Meta-analysis of randomized trials comparing carotid endarterectomy and endovascular treatment.
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OBJECTIVE AND DESIGN: In order to evaluate the comparative efficacy and safety of carotid angioplasty with or without stent placement (CAS) versus carotid endarterectomy (CEA) we performed a meta-analysis of the presently available randomized studies. MATERIALS AND METHODS: A multiple electronic health database search on all randomized trials describing CAS compared with CEA in patients with symptomatic or asymptomatic carotid artery stenosis was performed. RESULTS: Seven trials totalling 2972 patients (1480 randomized to CEA and 1492 randomized to CAS) were included in the meta-analysis. Results significantly favoured CEA over CAS in terms of death or any stroke at 30 days after procedure; the risk of death, any stroke, or myocardial infarction at 30 days; ipsilateral ischaemic stroke at 30 days; any stroke at 30 days; death or stroke at 6 months; and the risk of procedural failure. There was a significantly reduced risk of cranial neuropathy at 30 days after CAS. There was no significant difference between CAS and CEA groups in the odds of death or disabling stroke at 30 days, death or stroke at 1 year after the procedure, and ipsilateral intracerebral bleeding at 30 days. CONCLUSIONS: The results of this meta-analysis suggest that CEA can be performed with more safety than CAS. As a result, CEA remains the "gold standard" treatment for suitable de novo carotid stenosis and CAS should only be performed within randomized trials of stenting versus surgery. (+info)
Signs and symptoms predictive of respiratory failure in patients with foodborne botulism in Thailand.
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We conducted a clinical study of 137 patients with home-canned bamboo shoot botulism at Nan Hospital, northern Thailand. The median age of the patients was 44 years (range = 14-74 years) and 36.2% were male. The median incubation period was 2 days (range = 1-8 days). Forty-three patients (31.4%) developed respiratory failure, but there were no deaths. Patients who did not have either nausea or vomiting and did not have urinary retention that required Foley catheterization was less likely to develop respiratory failure. This clinical predictor rule had a sensitivity of 75.5% and a specificity of 90.7%. The clinical syndrome most predictive of respiratory failure was nausea or vomiting and any cranial neuropathy with urinary retention or difficulty swallowing. This clinical syndrome had a sensitivity of 69.8% and a specificity of 93.6%. These clinical characteristics could help triage large numbers of patient in the event of a future outbreak. (+info)
Coeliac disease presenting with cerebellar degeneration.
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A case of rapidly progressive cerebellar degeneration with bilateral sixth nerve palsies is described in whom investigation revealed the presence of unsuspected coeliac disease. In spite of treatment with a gluten free diet, rapid fatal deterioration occurred. Coeliac disease should be considered in patients with encephalopathy of obscure origin. (+info)
Inferior alveolar nerve paresthesia caused by a dentigerous cyst associated with three teeth.
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The dentigerous cyst is a common pathologic entity associated with an impacted tooth, usually third molars. They generally are asymptomatic, being found on routine dental radiographic examination. This report describes the case of a 43 year old male with a large dentigerous cyst associated with mandibular canine, first and second premolar teeth that caused paresthesia of the inferior alveolar nerve. (+info)
Transcervical carotid stenting with flow reversal is safe in octogenarians: a preliminary safety study.
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BACKGROUND: The use of carotid stenting in octogenarian patients is controversial; some authors consider this population at high risk for the procedure. Anatomic vascular complexity may be an important reason for the high reported rates of periprocedural thromboembolic complications. Transcervical carotid angioplasty and stenting (TCS) with flow reversal avoids aortic arch instrumentation. In this study, we analyzed our experience with TCS in octogenarian patients and compared the results with those of carotid endarterectomy (CEA) in the same age group in terms of safety. METHODS: The study included 81 patients, > or =80 years, a retrospective cohort of 45 consecutive patients treated with CEA (January 2002 to January 2005), and a prospective cohort of 36 consecutive patients treated with TCS with protective flow reversal (January 2005 to January 2007). Patients were considered symptomatic according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria. Stenting indication was established on the SAPPHIRE criteria. General anesthesia was used in patients undergoing CEA, and local anesthesia in those receiving TCS. Primary endpoints were: stroke, death, or acute myocardial infarction within 30 days. Secondary endpoints were peripheral nerve paralysis and cervical hematoma. Statistical significance for between-group differences was assessed by Pearson chi(2) or Fisher exact test, and Student t test. A P value of <.05 was considered statistically significant. Follow-up was limited to 30 days. RESULTS: Baseline epidemiological characteristics and revascularization indications were similar between both groups. Mean age was significantly higher in the TCS group (83.5 +/- 3.35) than the CEA group (81.7 +/- 1.55) (P = .004). Percentage of symptomatic lesions was similar: 30.6% in TCS vs 44.4% in CEA (P = .2). Comorbid conditions (respiratory or cardiac) were more frequent in TCS group (61.6% vs 26.6%; P = .002). There were no significant differences between groups for the primary endpoints: 4.4% (one stroke, one acute myocardial infarction) for CEA vs 0% for TCS (P = .5). Among CEA patients, there were two peripheral nerve palsies (4.4%) and one cervical hematoma (2.2%); there were no such complications with TCS (P = .5 and P = 1, respectively). In one asymptomatic TCS patient, Doppler study at 24 hours following the procedure showed a common carotid artery dissection, which was treated by a common carotid to internal carotid bypass. CONCLUSIONS: In this preliminary experience, transcervical carotid angioplasty and stenting with flow reversal for cerebral protection was as safe at short term as carotid endarterectomy in octogenarian patients, who additionally had considerable comorbidity; thus, it may be possible to extend the indications for carotid revascularization in this population. Studies in larger patient series are required to confirm the trends observed in this study. (+info)
Association between minor and major surgical complications after carotid endarterectomy: results of the New York Carotid Artery Surgery study.
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OBJECTIVE: Most studies on outcomes of carotid endarterectomy (CEA) have focused on the major complications of death and stroke. Less is known about minor but more common surgical complications such as hematoma, cranial nerve palsy, and wound infection. This study used data from a large, population-based cohort study to describe the incidence of minor surgical complications after CEA and examine associations between minor and major complications. METHODS: The New York Carotid Artery Surgery (NYCAS) study examined all Medicare beneficiaries who underwent CEA from January 1998 to June 1999 in NY State. Detailed clinical information on preoperative characteristics and complications < or =30 days of surgery was abstracted from hospital charts. Associations between minor (cranial nerve palsies, hematoma, and wound infection) and major complications (death/stroke) were examined with chi(2) tests and multivariate logistic regression. RESULTS: The NYCAS study had data on 9308 CEAs performed by 482 surgeons in 167 hospitals. Overall, 10% of patients had a minor surgical complication (cranial nerve (CN) palsy, 5.5%; hematoma, 5.0%; and wound infection, 0.2%). Cardiac complications occurred in 3.9% (myocardial 1.1%, unstable angina 0.9%, pulmonary edema 2.1%, and ventricular tachycardia 0.8%). In both unadjusted and adjusted analyses, the occurrence of any minor surgical complication, CN palsy alone, or hematoma alone was associated with 3 to 4-fold greater odds of perioperative stroke or combined risk of death and nonfatal stroke (P < 0.0001). Patients with cardiac complications had 4 to 5-fold increased odds of stroke or combined risk of death and stroke. CONCLUSION: Minor surgical complications are common after CEA and are associated with much higher risk of death and stroke. Patient factors, process factors, and direct causality are involved in this relationship, but future work will be needed to better understand their relative contributions. (+info)
Corneal involvement in rheumatoid arthritis: an in vivo confocal study.
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Unruptured large and giant carotid artery aneurysms presenting with cranial nerve palsy: comparison of clinical recovery after selective aneurysm coiling and therapeutic carotid artery occlusion.
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