Objective Do asymptomatic restenoses > 70% after carotid endarterectomy (CEA) and carotid stenting (CAS) increase the risk of late ipsilateral stroke? Methods Systematic review identified 11 ...randomised controlled trials (RCTs) reporting rates of restenosis > 70% (and/or occlusion) in patients who had undergone CEA/CAS for the treatment of primary atherosclerotic disease, and nine RCTs reported late ipsilateral stroke rates. Proportional meta-analyses and odds ratios (OR) at end of follow-up were performed. Results The weighted incidence of restenosis > 70% was 5.8% after “any” CEA, median 47 months (11 RCTs; 4249 patients); 4.1% after patched CEA, median 32 months (5 RCTs; 1078 patients), and 10% after CAS, median 62 months (5 RCTs; 2716 patients). In four RCTs (1964 patients), one of 125 (0.8%) with restenosis > 70% (or occlusion) after CAS suffered late ipsilateral stroke over a median 50 months, compared with 37 of 1839 (2.0%) in CAS patients with no significant restenosis (OR 0.87; 95% CI 0.24–3.21; p = .8339). In seven RCTs (2810 patients), 13 out of 141 (9.2%) with restenosis > 70% (or occlusion) after CEA suffered late ipsilateral stroke over a median 37 months, compared with 33 out of 2669 (1.2%) in patients with no significant restenoses (OR 9.02; 95% CI 4.70–17.28; p < .0001). Following data correction to exclude patients whose surveillance scan showed no evidence of restenosis > 70% before stroke onset, the prevalence of stroke ipsilateral to an untreated asymptomatic > 70% restenosis was seven out of 135 (5.2%) versus 40 out of 2704 (1.5%) in CEA patients with no significant restenosis (OR 4.77; 95% CI 2.29–9.92). Conclusions CAS patients with untreated asymptomatic > 70% restenosis had an extremely low rate of late ipsilateral stroke (0.8% over 50 months). CEA patients with untreated, asymptomatic > 70% restenosis had a significantly higher risk of late ipsilateral stroke (compared with patients with no restenosis), but this was only 5% at 37 months. Overall, 97% of all late ipsilateral strokes after CAS and 85% after CEA occurred in patients without evidence of significant restenosis or occlusion.
The early risk of stroke after a patient suffers a transient ischemic attack (TIA)/minor stroke is significantly higher than previously thought. In most health systems, this (unfortunately) means ...that many vulnerable patients will have suffered their stroke before having had any chance of being considered for carotid endarterectomy (CEA) or carotid angioplasty with stenting (CAS). The problem is then compounded by institutional delays in finally undertaking CEA/CAS, which leads to even greater diminishing benefit to the patient. Notwithstanding the fact that the international trials used a 6-month threshold for inclusion, it remains an unpalatable fact that if CEA/CAS is delayed beyond 12 weeks in symptomatic patients with North American Symptomatic Carotid Endarterectomy Trial (NASCET) 50% to 99% stenoses, the patient is exposed to all of the risks of intervening, but gains little in the way of long-term stroke prevention. The take-home message is, therefore, very simple; “intervene early to prevent more strokes”. Occam's razor has never been sharper!
Objective A daily Rapid-Access TIA Clinic was introduced in 2008, where symptomatic patients were started on 75 mg aspirin + 40 mg simvastatin by the referring doctor, before attending the clinic. ...Following clinic assessment, patients with 50–99% stenoses were transferred to the vascular unit for carotid endarterectomy (CEA). In two audits ( n = 212 patients), the median delay from transfer to the vascular unit to undergoing CEA was 3 days, during which time 28 patients (13%) suffered recurrent neurological events. It was hypothesized that early introduction of dual antiplatelet therapy (by adding clopidogrel 75 mg once parenchymal haemorrhage was excluded in the TIA clinic) might significantly reduce recurrent events between transfer to the surgical unit and undergoing CEA. Methods Prospective audit in 100 consecutive, recently symptomatic patients receiving dual antiplatelet therapy. Endpoints were: prevalence of recurrent events between transfer from the TIA clinic and undergoing CEA; rates of spontaneous embolization prior to undergoing CEA; and prevalence of haemorrhagic complications Results The median delay from symptom to CEA was 8 days (IQR 5–15). The median delay between transfer from the TIA clinic to CEA was 3 days (IQR 2–5), during which time three patients (3%) suffered recurrent TIAs. This represents a fivefold reduction compared with previous audit data (OR 4.9, 95% CI 1.5–16.6, p = .01) and was matched by a fourfold reduction in the prevalence of spontaneous embolization from 39/189 (21%) previously to 5/83 (5%) in the current audit (OR 4.1, 95% CI 1.5–10.7, p = .0047). The 30-day death/stroke rate was 1%. There were three haemorrhagic complications: stroke caused by haemorrhagic transformation of an infarct; exploration for neck haematoma; and debridement and skin grafting for spontaneous shin haematoma. Conclusion Early introduction of dual antiplatelet therapy was associated with a significant reduction in recurrent neurological events and spontaneous embolization prior to CEA, without incurring a significant increase in major peri-operative bleeding complications.
Jump take-off momentum has previously been proposed as an alternative test to predict sprint momentum. This study used a data simulation to replicate and systematically investigate relationships ...reported in previous studies between body mass, vertical jump performance, and sprint performance. Results were averaged for 1000 simulated data sets in each condition, and the effects of various parameters on correlations between jump momentum and sprint momentum were determined. The ability of jump take-off momentum to predict sprint momentum is greatest under relatively high inter-individual variation in body mass and relatively low inter-individual variation in jump height. This is largely due to the increased emphasis on body mass in these situations. Even under zero or a small negative (r = −0.30) correlation between jump height and sprint velocity, the correlation between the two momenta remained very large (r ≥ 0.76) on average. There were no investigated conditions under which jump momentum was most frequently a significantly (p < 0.05) greater predictor of sprint momentum compared to simply using body mass alone. Furthermore, between-individual correlations should not be used to make inferences or predictions for within-individual applications (e.g. predicting or evaluating the effects of a longitudinal training intervention). It is recommended that any rationale for calculating and/or monitoring jump take-off momentum should be separate from its ability to predict sprint momentum. Indeed, body mass alone may be a better predictor of sprint momentum.
Highlights
This study replicated and systematically perturbed relationships reported in the literature to investigate factors contributing to correlations between jump momentum and sprint momentum.
The ability of jump take-off momentum to predict sprint momentum is greatest under relatively high inter-individual variation in body mass and relatively low inter-individual variation in jump height. This is largely due to the increased emphasis on body mass in these situations.
Even under zero or a small negative correlation between jump height and sprint velocity, the correlation between the two momenta remained very large on average. There were no investigated conditions under which jump momentum was a better predictor of sprint momentum compared to simply using body mass alone.
It is recommended that any rationale for calculating and/or monitoring jump take-off momentum should be separate from its ability to predict sprint momentum. Indeed, body mass alone may be a better inter-individual predictor of sprint momentum if such a prediction were deemed necessary.
Objective The aim of this review was to identify clinical and/or imaging parameters that are associated with an increased (decreased) risk of early/late stroke in patients with symptomatic carotid ...disease. In the first 14 days Natural history studies suggest that 8–15% of patients with 50–99% stenoses will suffer a stroke within 72 hours of their index symptom. Currently, there are insufficient validated data to identify highest-risk patients for emergency carotid endarterectomy (CEA), but an increased risk of stroke appears to be predicted by (i) an ABCD2 score of 4–7; (ii) the presence of acute cerebral injury on CT/MRI; (iii) Gray Scale Median (GSM) <15, (iv) spontaneous embolisation on Transcranial Doppler (TCD); and (v) increased fluorodeoxyglucose (FDG) uptake in the carotid plaque on positron emission tomography (PET). A future goal must be to develop predictive algorithms (based on accessible imaging strategies) for identifying acutely symptomatic patients with highly unstable plaques for emergency CEA. Medium to long term In the randomised trials, about 70% of patients with symptomatic 70–99% stenoses were stroke-free on “best medical therapy” at 5 years. Clinical predictors of increased stroke risk include (i) male gender; (ii) age >75; (iii) hemispheric symptoms; and (iv) increasing comorbidity. Imaging features associated with increased stroke risk include (i) irregular stenoses; (ii) contralateral occlusion; (iii) increasing stenosis severity, but not subocclusion; (iv) tandem intracranial disease; (v) a failure to recruit intracranial collaterals; (vi) low GSM; (vii) MR diagnosis of intra-plaque haemorrhage; (vii) spontaneous embolisation on TCD; and (viii) increased FDG uptake in the carotid plaque on PET. Clinical/imaging parameters associated with a lower risk of stroke include (i) female gender, especially those with 50–99% stenoses; (ii) ocular symptoms/lacunar stroke; (iii) smooth stenoses; and (iv) chronic subocclusion.
There have been considerable advances in rock coast research in the past decade, as measured in terms of the number of active researchers and in the number of research papers being produced. This ...review, although not exhaustive, highlights many of the improvements that have been made in our ability to identify and measure the processes shaping rock coasts, at a range of spatial and temporal scales. We review how researchers are experimenting with new techniques; grappling with quantifying the effects of multiple processes on resultant landforms; and exploring how well rock coast systems relate to wider geomorphological and earth science debates. Recent research, including those in this special issue, aptly demonstrate the scientific benefits that can be accrued by studying rock coasts at a variety of spatial and temporal scales, by considering the effect of the wide range of processes that operate on them, and by the application of new measurement techniques and approaches. Despite these advances, there is ample scope for future research, which could profit from increasing collaboration with other coastal geomorphologists and allied earth science disciplines in order to identify and quantify linkages between rock coasts and other coastal systems. It is also important that new research considers how rock coasts will respond to extreme events and to risks associated with changing climate, and to how rock coast geomorphology might contribute, beyond coastal science, to wider debates in theoretical geomorphology.
Adding Insight to Injury Naylor, A.R.; Spence, J.D.
European journal of vascular and endovascular surgery,
March 2020, 2020-03-00, 20200301, Letnik:
59, Številka:
3
Journal Article
Objective Recent studies with asymptomatic carotid patients on best medical management have shown that the annual risk of stroke has decreased to approximately 1%. There is no evidence that a similar ...decrease in mortality has occurred. In addition, the intensity of statin therapy for these patients has not yet been determined. The aims of this review were to determine (a) the reported long-term all-cause and cardiac-related mortality in patients with asymptomatic carotid stenosis (ACS) > 50%, (b) whether there has been a decrease in mortality in recent years, (c) the available methods of mortality risk stratification, and (d) whether the latest ACC/AHA guidelines on the treatment of serum lipids can be applied to this group of patients. Methods Systematic review of PubMed, EuroPubMed, and Cochrane Library and meta-analysis using random effects for pooled proportions were performed regarding long-term all-cause and cardiac-related mortality and the associated risk factors in ACS patients. The last day for literature search was October 30, 2014. Results Seventeen studies were retrieved reporting 5-year all-cause mortality in 11,391 patients with ACS >50%. The 5-year cumulative all-cause mortality across all 17 studies was 23.6% (95% CI 20.50–26.80). Twelve additional studies, reporting both all-cause and cardiac mortality with a minimum of 2 year follow-up and involving 4,072 patients were identified. Of the 930 deaths reported, 589 (62.9%; 95% CI 58.81–66.89) were cardiac-related. This translates into an average cardiac-related mortality of 2.9% per year. Conclusions All-cause and cardiac mortality in ACS patients are very high. Although risk stratification is possible, most patients are classified as high risk. In view of this high risk, aggressive statin therapy is indicated if the new ACC/AHA guidelines on serum lipids are to be adhered to.
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