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West Carson, CA, United States

Kim J.J.,Harbor University of California | Schwartz S.,Harbor University of California | Wen J.,Harbor University of California | De Virgilio C.,Harbor University of California | And 5 more authors.
American Surgeon | Year: 2015

Cognitive and emotional outcomes after carotid endarterectomy (CEA) and carotid artery stenting with embolic protection device (CAS + EPD) are not clear. Patients were entered prospectively into a United States Food and Drug Administration.approved singlecenter physiciansponsored investigational device exemption between 2004 and 2010 and received either CEA or CAS + EPD. Patients underwent cognitive testing preprocedure and at 6, 12, and 60 months postprocedure. Cognitive domains assessed included attention, memory, executive, motor function, visual spatial functioning, language, and processing speed. Beck Depression and anxiety scales were also compared. There were a total of 38 patients that met conventional indications for carotid surgery (symptomatic with .50% stenosis or asymptomatic with .70% stenosis).12 patients underwent CEA, whereas 26 patients underwent CAS + EPD. Both CEA and CAS + EPD patients showed postprocedure improvement in memory and executive function. No differences were seen at followup in regards to emotional dysfunction (depression and anxiety), attention, visual spatial functioning, language, motor function, and processing speed. Only two patients underwent neuropsychiatric testing at 60 months.these CAS + EPD patients showed sustained improvement in memory, visual spatial, and executive functions. In conclusion, cognitive and emotional outcomes were similar between CEA and CAS + EPD patients. © 2015 by the Southeastern Surgical Congress. Source

Vora A.N.,Duke University | Holmes D.N.,University of California at Los Angeles | Rokos I.,Harbor University of California | Roe M.T.,Harvard University | And 7 more authors.
JAMA Internal Medicine | Year: 2015

IMPORTANCE Guidelines for patients with ST-segment elevationmyocardial infarction (STEMI) recommend timely reperfusion with primary percutaneous coronary intervention (pPCI) or fibrinolysis. Among patients with STEMI who require interhospital transfer, it is unclear how reperfusion strategy selection and outcomes vary with interhospital drive times. OBJECTIVE To assess the association of estimated interhospital drive times with reperfusion strategy selection among transferred patients with STEMI in the United States. DESIGN, SETTING, AND PARTICIPANTS We identified 22 481 patients eligible for pPCI or fibrinolysis who were transferred from 1771 STEMI referring centers to 366 STEMI receiving centers in the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines database between July 1, 2008, and March 31, 2012. MAIN OUTCOMES AND MEASURES In-hospital mortality and major bleeding. RESULTS The median estimated interhospital drive time was 57 minutes (interquartile range [IQR], 36-88 minutes). When the estimated drive time exceeded 30 minutes, only 42.6%of transfer patients treated with pPCI achieved the first door-to-balloon time within 120 minutes. Only 52.7%of eligible patients with a drive time exceeding 60 minutes received fibrinolysis. Among 15 437 patients with estimated drive times of 30 to 120 minutes who were eligible for fibrinolysis or pPCI, 5296 (34.3%) received pretransfer fibrinolysis, with a median door-to-needle time of 34 minutes (IQR, 23-53 minutes). After fibrinolysis, the median time to transfer to the STEMI receiving center was 49 minutes (IQR, 34-69 minutes), and 97.1%underwent follow-up angiography. Patients treated with fibrinolysis vs pPCI had no significant mortality difference (3.7%vs 3.9%; adjusted odds ratio, 1.13; 95%CI, 0.94-1.36) but had higher bleeding risk (10.7%vs 9.5%; adjusted odds ratio, 1.17; 95%CI, 1.02-1.33). CONCLUSIONS AND RELEVANCE In the United States, neither fibrinolysis nor pPCI is being optimally used to achieve guideline-recommended reperfusion targets. For patients who are unlikely to receive timely pPCI, pretransfer fibrinolysis, followed by early transfer for angiography, may be a reperfusion option when potential benefits of timely reperfusion outweigh bleeding risk.. Copyright © 2015 American Medical Association. All rights reserved. Source

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