Heart rate reduction is the cornerstone of the treatment of angina. The purpose of this study was to explore the prognostic value of heart rate in patients with stable coronary artery disease(CAD). Methods and results...Heart rate reduction is the cornerstone of the treatment of angina. The purpose of this study was to explore the prognostic value of heart rate in patients with stable coronary artery disease(CAD). Methods and results: We assessed the relationship between resting heart rate at baseline and cardiovascular mortality/ morbidity, while adjusting for risk factors. A total of 24 913 patients with suspected or proven CAD from the Coronary Artery Surgery Study registry were studied for a median followup of 14.7 years. All-cause and cardiovascular mortality and cardiovascular rehospitalizations were increased with increasing heart rate(P< 0.0001). Patients with resting heart rate ≥ 83 bpm at baseline had a significantly higher risk for total mortality[hazard ratio(HR)=1.32, CI 1.19- 1.47, P< 0.0001]- and cardiovascular mortality(HR=1.31, CI 1.15- 1.48, P< 0.0001) after adjustment for multiple clinical variables when compared with the reference group. When comparing patients with heart rates between 77- 82 and ≥ 83 bpm with patients with a heart rate ≤ 62 bpm, the HR values for time to first cardiovascular rehospitalization were 1.11 and 1.14, respectively(P< 0.001 for both). Conclusion: Resting heart rate is a simple measurement with prognostic implications. High resting heart rate is a predictor for total and cardiovascular mortality independent of other risk factors in patients with CAD.展开更多
Context: Cardiogenic shock remains the major cause of death for patients hospitalized with acute myocardial infarction(MI). Although survival in patients with cardiogenic shock complicating acute MI has been shown to ...Context: Cardiogenic shock remains the major cause of death for patients hospitalized with acute myocardial infarction(MI). Although survival in patients with cardiogenic shock complicating acute MI has been shown to be significantly higher at 1 year in those receiving early revascularization vs initial medical stabilization, data demonstrating long-term survival are lacking. Objective: To determine if early revascularization affects long-term survival of patients with cardiogenic shock complicating acute MI. Design, Setting, and Patients: The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock(SHOCK) trial, an international randomized clinical trial enrolling 302 patients from April 1993 through November 1998 with acute myocardial infarction complicated by cardiogenic shock(mean[SD] age at randomization, 66[11] years); long-term follow-up of vital status, conducted annually until 2005, ranged from 1 to 11 years(median for survivors, 6 years). Main Outcome Measures: All-cause mortality during long-term follow-up. Results: The group difference in survival of 13 absolute percentage points at 1 year favoring those assigned to early revascularization remained stable at 3 and 6 years(13.1%and 13.2%, respectively; hazard ratio[HR], 0.74; 95%confidence interval[CI], 0.57-0.97; log-rank P=.03). At 6 years, overall survival rates were 32.8%and 19.6%in the early revascularization and initial medical stabilization groups, respectively. Among the 143 hospital survivors, a group difference in survival also was observed(HR, 0.59; 95%CI, 0.36-0.95; P=.03). The 6-year survival rates for the hospital survivors were 62.4%vs 44.4%for the early revascularization and initial medical stabilization groups, respectively, with annualized death rates of 8.3%vs 14.3%and, for the 1-year survivors, 8.0%vs 10.7%. There was no significant interaction between any subgroup and treatment effect. Conclusions: In this randomized trial, almost two thirds of hospital survivors with cardiogenic shock who were treated with early revascularization were alive 6 years later. A strategy of early revascularization resulted in a 13.2%absolute and a 67%relative improvement in 6-year survival compared with initial medical stabilization. Early revascularization should be used for patients with acute MI complicated by cardiogenic shock due to left ventricular failure.展开更多
Context: Experimental and epidemiological data suggest that vitamin E supplementation may prevent cancer and cardiovascular events. Clinical trials have generally failed to confirm benefits, possibly due to their rela...Context: Experimental and epidemiological data suggest that vitamin E supplementation may prevent cancer and cardiovascular events. Clinical trials have generally failed to confirm benefits, possibly due to their relatively short duration. Objective: To evaluate whether long-term supplementation with vitamin E decreases the risk of cancer, cancer death, and major cardiovascular events. Design, Setting, and Patients: A randomized, double-blind, placebo-controlled international trial(the initial Heart Outcomes Prevention Evaluation[HOPE] trial conducted between December 21, 1993, and April 15,1999) of patients at least 55 years old with vascular disease or diabetes mellitus was extended(HOPE-The Ongoing Outcomes[HOPE-TOO]) between April 16,1999, and May 26, 2003. Of the initial 267 HOPE centers that had enrolled 9541 patients, 174 centers participated in the HOPE-TOO trial. Of 7030 patients enrolled at these centers, 916 were deceased at the beginning of the extension, 1382 refused participation, 3994 continued to take the study intervention, and 738 agreed to passive follow-up. Median duration of follow-up was 7.0 years. Intervention: Daily dose of natural source vitamin E(400 IU) or matching placebo. Main Outcome Measures: Primary outcomes included cancer incidence, cancer deaths, and major cardiovascular events(myocardial infarction, stroke, and cardiovascular death). Secondary outcomes included heart failure, unstable angina, and revascularizations. Results: Among all HOPE patients, there were no significant differences in the primary analysis: for cancer incidence, there were 552 patients(11.6%) in the vitamin E group vs 586(12.3%) in the placebo group(relative risk[RR], 0.94; 95%confidence interval[CI], 0.84-1.06; P=.30); for cancer deaths, 156(3.3%) vs 178(3.7%), respectively(RR, 0.88; 95%CI, 0.71-1.09; P=.24); and for major cardiovascular events, 1022(21.5%) vs 985(20.6%), respectively(RR, 1.04; 95%CI, 0.96-1.14; P=.34). Patients in the vitamin E group had a higher risk of heart failure(RR, 1.13; 95%CI, 1.01-1.26; P=.03) and hospitalization for heart failure(RR, 1.21; 95%CI, 1.00-1,47; P=.045). Similarly, among patients enrolled at the centers participating in the HOPE-TOO trial, there were no differences in cancer incidence, cancer deaths, and major cardiovascular events, but higher rates of heart failure and hospitalizations for heart failure. Conclusion: In patients with vascular disease or diabetes mellitus, longterm vitamin E supplementation does not prevent cancer or major cardiovascular events and may increase the risk for heart failure.展开更多
Background and Purpose:Low socioeconomic status is associated with increased morbidity and mortality from stroke. The purpose of this study was to investigat e the association between 4 independent measures of socioec...Background and Purpose:Low socioeconomic status is associated with increased morbidity and mortality from stroke. The purpose of this study was to investigat e the association between 4 independent measures of socioeconomic status and mor tality of patients with acute ischemic stroke and transient ischemic attack. Met hods:Socioeconomic status was assessed by taking into account levels of educati on, occupation, occupational status, and income. The end point was overall morta lity. We used Cox proportional hazard models to adjust for age, sex, and severit y of stroke on admission. Results:A total of 2606 stroke patients were followed up for a median of 2.5 years. Unskilled workers had a hazard ratio of 1.87 for death after stroke (95%CI, 1.37 to 2.55) and skilled workers had a hazard ratio of 1.61(95%CI, 1.23 to 2.11) compared with white-collar workers.Of 4 income g roups, patients with the second lowest level of income had a hazard ratio of 1.6 0 (95%CI, 1.10 to 2.33) and patients with the third lowest level of income had a hazard ratioof 1.71 (95%CI, 1.25 to 2.32) compared with patients with the highest income. The hazard ratio for death after stroke for early retired patients was 1.75 (95%CI, 1.01 to 3.0 4) compared with stroke patients in the active work force at the time of the eve nt.Conclusions:Socioeconomic status is associated with survival of patients wit h acute stroke after adjustment for age, sex, and severity of stroke. The influe nce of socioeconomic status seems to continue to affect the outcome largely inde pendent of stroke severity.展开更多
Objective: To compare characteristics, management, and outcome of myocardial infarction(MI) in men and women. Design: Prospective observational study. Setting: District general hospital in southwest Scotland. Particip...Objective: To compare characteristics, management, and outcome of myocardial infarction(MI) in men and women. Design: Prospective observational study. Setting: District general hospital in southwest Scotland. Participants: 966 men and 597 women admitted with first MI between 1994 and 2000 with follow up to the end of 2001. Results: 393(40.7%) men and 305(51.1%)women died during a median follow up of 3.4 years for the survivors. Univariate analysis indicated an excess mortality among women(hazard ratio(HR) 1.45, 95%confidence interval(CI) 1.25 to 1.68), which disappeared after adjustment for age, smoking, comorbidity, previous vascular disease, diabetes, hypertension, and social deprivation(HR 1.02, 95%CI 0.87 to 1.20). There was also an excess early mortality within 30 days among women(HR 1.54, 95%CI 1.20 to 1.98), though this did not retain significance after adjustment for the same covariates(HR 1.04, 95%CI 0.79 to 1.37). Small and insignificant differences were found in the proportion of men and women receiving thrombolysis on admission and secondary prophylactic drugs at discharge, except for statins and βblockers, which were respectively more(adjusted odds ratio 1.48, 95%CI 1.10 to 1.98) and less(adjusted odds ratio 0.78, 95%CI 0.60 to 1.00) commonly prescribed to women. Conclusion: Results suggest that the poorer outcome for women after MI reported in other studies may reflect sex bias in management as well as differences in age and co-morbidity and support the view that if women have access to the same quality of care as men then survival will be the same.展开更多
BACKGROUND: Cardiovascular disease is an important complication in pati ents wi th systemic lupus erythematosus (SLE). Variant alleles of the mannose-binding l ectin gene are associated with SLE as well as with severe...BACKGROUND: Cardiovascular disease is an important complication in pati ents wi th systemic lupus erythematosus (SLE). Variant alleles of the mannose-binding l ectin gene are associated with SLE as well as with severe atherosclerosis. We de termined whether mannose-binding lectin variant alleles were associated with an increased risk of arterial thrombosis among patients with SLE. METHODS: Mannose -binding lectin alleles were genotyped by means of a polymerase-chain-reactio n assay in 91 Danish patients with SLE. Arterial and venous thromboses occurring after the diagnosis of SLE were assessed in a prospective study. Arterial and v enous thromboses were confirmed by appropriate diagnostic methods. RESULTS: Fift y-four patients had no mannose-binding lectin variant alleles (A/A genotype), 30 were heterozygous (A/O genotype), and 7 were homozygous (O/O genotype). Durin g a median follow-up of 9.1 years, arterial thromboses (cerebral or myocardial infarction or leg embolus) developed in 6 of the 7 patients with the O/O genotyp e, as compared with 18 of the 84 patients with the other two genotypes (hazard r atio, 5.8; 95 percent confidence interval, 2.2 to 15.2; overall incidence, 26 pe rcent). After correction for other known risk factors, the hazard ratio was 7.0 (95 percent confidence interval, 1.9 to 25.4). Venous thromboses, which occurred in 14 patients, were statistically unrelated to the mannose-binding lectin gen otype. CONCLUSIONS: Among patients with SLE, homozygosity for mannose-binding l ectin variant alleles is associated with an increased risk of arterial thrombosi s. The risk of venous thrombosis is not increased, indicating that mannose-bind ing lectin has a specific role in providing protection against arterial thrombos is.展开更多
To determine the safety and efficacy of clitoral -sparing surgery in women with squamous cell carcinoma (SCCA)of the anterior vulva not involving the clitoris.Patients with vulvar SCCA diagnosed between 1984a nd 2000w...To determine the safety and efficacy of clitoral -sparing surgery in women with squamous cell carcinoma (SCCA)of the anterior vulva not involving the clitoris.Patients with vulvar SCCA diagnosed between 1984a nd 2000were i-dentified and data collected.In thi s descriptive analysis,women treated with complete radical vulvectomy were compared to those treated with clito ral -sparing modified radical vulvectomy.All slides were re -reviewed.Of the41women with vulvar carcinoma,13had clitoral -spar-ingmodified vulvectomies(group A)while the remaining 28underwent complete radical vulvectomies(group B ).The13patients in group A included,8with stage I,2stage II,2stage III,and 1with stage IV disease.The two groups had similar demographic and patholo gic prognostic factors.After a median follow -up of 59months,no patients in group A had loco -regional failure.C litoral -sparing vul-var cancer surgery does not compromi se the rate of loco -regional control in patients and may be offered to selected women.展开更多
Context: Basilar artery occlusion(BAO) is an infrequent disease with high morbidity and mortality. Intra-arterial thrombolysis is advocated for treatment but is limited to use at specialized centers. Objective: To eva...Context: Basilar artery occlusion(BAO) is an infrequent disease with high morbidity and mortality. Intra-arterial thrombolysis is advocated for treatment but is limited to use at specialized centers. Objective: To evaluate outcomes for patients with BAO treated with intravenous thrombolytic therapy. Design, Setting, and Participants: During 1995 to 2003, 50 consecutive patients with angiographically proven BAO were treated according to an institutional therapy protocol based on intravenous thrombolysis with recombinant tissue plasminogen activator(alteplase). Patients were treated at an urban university teaching hospital receiving all patients with ischemic stroke who were considered for thrombolysis in a catchment area of 1.5 million inhabitants in Helsinki, Finland. Intervention: Intravenous administration of alteplase(0.9 mg/kg) during a 1-hour infusion. Main Outcome Measures: Basilar artery recanalization determined by magnetic resonance angiography and clinical outcomes at 3 months and at 1 year or longer determined by modified Rankin Scale and Barthel Index scores. Results: Recanalization was studied in 43 patients and verified in 26(52%) of all patients. By 3 months, 20 patients(40%) had died while 11 had good outcomes(modified Rankin Scale score, 0-2); 12(24%) reached independence in activities of daily living(Barthel Index score, 95-100), and 6(16%) were severely disabled(Barthel Index score, 0-50). In the long term(median follow-up 2.8 years), 15 patients(30%) reached good outcomes(modified Rankin Scale score, 0-2) while 23(46%) died. Conclusions: Intravenous administration of alteplase for patients with BAO appears to be associated with rates of survival, recanalization, and independent functional outcome comparable with those reported with endovascular approaches. These data suggest that a randomized trial is needed to compare these approaches for treatment of BAO.展开更多
BACKGROUND: Sudden death from cardiac causes remains a leading cause of death among patients with congestive heart failure(CHF). Treatment with amiodarone or an implantable cardioverter-defibrillator(ICD) has been pro...BACKGROUND: Sudden death from cardiac causes remains a leading cause of death among patients with congestive heart failure(CHF). Treatment with amiodarone or an implantable cardioverter-defibrillator(ICD) has been proposed to improve the prognosis in such patients. METHODS: We randomly assigned 2521 patients with New York Heart Association(NYHA) class II or III CHF and a left ventricular ejection fraction(LVEF) of 35 percent or less to conventional therapy for CHF plus placebo(847 patients), conventional therapy plus amiodarone(845 patients), or conventional therapy plus a conservatively programmed, shock-only, single-lead ICD(829 patients). Placebo and amiodarone were administered in a doubleblind fashion. The primary end point was death from any cause. RESULTS: The median LVEF in patients was 25 percent; 70 percent were in NYHA class II, and 30 percent were in class III CHF. The cause of CHF was ischemic in 52 percent and nonischemic in 48 percent. The median follow-up was 45.5 months. There were 244 deaths(29 percent) in the placebo group, 240(28 percent) in the amiodarone group, and 182(22 percent) in the ICD group. As compared with placebo, amiodarone was associated with a similar risk of death(hazard ratio, 1.06; 97.5 percent confidence interval, 0.86 to 1.30; P=0.53) and ICD therapy was associated with a decreased risk of death of 23 percent(0.77; 97.5 percent confidence interval, 0.62 to 0.96; P=0.007) and an absolute decrease in mortality of 7.2 percentage points after five years in the overall population. Results did not vary according to either ischemic or nonischemic causes of CHF, but they did vary according to the NYHA class. CONCLUSIONS: In patients with NYHA class II or III CHF and LVEF of 35 percent or less, amiodarone has no favorable effect on survival, whereas single-lead, shock-only ICD therapy reduces overall mortality by 23 percent.展开更多
The authors reviewed preoperative MRI and EEG findings in relation to postsurg ical outcome in 17 patients with refractory epilepsy due to tuberous sclerosis c omplex (TSC). Resecting concordant MRI (main tuber) and E...The authors reviewed preoperative MRI and EEG findings in relation to postsurg ical outcome in 17 patients with refractory epilepsy due to tuberous sclerosis c omplex (TSC). Resecting concordant MRI (main tuber) and EEG abnormalities offere d seizure freedom (8/9, 89%; median follow-up 25 months) comparable to other f ocal etiologies. Patients with nonconcordant MRI and EEG findings did less well (3/8, 38%, seizure free; p=0.027, OR=13).展开更多
BACKGROUND: Previous trials have demonstrated that lowering low-density lipoprotein(LDL) cholesterol levels below currently recommended levels is beneficial in patients with acute coronary syndromes. We prospectively ...BACKGROUND: Previous trials have demonstrated that lowering low-density lipoprotein(LDL) cholesterol levels below currently recommended levels is beneficial in patients with acute coronary syndromes. We prospectively assessed the efficacy and safety of lowering LDL cholesterol levels below 100 mg per deciliter(2.6 mmol per liter) in patients with stable coronary heart disease(CHD). METHODS: A total of 10,001 patients with clinically evident CHD and LDL cholesterol levels of less than 130 mg per deciliter(3.4 mmol per liter) were randomly assigned to double-blind therapy and received either 10 mg or 80 mg of atorvastatin per day. Patients were followed for a median of 4.9 years. The primary end point was the occurrence of a first major cardiovascular event, defined as death from CHD, nonfatal non-procedure-related myocardial infarction, resuscitation after cardiac arrest, or fatal or nonfatal stroke. RESULTS: The mean LDL cholesterol levels were 77 mg per deciliter(2.0 mmol per liter) during treatment with 80 mg of atorvastatin and 101 mg per deciliter(2.6 mmol per liter) during treatment with 10 mg of atorvastatin. The incidence of persistent elevations in liver aminotransferase levels was 0.2 percent in the group given 10 mg of atorvastatin and 1.2 percent in the group given 80 mg of atorvastatin(P< 0.001). A primary event occurred in 434 patients(8.7 percent) receiving 80 mg of atorvastatin, as compared with 548 patients(10.9 percent) receiving 10 mg of atorvastatin, representing an absolute reduction in the rate of major cardiovascular events of 2.2 percent and a 22 percent relative reduction in risk(hazard ratio, 0.78; 95 percent confidence interval, 0.69 to 0.89; P< 0.001). There was no difference between the two treatment groups in overall mortality. CONCLUSIONS: Intensive lipid-lowering therapy with 80 mg of atorvastatin per day in patients with stable CHD provides significant clinical benefit beyond that afforded by treatment with 10 mg of atorvastatin per day. This occurred with a greater incidence of elevated aminotransferase levels.展开更多
Background: Mycosis fungoides (MF) is the most common skin lymphoma. The aetiology of MF remains unknown, and no therapy has to date significantly altered patient survival. Objective: The present study examines trends...Background: Mycosis fungoides (MF) is the most common skin lymphoma. The aetiology of MF remains unknown, and no therapy has to date significantly altered patient survival. Objective: The present study examines trends in survival of MF patients in a well- defined population- based disease group, namely patients registered over a 40- year period at the Thames Cancer Registry, Southeast England. Methods: The Thames Cancer Registry is a population- based registry, covering a population of approximately 14 million people. Data were taken from the Surveillance, Epidemiology and End Results cancer registry programme and the National Centre for Health Statistics. The database was used to identify cases of MF diagnosed between 1961 and 2000. A total of 985 records were identified, 821 (83% ) of which had complete information on age, sex, year of diagnosis and area of residence. The observed and relative survivals of patients diagnosed during the periods 1971- 1975, 1981- 1985 and 1991- 1995 were examined over a 5- year period of follow- up, using the relsurv Stata program to perform Cox proportional hazard analysis. Results: A total of 821 MF eligible patients were available with a median followup of 4.3 years and a maximum follow- up of 30 years. The overall 5- year relative survival rate was 80% , and there was marked improvement between 1971 and 1981. The prognostic factors leading to a significantly poorer survival were high age, male sex, the presence of the Sé zary syndrome, the use of hormone treatment and radiotherapy. Conclusions: A statistically significantly better survival over the last 20 years was found. The prognosis is generally good for most patients but not all. The best survival was seen for the female patients under 45 years of age without the presence of the Sé zary syndrome. This difference in survival may be partly due to a difference in the disease stage or different treatment, or to both.展开更多
Background-Patients with heart failure are at increased risk of sudden death and death attributed to progressive pump failure. We assessed the effect of Candesartan on cause-specific mortality in patients enrolled in ...Background-Patients with heart failure are at increased risk of sudden death and death attributed to progressive pump failure. We assessed the effect of Candesartan on cause-specific mortality in patients enrolled in the Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity(CHARM) program. Methods and Results-The CHARM program consisted of 3 component trials that enrolled patients with symptomatic heart failure: CHARM-Alternative(n=2028; LVEF=40%and ACE intolerant), CHARM-Added(n=2548; LVEF=40%, already on ACE inhibitors), and CHARM-Preserved(n=3023; LVEF >40%). Patients were randomized to candesartan, titrated to 32 mg QD, or placebo and were followed up for a median of 37.7 months. All deaths were reviewed by a blinded adjudication committee and categorized according to prespecified definitions on the basis of a narrative and source documentation. The number and rate of deaths by cause were calculated for each of the component trials and the overall program. Of all the patients, 8.5%died suddenly, and 6.2%died of progressive heart failure. Candesartan reduced both sudden death (HR 0.85 [0.73 to 0.99], P=0.036) and death from worsening heart failure(HR 0.78[0.65 to 0.94], P=0.008). These reductions were most apparent in the patients with LVEF=40%. Conclusions-Candesartan reduced sudden death and death from worsening heart failure in patients with symptomatic heart failure, although this reduction was most apparent in patients with systolic dysfunction.展开更多
BACKGROUND: Angiography shows that stereotactic radiosurgery obliterates most cerebral arteriovenous malformations after a latency period of a few years. However, the effect of this procedure on the risk of hemorrhage...BACKGROUND: Angiography shows that stereotactic radiosurgery obliterates most cerebral arteriovenous malformations after a latency period of a few years. However, the effect of this procedure on the risk of hemorrhage is poorly understood. METHODS: We performed a retrospective observational study of 500 patients with malformations who were treated with radiosurgery with use of a gamma knife. The rates of hemorrhage were assessed during three periods: before radiosurgery, between radiosurgery and the angiographic documentation of obliteration of the malformation (latency period), and after angiographic obliteration. RESULTS: Forty- two hemorrhages were documented before radiosurgery (median follow- up, 0.4 year), 23 during the latency period (median follow- up, 2.0 years), and 6 after obliteration (median follow- up, 5.4 years). As compared with the period between diagnosis and radiosurgery, the risk of hemorrhage decreased by 54 percent during the latency period (hazard ratio, 0.46; 95 percent confidence interval, 0.26 to 0.80; P=0.006) and by 88 percent after obliteration (hazard ratio, 0.12; 95 percent confidence interval, 0.05 to 0.29; P < 0.001). The risk was significantly reduced during the period after obliteration, as compared with the latency period (hazard ratio, 0.26; 95 percent confidence interval, 0.10 to 0.68; P=0.006). The reduction was greater among patients who presented with hemorrhage than among those without hemorrhage at presentation and similar in analyses that took into account the delay in confirming obliteration by means of angiography and analyses that excluded data obtained during the first year after diagnosis. CONCLUSIONS: Radiosurgery significantly decreases the risk of hemorrhage in patients with cerebral arteriovenous malformations, even before there is angiographic evidence of obliteration. The risk of hemorrhage is further reduced, although not eliminated, after obliteration.展开更多
Purpose: The purpose of this study was to retrospectively evaluate whether it is possible to decrease the risk of Molteno tube erosion through the conjunctiva by using a newtechniquewhere the silicone tube is inserted...Purpose: The purpose of this study was to retrospectively evaluate whether it is possible to decrease the risk of Molteno tube erosion through the conjunctiva by using a newtechniquewhere the silicone tube is inserted into a scleral tunne l instead of being covered only by the con- junctiva. Methods: We reviewed Molteno implants carried out at theUniversity H ospital ofOulu, in 332 patientswho underwent traditionalMolteno implantation bet ween October 1986 and October 1998 and 92 patients who underwent surgery with th e new technique between November 1998 and April 2001. Results: With our former t echnique, conjunctival erosions occurred in 15 eyes of 15 patients (4.5%)-afte r a median follow-up of 3.5 months (range 1-72 months); no conjunctival compli cations were discovered in patients who underwent surgery using the new techniqu e during a median follow-up of 22 months (range 10-39 months). (p=0.038, twosa mple test of proportions). Conclusion: Inserting the Molteno tube into a scleral tunnel prevents tube extrusion through the conjunctiva in eyes with Molteno imp lants. The technique for making the scleral tunnel is described.展开更多
Background: Autoimmune hepatitis (AIH) is an immune mediated chronic liver diseasewith a prevalence of 17 cases/100,000. Resistance to the standard treatment of AIH (prednisone and azathioprine) occurs in 15%to 20%. T...Background: Autoimmune hepatitis (AIH) is an immune mediated chronic liver diseasewith a prevalence of 17 cases/100,000. Resistance to the standard treatment of AIH (prednisone and azathioprine) occurs in 15%to 20%. There is currently no standard treatment of patients with steroid refractory AIH. Goals: Determine the efficacy of tacrolimus in the treatment of steroid refractory AIH. Methods: This is a retrospective study evaluating the efficacy of Tacrolimus in the treatment of steroid refractory AIH. Results: Between October 1998 and February 2002, 11 patients with steroid refractory AIH were treated with tacrolimus. Mean age was 63 years. Median duration of steroid treatment before starting tacrolimus was 9 months. Median duration of tacrolimus treatment was 25 months. Median follow up period was 16 months. Median baseline ALT, AST were 77 U/L and 68 U/L and became 21 U/L and 32 U/L respectively at end of follow up (P = 0.005 and 0.01 respectively). Significant weight reduction was seen in all patients (P = 0.02). Tacrolimus treatment was safe and well tolerated. Conclusion: Use of low dose tacrolimus led to successful biochemical and histologic remission and weaning off prednisone in patients with steroid refractory AIH. This data supports further studies in evaluating the use of tacrolimus in the treatment of AIH.展开更多
Objective: To determine if individuals ultimately diagnosed with Alzheimer dis ease (AD) exhibited evidence of cognitive impairment on neuropsychological tests administered between1.5 years and 8.1 years before dement...Objective: To determine if individuals ultimately diagnosed with Alzheimer dis ease (AD) exhibited evidence of cognitive impairment on neuropsychological tests administered between1.5 years and 8.1 years before dementia onset. Methods: A t otal of 693 community-dwelling individuals, part of the Cardiovascular Health S tudy, completed a neuropsychological test battery in 1991/92. Subjects were foll owed annually over the next 8 years (median follow-up = 7.4 years). Seventy-tw o individuals were ultimately diagnosed with AD (median follow-up = 4.5 years): 24 with AD onset 1.5 to 3.4 years after baseline neuropsychological testing, 20 with AD onset 3.5 to 5.0 years after testing, and 28 with onset 5.1 to 8.1 year s after testing. A total of 621 individuals remained nondemented throughout the 8 years of follow-up (median follow-up = 7.5 years). Results: Subjects ultimat ely diagnosed with AD had poorer scores on baseline neuropsychological measures than subjects who remained nondemented. Although individuals closest to AD onset (i.e., 1.5 to 3.4 years) performed the most poorly, cognitive impairment was de tected in individuals who did not develop AD until 5 to 8 years later. Conclusio ns: Cognitive changes can be detected well before onset of Alzheimer disease.展开更多
Background. We evaluated the efficacy of emergency balloon-occluded retrograde transvenous obliteration (B-RTO) performed within 24h after initial hemostasi s for the prevention of rebleeding from ruptured gastric var...Background. We evaluated the efficacy of emergency balloon-occluded retrograde transvenous obliteration (B-RTO) performed within 24h after initial hemostasi s for the prevention of rebleeding from ruptured gastric varices. Methods. From December 1995 to March 2003, 11 patients who had undergone B-RTO within 24h aft er the control of gastric variceal bleeding at Maebashi Red Cross Hospital were investigated. They were followed up for complete eradication, recurrence of vari ces, and rebleeding. Efficacy was determined by endoscopic examination and compu ted tomography. Results. The 4 patients with acute bleeding from ruptured gastri c varices were treated with endoscopic therapy-endoscopic variceal ligation (EV L) in 2 patients, and clipping treatment in 2. Initial hemostasis was achieved i n all 4; the other 7 patients had already stopped bleeding at endoscopy. After h emostasis was achieved, emergency B-RTO was immediately performed within 24h an d was successful in all 11 patients. Ten (90.9%) of the 11 gastric varices were obliterated and the other 1 (9.1%) was diminished in size. During the mean fol low-up period of 1136 days, no rebleeding or recurrence as found. Four patients died during the follow-up period, but none died from variceal bleeding. Surviv al rates were 90.9%and 70.7%, respectively, at 1 year and 3 years. In 6 patien ts, development of esophageal varices appeared during the follow-up period, all of which were controlled by usual endoscopic therapy. No severe side effects we re found after the B-RTO treatment. Conclusions. Emergency B-RTO is an effecti ve treatment for the prevention of rebleeding from ruptured gastric varices.展开更多
文摘Heart rate reduction is the cornerstone of the treatment of angina. The purpose of this study was to explore the prognostic value of heart rate in patients with stable coronary artery disease(CAD). Methods and results: We assessed the relationship between resting heart rate at baseline and cardiovascular mortality/ morbidity, while adjusting for risk factors. A total of 24 913 patients with suspected or proven CAD from the Coronary Artery Surgery Study registry were studied for a median followup of 14.7 years. All-cause and cardiovascular mortality and cardiovascular rehospitalizations were increased with increasing heart rate(P< 0.0001). Patients with resting heart rate ≥ 83 bpm at baseline had a significantly higher risk for total mortality[hazard ratio(HR)=1.32, CI 1.19- 1.47, P< 0.0001]- and cardiovascular mortality(HR=1.31, CI 1.15- 1.48, P< 0.0001) after adjustment for multiple clinical variables when compared with the reference group. When comparing patients with heart rates between 77- 82 and ≥ 83 bpm with patients with a heart rate ≤ 62 bpm, the HR values for time to first cardiovascular rehospitalization were 1.11 and 1.14, respectively(P< 0.001 for both). Conclusion: Resting heart rate is a simple measurement with prognostic implications. High resting heart rate is a predictor for total and cardiovascular mortality independent of other risk factors in patients with CAD.
文摘Context: Cardiogenic shock remains the major cause of death for patients hospitalized with acute myocardial infarction(MI). Although survival in patients with cardiogenic shock complicating acute MI has been shown to be significantly higher at 1 year in those receiving early revascularization vs initial medical stabilization, data demonstrating long-term survival are lacking. Objective: To determine if early revascularization affects long-term survival of patients with cardiogenic shock complicating acute MI. Design, Setting, and Patients: The Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock(SHOCK) trial, an international randomized clinical trial enrolling 302 patients from April 1993 through November 1998 with acute myocardial infarction complicated by cardiogenic shock(mean[SD] age at randomization, 66[11] years); long-term follow-up of vital status, conducted annually until 2005, ranged from 1 to 11 years(median for survivors, 6 years). Main Outcome Measures: All-cause mortality during long-term follow-up. Results: The group difference in survival of 13 absolute percentage points at 1 year favoring those assigned to early revascularization remained stable at 3 and 6 years(13.1%and 13.2%, respectively; hazard ratio[HR], 0.74; 95%confidence interval[CI], 0.57-0.97; log-rank P=.03). At 6 years, overall survival rates were 32.8%and 19.6%in the early revascularization and initial medical stabilization groups, respectively. Among the 143 hospital survivors, a group difference in survival also was observed(HR, 0.59; 95%CI, 0.36-0.95; P=.03). The 6-year survival rates for the hospital survivors were 62.4%vs 44.4%for the early revascularization and initial medical stabilization groups, respectively, with annualized death rates of 8.3%vs 14.3%and, for the 1-year survivors, 8.0%vs 10.7%. There was no significant interaction between any subgroup and treatment effect. Conclusions: In this randomized trial, almost two thirds of hospital survivors with cardiogenic shock who were treated with early revascularization were alive 6 years later. A strategy of early revascularization resulted in a 13.2%absolute and a 67%relative improvement in 6-year survival compared with initial medical stabilization. Early revascularization should be used for patients with acute MI complicated by cardiogenic shock due to left ventricular failure.
文摘Context: Experimental and epidemiological data suggest that vitamin E supplementation may prevent cancer and cardiovascular events. Clinical trials have generally failed to confirm benefits, possibly due to their relatively short duration. Objective: To evaluate whether long-term supplementation with vitamin E decreases the risk of cancer, cancer death, and major cardiovascular events. Design, Setting, and Patients: A randomized, double-blind, placebo-controlled international trial(the initial Heart Outcomes Prevention Evaluation[HOPE] trial conducted between December 21, 1993, and April 15,1999) of patients at least 55 years old with vascular disease or diabetes mellitus was extended(HOPE-The Ongoing Outcomes[HOPE-TOO]) between April 16,1999, and May 26, 2003. Of the initial 267 HOPE centers that had enrolled 9541 patients, 174 centers participated in the HOPE-TOO trial. Of 7030 patients enrolled at these centers, 916 were deceased at the beginning of the extension, 1382 refused participation, 3994 continued to take the study intervention, and 738 agreed to passive follow-up. Median duration of follow-up was 7.0 years. Intervention: Daily dose of natural source vitamin E(400 IU) or matching placebo. Main Outcome Measures: Primary outcomes included cancer incidence, cancer deaths, and major cardiovascular events(myocardial infarction, stroke, and cardiovascular death). Secondary outcomes included heart failure, unstable angina, and revascularizations. Results: Among all HOPE patients, there were no significant differences in the primary analysis: for cancer incidence, there were 552 patients(11.6%) in the vitamin E group vs 586(12.3%) in the placebo group(relative risk[RR], 0.94; 95%confidence interval[CI], 0.84-1.06; P=.30); for cancer deaths, 156(3.3%) vs 178(3.7%), respectively(RR, 0.88; 95%CI, 0.71-1.09; P=.24); and for major cardiovascular events, 1022(21.5%) vs 985(20.6%), respectively(RR, 1.04; 95%CI, 0.96-1.14; P=.34). Patients in the vitamin E group had a higher risk of heart failure(RR, 1.13; 95%CI, 1.01-1.26; P=.03) and hospitalization for heart failure(RR, 1.21; 95%CI, 1.00-1,47; P=.045). Similarly, among patients enrolled at the centers participating in the HOPE-TOO trial, there were no differences in cancer incidence, cancer deaths, and major cardiovascular events, but higher rates of heart failure and hospitalizations for heart failure. Conclusion: In patients with vascular disease or diabetes mellitus, longterm vitamin E supplementation does not prevent cancer or major cardiovascular events and may increase the risk for heart failure.
文摘Background and Purpose:Low socioeconomic status is associated with increased morbidity and mortality from stroke. The purpose of this study was to investigat e the association between 4 independent measures of socioeconomic status and mor tality of patients with acute ischemic stroke and transient ischemic attack. Met hods:Socioeconomic status was assessed by taking into account levels of educati on, occupation, occupational status, and income. The end point was overall morta lity. We used Cox proportional hazard models to adjust for age, sex, and severit y of stroke on admission. Results:A total of 2606 stroke patients were followed up for a median of 2.5 years. Unskilled workers had a hazard ratio of 1.87 for death after stroke (95%CI, 1.37 to 2.55) and skilled workers had a hazard ratio of 1.61(95%CI, 1.23 to 2.11) compared with white-collar workers.Of 4 income g roups, patients with the second lowest level of income had a hazard ratio of 1.6 0 (95%CI, 1.10 to 2.33) and patients with the third lowest level of income had a hazard ratioof 1.71 (95%CI, 1.25 to 2.32) compared with patients with the highest income. The hazard ratio for death after stroke for early retired patients was 1.75 (95%CI, 1.01 to 3.0 4) compared with stroke patients in the active work force at the time of the eve nt.Conclusions:Socioeconomic status is associated with survival of patients wit h acute stroke after adjustment for age, sex, and severity of stroke. The influe nce of socioeconomic status seems to continue to affect the outcome largely inde pendent of stroke severity.
文摘Objective: To compare characteristics, management, and outcome of myocardial infarction(MI) in men and women. Design: Prospective observational study. Setting: District general hospital in southwest Scotland. Participants: 966 men and 597 women admitted with first MI between 1994 and 2000 with follow up to the end of 2001. Results: 393(40.7%) men and 305(51.1%)women died during a median follow up of 3.4 years for the survivors. Univariate analysis indicated an excess mortality among women(hazard ratio(HR) 1.45, 95%confidence interval(CI) 1.25 to 1.68), which disappeared after adjustment for age, smoking, comorbidity, previous vascular disease, diabetes, hypertension, and social deprivation(HR 1.02, 95%CI 0.87 to 1.20). There was also an excess early mortality within 30 days among women(HR 1.54, 95%CI 1.20 to 1.98), though this did not retain significance after adjustment for the same covariates(HR 1.04, 95%CI 0.79 to 1.37). Small and insignificant differences were found in the proportion of men and women receiving thrombolysis on admission and secondary prophylactic drugs at discharge, except for statins and βblockers, which were respectively more(adjusted odds ratio 1.48, 95%CI 1.10 to 1.98) and less(adjusted odds ratio 0.78, 95%CI 0.60 to 1.00) commonly prescribed to women. Conclusion: Results suggest that the poorer outcome for women after MI reported in other studies may reflect sex bias in management as well as differences in age and co-morbidity and support the view that if women have access to the same quality of care as men then survival will be the same.
文摘BACKGROUND: Cardiovascular disease is an important complication in pati ents wi th systemic lupus erythematosus (SLE). Variant alleles of the mannose-binding l ectin gene are associated with SLE as well as with severe atherosclerosis. We de termined whether mannose-binding lectin variant alleles were associated with an increased risk of arterial thrombosis among patients with SLE. METHODS: Mannose -binding lectin alleles were genotyped by means of a polymerase-chain-reactio n assay in 91 Danish patients with SLE. Arterial and venous thromboses occurring after the diagnosis of SLE were assessed in a prospective study. Arterial and v enous thromboses were confirmed by appropriate diagnostic methods. RESULTS: Fift y-four patients had no mannose-binding lectin variant alleles (A/A genotype), 30 were heterozygous (A/O genotype), and 7 were homozygous (O/O genotype). Durin g a median follow-up of 9.1 years, arterial thromboses (cerebral or myocardial infarction or leg embolus) developed in 6 of the 7 patients with the O/O genotyp e, as compared with 18 of the 84 patients with the other two genotypes (hazard r atio, 5.8; 95 percent confidence interval, 2.2 to 15.2; overall incidence, 26 pe rcent). After correction for other known risk factors, the hazard ratio was 7.0 (95 percent confidence interval, 1.9 to 25.4). Venous thromboses, which occurred in 14 patients, were statistically unrelated to the mannose-binding lectin gen otype. CONCLUSIONS: Among patients with SLE, homozygosity for mannose-binding l ectin variant alleles is associated with an increased risk of arterial thrombosi s. The risk of venous thrombosis is not increased, indicating that mannose-bind ing lectin has a specific role in providing protection against arterial thrombos is.
文摘To determine the safety and efficacy of clitoral -sparing surgery in women with squamous cell carcinoma (SCCA)of the anterior vulva not involving the clitoris.Patients with vulvar SCCA diagnosed between 1984a nd 2000were i-dentified and data collected.In thi s descriptive analysis,women treated with complete radical vulvectomy were compared to those treated with clito ral -sparing modified radical vulvectomy.All slides were re -reviewed.Of the41women with vulvar carcinoma,13had clitoral -spar-ingmodified vulvectomies(group A)while the remaining 28underwent complete radical vulvectomies(group B ).The13patients in group A included,8with stage I,2stage II,2stage III,and 1with stage IV disease.The two groups had similar demographic and patholo gic prognostic factors.After a median follow -up of 59months,no patients in group A had loco -regional failure.C litoral -sparing vul-var cancer surgery does not compromi se the rate of loco -regional control in patients and may be offered to selected women.
文摘Context: Basilar artery occlusion(BAO) is an infrequent disease with high morbidity and mortality. Intra-arterial thrombolysis is advocated for treatment but is limited to use at specialized centers. Objective: To evaluate outcomes for patients with BAO treated with intravenous thrombolytic therapy. Design, Setting, and Participants: During 1995 to 2003, 50 consecutive patients with angiographically proven BAO were treated according to an institutional therapy protocol based on intravenous thrombolysis with recombinant tissue plasminogen activator(alteplase). Patients were treated at an urban university teaching hospital receiving all patients with ischemic stroke who were considered for thrombolysis in a catchment area of 1.5 million inhabitants in Helsinki, Finland. Intervention: Intravenous administration of alteplase(0.9 mg/kg) during a 1-hour infusion. Main Outcome Measures: Basilar artery recanalization determined by magnetic resonance angiography and clinical outcomes at 3 months and at 1 year or longer determined by modified Rankin Scale and Barthel Index scores. Results: Recanalization was studied in 43 patients and verified in 26(52%) of all patients. By 3 months, 20 patients(40%) had died while 11 had good outcomes(modified Rankin Scale score, 0-2); 12(24%) reached independence in activities of daily living(Barthel Index score, 95-100), and 6(16%) were severely disabled(Barthel Index score, 0-50). In the long term(median follow-up 2.8 years), 15 patients(30%) reached good outcomes(modified Rankin Scale score, 0-2) while 23(46%) died. Conclusions: Intravenous administration of alteplase for patients with BAO appears to be associated with rates of survival, recanalization, and independent functional outcome comparable with those reported with endovascular approaches. These data suggest that a randomized trial is needed to compare these approaches for treatment of BAO.
文摘BACKGROUND: Sudden death from cardiac causes remains a leading cause of death among patients with congestive heart failure(CHF). Treatment with amiodarone or an implantable cardioverter-defibrillator(ICD) has been proposed to improve the prognosis in such patients. METHODS: We randomly assigned 2521 patients with New York Heart Association(NYHA) class II or III CHF and a left ventricular ejection fraction(LVEF) of 35 percent or less to conventional therapy for CHF plus placebo(847 patients), conventional therapy plus amiodarone(845 patients), or conventional therapy plus a conservatively programmed, shock-only, single-lead ICD(829 patients). Placebo and amiodarone were administered in a doubleblind fashion. The primary end point was death from any cause. RESULTS: The median LVEF in patients was 25 percent; 70 percent were in NYHA class II, and 30 percent were in class III CHF. The cause of CHF was ischemic in 52 percent and nonischemic in 48 percent. The median follow-up was 45.5 months. There were 244 deaths(29 percent) in the placebo group, 240(28 percent) in the amiodarone group, and 182(22 percent) in the ICD group. As compared with placebo, amiodarone was associated with a similar risk of death(hazard ratio, 1.06; 97.5 percent confidence interval, 0.86 to 1.30; P=0.53) and ICD therapy was associated with a decreased risk of death of 23 percent(0.77; 97.5 percent confidence interval, 0.62 to 0.96; P=0.007) and an absolute decrease in mortality of 7.2 percentage points after five years in the overall population. Results did not vary according to either ischemic or nonischemic causes of CHF, but they did vary according to the NYHA class. CONCLUSIONS: In patients with NYHA class II or III CHF and LVEF of 35 percent or less, amiodarone has no favorable effect on survival, whereas single-lead, shock-only ICD therapy reduces overall mortality by 23 percent.
文摘The authors reviewed preoperative MRI and EEG findings in relation to postsurg ical outcome in 17 patients with refractory epilepsy due to tuberous sclerosis c omplex (TSC). Resecting concordant MRI (main tuber) and EEG abnormalities offere d seizure freedom (8/9, 89%; median follow-up 25 months) comparable to other f ocal etiologies. Patients with nonconcordant MRI and EEG findings did less well (3/8, 38%, seizure free; p=0.027, OR=13).
文摘BACKGROUND: Previous trials have demonstrated that lowering low-density lipoprotein(LDL) cholesterol levels below currently recommended levels is beneficial in patients with acute coronary syndromes. We prospectively assessed the efficacy and safety of lowering LDL cholesterol levels below 100 mg per deciliter(2.6 mmol per liter) in patients with stable coronary heart disease(CHD). METHODS: A total of 10,001 patients with clinically evident CHD and LDL cholesterol levels of less than 130 mg per deciliter(3.4 mmol per liter) were randomly assigned to double-blind therapy and received either 10 mg or 80 mg of atorvastatin per day. Patients were followed for a median of 4.9 years. The primary end point was the occurrence of a first major cardiovascular event, defined as death from CHD, nonfatal non-procedure-related myocardial infarction, resuscitation after cardiac arrest, or fatal or nonfatal stroke. RESULTS: The mean LDL cholesterol levels were 77 mg per deciliter(2.0 mmol per liter) during treatment with 80 mg of atorvastatin and 101 mg per deciliter(2.6 mmol per liter) during treatment with 10 mg of atorvastatin. The incidence of persistent elevations in liver aminotransferase levels was 0.2 percent in the group given 10 mg of atorvastatin and 1.2 percent in the group given 80 mg of atorvastatin(P< 0.001). A primary event occurred in 434 patients(8.7 percent) receiving 80 mg of atorvastatin, as compared with 548 patients(10.9 percent) receiving 10 mg of atorvastatin, representing an absolute reduction in the rate of major cardiovascular events of 2.2 percent and a 22 percent relative reduction in risk(hazard ratio, 0.78; 95 percent confidence interval, 0.69 to 0.89; P< 0.001). There was no difference between the two treatment groups in overall mortality. CONCLUSIONS: Intensive lipid-lowering therapy with 80 mg of atorvastatin per day in patients with stable CHD provides significant clinical benefit beyond that afforded by treatment with 10 mg of atorvastatin per day. This occurred with a greater incidence of elevated aminotransferase levels.
文摘Background: Mycosis fungoides (MF) is the most common skin lymphoma. The aetiology of MF remains unknown, and no therapy has to date significantly altered patient survival. Objective: The present study examines trends in survival of MF patients in a well- defined population- based disease group, namely patients registered over a 40- year period at the Thames Cancer Registry, Southeast England. Methods: The Thames Cancer Registry is a population- based registry, covering a population of approximately 14 million people. Data were taken from the Surveillance, Epidemiology and End Results cancer registry programme and the National Centre for Health Statistics. The database was used to identify cases of MF diagnosed between 1961 and 2000. A total of 985 records were identified, 821 (83% ) of which had complete information on age, sex, year of diagnosis and area of residence. The observed and relative survivals of patients diagnosed during the periods 1971- 1975, 1981- 1985 and 1991- 1995 were examined over a 5- year period of follow- up, using the relsurv Stata program to perform Cox proportional hazard analysis. Results: A total of 821 MF eligible patients were available with a median followup of 4.3 years and a maximum follow- up of 30 years. The overall 5- year relative survival rate was 80% , and there was marked improvement between 1971 and 1981. The prognostic factors leading to a significantly poorer survival were high age, male sex, the presence of the Sé zary syndrome, the use of hormone treatment and radiotherapy. Conclusions: A statistically significantly better survival over the last 20 years was found. The prognosis is generally good for most patients but not all. The best survival was seen for the female patients under 45 years of age without the presence of the Sé zary syndrome. This difference in survival may be partly due to a difference in the disease stage or different treatment, or to both.
文摘Background-Patients with heart failure are at increased risk of sudden death and death attributed to progressive pump failure. We assessed the effect of Candesartan on cause-specific mortality in patients enrolled in the Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity(CHARM) program. Methods and Results-The CHARM program consisted of 3 component trials that enrolled patients with symptomatic heart failure: CHARM-Alternative(n=2028; LVEF=40%and ACE intolerant), CHARM-Added(n=2548; LVEF=40%, already on ACE inhibitors), and CHARM-Preserved(n=3023; LVEF >40%). Patients were randomized to candesartan, titrated to 32 mg QD, or placebo and were followed up for a median of 37.7 months. All deaths were reviewed by a blinded adjudication committee and categorized according to prespecified definitions on the basis of a narrative and source documentation. The number and rate of deaths by cause were calculated for each of the component trials and the overall program. Of all the patients, 8.5%died suddenly, and 6.2%died of progressive heart failure. Candesartan reduced both sudden death (HR 0.85 [0.73 to 0.99], P=0.036) and death from worsening heart failure(HR 0.78[0.65 to 0.94], P=0.008). These reductions were most apparent in the patients with LVEF=40%. Conclusions-Candesartan reduced sudden death and death from worsening heart failure in patients with symptomatic heart failure, although this reduction was most apparent in patients with systolic dysfunction.
文摘BACKGROUND: Angiography shows that stereotactic radiosurgery obliterates most cerebral arteriovenous malformations after a latency period of a few years. However, the effect of this procedure on the risk of hemorrhage is poorly understood. METHODS: We performed a retrospective observational study of 500 patients with malformations who were treated with radiosurgery with use of a gamma knife. The rates of hemorrhage were assessed during three periods: before radiosurgery, between radiosurgery and the angiographic documentation of obliteration of the malformation (latency period), and after angiographic obliteration. RESULTS: Forty- two hemorrhages were documented before radiosurgery (median follow- up, 0.4 year), 23 during the latency period (median follow- up, 2.0 years), and 6 after obliteration (median follow- up, 5.4 years). As compared with the period between diagnosis and radiosurgery, the risk of hemorrhage decreased by 54 percent during the latency period (hazard ratio, 0.46; 95 percent confidence interval, 0.26 to 0.80; P=0.006) and by 88 percent after obliteration (hazard ratio, 0.12; 95 percent confidence interval, 0.05 to 0.29; P < 0.001). The risk was significantly reduced during the period after obliteration, as compared with the latency period (hazard ratio, 0.26; 95 percent confidence interval, 0.10 to 0.68; P=0.006). The reduction was greater among patients who presented with hemorrhage than among those without hemorrhage at presentation and similar in analyses that took into account the delay in confirming obliteration by means of angiography and analyses that excluded data obtained during the first year after diagnosis. CONCLUSIONS: Radiosurgery significantly decreases the risk of hemorrhage in patients with cerebral arteriovenous malformations, even before there is angiographic evidence of obliteration. The risk of hemorrhage is further reduced, although not eliminated, after obliteration.
文摘Purpose: The purpose of this study was to retrospectively evaluate whether it is possible to decrease the risk of Molteno tube erosion through the conjunctiva by using a newtechniquewhere the silicone tube is inserted into a scleral tunne l instead of being covered only by the con- junctiva. Methods: We reviewed Molteno implants carried out at theUniversity H ospital ofOulu, in 332 patientswho underwent traditionalMolteno implantation bet ween October 1986 and October 1998 and 92 patients who underwent surgery with th e new technique between November 1998 and April 2001. Results: With our former t echnique, conjunctival erosions occurred in 15 eyes of 15 patients (4.5%)-afte r a median follow-up of 3.5 months (range 1-72 months); no conjunctival compli cations were discovered in patients who underwent surgery using the new techniqu e during a median follow-up of 22 months (range 10-39 months). (p=0.038, twosa mple test of proportions). Conclusion: Inserting the Molteno tube into a scleral tunnel prevents tube extrusion through the conjunctiva in eyes with Molteno imp lants. The technique for making the scleral tunnel is described.
文摘Background: Autoimmune hepatitis (AIH) is an immune mediated chronic liver diseasewith a prevalence of 17 cases/100,000. Resistance to the standard treatment of AIH (prednisone and azathioprine) occurs in 15%to 20%. There is currently no standard treatment of patients with steroid refractory AIH. Goals: Determine the efficacy of tacrolimus in the treatment of steroid refractory AIH. Methods: This is a retrospective study evaluating the efficacy of Tacrolimus in the treatment of steroid refractory AIH. Results: Between October 1998 and February 2002, 11 patients with steroid refractory AIH were treated with tacrolimus. Mean age was 63 years. Median duration of steroid treatment before starting tacrolimus was 9 months. Median duration of tacrolimus treatment was 25 months. Median follow up period was 16 months. Median baseline ALT, AST were 77 U/L and 68 U/L and became 21 U/L and 32 U/L respectively at end of follow up (P = 0.005 and 0.01 respectively). Significant weight reduction was seen in all patients (P = 0.02). Tacrolimus treatment was safe and well tolerated. Conclusion: Use of low dose tacrolimus led to successful biochemical and histologic remission and weaning off prednisone in patients with steroid refractory AIH. This data supports further studies in evaluating the use of tacrolimus in the treatment of AIH.
文摘Objective: To determine if individuals ultimately diagnosed with Alzheimer dis ease (AD) exhibited evidence of cognitive impairment on neuropsychological tests administered between1.5 years and 8.1 years before dementia onset. Methods: A t otal of 693 community-dwelling individuals, part of the Cardiovascular Health S tudy, completed a neuropsychological test battery in 1991/92. Subjects were foll owed annually over the next 8 years (median follow-up = 7.4 years). Seventy-tw o individuals were ultimately diagnosed with AD (median follow-up = 4.5 years): 24 with AD onset 1.5 to 3.4 years after baseline neuropsychological testing, 20 with AD onset 3.5 to 5.0 years after testing, and 28 with onset 5.1 to 8.1 year s after testing. A total of 621 individuals remained nondemented throughout the 8 years of follow-up (median follow-up = 7.5 years). Results: Subjects ultimat ely diagnosed with AD had poorer scores on baseline neuropsychological measures than subjects who remained nondemented. Although individuals closest to AD onset (i.e., 1.5 to 3.4 years) performed the most poorly, cognitive impairment was de tected in individuals who did not develop AD until 5 to 8 years later. Conclusio ns: Cognitive changes can be detected well before onset of Alzheimer disease.
文摘Background. We evaluated the efficacy of emergency balloon-occluded retrograde transvenous obliteration (B-RTO) performed within 24h after initial hemostasi s for the prevention of rebleeding from ruptured gastric varices. Methods. From December 1995 to March 2003, 11 patients who had undergone B-RTO within 24h aft er the control of gastric variceal bleeding at Maebashi Red Cross Hospital were investigated. They were followed up for complete eradication, recurrence of vari ces, and rebleeding. Efficacy was determined by endoscopic examination and compu ted tomography. Results. The 4 patients with acute bleeding from ruptured gastri c varices were treated with endoscopic therapy-endoscopic variceal ligation (EV L) in 2 patients, and clipping treatment in 2. Initial hemostasis was achieved i n all 4; the other 7 patients had already stopped bleeding at endoscopy. After h emostasis was achieved, emergency B-RTO was immediately performed within 24h an d was successful in all 11 patients. Ten (90.9%) of the 11 gastric varices were obliterated and the other 1 (9.1%) was diminished in size. During the mean fol low-up period of 1136 days, no rebleeding or recurrence as found. Four patients died during the follow-up period, but none died from variceal bleeding. Surviv al rates were 90.9%and 70.7%, respectively, at 1 year and 3 years. In 6 patien ts, development of esophageal varices appeared during the follow-up period, all of which were controlled by usual endoscopic therapy. No severe side effects we re found after the B-RTO treatment. Conclusions. Emergency B-RTO is an effecti ve treatment for the prevention of rebleeding from ruptured gastric varices.
