Best Medical Treatment Research Articles

Endovascular Repair Compared With Medical Management of Patients With Uncomplicated Type B Acute Aortic Dissection

BackgroundThoracic endovascular aortic repair (TEVAR) has been used in patients with uncomplicated type B acute aortic dissection (B-AAD) to reduce late morbidity and mortality. The outcomes of comparisons between TEVAR and best medical treatment (BMT) on patients with uncomplicated type B-AAD are inconsistent in the published reports. ObjectivesThis study sought to further clarify the early and long-term (11-year) outcomes of TEVAR in patients with uncomplicated type B-AAD compared with those with BMT treatment. MethodsBetween February 2003 and August 2014, 338 patients with uncomplicated type B-AAD were retrospectively identified in 3 tertiary medical centers. Information about baseline characteristics was collected from medical records. Images were retrieved from the imaging archiving system, and the thrombosis status of the false lumen and extent of the dissection were evaluated via computed tomography angiography. Early and late outcomes were recorded and analyzed. ResultsTEVAR procedures were performed on 184 patients (TEVAR group) and BMT for 154 patients (BMT group). Early events and 30-day mortality were not significantly different between the 2 groups. Patients receiving BMT had significantly higher aortic-related adverse events compared with those in the TEVAR group (p = 0.025). All-cause mortality with TEVAR was significantly lower than that of BMT (p = 0.01). ConclusionsThis study confirmed the feasibility of TEVAR for uncomplicated type B aortic dissection in the acute setting with fewer aortic-related adverse events and a lower mortality rate compared with BMT.

Development of a Microsimulation Model to Predict Stroke and Long-Term Mortality in Adherent and Nonadherent Medically Managed and Surgically Treated Octogenarians with Asymptomatic Significant Carotid Artery Stenosis

The primary study objective was to develop a microsimulation model to predict preventable first-ever and recurrent strokes and mortality for a population of medically or surgically managed octogenarians with substantial (>60%) asymptomatic carotid artery stenosis and comparing an adherent with a real-world nonadherent best medical treatment (BMT) regimen subjected to sex. A Monte Carlo microsimulation model was constructed with a 14-year time horizon and with 10,000 patients. Probabilities and values for clinical outcomes were obtained from the current literature. The stratification of the microsimulation estimates by treatment strategy within the female group of octogenarians showed a statistically significant lower stroke rate during follow-up for carotid endarterectomy (CEA) compared with nonadherent BMT (P < 0.0001) as well as compared with adherent BMT (P < 0.0001). In male octogenarians, the CEA strategy was also associated with statistically significant lower stroke rates compared with adherent and nonadherent BMT (P < 0.0001 and P < 0.0001, respectively). For each treatment strategy, female octogenarians had a statistically significant longer overall long-term survival compared with male octogenarians (P < 0.0001, respectively). In terms of stratification by sex, in octogenarian men and women, long-term survival was significantly better for adherent BMT compared with nonadherent BMT, and CEA was associated with a significant better long-term survival compared with nonadherent BMT. In the present microsimulation, in real-world drug adherence, it was likely that a strategy of early endarterectomy was beneficial in octogenarians with significant asymptomatic carotid artery disease compared with BMT alone.

Economic Analysis of Deep Brain Stimulation in Parkinson Disease: Systematic Review of the Literature

Parkinson disease (PD) is a chronic multifaceted neurodegenerative disorder of adult onset that affects quality of life and places a burden on patients, caregivers, and society. In early disease, dopaminergic therapy improves motor symptoms, but as the disease progresses, symptoms tend to increase in frequency and severity, even with best medical treatment (BMT). Deep brain stimulation (DBS) becomes an option for certain patients, but cost becomes an important issue. We performed a systematic review of the literature of economic studies of the use of DBS in patients with PD, including costs studies or economic evaluations expressed as cost per improvement in quality life, decrease in dose of pharmacological treatments, and the decrease of caregiver burden. We reviewed the following databases: Medline/PubMed, Embase, Cochrane Database of Systematic Reviews, LILACS, Cochrane Central Register of Controlled Trials, WHO International Clinical Trials Registry Platform ICTRP portal and ClinicalTrials.gov from 1980 to 2015. Costs have been converted or adjusted to 2016 US dollars (US$). Nine studies were identified. The average cost of DBS for a patient with PD in 5 years is US$186,244. The quality-adjusted life year was higher in DBS compared with BMT after at least 2 years of treatment, with an average incremental cost utility ratio of US$41,932 per additional quality-adjusted life year gained. Costs in the first year are higher with DBS because of direct costs related to the surgical procedure, the device, and the more frequent controls. Studies show better results with a longer time horizon (up to 5 years). DBS is a cost-effective intervention for patients with advanced PD, but it has a high initial cost compared with BMT. However, DBS reduces pharmacologic treatment costs and should also reduce direct, indirect, and social costs of PD on the long term.

SPACE-2: A Missed Opportunity to Compare Carotid Endarterectomy, Carotid Stenting, and Best Medical Treatment in Patients with Asymptomatic Carotid Stenoses

Because of recent advances in best medical treatment (BMT), it is currently unclear whether any additional surgical or endovascular interventions confer additional benefit, in terms of preventing late ipsilateral carotid territory ischemic stroke in asymptomatic patients with significant carotid stenoses. The aim was to compare the stroke-preventive effects of BMT alone, with that of BMT in combination with carotid endarterectomy (CEA) or carotid artery stenting (CAS) in patients with high grade asymptomatic extracranial carotid artery stenosis. SPACE-2 was planned as a three-armed, randomized controlled trial (BMT alone vs. CEA plus BMT vs. CAS plus BMT, ISRCTN 78592017). However, because of slow patient recruitment, the three-arm study design was amended (July 2013) to become two parallel randomized studies (BMT alone vs. CEA plus BMT, and BMT alone vs. CAS plus BMT). The change in study design did not lead to any significant increase in patient recruitment, and trial recruitment ceased after recruiting 513 patients over a 5 year period (CEA vs. BMT (n=203); CAS vs. BMT (n=197), and BMT alone (n=113)). The 30 day rate of death/stroke was 1.97% for patients undergoing CEA, and 2.54% for patients undergoing CAS. No strokes or deaths occurred in the first 30 days after randomization in patients randomized to BMT. There were several potential reasons for the low recruitment rates into SPACE-2, including the ability for referring doctors to refer their patients directly for CEA or CAS outwith the trial, an inability to convince patients (who had come "mentally prepared" that an intervention was necessary) to accept BMT, and other economic constraints. Because of slow recruitment rates, SPACE-2 had to be stopped after randomizing only 513 patients. The German Research Foundation will provide continued funding to enable follow up of all recruited patients, and it is also planned to include these data in any future meta-analysis prepared by the Carotid Stenosis Trialists Collaboration.

Efficacy and safety of subthalamic nucleus deep brain stimulation combined with drug therapy for treating Parkinson's disease: a Meta-analysis

Objective To evaluate the efficacy and safety of subthalamic nucleus deep brain stimulation (STN-DBS) combined with drug therapy for treating Parkinson's disease (PD). Methods Retrieve relevant randomized controlled trials (RCTs) from online databases (January 1, 1980-October 1, 2016) as PubMed, EBMASE/SCOPUS and Cochrane Library with key words: subthalamic nucleus, deep brain stimulation, DBS, STN, Parkinson disease, random. Selection of studies was performed according to pre-designed inclusion and exclusion criteria. Quality of studies was evaluated by using Jadad Scale and Cochrane Handbook for Systematic Reviews of Interventions. All data were pooled by RevMan 5.2 software for Meta-analysis. Results The research enrolled 3245 articles, from which 6 studies with Jadad score ≥ 4 were chosen after excluding duplicates and those not meeting the inclusion criteria. A total of 958 PD patients were included. Meta-analysis showed that comparing with best medical treatment (BMT), STN-DBS combined with drug therapy significantly reduced the scores of Unified Parkinson's Disease Rating Scale (UPDRS)Ⅲ in the "on" phase ( SMD =-0.570, 95%CI: -0.710—0.430; P = 0.000) and in the "off" phase ( SMD =-1.170, 95%CI: -1.500—0.850; P = 0.000), UPDRSⅠscore ( SMD =-0.150, 95%CI: -0.290—0.010; P = 0.030), and 39-Item Parkinson's Disease Questionnaire (PDQ-39) score ( SMD =-0.510, 95%CI: -0.660—0.370; P = 0.000). But it can increase the occurrence of severe adverse events ( RD = 0.140, 95% CI:0.090-0.190; P = 0.000) and dysarthria ( RD = 0.070, 95%CI: 0.010-0.120; P = 0.020), while decrease the occurrence of dyskinesia ( RR = 0.450, 95% CI: 0.330-0.620; P = 0.000). Conclusions Subthalamic nucleus deep brain stimulation combined with drug therapy could greatly improve motor function, mental status and quality of life of PD patients, however, clinicians should pay more attention to the increased risk of severe adverse events and dysarthria after operation. DOI: 10.3969/j.issn.1672-6731.2017.02.006

Definition of Best Medical Treatment in Asymptomatic and Symptomatic Carotid Artery Stenosis.

Implementation of best medical treatment (BMT) is the cornerstone of the management of patients with either asymptomatic or symptomatic carotid artery stenosis. We review the literature to define the components of BMT. Smoking cessation, maintaining a healthy body weight, moderate exercise, and a Mediterranean diet are essential lifestyle measures. Moderate alcohol consumption may also be beneficial but recommending it to patients may be hazardous if they consume too much. The importance of lifestyle measures is largely underestimated by both physicians and patients. Blood pressure and diabetes control, antiplatelet agents, and lipid-lowering treatment with statins/ezetimibe comprise the pharmacological components of BMT. Initiation of an intensive regimen of BMT is a sine qua non for patients with carotid artery stenosis whether or not they are offered or undergo an invasive revascularization procedure.

Issues to Be Addressed and Hopefully Resolved in the Carotid Revascularization Endarterectomy Versus Stenting Trial 2.

The superiority of carotid endarterectomy (CEA) plus best medical treatment (BMT) over BMT alone for the management of patients with asymptomatic carotid stenosis is based on randomized controlled trials that recruited patients up to 30 years ago. Best medical treatment has improved considerably since that time with respect to stroke prevention. Furthermore, a new carotid intervention has emerged during the last 2 decades and has gradually become established, that is, carotid artery stenting (CAS). Consequently, the efficacy of current BMT alone needs to be compared not only with CEA plus BMT but also with CAS plus BMT to determine which strategy achieves the optimal stroke prevention rates. This article highlights the purpose of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) 2 and discusses the issues that CREST-2 will hopefully provide answers to.

Impact of Real-World Adherence with Best Medical Treatment on Cost-Effectiveness of Carotid Endarterectomy for Asymptomatic Carotid Artery Stenosis

To present a model of decision and cost-effectiveness analysis that allows assessing the trade-off between the short-term risks of performing a carotid endarterectomy (CEA) and the rate of preventable future events and the impact of real-world adherence of best medical treatment (BMT) on cost-effectiveness of both therapeutic options. We used data from the current literature to define values for a base case and perform a sensitivity analysis. The primary end point was a comparison of the fatal and disabling stroke-free survival during a 5-year period in a cohort of hypothetical patients who presented asymptomatic severe carotid stenosis and were treated with either prophylactic CEA or adherent and nonadherent best medical treatment, respectively. The difference in estimated fatal and disabling stroke-free survival favoring endarterectomy in patients with asymptomatic severe carotid stenosis is 44 days over the course of 5 years in case of nonadherent best medical treatment. Over a 5-year time horizon, prophylactic CEA would be cost-effective in 50.8% of bootstrap replicates and nonpersistent BMT might be economically dominant in 11.1%. The probability that CEA would be cost-effective at a willingness-to-pay (WTP) threshold of Euro 50,000/quality-adjusted life year gained was 71.8%. In 17.9% prophylactic CEA would be more costly and effective than persistent BMT, but its incremental cost-effectiveness ratio was greater than the WTP, so persistent BMT would be optimal. In this model, in case of real-world drug adherence, it was likely that a strategy of early endarterectomy might be a cost-effective or even the dominant therapeutic option in comparison with a strategy of medical therapy alone (deferred surgery). If background any-territory stroke rates on contemporary medical therapy would fall substantially below 0.7%, surgery would cease to be cost-effective.

Evidence for management of carotid artery stenosis.

In this review, we presented the evidence concerning carotid artery stenosis treatment in symptomatic stenosis and asymptomatic stenosis separately, and discussed the future challenges. The validity of carotid endarterectomy (CEA) to treat moderate or greater degree of symptomatic carotid artery stenosis appears to be established. Due to the additional option of carotid artery stenting (CAS), it is necessary to comprehensively determine whether CEA or CAS is more appropriate for each individual patient. Moreover, since there are rapid advancements in devices for CAS and improvements in treatment outcomes, continual learning of the latest treatment method is essential. For asymptomatic stenosis, due to improvements in the outcomes with best medical treatment (BMT), it is essential to re-evaluate the use of invasive CEA/CAS. Continual verification of the latest randomized clinical trial that compares CEA, CAS, and BMT, and establishment of a diagnostic method that can accurately extract the group of patients who have the highest future risk of developing ischemia, are desired.

Laparoscopic/laparoscopic-assisted abdominal aortic aneurysm (AAA) repair is associated with less post-operative pain, fewer post-operative complications and a quicker return to normal function than open AAA repair

s / International Journal of Surgery 12 (2014) S13eS117 S110 for abdominal aortic aneurysm. 14.3% of patients had ankle-brachial pressure indexes (ABPI) carried out. 11.4% of GP were not confident of making the diagnosis, 20% of GPs were not able to or did not institute best medical treatment (BMT) in the community. 20% of patients referred had symptoms limiting lifestyle. Conclusions: We are not meeting the minimum requirements for clinical examination and ABPI measurements. This could be because GP’s often do not feel confident to diagnose IC and we can speculate as to whether education or increasing secondary care provisionwould be most appropriate. 0144: LAPAROSCOPIC/LAPAROSCOPIC-ASSISTED ABDOMINAL AORTIC ANEURYSM (AAA) REPAIR IS ASSOCIATED WITH LESS POST-OPERATIVE PAIN, FEWER POST-OPERATIVE COMPLICATIONS AND A QUICKER RETURN TO NORMAL FUNCTION THAN OPEN AAA REPAIR Philip C. Bennett *, Ijaz Ahmad, Sohail Choksy, Simon MacKenzie, Christopher Backhouse, Adam Q. Howard. Colchester Hospital University NHS Foundation Trust, Essex, UK. Introduction: To compare patient outcomes between laparoscopic/ laparoscopic assisted (LR) and open repair (OR) of AAA in subjects in whom endovascular repair was inappropriate. Methods: All patients undergoing either LR or OR since 2007 were included. Demographics, operative details and patient outcomes were prospectively recorded. Results: 104 patientswere investigated (51 LR; 53OR,median age 72[66-75] years, 92.3%male). The 2 groups had equivalent ages, sex distribution and VPOSSUM scores. LR procedures had longer aortic clamp times and longer operation times than OR ((90[63-120] vs. 76[57-105] minutes, p1⁄40.048) and (330[270-390] vs. 240[180-300] minutes, p 5(p 5 (OR:17.831, 95%CI 2.713117.193; P1⁄40.003) remained significant on multivariable analysis. Conclusions: Failure to respond to TNS devices may be predicted by greater calf circumference and neuropathy score of >5. Identifying such patients can save time and prove cost-effective. 0177: IMPROVING ACUTE VASCULAR ADMISSIONS AT A TERTIARY REFERRAL CENTRE BY IDENTIFYING AND QUANTIFYING DELAYS IN PATIENT CARE Simon Bellringer *, Jiten Patel, Benjamin Pettifer, Matthew Button, Lola Eid. Brighton University Hospital NHS Trust, Brighton, UK. Introduction: 1. To identify delays in surgical and interventional radiology (IR) procedures for acute vascular patients in a regional vascular centre. 2. To quantify these delays based on NCEPOD guidelines (NCEPOD recommendations http://www.ncepod.org.uk/pdf/NCEPODRecommendations. pdf) 3. To make appropriate recommendations to improve the care pathway of these patients Methods: The audit was carried out over a period of one calendar month. All acute vascular patients requiring a definitive radiological or surgical intervention were included. Time of decision to intervene and time of intervention were recorded for each patient. Results: 26 patients were included. Average time from decision to treat surgically to surgical intervention was 23 hours and 3 minutes and for IR was 52 hours and 33 minutes. The longest wait recorded was 116 hours and 12 minutes (for an IR procedure over a 4 day bank holiday weekend) Conclusions: This audit identified significant delays in definitive treatment for some patients due to shared CEPOD lists and limited availability of IR services. These findings highlight some of the challenges that regional centres face when an increase in service demand precedes the required expansion of services. Recommendation for additional IR sessions and a dedicated vascular CEPOD list were made. 0195: SYSTEMIC INFLAMMATORY RESPONSE SYNDROME SCORE MAY INDICATE INCREASED RISK OF MAJOR AMPUTATION IN PATIENTS WITH DIABETIC FOOT INFECTION Jon Griffin *, Rachel Williams , Chinonso Nwoguh , Perbinder Grewal . Perth Royal Infirmary, Perth, UK; Queen Alexandra Hospital, Portsmouth,

Spinal cord stimulation and pain relief in painful diabetic peripheral neuropathy: a prospective two-center randomized controlled trial.

Painful diabetic peripheral neuropathy (PDPN) is a common complication of diabetes mellitus. Unfortunately, pharmacological treatment is often partially effective or accompanied by unacceptable side effects, and new treatments are urgently needed. Small observational studies suggested that spinal cord stimulation (SCS) may have positive effects. We performed a multicenter randomized clinical trial in 36 PDPN patients with severe lower limb pain not responding to conventional therapy. Twenty-two patients were randomly assigned to SCS in combination with the best medical treatment (BMT) (SCS group) and 14 to BMT only (BMT group). The SCS system was implanted only if trial stimulation was successful. Treatment success was defined as ≥50% pain relief during daytime or nighttime or "(very) much improved" for pain and sleep on the patient global impression of change (PGIC) scale at 6 months. Trial stimulation was successful in 77% of the SCS patients. Treatment success was observed in 59% of the SCS and in 7% of the BMT patients (P < 0.01). Pain relief during daytime and during nighttime was reported by 41 and 36% in the SCS group and 0 and 7% in the BMT group, respectively (P < 0.05). Pain and sleep were "(very) much improved" in 55 and 36% in the SCS group, whereas no changes were seen in the BMT group, respectively (P < 0.001 and P < 0.05). One SCS patient died because of a subdural hematoma. Treatment success was shown in 59% of patients with PDPN who were treated with SCS over a 6-month period, although this treatment is not without risks.

Carotid endarterectomy for asymptomatic carotid stenosis in the very elderly

The indication for carotid endarterectomy (CEA) is uncertain in patients with asymptomatic severe (≥60% luminal narrowing according to the North American Symptomatic Carotid Endarterectomy Trial criteria) carotid stenosis (ASCS), especially in the very elderly, because current evidence suggests that the risk of future stroke has been dropping in the past two decades owing to the recent advances in medical therapy. The aim of this observational study was to compare early and late outcomes in patients ≥80 years old with ASCS treated with CEA plus best medical treatment (BMT) or with BMT alone. From 2005 to 2012, 69 octogenarians with ASCS underwent CEA plus BMT (group 1), and another 54 received BMT alone (group 2). All operations were eversion CEAs. BMT included lipid-lowering drugs, new antiplatelet and antihypertensive agents, avoidance of smoking, careful blood pressure and glycemic control, and lifestyle changes. Follow-up with serial ultrasonographic examination was obtained in 118 patients for a median 4.4-year period. There were no perioperative (30-day) strokes or deaths and one transient ischemic attack (1.4%). One late minor stroke developed in a CEA patient (1.5%). No late restenoses or occlusions were detected. Five patients in group 2 (9.6%) became symptomatic (one transient ischemic attack and four minor strokes) and subsequently underwent successful CEA; all their carotid plaques were complicated by ulceration and intraplaque hemorrhage (with plaque progression in four cases), confirmed by computed tomography images. The rate of freedom from cerebral ischemic events at 5 years showed a significant benefit for elderly patients who had CEA vis-à-vis those who did not (98% vs 84%; P = .04), and so did the 5-year rate of freedom from ipsilateral carotid disease progression (100% vs 91%; P = .01). At 5 years, the mortality rate was comparable for elderly patients whether they had CEA or not (66% vs 68%; P = .65). CEA is a safe, effective, and durable treatment for ASCS in patients aged 80 years or more, carrying an insignificant perioperative stroke/death risk. CEA associated with BMT seems preferable to BMT alone in preventing the risk of ipsilateral ischemic events, without translating into a longer survival.

Pilot study of high-intensity focused ultrasound ablation as a bridging therapy for hepatocellular carcinoma patients wait-listed for liver transplantation.

The objective of this study was to investigate the outcomes of high-intensity focused ultrasound (HIFU) ablation as a bridging therapy for patients with hepatocellular carcinoma (HCC) who had been wait-listed for deceased donor liver transplantation (DDLT). Adult patients with unresectable and unablatable HCCs within the University of California San Francisco criteria who had been wait-listed for DDLT were screened for their suitability for HIFU ablation as a bridging therapy if they were not suitable for transarterial chemoembolization (TACE). Treatment outcomes for patients receiving HIFU ablation, TACE, and best medical treatment (BMT) were compared. Fifty-one patients were included in the analysis. Before the introduction of HIFU ablation, only 39.2% of the patients had received bridging therapy (TACE only, n = 20). With HIFU ablation in use, the rate increased dramatically to 80.4% (TACE + HIFU, n = 41). The overall dropout rate was 51% (n = 26). Patients in the BMT group had a significantly higher dropout rate (P = 0.03) and significantly poorer liver function as reflected by higher Model for End-Stage Liver Disease scores and higher Child-Pugh grading. Clinically relevant ascites was found in 5 patients in the HIFU group and 2 patients in the BMT group, but none was found in the TACE group (P = 0.01 and P = 0.03, respectively). The TACE and HIFU groups had comparable percentages of tumor necrosis in excised livers (P = 0.35), and both were significantly higher than that in the BMT group (P = 0.01 and P = 0.02, respectively). In conclusion, HIFU ablation was safe even for HCC patients with Child-Pugh C disease. Its adoption increased the percentage of patients receiving bridging therapy from 39.2% to 80.4%. A randomized controlled trial for further validation of its efficacy is warranted.

Endovascular Repair of Acute Uncomplicated Aortic Type B Dissection Promotes Aortic Remodelling: 1 Year Results of the ADSORB Trial

Uncomplicated acute type B aortic dissection (AD) treated conservatively has a 10% 30-day mortality and up to 25% need intervention within 4 years. In complicated AD, stent grafts have been encouraging. The aim of the present prospective randomised trial was to compare best medical treatment (BMT) with BMT and Gore TAG stent graft in patients with uncomplicated AD. The primary endpoint was a combination of incomplete/no false lumen thrombosis, aortic dilatation, or aortic rupture at 1 year. The AD history had to be less than 14 days, and exclusion criteria were rupture, impending rupture, malperfusion. Of the 61 patients randomised, 80% were DeBakey type IIIB. Thirty-one patients were randomised to the BMT group and 30 to the BMT+TAG group. Mean age was 63 years for both groups. The left subclavian artery was completely covered in 47% and in part in 17% of the cases. During the first 30 days, no deaths occurred in either group, but there were three crossovers from the BMT to the BMT+TAG group, all due to progression of disease within 1 week. There were two withdrawals from the BMT+TAG group. At the 1-year follow up there had been another two failures in the BMT group: one malperfusion and one aneurysm formation (p = .056 for all). One death occurred in the BMT+TAG group. For the overall endpoint BMT+TAG was significantly different from BMT only (p < .001). Incomplete false lumen thrombosis, was found in 13 (43%) of the TAG+BMT group and 30 (97%) of the BMT group (p < .001). The false lumen reduced in size in the BMT+TAG group (p < .001) whereas in the BMT group it increased. The true lumen increased in the BMT+TAG (p < .001) whereas in the BMT group it remained unchanged. The overall transverse diameter was the same at the beginning and after 1 year in the BMT group (42.1 mm), but in the BMT+TAG it decreased (38.8 mm; p = .062). Uncomplicated AD can be safely treated with the Gore TAG device. Remodelling with thrombosis of the false lumen and reduction of its diameter is induced by the stent graft, but long term results are needed.

Abstract T P23: Endovascular Treatment of Stroke in Elderly Patients: Comparison With Conventional Thrombolysis and Best Medical Treatment

Background and Purpose: Elderly patients have often been excluded from randomized stroke trials. The benefit of endovascular treatment of stroke in these patients remains uncertain. We sought to evaluate the outcomes of elderly patients treated endovascularly compared to those treated with conventional thrombolysis or best medical therapy. Methods: We retrospectively reviewed all stroke patients admitted to our center between 2008-2011. We included all patients age 75 or older with large vessel occlusion presenting within 8 hours of stroke onset. We evaluated outcomes at discharge including modified rankin score (mRS) and mortality as well as symptomatic intracerebral hemorrhage (sICH) within 24 hours for patients receiving endovascular treatment (EVT) with or without conventional thrombolysis , intravenous thrombolysis (IVT) or best medical treatment (BMT). Good outcome was defined as mRS of 3 or less at discharge. Results: A total of 91 patients met the inclusion criteria. 41 patients underwent EVT, 19 received IVtpa, and 31 BMT. Baseline NIHSS was not significantly different between the groups (17 SD 7, 16 SD 5, 14 SD 8 respectively). There was no difference in good outcomes between patients undergoing EVT compared to BMT (unadjusted OR 1.46, 95% CI 0.44-4.9), IVT compared to BMT (OR 2.4, 95% CI 0.62-9.36), or EVT compared to IVT (OR 0.61, 95% CI 0.18-2.06). There was no difference in mortality for the EVT, IVT, and BMT groups (22%, 26%, and 16% respectively, chi square p=0.79 for intergroup differences). Similarly there was no difference in rates of sICH 12%, 11%, and 3% p=0.41. Conclusion: Despite similar mortality and cerebral hemorrhage rates, we found no difference in good outcome for elderly patients treated with endovascular therapy or intravenous thrombolysis compared to best medical treatment within 8 hours of stroke onset. Larger studies are needed to clarify the role of intervention in elderly stroke patients.

Effects of deep brain stimulation of the subthalamic nucleus on freezing of gait in Parkinson's disease: a prospective controlled study

BackgroundFreezing of gait (FOG) is a debilitating gait disorder in Parkinson's disease (PD) with partial responsiveness to dopaminergic medication. To date, notions about the effects of subthalamic deep brain stimulation...

Part One: For the Motion. Level 1 Evidence is Necessary Comparing TEVAR and Medical Management of Uncomplicated Type B Aortic Dissection

Part One: For the Motion. Level 1 Evidence is Necessary Comparing TEVAR and Medical Management of Uncomplicated Type B Aortic Dissection

Part Two: Against the Motion. We do not Need Level 1 Evidence Comparing Best Medical Treatment with TEVAR in Patients with Uncomplicated Type B Aortic Dissection

Be it resolved that we do not need level 1 evidence comparing best medical treatment (BMT) with thoracic endovascular aortic repair (TEVAR) in patients with uncomplicated type B aortic dissection (BAD). There is reasonable level 1 evidence available for subacute/chronic type B dissection (Investigation of STEnt Grafts in Aortic Dissection [INSTEAD] trial 1 ) and we concede that the longterm results of this trial are needed to help clarify initial findings. We will argue instead that level 1 evidence for acute uncomplicated BAD and, consequently, the Acute Dissection Stent-graft Or Best medical treatment (ADSORB) trial, 2 was not required, nor has it resulted in clinically applicable information. Rather than focusing on whether all BADs should be treated with TEVAR or not, we need to determine which group of patients will find the most benefit. We are well on our way to understanding this without the need of a randomized trial. One core issue in the study of BADs is that many of its features are not uniformly defined.The only generally agreed upon definition is that Stanford type B or Debakey III aortic dissectionoriginatesinthedescendingthoracicaortawithout retrograde extension into the ascending aorta. BADs are considered complicated if they involve malperfusion or rupture, but studies are inconsistent on whether they include other symptoms, such as refractory hypertension and persistent pain. 3 Imaging findings such as an increase in periaortic hematoma and hemorrhagic pleural effusion clearly increase morbidity and mortality, but are inconsistently reported. 4 Historically, BAD is considered acute when it occurs within 14 days of symptom onset, while a dissection discovered after 2 weeks is considered chronic. In recent years, the term “subacute” has been used, further confounding the temporal classification. The INSTEAD trial is the only randomized controlled trial (RCT) of subacute or chronic type B dissections treated with TEVAR plus BMT versus BMT plus surveillance. 1 Conversely,the ADSORB trial,the 1-year results of which have recently been published, is the only RCT of acute type B dissections treated with TEVAR plus BMTversus BMT. 2 BMT generally involves lowering patients’ blood pressure to approximately 120 mmHg systolic over 80 mmHg diastolic. Beta blockade is usually first-line therapy and is supplemented by diuretics, angiotensin-converting enzyme inhibitors, calcium channel blockers, and sometimes ablockers in refractory cases. 5e7 TEVAR involves endograft

A longitudinal study of Type-B aortic dissection and endovascular repair scenarios: Computational analyses

Conservative medical treatment is commonly first recommended for patients with uncomplicated Type-B aortic dissection (AD). However, if dissection-related complications occur, endovascular repair or open surgery is performed. Here we establish computational models of AD based on radiological three-dimensional images of a patient at initial presentation and after 4-years of best medical treatment (BMT). Computational fluid dynamics analyses are performed to quantitatively investigate the hemodynamic features of AD. Entry and re-entries (functioning as entries and outlets) are identified in the initial and follow-up models, and obvious variations of the inter-luminal flow exchange are revealed. Computational studies indicate that the reduction of blood pressure in BMT patients lowers pressure and wall shear stress in the thoracic aorta in general, and flattens the pressure distribution on the outer wall of the dissection, potentially reducing the progressive enlargement of the false lumen. Finally, scenario studies of endovascular aortic repair are conducted. The results indicate that, for patients with multiple tears, stent-grafts occluding all re-entries would be required to effectively reduce inter-luminal blood communication and thus induce thrombosis in the false lumen. This implicates that computational flow analyses may identify entries and relevant re-entries between true and false lumen and potentially assist in stent-graft planning.

Preliminary Results of Randomized Controlled Study on Decompressive Craniectomy in Treatment of Malignant Middle Cerebral Artery Stroke

Studies on decompressive craniectomy (DCE) after a malignant middle cerebral artery (MCA) stroke in selected population show an increased probability of survival without increasing the number of very severely disabled. Cerebral infarct volume (CIV) as a triage criterion for performing surgery has not been discussed in literature. The aim of this study was to investigate the value of CIV and initial National Institutes of Health Stroke Scale (NIHHS) and Glasgow Coma Scale (GCS) scores as possible triage criteria in the surgical treatment of patients with "malignant" MCA stroke. According to the study protocol, 28 patients with a malignant MCA stroke were included and analyzed prospectively. The patients were randomly divided either into the DCE plus best medical treatment (BMT) group or BMT alone group. CIV and NIHHS and GCS scores were measured at time of enrollment in every case. Clinical outcome was evaluated 1 year after the treatment. Six patients survived: 5 in the DCE group (none of them was older than 60 years) and 1 in the BMT group (P=0.03/0.06). Among survivors, none had a cerebral infarct volume of more than 390 cm(3) (P=0.05). All survivors in the DCE group had favorable outcomes. There was no significant difference in the NIHSS and GCS scores between the groups and survivors/nonsurvivors (P>0.05). Decompressive surgery in the selected patients is likely to increase the probability of survival with a favorable outcome without increasing the number of severely disabled survivors. Patients with CIV of more than 390 cm(3) may be bad candidates for DCE, and the prognosis is likely to be bad regardless the treatment strategy. The initial NIHHS and GCS scores did not prove any prognostic value in outcome.