Remote endarterectomy: lessons learned after more than 100 cases.
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BACKGROUND: Bypass procedures have been the mainstay of treatment of extensive external iliac and superficial femoral artery (SFA) occlusive disease, particularly total occlusions. Since the early 1990s, reports from Europe have espoused the virtues of endarterectomy of the superficial femoral and iliac arteries from a small groin incision, but adoption in the United States has been limited. Over the past 4 years, we have explored the technical challenges and durability of this procedure and report our findings. METHODS: Remote endarterectomy from an inguinal incision was the primary treatment option for all patients considered surgical candidates for vascular reconstruction of the external iliac and superficial femoral arteries. All data were entered into an outcomes database prospectively and reviewed retrospectively. After the procedure, duplex ultrasound surveillance was performed quarterly the first year and semi-annually thereafter. RESULTS: Remote endarterectomy was the planned procedure in 133 patients. The mean age was 68 years, 68% were men, and 31% were diabetic. The indications for the procedure were claudication in 57% and limb salvage in 43%. In 16 patients (12%), technical issues precluded the completion of the remote endarterectomy and a bypass was performed. Successful retrograde iliac endarterectomy was performed in 7 patients, SFA endarterectomy in 105 patients, and combined retrograde iliac and antegrade SFA in 5 patients. The average duration of the procedure was 162 minutes +/- 69 minutes (SD). Half of the patients were discharged on the first postoperative day, and the average length of stay was 2.52 days. The mean follow-up was 19 months, with a primary patency of 70% at 30 months by life-table analysis. Limb salvage was 94%. CONCLUSIONS: Remote endarterectomy is a viable and durable alternative to standard bypass procedures. It has equivalent patency to published results of bypass or endovascular procedures of the external iliac and superficial femoral arteries and may soon replace bypass as the preferred procedure for long-segment occlusions of these vessels. (+info)
Switching immunosuppression medications after renal transplantation--a common practice.
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BACKGROUND: The rate of change to immunosuppression discharge regimens over time is unknown. We examined the frequency of changes to initial drug treatment regimens and factors associated with a drug change following renal transplantation. METHODS: Scientific Registry of Transplant Recipients data from adult recipients who underwent primary renal transplantation between January 1998 and December 2002 were analysed. The Kaplan-Meier analysis was used to determine the frequency of regimen changes for the most common immunosuppression discharge regimens, type of change, and to examine switching between the calcineurin inhibitors tacrolimus (Tacro) and ciclosporin United States Pharmacopera (USP) modified (CsA). Cox proportional hazard regression was used to examine recipient, donor and transplant characteristics associated with a drug change. RESULTS: The majority of patients experienced a change to their discharge regimen post-transplantation, and more changes were observed within higher-risk sub-groups of patients. Switching from CsA to Tacro was more common than Tacro to CsA. Significant factors associated with a drug change included those associated with graft loss. CONCLUSIONS: Significant immunosuppression regimen changes occur during the first 4 years post-transplantation. It is possible that early graft survival benefits proven in prospective clinical trials may not translate into long-term success in clinical practice, possibly in part because efficacious regimens are not necessarily maintained long-term. (+info)
High-efficiency short daily haemodialysis--morbidity and mortality rate in a long-term study.
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BACKGROUND: In conventional haemodialysis (CHD), the morbidity and mortality rate is unacceptably high; consequently, variations in the length and frequency of the haemodialysis sessions have been studied to reduce the complications of dialysis treatment. In this sense, high-efficiency short daily haemodialysis (SDHD) has been proposed as an alternative for patients on renal replacement therapy. In this study, we have related our experience with this dialysis modality. METHODS: Twenty-six patients (16 males, mean age 35.6 +/- 14.7 years) were treated by SDHD for 33.6 +/- 18.5 months (range 6-57 months). The mean time on CHD before the switch to SDHD was 25.5 +/- 31.9 months (range 1-159 months). In 23 (88.5%) patients, native arteriovenous fistulae were used for vascular access. SDHD was performed six times a week, 1.5-2 h per session, and high flux polysulfone dialysers (surface area: 1.8 m(2)) were employed. The blood flow and dialysate flow rate were 350 and 800 ml/min, respectively. RESULTS: In this trial, the patient survival was 100%. The vascular access survival after 12, 24, 36 and 48 months on SDHD was 100, 89, 89 and 80%, respectively. There were three failures of vascular access in 72.7 patient-years (0.04 failures/patient-year). In 15 patients on SDHD during 36 consecutive months, the vascular access survival after 12, 24, 36 and 48 months was 100, 93, 93 and 84%, respectively. Also, in this group of patients, there were 0.27 hospitalizations/patient-year and 1.24 days of hospitalizations/patient-year. CONCLUSIONS: We concluded that in a long-time study of patients on SDHD the morbidity and mortality rate is very low. Furthermore, we observed that failures of vascular access are not a significant problem. Consequently, we believe that SDHD is a powerful renal replacement therapy for treatment of patients on maintenance haemodialysis. (+info)
Association of cigarette smoking with HIV prognosis among women in the HAART era: a report from the women's interagency HIV study.
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OBJECTIVE: We assessed the association of cigarette smoking with the effectiveness of highly active antiretroviral therapy (HAART) among low-income women. METHODS: Data were analyzed from the Women's Interagency HIV Study, a multisite longitudinal study up to 7.9 years for 924 women representing 72% of all women who initiated HAART between July 1, 1995, and September 30, 2003. RESULTS: When Cox's regression was used after control for age, race, hepatitis C infection, illicit drug use, previous antiretroviral therapy, and previous AIDS, smokers on HAART had poorer viral responses (hazard ratio [HR]=0.79; 95% confidence interval [CI]=0.67, 0.93) and poorer immunologic response (HR=0.85; 95% CI=0.73, 0.99). A greater risk of virologic rebound (HR=1.39; 95% CI=1.06, 1.69) and more frequent immunologic failure (HR=1.52; 95% CI=1.18, 1.96) were also observed among smokers. There was a higher risk of death (HR=1.53; 95% CI=1.08, 2.19) and a higher risk of developing AIDS (HR=1.36; 95% CI=1.07, 1.72) but no significant difference between smokers and nonsmokers in the risk of death due to AIDS. CONCLUSIONS: Some of the benefits provided by HAART are negated in cigarette smokers. (+info)
Potential biases in estimates of hepatitis C RNA clearance in newly acquired hepatitis C infection among a cohort of injecting drug users.
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Estimates of hepatitis C virus (HCV) clearance following acute infection range from 14 to 46%. This wide range is likely to be due to the characteristics of the populations studied and analysis methods. This paper examines how differing definitions of clearance parameters affect estimates of viral clearance in a cohort of 85 injecting drug users with newly acquired HCV infection. Kaplan-Meier estimates of time to HCV clearance were determined using varying definitions of eligible cohort, viral clearance, date of infection and date of clearance. Based on which combinations of definitions were used, the number of subjects eligible for analysis ranged from 27 to 75, clearance rate ranged from 14 to 68% and time to achieving 25% clearance ranged from approximately 5 months to 14 months. Standardized definitions and methodologies are required to enable valid comparisons of rates of clearance across newly acquired HCV infection natural history studies. (+info)
The association of lipid levels with mortality in patients on chronic peritoneal dialysis.
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BACKGROUND: The role of traditional risk factors, including plasma lipids, in the pathogenesis of cardiovascular (CV) disease in chronic dialysis patients is unclear. Previous studies have suggested that lower serum total cholesterol (TC) is associated with higher mortality in patients on chronic haemodialysis (HD). Whether this relationship is specific to the HD population or is common to the uraemic state is unclear. The present study evaluated the association of serum TC and triglycerides with clinical outcomes in chronic peritoneal dialysis (PD) patients. METHODS: Data of 1053 PD patients from the United States Renal Data System (USRDS) prospective Dialysis Morbidity and Mortality Study Wave 2 were examined. Cox regression was used to evaluate the relationship between lipid levels and mortality. RESULTS: Patients with TC levels < or =125 mg/dl (3.24 mmol/l) had a statistically significant increased risk of an all-cause mortality, including those taking or not taking lipid-modifying medications, compared with the reference of 176-225 mg/dl (4.54-5.83 mmol/l). In stratified analysis, this association was demonstrated in patients with serum albumin >3.0 g/dl (30 g/l), but not with albumin < or =3.0 g/dl. Compared with patients with triglyceride levels of 201-300 mg/dl (2.27-3.39 mmol/l), a statistically significant reduction of all-cause, but not CV, mortality was observed in patients with triglyceride levels of 101-200 mg/dl (1.14-2.26 mmol/l), as well as in the subgroup with serum albumin levels <3.0 g/dl (30 g/l) and triglycerides of < or =100 mg/dl (1.13 mmol/l) and 101-200 mg/dl (1.14-2.26 mmol/l). CONCLUSIONS: While confounding factors and causal pathways have not been clearly identified, aggressive lowering of plasma cholesterol in PD patients is not supported by this study, however, treatment of hypertriglyceridaemia may be warranted with triglyceride levels >200 mg/dl (2.26 mmol/l). (+info)
Surgical treatment of giant cell tumour of long bone with anhydrous alcohol adjuvant.
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This study was designed to evaluate the feasibility and effectiveness of the use of anhydrous alcohol as an adjuvant treatment for giant cell tumours (GCTs) of long bone. Between October 1989 and January 2004, 42 GCT patients were treated and followed up for an average of 4.1 years (range 1-13 years). Mean patient age was 34 years (range 17-67 years). After curettage and additional burring, anhydrous alcohol was used as an adjuvant therapy in all patients before the bone defect was filled with bone graft or cement. Four patients (9.5%) experienced local recurrence. There were no alcohol-related complications. Recurrence-free probability was 87.6% at final follow-up (13 years) after index surgery by Kaplan-Meyer analysis. Our data suggest that anhydrous alcohol can be used as an effective safe adjuvant for the treatment of GCT of long bone. (+info)
Constructing molecular classifiers for the accurate prognosis of lung adenocarcinoma.
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PURPOSE: Individualized therapy of lung adenocarcinoma depends on the accurate classification of patients into subgroups of poor and good prognosis, which reflects a different probability of disease recurrence and survival following therapy. However, it is currently impossible to reliably identify specific high-risk patients. Here, we propose a computational model system which accurately predicts the clinical outcome of individual patients based on their gene expression profiles. EXPERIMENTAL DESIGN: Gene signatures were selected using feature selection algorithms random forests, correlation-based feature selection, and gain ratio attribute selection. Prediction models were built using random committee and Bayesian belief networks. The prognostic power of the survival predictors was also evaluated using hierarchical cluster analysis and Kaplan-Meier analysis. RESULTS: The predictive accuracy of an identified 37-gene survival signature is 0.96 as measured by the area under the time-dependent receiver operating curves. The cluster analysis, using the 37-gene signature, aggregates the patient samples into three groups with distinct prognoses (Kaplan-Meier analysis, P < 0.0005, log-rank test). All patients in cluster 1 were in stage I, with N0 lymph node status (no metastasis) and smaller tumor size (T1 or T2). Additionally, a 12-gene signature correctly predicts the stage of 94.2% of patients. CONCLUSIONS: Our results show that the prediction models based on the expression levels of a small number of marker genes could accurately predict patient outcome for individualized therapy of lung adenocarcinoma. Such an individualized treatment may significantly increase survival due to the optimization of treatment procedures and improve lung cancer survival every year through the 5-year checkpoint. (+info)