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Carotid endarterectomy (TEA) has proven to be beneficial for symptomatic patients. Anticoagulation (AC) and antiplatelet therapy (ASA) have been shown to prolong life following vascular surgery in patients with occlusive arterial disease (PAOD). To determine whether ASA or AC prolong life after TEA, retrospective analysis was undertaken, since cerebral haemorrhage is associated with the use of both drugs, especially AC. Between 1979-1986, 328 patients with stenotic lesions of the carotid bifurcation were operated upon electively. Patient survival and causes of death were the primary end points of the analysis. Recent data were obtained from the Austrian Central Bureau of Statistics. Cumulative survival rates were calculated by Kaplan-Meier estimation and differences determined by Breslow and Mantel tests. 36 patients were on AC, 157 on ASA and 135 remained without medication (0-group). Since the common risk factors in PAOD were unevenly distributed between groups, a stepwise Cox regression model was applied which revealed age (p < 0.01), cardiac pathology (p < 0.01) and diabetes (p < 0.05) as relevant for survival. Therefore, ASA patients and 0-group patients were selected and matched, employing the aforementioned prognostic criteria, and compared to the patients on long-term AC for various indications (vein bypass surgery, myocardial infarction, pulmonary embolism; i.e. data-matching). The median postoperative survival was 7.72 years for ASA and 8.48 years for AC, compared to 6.07 years for the 0-group (p = 0.0095 Breslow, p = 0.477 Mantel). There was no significant difference between AC and ASA treated patients. Irrespective of medication, the causes of death were well balanced, and no higher incidence of intracerebral haemorrhage was detected.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Anticoagulants, antiaggregants or nothing following carotid endarterectomy? 835 90

Recurrent stenosis (> 50%) after carotid endarterectomy is reported with a frequency ranging from 7-20%. 232 patients undergoing carotid endarterectomy were randomised to low-dose acetylsalicylic acid (ASA, 75 mg daily) or placebo (identical tablets). The treatment was started the day before surgery and continued for 6 months. All patients were followed clinically for 1 year. Doppler examination was performed preoperatively (n = 230) and postoperatively (n = 228) and at follow-up at 2 (n = 220) and at 6 months (n = 174) after surgery. The degree of stenosis was estimated from the maximum Doppler frequency shift in the internal carotid artery. Recurrent stenosis of 30% or more was detected in 85 of the 220 patients (38.6%) at 2 months, and at 6 months in 73 of the 174 examined patients (42.0%). Stenosis > 50% was seen in 16 patients (9.2%) and occlusion was found in four patients (1.8%) at 6 months. No difference between the low-dose ASA-treated group (n = 112) compared to the placebo group (n = 108) was seen regarding recurrent stenosis. Women had an increased risk of recurrent stenosis (p < 0.001), whereas other factors such as age, hyperlipidaemia, diabetes and smoking were not associated with increased risk. Importantly, the number of neurological events did not differ between those with or without restenosis. Therefore, the indications for surgery of asymptomatic recurrent stenosis are questionable. The progress of arteriosclerosis in the contralateral carotid artery did not differ between the treatment groups.
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PMID:Can recurrent stenosis after carotid endarterectomy be prevented by low-dose acetylsalicylic acid? A double-blind, randomised and placebo-controlled study. 835 92

We compared stroke severity, risk factors, and prognosis in patients with recurrent versus first-ever stroke. In the Copenhagen Stroke Study, we prospectively studied 1,138 unselected patients with acute stroke. Stroke was recurrent in 265 (23%) despite most of these patients being given prophylactic treatment prior to recurrence. Only 12% of patients with atrial fibrillation were receiving anticoagulant treatment prior to recurrence. In multivariate analysis, recurrence was more frequently associated with a history of TIA, atrial fibrillation, male gender, and hypertension, but not with age, daily alcohol consumption, smoking, diabetes, ischemic heart disease, serum cholesterol, or hematocrit. Mortality was almost doubled compared with patients with a first-ever stroke. In survivors, however, both neurologic and functional outcomes and the speed of recovery were, in general, similar in the two groups. Despite similar neurologic impairments, patients with recurrence contralateral to their first stroke had markedly more severe functional disability after completed rehabilitation than patients with ipsilateral recurrence, implying that the ability to compensate functionally is decreased in patients with contralateral recurrence. Our findings emphasize the importance of consistent anticoagulant treatment for stroke patients with atrial fibrillation and close blood pressure control in stroke patients with hypertension. Other prophylactic measures are needed in patients in whom ASA fails to prevent recurrence. Patients with recurrent stroke have a markedly higher mortality than patients with a first-ever stroke, but those who survive recover as well and as fast as patients with a first-ever stroke. However, if recurrence is contralateral to the first stroke, functional recovery is poorer.
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PMID:Stroke recurrence: predictors, severity, and prognosis. The Copenhagen Stroke Study. 910 73

The objective of this study was to determine if aspirin reduces the incidence of second eye involvement after nonarteritic anterior ischemic optic neuropathy (NAION) in one eye. Records were reviewed of 131 patients who sustained unilateral NAION. Of these, the 33 patients who sustained second eye NAION were compared to those followed for a minimum of 2 years without sustaining a second eye NAION (67). Thirty-one of the 131 patients were excluded because of inadequate follow-up. Except for diabetes (relative risk [RR] 1.43, p = 0.05), the incidence of second eye NAION was independent of gender, age, cup/disk, hypertension, anemia, and migraine. The degree of visual acuity or field dysfunction in the first eye correlated poorly with the acuity (r = 0.28) and field (r = 0.33) loss in the second eye. Aspirin (65-1,300 mg) taken two or more times per week decreased the incidence (17.5% vs. 53.5%) and relative risk (RR = 0.44, p = 0.0002) of second eye AION regardless of the usual risk factors. Even after eliminating those patients who had bilateral disease when first referred, ASA still reduced the incidence of second eye involvement (35% vs. 13%, RR = 0.74, p = 0.01). Aspirin may be an effective means of reducing second eye NAION.
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PMID:Aspirin reduces the incidence of second eye NAION: a retrospective study. 942 77

Despite diagnostic and therapeutic advances, mesenteric vascular occlusion with intestinal infarction is often fatal. Parameters determining the high mortality are seldom discussed in the literature. By univariate statistical analysis we correlated the therapeutic outcome of our patients to 20 parameters. Between 1 January 1984 and 30 April 1996 we treated 22 men and 18 women with acute bowel ischemia of vascular origin. All patients underwent laparotomy, 40% (n = 16) due to the diagnosis of mesenteric infarction. In 15% (n = 6) the laparotomy was only exploratory; in 34 cases (85%) bowel resection was carried out. Mortality for all patients was 55% (n = 22). Univariate analysis of the 20 parameters showed that the therapeutic outcome was significantly correlated to a pre-existing diabetes, the course of hospitalization, and the high ASA class. There was no correlation to the length of resected bowel. Most parameters that determine the mortality of bowel infarction are pre-existing and cannot be influenced, but survival can be achieved in some patients if radical and aggressive resection is carried out at the side of almost complete small bowel infarction and followed by an elective second-look operation. Even short-bowel syndrome can be treated. Patients can return to a near normal lifestyle with an acceptable quality of life with the aid of parenteral nutrition at home.
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PMID:[Fatal outcome factors of intestinal infarct of primary vascular origin]. 949 3

We reported the immediate recovery period of 705 consecutive patients post general or head-neck-breast surgery, 590 were looked after in the recovery room (RR) and 115 were admitted into the intensive care unit (ICU) right after surgery. Group I were "young" (aged 15-45 years), group II were "middle aged" (46-60 years) and group III were "elderly" (> 60 years). Twenty-seven per cent of the elderly patients were sent to the ICU, whereas, 8.4 per cent of the young and 14.7 of the middle-aged group were looked after in the ICU. In RR patients, the young group were in better ASA class and had significantly fewer underlying diseases than the middle-aged and elderly groups; the most common of which were hypertension, diabetes and anemia. Elderly patients spent a significantly longer time in the RR than the young group but the risk of complication was not different. The most frequent complication was pain and elderly patients more frequently suffered from pain than the young group. Post-anesthetic recovery score (after Aldrete and Kroulik) was lower in the elderly on arrival and at 15, 30, 60 minutes in the RR but there was no clinical significance. In ICU patients, the 3 groups' intubation rates were not different and although the duration of intermittent positive pressure ventilation and duration of stay in the ICU were longest in the elderly group, there was no statistically significant difference. The mortality rate was highest in the elderly. We concluded that elderly patients had a worse immediate recovery period.
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PMID:Comparison of immediate recovery period among young, middle-aged and elderly patients. 967 82

The objectives of this paper are to assess whether two indices of intrinsic infection risk (the SENIC and the NNIS index) predict in-hospital mortality and the attributable in-hospital mortality due to nosocomial infection in surgical patients. A prospective study on 4714 patients admitted to three hospitals has been carried out. The relative risk and its 95% confidence interval (CI) were estimated. Multiple-risk factors adjusted for odds ratios (OR) were yielded by logistic regression analysis. Overall, 119 patients (2.5%) died before hospital discharge. Both the SENIC and the NNIS indices were related to in-hospital mortality in crude data. After controlling for several variables (age, sex, ASA score, cancer, renal failure, diabetes mellitus, stay at the ICU), the SENIC index did not show any significant trend with mortality (P = 0.252), whereas the trend was significant for the NNIS index (P < 0.001). Risk of death in patients with one nosocomial infection was 7.5%, and in patients developing more than one nosocomial infection was 17.1%. After adjusting for several confounding variables, the development of an organ/space surgical site infection was significantly related to mortality (OR = 4.5, 95% CI 1.5-15.6) as was blood infection (OR = 17.3, 95% CI 3.5-87.0). The association of a surgical site infection and either a respiratory tract infection or a blood infection also increased significantly the risk of in-hospital mortality (OR = 3.3, 95% CI 1.2-8.7). In conclusion, the NNIS index is a good predictor of in-hospital mortality. Patients developing an organ/space surgical site infection and/or a blood infection have an increased risk of in-hospital mortality.
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PMID:Nosocomial infection, indices of intrinsic infection risk, and in-hospital mortality in general surgery. 1020 22

Laparoscopic adrenalectomy has recently been shown to be a safe and effective procedure for treating a variety of benign adrenal tumors. Advanced age, with its concomitant comorbid conditions, has been believed to be associated with more postoperative complications in laparoscopic procedures. The purpose of this study was to evaluate the outcome of laparoscopic adrenalectomy in patients age 65 and older. From June 1992 to February 1998, 14 patients (4 men and 10 women) with a mean age of 69 years underwent 17 laparoscopic adrenalectomies. In 12 procedures, a transperitoneal lateral decubitus flank approach was used. The lesion was a nonfunctioning adenoma in three patients, aldosterone adenoma in four, Cushing's syndrome in four, and pheochromocytoma in one. A retroperitoneal lateral decubitus approach was used in five procedures. The lesion was a nonfunctioning adenoma in one patient, aldosterone adenoma in one, Cushing's adenoma in one, and pheochromocytoma in two. Seventy-eight percent of these patients had comorbid conditions, including hypertension, diabetes, chronic obstructive airway disease, coronary artery disease, and cardiac dysrhythmia. The preoperative physical status was as ASA Class II in 11 patients and ASA III in 3. Two of the 17 laparoscopies were converted to open surgery (11%), in one because of difficulties in dissecting extraperitoneally a mass >8 cm, and in the other because of difficulties in localization of a 3-cm mass. The median surgical time was 95 +/- 33 minutes. The mean analgesia requirements were 3 doses of (range 2-7) ketorolac. There were no deaths. Postoperative morbidity consisted of pulmonary atelectasis in one patient and urinary tract infection in two patients. The median hospital stay was 3 days (range 2-4 days). We conclude that laparoscopic adrenalectomy in the elderly population is safe and offers low morbidity, fast recovery, and a short hospital stay. Age alone should not be a contraindication to treating adrenal tumors laparoscopically.
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PMID:Laparoscopic adrenalectomy in the elderly. 1048 24

Risk factor control has been shown to reduce the incidence of coronary events in patients with or without preceding infarction. Secondary prevention should therefore be borne in mind by every cardiologist. In order to test this concept and/or to promote secondary prevention in our country, the following survey was conducted by our working group for epidemiology and prevention. All interventional centres of the country (7 million inhabitants) were asked to report relevant data of 50 consecutive patients with PTCA in a structured questionnaire. Thirteen centres responded and we report the data of 650 patients. The mean proportion of women was 28%, the mean age 61.1 years and the mean stent rate 49.8%. The indications for PTCA varied widely: stable angina 10-74%, unstable angina 10-86%, primary PTCA 0-22%. The risk factor history was distributed as follows: diabetes 12-46% (mean 22.3%), hypertension 32-68% (mean 54.2%), current smoking 6-56% (mean 21.9%), and total cholesterol (TChol) > 200 mg/dl: 30-78% (mean 60.3%). Current lipid values were available for T chol. in 44-100% (mean 84.5%) and for LDL in 4-100% (mean 67.1%). Dietary counselling by a dietician was done in 4-100% of patients (mean 35.6%) Information concerning the hazards of smoking was given to 25-100% (mean 83.6%) of current smokers. Drug treatment at hospital discharge was as follows: 84-100% (mean 93.1%) received ASA, 24-74% (mean 49.8%) ticlopidine, 6-84% (mean 53.3%) nitrates, 34-82% (mean 60.2%) beta blockers, 10-70% (mean 39.5%) ACE inhibitors, 4-74% (mean 4 7.2%) lipid lowering drugs, 7-48% (mean 17.8%) calcium antagonists, 0-12% (mean 6.1%) digitalis and 0-28% (mean 13.6%) diuretics. Follow-up data were collected in 4 centres at 6 months post discharge and were available for 174 patients. Here we found an increase in the prescription of calcium antagonists, digitalis and statins. The following conclusions were drawn at a conference in which all centres participated: lipid values should be available for each patient at PTCA, dietary counselling should be initiated for every patient during hospitalisation (and continued by the family physician) and the national cardiac society should promote guidelines for the use of drugs in which the variation in use is too wide at present. It should be ensured that these guidelines are implemented not only in patients after AMI but also in those after PTCA.
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PMID:[Secondary prevention following coronary intervention. Survey of 13 intervention centers in Austria]. 1051 Aug 42

The purpose of the present research has been to identify a cellular parameter to be used as an index of increased cell proliferation and, therefore, the likelihood of recurrence. A total of 114 patients with bilateral nasal polyposis underwent naso-ethmoid dissection under endoscopy. Of these, 36 were affected by allergic rhinopathy, 6 bronchial asthma, 9 ASA syndrome and 9 diabetes mellitus; in addition 33 cases were classified as recurrences. The polyp material from each patient was analyzed using a Coulter XL cytofluorimeter, evaluating the cycles of approximately 10-20 thousand cells. The objective was to identify the nasal polyp activity status in the various patients, evaluating cell proliferation indicated by the percentage of cells in phase S and G2 + M. Of the 114 patients, 21 were ruled out of the study because of a high degree of cell debris. Cytofluorimetry made it possible to identify 3 groups based on the different percentage of cells in the genomic synthesis phase. In the first group (A) of 42 patients, the number of cells in the active phase ranged from 2.1% to 10%. The second group (B) of 21 patients showed a percentage in the 14.7-41.9% range. The third group (C) of 30 patients--all affected by recurrent polyps--showed a high percentage (25%-49.8%) of cells in the active phase. It is interesting to note that: 1. A full 91% of the allergic patients fell within group A. 2. Of the 9 patients with ASA, 7 were in the group with recurrences. 3. The 30 patients affected by recurrent polyps were all in group C and that of these 12 had more than one recurrence, expressing a higher percentage of active cells. The above appears to indicate that the cell parameter evaluated here cytofluorimetrically may be a new, simple, reliable index to predict nasal polyps recurrences.
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PMID:[Study on cell proliferation in nasal polyposis as predictive index of recurrence]. 1073 28


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