Carotid artery surgery--critical analysis of indications in a regional Finnish vascular center.

BACKGROUND: The purpose of this study was to analyze retrospectively the treatment of patients referred for carotid artery stenosis to a vascular surgical unit in the 1990's. Main attention was paid to the appropriateness of the indications for CEA. MATERIAL AND METHODS: In the Pirkanmaa region (population of 440 000), all carotid surgery is performed in the regional University Hospital. All new referrals for vascular surgery because of carotid stenosis or bruit in 1990, 1992, 1994, 1996 and 1998 were included and case records reviewed. RESULTS: Four hundred patients were referred. Indication for referral was a neurologic event in 46.2%, indefinite symptom in 27.9% and asymptomatic stenosis or carotid bruit in 25.9%. Most patients underwent carotid ultrasound as first imaging (93.7%). Almost half of the patients were operated (n=176). The 30-day combined stroke and death rate was 6.5%. Appropriate indication for CEA was found in 31.6%. Over half (57.0%) of the indications were considered uncertain and 11.4% inappropriate, most of these patients having asymptomatic stenosis. CONCLUSION: Patients with asymptomatic stenosis underwent CEA relatively often and the proportion of inappropriate indications was too high. Evaluation of indications and perioperative complications is highly important in carotid surgery.

Decision making in terminal care: a survey of finnish doctors' treatment decisions in end-of-life scenarios involving a terminal cancer and a terminal dementia patient.

GOALS: The physicians' decision-making process in terminal care is complex: medical, ethical, legal and psychological aspects are all involved, particularly in critical situations. Here, a study was made of the association of personal background factors with end-of-life decisions. METHODS: A questionnaire was sent to 300 surgeons, 300 internists, 500 health centre practitioners (GPs) and all 82 Finnish oncologists. The response rate was 62%. Two scenarios were presented: one involving a terminal cancer patient, the other a dementia patient. Sociodemographic factors, general life values and attitudes related to end-of-life care were asked. MAIN RESULTS: In the cancer case (Scenario 1) 17%, and in the dementia case (Scenario 2) 43% of all the respondents chose active treatment. In a logistic regression analysis of treatment decisions in Scenario 1, physician's age, specialty, marital status and attitudes to assisted suicide and withdrawal of life-sustaining treatment (LST) entered the model. In Scenario 2, the variables were physician's age, physician's own experience of severe disease in the family, attitude to withdrawal of LST and opinion of advanced directives. CONCLUSIONS: Doctors' end-of-life decisions vary widely according to personal background factors. The findings underline the importance of advance communication, making these decisions in accordance with the patient's wishes.

Factors affecting physicians' decisions to forgo life-sustaining treatments in terminal care.

OBJECTIVES: Treatment decisions in ethically complex situations are known to depend on a physician's personal characteristics and medical experience. We sought to study variability in decisions to withdraw or withhold specific life-supporting treatments in terminal care and to evaluate the association between decisions and such background factors. DESIGN: Readiness to withdraw or withhold treatment options was studied using a terminal cancer patient scenario with alternatives. Physicians were asked about their attitudes, life values, experience, and training; sociodemographic data were also collected. SETTING: Finnish physicians, postal survey. SURVEY SAMPLE: Five hundred general practitioners, 300 surgeons, 300 internists, and 82 oncologists. RESULTS: Treatments most often forgone were blood transfusion (82%) and thrombosis prophylaxis (81%). Least willingly abandoned were intravenous (i.v.) hydration (29%) and supplementary oxygen (13%). Female doctors were less likely to discontinue thrombosis prophylaxis (p=0.022) and supplementary oxygen (p<0.001), but more readily x ray (p=0.039) and laboratory (p=0.057) examinations. Young doctors were more likely to continue antibiotics (p=0.025), thrombosis prophylaxis (p=0.006), supplementary oxygen (p=0.004) and laboratory tests (p=0.041). Oncologists comprised the specialty most ready to forgo all studied treatments except antibiotics and blood transfusion. The family's wishes (alternative 1) significantly increased treatment activity. Young and female practitioners and oncologists were most influenced by family appeal. Advance directives (alternative 2) made decisions significantly more reserved and uniform. Different factors in the physician's background were found to predict decisions to withdraw antibiotics or i.v. hydration. CONCLUSION: The considerable variation observed in doctors' decisions to forgo specific life-sustaining treatments (LST) was seen to depend on their personal background factors. Experience, supervision, and postgraduate education seemed to be associated with more reserved treatment decisions. To increase the objectivity of end of life decisions, training, and research are of prime significance in this ethically complex area of medicine.

The fate of AAA patients referred electively to vascular surgical unit.

BACKGROUND: The ideal treatment of abdominal aortic aneurysms (AAA) is to operate aneurysms likely to rupture, without exposing other cases to major surgery. The purpose here was to analyse retrospectively the management of AAA in a well-defined geographical region in the 1990's. METHODS: 194 new vascular surgical outpatient consultations due to AAA were done to the regional vascular centre during the years 1990, 1992, 1994, 1996 and 1998. Data were collected from case records. Statistics Finland provided causes and dates of death. RESULTS: The mean observed annual AAA incidence was 9.0 per 100 000 inhabitants and it rose significantly (33.3%) during the study period. The duration of follow-up varied between 0 and 129 months. The 5/8-year cumulative mortality was 37.3/50.7%. The most common causes of death were AAA-related (31.7%), cardiac (29.1%) or malignancy (19.0%). Twenty-five patients with small AAA were referred to primary health care sector for further follow-up. There were no RAAA (ruptured AAA) deaths in this group. The cumulative 5/8-year mortality was 43.2/49.9%. One hundred patients underwent an elective aneurysm repair with in-hospital mortality of 7.0%. The cumulative 5/8-year mortality was 23.7/35.4%. Twelve patients refused elective treatment. The cumulative 5/8-year mortality was 45.1/ 63.4% and 5/7 deaths were due to RAAA. Twenty-three patients were unfit for elective repair. The cumulative 5/8-year mortality was 87.0%/100% and 5/20 deaths were caused by RAAA. The cumulative 5/8-year RAAA-rate in the patients with AAA more than 5.0 cm in diameter and outside elective aneurysm-repair (n = 23) was 51.9%/100.0%. CONCLUSION: The observed incidence of AAA increased during the 1990's. Half of the patients underwent an elective procedure. Patients unfit for surgery died mainly for other reasons than RAAA. Most patients with AAA over 5.5 cm not subjected to elective procedure, died of rupture.

To resuscitate or not: a dilemma in terminal cancer care.

One of the difficult dilemmas in terminal care is the decision on whether to start or withhold cardiopulmonary resuscitation (CPR). Is this decision made on purely medical grounds, or is it also influenced by the physician's personal characteristics or education? The aim of this study was to look at factors affecting this decision. A questionnaire was sent out to a stratified sample of 1180 Finnish doctors. The response rate was 62%. The physicians were asked whether they would (a) start CPR or (b) withhold CPR in a scenario describing the unexpected death of a young terminal cancer patient. Data were also collected on demographics, post-graduate training, experience of terminal care, general life values and attitudes, and experiences of severe illness in the family. The proportion of surgeons, internists, GPs and oncologists who said they would have started CPR was 16, 10, 19 and 14%, respectively. Among physicians aged under 35 years, from 35 to 49 years and over 49 years, the proportions of physicians choosing active CPR were 29, 14 and 13%, respectively (P<0.001). As for those with personal experience of terminal care, 13% indicated they would have started CPR compared with 23% of those who had no experience (P<0.01). Those who made a decision in favour of CPR showed a significantly (P<0.001) more negative attitude to withdrawing life-sustaining treatment and valued length of life to a much greater extent (P<0.01).

Validity of the new American College of Rheumatology criteria for neuropsychiatric lupus syndromes: a population-based evaluation.

OBJECTIVE: To assess the validity of the recently developed American College of Rheumatology (ACR) nomenclature for neuropsychiatric systemic lupus erythematosus (NPSLE). METHODS: We conducted a cross-sectional, population-based study covering an area with 440,000 people. A total of 46 patients aged 16 to 65 years fulfilled the criteria for a definite diagnosis of SLE. One control for each patient matched by age, sex, education, and place of residence was randomly identified from the population register. All patients and controls underwent a clinical neurologic examination and neuropsychological testing. The data were analyzed using conditional logistic regression methods. RESULTS: Forty-two patients (91%) and 25 controls (56%) fulfilled at least one of the ACR NPSLE criteria, which gave an odds ratio (OR) of 9.5 (95% confidence interval [CI] 2.2-40.8) but low specificity (0.46). Cognitive dysfunction was the most common syndrome detected in 37 patients (80%). A revised set of 16 criteria excluding the syndromes without evidence for neuronal damage resulted in improved specificity (OR 7.0, 95% CI 2.1-23.5, specificity 0.93). CONCLUSION: The proposed 19 ACR criteria did not differentiate SLE patients from controls, nor NPSLE patients from other SLE patients. The revised NPSLE criteria proposed by us performed well in our population but should be evaluated in a larger patient population.

Anti-inflammatory effects of 17beta-estradiol pretreatment in men after coronary artery surgery.

OBJECTIVE: To investigate the anti-inflammatory and hemodynamic effects of 17beta-estradiol in men undergoing elective coronary artery bypass graft surgery (CABG). DESIGN: Prospective, randomized, controlled. SETTING: Operating room and intensive care unit in a university hospital. PARTICIPANTS: Twenty-one men undergoing primary, elective CABG surgery. INTERVENTION: 17beta-estradiol, 2mg, was given orally twice in 14 hours before the operation. MEASUREMENTS AND MAIN RESULTS: Leukocyte counts, plasma myeloperoxidase, tumor necrosis factor-alpha, interleukin (IL)-6, IL-8, and IL-10 were measured perioperatively. Leukocyte counts were lower in the 17beta-estradiol group than in controls at 6 hours (11.4 +/- 2.0 hours v 15.5 +/- 4.7 hours x 10(9)/L) and 20 hours (11.6 +/- 1.9 hours v 13.6 +/- 2.5 hours x 10(9)/L) after reperfusion (p = 0.03). The release of myeloperoxidase was lower in the 17beta-estradiol group than in controls (5 minutes; 634.4 +/- 213.1 microg/mL v 773.1 +/- 209.3 microg/mL; 4 hours, 305.0 +/- 108.0 microg/mL v 441.3 +/- 191.6 microg/mL; p = 0.02). Systemic vascular resistance index was lower just after cardiopulmonary bypass, and cardiac index was higher postoperatively in the 17beta-estradiol group as compared with controls. CONCLUSION: Pretreatment with 17beta-estradiol can limit leukocyte activation in men after CABG surgery.

Cytokine responses and myocardial injury in coronary artery bypass grafting.

OBJECTIVE: Cardiopulmonary bypass is acknowledged to be one of the major causes of a complex systemic inflammatory response after cardiac surgery, and it may contribute to postoperative complications and even multiple organ dysfunction. We here compared the cytokine responses and the degree of myocardial injury after coronary artery bypass grafting with or without cardiopulmonary bypass. METHODS: Nine patients underwent off-pump revascularization and 13 with cardiopulmonary bypass. Plasma levels of tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-6, IL-8 and IL-10 were measured before anesthesia induction, and 5 min, 1, 4, and 20 h after reperfusion to the myocardium. Levels of the MB isoenzyme of creatine kinase (CK-MB) were also measured after the operation. RESULTS: Levels of TNF-alpha were low in both groups. A delayed elevation of IL-6 was noted in the off-pump group. IL-8 and IL-10 levels were significantly higher in the CPB than in the off-pump patients after reperfusion (p=0.006 and 0.001 respectively). Postoperative CK-MB levels were significantly higher in the CPB than in the off-pump group (p=0.001). Cytokine levels correlated with CK-MB values. CONCLUSION: The results indicated that off-pump revascularization was associated with reduced cytokine responses and less severe myocardial injury. The degree of myocardial injury, as defined by CK-MB release, correlated with cytokine release. Intervention designed to reduce cytokine responses in cardiac surgery may be advantageous for patients with severe comorbidity.

Visual analogue scale, urinary incontinence severity score and 15 D--psychometric testing of three different health-related quality-of-life instruments for urinary incontinent women.

OBJECTIVE: The purpose of this study is psychometric assessment of disease-specific questionnaire, Urinary Incontinence Severity Score (UISS) and Visual Analogue Scale (VAS) in urinary incontinent women. We also investigated functional relationship between UISS, VAS and 15D-valid, generic health-related quality-of-life (HRQoL) instrument. MATERIALS AND METHODS: Eighty-two incontinent female patients were recruited for the study that included baseline investigation and re-evaluation 13 months (range 6-21 months) after treatment. Twenty-nine control women who had urinary incontinence but were not bothered by it completed the HRQoL measurements. RESULTS: Internal consistency and content validity of UISS was good. Both measures UISS and VAS were reproducible, Spearman's rank correlation between test-retest were 0.88 and 0.85 respectively. The control women's UISS, 15D and VAS scores were significantly lower than the patient's scores (p<0.001, Mann-Whitney U test) which proves to be a good discriminant. The changes in pad test correlated moderately well with those in the VAS and UISS. The UISS, VAS and 15D in the improved group had responsiveness (Guyatt's) statistics: 1.48, 1.74 and -0.80 respectively. CONCLUSION: The UISS and VAS proved to be valid, reproducible and responsive to treatment for UI women. The functionality of the 15D was good but it demonstrated less sensitivity to changes after treatment.