Carotid Endarterectomy: Update on the Gold Standard Treatment for Carotid Stenosis

2005 ◽  
Vol 71 (8) ◽  
pp. 647-652 ◽  
Author(s):  
Nancy L. Harthun ◽  
A.J. Baglioni ◽  
Gail L. Kongable ◽  
Timothy D. Meakem ◽  
Kenneth J. Cherry
Keyword(s):  
Clinical Trials ◽  
Length Of Stay ◽  
Carotid Endarterectomy ◽  
Randomized Clinical Trials ◽  
Hospital Costs ◽  
Carotid Stenting ◽  
Veterans Administration ◽  
Lengths Of Stay ◽  
Related Group ◽  
Median Hospital

Many prospective, randomized clinical trials evaluating the safety and efficacy of carotid endarterectomy (CEA) versus medical management in the prevention of ischemic stroke were performed in the 1990s. Clinical trials are underway that will compare CEA outcomes to carotid stenting; however, relatively few studies have examined the outcomes of modern CEA. The purpose of this report is to examine current outcomes of CEA and evaluate hospital costs and length of stay. Statewide results were collected for all hospitals, except Veterans Administration hospitals, by Virginia Health Information (VHI). Data for the years 1997–2001 were evaluated, and data were based on the All Patient Refined Diagnostic Related Group (APR-DRG; 3M Company). A total of 14,095 CEAs were performed in a 5-year period. The mortality of patients undergoing CEA was 0.5 per cent. The stroke rate was 1 per cent overall and decreased each year of the study. Mean and median lengths of hospital stay were 3 and 2 days, respectively. Length of stay decreased over the course of this study. Mean and median hospital costs were $14,331 and $11,268. Higher rates of mortality and stroke and higher costs were observed at low-volume hospitals. The need for CEA is substantial. CEA is safe and inexpensive. The data presented here demonstrates continued refinement in CEA, leading to a very low rate of perioperative adverse events, declining lengths of stay, and low hospital costs.

The evidence for introducing case-finding for delirium and dementia in older medical inpatients in a New Zealand hospital

2022 ◽  
pp. 103985622110624
Author(s):  
Sarah Cullum ◽  
Yezen Kubba ◽  
Chris Varghese ◽  
Christin Coomarasamy ◽  
John Hopkins
Keyword(s):  
Cognitive Impairment ◽  
New Zealand ◽  
Length Of Stay ◽  
Assessment Tool ◽  
Hospital Costs ◽  
Case Finding ◽  
Risk Of Death ◽  
Lengths Of Stay ◽  
Medical Wards ◽  
Hospital Inpatients

Objective The aim of this project was to make the case to the managers of a large urban teaching hospital in New Zealand for the introduction of systematic case-finding for pre-existing cognitive impairment/dementia in older hospital inpatients that screen positive for delirium. Method Two hundred consecutive acute admissions aged 75+ in four medical wards were assessed using the 4AT assessment tool for delirium and the Alzheimer Questionnaire (AQ) for pre-existing cognitive impairment/dementia. Length of stay and mortality at 1 year were also collected. Results Over a third of the sample screened positive for delirium and nearly two-thirds of these also screened positive for dementia. The median length of stay was 5 days for delirium without dementia and 7 days for delirium with dementia, compared to 3 days for those who screened negative for both. After adjustment for age, gender and ethnic group, people who screened positive for delirium (with or without dementia) had 50% longer length of stay ( p < 0.05) and at least double the risk of death ( p < 0.05). Conclusion Older hospital inpatients that screen positive for delirium and dementia using 4AT and AQ have longer lengths of stay and higher mortality. Identification may lead to more timely interventions that help to improve health outcomes and reduce hospital costs.

Assessing the Predictive Validity of the RAND/UCLA Appropriateness Method Criteria for Performing Carotid Endarterectomy

1998 ◽  
Vol 14 (4) ◽  
pp. 707-727 ◽  
Author(s):  
Paul G. Shekelle ◽  
Mark R. Chassin ◽  
R. E. Park
Keyword(s):  
Clinical Trials ◽  
Carotid Endarterectomy ◽  
Predictive Validity ◽  
Randomized Clinical Trials

AbstractWe assessed the predictive validity of an expert panel's ratings of the appropriateness of carotid endarterectomy by comparing ratings to the results of subsequent randomized clinical trials. We found the trials confirmed the ratings for 44 indications (covering almost 30% of operations performed in 1981) and refuted the ratings for none.

scholarly journals Major Adverse Kidney Events in Pediatric Sepsis

2019 ◽  
Vol 14 (5) ◽  
pp. 664-672 ◽  
Author(s):  
Scott L. Weiss ◽  
Fran Balamuth ◽  
Cary W. Thurm ◽  
Kevin J. Downes ◽  
Julie C. Fitzgerald ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Length Of Stay ◽  
Confidence Interval ◽  
Hospital Costs ◽  
Kidney Dysfunction ◽  
Total Hospital ◽  
All Cause Mortality ◽  
Kidney Replacement Therapy ◽  
Pediatric Sepsis ◽  
Major Adverse Kidney Events

Background and objectivesMajor adverse kidney events, a composite of death, new kidney replacement therapy, or persistent kidney dysfunction, is a potential patient-centered outcome for clinical trials in sepsis-associated kidney injury. We sought to determine the incidence of major adverse kidney events within 30 days and validate this end point in pediatric sepsis.Design, setting, participants, & measurementsWe conducted a retrospective observational study using the Pediatric Health Information Systems Plus database of patients >6 months to <18 years old with a diagnosis of severe sepsis/septic shock; orders for bacterial blood culture, antibiotics, and at least one fluid bolus on hospital day 0/1; and known hospital disposition between January 2007 and December 2011. The primary outcome was incidence of major adverse kidney events within 30 days. Major adverse kidney events within 30 days were validated against all-cause mortality at hospital discharge, hospital length of stay, total hospital costs, hospital readmission within 30 days and 1 year, and lowest eGFR between 3 months and 1 year after discharge. We reported incidence of major adverse kidney events within 30 days with 95% confidence intervals using robust SEM and used multivariable logistic regression to test the association of major adverse kidney events within 30 days with hospital costs and mortality.ResultsOf 1685 admissions, incidence of major adverse kidney events within 30 days was 9.6% (95% confidence interval, 8.1% to 11.0%), including 4.5% (95% confidence interval, 3.5% to 5.4%) death, 1.7% (95% confidence interval, 1.1% to 2.3%) kidney replacement therapy, and 5.8% (95% confidence interval, 4.7% to 6.9%) persistent kidney dysfunction. Patients with versus without major adverse kidney events within 30 days had higher all-cause mortality at hospital discharge (28% versus 1%; P<0.001), higher total hospital costs ($61,188; interquartile range, $21,272–140,356 versus $28,107; interquartile range, $13,056–72,697; P<0.001), and higher proportion with eGFR<60 ml/min per 1.73 m2 between 3 months and 1 year after discharge (19% versus 4%; P=0.001). Major adverse kidney events within 30 days was not associated with length of stay or readmissions.ConclusionsIn children with sepsis, major adverse kidney events within 30 days are common, feasible to measure, and a promising end point for future clinical trials.PodcastThis article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_04_18_CJASNPodcast_19_05_.mp3

The Effect of a Critical Pathway on Patients’ Outcomes After Carotid Endarterectomy

2002 ◽  
Vol 11 (3) ◽  
pp. 250-258 ◽  
Author(s):  
Daleen Aragon ◽  
Virginia Burton ◽  
Jacqueline F. Byers ◽  
Michael Cohen
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Quality Of Care ◽  
Length Of Stay ◽  
Carotid Endarterectomy ◽  
Diagnostic Procedures ◽  
Critical Pathway ◽  
Lengths Of Stay ◽  
Implementation Costs

• Background In 1996, an integrated plan of care was implemented to improve quality of care for patients undergoing elective carotid endarterectomy. Goals were to reduce length of stay, costs, number of preoperative and intensive care unit admissions, and use of diagnostic procedures yet maintain good outcomes.• Objectives To determine whether use of the integrated plan of care met the goals.• Methods Data on financial and process outcomes, use of angiographic diagnostic procedures, and demographics were retrieved from the hospital’s database for all patients who had elective carotid endarterectomy without cerebral infarction.• Results A total of 783 patients met inclusion criteria: 129 before implementation of the plan of care, 66 during the 6-month transition, and 588 after implementation. Preoperative angiography was done in 32% of patients before implementation, 11% during the transition, and 4% after implementation. Percentages of patients admitted to the intensive care unit were 77% before implementation, 24% during transition, and 9% after implementation. Mean lengths of stay were 2.93 days before implementation, 2.12 days during transition, and 1.68 days after implementation. Costs per case were $7798 before implementation, $5750 during transition, and $5387 after implementation. Analysis of variance revealed significant differences between groups in total length of stay (P=.001), preoperative length of stay (P&lt;.001), and costs (P&lt;.001).• Conclusion Use of the integrated plan of care reduced length of stay, costs, admissions to intensive care units, and use of cerebral angiography. Use of the plan improved resource utilization while maintaining quality of care.

scholarly journals Carotid stenting with proximal cerebral protection in symptomatic low-grade vulnerable recurrent carotid stenosis

2018 ◽  
Vol 9 (6) ◽  
pp. 125-133 ◽  
Author(s):  
Joaquin de Haro ◽  
Javier Rodriguez-Padilla ◽  
Silvia Bleda ◽  
Cristina Cañibano ◽  
Ignacio Michel ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Carotid Stenosis ◽  
Randomized Clinical Trials ◽  
Survival Rates ◽  
Carotid Stenting ◽  
Cerebral Protection ◽  
Low Grade ◽  
Carotid Revascularization ◽  
Technical Success Rate ◽  
Plaque Ulceration

Background: Although the management of carotid disease is well established for symptomatic lesions ⩾70%, carotid revascularization for symptomatic low-grade (⩽50%) stenosis is not actually supported by data from randomized clinical trials. Such patients may occasionally have recurrent neurological symptoms despite optimal medical treatment owing to vulnerable plaques. In such cases, carotid artery stenting (CAS) may represent an option for treatment but this has not been tested in clinical trials. This study analyzed early and long-term outcomes of CAS performed in patients with low-grade symptomatic recurrent carotid stenosis. Methods: From a prospective registry of 322 carotid revascularization in symptomatic patients, 21 consecutive patients with low-grade symptomatic recurrent carotid stenosis who underwent CAS with proximal cerebral protection device Mo.Ma, after ruling out any other source of cerebral embolization, were involved in the study. All patients had suggestive evidence of unstable plaque or plaque ulceration. Results: Procedural technical success rate was 100%. No 30-day stroke or death occurred, and no patients had recurrent neurological events related to the revascularized hemisphere during follow up. No 30-day local complications were reported. No late carotid occlusions were detected. There was one late death, and no stroke-related deaths. Survival rates were 100% at 1 year and 96% at 3 years. Conclusions: This study shows that CAS is a well-tolerated, effective and durable treatment for patients with recurrent symptomatic low-grade carotid stenosis associated with a vulnerable plaque. Patients had excellent protection against further ischemic events and survived long enough.

L-arginine effect on inflammatory mediators: A systematic review of randomized controlled clinical trials

2019 ◽  
pp. 1-9 ◽  
Author(s):  
Seyed Reza Mirhafez ◽  
Mitra Hariri
Keyword(s):  
Systematic Review ◽  
Clinical Trials ◽  
Inflammatory Mediators ◽  
Randomized Clinical Trials ◽  
Randomized Controlled Clinical Trials ◽  
Patients With Cancer ◽  
Reactive Protein ◽  
Randomized Controlled ◽  
Human Adults ◽  
Factor Α

Abstract. L-arginine is an important factor in several physiological and biochemical processes. Recently, scientists studied L-arginine effect on inflammatory mediators such as C-reactive protein (CRP), tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6). We conducted a systematic review on randomized controlled trials assessing L-arginine effect on inflammatory mediators. We searched data bases including Google scholar, ISI web of science, SCOPUS, and PubMed/Medline up to April 2019. Randomized clinical trials assessing the effect of L-arginine on inflammatory mediators in human adults were included. Our search retrieved eleven articles with 387 participants. Five articles were on patients with cancer and 6 articles were on adults without cancer. L-arginine was applied in enteral form in 5 articles and in oral form in 6 articles. Eight articles were on both genders, two articles were on women, and one article was on men. L-arginine could not reduce inflammatory mediators among patients with and without cancer except one article which indicated that taking L-arginine for 6 months decreased IL-6 among cardiopathic nondiabetic patients. Our results indicated that L-arginine might not be able to reduce selected inflammatory mediators, but for making a firm decision more studies are needed to be conducted with longer intervention duration, separately on male and female and with different doses of L-arginine.

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