Multistate utilization, processes, and outcomes of carotid endarterectomy.

OBJECTIVES: The purpose of this study was to describe variation in utilization, care processes, and outcomes for carotid endarterectomy (CEA) procedures in 10 states. METHODS: We reviewed the medical records of Medicare patients who underwent 10,561 CEA procedures between June 1, 1995, and May 31, 1996, in 10 different states to determine indications, care processes, and outcomes. This study also included medical record review of hospital readmissions within 30 days of the procedure and identification of out-of-hospital deaths from the Medicare beneficiary files. RESULTS: Utilization rates of CEA varied from 25.7 to 38.4 procedures per 10,000 Medicare beneficiaries among states. The overall combined event rate (30-day stroke or mortality) was 5.2% for primary CEA alone (n = 9945). The mortality rate was 1.5%, and the nonfatal stroke rate was 3.7%. Combined event rates (CEA alone) by surgical indication were 7.7% for stroke (n = 1037), 7.4% for transient ischemic attack (n = 1304), 5.3% for nonspecific symptoms (n = 3713), and 3.7% for asymptomatic patients (n = 3891). The combined event rates (CEA alone) among states ranged from 4.1% to 7.7% with the event rates in asymptomatic patients ranging from 2.3% to 6.7%. In a multivariate analysis (correcting for indication), the use of preoperative antiplatelet agents (odds ratio [OR], 0.70), intraoperative heparin (OR, 0.49), and patch angioplasty (OR, 0.73) was significantly associated with lower combined event rates. There were significant differences among states in the use of preoperative antiplatelet therapy (range, 56%-70%) and patch angioplasty (range, 11%-49%). Combined event rates for repeat procedures (n = 380) and CEA combined with coronary artery bypass grafting (n = 236) were 6.3% and 17.4%, respectively. CONCLUSIONS: The striking variation among states suggests that there is room for improvement in the utilization, care processes, and outcomes of CEA. All surgeons performing CEA should participate in outcome assessment and adopt protocols that include the routine administration of antiplatelet agents preoperatively, the use of heparin intraoperatively, and patch angioplasty of the endarterectomy site.

Carotid endarterectomy among Medicare beneficiaries: a statewide evaluation of appropriateness and outcome.

BACKGROUND AND PURPOSE: We sought to examine the appropriateness and the surgical outcomes of carotid endarterectomy (CE) in unselected community hospitals to identify opportunities for improvement. METHODS: We performed a retrospective review of all CEs performed on Medicare beneficiaries in Georgia in 1993 (n = 1945). Conclusions regarding appropriateness were based on current guidelines as interpreted by a physician reviewer and were supported by the aggregate results of structured, blinded overreading by clinicians with relevant expertise. Adverse outcomes were confirmed and rated as to severity by a physician. Outcomes were correlated with demography, vascular anatomic findings, comorbidity, surgical techniques, and hospital characteristics. RESULTS: The majority of the patients (51%) were asymptomatic at presentation. CEs were performed appropriately in 96.1% of the cases in accordance with current guidelines. There was no significant difference in the rate of appropriateness between the symptomatic (96%) and the asymptomatic patients (96.4%). Survival without stroke or myocardial infarction (MI) was 94.3%. The 30-day mortality was 1.9%; moderate to severe strokes occurred in 1.8%, stroke-related death in 0.7%, MI in 1.1%, and MI-related death in 0.5%. Those hospitals performing <10 CEs in the observed year had a statistically significant higher morbidity and mortality as well as an increase in less severe complications such as hematomas, wound dehiscence, wound infection, and pneumonia than did hospitals with higher volume of CEs.. Older patients and women had statistically significantly higher morbidity and mortality. Patients with a Charlson Severity Index score of > or =1 had a risk for adverse outcomes 3.4 times higher than patients with a score of 0 after adjustment for age and sex. CONCLUSIONS: The great majority of CEs performed in Georgia on Medicare patients were appropriate, according to current guidelines. Slightly more than half of the patients were asymptomatic as defined in the Asymptomatic Carotid Atherosclerosis Study. In hospitals performing

Treatment trial of oxiracetam in Alzheimer's disease.

Twenty-four carefully assessed patients with probable Alzheimer's disease were enrolled in a double-blind, placebo-controlled treatment study of oxiracetam, a nootropic agent reported to improve memory performance in patients with dementia. A broad battery of neuropsychological tests failed to reveal any improvement in the treated group or in any treated patient when individual test scores were analyzed. These findings indicate that oxiracetam is ineffective in reducing cognitive impairment due to Alzheimer's disease.

Pentoxifylline in acute nonhemorrhagic stroke. A randomized, placebo-controlled double-blind trial.

The efficacy and safety of pentoxifylline were assessed in 297 adult patients with ischemic stroke in a multicenter, double-blind, randomized and placebo-controlled trial. Treatment was started within 12 hours after the stroke onset. Study medication was administered intravenously continuously (16 mg/kg/day, maximum 1,200 mg/day) for 3 days and per os (400 mg t.i.d.) for the remainder of 28 days. Demographic data were comparable, and functional impairment and mortality (pentoxifylline 12%, placebo 10%) were not different between the two groups. Neurologic deficit scores improved from baseline admission scores during the 4-week study in both groups but did not differ between groups at admission or throughout the study except during the first few days when the consciousness level (Days 1 and 2), motor function (Days 1 and 2), cranial nerve function (Days 1-4), and total neurologic deficit scores (Days 1 and 2) were better in the pentoxifylline group than in the placebo group, especially in a subset of patients with severe deficits at admission. Laboratory values and side effects were also comparable between groups. Our study indicates that pentoxifylline can be given safely in patients with acute ischemic stroke. Although pharmacologic effects were present during the first few days, the clinical benefits were small and not sustained.

Juvenile spinal muscular atrophy: a new hexosaminidase deficiency phenotype.

A 24-year-old Ashkenazi Jewish man was evaluated for a nine-year history of progressive leg weakness with fasciculations. Electromyography, nerve conduction velocities, muscle biopsy, and serum creatine kinase were consistent with anterior horn cell disease. On rectal biopsy, ganglion cells were filled with membranous cytoplasmic bodies and an unusual submucosal layer of periodic acid-Schiff positive histiocytes filled with granules was seen. Hexosaminidase A in serum and leukocytes was severely decreased in the patient and partially decreased in parents and a brother. A paternal relative had classic infantile Tay-Sachs disease. Juvenile spinal muscular atrophy in this patient, closely resembling the Kugelberg-Welander phenotype, resulted from an alpha-locus hexosaminidase deficiency disorder, possibly a genetic compound of HEX alpha 2 and a milder hexosaminidase alpha-locus allele. Other cases of hexosaminidase deficiency have included anterior horn cell disease as part of a more complex disorder, but this is the first case, to our knowledge, of a hexosaminidase deficiency disorder presenting as spinal muscular atrophy.

Risk of stroke in asymptomatic persons with cervical arterial bruits: a population study in Evans County, Georgia.

A survey of the rural community in Evans County, Georgia, revealed cervical arterial bruits in 72 (4.4 per cent) of 1620 persons 45 years of age of older without previous stroke, transient ischemic attacks, or overt ischemic heart disease. The prevalence of such asymptomatic bruits increased with age and was greater in women and persons with hypertension. We estimated the risk of stroke associated with cervical bruits during a six-year follow-up period, taking age and blood pressure into account. The presence of asymptomatic bruits was associated with a significantly higher risk of stroke in men but not in women, with odds ratios of 7.5 and 1.6, respectively. Despite the high risk of stroke among men with bruits, the correlation between the location of the bruits and the type of subsequent stroke was poor. Moreover, cervical bruits in men were a risk factor for death from ischemic heart disease. We suggest that asymptomatic cervical bruits are an indication of systemic vascular disease and do not themselves justify invasive diagnostic procedures or surgical correction of underlying extracranial arterial lesions.

Epidemiologic study of migraine symptoms in young women.

Information about headache was collected from a nonclinical sample of 451 women, aged 15 to 44, in 12 major U.S. cities. Questions were asked in regard to the presence in the past year of headache, and of the following characteristic symptoms of migraine: unilateral location, throbbing quality, visual aura, vomiting, and severity sufficient to affect daily activities. Twenty-three percent of the women had headaches with two or more of these characteristics. The frequency of such symptoms was significantly greater in women who smoked or formerly had smoked cigarettes, in women with lower incomes and poor education, and in women with a history of hypertension, stomach ulcer, fainting, and a variety of emotional complaints. The frequency of reported symptoms of migraine did not vary significantly according to age, race, marital status, use of oral contraceptives, or number of living children. These findings do not support the commonly held clinical impression that migraine is uncommon among blacks or among the poorly educated.