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Day Outcomes (day + outcome)
Selected AbstractsRelationship between a Clear-cut Alternative Noncardiac Diagnosis and 30-day Outcome in Emergency Department Patients with Chest PainACADEMIC EMERGENCY MEDICINE, Issue 3 2007Judd E. Hollander MD Background: Accurate identification of patients with acute coronary syndromes (ACSs) in the emergency department (ED) remains problematic. Studies have not been able to identify a cohort of patients that are safe for immediate ED discharge; however, prior studies have not examined the utility of a clear-cut alternative noncardiac diagnosis. Objectives: To compare the 30-day event rate in ED chest pain patients who were diagnosed with a clear-cut alternative noncardiac diagnosis with the 30-day event rate in the cohort of patients in whom a definitive diagnosis could not be made in the ED. Methods: This was a prospective cohort study of consecutive ED patients with potential ACS. Data included demographics, medical and cardiac history, laboratory and electrocardiogram results, and whether or not the treating physician ascribed the condition to a clear-cut alternative noncardiac diagnosis. The main outcome was death, acute myocardial infarction (AMI), or revascularization within 30 days, as determined by phone follow-up or medical record review. Results: The investigators enrolled 1,995 patients in the ED who had potential ACSs. Overall, 77 had a final hospital diagnosis of AMI (4%). Within 30 days, 73 patients received revascularization (4%), and 26 died (1%). There were 599 (30%) patients given a clear-cut alternative noncardiac diagnosis. Comparing the patients with a clear-cut alternative noncardiac diagnosis with those without an obvious noncardiac diagnosis, the presence of a clear-cut alternative noncardiac diagnosis was associated with a reduced risk of an in-hospital triple-composite endpoint (death, MI, and revascularization), with a risk ratio of 0.32 (95% confidence interval [CI] = 0.19 to 0.55) and 30-day triple-composite endpoint with a risk ratio of 0.45 (95% CI = 0.29 to 0.69); however, patients with a clear-cut alternative noncardiac diagnosis still had a 4% event rate at 30 days (95% CI = 2.4% to 5.6%). Conclusions: In the ED chest pain patient, the presence of a clear-cut alternative noncardiac diagnosis reduces the likelihood of a composite outcome of death and cardiovascular events within 30 days. However, it does not reduce the event rate to an acceptable level to allow ED discharge of these patients. [source] Early treatment after a symptomatic event is not associated with an increased risk of stroke in patients undergoing carotid stentingEUROPEAN JOURNAL OF NEUROLOGY, Issue 1 2008K. Gröschel A recently symptomatic carotid artery stenosis carries a high risk of subsequent ischaemic events and thus requires rapid treatment. We investigated the influence of the time delay between the last symptomatic event of a carotid stenosis and subsequent carotid artery stenting (CAS) with respect to the combined 30-day outcome of stroke and death. In a group of 320 patients undergoing CAS the median delay before the intervention was 19 days (interquartile range 10,36) and the combined 30-day complication rate was 8.4%. Time delay was not significantly associated with peri-procedural complications, regardless of whether this variable was dichotomized (<14 days and ,14 days), separated into interquartile ranges or analysed as a continuous variable. Our results indicate that early CAS is not associated with an increased complication rate in patients with a recently symptomatic carotid stenosis. Thus, if CAS has been selected as the treatment modality for a patient, it should be performed as soon as possible to maximize the benefit of the intervention in reducing the risk of stroke. [source] Thirty-day Outcomes of Emergency Department Patients Undergoing Electrical Cardioversion for Atrial Fibrillation or FlutterACADEMIC EMERGENCY MEDICINE, Issue 4 2010Frank Xavier Scheuermeyer MD Abstract Objectives:, While the short-term (<7-day) safety and efficiency of electrical cardioversion for emergency department (ED) patients with atrial fibrillation or flutter have been established, the 30-day outcomes with respect to stroke, thromboembolic events, or death have not been investigated. Methods:, A two-center cohort of consecutive ED patients undergoing cardioversion for atrial fibrillation or flutter between January 1, 2000, and September 30, 2007, was retrospectively investigated. This cohort was probabilistically linked with both a regional ED database and the provincial health registry to determine which patients had a subsequent ED visit or hospital admission, stroke, or thromboembolic event or died within 30 days. In addition, trained reviewers performed a detailed chart abstraction on 150 randomly selected patients, with emphasis on demographics, vital signs, medical treatment, and predefined adverse events. Hemodynamically unstable patients or those whose condition was the result of an underlying acute medical diagnosis were excluded. Data were analyzed by descriptive methods. Results:, During the study period, 1,233 patients made 1,820 visits for atrial fibrillation or flutter to the ED. Of the 400 eligible patients undergoing direct-current cardioversion (DCCV), no patients died, had a stroke, or had a thromboembolic event in the following 30 days (95% confidence interval [CI] = 0.0 to 0.8% for all outcomes). A total of 141 patients were included in the formal chart review, with five patients (3.5%, 95% CI = 0.5% to 6.6%) failing cardioversion, six patients (4.3%, 95% CI = 0.9% to 7.6%) having a minor adverse event that did not change disposition, and five patients (3.5%, 95% CI = 0.5% to 6.6%) admitted to hospital at the index visit. Conclusions:, Cardioversion of patients with atrial fibrillation or flutter in the ED appears to have a very low rate of long-term complications. ACADEMIC EMERGENCY MEDICINE 2010; 17:408,415 © 2010 by the Society for Academic Emergency Medicine [source] The STRokE DOC trial technique: ,video clip, drip, and/or ship'INTERNATIONAL JOURNAL OF STROKE, Issue 4 2007B. C. Meyer Rationale To describe the clinical trial methods of a site-independent telemedicine system used in stroke. Aims A lack of readily available stroke expertise may partly explain the low rate of rt-PA use in acute stroke. Although telemedicine systems can reliably augment expertise available to rural settings, and may increase rt-PA use, point-to-point systems do require fixed base stations. Site-independent systems may minimize delay. The STRokE DOC trial assesses whether site-independent telemedicine effectively and efficiently brings rt-PA to a remote population. Design STRokE DOC is a 5-year, 400-participant, noninvasive trial, comparing two consultative techniques at four remote sites. Participants are randomized to acute ,STRokE DOC telemedicine' or ,telephone' consultations. Treatment decision accuracy is adjudicated at two time points, using three levels of data availability and an independent auditor. Study outcomes The primary outcome measure is whether there was a ,correct decision to treat or not to treat using rt-PA' at each of three adjudication levels (primarily at Level #2). Secondary outcomes include the number of thrombolytic recommendations, intracerebral hemorrhage, and 90-day outcomes. Using the STRokE DOC system (or telephone evaluation), medical history, neurologic scales, CT interpretations, and recommendations have been completed on over 200 participants to date. Of the initial 11, nonrandomized, ,run-in' patients, six (65%) were evaluated wirelessly, and five (45%) were evaluated with a site-independent LAN or cable modem. Three (27%) received rt-PA. The adjudication methodology was able to show both agreements and disagreements in these 11 cases. It is feasible to perform site-independent stroke consultations, and adjudicate those cases, using the STRokE DOC system and trial design. Telemedicine efficacy remains to be proven. [source] Carotid artery stenting in high surgical risk patients using the FiberNet® embolic protection system: The EPIC trial results,CATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 6 2010FACC, Subbarao Myla MD Abstract Objective: The multicenter EPIC (FiberNet Embolic Protection System in Carotid Artery Stenting Trial) single-arm trial evaluated the 30-day outcomes of a new design concept for embolic protection during carotid artery stenting (CAS). Background: Embolic protection filters available for use during CAS include fixed and over-the-wire systems that rely on embolic material capture within a "basket" structure. The FiberNet® Embolic Protection System (EPS), which features a very low crossing profile, consists of a three-dimensional fiber-based filter distally mounted on a 0.014 inch guidewire with integrated aspiration during filter retrieval. Methods: The trial enrolled 237 patients from 26 centers. Demographics, clinical and lesion characteristics, as well as adverse events through a 30-day follow-up were recorded. The mean age of the patients was 74 years, 64% were male and 20% had symptomatic carotid artery disease. Results: The combined major adverse event (MAE) rate at 30 days for all death, stroke, and myocardial infarction was 3.0%. There were three major strokes (two ischemic and one hemorrhagic) and two minor strokes (both ischemic) for a 2.1% 30-day stroke rate. The procedural technical success rate was 97.5% and macroscopic evidence of debris was reported in 90.9% of the procedures. Conclusions: The FiberNet EPS, used with commercially available stents, produced low stroke rates following CAS in high surgical risk patients presenting with carotid artery disease. The unique filter design including aspiration during retrieval may have contributed to the low 30-day stroke rate reported during CAS in patients considered at high risk for complications following carotid endarterectomy (CEA). © 2009 Wiley-Liss, Inc. [source] Carotid stenting with a new system for distal embolic protection and stenting in high-risk patients: The carotid revascularization with ev3 arterial technology evolution (CREATE) feasibility trialCATHETERIZATION AND CARDIOVASCULAR INTERVENTIONS, Issue 1 2004Robert D. Safian MD Abstract The purpose of this study was to evaluate the feasibility of carotid artery revascularization using a new system for carotid stenting and distal embolic protection in 30 patients with severe carotid stenosis and high risk for carotid endarterectomy (Carotid Revascularization With ev3 Arterial Technology Evolution, or CREATE). Previous studies suggest that patients with carotid stenosis and serious comorbid cardiopulmonary and anatomic conditions are at high risk for carotid endarterectomy. All patients underwent percutaneous revascularization using the Protégé GPS self-expanding nitinol stent (ev3, Plymouth, MN) and the Spider distal embolic protection system (ev3). In-hospital and 30-day outcomes were analyzed. High-risk features included age > 75 years (63%), left ventricular ejection fraction < 35% (20%), and restenosis after prior carotid endarterectomy (53%). Procedural success was 100%. In-hospital complications included severe vasovagal reactions in six patients (20%) and a popliteal embolus in one patient (3.3%), treated by successful embolectomy. During 30 days of follow-up, two patients (6.6%) experienced minor neurological deficits, including transient expressive aphasia that resolved without therapy in one patient and homonymous hemianopsia due to contralateral posterior circulation stroke in one patient. This study supports the feasibility of percutaneous carotid artery revascularization with the Protégé GPS self-expanding stent and Spider distal embolic protection system, which will be evaluated in a large multicenter pivotal trial (CREATE Pivotal Trial). Catheter Cardiovasc Interv 2004;63:1,6. © 2004 Wiley-Liss, Inc. [source] Multiple synchronous colonic anastomoses: are they safe?COLORECTAL DISEASE, Issue 2 2010S. D. Holubar Abstract Objective, To evaluate short-term outcomes after construction of synchronous colonic anastomoses without fecal diversion. Method, Using a prospective procedural database, all adult general surgery patients who underwent two synchronous segmental colon resections and anastomoses without ostomy at our institution from 1992,2007 were identified. Demographics, operative techniques, and 30-day outcomes are reported. Results are number (percent) of patients or median (interquartile range). Results, Over 15 years, 69 patients underwent double colonic anastomoses [40 males, age 63 (45,76) years, BMI 25.3 (22.9,28.7) kg/m2]. Multiple colonic anastomoses were performed in one of every 201 colectomies during the study period (0.5%). The operation was an emergency in two (3%) cases; most cases were clean-contaminated 56 (81%). Ten (17%) cases were laparoscopic-assisted with a 44% conversion rate. Length of stay was seven (5,10) days. Overall 30-day morbidity was 36% including nine (13%) surgical site infections, two (2.9%) intra-abdominal abscesses requiring percutaneous drainage, and one (1.4%) wound dehiscence. There were no anastomotic leaks or fistulas, and two patients (2.9%) died within 30 days from pulmonary sepsis and complications from a distal anastomotic hemorrhage, respectively. Conclusions, Synchronous colon anastomoses without fecal diversion do not appear to be associated with an increased risk of complications and can be safely constructed in selected patients. [source] | ||||||||||