Surgery and stenting As combined treatment of a symptomatic tandem stenosis of the carotid artery.

International co-operative studies have demonstrated a benefit from surgery for symptomatic and asymptomatic patients affected by internal carotid artery stenosis of 60-70%. The presence of a tandem lesion, intracranial or extracranial, may annul the benefit of surgery. Such patients may thus represent a challenging problem for management if age, good general conditions and a normal neurological status favour a therapy. A 54-year-old man developed transient ischaemic attacks of the left hemisphere; his general condition was good, and neurological status was normal. Angiography showed a tight stenosis at the left common carotid artery near the ostium and at the homolateral carotid bifurcation. At first, a self-expanding wall stent was placed at the level of the common carotid artery stenosis, and immediately after a standard endarterectomy under general anaesthesia was performed. The postoperative course was normal and was complicated only by the presence of a mild deficit of the hypoglossal nerve due to the presence of a high bifurcation. The early and late outcome of our case suggests that stenosis of the proximal common carotid artery may be successfully treated by stenting. While awaiting additional data about this new technology, endovascular techniques and surgery may be complementary in the management of patients suffering from such tandem lesions.

The influence of length of stay in the ICU on power of discrimination of a multipurpose severity score (SAPS). ARCHIDIA.

OBJECTIVE: To assess how the power of discrimination of a multipurpose severity score (Simplified Acute Physiology Score; SAPS) changes in relation to the length of stay (LOS) in the intensive care unit (ICU). DESIGN: In order to compute the SAPS probability, a model derived from logistic regression was developed in a cohort of 8059 patients. Measures of calibration (goodness-of-fit statistics) and discrimination [receiver operating characteristic (ROC) curve and relative area under the curve (AUC)] were adopted in a developmental set (5389 patients) and a validation set (2670 patients), both randomly selected. Once the logit was developed and the model validated, the whole database (8059 patients) was again assembled. To evaluate the accuracy of first-day SAPS probability over time, area under the ROC curve was computed for each of the initial 10 days of ICU care and for day 15. SETTING: 24 Italian ICUs. PATIENTS: A total of 8059 patients out of 10065 consecutive admissions over a period of 3 years (1990-1992) were included in this study. Patients whose SAPS was not correctly compiled (n = 687), patients younger than 18 years (n = 442), and patients whose LOS was less than 24 h (n = 877) were excluded from this analysis. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The logistic model gave good results in terms of calibration and discrimination, both in the developmental set (goodness-of-fit: chi 2 = 9.24, p = 0.32; AUC = 0.79 +/- 0.01) and in the validation set (goodness-of-fit: chi 2 = 8.95, p = 0.537; AUC = 0.78 +/- 0.01). The AUC for the whole database showed a loss in discrimination closely related to LOS: 0.79 +/- 0.01 at a day 1 and 0.59 +/- 0.02 at day 15. CONCLUSION: The logistic model that we developed meets high standards for discrimination and calibration. However, SAPS loses its discriminative power over time; accuracy of prediction is maintained at an acceptable level only in patients who stay in the ICU no longer than 5 days. The stay in the ICU represents a complex variable, which is not predictable, that influences the performance of SAPS on the first day.

[Adequacy of admission in neurosurgical intensive care]. / Appropriatezza dei ricoveri in terapia intensiva neurochirurgica.

OBJECTIVE: The Intensive Care Units of Milano metropolitan area are characterized by difficulties of hospitalization for acutely injured patients due to the low bed availability. We evaluated the problem trying to find out possible solutions. DESIGN: On the day of achieved neurological and neurosurgical stability-defined as the day when the intracranial pressure and jugular venous oxygen saturation monitoring, hyperventilation, osmotic therapy were considered no longer needed--the monitoring procedures and instrumental and/or pharmacological treatments that the patients received were recorded and classified as follows: 1) intensive, 2) intermediate, 3) non-intensive. PATIENTS: All the acutely injured patients admitted at five Neurosurgical ICUs during June-July and October-November 1994 have been studied. Only one of these ICUs had a "sub-intensive unit". MEASUREMENTS AND MAIN RESULTS: 391 patients (29.9%) aneurysms and arteriovenous malformations, 25.1% tumours, 2.8% head injuries, 8.7% spontaneous intracranial haematomas, 13.5% various pathologies) were studied. Out of them 358 had an acute brain failure. 16.5% died during brain failure and 83.5% reached neurological stability within 3 days. When neurological stability was reached 32.1% of patients could be classified as "intensive", 63.6% as "intermediate" and 4.3% as "unintensive". In the four ICUs, without sub-intensive ward facilities, 361 patients were admitted with a total amount of 2292 days of hospitalization. Among them 61.9% were spent for a) patients with no brain injury (32 pts/113 days), b) postoperative patients (113 pts/167 days), c) patients in stable neurological conditions (159 pts/1139 days). Therefore, only 38% of the days recorded were given to patients that needed neurointensive care. CONCLUSION: Out data suggest that the receptivity for acute injured patients could be increased creating recovery room units and intermediate post-intensive units together with a better interchange between general and neurosurgical ICUs.

Influences of neural mechanisms on heart period and arterial pressure variabilities in quadriplegic patients.

The heart period (R-R) variability power spectrum presents two components, at low (LF; approximately 0.10 Hz) and high (approximately 0.25 Hz) frequencies, whose reciprocal powers appear to furnish an index of sympathovagal interaction modulating heart rate. In addition, the LF component of the systolic arterial pressure variability spectrum furnishes a marker of sympathetic modulation of vasomotor activity. The contribution of spinal and supraspinal neural circuits to the genesis of these rhythmic oscillatory components remains largely unsettled. Therefore we performed spectral analysis of R-R and systolic arterial pressure variabilities in 15 chronic neurologically complete quadriplegic patients (QP) and in 15 control subjects during resting conditions, controlled respiration, and head-up tilt. At rest, in seven QP the LF component was undetectable in both cardiovascular variability spectra; in two QP this component was present only in R-R variability spectrum, whereas the remaining six showed a significantly reduced LF in both signals. In QP, the LF component, when present, underwent paradoxical changes with respect to controls, decreasing during tilt and increasing during controlled respiration. In five QP in whom the recording session was repeated after 6 mo, a significant increase in LF was observed in both variability spectra. These data confirm the finding that a disconnection of sympathetic outflow from supraspinal centers can cause the disappearance of the LF spectral component. However, LF presence in some QP supports the hypothesis of a spinal rhythmicity likely to be modulated by the afferent sympathetic activity.

[A retrospective study on the use of preoperative percutaneous drainage in uncomplicated obstructive jaundice]. / Studio retrospettivo sull'impiego dei drenaggi percutanei preoperatori nell'ittero ostruttivo non complicato.

This study concerns a retrospective analysis of the use of preoperative percutaneous biliary drainage in the treatment of obstructive jaundice complicated or not by cholangitis. From 1980 to 1987, 87 patients were selected; among these, only those with bilirubin greater than 5 mg% and an overt indication to surgery were included in the study. It was so possible to match two relatively homogeneous populations, e.g. patients submitted to preoperative drainage vs patients not drained. According to our experience, a preoperative percutaneous biliary drainage does not affect postoperative mortality, incidence of immediate postoperative complications and length of hospitalisation. These results are probably linked to a predominant use of the drainage in absence of infectious complications.