Clinical follow-up rather than duplex surveillance after carotid endarterectomy

AbstractPurpose: The value of duplex surveillance and the significance of contralateral carotid disease after endarterectomy have been assessed.Methods: Three hundred five patients were observed prospectively after carotid endarterectomy for a median time of 36 months (range, 6 to 96 months), with duplex surveillance performed at 1 day; 1 week; 3, 6, 9, and 12 months; and then each year after endarterectomy.Results: Thirty patients (10%) had ipsilateral symptoms (13 strokes, 17 transient ischemic attacks [TIAs]) at a median time of 6 months (range, 0 to 60 months). Life table analysis demonstrated that ipsilateral stroke was equally common for patients who had ≥50% restenosis (3% at 36 months) and those who did not (6% at 36 months, p > 0.5). Twenty-three patients (8%) developed symptoms (stroke 5, TIA 14) attributable to the contralateral carotid artery at a median time of 9 months (range, 0 to 36 months) after endarterectomy. By life table analysis, 40% of patients with 70% to 99%, 6% with 50% to 69%, 1% with <50% contralateral internal carotid stenosis, and 5% with contralateral carotid occlusion at the time of endarterectomy had a contralateral TIA in the 36 months after endarterectomy ( p < 0.01). However, contralateral stroke was not significantly more common for patients with severe contralateral internal carotid stenosis demonstrated at the time of endarterectomy (<50% stenosis, 0%; 50% to 69%, 3%; 70% to 99%, 7%; occlusion, 6% stroke rate at 36 months). Seven of the 32 patients who developed progression of contralateral disease had a TIA, compared with 11 of 227 patients who did not develop progression of contralateral disease ( p < 0.01). None of the 12 patients who progressed from a <70% to a 70% to 99% contralateral stenosis had a stroke.Conclusions: After carotid endarterectomy restenosis is rarely associated with symptoms; contralateral stroke is rare and is not associated with progressive internal carotid artery disease suitable for endarterectomy. This study has shown no benefit from long-term duplex surveillance after carotid endarterectomy. Selective clinical follow-up of patients who have high-grade contralateral stenoses would appear more appropriate. (J Vasc Surg 1997;25:55-63.

Costs and quality of life for prehabilitation and early rehabilitation after surgery of the lumbar spine

During the recent years improved operation techniques and administrative procedures have been developed for early rehabilitation. At the same time preoperative lifestyle intervention (prehabilitation) has revealed a large potential for additional risk reduction

Infrarenal aortic surgery with a 3-day hospital stay: A report on success with a clinical pathway

AbstractPurpose: This paper reports on an experience with a clinical pathway for elective infrarenal aortic surgery (AS) that targeted hospital discharge on postoperative day (POD) 3. The pathway incorporated early feeding, early ambulation, and selective use of the intensive care unit (ICU). Methods: A review of 50 consecutive hospital discharges after AS (aneurysm repair and aortofemoral bypass grafting) by a single surgeon performed from April 1996 through June 1998 with this clinical pathway is reported. The data collected included morbidity rate, mortality rate, length of stay (LOS), and number of hospital readmissions. Results: The average LOS for all patients was 3.0 days. Only six patients (12%) were admitted to the ICU. Discharge on POD 3 was achieved in 80% of the group (40 of 50), and increasing experience improved compliance, with 92% of the most recent 25 patients (23 of 25) being discharged by POD 3. Eleven of these 25 patients (44%) were discharged on POD 2. No patient was readmitted to the hospital within a 30-day period after discharge. There was no mortality after AS during this period. Conclusion: Factors that limit the discharge of patients recovering from AS include the ability to ambulate independently and to tolerate a diet. Ambulation and feeding on POD 1 were well tolerated by most patients, which shortened the period of hospitalization. Admission to the ICU was infrequently required when a monitored surgical step-down unit was available. Discharge by POD 3 for AS has been proven to be routinely achievable, safe, and well accepted by patients and to reduce the cost of hospitalization. (J Vasc Surg 1999;29:787-92.

EVIDENCE FOR A SECOND LOW LYING nΠ∗\Pi^{*} SINGLET STATE OF PYRAZINE

Author Institution: Department of Chemistry, Williams College WilliamstownThe absorption spectra of pyrazine and some methyl and chloropyrazines have been measured and compared in the region of the ${^{1}} B_{3u} - {^{1}}Ag$, n$\Pi^{*}$ transition of pyrazine. The vapor spectrum of 2, 6-dimethyl pyrazine shows a weak but allowed band system (0,0 at 31 $158 cm^{-1}$) in addition to the stronger, but very broad pyrazine $n\Pi^{*}$ transition ($0, 0 \sim 31 380$ $cm^{-1}$). Rotational contours of the vibronic bands of the weak system and symmetry considerations are consistent with an assignment of this system as the $^{1}B_{2g} (n_-\rightarrow \Pi_{4})$ transition of pyrazine. Vapor absorption spectra, and $4^{\circ} K$ absorption, emission, and excitation spectra of several of the pyrazine derivatives provide additional indirect evidence for an additional low-lying state