US nationwide trends in carotid revascularization: hospital outcome and predictors of outcome from 1998 to 2007.

OBJECTIVES: The goals of the study were to assess US nationwide trends in hospital outcome following carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS) and to determine potential predictors of outcome. METHODS: The Nationwide Inpatient Sample, constituting a 20% representative and stratified sample of non-federal US hospitals, was analyzed retrospectively from years 1998 to 2007. RESULTS: The annual number of CEA decreased (137,877-111,658) and increased for CAS (2318-14,415). Inhospital mortality following CEA decreased from 0.4% to 0.3% (P < 0.001), whereas long-term facility (LTF) discharge increased from 8.2% to 10.5% (P < 0.001). Discharge outcome improved for CAS in both categories (mortality 2-0.5%; LTF discharge 10.7-8.3%; both P < 0.001). The trend analysis revealed an increase in patient age and a worsening comorbid profile over time. Age, women, length of stay, atrial fibrillation, and carotid stenosis with infarction were important determinants of unfavorable hospital outcome. CONCLUSION: From a nationwide practice perspective, the number of carotid revascularizations fell by 10%. CEA has resulted in stable hospital mortality rates. Meanwhile, CAS has been increasingly utilized with overall improvement in short-term outcome. Our results further suggest a decrease in the number of patients with treatment-eligible carotid disease over time. However, the increasing prevalence of high-risk comorbidity in the aging population may pose a challenge to revascularization strategies.

US nationwide trends in carotid revascularization: is there a clinical opportunity cost associated with the introduction of novel medical devices?

OBJECTIVES: Nationwide practice patterns during the implementation of novel technology, such as carotid angioplasty and stenting (CAS) and embolic protection devices (EPD), and the clinical impact thereof have received less attention. METHODS: The Nationwide Inpatient Sample, constituting a 20% representative sample of non-federal US hospitals, was analyzed from years 1998 to 2007. Hospital outcome was stratified into in-hospital mortality (IHM), long-term facility discharge, and home/ short-term facility discharge (HSF). RESULTS: Discharge outcome improved for CAS over the decade. However, this improvement occurred in two phases with a period of worsening (2003-2005) in between. During this transition period, the risk of IHM following CAS was increased (RR 1.29-2.43) and was lower for good outcome (HSF: RR 0.97-0.99) when compared with 2002/2003. During the same transition period, carotid endarterectomy (CEA) was associated with a lower risk of IHM (RR 0.75-1.00), but also a lower risk of HSF (RR 0.98-0.99). CONCLUSIONS: The results lead to the hypothesis that the nationwide introduction of CAS-EPD may have been associated with temporary increases in in-hospital mortality and discharge morbidity. If such 'clinical opportunity costs' exist with the widespread introduction and adoption of new medical technology with proven efficacy in randomized trials, effective mechanisms are needed for mitigation or prevention during the transition period.

Fish consumption and school grades in Swedish adolescents: a study of the large general population.

AIM: To study the associations between fish intake and academic achievement as cognitive parameter among Swedish adolescents. METHODS: In 2000, a questionnaire including respiratory items, socioeconomic conditions and dietary information was mailed to all schoolchildren (n = 18 158), aged 15 and living in Västra Götaland region of Sweden. The questionnaire was returned by 10 837 subjects. One year later, the total school grades for each subject who had completed the questionnaire and who included their full personal identification number were obtained from the national registers. Multiple linear regression models were applied to evaluate the association between fish intake and academic grades among 9448 schoolchildren, while adjusting for potential confounders, e.g. parents' education. RESULTS: Grades were higher in subjects with fish consumption once a week compared with subjects with fish consumption of less than once a week (reference group) [increment in estimate 14.5, 95% confidence interval (CI) 11.8-17.1]. Grades were even higher in subjects with fish consumption of more than once a week compared with the reference group (increment in estimate 19.9, 95% CI 16.5-23.3). In the model stratified for parents' education, there were still higher grades among subjects with frequent fish intake in all educational strata (p < 0.01). CONCLUSION: Frequent fish intake among schoolchildren may provide benefits in terms of academic achievement.

Does tobacco smoking influence the occurrence of hand eczema?

BACKGROUND: Tobacco smoking is known to influence various inflammatory skin diseases and an association between tobacco smoking and hand eczema has been proposed in some studies. OBJECTIVES: To examine a possible association between reported current tobacco smoking and the occurrence of hand eczema. SUBJECTS AND METHODS: Previously collected questionnaire data on the occurrence of hand eczema in three occupational cohorts and corresponding controls from the general population were studied. The questionnaires used included questions on 1-year prevalence of hand eczema and questions on smoking habits. For one occupational group, hairdressers and their controls, information on amount of smoking was obtained. Information on age, sex and history of atopy was also available. RESULTS: In total, answers regarding smoking and hand eczema were obtained from 13,452 individuals. Out of 3493 smokers, 437 (12.5%) reported hand eczema compared with 1294 out of 9959 nonsmokers (13.0%) (P = 0.51). With regard to the number of cigarettes smoked, 22.6% of the hairdressers smoking more than 10 cigarettes per day reported hand eczema compared with 17.4% of those smoking 0-10 cigarettes per day (P = 0.01). Corresponding figures for the controls were 14.5% and 11.7%, respectively (P = 0.06). CONCLUSIONS: No clear association was found between 1-year prevalence of hand eczema and smoking. Heavy smoking, more than 10 cigarettes per day, may give a slightly increased risk of hand eczema. Further studies with information on the amount of tobacco consumption and on possible confounders are needed to evaluate smoking as a risk factor for hand eczema.

Contrast enhancement hyperdensity after endovascular coiling of intracranial aneurysms.

BACKGROUND AND PURPOSE: Endovascular coil embolization is used increasingly to treat cerebral aneurysms. The purpose of our study was to quantify the incidence of CT-detectable abnormalities after aneurysm coiling and map the radiographic and clinical progression. MATERIALS AND METHODS: We reviewed the radiographic and clinical sequelae of 30 consecutive patients with aneurysms who underwent endosaccular coiling followed by head CT scans. Patients with CT abnormalities received follow-up scans at 4 to 6 hours and 20 to 25 hours. Contrast enhancement was defined as CT hyperdensities with progressive resolution over 25 hours and a Hounsfield unit (HU) of less than 70. The incidence of CT abnormalities was recorded and correlated with amount of contrast used, use of antiplatelet agents, procedure time, and clinical sequelae. RESULTS: Seven patients (23%) had new hyperdensities on CT scan. Four showed gyral hyperattenuation; 1 showed basal ganglia hyperattenuation, and 2 showed a combination of these patterns. All were asymptomatic and were consistent with contrast enhancement, with complete resolution in 5 of 7 and partial resolution in 2 of 7 by 20 to 25 hours. Antithrombotic or antiplatelet medication was continued in all cases. The amount of contrast used (P = .014) and the use of antiplatelet medication (P = .029) were statistically correlated with the presence of hyperattenuation after aneurysm coiling, whereas the length of the procedure was not (P = .162). CONCLUSION: Contrast enhancement, unlike contrast extravasation, is a fairly common and clinically benign finding after aneurysm coiling. The enhancement resolves by 25 hours in most cases, regardless of the continuation of antithrombotic or antiplatelet therapy.

Treatment of cerebral aneurysms with hydrogel-coated platinum coils (HydroCoil): early single-center experience.

PURPOSE: The authors report their experience using HydroCoils in the treatment of cerebral aneurysms. METHODS: We performed a retrospective review of the first 100 nonrandomized patients (104 coiled saccular cerebral aneurysms) treated with HydroCoils during a 27-month period. RESULTS: The average percentage of HydroCoil by length detached in treated aneurysms was 45.5% (range, 9.9-100%). Immediate postprocedure angiography demonstrated complete aneurysm occlusion in 34%, neck remnant in 35%, and incomplete occlusion in 32%. Immediate procedure-related morbidity and mortality rates were 5.8% and 0%, respectively. Angiographic follow-up was obtained in 51% (51/100 patients; 53/104 aneurysms; average, 10.3 months; range, 0-31 months). In these 53 angiographically followed aneurysms, the overall recanalization rate was 21%: no recanalization occurred in 23 aneurysms with small size (<10 mm)/small neck (<4 mm) (S/S); 4 recanalizations occurred in 7 aneurysms with small size/wide neck (>4 mm) (S/W); 6 recanalizations (27%) occurred in 22 large (L) aneurysms (>10-25 mm, 70% angiographic follow-up); and 1 giant (G) (>25 mm) aneurysm recanalized. A large proportion of aneurysms that were not initially completely occluded were completely occluded on follow-up (15/43 [35%]). Clinical follow-up was obtained in 73 patients (73%; average, 5.3 months; range, 0-24 months): 93% of these patients were neurologically improved or unchanged. Three patients rehemorrhaged and 3 patients with unruptured aneurysms developed delayed hydrocephalus. CONCLUSIONS: The overall safety profile of HydroCoils appears acceptable. Preliminary midterm observations suggest less coil compaction/aneurysm recanalization in large aneurysms. However, HydroCoil-related delayed hydrocephalus is a concern.

MR spectroscopic changes in the rat hippocampus following proton radiosurgery.

PURPOSE: To identify MR spectroscopic changes in the rat hippocampus following proton radiosurgery. METHODS AND MATERIALS: A group of 12 rats were treated with Bragg peak proton beam irradiation involving the right hippocampus. Single doses of 30 CGE, 50 CGE, 70 CGE, 90 CGE were delivered to groups of 3 animals using single fraction technique. Animals were imaged using a standard 3 T GE Signa MRI at 4 months following treatment. An untreated animal was also studied. A 3'' surface coil was employed to obtain T1 weighted coronal pre- and post-gadolinium images (TR 600 and TE 30) and dual echo T2 weighted coronal images (TR 3000, TE 30/90). Volumetric analysis with custom software was done to evaluate areas of increased signal on T2 weighted images and the development of hydrocephalus was examined. Animals were sacrificed and specimens of the treated hippocampus were harvested for High Resolution Magic Angle Spinning MR Spectroscopy (HRMAS) followed by histopathology of the tissue samples. Peak values of choline, creatine, N-acetyl aspartate and lipids were evaluated and compared. RESULTS: Peak tissue injury occurred in the surviving 90 CGE animal by both T2 weighted and post-gadolinium imaging. Gadolinium enhancement was seen in decreasing volumes of tissue at dosage levels from 90 to 50 CGE. Hydrocephalus was seen on the untreated side in the 90 CGE animal likely because of mass effect, while it was seen in small degrees in the side of treatment in the 70 and 50 CGE animals. Histopathology showed changes at 90 and 70 CGE, but not at 50 or 30 CGE at this time point using H and E stains. HRMAS showed spectroscopic changes in the surviving 90 and 70 CGE animals but not in the 50 and 30 CGE animals. Statistical significance was not reached because of the small sample size. CONCLUSIONS: Following single dose proton radiosurgery of rat hippocampus, HRMAS is able to identify metabolic changes induced by radiation. Studies built on these principles may help develop non-invasive MR spectroscopic methods to distinguish radiation changes from tumor recurrence.

Pediatric Thoraco-lumbar Paraspinal Arteriovenous Fistulas along the Segmental Nerve. Diagnosis and Endovascular Treatment.

SUMMARY: To characterize the clinical presentation, imaging features and endovascular treatment of paraspinal non-vertebral arteriovenous fistulas along the segmental nerve. Retrospective review was performed on the five patients identified in our database covering 1985 to 2003. All patients presented with an incidentally found continuous murmur over the upper paraspinal or parasternal regions before three years old. In four patients, the AV fistula was in the mid-thoracic level and at L3 in one. All AV fistulas were a high-flow single-hole fistula at the neural foramen with venous drainage into paraspinal and epidural veins without intradural reflux. All fistulas were endovascularly occluded in the same session as the diagnostic angiography. The fistula was occluded with detachable coils in one case and with N-butylcyanoacrylate (NBCA) with flow control in four cases. Complete occlusion of the fistula was obtained in all cases and all patients remained neurologically intact at the last follow up (average six years). Non-vertebral paraspinal arteriovenous fistula along the segmental nerve is a specific disease entity seen in children. Embolization is the first choice of treatment for this disease.

Exposure-response relations for work related respiratory symptoms and sensitisation in a cohort exposed to alpha-amylase.

AIMS: To explore relations between exposure to fungal alpha-amylase and the risk of new work related respiratory symptoms or sensitisation. METHODS: A prospective cohort study among 300 bakers and millers was followed up for a maximum of seven years. Exposure to alpha-amylase was estimated by air measurements and questionnaires and classified into three categories. Symptoms were recorded with a self-administered questionnaire and skin sensitisation assessed using skin prick test (SPT). RESULTS: There were 36 new cases of chest symptoms, 86 of eyes/nose symptoms, and 24 of a positive SPT to alpha-amylase. There were exposure-response relations for chest and eyes/nose symptoms and for sensitisation, and a significantly increased prevalence ratio for chest symptoms in the highest exposure category. CONCLUSION: A reduction in alpha-amylase exposure is likely to reduce the risk for respiratory morbidity in bakery workers.

Hand eczema in 45 bakers - a clinical study.

The skin of bakers is heavily exposed to dough, spices, water and detergents. This is follow-up of a previous Swedish questionnaire study showing bakers to have a 3-fold increased risk of hand eczema. The aims were to establish diagnoses and to study consequences of hand eczema. From a cohort study of 2226 bakers, a random sample among bakers reporting hand eczema was examined. Of 60 randomly selected bakers reporting a history of hand eczema, 52 attended an examination comprising a standardized interview, documentation of clinical skin signs, patch testing and prick testing with standard and bakery series, and serum analyses. In all, 45 bakers confirmed a history of hand eczema, for which 11 (24%) had been on sick leave, with a median duration of 14 weeks. 13 (29%) had changed their occupation due to skin disease, 19 had positive patch test reactions to standard contact allergens - and 5 to bakery contact allergens. 16 bakers had positive prick tests to standard allergens, 10 to bakery allergens, of whom 9 reacted to flours. Since considerable medical and social consequences of hand eczema are seen, thorough diagnosis of contact allergy and IgE-mediated allergy in bakers, as well as preventive measures, are essential.

Incidence of asthma in female Swedish hairdressers.

OBJECTIVE: To investigate the risk of asthma in hairdressers. METHODS: The incidence of asthma was retrospectively estimated in a Swedish nationwide study including all female hairdressers certified from vocational schools from 1970 to 1995, and a stratified sample of women from the general population were referents. A postal questionnaire included questions on respiratory tract symptoms, atopy, smoking, working periods as a hairdresser, and number of specific hair treatments performed/week. Reported exposures were validated by occupational hygienists. Rate ratios of incidence (IRRs) of asthma were estimated by Poisson regression, adjusted for calendar year of observation, hay fever, smoking, and region of domicile. RESULTS: The crude incidences of asthma/1000 person-years were: 3.9 during active years as a hairdresser, 2.8 among the hairdressers when not working in the profession, and 3.1 among the referents. The corresponding IRR for being an active hairdresser compared with the referents was 1.3 (95% confidence interval (95% CI) 1.0 to 1.6). Moderate effects on risk of asthma were found both from hairdressing work (IRR=1.6 (1.1 to 2.2) among never-smokers) and from smoking (IRR=1.6 (1.2 to 2.2) among referents). However, the combined effect from hairdressing work and smoking (IRR=1.5 (1.0 to 2.1)) was less than expected (p=0.02). No effect modification by respiratory atopy was found. The hairdressers most often performing hair bleaching treatments (IRR=1.5 (0.7 to 3.0)) or using hair spray (IRR=1.4 (0.8 to 2.4)) had, compared with the most infrequent users, a slightly, but not significantly higher incidence of asthma. Exposure to persulphates in hair bleach was estimated to be 0.04-0.15 mg/m(3) during mixing of the powder. Reported average number of bleaching treatments agreed well with those performed according to a diary. CONCLUSIONS: Active hairdressing work was associated with a moderately increased incidence of asthma among lifelong non-smokers. The results are moderately supportive, but not conclusive, of associations between asthma and exposure to hair bleach or hair spray.

Adult-onset asthma is associated with self-reported mold or environmental tobacco smoke exposures in the home.

BACKGROUND: In recent years, we have gained better knowledge about the influence of indoor environments on respiratory symptoms and asthma. The purpose of this study was to examine certain exposures in the home environment and the risk of adult-onset asthma. METHODS: A nested case-referent study of adult-onset asthma was performed in a random population sample (n = 15813), aged 20-50 years. Cases for the study included subjects reporting "physician-diagnosed" asthma (n= 174). The referents (n = 870) were randomly selected from the whole population sample. The case-referent sample was investigated with a comprehensive mailed questionnaire about exposures in the home environment, asthma, respiratory symptoms, smoking habits, and atopy. Odds ratios (OR) with 95% confidence intervals (CI) were calculated while controlling for age, sex, smoking, and atopy. RESULTS: Increased adjusted OR for asthma were associated with exposure to molds (OR 2.2, 95%, CI 1.4-3.5), environmental tobacco smoke (OR 2.4, 95%, CI 1.4-4.1), and the presence of a wood stove (OR 1.7, 95% CI 1.2-2.5). CONCLUSIONS: This population-based case-referent study indicates that self-reported domestic exposures to molds or environmental tobacco smoke can be associated with adult-onset asthma.

Extramedullary hemangioblastoma of the conus medullaris.

BACKGROUND: We report the case of an extramedullary pathologically proven hemangioblastoma of the conus medullaris. As spinal dural arteriovenous fistulas most commonly present with a conus medullaris syndrome, our presentation of the MRI, myelographic, and angiographic findings of this unique lesion may be useful in differentiating these two entities. CLINICAL MATERIAL: We report the case of a 57 year old woman with a two year history of progressive low back and right lower extremity pain and weakness. Spinal MRI and myelography demonstrated serpiginous vasculature on the dorsum of the spinal cord consistent with either a vascular tumor or malformation. Selective spinal angiography was thus undertaken by the neuroendovascular team which revealed a tumor nodule consistent with vascular tumor. T12-L1 laminectomy was performed and a 6 mm vascularized tumor was found in the intradural extramedullary compartment adjacent to the conus medullaris. The tumor was completely removed and pathological analysis was consistent with hemangioblastoma. CONCLUSION: This report documents a unique location for extramedullary spinal hemangioblastomas. Although both MRI and myelography are helpful in studying these lesions, angiography remains the gold standard in differentiating between vascular tumor and malformation. We suggest that the angiography be performed by a neurointerventional team to facilitate embolization, should this be warranted.

Asthma on the job: work-related factors in new-onset asthma and in exacerbations of pre-existing asthma.

Occupational asthma (OA) can be defined as variable airways narrowing causally related to exposure in the working environment to airborne dusts, gases, vapours or fumes. There are many agents in the work-place that can induce asthma or cause substantial deterioration in pre-existing asthma. It has been estimated that 5-15% of adult-onset asthma can be attributed to occupational exposures. Hence adult patients, especially those with new-onset asthma, must be investigated with regard to occupational risk factors for disease. The prognosis for OA is improved if the causal exposure is controlled either by controlling the exposure at the workplace or by moving the patient out of the workplace.

Exposure-response relations for self reported asthma and rhinitis in bakers.

OBJECTIVES: To explore relations between two estimates of exposure to inhalable flour dust, and the incidence rates (IRs) of asthma and rhinitis in bakers. METHODS: This was a retrospective cohort study among 2923 bakers. A posted questionnaire registered the disease and work history. For every year, each baker was assigned an estimate of the exposure concentration to inhalable flour dust derived from reported job-tasks and dust measurements. Exposure at onset of disease was expressed as current dust exposure concentration, and as cumulative dose of exposure to dust. A multiple Poisson regression analysis assessed the impacts of the exposure estimates on the IRs of asthma and rhinitis. RESULTS: IRs of asthma and rhinitis increased by dust concentration at onset of disease. The IR of asthma for the bakers with highest exposure (dough makers) was 7. 3/1000 person-years in men and 6.5 in women and for rhinitis 43.4 and 38.5, respectively. There was a significant association between the dust concentration at onset of disease and the risk for asthma or rhinitis, but not of the cumulative exposure. CONCLUSION: The risk of asthma seemed to be increased at inhalable dust concentrations >/=3 mg/m(3) (dough making or bread forming), whereas the risk of rhinitis was increased at all concentrations >/=1 mg/m(3), indicating an increased risk in all bakery job-tasks. The risks seemed to be less dependent on the cumulative exposure dust than the inhalable dust concentrations.

Adult-onset asthma and occupational exposures.

OBJECTIVES: This study examined certain occupational exposures and the risk for adult-onset asthma. METHODS: A nested case-referent study of adult-onset asthma was performed on a random population sample (N=15813), aged 21 to 51 years. Cases for the study included 2 groups: subjects reporting "physician-diagnosed" asthma (N=251) and a broader "asthma" group (N=362). The "asthma" group consisted of subjects with "physician-diagnosed" asthma (N=251) and subjects reporting asthma-like symptoms without having "physician-diagnosed" asthma (N=111). The referents (N=2044) were randomly selected from the whole population sample. The case-referent sample was investigated with a comprehensive questionnaire about occupational exposures, asthma, respiratory symptoms, smoking, and atopy. Odds ratios were calculated with stratification for gender, year of diagnosis, and birth year. RESULTS: The highest odds ratio for "physician-diagnosed" asthma was associated with exposure to flour dust [odds ratio (OR) 2.8, 95% confidence interval (95% CI) 1.5-5.2] and the occupational handling of resin-based paints (isocyanates) (OR 3.0, 95% CI 1.6-5.9). Exposure to welding fumes, textile dust, and work with glues containing acrylates was also associated with an increased odds ratio for "physician-diagnosed" asthma. Including persons with asthma-like symptoms (ie, the asthma group) showed similar results. CONCLUSION: This population-based case-referent study from Sweden indicates that occupational exposure to acrylate-based compounds and welding fumes is associated with increased risk for adult-onset asthma.