Showing papers by "Lenox Hill Hospital published in 2010"

Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis

Abstract: For 2502 patients over a median follow-up period of 2.5 years, there was no significant difference in the estimated 4-year rates of the primary end point between the stenting group and the endarterectomy group (7.2% and 6.8%, respectively; hazard ratio with stenting, 1.11; 95% confidence interval, 0.81 to 1.51; P = 0.51). There was no differential treatment effect with regard to the primary end point according to symptomatic status (P = 0.84) or sex (P = 0.34). The 4-year rate of stroke or death was 6.4% with stenting and 4.7% with endarterectomy (hazard ratio, 1.50; P = 0.03); the rates among symptomatic patients were 8.0% and 6.4% (hazard ratio, 1.37; P = 0.14), and the rates among asymptomatic patients were 4.5% and 2.7% (hazard ratio, 1.86; P = 0.07), respectively. Periprocedural rates of individual components of the end points differed between the stenting group and the endarterectomy group: for death (0.7% vs. 0.3%, P = 0.18), for stroke (4.1% vs. 2.3%, P = 0.01), and for myocardial infarction (1.1% vs. 2.3%, P = 0.03). After this period, the incidences of ipsilateral stroke with stenting and with endarterectomy were similarly low (2.0% and 2.4%, respectively; P = 0.85). CONCLUSIONS Among patients with symptomatic or asymptomatic carotid stenosis, the risk of the composite primary outcome of stroke, myocardial infarction, or death did not differ significantly in the group undergoing carotid-artery stenting and the group undergoing carotid endarterectomy. During the periprocedural period, there was a higher risk of stroke with stenting and a higher risk of myocardial infarction with endarterectomy. (ClinicalTrials.gov number, NCT00004732.)

Revised SHEA Position Paper: Influenza Vaccination of Healthcare Personnel

Abstract: Executive SummaryThis document serves as an update and companion piece to the 2005 Society for Healthcare Epidemiology of America (SHEA) Position Paper entitled “Influenza Vaccination of Healthcare Workers and Vaccine Allocation for Healthcare Workers During Vaccine Shortages.” In large part, the discussion about the rationale for influenza vaccination of healthcare personnel (HCP), the strategies designed to improve influenza vaccination rates in this population, and the recommendations made in the 2005 paper still stand. This position paper notes new evidence released since publication of the 2005 paper and strengthens SHEA's position on the importance of influenza vaccination of HCP. This document does not discuss vaccine allocation during times of vaccine shortage, because the 2005 SHEA Position Paper still serves as the Society's official statement on that issue.

The Carotid Revascularization Endarterectomy versus Stenting Trial: credentialing of interventionalists and final results of lead-in phase.

Abstract: The success of carotid artery stenting in preventing stroke requires a low risk of periprocedural stroke and death. A comprehensive training and credentialing process was prerequisite to the randomized Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) to assemble a competent team of interventionalists with low periprocedural event rates. Interventionalists submitted cases to a multidisciplinary Interventional Management Committee. This committee evaluated 427 applicants. Of these, 238 (56%) were selected to participate in the training program and the lead-in phase, 73 (17%) who had clinical registry experience and satisfactory results with the devices used in CREST were exempt from training and were approved for the randomized phase, and 116 (27%) did not qualify for training. At 30 days in the lead-in study, stroke, myocardial infarction, or death occurred in 6.1% of symptomatic subjects and 4.8% of asymptomatic subjects. Stroke or death occurred in 5.8% of symptomatic subjects and 3.8% of asymptomatic subjects. Outcomes were better for younger subjects and varied by operator training. Based on experience, training, and lead-in results, the Interventional Management Committee selected 224 interventionalists to participate in the randomized phase of CREST. We believe that the credentialing and training of interventionalists participating in CREST have been the most rigorous reported to date for any randomized trial evaluating endovascular treatments. The study identified competent operators, which ensured that the randomized trial results fairly contrasted outcomes between endarterectomy and stenting.

Design of the Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST)

Abstract: Rationale Carotid endarterectomy (CEA) and medical therapy were shown superior to medical therapy alone for symptomatic (≥50%) and asymptomatic (≥60%) stenosis. Carotid angioplasty stenting (CAS) offers a less invasive alternative. Establishing safety, efficacy, and durability of CAS requires rigorous comparison with CEA in symptomatic and asymptomatic patients.

Complementary and alternative medicine and supportive care at leading cancer centers: a systematic analysis of websites.

Abstract: Background: With increasing frequency, patients with cancer and their family members are turning to the Internet to educate themselves about their disease and treatment options, including ...

Carotid artery stenting versus surgery: adequate comparisons?

Abstract: A moratorium on carotid artery stenting (CAS) has been recently proposed. Current randomised evidence supports the notion that carotid endarterectomy (CEA) is better than CAS. A meta-analysis of the randomised trials compared the two strategies and included data from the recent International Carotid Stenting Study (ICSS). This meta-analysis indicated that patients who received CAS had a signifi cant increased risk of 30-day death or stroke compared with patients who received CEA (odds ratio 1·60; 95% CI 1·26–2·02). As randomised clinical trials are the gold standard of clinical investigation, it seems unwise to challenge them. However, for the comparison of CAS versus CEA, most of the randomised trials should be considered not only scientifi cally but also ethically questionable because the endovascular experience required for interventionalists to be eligible for the studies was minimal (table). As a consequence, patients allocated to CAS might have been exposed to unnecessary risk and the assessment of safety and effi cacy of the endovascular approach confounded. In the French Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) study, a lifetime experience of at least 12 CAS interventions was required. Alternatively, a minimum of fi ve CAS procedures was deemed to be suffi cient if the interventionalist had a lifetime experience of at least 30 stenting procedures in supraaortic vessels. The rationale for this adjustment is diffi cult to understand given that subclavian and carotid interventions diff er substantially. For investigators who did not comply with these minimum requirements, the EVA-3S protocol allowed the procedure “under the supervision of an experienced tutor”, defi ned in the protocol as “a clinician who qualifi ed to perform stenting in this study”. In later correspondence, the investigators acknowledged that only 16% of the 265 patients treated with stenting were managed by operators who had done more than 50 CAS procedures in their lifetime and that 39% of patients were treated by physicians in training. Although such a track record can hardly be defi ned as good clinical practice or trial conduct, the information was not thought to be suffi ciently relevant to be reported in any of the EVA-3S publications. Concerns about CAS safety in the EVA-3S trial were raised after the enrolment of 80 patients in the endovascular arm. The safety committee recommended stopping the performance of CAS without the use of embolic protection devices, because the 30-day rate of stroke among patients undergoing un protected CAS was 26·7%, which was 3·9 times higher than that of patients treated with embolic protection (8·6%). However, in the clinical alert published by the EVA-3S investigators, the experience of the interventionalists was not questioned because “a learning eff ect is also unlikely to explain the diff erent complications rates, since protected CAS is a more complex technique than unprotected CAS”. This quote reveals a fundamental gap in understanding of the CAS procedure. In real-life practice, the use of embolic protection devices is widely embraced by experienced CAS interventionalists, whereas those with less expertise might be reluctant to use these devices. Additional evidence of the little endovascular experience among the investigators of EVA-3S is derived from the high rate of emergent conversion from CAS to CEA (5%). The fact that CAS was never reimbursed in France did not help the investigators to gain exposure to the procedure. According to the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) study, a minimum of 25 successful consecutive CAS procedures was needed to participate as an investigator. However, a subsequent report revealed that, during the course of the trial, the protocol was amended to allow for tutoring of physicians who had only undertaken ten CAS procedures. Finally, in ICSS, a minimum of 50 total stenting procedures was required as long as at least ten of these involved the carotid artery. Tutor-assisted procedures were allowed for investigators with insuffi cient experience, again raising the concern of adequacy of training. The inexperience of the EVA-3S, SPACE, and ICSS investigators might have exposed the endovascular patients to an increased risk, not only because of insuffi cient operator skills, but also (and equally important) owing to inappropriate selection of patients. Interventions in patients with complex anatomy at the level of the aortic arch and supra-aortic vessels require more catheter manipulation than in patients with less tortuous or diseased vessels and place patients at increased risk of periprocedural stroke.

Effect of weight loss after bariatric surgery on skin and the extracellular matrix.

Abstract: Background:Obese patients experience dramatic physical and metabolic changes in the skin and its collagen Bariatric surgery is known to result in significant improvement in obesity-associated comorbid conditions and metabolic disturbances The aim of this study was to evaluate skin quality followin

Revision total hip arthroplasty for ceramic head fracture: a long-term follow-up.

Abstract: The results of revision total hip arthroplasty (THA) for ceramic head fracture have generally been disappointing, largely due to third body wear after incomplete synovectomy. We have followed 8 patients who sustained ceramic head fractures and were subsequently revised to a metal-on-polyethylene articulation. There were no revisions for osteolysis or aseptic loosening at a mean follow-up of 10.5 years. The yearly wear rates of each of 5 of these THAs after revision were compared with 6 matched metal-on-polyethylene THAs; there were no significant differences in wear rates. Greater than 10-year survivorship with a metal-on-polyethylene bearing couple is possible after revision THA for a ceramic head fracture if a complete and thorough synovectomy can be performed. Our technique of synovectomy will be described.

Early Reactive Synovitis and Osteolysis after Total Hip Arthroplasty

Abstract: Background Little is known about intraarticular pathology following THA prior to the radiographic appearance of osteolysis, primarily due to imaging limitations. MRI has recently been applied to imaging the postarthroplasty hip with the ability to detect periarticular bony and soft tissue pathology; specifically, it is able to detect abnormal synovial patterns and focal bone loss well before the radiographic appearance of osteolysis.

High Fusion Rates with Circular Plate Fixation for Four-corner Arthrodesis of the Wrist

Abstract: Background Scaphoid excision and four-corner fusion is commonly performed to reconstruct advanced scapholunate collapse and scaphoid nonunion with collapse. Metallic plates were introduced for achieving fixation of the four carpal bones. Although the developer reported high rates of fusion, several other early reports of circular plate fixation suggest higher complication rates and inferior outcomes compared with traditional fixation techniques.

Warfarin Versus New Agents: Interpreting the Data

Abstract: Stroke prevention in atrial fibrillation (AF) is a rapidly expanding indication for lifelong oral anticoagulation. The vitamin K antagonists (VKAs) effectively prevent stroke, but are notoriously difficult to manage and are associated with frequent adverse events. These factors account for the widespread underuse of warfarin for patients with AF who are qualified candidates for therapy. New oral anticoagulants with different mechanisms of action are beginning to exit phase III trials and may replace the VKAs for a number of indications, especially AF. The oral direct thrombin and Xa inhibitors are furthest along in development. Dabigatran etexilate, a thrombin inhibitor, has recently shown excellent outcomes in the prevention of stroke in patients with AF. The oral Xa inhibitors are still in phase III trials for stroke prevention in AF, but results from trials for other indications look promising. These short-acting, short-duration, unmonitored drugs are not without limitations and potential adverse effects. The perceived drawbacks of the VKAs may actually be assets in the management of patients with AF, and the pros and cons of each class of drug must be taken into account as physicians consider or patients request transition to a new class of oral anticoagulants.

Impact of heart failure on the incidence of contrast-induced nephropathy in patients with chronic kidney disease.

Abstract: We randomized patients with chronic kidney disease (serum creatinine ≥ 1.5 mg/dl or glomerular filtration rate (GFR) <60 ml/min/1.73 m²) in a double-blind fashion to receive saline or sodium bicarbonate prior to and after cardiac or vascular angiography. The primary endpoint was contrast-induced nephropathy (CIN), defined as an increase in serum creatinine by 25% or by 0.5 mg/dl from baseline. Patients with congestive heart failure (CHF), cardiac ejection fraction (EF) <30%, or GFR < 20 ml/min/1.73 m² were excluded. The study was discontinued (after 142 patients were randomized) due to a low incidence of CIN (1.5%). We retrospectively identified all cases of CIN (n = 30) at our institution during the same time period to see if these patients differed from our trial sample. There was no difference in serum creatinine (1.7 ± 0.4 vs. 1.7 ± 0.6 mg/dL), GFR (42.7 ± 9.7 vs. 45.3 ± 3.2 ml/min), incidence of diabetes (51.8% vs. 63.3%), contrast volume (121.7 ± 63.8 vs. 122.7 ± 68.3 ml), ACE inhibitor or angiotensin receptor blocker use (54.0% vs 63.3%), and periprocedure diuretic use (33.1% vs 26.7%). On multivariate analysis, only a cardiac ejection fraction (EF) of less than 40% was significantly associated with CIN (odds ratio, 4.52; 95% confidence interval, 1.30–15.71; P = 0.02). In all, 22/30 patients (73.3%) who developed CIN had at least one or more characteristics that would have excluded their enrollment in our randomized trial including evidence of congestive heart failure (17/30 patients), EF less than 30% (9 patients), age greater than 85 years (2 patients), or advanced renal failure with a baseline GFR of less than 20 cc/min (1 patient). In summary, patients with CKD without evidence of CHF who receive adequate hydration appear to have a very low risk of CIN associated with angiography. A low EF (less than 40%) appeared to be the most significant risk factor for CIN in our population.

Accuracy of diagnostic injection in differentiating source of atypical hip pain.

Abstract: It is not uncommon to encounter patients with atypical hip or lower extremity pain, ill-defined clinicoradiological features, and concomitant hip and lumbar spine arthritis. The purpose of this study is to present our experience using the response resulting from a combined anesthetic-steroid hip injection for treatment selection in these patients. A retrospective analysis of 204 consecutive diagnostic hip injections was undertaken. Patient charts were scrutinized for outcomes of injection and treatment. Our findings suggest that the relief of symptoms following injection of local anesthetic and steroid into the hip joint has a sensitivity of 91.5%, specificity and positive predictive value of 100%, and negative predictive value of 84.6% for response to total hip arthroplasty. We thereby believe that this is a reliable test with low morbidity and can predict the potential benefit of total hip arthroplasty in this diagnostically challenging group of patients.

Subscapularis management in open shoulder surgery.

Abstract: Management of the subscapularis in open shoulder surgery is a controversial topic. Subscapularis tenotomy has been the traditional approach, but other techniques have recently been developed to preserve the integrity of the subscapularis tendon. These include subscapularis peel, subscapularis split, and lesser tuberosity osteotomy. The biologic healing and biomechanical properties associated with each surgical approach must be evaluated to determine the best option for each patient. A strong, anatomic repair is required to achieve optimal clinical outcomes.

The Risk of Direct Peroneal Nerve Injury Using the Ranawat Inside-Out Lateral Release Technique in Valgus Total Knee Arthroplasty

Abstract: The purposes of our study are to define a "danger zone" and a "safe zone" to avoid common peroneal nerve direct injury performing the "inside-out" release technique of posterior-lateral corner during total knee arthroplasty and to identify anatomic landmarks to localize the nerve before the soft-tissues release. Twenty cadaver dissections were used for testing. The distance from the nerve to the posterior-lateral corner of the tibia and to the posterior border of the iliotibial band averaged, respectively, 13.5 and 35.8 mm. The nerve is at risk during the release of the posterior-lateral capsule, in the triangle defined by the popliteus tendon, the tibial cut surface, and the most posterior fibers of iliotibial band (danger zone), but not during pie-crusting of the iliotibial band (safe zone).

Mucosal healing as an index of colitis activity: back to histological healing for future indices.

Abstract: D iscussions of mucosal healing as an index of response to therapy for ulcerative, Crohn’s, and indeterminate colitis seem endless. Recent excellent reviews on the topic include those by Rutgeerts et al, Rubin, Kane et al, Schitzler et al, and Pineton de Chambrun et al. In these reviews, 80%–90% of the references are from the most recent decade and they include minimal criteria for histological healing. The gamut of criteria for ‘‘mucosal healing’’ includes:

Early Post-operative Periprosthetic Femur Fracture in the Presence of a Non-cemented Tapered Wedge Femoral Stem:

Abstract: Non-cemented femoral fixation in hip arthroplasty has become the standard of practice in the USA. However, recent literature has brought attention to an increasing incidence of periprosthetic femur fractures with certain stem designs. This study examines reasons for early periprosthetic femur fractures in patients with a hip arthroplasty performed using a non-cemented tapered wedge stem design. A multivariate analysis using a matched-cohort design was performed to assess any potential risk factors that may predispose to such fractures. Six of 2,220 hips (0.3%) suffered a periprosthetic femur fracture within the first year after surgery; five of six were Vancouver Type B2. The average time to fracture was 9 weeks. This group of patients had a significantly higher canal–flare index and lower canal–calcar ratio. This complication may be preventable by having a better appreciation of the fit between the implant and the bone during pre-operative planning, with the goal of avoiding a proximal–distal mismatch.

New Assessment of Forearm Strength: Reliability and Validity

Abstract: OBJECTIVE. The objective was to determine the reliability of a portable forearm strength hydraulic dynamometer with a doorknob handle and assess its validity compared with a Cybex 6000 (Cybex International, Inc., Medway, MA) isometric torque assessment. METHOD. Eighteen volunteers (with a total of 30 forearms) participated in this one-session methodological study to determine the intra- and interrater reliability and criterion validity of a forearm dynamometer. RESULTS. Intrarater reliability for both assessors for pronation was (intraclass correlation coefficient [ICC]3,1 = .937�.961) and for supination was (ICC3,1 = .923�.968). Interrater reliability for pronation was ICC3,2 = .927 and for supination was ICC3,2 = .847. Criterion validity of the Baseline hydraulic dynamometer (Fabrication Enterprises Inc., White Plains, NY) compared with the Cybex 6000 was .574�.664 for pronation and .749�.750 for supination. CONCLUSION. The Baseline hydraulic dynamometer with a more functional doorknob handle had good intra- and interrater reliability and demonstrated moderate validity compared with Cybex 6000 strength testing

The anatomic location of digital glomus tumor recurrences.

Abstract: Purpose We examined the anatomic location of recurrences of digital glomus tumors treated with surgical excision to make inferences on the causes of recurrence. Methods We retrospectively reviewed 12 cases of glomus tumors of the hand treated surgically over an 8-year period. Two of these patients presented with recurrences after previous glomus tumor excision surgery elsewhere. The location of recurrences, duration of symptoms, gender, revision surgeries, and histological specimens were analyzed. Results All tumors developed in the periungual and subungual area of the digits. Five of the 12 patients had recurrences, with one of these patients having a second recurrence after revision surgery. All recurrent tumors occurred in new, separate locations from the original lesions. The recurrences presented from 2 months to 5 years after the initial surgery. All surgical specimens from the index surgeries, as well as revision procedures, were examined by a pathologist and confirmed to be glomus tumors. There were no discernible differences in the histology features of the tumors that recurred compared to those that did not. Conclusions Traditionally, recurrences of digital glomus tumors after surgical excision are thought to be rare. Inadequate resection was considered the likely cause in most cases. However, recurrent symptoms might be attributed to small, synchronous, satellite lesions not detected during the original surgery. A careful preoperative and intraoperative examination for synchronous lesions should be made, and patients should be informed of the risk of recurrent symptoms.

Increased vascular access complications in patients with renal dysfunction undergoing percutaneous coronary procedures using arteriotomy closure devices.

Abstract: BACKGROUND Arteriotomy closure device (ACD) use has increased following percutaneous transfemoral coronary procedures (PTCP). However, their safety in patients with chronic kidney disease (CKD) is not known. Therefore, we evaluated the complication rates of ACD among patients with CKD. METHODS Six-hundred ten consecutive patients who underwent PTCP and ACD were retrospectively studied. Patients were grouped according to their creatinine clearance (CrCl in ml/min/1.73 m2) calculated by the Cockcroft-Gault formula using the National Kidney Foundation classification system; Stage I (CrCl > or = 90); Stage II (60-89); Stage III (30-59); Stage IV (15-29); and Stage V (< or = 15). The primary endpoint was the combined incidence of pseudoaneurysm, retroperitoneal hematoma, femoral artery thrombosis, surgical vascular repair, and groin infection. RESULTS Among 610 patients 283 (46%) underwent PCI. The primary endpoint was seen in 66 (10.8%) patients. Univariate predictors of primary outcome were lower CrCl (p < 0.001), and presence of peripheral vascular disease (p = 0.03). There was an inverse relationship between CrCl and complication rate. CKD was the strongest independent multivariate predictor for the primary endpoint (OR 1.032; 95% CI 1.019-1.046; p < 0.0001), driven by higher infection (p < 0.0001), thrombosis (p = 0.003) and hematoma (p = 0.007). CONCLUSIONS Renal function appears to be significantly associated with vascular access-site complications. Worsening renal function is associated with higher vascular access site complications, largely driven by an increased infection rate.

Extracorporeal life support for pandemic influenza: the role of extracorporeal membrane oxygenation in pandemic management.

Abstract: The recent global threat of a severe pandemic influenza outbreak has suggested that extracorporeal life support will begin to play an evolving role in the care of critically ill influenza stricken patients. The highly communicable attributes of influenza could result in widespread infection and an associated increased need for advanced life support. Supply and demand equilibrium may be abruptly disrupted, and ethical decisions regarding the allocation of life saving resources will inevitably need to be made. Protocol oriented planning, research analysis, and advanced technologies are critical factors in averting catastrophe. This review article details the epidemiology, diagnostic techniques, and interventions for the influenza A virus, including H1N1.