hypothesized that
   creation of a controlled right-to-left shunt would result in decompression of the right
   ventricle and improved systemic cardiac output at tolerable oxygen saturations. We
   also hypothesized that a peripheral veno-arterial shunt is physiologically superior to a
   central shunt. Methods. Right atrial-femoral artery and right atrial-left atrial shunts
   were created in a large animal model (calf). Right-sided circulatory failure was
   induced by banding the pulmonary artery. Hemodynamic measures and blood gas
   determinations were obtained during nonshunted and shunted states. Results.
   Peripheral and central shunts resulted in decreased right-sided pressures and
   increased cardiac output. Arterial oxygen saturation remained greater than 90%
   during shunting. The peripheral shunt had the added advantage of decreasing left
   ventricular end-diastolic pressure and left ventricular stroke work. Conclusions. A
   controlled right-to- left shunt improved hemodynamics and cardiac output in a large
   animal model with right-sided circulatory failure. This strategy may be useful in the
   management of transplant and left ventricular assist device recipients with
   perioperative right- sided circulatory failure. Our studies also indicate that creation of
   a peripheral shunt has both physiologic and technical advantages over a central shunt
Keywords:         animal/ASSIST          DEVICE/ATRIAL             SEPTOSTOMY/cardiac
   output/hemodynamics/LEFT                              HEART/management/PRIMARY
   PULMONARY-HYPERTENSION/RIGHT                                           VENTRICULAR
Bavaria, J.E., Woo, Y.J., Hall, R.A., Carpenter, J.P. and Gardner, T.J. (1995),
   Retrograde Cerebral and Distal Aortic Perfusion During Ascending and
   Thoracoabdominal Aortic Operations. Annals of Thoracic Surgery, 60 (2), 345-353.
Abstract: Background. Several alternative circulatory management techniques during
   thoracic aortic reconstruction have been implemented at this institution. This study
   was performed to assess whether retrograde cerebral perfusion during proximal
   aortic operations and distal aortic perfusion during thoracoabdominal aortic
  operations have improved outcomes. Methods. A retrospective review of 156
  patients undergoing elective and emergent operations of the thoracic aorta over the
  past 7 years was performed. Seventy-five patients underwent proximal aortic
  procedures: 22 with ascending aneurysms, 45 with type A dissections, and 8 with
  arch reconstructions. Eighty-one patients underwent descending thoracic or
  thoracoabdominal procedures: 26 with Crawford type I aneurysms, 18 with type II, 8
  with type III, 8 with type IV, 11 with traumatic transections, and 10 with type B
  dissections. Outcomes measured were neurologic injury, renal failure, and mortality.
  Results. For proximal aortic procedures, the stroke rate was 12% using
  cardiopulmonary bypass and 48% using hypothermic circulatory arrest. The addition
  of retrograde cerebral perfusion decreased the stroke rate to 0% (p < 0.01) and the
  mortality rate to 7.1% compared with 37% for hypothermic circulatory arrest (p <
  0.05). For thoracic and thoracoabdominal aortic operations, straight cross-clamping
  resulted in a 27% rate of spinal cord injury and a 24% rate of renal failure, whereas
  the addition of distal aortic bypass resulted in a statistically significant reduction (p <
  0.01) in neurologic injury to 7% and a notable, but not statistically significant,
  decrease in renal failure to 13%. Distal aortic bypass also reduced the mortality rate
  from 22% to 7% (p < 0.05). Conclusions. Retrograde cerebral perfusion decreases
  the stroke rate and mortality rate in proximal aortic operations and distal aortic
  perfusion decreases the rates of neurologic injury, renal failure, and mortality in
  thoracoabdominal aortic operations
Keywords:         aorta/ARCH           ANEURYSM/BRAIN/BYPASS/cardiopulmonary
  bypass/CIRCULATORY               ARREST/DISSECTION/EXPERIENCE/hypothermic
  cerebral perfusion/stroke/SURGERY/SURGICAL-TREATMENT
Akins, C.W., Moncure, A.C., Daggett, W.M., Cambria, R.P., Hilgenberg, A.D.,
  Torchiana, D.F. and Vlahakes, G.J. (1995), Safety and Efficacy of Concomitant
  Carotid and Coronary-Artery Operations. Annals of Thoracic Surgery, 60 (2),
Abstract: Background. Controversy exists concerning the best management for patients
  with concurrent severe carotid and coronary artery disease. Methods. The records of
  200 consecutive patients having concurrent carotid endarterectomy and coronary
  artery bypass grafting from 1979 to 1993 were reviewed, and follow-up was obtained
  (99% complete). Of the group (77% male; mean age, 67 years), 134 (67%) had
  unstable angina, 130 (65%) had triple- vessel disease, and 86 (43%) had left main
  coronary stenosis. Preoperative investigation revealed asymptomatic bruits in 116
  (58%), transient ischemia in 65 (32%), strokes in 31 (16%), and bilateral carotid
  disease in 44 patients (22%). Nonelective operations were required in 66 patients
  (33%). Results. Hospital death occurred in 7 patients (3.5%), myocardial infarction
  in 5 (2.5%), and permanent stroke in 6 (3%). Ten- year actuarial event-free rates
  were as follows: death, 58%; myocardial infarction, 81%; stroke, 92%; percutaneous
  angioplasty, 98%; redo coronary artery grafting, 94%; and all morbidity and
  mortality, 56%. Significant multivariate predictors of hospital death were
  postoperative stroke, failure to use an internal mammary artery graft, intraoperative
  intraaortic balloon, and nonelective operation. Significant predictors of postoperative
  stroke were peripheral vascular disease and unstable angina. Significant predictors of
  prolonged hospital stay were postoperative stroke, advanced age, and nonelective
  operation. Conclusions. Concomitant carotid endarterectomy and coronary bypass
  grafting can be performed with acceptably low operative risk and good long-term
  freedom from coronary and neurologic events
Keywords:         age/angina/bypass/bypass         grafting/BYPASS-SURGERY/carotid
  endarterectomy/CEREBROVASCULAR-DISEASE/coronary                     artery      bypass
  grafting/coronary                                                                artery
  ent/unstable angina/vascular disease
Pagano, D., Carey, J.A., Patel, R.L., Allen, S.M., Tsang, G.M.K., Hutton, P., Lilley, J.P.,
  Faroqui, M.H. and Bonser, R.S. (1995), Retrograde Cerebral Perfusion -
  Clinical-Experience in Emergency and Elective Aortic Operations. Annals of
  Thoracic Surgery, 59 (2), 393-397.
Abstract: We recently have used retrograde cerebral perfusion via the superior vena
  cava in association with hypothermic circulatory arrest as an adjunct to cerebral
  protection during aortic arch operations. Between April 1993 and March 1994, 23
  patients (14 male; 9 female; median age, 64 years; age range, 25 to 76 years; 14
  emergency, 9 elective) underwent operation on the ascending aorta, aortic arch, or
  both for acute dissection (11) or aneurysm (12). Aortic root replacement was
  performed in 13 patients (7 with arch replacement), ascending aortic replacement in
  7 (4 with arch replacement), isolated aortic arch replacement in 2, and repair of sinus
  of Valsalva aneurysm in 1. Coronary artery bypass grafting was performed in 4
  patients. Hypothermic circulatory arrest (15 degrees C) and retrograde cerebral
  perfusion were implemented in all cases (median circulatory arrest time, 21 minutes;
  range, 13 to 51 minutes; median retrograde cerebral perfusion time, 20 minutes;
  range, 12 to 50 minutes). Three hospital deaths occurred (atheromatous embolic
  stroke, sepsis, rupture of infrarenal aortic aneurysm). The remaining patients had no
  neurologic damage (median intensive therapy unit stay, 1 day; range, 1 to 5 days).
  Retrograde cerebral perfusion is easy to establish and safe, and may improve brain
  protection during hypothermic circulatory arrest
Keywords:         acute/age/aneurysm/aorta/aortic         arch      replacement/ARCH
  ANEURYSM/ASCENDING                                        AORTA/brain/bypass/bypass
  grafting/CIRCULATORY             ARREST/DISSECTION/hypothermic              circulatory
  arrest/MANAGEMENT/REPAIR/retrograde                                            cerebral
Murkin, J.M. (1995), The Role of Cpb Management in Neurobehavioral Outcomes
  After Cardiac-Surgery. Annals of Thoracic Surgery, 59 (5), 1308-1311.
Abstract: Recent developments in techniques for managing cardiopulmonary bypass are
  outlined with a view toward interventions aimed at decreasing the incidence of
  perioperative central nervous system dysfunction and overt stroke. Recent reports
  assessing central nervous system dysfunction after hypothermic and normothermic
  cardiopulmonary bypass are reviewed and critiqued along with data assessing
  techniques for cerebral protection during hypothermic circulatory arrest. Controversy
  surrounding optimal pH management is explored along with a proposal that pH-stat
  may be most satisfactory to ensure better brain cooling where circulatory arrest is
  anticipated, whereas alpha-stat may avoid cerebral hyperemia and thus decrease the
  cerebral embolic load during moderate hypothermic cardiopulmonary bypass. Newer
  developments in cerebral monitoring techniques are also reviewed
Keywords:     BRAIN/bypass/CARDIOPULMONARY                   BYPASS/central      nervous
  system/CEREBRAL             BLOOD-FLOW/HYPOTHERMIC                   CIRCULATORY
Shibata, Y., Abe, T., Kuribayashi, R., Sekine, S., Seki, K., Yamagishi, I. and Chanda, J.
   (1996), Surgical treatment of isolated secundum atrial septal defect in patients more
   than 50 years old. Annals of Thoracic Surgery, 62 (4), 1096-1099.
Abstract: Background. Arrhythmia-related thromboembolic accidents continue to occur
   in patients even after closure of secundum atrial septal defect. Older age is usually
   not a contraindication to the repair of an atrial septal defect. To assess the importance
   of the type of management in elderly patients with atrial septal defect our clinical
   experience is reviewed. Methods. Between 1974 and 1994, 49 patients 50 years of
   age or older (average, 57.4 years) underwent surgical closure of secundum atrial
   septal defect. All patients have been followed up for 2 to 21 years (mean, 9.7 years).
   Results. There were no operative deaths. Functional classes in most of the patients
   were improved after operation. There were two cerebrovascular thromboembolic
   accidents with one permanent neurologic dysfunction, hemiparesis, and one septal
   dehiscence in the early postoperative period. One patient (2%) died of renal failure 6
   years after operation, late arrhythmias developed in 3 patients (6%), 3 patients had a
   late stroke (6%), and 1 patient was not available for follow-up. Conclusions.
   Long-term operative results are satisfactory and beneficial to the quality of life in
   elderly patients. Because there is no safe and effective nonsurgical alternative to
   surgical closure, atrial septal defect repair in elderly patients without severe
   pulmonary vascular disease should not be delayed once the diagnosis had been made
Gillinov, A.M., Shah, R.V., Curtis, W.E., Stuart, R.S., Cameron, D.E., Baungartner,
   W.A. and Greene, P.S. (1996), Valve replacement in patients with endocarditis and
   acute neurologic deficit. Annals of Thoracic Surgery, 61 (4), 1125-1129.
Abstract: Background. Acute neurologic deficits occur in up to 40% of patients with left
   heart endocarditis. Appropriate evaluation and management of patients with acute
   neurologic dysfunction who require valve operations for endocarditis remain
   controversial. This retrospective review was undertaken to develop recommendations
   for the evaluation and treatment of these challenging patients. Methods. From 1983
   to 1995, 247 patients underwent operations for left heart native valve endocarditis at
   the Johns Hopkins Hospital. From a review of medical and pathology records, 34
   patients (14%) with preoperative neurologic deficits were identified. Data on these
   34 patients were recorded and analyzed. Results. Causes of neurologic dysfunction
   included embolic cerebrovascular accident (n = 23, 68%), embolic cerebrovascular
   accident with hemorrhage (n = 4, 12%), ruptured mycotic aneurysm (n = 3, 9%),
   transient ischemic attack (n = 2, 6%), and meningitis (n = 2, 6%). Preoperative
   diagnostic studies included computed tomography (32 patients), magnetic resonance
   imaging (11 patients), cerebral angiogram (14 patients), and lumbar puncture (2
   patients). Computed tomography demonstrated structural lesions in 29 of 32 patients;
   in only 1 patient did magnetic resonance imaging reveal a lesion not already seen on
   computed tomography. Of 14 patients having cerebral angiograms, 7 had a mycotic
   aneurysm. Three mycotic aneurysms had ruptured, and these were clipped before
   cardiac operations. The mean interval from onset of neurologic deficit to cardiac
   operation was 22.2 +/- 2.8 days for all patients and 22.1 +/- 3.0 days for those with
   embolic cerebrovascular accident. The hospital mortality rate was 6%. New or worse
   neurologic deficits occurred in 2 patients (6%). Conclusions. Neurologic deficits are
   common in patients with endocarditis referred for cardiac operations. Despite
  substantial preoperative morbidity, most of these patients do well if the operation can
  be delayed for 2 to 3 weeks. Computed tomography scan is the preoperative imaging
  technique of choice, as routine magnetic resonance imaging and cerebral angiogram
  are unrewarding. Cerebral angiogram is indicated only if computed tomography
  reveals hemorrhage
  tomography/magnetic                                                             resonance
Svensson, L.G., Sun, J.P., Cruz, H.A. and Shahian, D.M. (1996), Endarterectomy for
  calcified porcelain aorta associated with aortic valve stenosis. Annals of Thoracic
  Surgery, 61 (1), 149-152.
Abstract: Background. A calcified porcelain aorta may complicate aortic valve insertion
  and require an alternative, more complex method for valve replacement. The reason
  for this is that sutures cannot be inserted through the calcific plates in the annulus
  and ascending aorta. Methods. In 6 patients with an average age of 73.8 years (range,
  65 to 81 years), we performed the simpler procedure of aortic endarterectomy of the
  calcific plates with the aortic valve replacement. We realized that there may be an
  increased risk of postoperative complications, particularly stroke. The calcific plates
  were fractured to allow debridement of the calcium. In addition, an endarterectomy
  was performed of the left main coronary ostium in 2 patients, and 5 patients also had
  coronary artery bypass grafting performed. Results. All 6 patients underwent
  successful operations without major complications. On follow-up, echocardiography
  or computed tomographic scans in 3 patients have not shown dilation of the
  ascending aorta. Conclusion. Endarterectomy of the aorta may be an option in the
  management of patients with calcification of the aorta
Keywords: age/aorta/ATHEROSCLEROTIC ASCENDING AORTA/bypass/bypass
  grafting/complications/coronary                          artery                    bypass
  grafting/EXPERIENCE/MANAGEMENT/postoperative complications/stroke
Subramanian, V.A., Mccabe, J.C. and Geller, C.M. (1997), Minimally invasive direct
  coronary artery bypass grafting: Two year clinical experience. Annals of Thoracic
  Surgery, 64 (6), 1648-1653.
Abstract: Background. Interest in minimally invasive coronary artery bypass grafting
  has been increasing. Methods. From April 1994 through December 1996, 199
  patients (age, 36 to 93 years) underwent minimally invasive coronary artery bypass
  grafting through minithoracotomy, subxiphoid, and lateral thoracotomy incisions,
  with internal mammary artery, gastroepiploic artery, and composite grafts placed
  using local coronary artery occlusion. Results. The conversion rate to sternotomy
  was 7% (14/199). Preoperative risk factors included unstable angina (n = 83),
  reoperative coronary artery bypass grafting (n = 54), low ejection fraction (n = 53),
  congestive heart failure (n = 44), renal insufficiency (n = 25), chronic obstructive
  pulmonary disease (n = 36), cerebrovascular accident (n = 22), and diffuse vascular
  disease (n = 47). Morbidity included wound infections (n = 5), reoperation for
  management of bleeding (n = 6) and acute graft occlusion (n = 2), perioperative
  stroke (n = 1), atrial fibrillation (n = 14), and perioperative myocardial infarction (n =
  7). The operative mortality was 3.8% (7/185). The number of grafts placed in 185
  patients was as follows: single, 156; double, 28; and triple, 1. Early (less than 36
  hours) angiography and Doppler flow assessment of the coronary anastomoses in
  85% of the patients showed that 92% were patent. Routine use of mechanical
   stabilization of the coronary artery since April 1996 was found to be associated with
   an increase in the patency rate of the left internal mammary artery-left anterior
   descending coronary artery anastomosis to 97%, versus 89% (p = 0.055) associated
   with conventional immobilization techniques. Of the 148 patients followed up
   beyond 1 month (range, 1 to 32 months; mean, 9.2 +/- 7.4 months) postoperatively, 3
   have died (3 to 7 months), and of the 145 survivors the cardiac-related event
   (percutaneous transluminal coronary angioplasty, reoperation, readmission for
   recurrent angina, and congestive heart failure)-free interval was 93%. Conclusions.
   The minimally invasive coronary artery bypass grafting operation is safe and
   effective. Regional cardiac wall mechanical immobilization enhances the early graft
   patency and must be considered an essential part of this operation. (C) 1997 by The
   Society of Thoracic Surgeons
Keywords:                          acute/age/angina/angiography/angioplasty/artery/atrial
   fibrillation/bypass/bypass                           grafting/CARDIOPULMONARY
   BYPASS/cerebrovascular/congestive heart failure/coronary artery bypass/coronary
   artery                 bypass                grafting/disease/Doppler/fibrillation/heart
   infarction/operative/patent/percutaneous              transluminal              coronary
   angioplasty/perioperative                myocardial                 infarction/renal/risk
   factors/stroke/transluminal/unstable angina/vascular disease
Trachiotis, G.D. and Pfister, A.J. (1997), Management strategy for simultaneous carotid
   endarterectomy and coronary revascularization. Annals of Thoracic Surgery, 64 (4),
Abstract: Background. The occurrence of significant carotid artery disease in patients
   requiring coronary artery bypass grafting (CABG) results in a dilemma regarding the
   best surgical management. Our philosophy has been to perform simultaneous carotid
   endarterectomy and CABG. We reviewed the efficacy of this therapy in patients
   treated at a large community-based hospital. Methods. During a 6-year period, from
   1990 to 1996, 88 patients underwent simultaneous carotid endarterectomy and
   CABG. All patients underwent preoperative four-vessel arch arteriography and
   standard coronary angiography. The principal indications for combined procedures
   were the need for CABG and (1) symptomatic carotid artery disease; (2) internal
   carotid artery stenosis of 80% or more, with or without contralateral disease; or (3)
   an ulcerated, unstable internal carotid artery lesion, regardless of degree of stenosis.
   The average patient age was 68 years, and there was a 3:1 male-to-female
   predominance. All procedures were performed with the patients under general
   anesthesia. The carotid endarterectomy was performed first, and an intraluminal
   shunt was used in all patients. Results. The average degree of stenosis on the
   operated side was 86.2%. An average of 3.6 coronary bypasses per patient were
   performed. Morbidity included four strokes (4.5%). There were no perioperative
   myocardial infarctions. There were three hospital deaths (3.4%). The combined
   permanent stroke and mortality rate was 6.8%. Univariate predictors of stroke were
   an elevated serum creatinine level, a pulmonary complication, and left main coronary
   artery disease. Univariate predictors of hospital death were stroke, an elevated serum
   creatinine level, peripheral vascular disease, and left main coronary artery disease.
   Multivariate predictors of a prolonged hospitalization were stroke, an elevated serum
   creatinine level, and a pulmonary complication. Eighty-five patients (96.6%) were
   discharged and alive at 30 days. Conclusions. In the context of the indications we
   used to select patients for simultaneous carotid endarterectomy and CABG, the
   combined permanent stroke and mortality rate was less than 7%. Our management
  strategy identified patients that were at increased surgical risk as a result of advanced
  carotid and coronary artery disease: In our practice, simultaneous carotid
  endarterectomy and CABG is the preferred surgical approach for these high-risk
  patients and results in a low in-hospital morbidity and mortality using a single
  anesthetic and hospitalization. (C) 1997 by The Society of Thoracic Surgeons
Keywords:               age/angiography/ARTERY                    BYPASS/bypass/bypass
  artery/carotid endarterectomy/coronary artery bypass grafting/coronary artery
  disease/DISEASE/endarterectomy/hospitalization/internal/internal           carotid/internal
  carotid                                  artery/management/mortality/MYOCARDIAL
  STROKE/therapy/vascular disease
Savage, R.M., Lytle, B.W., Aronson, S., Navia, J.L., Licina, M., Stewart, W.J., Starr,
  N.J. and Loop, F.D. (1997), Intraoperative echocardiography is indicated in high-risk
  coronary artery bypass grafting. Annals of Thoracic Surgery, 64 (2), 368-373.
Abstract: Background. Intraoperative echocardiography is a valuable monitoring and
  diagnostic technology used in cardiac surgery. This reports our clinical study of the
  usefulness of intraoperative echocardiography to both surgeons and anesthesiologists
  for high-risk coronary artery bypass grafting. Methods. From March to November
  1995, 82 consecutive high-risk patients undergoing coronary artery bypass grafting
  were studied in a four-stage protocol to determine the efficacy of intraoperative
  echocardiography in management planning. Alterations in surgical and
  anesthetic/hemodynamic management initiated by intraoperative echocardiography
  findings were documented in addition to perioperative morbidity and mortality.
  Results. Intraoperative echocardiography initiated at least one major surgical
  management alteration in 27 patients (33%) and at least one major
  anesthetic/hemodynamic change in 42 (51%). Mortality and the rate of myocardial
  infarction in this consecutive high-risk study population using intraoperative
  echocardiography and in a similar group of patients without the use of intraoperative
  echocardiography was 1.2% versus 3.8% (not significant) and 1.2% versus 3.5% (not
  significant), respectively. Conclusions. We conclude that when all of the isolated
  diagnostic and monitoring applications of perioperative echocardiography are
  routinely and systematically performed together, it is a safe and viable tool that
  significantly affects the decision-making process in the intraoperative care of
  high-risk patients undergoing primary isolated coronary artery bypass grafting and
  may contribute to the optimal care of these patients. (C) 1997 by The Society of
  Thoracic Surgeons
Keywords: bypass/bypass grafting/cardiac surgery/CARDIAC-SURGERY/coronary
  artery         bypass/coronary           artery        bypass            grafting/decision
Sundt, T.M., Murphy, S.F., Barzilai, B., Schuessler, R.B., Mendeloff, E.N., Huddleston,
  C.B., Pasque, M.K. and Gay, W.A. (1997), Previous coronary artery bypass grafting
  is not risk factor for aortic valve replacement. Annals of Thoracic Surgery, 64 (3),
Abstract: Background. The risk of aortic valve replacement (AVR) after previous
  coronary artery bypass grafting (CABG) is controversial. Its magnitude influences
  the threshold for recommending this procedure and has been cited in arguments
  regarding the optimal management of mild aortic stenosis at primary CABG. We
  therefore reviewed our experience with reoperative AVR +/- CABG and the primary
  combined procedure. Methods. Between January 1, 1985, and June 30, 1996, 427
  patients underwent primary AVR + CABG, and 52 underwent AVR +/- CABG after
  prior CABG. Demographics, operative characteristics, and operative results were
  compared between groups. Data for all patients were pooled and analyzed
  collectively for risk factors influencing mortality. Results. The extent of native
  coronary artery disease and the incidence of prior myocardial infarction and stroke
  were greater in the reoperative group. Aortic cross-clamp and cardiopulmonary
  bypass times were slightly shorter, and fewer distal anastomoses were performed in
  the reoperative group. Operative mortality (primary group, 6.3% versus reoperative
  group, 7.4%) and morbidity were similar. Stepwise multivariate logistic regression
  analysis identified age, perioperative myocardial infarction, intraaortic balloon
  support, ventricular arrhythmia, perioperative stroke, and development of renal
  failure or acute respiratory distress syndrome, but not reoperative status, as predictors
  of mortality. Conclusions. The risk of AVR after previous CABG is similar to that
  for primary AVR + CABG. Valve replacement should, therefore, be pursued despite
  prior CABG when hemodynamically significant aortic stenosis develops.
  Furthermore, a circumspect approach to ''prophylactic'' AVR for mild aortic stenosis
  at primary CABG seems warranted. (C) 1997 by The Society of Thoracic Surgeons
Keywords:      acute/ADULTS/age/bypass/bypass           grafting/CABG/cardiopulmonary
  bypass/coronary artery bypass/coronary artery bypass grafting/coronary artery
  infarction/PROGRESSION/risk factors/STENOSIS/stroke/SURGERY
Takach, T.J., Reul, G.J., Cooley, D.A., Duncan, J.M., Ott, D.A., Livesay, J.J., Hallman,
  G.L. and Frazier, O.H. (1997), Is an integrated approach warranted for concomitant
  carotid and coronary artery disease? Annals of Thoracic Surgery, 64 (1), 16-22.
Abstract: Background. The management of patients with severe, concomitant coronary
  and carotid artery occlusive disease is controversial. Methods. Between 1975 and
  1996, 512 patients (mean age, 64.9 years; 70% male) were admitted for coronary
  revascularizatian; 316 (61.7%) had asymptomatic, severe carotid disease (stenosis
  >70%) and 196 (38.3%) had symptomatic carotid disease (159 [31.1%] with transient
  ischemia and 37 [7.2%] with completed stroke). In group 1, coronary
  revascularization and carotid endarterectomy were simultaneously performed in 255
  patients (49.8%) with unstable angina. In group 2 (staged approach), carotid
  endarterectomy was performed before coronary revascularization in 257 patients
  (50.2%) without unstable angina. Results. Before 1986, the incidence oi: stroke and
  death was greater in group 1 (n = 149) than in group 2 (n = 156) (14 [9.4%] versus 4
  [2.6%]; p < 0.01). Since 1986, outcomes in group 1 (n = 106) and group 2 (n = 101)
  have been similar for stroke (2 [1.9%] versus 2 [2.0%]), death (4 [3.8%] versus 3
  [3.0%]), and myocardial infarction (4 [3.8%] versus 5 [5.0%]). Significant univariate
  and multivariate predictors of adverse outcome were primarily heart-related
  (reoperation, intraaortic balloon use, ejection fraction <0.50, and angina grade 4 for
  death; age >70 years and congestive heart failure Fnr sh stroke). Conclusions.
  Despite highly selected populations, contemporary surgical results do not indicate
  that staged treatment of severe, concomitant coronary and carotid artery occlusive
  disease has an advantage over simultaneous treatment. Advances in myocardial
  protection and perioperative hemodynamic management may account for the low
  incidences of stroke and death in these operations. (C) 1997 by The Society of
  Thoracic Surgeons
Keywords:         age/angina/ASSOCIATION/BYPASS/CARDIAC-SURGERY/carotid
  artery/carotid endarterectomy/CEREBROVASCULAR-DISEASE/coronary artery
  nt/unstable angina
Barbut, D., Lo, Y.W., Gold, J.P., Trifiletti, R.R., Yao, F.S.F., Hager, D.N., Hinton, R.B.
  and Isom, O.W. (1997), Impact of embolization during coronary artery bypass
  grafting on outcome and length of stay. Annals of Thoracic Surgery, 63 (4),
Abstract: Background. Transcranial Doppler ultrasonography detects emboli in most
  patients during coronary artery bypass grafting. However, the significance of these
  emboli has not yet been established. Methods. We monitored 82 patients during
  coronary artery bypass grafting with this technique and related the numbers of
  emboli to the outcomes and length of hospital stay. Results. We detected cerebral
  emboli in all patients. Patients with stroke (n = 4; 4.9%) had a mean of 449 emboli,
  as compared with 169 emboli in patients without stroke (n = 78) (p = 0.005). Patients
  with major cardiac complications (n = 7) had a mean of 392 emboli, as compared
  with 163 in patients without such complications (n = 75) (p = 0.003). The mean
  hospital stay of survivors was 8.6 days in patients with fewer than 100 emboli (n =
  40), 13.5 days in patients with 101 to 300 emboli (n = 23), 16.3 days in those with
  301 to 500 emboli (n = 16), and 55.8 days in patients with more than 500 emboli (n =
  6) (p = 0.0007). This relation was unchanged when patients with complications were
  excluded. The correlation between embolization and outcome was independent of the
  extent of aortic atheroma or age. Conclusions. Emboli detected during coronary
  artery bypass grafting are significantly related to major cardiac and neurologic
  complications and affect length of stay in all patients, even in the absence of such
  specific complications. (C) 1997 by The Society of Thoracic Surgeons
Keywords:       age/AIR-EMBOLISM/BALLOON                  ANGIOPLASTY/bypass/bypass
  grafting/CARDIOPULMONARY BYPASS/cerebral/complications/coronary artery
  bypass/coronary                                artery                            bypass
Landreneau, R.J., Wiechmann, R.J., Hazelrigg, S.R., Santucci, T.S., Boley, T.M.,
  Magee, M.J. and Naunheim, K.S. (1998), Success of laparoscopic fundoplication for
  gastroesophageal reflux disease. Annals of Thoracic Surgery, 66 (6), 1886-1892.
Abstract: Background. We explored the efficacy of laparoscopic fundoplication (LF) in
  patients with uncomplicated, medically recalcitrant pathologic gastroesophageal
  reflux disease (GERD) for whom we previously would have recommended open
  surgical repair. Methods. From January 1994 to January 1998, rue performed LF on
  150 patients (80 men and 70 women) with GERD recalcitrant to maximal medical
  therapy. No patient suffered from esophageal stricture or epithelial dysplasia;
  however 16% (24 of 150) had benign Barrett's mucosa. Preoperative esophageal
  manometry and 24-hour pH testing were obtained in 93% (139 of 150) and 89% (134
  of 150) of patients, respectively. Nissen LF (n = 123), Toupet LF (n = 26), or Dor LF
  (n = 1) were accomplished over a large (54 F) intraesophageal bougie. Preoperative
  (1 month) and postoperative (>6 month) symptom scoring were assessed on a 0 to 10
  scale. Thirty-eight patients with a greater than 6-month postoperative period had
  manometry and pH studies performed. Results. The laparoscopic approach was
  successful in 99% (148 of 150) of patients, and there has been no mortality.
  Operative time was 160 +/- 59 minutes. Open conversion was required for 2 patients:
  because of difficulty with dissection owing to adhesions in I case and due to
  perforation in another. Reoperation was required for 5 patients (1 paraesophageal, 2
  dysphagia, 2 recurrent reflux). Major postoperative complications involved stroke
  and pancreatitis in 1 patient each. Mean hospital stay was 2.6 +/- 1.2 days, full
  activity resumed by 7 days. postoperative esophageal pH testing among 38 patients
  tested more than 6 months after operation demonstrated normal esophageal acid
  exposure in all but 2. GERD symptoms were relieved at 1 month, 6 months, and after
  1 year in 95% (128 of 135), 94% (99 of 105), and 93% (65 of 70) of patients,
  respectively. Conclusions. Intermediate-term results with LF suggest this to be a
  reasonable approach to surgical management of medically recalcitrant uncomplicated
  GERD. Thoracic surgeons interested in GERD should become familiar with
  minimally invasive surgical approaches. (C) 1998 by The Society of Thoracic
Takach, T.J., Reul, G.J., Cooley, D.A., Livesay, J.J., Duncan, J.M., Ott, D.A. and
  Hallman, G.L. (1998), Concomitant occlusive disease of the coronary arteries and
  great vessels. Annals of Thoracic Surgery, 65 (1), 79-84.
Abstract: Background. Although an increasing number of elderly and high- risk patients,
  including those with generalized atherosclerosis, are undergoing coronary
  revascularization, few reports exist regarding the management of patients who have
  both occlusive disease of the great vessels and coronary artery disease. Methods.
  Between 1972 and 1996, 31 consecutive patients (mean age, 56.5 years; 74% men)
  with multivessel coronary artery disease and symptomatic occlusive disease of the
  great vessels (25 single-vessel, 80.6%; 6 multiple-vessel, 19.4%) had 40 great vessels
  reconstructed by transthoracic bypass (n = 17, 42.5%), transthoracic endarterectomy
  (n = 8, 20%), or extrathoracic bypass (n = 15, 37.5%). All patients had simultaneous
  coronary artery bypass grafting (mean, 2.6 grafts per patient), and 8 patients had 10
  distal carotid bifurcation endarterectomies (6 staged, 4 simultaneous). Results. The
  early primary patency rate was 100%, and symptoms resolved completely in all 31
  patients. There was 1 in-hospital death (3.2%) in a patient who had a respiratory
  arrest 11 days after operation. Perioperative morbidity included two myocardial
  infarctions (6.5%) and one opposite-hemisphere, embolic stroke (3.2%). Long-term
  follow-up of the 30 survivors (167.4 patient-years; mean, 5.6 years per patient)
  documented 5- and 10-year actuarial survival rates of 88.6% and 60.4%, respectively,
  with a 100% late brachiocephalic primary patency rate. Ten-year actuarial rates of
  freedom from the following events were as follows: death, 60.4%; myocardial
  infarction, 82.5%; stroke, 90.9%; percutaneous transluminal coronary angioplasty or
  redo coronary artery bypass grafting, 95.2%; and vascular operation or amputation,
  78.4%. Conclusions. Depending on the anatomic distribution of the disease, an
  integrated approach to great vessel reconstruction that incorporated transthoracic and
  extrathoracic approaches and techniques of endarterectomy and bypass resulted in
  few adverse outcomes and excellent long-term patency. Simultaneous
  revascularization of the great vessels and coronary arteries can produce immediate
  and long-term, symptom-free outcome with acceptably low operative risk. (C) 1998
  by The Society of Thoracic Surgeons
  grafting/carotid/coronary artery bypass/coronary artery bypass grafting/coronary
  artery                                                                 disease/coronary
  infarction/operative/outcome/outcomes/percutaneous           transluminal      coronary
Wass, C.T., Waggoner, J.R., Cable, D.G., Schaff, H.V., Schroeder, D.R. and Lanier,
  W.L. (1998), Selective convective brain cooling during hypothermic
  cardiopulmonary bypass in dogs. Annals of Thoracic Surgery, 66 (6), 2008-2014.
Abstract: Background. Neurologic complications, primarily resulting from ischemic
  insults, represent the leading cause of morbidity and disability, and the second most
  common source of death, after cardiac operations. Previous studies have reported that
  increases las occur during the rewarming phase of cardiopulmonary bypass [CPB])
  or decreases in brain temperature of a mere 0.5 degrees to 2 degrees C can
  significantly worsen or improve, respectively, postischemic neurologic outcome. The
  purpose of the present study was to evaluate a novel approach of selectively cooling
  the brain during hypothermic CPB and subsequent rewarming. Methods. Sixteen
  dogs were anesthetized with either intravenous pentobarbital or inhaled halothane (n
  = 8 per group). Normocapnia (alpha stat technique) and a blood pressure near 75 mm
  Hg were maintained. Temperatures were monitored by placing thermistors in the
  esophagus (ie, core), parietal epidural space, and brain parenchyma at depths of 1
  and 2 cm beneath the dura. During CPB, core temperature was actively cycled from
  38 degrees C to 28 degrees C, and then returned to 38 degrees C. Forced air
  pericranial cooling lair temperature of approximately 13 degrees C) was initiated
  simultaneous with the onset of CPB, and maintained throughout the bypass period.
  Brain-to-core temperature gradients were calculated by subtracting the core
  temperature from regional brain temperatures. Results. In halothane-anesthetized
  dogs, brain temperatures at all monitoring sites were significantly less than core
  during all phases of CPB, with one exception (2 cm during systemic cooling). Brain
  cooling was most prominent during and after systemic rewarming. For example,
  during systemic rewarming, average temperatures in the parietal epidural space, and
  1 and 2 cm beneath the dura, were 3.3 degrees +/- 1.3 degrees C (mean +/- standard
  deviation), 3.2 degrees +/- 1.4 degrees C, and 1.6 degrees +/- 1.0 degrees C, cooler
  than the core, respectively. Similar trends, but of a greater magnitude, were noted in
  pentobarbital-anesthetized dogs. For example, during systemic rewarming,
  corresponding brain temperatures were 6.5 degrees +/- 1.7 degrees C, 6.3 degrees +/-
  1.6 degrees C, and 4.2 degrees +/- 1.3 degrees C cooler than the core, respectively.
  Conclusions. The magnitude of selective brain cooling observed in both study groups
  typically exceeded the 0.5 degrees to 2.0 degrees C change previously reported to
  modulate ischemic injury, and was most prominent during the latter phases of CPB.
  When compared with previous research from our laboratory, application of cold
  forced air to the cranial surface resulted in brain temperatures that were cooler than
  those observed during hypothermic CPB without pericranial cooling. On the basis of
  the assumption that similar beneficial brain temperature changes can be induced in
  humans, we speculate that selective convective brain cooling may enable clinicians
  to improve neurologic outcome after hypothermic CPB. (C) 1998 by The Society of
   Thoracic Surgeons
Keywords:          ACUTE            STROKE/alpha-stat/blood           pressure/brain/brain
King, R.C., Kanithanon, R.C., Shockey, K.S., Spotnitz, W.D., Tribble, C.G. and Kron,
   I.L. (1998), Replacing the atherosclerotic ascending aorta is a high-risk procedure.
   Annals of Thoracic Surgery, 66 (2), 396-401.
Abstract: Background. Improved techniques in cerebral and myocardial protection have
   made replacement of the chronically aneurysmal ascending thoracic aorta a safe and
   effective procedure. We hypothesized that patients with severe ascending or aortic
   arch atherosclerosis were at greater risk for operative complications during ascending
   aortic replacement because of the diffuse nature of their atherosclerotic process.
   Methods. We retrospectively analyzed the records of 17 patients who received
   ascending aortic replacement during elective coronary artery bypass grafting (CABG)
   because of the intraoperative finding of severe atherosclerosis. All 17 patients
   underwent tube graft replacement of the ascending aorta under hypothermic
   circulatory arrest and retrograde cerebral perfusion before coronary artery bypass
   grafting. The outcomes for these patients were compared with those of a control
   group of 89 consecutive patients who underwent replacement for ascending thoracic
   aortic aneurysm. Results. The hospital mortality rate for replacement of the
   ascending thoracic aorta for severe atherosclerosis was 23.5% (4/17) versus 2.25% (2
   of 89) for the control group (p = 0.006). The incidence of cerebrovascular accident in
   the atherosclerotic group was 17.6% (3/17) and 3.37% (3/89) for the control group (p
   = 0.051). Nine of 17 atherosclerotic patients (52.9%) had operative morbidity. Only
   20.2% (18 of 89) of the control patients had nonfatal postoperative complications.
   Conclusions. The severely atherosclerotic ascending aorta is a marker of diffuse
   atherosclerosis. Despite improved techniques of myocardial and cerebral protection,
   we have been unable to duplicate our success with ascending thoracic aneurysm
   repair. Preoperative screening of the ascending aorta by chest computed tomography
   may be appropriate in select high-risk patients to determine operability. (C) 1998 by
   The Society of Thoracic Surgeons
Keywords:               aneurysm/aorta/aortic               aneurysm/ATHEROMATOUS
   DISEASE/atherosclerosis/bypass/bypass                                grafting/BYPASS
   tomography/coronary           artery        bypass/coronary        artery       bypass
   grafting/CORONARY-ARTERY SURGERY/EXPERIENCE/hospital/hypothermic
   complications/retrograde            cerebral          perfusion/STROKE/THORACIC
Stowe, C.L., Baertlein, M.A., Wierman, M.D., Rucker, M. and Ebra, G. (1998),
   Surgical management of ascending and aortic arch disease: Refined techniques with
   improved results. Annals of Thoracic Surgery, 66 (2), 388-395.
Abstract: Background. Treatment of aneurysms of the ascending aorta, arch aorta, or
   both is surgically challenging and has traditionally carried a high hospital mortality
   rate. The use of refined operative techniques, including improved grafts, enhanced
   myocardial protection, retrograde cerebral perfusion with circulatory arrest,
  transesophageal echocardiography, and control of hematologic factors, has resulted
  in reduced hospital mortality rates. Methods. We conducted a retrospective analysis
  of records of 117 consecutive patients who underwent 118 procedures between
  March 1987 and September 1997, for graft replacement of the ascending or
  transverse aortic arch with or without aortic valve reconstruction or replacement.
  There were 67 men (57.3%) and 50 women (42.7%). The mean age was 61.4 years
  (range, 16 to 81 years). Aortic abnormalities were medial degeneration in 59 patients
  (50.0%), dissection in 28 patients (23.7%), atherosclerosis in 16 patients (13.6%),
  Marfan's syndrome in 8 patients (6.8%), and other in 7 patients (5.9%). Results. The
  ascending aorta alone was replaced in 58 patients (49.2%), ascending and arch aorta
  in 56 patients (47.5%), and isolated arch aorta in 4 patients (3.4%). Twenty-six
  patients (22.0%) required aortic valve reconstruction, 17 patients (14.4%) had
  separate aortic valve replacement, and 37 patients (31.4%) received a valve conduit.
  Overall hospital mortality rate was 3.4% (4 of 117 patients). Postoperative
  complications included myocardial infarction in 3 patients (2.5%), stroke in 7
  patients (5.9%), pulmonary insufficiency in 22 patients (18.6%), renal insufficiency
  in 4 patients (3.4%), and reoperation for bleeding in 8 patients (6.8%). There were no
  deep sternal wound infections. Follow-up was completed for 112 (99.1%) of 113
  survivors and ranged from 1 month to 10.6 years (mean, 39.5 months). Actuarial
  survival for patients discharged from the hospital was 87.9% +/- 3.7% (standard error
  of the mean) at 3 years and 79.7% +/- 5.8% at 6 years. Conclusions. Graft
  replacement of the ascending and transverse aortic arch, although technically
  demanding, can be performed with low hospital mortality and morbidity rates. (C)
  1998 by The Society of Thoracic Surgeons
Keywords:       age/ANEURYSM          REPAIR/ANGIOGRAPHY/aorta/aortic              valve
  rates/myocardial infarction/OPERATIONS/REPLACEMENT/retrograde cerebral
Tanoue, Y., Tominaga, R., Ochiai, Y., Fukae, K., Morita, S., Kawachi, Y. and Yasui, H.
  (1999), Comparative study of retrograde and selective cerebral perfusion with
  transcranial Doppler. Annals of Thoracic Surgery, 67 (3), 672-675.
Abstract: Background: Retrograde cerebral perfusion (RCP) is a simple technique and is
  expected to provide cerebral protection. However, ifs optimum management and
  limitations remain unclear. Transcranial Doppler has been used to monitor cerebral
  perfusion. Using this Doppler technique, we compared cerebral blood flow for RCP
  with that for selective cerebral perfusion. Methods. Thirty-two consecutive patients
  underwent elective surgical repair of an aortic aneurysm involving the aortic arch at
  Kyushu University Hospital. Retrograde cerebral perfusion was used in 15 patients
  and selective cerebral perfusion, in 17 patients. Continuous measurement of middle
  cerebral artery blood now velocities was performed by transcranial Doppler
  technique. Results. Retrograde middle cerebral artery blood flow velocities during
  RCP could be measured in only 3 patients, whereas middle cerebral artery blood
  flow velocities during selective cerebral perfusion could be measured in all but 1
  woman. The increase in middle cerebral artery blood flow velocities after RCP was
  significantly greater than that after selective cerebral perfusion. Conclusions. The
  measurement of middle cerebral artery blood flow velocities with transcranial
  Doppler technique is practicable during selective cerebral perfusion but difficult
  during RCP. The increase in middle cerebral artery blood flow velocities after RCP
  indicates reactive hyperemia and reflects the critical decrease in cerebral blood flow
  during this type of perfusion. (Ann Thorac Surg 1999;67:672-5) (C) 1999 by The
  Society of Thoracic Surgeons
Keywords:              aneurysm/aortic           aneurysm/AORTIC-ARCH/artery/blood
  flow/BLOOD-FLOW/BRAIN/cerebral/cerebral               blood     flow/CIRCULATORY
  ARREST/Doppler/HYPOTHERMIA/management/measurement/middle                        cerebral
  artery/OPERATIONS/PROTECTION/STROKE/transcranial Doppler
Okita, Y., Ando, M., Minatoya, K., Kitamura, S., Takamoto, S. and Nakajima, N.
  (1999), Predictive factors for mortality and cerebral complications in arteriosclerotic
  aneurysm of the aortic arch. Annals of Thoracic Surgery, 67 (1), 72-78.
Abstract: Background. The incidence of cerebral complications is high in patients with
  aortic arch aneurysm. Methods. Between December 1977 and December 1995, 246
  patients with arteriosclerotic arch aneurysm underwent operation. Thirty-nine
  patients had an aneurysm involving the entire arch, 193 had only distal arch
  aneurysm, and 14 had arch aneurysm extending to the descending aorta.
  Eighty-seven patients underwent replacement of the total arch, 85 had replacement of
  only the distal arch, 14 had simultaneous replacement of the descending aorta, 45 had
  patch repair, and 15 had thromboexclusion. Selective cerebral perfusion was used in
  112 patients and partial bypass in 58 in the earlier series of patients, but deep
  hypothermic circulatory arrest with retrograde cerebral perfusion technique was
  exclusively applied in the most recent 76 patients. Results. There were 50 (20%)
  early deaths and 37 (19%) late deaths. Postoperative stroke was found in 26 (11%)
  patients of which 13 (50%) died. Mutual predictive factors for postoperative
  mortality and stroke were earlier series, preoperative chronic renal failure, ruptured
  aneurysm, arch clamping during procedure, and using partial cardiopulmonary
  bypass. Among 129 patients operated on during the most recent 5 years, early
  mortality and incidence of stroke decreased to 14.7% and 6.9%, respectively.
  Conclusions. Results of operations for arteriosclerotic aneurysms of the transverse
  aortic arch in 246 patients during a period of 17 years have been improving but are
  still not satisfactory. (C) 1999 by The Society of Thoracic Surgeons
Keywords:         aneurysm/aorta/ASCENDING           AORTA/BRAIN/bypass/CARDIAC
  OPERATIONS/cardiopulmonary                     bypass/cerebral/chronic             renal
  failure/CIRCULATORY                ARREST/complications/DISSECTION/hypothermic
  etrograde cerebral perfusion/stroke/SURGERY/SURGICAL-TREATMENT
Azakie, A., McElhinney, D.B., Messina, L.M. and Stoney, R.J. (1999), Common
  brachiocephalic trunk: Strategies for revascularization. Annals of Thoracic Surgery,
  67 (3), 657-660.
Abstract: Background. A common brachiocephalic trunk, in which both common
  carotid arteries and the right subclavian artery arise from a single trunk off the arch,
  is a normal variant of aortic arch branching that occurs in approximately 10% of the
  population. Because three of the four primary sources of cerebral blood flow arise
  from a single aortic branch, stenosis or occlusion of a common trunk can cause
  severe ischemic consequences. Common trunk revascularization has been described,
  but there have been no reports focusing on the management options for occlusive
  disease of this vascular anatomy. Methods. A retrospective review of our experience
  with innominate artery revascularization identified 6 patients who underwent
  revascularization of a common brachiocephalic trunk between 1977 and 1997 All
  patients were symptomatic, with either total occlusion (n = 3) or critical stenosis (n =
  3) caused by atherosclerosis (n = 5) or Takayasu's arteritis (n = 1). Revascularization
  was achieved by a prosthetic bypass graft from the ascending aorta to the innominate
  or left common carotid arteries or both (n = 5); or transarterial endarterectomy (n =
  1). Concomitant endarterectomy of branch vessels was performed in 3 patients.
  Results. There was one perioperative death from myocardial infarction, and one
  perioperative stroke, with death occurring 1 month after hospital discharge. One
  patient developed cerebral hyperperfusion syndrome 1 week after endarterectomy
  that resolved without sequelae with antihypertensive medications. During a
  follow-up period ranging from 1 to 20 years, there was one late death from
  congestive heart failure 5 years after operation. All surviving patients are alive and
  free from symptomatic recurrence. Conclusions. Revascularization for occlusive
  disease of a common brachiocephalic trunk can be achieved with effective and
  durable relief of symptoms using either a prosthetic bypass graft or endarterectomy.
  However, neurologic complications in 2 patients, which were fatal in 1, attest to the
  potential cerebral ischemic threat posed by occlusive disease of a common
  brachiocephalic trunk. (Ann Thorac Surg 1999;67:657-60) (C) 1999 by The Society
  of Thoracic Surgeons
Keywords:      aorta/arteries/artery/ARTERY       OCCLUSIVE         DISEASE/ascending
  aorta/atherosclerosis/blood        flow/bypass/carotid/carotid      arteries/CAROTID
  ENDARTERECTOMY/cerebral/cerebral blood flow/complications/congestive heart
Leyh, R.G., Bartels, C., Notzold, A. and Sievers, H.H. (1999), Management of porcelain
  aorta during coronary artery bypass grafting. Annals of Thoracic Surgery, 67 (4),
Abstract: Background. Patients with porcelain aorta carry a high risk of systemic
  embolism during coronary artery bypass grafting. No currently proposed surgical
  approach avoids manipulation of the heavily calcified ascending aorta. A novel
  surgical approach avoiding manipulation of the porcelain aorta was evaluated with
  regard to its efficacy in prevention of atheroemboli. Methods. The following surgical
  protocol was performed in 23 patients with porcelain aorta: (1) arterial cannulation of
  the axillary artery, (2) hypothermic fibrillatory arrest for performance of the distal
  anastomosis, and (3) construction of the proximal anastomosis to the inominate
  artery or to a disease-free area of the ascending aorta during hypothermic circulatory
  arrest. Results. The postoperative course was uneventful in all patients. No patient
  experienced a cerebrovascular accident or visceral organ injury as a result of
  atheroemboli. Conclusions. The proposed surgical approach is safe and reliable in
  patients with porcelain aorta and has the potential to reduce the prevalence of stroke
  and systemic embolization associated with coronary artery bypass grafting in patients
  with porcelain aorta. (Ann Thorac Surg 1999;67:986-8) (C) 1999 by The Society of
  Thoracic Surgeons
Keywords: aorta/ARCH/artery/ascending aorta/ATHEROSCLEROTIC ASCENDING
  AORTA/axillary                                                    artery/bypass/bypass
  grafting/CARDIAC-SURGERY/cerebrovascular/coronary/coronary                       artery
  bypass/coronary artery bypass grafting/embolism/embolization/hypothermic
  circulatory      arrest/injury/OPERATIONS/prevalence/prevention/STROKE/surgical
Borger, M.A., Fremes, S.E., Weisel, R.D., Cohen, G., Rao, V., Lindsay, T.F. and
   Naylor, C.D. (1999), Coronary bypass and carotid endarterectomy: Does a combined
   approach increase risk? A metaanalysis. Annals of Thoracic Surgery, 68 (1), 14-20.
Abstract: Background. Patients with concomitant carotid and coronary artery disease
   present a surgical dilemma. We compared the stroke and mortality rates for
   combined coronary artery bypass grafting and carotid endarterectomy in which both
   procedures were performed under a single anesthetic, versus a staged approach, in
   which coronary artery bypass grafting and carotid endarterectomy were performed
   separately. Methods. A computerized MEDLINE search supplemented with a manual
   bibliographic review was performed for all peer-reviewed English language
   publications that contained both combined and staged coronary artery bypass
   grafting/carotid endarterectomy patient cohorts. Outcomes of interest were stroke,
   death, and stroke or death; aggregation of outcome rates was performed with the
   Mantel-Haenszel method. Results. Sixteen studies were identified with a total of 844
   combined patients and 920 staged patients. None of the studies was completely
   randomized. The combined surgical group had a higher prevalence of unstable
   angina; the two groups had a similar prevalence of symptomatic carotid disease and
   severe carotid stenosis. Meta-analysis revealed a significantly increased risk of the
   composite end point, stroke or death, for patients undergoing combined procedures
   (relative risk 1.49; 95% confidence interval 1.03- 2.15; p = 0.034). There was also a
   trend toward increased risk during combined procedures for the end points of stroke
   (relative risk 1.50; 95% confidence interval 0.97-2.32; p = 0.068) and death (relative
   risk 1.55; 95% confidence interval 0.94-2.53; p = 0.084) considered separately. The
   crude event rates for stroke were 6.0% versus 3.2% for combined versus staged
   procedure, 4.7% versus 2.9% for death, and 9.5% versus 5.7% for stroke or death.
   Two of the 16 individual studies showed a statistically significant increase in the risk
   of stroke or death for combined procedure (p < 0.05). Conclusions. Combined
   coronary artery bypass grafting and carotid endarterectomy may be associated with a
   higher risk of stroke or death than staged procedures. A randomized trial needs to be
   performed to determine the optimal management of patients with concomitant
   carotid and coronary artery disease. (C) 1999 by The Society of Thoracic Surgeons
Keywords:                 angina/artery/ARTERY                   BYPASS/bypass/bypass
   grafting/CARDIAC-SURGERY/carotid/carotid                        endarterectomy/carotid
   stenosis/combined/concomitant/coronary/coronary artery bypass/coronary artery
   bypass grafting/coronary artery disease/death/disease/endarterectomy/GRAFT-
   risk/REVASCULARIZATION/review/risk                                                    of
   stroke/STENOSIS/STROKE/studies/unstable angina/VASCULAR-DISEASE
John, R., Choudhri, A.F., Weinberg, A.D., Ting, W., Rose, E.A., Smith, C.R. and Oz,
   M.C. (2000), Multicenter review of preoperative risk factors for stroke after coronary
   artery bypass grafting. Annals of Thoracic Surgery, 69 (1), 30-35.
Abstract: Background. Stroke complicates the postoperative course in 1% to 6% of
   patients undergoing coronary revascularization. There has been no large scale
   mandatory database reporting on the incidence of stroke after coronary
   revascularization. Methods. A multicenter regional database from the Bureau of
   Health Care Research Information Services, New York State Department of Health,
   on 19,224 patients who underwent coronary revascularization in 31 hospitals within
   New York State during 1995 was analyzed to determine the risk factors for
   postoperative stroke. Results. The incidence of postoperative stroke was 1.4% (n =
   270). Hospital mortality for patients who had a stroke was 24.8%, compared with
  2.0% for the rest of the patient population. Postoperative stroke increased the
  hospital length of stay threefold (27.9 +/- 1.9 versus 9.1 +/- 0.9 days, p < 0.0001).
  Multivariable logistic regression identified the following variables to be significantly
  associated with a postoperative stroke: calcified aorta (P < 0.0001; odds ratio [OR],
  3.013), prior stroke (p 0.0003; OR, 1.909), age (p < 0.0001; OR, 1.522 per 10 years),
  carotid arterial disease (p = 0.002; OR, 1.590), duration of cardiopulmonary bypass
  (p = 0.0004; OR, 1.27 per 60 minutes), renal failure ((p = 0.0062; OR, 2.032),
  peripheral vascular disease (p = 0.0157; OR, 1.62), cigarette smoking (p = 0.0197;
  ORI 1.621), and diabetes mellitus (p = 0.0158; on, 1.373). Conclusions.
  Postoperative stroke increases mortality and length of stay after coronary
  revascularization. Several risk factors can be identified, and some of these factors are
  potentially amenable to intervention, either before or during coronary
  revascularization, and should also influence patient selection. (C) 2000 by The
  Society of Thoracic Surgeons
Keywords: age/aorta/arterial disease/artery/ASCENDING AORTA/bypass/bypass
  grafting/calcified                      aorta/CARDIAC-SURGERY/cardiopulmonary
  bypass/carotid/coronary/coronary       artery     bypass/coronary       artery   bypass
  grafting/coronary                                    revascularization/diabetes/diabetes
  mellitus/disease/hospital/incidence/length of stay/MANAGEMENT/mortality/patient
  selection/peripheral          vascular           disease/regional/regression/renal/renal
  failure/revascularization/review/risk/risk factors/smoking/stroke/vascular disease
Mizuno, T., Toyama, M., Tabuchi, N., Kuriu, K., Ozaki, S., Kawase, I. and Horimi, H.
  (2000), Thickened intima of the aortic arch is a risk factor for stroke with coronary
  artery bypass grafting. Annals of Thoracic Surgery, 70 (5), 1565-1570.
Abstract: Background. Perioperative stroke is one of the most serious complications of
  cardiac surgery. Methods. Using transesophageal echocardiography, we estimated
  the intimal thickness of the thoracic aorta as an index of the severity of aortic
  atherosclerosis to determine the risk of stroke in coronary artery bypass grafting
  (CABG) patients. The study population comprised 315 consecutive patients who
  underwent isolated CABG with cardiopulmonary bypass. Results. Five patients
  (1.6%) had perioperative cerebral stroke or systemic emboli. We compared the mean
  intimal thicknesses of the ascending aorta, aortic arch, and descending aorta. Mean
  thicknesses in patients without stroke were 2.07 +/- 0.76, 2.78 +/- 1.15, and 2.32 +/-
  1.21 mm, respectively, and mean thicknesses in the stroke patients were 1.94 +/- 0.55,
  6.94 +/- 3.79, and 3.39 +/- 1.85 mm, respectively. The patients with an intima of
  more than 5 mm at the aortic arch had a significantly greater incidence of
  perioperative stroke (p = 0.007). Conclusions. These results suggest that patients who
  have an aortic arch intima thickened to more than 5 mm are at a significantly high
  risk for perioperative stroke, and thus, the CABG procedure should be carefully
  evaluated to prevent such complications. (Ann Thorac Surg 2000;70:1565-70) (C)
  2000 by The Society of Thoracic Surgeons
Keywords:                                                      aorta/artery/ASCENDING
  grafting/CABG/cardiac                                 surgery/CARDIOPULMONARY
  BYPASS/cerebral/complications/coronary/coronary artery bypass/coronary artery
  bypass grafting/DISEASE/echocardiography/emboli/incidence/INTRAOPERATIVE
  STROKE/Japan/LENGTH/MANAGEMENT/risk                             factor/risk           of
Hirotani, T., Kameda, T., Kumamoto, T., Shirota, S. and Yamano, M. (2000), Stroke
   after coronary artery bypass grafting in patients with cerebrovascular disease. Annals
   of Thoracic Surgery, 70 (5), 1571-1576.
Abstract: Background. Stroke has been associated with a significantly increased
   mortality from coronary artery bypass grafting (CABG). To determine the predictors
   of stroke in patients undergoing CABG, we collected data on 472 consecutive
   patients. Methods. From March 1991 to March 1999, all patients undergoing CABG
   at our institution underwent routine duplex scanning of the extracranial carotid and
   vertebral arteries. Seven patients with symtomatic carotid stenosis were treated by
   carotid endarterectomy (CEA) before CABG. Results. There was a 10-fold increase
   in mortality (12.5%) associated with postoperative stroke. Many variables were
   analyzed by a mutivariate technique and the severity of extracranial carotid artery
   stenosis was determined to be the only independent predictor of postoperative stroke
   (p < 0.01). None of the patients with carotid artery occlusion and none of the patients
   who underwent CEA before CABG experienced a stroke. Conclusions. To reduce the
   stroke rate, the indications for prophylactic CEA may be extended for asymptomatic
   patients with carotid artery stenosis greater than 75%. (Ann Thorac Surg
   2000;70:1571-6) (C) 2000 by The Society of Thoracic Surgeons
Keywords:                arteries/artery/ASCENDING                 AORTA/bypass/bypass
   grafting/CABG/CARDIOPULMONARY BYPASS/carotid/carotid artery/carotid
   artery      occlusion/carotid      artery   stenosis/carotid     endarterectomy/carotid
   stenosis/cerebrovascular/cerebrovascular          disease/coronary/coronary      artery
   bypass/coronary                                artery                           bypass
Svensson, L.G., Longoria, J., Kimmel, W.A. and Nadolny, E. (2000), Management of
   aortic valve disease during aortic surgery. Annals of Thoracic Surgery, 69 (3),
Abstract: Background. Alternative management strategies for aortic valve disease and
   aortic operation include valve preservation and aortic repair (VPR), composite valve
   graft (CVG), or separate valve and aortic repair (SVR). We evaluated these
   approaches. Methods. Of 250 ascending/arch operations, 151 patients had aortic
   valvular disease and dissection (n = 56, 37%) or aneurysms operated between
   November 1990 and January 1998. Sixty-seven patients underwent CVG insertion,
   50 SVR, 13 VPR, and 21 only aortic repair alone (RA). Sixty (40%) patients also had
   aortic arch repairs and 53 (35%) coronary artery bypasses. Results, The early 30-day
   survival and stroke rates were 99% (150 of 151) and 0% (0 of 151), respectively:
   CVG 100% (67 of 67), 0%; VPR 100% (13 of 13), 0%; SVR 98% (49 of 50), 0%;
   RA 100% (21 of 21), 0% (p = not significant [NS]), On late follow- up of all patients
   (5 to 92 months; 96% complete 1998), 3 CVG,2 VPR, 6 SVR, and 0 RA patients
   died with respective 5-year Kaplan-Meier survival rates of 88.4%, 70%, 69%, and
   100% (p = 0.07, lag-rank test). The respective linear rates for stroke were 0%, 5.5%
   (n = 1), 0%, and 0%; for hemorrhage were 0%, 0%, 0%, and 0%; and for
   endocarditis were 2.2% (n = 3), 0%, 0%, and 0% (p = NS). There were 11 late deaths
   and no patient required reoperation or ruptured the ascending aorta or the aortic arch,
   Conclusions. With careful selection of the appropriate method excellent early and
   late results can be achieved, (C) 2000 by The Society of Thoracic Surgeons
Keywords:          ANEURYSM/aneurysms/aorta/aortic              valve/artery/ASCENDING
Nierich, A.P., Diephuis, J., Jansen, E.W.L., Borst, C. and Knape, J.T.A. (2000), Heart
   displacement during off-pump CABG: How well is it tolerated? Annals of Thoracic
   Surgery, 70 (2), 466-472.
Abstract: Background. Heart displacement during off-pump coronary artery bypass
   grafting (CABG) is necessary to expose the anastomosic sites. We analyzed the
   hemodynamic changes in relation to the grafted arteries. Methods. The relationship
   between surgical exposure and hemodynamic management was assessed in 150
   consecutive patients undergoing off-pump CABG utilizing the Octopus Tissue
   Stabilization System (Medtronic, Minneapolis, MN). Results. Surgical exposure by
   anterolateral thoracotomy showed no significant hemodynamic changes. Through
   sternotomy, stroke volume was significantly reduced by dislocation at all target sites:
   by 6% at the left anterior descending artery (LAD), 25% at the diagonal branch
   artery (D), 14% at the right coronary artery (RCA), and 21% at the obtuse marginal
   artery (OM). The application of head-down positioning (LAD, 56%; D, 74%; RCA,
   90%; OM, 96%) increased not only surgical exposure but also preload, producing
   correction of ventricular filling pressures and output. In a minority of cases,
   dopamine (3 to 5 mu was added to maintain baseline hemodynamic
   values (LAD, 5%; D, 15%; RCA, 7%; OM, 28%). Conclusions. Revascularization
   during anterolateral thoracotomy tvas uneventful. The sternotomy approach with
   heart displacement induced right heart compression. Mainly fluid redistribution Tvas
   sufficient to correct cardiac output. Once stabilized, systemic circulation remained
   unchanged during revascularization. (C) 2000 by The Society of Thoracic Surgeons
Keywords: arteries/artery/BEATING HEART/bypass/bypass grafting/CABG/cardiac
   output/CARDIOPULMONARY                 BYPASS/CORONARY/coronary                 artery
   bypass/coronary                              artery                            bypass
   grafting/management/Netherlands/Octopus/OCTOPUS                              TISSUE
   STABILIZER/revascularization/stroke/stroke volume
Trehan, N., Mishra, M., Kasliwal, R.R. and Mishra, A. (2000), Reduced neurological
   injury during CABG in patients with mobile aortic atheromas: A five-year follow-up
   study. Annals of Thoracic Surgery, 70 (5), 1558-1564.
Abstract: Background. Mobile atheromas of the thoracic aorta have been identified as a
   major cause of stroke after coronary artery bypass grafting (CABG). This
   prospective study was undertaken to identify mobile atheromas and to determine the
   incidence of immediate postoperative embolic events after suitable surgical
   modifications. Late clinical events attributable to embolization were also studied.
   Methods. Between January 1993 and July 1997, 3,660 patients scheduled for CABG
   underwent intraoperative transesophageal echocardiography to identify aortic
   atheromatous disease. The disease was graded as follows: grade I, plaques extending
   less than 5 mm into the aortic lumen; grade II, plaques extending more than 5 mm
   into the aortic lumen; and grade III, plaques with a mobile element. Only patients
   with grade III atheromas were included in the study. Various surgical modifications
   were done depending on the location of the lesion, eg, aortic arch atherectomy,
   CABG combined with transmyocardial laser revascularization, off-pump CABG by
   median sternotomy, and minimally invasive direct coronary artery bypass. Measured
   outcomes were death, stroke, and other vascular events, both early (within 1 week)
   and late (1 to 5 years) after operation. Results. Of the 3,660 patients, 104 (2.84%)
   had mobile atheromas. The perioperative stroke rate was 0.96%, and the incidence of
   other vascular events was 1.92% at 1 week. There was no embolic event in the group
   of 88 patients who underwent off-pump CABG. Of the study group, 98.07% are in
   regular follow-up. At 5 years, 1 patient had had a nonfatal stroke, and 2 patients had
   died of causes unrelated to atheromatous disease. Conclusions. The stroke rate was
   very low in patients with mobile aortic atheromas who underwent CABG after
   modification in surgical technique, especially off-pump CABG. A follow-up of 5
   years showed that patients with mobile atheromas have a very low incidence of
   spontaneous embolization. (Ann Thorac Surg 2000;70:1558-64) (C) 2000 by The
   Society of Thoracic Surgeons
Keywords: aorta/ARCH/artery/atheromatous/ATHEROSCLEROTIC ASCENDING
   AORTA/bypass/bypass            grafting/CABG/combined/coronary/coronary            artery
   bypass/coronary           artery        bypass         grafting/CORONARY-ARTERY
   TROKE/surgical                      technique/transesophageal/TRANSESOPHAGEAL
Trehan, N., Mishra, M., Kasliwal, R.R. and Mishra, A. (2000), Surgical strategies in
   patients at high risk for stroke undergoing coronary artery bypass grafting. Annals of
   Thoracic Surgery, 70 (3), 1037-1045.
Abstract: Background. Perioperative stroke represents one of the major complications
   following coronary artery bypass grafting (CABG). The present study was designed
   to evaluate the use of an individualized surgical approach for reducing neurological
   injury in patients undergoing CABG at high risk of stroke from aortic atherosclerosis
   or carotid disease. Methods. Between January 1993 and June 1999, 6,138 patients
   undergoing elective CABG were evaluated by intraoperative transesophageal
   echocardiography. Patients were screened preoperatively for internal carotid artery
   disease. Based on the intraoperative transesophageal echocardiography findings the
   surgical technique was individualized: hypothermic circulatory arrest with aortic
   atherectomy, CABG combined with transmyocardial laser revascularization on the
   beating heart, off-pump CABG by midsternotomy, ministernotomy, minimally
   invasive direct CABG, hybrid procedure, and so on. Patients were divided into four
   groups: a low-risk group (no significant aortic or carotid disease); an aortic
   atheromatous disease group (A.ATH); a carotid disease group (CD); and a carotid
   disease combined with aortic atheromatous disease group (CD + A.ATH). Results.
   The incidence of stroke in the low-risk group (n = 5,043) was 0.92% compared with
   0.96% in the A.ATH group (n = 918). In the CD group (n = 166) the incidence of
   stroke was 0.6% whereas it was 0% in the CD + A.ATH group (n = 11). Conclusions.
   Preoperative and intraoperative screening can detect extensive atherosclerosis of the
   proximal aorta and internal carotid artery. Selective use of surgical techniques in this
   group of high-risk patients can prevent adverse neurologic sequelae while achieving
   complete myocardial revascularization. (Ann Thorac Surg 2000;70:1037-45) (C)
   2000 by The Society of Thoracic Surgeons
Keywords:                                                         aorta/artery/ASCENDING
   BYPASS/carotid/carotid                          artery/carotid                     artery
   disease/combined/complications/coronary/coronary artery bypass/coronary artery
   bypass              grafting/DISEASE/echocardiography/EXPERIENCE/hypothermic
   circulatory     arrest/incidence/injury/internal/internal     carotid/internal    carotid
   artery/INTRAOPERATIVE                                            TRANSESOPHAGEAL
   ECHOCARDIOGRAPHY/MANAGEMENT/minimally                                 invasive/myocardial
   revascularization/revascularization/risk of stroke/screening/strategies/stroke/surgical
  approach/surgical technique/transesophageal/transesophageal echocardiography
van Wermeskerken, G.K., Lardenoye, J.W.H., Hill, S.E., Grocott, H.P., Phillips-Bute,
  B., Smith, P.K., Reves, J.G. and Newman, M.F. (2000), Intraoperative physiologic
  variables and outcome in cardiac surgery: Part II. Neurologic outcome. Annals of
  Thoracic Surgery, 69 (4), 1077-1083.
Abstract: Background. The impact of alterable physiologic variables on neurologic
  outcome after coronary artery bypass grafting procedures is unknown. The purpose
  of this study was to determine whether minimum intraoperative hematocrit,
  maximum glucose concentration, or mean arterial pressure during cardiopulmonary
  bypass influences risk-adjusted neurologic outcome after coronary artery bypass
  grafting. Methods. Outcome data from 2,862 patients undergoing coronary artery
  bypass grafting were merged with intraoperative physiologic data. A preoperative
  stroke risk index was calculated for each patient. Variables found significant by
  univariate logistic regression were tested in a multivariable model to determine
  association with. outcome. Results. The incidence of stroke or coma in the study
  population was 1.3%. After controlling for stroke risk and bypass time, only an index
  of low mean arterial pressure during bypass retained a significant inverse association
  with outcome (p = 0.0304). Conclusions. This study found no evidence that glucose
  concentration or minimum hematocrit are associated with major adverse neurologic
  outcome. The association between lower pressure during bypass and decreased
  incidence of stroke or coma persisted in all risk groups. This points to mechanisms
  other than hypoperfusion as the primary cause of neurologic injury associated with
  cardiac surgery. (C) 2000 by The Society of Thoracic Surgeons
Keywords:                artery/BENEFITS/bypass/bypass                  grafting/cardiac
  surgery/CARDIOPULMONARY                 BYPASS/coma/coronary/coronary           artery
  bypass/coronary          artery       bypass        grafting/CORONARY-ARTERY
  ke/STROKE RISK/surgery
Kern, J.A. and Arnold, S. (2000), Massive cerebral embolization: Successful treatment
  with retrograde perfusion. Annals of Thoracic Surgery, 69 (4), 1266-1268.
Abstract: Stroke is an unpredictable and morbid complication of cardiac operations. We
  report a patient who suffered massive bilateral cerebral embolization during aortic
  cannulation for coronary bypass. This was treated successfully with hypothermic
  circulatory arrest and high flow retrograde cerebral perfusion. The patient suffered
  only minimal neurologic impairment and improved rapidly. She was discharged
  home on postoperative day 7 neurologically intact. (C) 2000 by The Society of
  Thoracic Surgeons
Keywords:                               bypass/cerebral/complication/coronary/coronary
  bypass/CORONARY-ARTERY                     BYPASS/embolization/home/hypothermic
  circulatory                                 arrest/MANAGEMENT/PARTICULATE
  EMBOLIZATION/perfusion/retrograde                                             cerebral
Weinstein, G.S. (2001), Left hemispheric strokes in coronary surgery: Implications for
  end-hole aortic cannulas. Annals of Thoracic Surgery, 71 (1), 128-132.
Abstract: Background. Perioperative stroke (POS) is a devastating complication of
  coronary artery bypass grafting (CABG). Many studies have been published
  concerning risk factors and possible causes of POS but none have studied which side
  of the brain is more frequently involved. The finding of a strong preponderance of
  left-sided strokes calls into question some widely held theories as to the cause of
  POS and implicates end- hole aortic perfusion catheters as a major factor. Methods.
  During a 3-year period (1996 to 1998), prospective data were collected on all 2,217
  consecutive CABG patients at one hospital (with surgery by different surgeons in
  different groups). Strokes were classified as perioperative (within 3 days of surgery)
  or late (beyond 3 days but during hospitalization). Results. There were a total of 51
  strokes (2.3%): 21 left, 10 right, 7 bilateral, 7 lacunar, 1 brainstem, and 5
  indeterminate. There were 18 major territorial perioperative strokes on the left side
  and 6 on the right side. Thus, 75% (18 of 24) of POS were left-sided. Stroke patients
  were significantly younger than nonstroke patients (66.3 +/- 10.52 versus 71.4 +/-
  8.47 years, p = 0.009). Other demographic data did not differ significantly.
  Conclusions. If aortic clamping, cannulation, or manipulation were responsible for
  most strokes, then right-sided strokes should predominate, as the innominate artery is
  closest to the source of such emboli. In contrast, end-hole aortic cannulas direct a
  high-velocity jet at the left carotid orifice and may be responsible for a large
  proportion of POS. Side-hole aortic cannulas may reduce the incidence of this
  complication. (Ann Thorac Surg 2001;71:128-32) (C) 2001 by The Society of
  Thoracic Surgeons
Keywords:      artery/ARTERY         BYPASS/ATHEROSCLEROTIC                   ASCENDING
  AORTA/brain/bypass/bypass                                     grafting/CABG/CARDIAC
  BYPASS/carotid/complication/coronary/coronary artery bypass/coronary artery
  bypass                                                                  grafting/coronary
  A/perfusion/RISK/risk factors/stroke/studies/surgery
Dylewski, M., Canver, C.C., Chanda, J., Darling, R.C. and Shah, D.M. (2001),
  Coronary artery bypass combined with bilateral carotid endarterectomy. Annals of
  Thoracic Surgery, 71 (3), 777-781.
Abstract: Background. Surgical management of patients presenting for coronary artery
  bypass grafting with significant bilateral carotid artery stenosis has not been well
  defined. In this study, our preliminary results of coronary artery bypass grafting with
  concomitant bilateral carotid endarterectomy have been reviewed. Methods. A
  retrospective nonrandomized chart review was performed in 33 patients with
  unstable angina and bilateral carotid artery stenosis, more than 70%, undergoing
  simultaneous corollary artery bypass grafting and bilateral carotid endarterectomy
  using an eversion technique. Results. Concomitant coronary artery bypass grafting
  with bilateral carotid endarterectomy was performed urgently in 24 (73%) and
  electively in 9 (27%) patients. The average carotid artery cross-clamp and total
  perfusion times were 14.7 +/- 4.9 minutes and 123 +/- 29.2 minutes, respectively.
  The average length of stay in the cardiopulmonary intensive care unit was 4.2 +/-
  14.2 days and total hospital stay was 16.2 +/- 20.5 days. Postoperative in-hospital
  stay was 14.9 +/- 20.3 days. There were no postoperative strokes. Twenty-one (64%)
  patients were discharged before the tenth postoperative day. Nonfatal postoperative
  complications occurred in 27% (9 of 33) of patients. The overall 30-day mortality
  was 6.1% (2 of 33) and that was unrelated to primary cardiac or cerebrovascular
  events. Conclusions. Favorable outcome supports the justification for performing
  concomitant coronary artery bypass grafting with bilateral carotid endarterectomies
  in selected patients. (C) 2001 by The Society of Thoracic Surgeons
Keywords:      angina/artery/bilateral    carotid    artery     stenosis/bilateral   carotid
  endarterectomy/bypass/bypass         grafting/carotid/carotid     artery/carotid    artery
   nary             artery            bypass/coronary              artery            bypass
   ENDARTERECTOMY/hospital/intensive care/intensive care unit/length of
   SURGERY/unstable angina
LeMaire, S.A., Miller, C.C., Conklin, L.D., Schmittling, Z.C., Koksoy, C. and Coselli,
   J.S. (2001), A new predictive model for adverse outcomes after elective
   thoracoabdominal aortic aneurysm repair. Annals of Thoracic Surgery, 71 (4),
Abstract: Background. Recent recommendations have emphasized individualized
   treatment based on balancing a patient's risk of thoracoabdominal aortic aneurysm
   rupture with the risk of an adverse outcome after surgical repair. The purpose of this
   study was to determine which preoperative risk factors currently predict an adverse
   outcome after elective thoracoabdominal aortic aneurysm repair. Methods. A single,
   composite end point termed adverse outcome was defined as the occurrence of any of
   the following: death within 30 days, death before discharge from the hospital,
   paraplegia, paraparesis, stroke, or acute renal failure requiring dialysis. A risk factor
   analysis was performed using data from 1,108 consecutive elective
   thoracoabdominal aortic aneurysm repairs. Results. The incidence of an adverse
   outcome was 13.0% (144 of 1,108 patients); predictors included preoperative renal
   insufficiency (p = 0.0001), increasing age (p = 0.0035), symptomatic aneurysms (p =
   0.020), and extent II aneurysms (p = 0.0001). These risk factors were used to
   construct an equation that estimates the probability of an adverse outcome for an
   individual patient. Conclusions. This new predictive model may assist in decisions
   regarding elective thoracoabdominal aortic aneurysm operations. For patients who
   are acceptable candidates, contemporary surgical management provides favorable
   results. (C) 2001 by The Society of Thoracic Surgeons
Keywords:                                            acute/age/aneurysm/aneurysms/aortic
   predictors/RATES/renal/renal                 failure/risk/risk              factor/RISK
   FACTOR-ANALYSIS/risk factors/rupture/stroke/treatment
Bittner, H.B. and Savitt, M.A. (2001), Management of porcelain aorta and calcified
   great vessels in coronary artery bypass grafting with off-pump and no-touch
   technology. Annals of Thoracic Surgery, 72 (4), 1378-1380.
Abstract: A 69-year-old woman presented with postinfarct unstable angina and
   decreased ventricular function secondary to significant left main coronary artery
   stenosis in combination with total right coronary artery occlusion. We did successful
   off-pump coronary revascularization in this patient with severely calcified ascending
   aorta and great vessels, subtotal aortobiiliac stenoses, a history of previous stroke,
   and right carotid endarterectomy. (C) 2001 by The Society of Thoracic Surgeons
Keywords:             angina/aorta/artery/ASCENDING                 AORTA/bypass/bypass
   grafting/carotid/carotid     endarterectomy/combination/coronary/coronary          artery
   bypass/coronary artery bypass grafting/coronary artery stenosis/coronary
   stroke/unstable angina
Murkin, J.M. (2001), Attenuation of neurologic injury during cardiac surgery. Annals of
   Thoracic Surgery, 72 (5), S1838-S1844.
Abstract: Neurologic injury after cardiac surgery can be divided into type I, including
   clinically apparent stroke, seizures stupor, or coma, and much more occurring type II
   injury, including intellectual deterioration, memory deficit, or seizures. Cerebral
   embolization is demonstrably etiologic in many such cases, and several new aortic
   cannulas are being introduced that are aimed at capturing or diverting potential
   cerebral emboli. No outcome data are yet available. Several potentially
   cerebroprotective pharmacologic therapies including thiopental, propofol, and
   nimodipine, have been assessed clinically but, generally, the results have been poor.
   Meta-analysis of the large North American aprotinin database of prospective,
   randomized, placebo-controlled clinical trials is suggestive of a cerebroprotective
   potential associated with high-dose aprotinin administration. (C) 2001 by The
   Society of Thoracic Surgeons
Keywords:                                     administration/APROTININ/ASCENDING
   AORTA/BLOOD/Canada/cardiac                           surgery/CARDIOPULMONARY
   BYPASS/cerebral/cerebral                                                emboli/clinical
Trehan, N., Mishra, M., Sharma, O.P., Mishra, A. and Kasliwal, R.R. (2001), Further
   reduction in stroke after off-pump coronary artery bypass grafting: A 10-year
   experience. Annals of Thoracic Surgery, 72 (3), S1026-S1032.
Abstract: Background. Perioperative stroke is a devastating complication after coronary
   artery bypass grafting (CABG). The reported incidence of neurologic complications
   after conventional CABG is 3% to 7%. With improved monitoring and surgical
   techniques, we have been able to achieve a drastic reduction in the stroke rate in our
   institution. This study evaluates the incidence of neurologic sequelae in patients who
   underwent off-pump CABG. Methods. Over a 10-year period from January 1990 to
   September 2000, off-pump coronary artery bypass (OPCAB) operation was
   performed on 2,800 patients of the 18,037 patients undergoing CABG during that
   time frame at the Escorts Heart Institute and Research Centre. Initially, OPCAB was
   performed selectively in the high-risk group of patients (atheromatous aorta, renal
   impairment, chronic obstructive pulmonary disease, octogenarians, etc). Lately we
   performed multivessel OPCABs electively in about 60% to 65% of the patients
   undergoing CABG. Results. Mean age of the patients was 58.0 +/- 9.91 years (range
   27 to 85 years) and mean number of grafts was 2.9 per patient. Neurologic
   complications (stroke/transient ischemic attack) occurred in 0.14% of patients.
   Overall hospital mortality in OPCAB patients was 2.14%, whereas mortality from
   neurologic complications was 0.07%. Predicted mortality (National Society of
   Thoracic Surgeons Cardiac Surgery Database Risk Model for CABG) for the entire
   patient group was 3.86% (p < 0.001). Conclusions. Although current techniques of
   monitoring and surgical procedures have significantly reduced the risk of stroke from
   CABG, our data strongly support OPCAB as a technique to further reduce stroke
   after CABG, especially in the high-risk group of patients. (C) 2001 by The Society of
   Thoracic Surgeons
Keywords:              age/aorta/AORTIC              ATHEROMAS/artery/ASCENDING
   BYPASS/complication/complications/coronary/coronary artery bypass/coronary
  artery                     bypass                     grafting/disease/hospital/hospital
Umana, J.P., Miller, D.C. and Mitchell, R.S. (2002), What is the best treatment for
  patients with acute type B aortic dissections - Medical, surgical, or endovascular
  stent- grafting? Annals of Thoracic Surgery, 74 (5), S1840-S1843.
Abstract: Background. Controversy continues regarding treatment for patients with
  acute type B aortic dissection. Methods. One hundred eighty-nine patients with acute
  type B aortic dissection managed over a 36-year period were analyzed
  retrospectively for three outcome endpoints: survival; freedom from reoperation, and
  freedom from late aortic-related complications or late death. Risk factors for death
  were identified using a multivariable Cox proportional hazards model. Then to
  account for patient selection bias, heterogeneity of the population, and continuous
  evolution in techniques, propensity score analysis was used to identify risk-matched
  cohorts (quintiles I and II) in which the results of medical (n = 111) or surgical (n =
  31) therapy were compared more comprehensively. Results. The two main
  determinants of death were shock (hazard ratio [HR] = 14.5, 95% confidence level
  [CL] 4.7,44.5; p < 0.001) and visceral ischemia (HR = 10.9, 95% CL 3.9, 30.3; p <
  0.001). Arch involvement, rupture, stroke, previous sternotomy, and coronary or lung
  disease roughly doubled the hazard. Female sex was also a significant but weaker
  independent predictor of death. Actuarial survival estimates for all patients were 71%,
  60%, 35%, and 17% at 1, 5, 10, and 15 years, respectively, and were similar for the
  medical and surgical patients. The Marfan syndrome predicted reoperation and late
  aortic complications or late death. In a separate analysis of the 142 patients in
  quintiles I and II, survival, freedom from reoperation, as well as freedom from late
  aortic complications or death were almost identical in the medical and surgical
  subsets. Conclusions. The poor long-term prognosis of patients with acute type B
  aortic dissection is determined primarily by dissection-related and patient-specific
  risk factors, which are not readily modifiable. Whether the outlook in the future will
  be improved using stent-grafts remains to be determined. (C) 2002 by The Society of
  Thoracic Surgeons
Keywords:                                                                     acute/aortic
  ANAGEMENT/NEW-YORK/outcome/patient                         selection/prognosis/risk/risk
Bartel, T., Vanheiden, H., Schaar, J., Mertzkirch, W. and Erbel, R. (2002),
  Biomechanical modeling of hemodynamic factors determining bulging of ventricular
  aneurysms. Annals of Thoracic Surgery, 74 (5), 1581-1587.
Abstract: Background. Ventricular aneurysm formation is a frequent complication of
  transmural myocardial infarction. The hemodynamic determinants of aneurysmal
  bulging remain unclear. Methods. A rubber heart placed in a water tank served as an
  in vitro model. Rhythmic injections of specific volumes into the tank simulated heart
  beats. The heart rate was adjustable in increments. A section of the heart model's
  wall was shielded from compression to simulate an aneurysm. To quantitate the
  relation between hemodynamics and bulging, pressures, echocardiographic
  measurements of maximal expansion, and mean velocity were recorded. Bulging
  volume, stroke volume, aneurysmal wall stress, and systemic resistance were
  calculated. Results. The mean velocity was the echocardiographic factor most closely
  related to bulging volume (r = 0.92, p < 0.01). When bulging indices were compared
  with hemodynamics, bulging volume and mean velocity were found to directly
   depend on heart rate Q = 0.66, p < 0.01; r = 0.70, p < 0.01). Polynomial regression
   revealed bulging volume to reach minimal values near 80 beats/min. Maximal
   systolic aneurysmal wall stress was closely related to the peak positive rate of
   pressure change (r = 0.94, p < 0.01) and moderately to stroke volume (r = 0.75, p <
   0.01). Filling pressures were unrelated to bulging. The greatest bulging volume
   reduction occurred below 790 dynes, (.) s (.) cm(-5); bulging was practically
   eliminated at systemic resistance values less than 395 dynes (.) s (.) cm(-5).
   Conclusions. Aneurysmal bulging and aneurysm formation depend mainly on heart
   rate, contractility, and afterload. This suggests that hemodynamic management may
   affect the extent of bulging in a clinical setting. (C) 2002 by The Society of Thoracic
Keywords:               2-DIMENSIONAL                   ECHOCARDIOGRAPHY/ACUTE
   rt/heart                         rate/hemodynamics/infarction/management/myocardial
   ASSESSMENT/regression/SIZE/stress/stroke/stroke                     volume/SYSTOLIC
Jacobs, M.L., Pourmoghadam, K.K., Geary, E.M., Reyes, A.T., Madan, N., McGrath,
   L.B. and Moore, J.W. (2002), Fontan's operation: Is aspirin enough? Is coumadin too
   much? Annals of Thoracic Surgery, 73 (1), 64-68.
Abstract: Background. Thromboembolism after Fontan's operation is attributed to low
   flow states, stasis in venous pathways, right to left shunts, blind cul-de-sacs,
   prosthetic materials, atrial arrhythmias, and hypercoagulable states. We assessed the
   efficacy of a strategy to reduce thromboembolic events including aspirin
   anticoagulation. Methods. From January 1996 through December 2000, 72 patients
   underwent Fontan procedures. Management included (1) avoidance of direct caval
   cannulation and central venous lines, (2) inotropic support for 48 to 72 hours to
   optimize cardiac output, (3) aortopulmonary anastomosis or suture closure of patent
   pulmonary valves, and (4) administration of aspirin (81 mg per day) beginning on
   postoperative day one. No other anticoagulation strategies were used. Surveillance
   included intraoperative and postoperative transesophageal echo, trans-thoracic echo
   at discharge, at first reevaluation, and at 6 month intervals, and catheterization 1 year
   after surgery. Results. There were no early or late deaths. Follow-up was completed
   with 2,882 patient-months and a mean of 40 months. There were no documented
   thromboembolic events; however, all suspicious occurrences were investigated by
   echo and brain imaging. There were no hemorrhagic events or aspirin-related
   complications. Conclusions. Low dose aspirin can be used safely in young patients
   with Fontan connections. At intermediate follow-up, the strategies described appear
   effective in preventing thromboembolic complications. Routine use of more
   aggressive anticoagulation regimens seems unwarranted. (C) 2002 by The Society of
   Thoracic Surgeons
Keywords:            administration/anastomosis/anticoagulation/arrhythmias/aspirin/atrial
   arrhythmias/brain/cardiac            output/catheterization/COAGULATION-FACTOR
   CAVOPULMONARY CONNECTION/transesophageal/valves
Kouchoukos, N.T., Masetti, P., Rokkas, C.K. and Murphy, S.F. (2002), Single-stage
   reoperative repair of chronic type A aortic dissection using the arch-first technique.
   Annals of Thoracic Surgery, 74 (5), S1800-S1802.
Abstract: Background. Management of the enlarged, chronically dissected aorta after
  previous repair of acute ascending aortic dissection or after a previous cardiac
  operation may present a formidable technical challenge and the optimal method of
  management is not clearly established. Methods. Twenty-one patients with chronic
  type A aortic dissection (mean age 57 years) underwent resection of the ascending
  aorta, the aortic arch, and varying segments of the descending thoracic aorta.
  Single-stage replacement with perfusion of the aortic arch first to minimize the
  duration of brain ischemia and a bilateral anterior thoracotomy (clamshell) incision
  were used. Fourteen patients had undergone previous repair of acute type A
  dissection. Seven patients had type A dissection after aortic valve replacement (3
  patients) or coronary artery bypass (4 patients). Marked enlargement of the aorta
  distal to the left subclavian artery precluded a two-stage repair. The mean interval
  between the initial and reoperative procedures was 69 months (range, 5 to 249).
  Results. There was 1 (4.8%) hospital death. Four patients required reoperation for
  bleeding. One patient required a right ventricular assist device that was successfully
  removed. Ten patients required assisted ventilation for more than 48 hours. All were
  successfully weaned from ventilatory support. No patient had a stroke or other
  adverse neurologic outcome. There has been I late death (mean follow-up 2 years).
  Conclusions. The single-stage, arch- first replacement technique is a safe and
  effective procedure for patients who require extensive reoperations for chronic
  expanding type A dissection. (C) 2002 by The Society of Thoracic Surgeons
Keywords: acute/age/ANEURYSMS/aorta/aortic dissection/aortic valve/aortic valve
  replacement/artery/ascending                                   aorta/bleeding/brain/brain
  ischemia/bypass/coronary/coronary                                                  artery
  sion/stroke/subclavian artery/thoracic aorta/valve replacement/ventilation
Zacharias, A., Schwann, T.A., Riordan, C.J., Clark, P.M., Martinez, B., Durham, S.J.,
  Engoren, M. and Habib, R.H. (2002), Operative and 5-year outcomes of combined
  carotid and coronary revascularization: Review of a large contemporary experience.
  Annals of Thoracic Surgery, 73 (2), 491-497.
Abstract: Background. Surgical treatment of concomitant coronary and carotid disease
  is controversial. Studies comparing staged versus combined coronary artery bypass
  grafting and carotid endarterectomy (CABG/CEA) report varying and often
  conflicting operative results. Also, few studies have investigated the long-term
  outcomes of combined surgery. Methods. We reviewed the operative outcome and
  5-year survival results of 189 consecutive patients (69 +/- 9 years old, 66 [35%]
  female patients) who underwent combined CABG/CEA between 1994 and 1999.
  Survival follow-up was conducted in February 2001 and the incidence of late stroke,
  carotid surgery, and myocardial infarction was investigated in all surviving patients
  by mail survey. A phone interview was done by a surgeon of patients with late
  strokes or repeated CEA. Results. Operative death occurred in 5 of 189 patients
  (2.65%) 4 of which were in- hospital deaths. A total of 5 (2 permanent, 3 transient
  [2.65%]) perioperative strokes were documented in these patients, and 1 of the
  perioperative strokes patients died in the hospital. In all, 156 of 189 patients (82.5%)
  were alive at the time of the study and completed surveys were collected from 153 of
  156 patients 98%). Of these 153 patients, 4 reported a late stroke (2.6%), 5 suffered a
  myocardial infarction (3.3%), and 16 (10.5%) underwent subsequent CEA (7
  ipsilateral to original CEA) Angioplasty (3 of 153, 2.0%) and redo surgery (1 of 153,
  0.66%) occurred infrequently. Median survival follow-up was 51 months (range 12
  to 84), and the corresponding 5-year Kaplan-Meier survival was 79.4%. This
  survival was similar to that of age-matched isolated CABG patients (n = 532) with
  documented history of cerebrovascular disease but no surgical carotid lesions.
  Conclusions. Our results suggest that combined CABG/ CEA is safe and may in fact
  reduce the risk of adverse outcomes in the intermediate term compared with age and
  risk- matched patients. We speculate the latter may be attributable to a
  cerebrovascular protective effect of CABG/CEA pending verification by randomized
  trials. An economic benefit of CABG/CEA may also be inferred from avoiding
  separate coronary and carotid operations and reduction in the high costs of
  perioperative stroke. (C) 2002 by The Society of Thoracic Surgeons
Keywords:                 age/artery/ARTERY                  DISEASE/BYPASS/bypass
  grafting/CABG/carotid/carotid           disease/carotid         endarterectomy/carotid
  surgery/cerebrovascular/cerebrovascular              disease/CEREBROVASCULAR-
  DISEASE/combined/concomitant/coronary/coronary artery bypass/coronary artery
  bypass                                                                grafting/coronary
  rction/MANAGEMENT/myocardial                                infarction/MYOCARDIAL
Byrne, J.G., Karavas, A.N., Filsoufi, F., Mihaljevic, T., Aklog, L., Adams, D.H., Cohn,
  L.H. and Aranki, S.F. (2002), Aortic valve surgery after previous coronary artery
  bypass grafting with functioning internal mammary artery grafts. Annals of Thoracic
  Surgery, 73 (3), 779-784.
Abstract: Background. Aortic valve surgery after coronary, artery bypass grafting
  (CABG) in the setting of patent pedicled internal mammary artery (IMA) grafts
  poses a high risk because of the underlying ischemic and valve disease. Unlike mitral
  valve surgery or CABG, in which aortic clamping (AoX) may be optional, aortic
  valve surgery uniformly requires AoX unless circulatory arrest is used. Management
  of the IMA graft in these circumstances has traditionally involved dissection and
  clamping to prevent regional myocardial warming and cardioplegia "washout" during
  AoX An alternative strategy involves avoiding dissection of the IMA, leaving the
  IMA graft open and establishing moderate-to-deep hypothermia during AoX and
  cardioplegic arrest. To date, no study has been published documenting the safety and
  efficacy of the latter practice. Methods. A total of 94 patients who had patent IMA
  graft and underwent aortic valve surgery under AoX and cardioplegia between April
  1992 and March 2001 were analyzed. The IMA was avoided and left open during
  AoX, and the patients were cooled systemically (median 20degreesC). Patients
  ranged in age from 55 to 90 years (median 73.5 years). Ejection fraction was 15% to
  83% (median 50%). Of the patients, 18 (19%) underwent minimally invasive upper
  hemi-resternotomy. Analysis for predictors of outcome was performed. Results. The
  operative mortality, perioperative myocardial infarction (MI), and stroke rates were
  6.4%, 7%, and 11%, respectively. No significant independent predictors of operative
  mortality or MI could be identified in the multivariate analysis, although a trend was
  shown for operative mortality with urgent procedures and patients requiring
  concomitant surgery of the ascending or arch aorta or aortic root. Advanced age and
  prolonged cardiopulmonary bypass predicted stroke in the multivariate analysis.
  There were five (5%) IMA injuries, all occurring during reentry or mediastinal
  dissection, but none in the subgroup of patients who underwent minimally invasive
  procedures. All patients survived. Conclusions. Patients undergoing aortic valve
  surgery after CABG in the presence of patent IMA represent a potentially high-risk
  group. Because AoX is almost uniformly required, a decision regarding the
  management of the IMA pedicle is needed. We have found that leaving the IMA
  undissected and unclamped is a reasonable strategy, provided that systemic cooling
  for myocardial protection is established to prevent regional warming and to
  compensate for cardioplegia washout effect during Aox. (C) 2002 by The Society of
  Thoracic Surgeons
Keywords:                    age/aorta/aortic                  valve/artery/bypass/bypass
  grafting/CABG/cardiopulmonary bypass/concomitant/coronary/coronary artery
  bypass/coronary                               artery                             bypass
  es/internal/ischemic/management/minimally          invasive/MORTALITY/multivariate
  myocardial                                            infarction/predictors/PREVIOUS
Chavanon, O., Durand, M., Hacini, R., Bouvaist, H., Noirclerc, M., Ayad, T. and Blin,
  D. (2002), Coronary artery bypass grafting with left internal mammary artery and
  right gastroepiploic artery, with and without bypass. Annals of Thoracic Surgery, 73
  (2), 499-504.
Abstract: Background. Total arterial and off-pump revascularization are increasingly
  used in coronary artery bypass grafting. This study describes our experience with the
  exclusive use of both left internal thoracic artery and gastroepiploic artery by means
  of a median sternotomy, with and without cardiopulmonary bypass, in a subgroup of
  patients with two-vessel disease. Methods. From January 1995 to July 2000, 171
  consecutive patients were reviewed in a prospective database. Ninety-one patients
  underwent coronary artery bypass grafting without cardiopulmonary bypass (group
  A), and 80 patients were operated on under cardiopulmonary bypass with aortic
  cross-clamp and cardioplegia (group B). Results. Patient data were similar in both
  groups except for the Euroscore (mean; 3.4 +/- 6.1, group A versus 2.5 +/- 4.5, group
  B; Euroscore > 6: 26.4%, group A versus 10%, group B; p < 0.05) and ejection
  fraction (mean, 54.6% +/- 15.8%, group A versus 63.1% +/- 12.7%, group B; p <
  0.001.). Severe aortic calcification was present in 6 group A patients, versus no
  patient in group B. Operative time was shorter in group A (185 versus 213 minutes, p
  < 0.0001), with less distal anastomoses (2.26 versus 2.5, p < 0.05). Conversion to
  cardiopulmonary bypass occurred in 1 patient, who was excluded from the study,
  Bleeding was higher in group A (852.6 +/- 288 mL versus 712.4 +/- 274 mL, p <
  0.05), but transfusion was similar in both groups. Atrial fibrillation, postoperative
  inotropic support, and hospital stay were similar in both groups. Myocardial
  infarction was less frequent in group A (1 versus 4). Postoperative intraaortic balloon
  pump was used in 2 patients (group B). One patient died (group A) and 1 had an
  embolic stroke (group B). After discharge, 2 more patients died (group A, day 91;
  group B day 141), and I patient suffered an embolic stroke (group B). One patient in
  each group presented with dysfunction of the gastroepiploic artery graft requiring
  successful percutaneous transluminal angioplasty on the right posterolateral artery.
  Conclusions. These results suggest that off-pump coronary artery bypass grafting
  using the left internal thoracic artery and gastroepiploic artery, is safe even in
  high-risk patients. This approach allows an absolute no-touch technique of the aorta.
  (C) 2002 by The Society of Thoracic Surgeons
Keywords: angioplasty/AORTA/artery/balloon/BEATING HEART/bypass/bypass
  grafting/CARDIOPULMONARY BYPASS/CONDUITS/coronary/coronary artery
  bypass/coronary              artery            bypass          grafting/disease/ejection
  -PUMP/percutaneous                                                         transluminal
  ransluminal/transluminal angioplasty
Schaff, H.V., Carrel, T.P., Jamieson, W.R.E., Jones, K.W., Rufilanchas, J.J., Cooley,
  D.A., Hetzer, R., Stumpe, F., Duveau, D., Moseley, P., van Boven, W.J.,
  Grunkemeier, G.L., Kennard, E.D. and Holubkov, R. (2002), Paravalvular leak and
  other events in silzone-coated mechanical heart valves: A report from AVERT.
  Annals of Thoracic Surgery, 73 (3), 785-792.
Abstract: Background. The Artificial Valve Endocarditis Reduction Trial (AVERT) was
  designed to compare endocarditis rates in Silzone versus conventional valves.
  Recruitment ended January 21, 2000, because of higher rates of paravalvular leakage
  in patients receiving the Silzone prosthesis. The present analysis determined late
  event rates that might be used in the management of approximately 36,000 patients
  who have received the Silzone prosthesis. Methods. A total of 807 patients in 19
  centers in North America and Europe were randomized. Mean age was 61 +/- 11
  years; 41% were women. Operations included aortic valve replacement in 59%,
  mitral valve replacement in 32%, and aortic and mitral valve replacements in 9%;
  41% had concomitant operations (26% coronary artery bypass grafting). Results.
  Major paravalvular leakage (followed by repair, explant, or mortality) occurred in 18
  of 403 patients receiving Silzone valves and 4 of 404 patients without Silzone valves
  (2-year event-free rates: 91.1% versus 98.9% conventional, p < 0.003). Similarly,
  2-year freedom from any explant was lower in the Silzone arm (19 versus :2 events;
  90.1% versus 99.4%, p = 0.0002). Rates of mortality and stroke were: similar during
  follow-up. Conclusions. Continued follow-up of AVERT supports the conclusion
  that the Silzone prosthesis has increased risk of paravalvular leakage requiring
  reoperation. Overall survival is similar in the two groups. (C) 2002 by The Society of
  Thoracic Surgeons 35
Keywords: age/ANTIMICROBIAL PROTECTION/aortic valve/aortic valve
  replacement/arm/artery/bypass/bypass grafting/concomitant/coronary/coronary artery
  bypass/coronary                                 artery                           bypass
  America/POLYESTER/risk/stroke/survival/valve replacement/valves/women
Wright, C.D., Graham, B.B., Grillo, H.C., Wain, J.C. and Mathisen, D.J. (2002),
  Pediatric tracheal surgery. Annals of Thoracic Surgery, 74 (2), 308-313.
Abstract: Background. Pediatric tracheal procedures are uncommon. We reviewed our
  experience to clarify management and results. Methods. Retrospective
  single-institution review of pediatric tracheal operations, 1978 to 2001. Results. One
  hundred sixteen children were evaluated, mean age 10.4 years (10 days to 18 years).
  Tracheal pathology was postintubation stenosis (n = 72; 62%), congenital stenosis (n
  = 23; 20%), neoplasm (n 8; 7%), tracheomalacia (n = 7; 6%), and trauma (n 6; 5%).
  Twenty-nine patients had previous tracheal operations. Thirty-six patients received
  only a minor procedure. Eighty patients had major operations: tracheal resection (n =
  46; 58%), laryngotracheal resection (n = 22; 28%), slide tracheoplasty (n = 7, 9%),
  and carinal resection (n = 5; 6%). The mean length of airway resected was 3.3 cm
  (1.5 to 6 cm), which represented 30% of the entire trachea. Twenty-eight patients
  (35%) had complications. These included tracheomalacia (n = 3), recurrent nerve
  injury (n = 3), laryngeal edema requiring intubation (n = 2), stroke (n = 1),
  esophageal leak (n = 1), and lobar collapse (n = 1). Nineteen patients had
  anastomotic failure: severe restenosis (n = 6), mild restenosis (n = 9), dehiscence (n =
  2), dehiscence with tracheoesophageal fistula (n = 1), and tracheoinnominate fistula
  (n = 1). Two children died (2.5%). Complications were more frequent in children
  less than 7 years of age (p = 0.05) and after previous operations (p = 0.02). Longer
  fractions of tracheal resection (> 30%) were more likely to result in anastomotic
  failure (P = 0.0005). Sixty-four (80%) patients achieved a stable airway free of any
  airway appliance. All patients with neoplasms are alive. Conclusions. The principles
  of adult tracheal operations are directly applicable to children and usually lead to a
  stable, satisfactory airway. Children tolerate anastomotic tension less well than adults;
  resections more than 30% have a substantial failure rate
Keywords: adult/adults/age/CHILDREN/complications/congenital/CRICOTRACHEAL
Anderson, C.A., Filsoufi, F., Aklog, L., Farivar, R.S., Byrne, J.G. and Adams, D.H.
  (2002), Liberal use of delayed sternal closure for postcardiotomy hemodynamic
  instability. Annals of Thoracic Surgery, 73 (5), 1484-1488.
Abstract: Background. The purpose of this retrospective study was to evaluate the
  current incidence, survival, and predictors of mortality for open chest management at
  our center. Methods. Our database was analyzed to identify adult postcardiotomy
  patients who left the operating room without primary sternal closure. Medical
  records were reviewed to determine mortality, postoperative complications, and
  pertinent hemodynamic data. Results. From November 1997 to June 2000, 5,177
  adults underwent cardiac procedures at our center. The incidence of open chest
  management was 1.7% (87 of 5,177), including 0.7% (16 of 2,254) for isolated
  coronary artery bypass grafting, 1.6% (15 of 912) for isolated valve, and 3.6% (47 of
  839) for combined valve/coronary bypass. Hospital survival was 76%. (66 of 87).
  Major complications included deep sternal infection (n = 4), stroke (n = 8), and
  dialysis (n = 13). Predictors of mortality by univariate analysis included ventricular
  assist device insertion (p = 0.003), new onset hemodialysis (p < 0.0005), reoperation
  for bleeding (p = 0.002), sternal infection (p = 0.042), mean length of delay before
  sternal closure (survivors = 3.2 days, nonsurvivors = 6.2 days; p = 0.031), higher
  mean dose of epinephrine at the time of chest closure (2.5 &mu;g versus 0.9 &mu;g,
  p = 0.011), and longer duration of high dose inotropic therapy (110 hours versus 43
  hours, p = 0.002). Multivariate analysis showed ventricular assistance and
  reoperation for bleeding as independent predictors of in-hospital death with odds
  ratios of 3.8 and 3.4, respectively. Conclusions. Liberal use of open chest
  management is useful in patients with postcardiotomy shock, and can be carried out
  with a relatively low incidence of sternal complications. Patients who require
  ventricular assistance or exploration for ongoing mediastinal bleeding continue to
  have a high mortality rate
Keywords:          adult/adults/artery/bleeding/bypass/bypass         grafting/CARDIAC
  BYPASS/combined/COMPLICATIONS/coronary/coronary artery bypass/coronary
  artery                                                                           bypass
Bavaria, J.E., Brinster, D.R., Gorman, R.C., Woo, Y.J., Gleason, T. and Pochettino, A.
  (2002), Advances in the treatment of acute type A dissection: An integrated approach.
  Annals of Thoracic Surgery, 74 (5), S1848-S1852.
Abstract: Background. Acute type A dissections require surgery to prevent death from
  proximal aortic rupture or malperfusion. Most series over the past decade have
  reported a death rate in the range of 15% to 30%. The objective of this study is to
  examine the effect of an integrated surgical approach on the treatment of acute type
  A dissections. Methods. From January 1994 to April 2002, 163 consecutive patients
  underwent repair of acute type A dissection. All had an integrated operative
  management as follows: intraoperative transesophageal echocardiography;
  hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion to replace
  the aortic arch; HCA established after 3 minutes of electroencephalographic silence
  in neuromonitored patients (60%) or after 45 minutes of cooling in patients who were
  not neuromonitored (40%); reinforcement of the residual arch tissue with a Teflon
  felt "neo-media;" carmulation of the arch graft to reestablish cardiopulmonary bypass
  at the completion of HCA (antegrade graft perfusion); and remodeling of the sinus of
  Valsalva segments with Teflon felt "neo-media" and aortic valve resuspension or
  replacement with a biological or mechanical valved conduit. When HCA times were
  greater than 50 minutes, antegrade cerebral perfusion is used. Since Februay 1999,
  BioGlue has been used as an anastomotic adjunct in the repair of type A dissections.
  Results. Mean age was 62 +/- 14 years, with 68% men and 15% with previous
  cardiac surgery. Seven percent of patients presented with a preoperative neurologic
  deficit, and 3% developed a new cerebrovascular accident after dissection repair. The
  in-hospital death rate was 9.8%. Excluding the patients with preoperative strokes
  (7%) and those with postoperative stroke (3%), the in-hospital death rate was 6.6%.
  In 6 patients, prompt changes in circulatory management consisting of switching
  cannulation sites or cross- clamp release with direct temporary aortic arch
  fenestration occurred when there were sudden changes in electroencephalogram
  during cooling. Conclusions. A standardized approach to the treatment of acute type
  A dissections has improved outcomes. Our 55% mortality in patients with
  preoperative cerebral vascular accident (CVA) suggests that this group may be
  candidates for medical or delayed surgical treatment. Conversely, our 6.6% mortality
  rate for neurologically intact patients warrants aggressive and expeditious surgical
  intervention. (C) 2002 by The Society of Thoracic Surgeons
Keywords:        acute/age/AORTIC         DISSECTION/aortic          valve/bypass/cardiac
  surgery/cardiopulmonary bypass/cerebral/cerebral perfusion/cerebral vascular
  accident/cerebrovascular/cerebrovascular                     accident/CIRCULATORY
  ARREST/death/dissection/echocardiography/hypothermic                          circulatory
  rograde cerebral        perfusion/rupture/stroke/surgery/surgical     approach/surgical
  treatment/switching/transesophageal/transesophageal echocardiography/treatment
Tanoue, Y., Ando, H., Fukumura, F., Umesue, M., Uchida, T., Taniguchi, K. and
  Tanaka, J. (2003), Ventricular energetics in endoventricular circular patch plasty for
  dyskinetic anterior left ventricular aneurysm. Annals of Thoracic Surgery, 75 (4),
Abstract: Background. The endoventricular circular patch plasty (Dor procedure)
  applies to patients with a left ventricular dysfunction due to an ischemic dilated
  ventricle. In the present study, we analyzed left ventricular energetics in patients who
  underwent the Dor procedure. Methods. We measured left ventricular contractility
  (end-systolic elastance; Ees), afterload (effective arterial elastance; Ea), and
  efficiency (ventriculoarterial coupling; Ea/Ees, and the ratio of stroke work and
  pressure-volume area; SW/PVA) based on the cardiac catheterization data before and
  after the Dor procedure in 8 patients with a postinfarction dyskinetic anterior left
  ventricular aneurysm. Concomitant procedures included coronary artery bypass
  grafting in all patients, mitral valve repair in one patient, and cryoablation in one
  patient. End-systolic elastance (Ees) and Ea were approximated as follows: Ees =
  mean arterial pressure/minimal left ventricular volume, and Ea = maximal left
  ventricular pressure/ (maximal left ventricular volume-minimal left ventricular
  volume), and thereafter Ea/Ees and SW/PVA were calculated. The left ventricular
  volume was normalized with the body surface area. Results. End-systolic elastance
  (Ees) increased after the Dor procedure (from 1.15 +/- 0.60 to 1.86 +/- 0.84 mm Hg
  m m(2). mL(-1), p < 0.01), thus resulting in an improvement in Ea/Ees and SW/PVA
  (from 2.94 +/- 1.11 to 1.64 +/- 0.49, p < 0.01, and from 0.426 +/- 0.110 to 0.559 +/-
  0.082, p < 0.01, respectively), even though Ea did not substantially change (from
  2.96 +/- 0.78 to 2.74 +/- 0.55 mm Hg. m(2) - mL(-1), p = 0.4). Conclusions. Left
  ventricular contractility and efficiency improves after the Dor procedure in patients
  with a dyskinetic anterior left ventricular aneurysm. However, afterload does not
  change. The use of appropriate afterload-reducing therapy thus plays an especially
  important role in the management of patients who undergo the Dor procedure. (C)
  2003 by The Society of Thoracic Surgeons
Keywords:                  aneurysm/artery/bypass/bypass                 grafting/cardiac
  catheterization/catheterization/contractility/coronary/coronary artery bypass/coronary
  artery        bypass       grafting/EFFICIENCY/ischemic/Japan/left          ventricular
  valve/NEW-YORK/SCARS/stroke/SURGERY/therapy/USA/ventricular aneurysm
Chachques, J.C., Argyriadis, P.G., Fontaine, G., Hebert, J.L., Frank, R.A., D'Attellis, N.,
  Fabiani, J.N. and Carpentier, A.F. (2003), Right ventricular cardiomyoplasty:
  10-year follow-up. Annals of Thoracic Surgery, 75 (5), 1464-1468.
Abstract: Background. Chronically depressed right ventricular (RV) function presents
  an unsolved therapeutic challenge in cardiac surgery. Despite recent advances in
  medical and surgical therapies, prognosis remains poor and patient's quality of life
  and mortality are frequently unacceptable. The aim of this study is to present the first
  clinical report and long-term results of RV dynamic cardiomyoplasty applied in
  patients with RV failure caused by isolated RV cardiomyopathies. Methods. Seven
  consecutive patients (5 males, 2 females; mean age, 40 +/- 9 years; range, 15 to 63
  years) from a series of 113 cardiomyoplasty procedures performed at Broussais and
  Pompidou Hospitals were evaluated. The mean duration of follow-up was 10 +/- 3.5
  years. All patients had predominant RV dysfunction, associated with tricuspid
  regurgitation in 6 patients. The cause of RV failure was arrhythmogenic
  cardiomyopathy (4 patients), ischemic (2 patients), and Uhl's disease (1 patient), and
  endomyocardial fibrosis (1 patient). Six patients were in preoperative New York
  Heart Association functional class III and 1 was in intermittent class III/IV. The
  mean preoperative ejection fraction (measured by isotopic technique) was 18% +/-
  5.7% for the right ventricle and 40% +/- 13% for the left ventricle. Right ventricular
  dynamic cardiomyoplasty consists of wrapping the RV free walls with the left
  latissimus dorsi muscle flap. The distal part of the latissimus dorsi muscle is fixed to
  the diaphragm and then electrostimulated. Six patients required associated tricuspid
  valve surgery. Results. There were no perioperative deaths. The mean duration of
  follow-up was 10 +/- 3.5 years. Six patients are alive with a remarkable quality of
  life, 4 are in New York Heart Association functional class I and 2 are in class II. One
  patient who was in New York Heart Association functional class 11 died in
  postoperative year 7 caused by stroke. At last follow-up, mean RV ejection fraction
  was 33% +/- 11.8% and left ventricular ejection fraction was 52% +/- 12.6%.
  Conclusions. The results of this long-term study demonstrate hemodynamic and
  functional improvements after RV cardiomyoplasty without perioperative mortality,
  no long-term malignant arrhythmias, and RV dysfunction related deaths. We believe
  that RV cardiomyoplasty, associated with tricuspid valve surgery when required,
  could be an effective treatment for severe RV failure. (C) 2003 by The Society of
  Thoracic Surgeons
Keywords:                                                        age/arrhythmias/cardiac
  ative/prognosis/PROSTHESES/quality/quality                                             of
Dowling, R.D., Gray, L.A., Etoch, S.W., Laks, H., Marelli, D., Samuels, L., Ebtwhistle,
  J., Couper, G., Vlahakes, G.J. and Frazier, O.H. (2003), The AbioCor implantable
  replacement heart. Annals of Thoracic Surgery, 75 (6), S93-S99.
Abstract: The AbioCor implantable replacement heart (IRH) is the first available totally
  implantable artificial heart. We recently initiated a multicenter trial of this device in
  patients with severe, irreversible biventricular failure. Patients who were not
  candidates for other therapies, including transplantation, were evaluated. All
  candidates were adults with inotrope- dependent biventricular failure, whose 30-day
  predicted mortality was higher than 70%. A three-dimensional computerized fit study
  predicted fit of the AbioCor thoracic unit in all recipients. At operation, the internal
  battery controller and transcutaneous energy transfer unit were placed. The AbioCor
  thoracic unit was placed in an orthotopic position after incision of the ventricals.
  There were 2 intaroperative deaths (due to intraoperative bleeding or aprotinin
  reaction). Four late deaths were recorded, 1 from multisystem organ failure and 3
  cerebrovascular accidents. Autopsy revealed thrombus on the atrial struts of the 3
  patients with cerebrovascular accident. Blood pumps and valves were clean on all
  patients. Significant morbidity was observed, primarily related to preexisting severity
  of illness. However, 3 patients recovered to the point of being able to take multiple
  trips outside of the hospital. Two patients were discharged from the hospital, with 1
  patient being discharg