Effect of MR angiography on the diagnosis and treatment of patients with suspected renovascular disease.

PURPOSE: Although the diagnostic accuracy of renal magnetic resonance (MR) angiography is established, its effect on referring physicians is unknown. The authors prospectively measured the effect of MR angiography results on referring physicians' diagnosis and treatment (plans) of patients with suspected renovascular disease. MATERIALS AND METHODS: Referring physicians prospectively completed questionnaires before and after MR angiography was performed during evaluation of their patients with suspected renovascular disease. The questionnaires asked them to estimate the probability (0%-100%) of their most likely diagnosis before and after receiving the imaging information. They were also asked for their anticipated and final treatment plans. The authors calculated the mean gain in diagnostic percentage confidence and the proportion of patients with changed initial diagnoses or anticipated management. A paired t-test was used to assess significance of the gains in diagnostic percentage confidence. RESULTS: Physicians prospectively completed pre- and post-MR-angiography questionnaires for 30 patients. MR angiography improved mean diagnostic certainty by 35% (P < .0001). MR angiography changed physicians' initial diagnoses in 12 patients (40%). Anticipated treatment plans were changed in 20 patients (67%). Invasive procedures were avoided in eight patients (27%). CONCLUSION: MR angiography has a substantial effect on the diagnostic and therapeutic decision-making of physicians managing patients with suspected renovascular disease.

Cytologic diagnosis of true thymic hyperplasia by combined radiologic imaging and aspiration cytology: a case report including flow cytometric analysis.

True thymic hyperplasia (TH) is an age-dependent increase in size and weight of the thymus gland, which by definition maintains a normal histologic architecture. TH can mimic other important diseases, including lymphofollicular hyperplasia, thymoma, lymphoma, and germ-cell tumors. Traditionally, separating these entities has required a formal surgical biopsy. Given that many of these conditions occur in children, this can be a traumatic experience for both the patient and family members. Fine-needle aspiration biopsy has the distinct advantage of being able to obtain diagnostic material without requiring general anesthesia. We are aware of only one previously reported case of an enlarged thymus being subjected to aspiration cytology. We therefore present a case of thymic hyperplasia in a 5-mo-old child diagnosed by combined radiologic and cytologic parameters, including flow cytometric analysis.

Fine needle aspiration cytology and core biopsy in the diagnosis of alveolar soft part sarcoma presenting with lung metastases. A case report.

BACKGROUND: Alveolar soft part sarcoma is a rare soft tissue tumor of uncertain origin usually affecting young adults. This neoplasm has early metastatic potential. Its cytologic features, particularly when presenting with metastases, have rarely been described. CASE: A 23-year-old male presented with shortness of breath and scapular pain. Routine chest roentgenograms revealed multiple lung nodules. Malignancy was established by percutaneous fluoroscopically guided fine needle aspiration on a lung nodule. Possible metastatic alveolar soft part sarcoma was suggested by cytology among few considerations in the differential diagnosis. Alveolar soft part sarcoma was confirmed by lung core biopsy and further supported by immunohistochemistry and electron microscopy. Tumor cells expressed muscle-specific actin and myoglobin, and contained diastase-resistant inclusions with periodic acid-Schiff stain. Ultrastructurally, peculiar, elongated intracytoplasmic crystalline bodies typical of this neoplasm were identified. A meticulous clinical search led to finding the primary tumor deeply located in the right posterior thigh. CONCLUSION: Aspiration cytology is a reliable, cost-efficient technique in the diagnostic workup of masses suspicious for malignancy.

Organisational variation, satisfaction, and women's time investment in prenatal care.

This study measured the amount of time women spent obtaining prenatal care, and related that time spent to satisfaction with care. Women with Medicaid coverage (n = 364) were interviewed about several parameters related to their most recent prenatal visit: (1) how long it took them to get to the visit; (2) how long they waited upon arrival; and (3) how much time they spent with practitioners during the visit. Women were asked questions regarding satisfaction with the most recent visit, and with their care in general. They received care from four sources: private practitioners, community health centres (CHCs), hospital clinics and health department clinics. Women's satisfaction with care decreased as time spent with practitioners decreased, relative to time spent travelling and waiting. Those obtaining care from CHCs were more likely to have shorter waiting times and longer visit times than women obtaining care from other sources. Women spent approximately 3 h during pregnancy in face-to-face contact with practitioners. Satisfaction with care is closely associated with women's relative time investment in obtaining care. Both satisfaction and time investment parameters vary widely by source of prenatal care.

Fine needle aspiration cytology of fibrous dysplasia: a case report.

BACKGROUND: Fibrous dysplasia (FD) is a benign disorder of bone consisting of intramedullary proliferation of fibrous tissue and irregularly distributed, poorly developed bone. Although tumorlike in appearance, FD is probably a condition resulting from failure of maturation from woven to lamellar bone. The histology of FD has been well characterized since Lichtenstein first reported it, in 1938; however, the cytologic appearance has been described only rarely. To our knowledge, this is the first case report of fine needle aspiration (FNA) cytomorphology of FD. CASE: A 30-year-old female with breast carcinoma, diagnosed a month earlier, underwent computed tomography-guided FNA of a rib lesion radiologically thought to represent FD, although metastatic cancer could not be excluded. The smears contained blood, occasional osteoclastic multinucleated giant cells and frequent C-shaped fibrillary structures with dark central areas and lighter peripheries, representing woven bone. The cytologic/radiologic impression of FD was confirmed histologically. CONCLUSION: FNA cytodiagnosis of FD is possible in the setting of consistent clinical and radiologic findings.

Early language development in children exposed to or infected with human immunodeficiency virus.

OBJECTIVES: To compare language development in infants and young children with human immunodeficiency virus (HIV) infection to language development in children who had been exposed to HIV but were uninfected, and (among subjects with HIV infection) to compare language development with cognitive and neurologic status. DESIGN: Prospective evaluation of language development in infected and in exposed but uninfected infants and young children. SETTING: Pediatric Infectious Disease Clinic, State University of New York-Health Science Center at Syracuse. SUBJECTS: Nine infants and young children infected with HIV and 69 seropositive but uninfected infants and children, age 6 weeks to 45 months. RESULTS: Mean Early Language Milestone Scale, 2nd edition (ELM-2) Global Language scores were significantly lower for subjects with HIV infection, compared with uninfected subjects (89.3 vs 96.2, Mann-Whitney U test). The proportion of subjects scoring >2 SD below the mean on the ELM-2 on at least one occasion also was significantly greater for subjects with HIV infection, compared with uninfected subjects (4 of 9 infected subjects, but only 5 of 69 uninfected subjects; Fisher's exact test). Seven of the 9 subjects with HIV infection manifested deterioration of language function. Four manifested unremitting deterioration; only 1 of these 4 demonstrated unequivocal abnormality on neurologic examination. Three subjects with HIV infection and language deterioration showed improvement in language almost immediately after the initiation of antiretroviral drug treatment. Magnetic resonance imaging or computed tomography of the brain were performed in 6 of 7 infected subjects with language deterioration, and findings were normal in all 6. ELM-2 Global Language scaled scores showed good agreement with the Bayley Mental Developmental Index or the McCarthy Global Cognitive Index (r = 0. 70). Language deterioration, or improvement in language after initiation of drug therapy, coincided with or preceded changes in global cognitive function, at times by intervals of up to 12 months. CONCLUSIONS: Language deterioration occurs commonly in infants and young children with HIV infection, is seen frequently in the absence of abnormalities on neurologic examination or central nervous system imaging, and may precede evidence of deterioration in global cognitive ability. Periodic assessment of language development should be added to the developmental monitoring of infants and young children with HIV infection as a means of monitoring disease progression and the efficacy of drug treatment.

The effects of in vitro fertilization on subsequent pregnancy outcome.

Objective: The purpose of this study was to look at the effects of assisted reproductive technology on subsequent pregnancy outcome variables.Methods: This retrospective study was performed using the Regional Perinatal Data System, a population-based birth registry. The data system is used by all 23 hospitals in the 14-county region of Central New York. 42,656 births were analyzed from January 1, 1995 through December 31, 1996. The associations between in vitro fertilization and premature rupture of membranes (PROM), preterm delivery (PTD), age, gravidity, parity, and race were evaluated using chi(2) and Fisher's two-tailed Exact analyses. Odds ratios represent the magnitude of the association.Results:Women undergoing in vitro fertilization were significantly more likely to experience PTD and PROM. They were significantly more likely to be nulliparous, primigravidas, or over the age of 34.Conclusions: This analysis shows a strong association between women who have undergone in vitro fertilization and adverse pregnancy outcomes including PROM and preterm delivery. This study suggests a need for intensified obstetric care and the assignment of high risk pregnancy status to those women who have undergone in vitro fertilization. This association has not been previously reported and underscores the need for a comprehensive data system to analyze adverse events within a region and develop strategies for prevention.

Risk factors in premature rupture of membranes.

Objective: This retrospective study was undertaken to investigate risk factors in women who have preterm premature rupture of membranes. This information will aid the clinician in targeting at-risk women for intensified obstetric care and entry into prevention programs.Methods: 28,725 deliveries were analyzed over a 16-month time frame (January 1, 1995-April 30, 1996). These data were collected via a 14 county, 23 hospital population based Perinatal Data System. The associations between premature rupture of membranes and risk factors were analyzed using chi(2) and Fisher's Exact test analyses. Odds ratios show the magnitude of these associations.Results: Risk factors included vaginal bleeding, tobacco usage, multiple births, polyhydramnios, maternal age <20 years and >34 years, congenital malformations, parity, race, in vitro fertilization, sexually transmitted disease, prior preterm delivery, and incompetent cervix. Premature rupture of membranes shows a significant association with prior preterm delivery, prior history of a low birth weight infant, incompetent cervix, tobacco use (12 pack per day), multiple births, parity, in vitro fertilization, sexually transmitted diseases, and viral diseases, P <.001 (for all of these risk factors), polyhydramnios and non-white race, P <.01.Conclusions: These associations help to develop a picture of the patient at risk for premature rupture of membranes. Strategies can be better developed to enter high-risk patients into prevention programs to maximize pregnancy outcomes.

Papanicolaou smears by the Bethesda system in endometrial malignancy: utility and prognostic importance.

OBJECTIVE: To evaluate the prognostic significance of the Bethesda system's cytologic categories in patients with endometrial malignancy. METHODS: Patients with biopsy or hysterectomy-proven endometrial malignancy and a Papanicolaou smear result reported using the Bethesda system within 1 year of diagnosis were identified through retrospective review of our computerized database. RESULTS: After introduction of the Bethesda system in our laboratory on November 1, 1992, until January 1, 1997, 112 eligible patients were identified (108 with carcinomas and four with carcinosarcomas). Patients with cytologic diagnoses of malignancy (n = 17) were significantly more likely to have International Federation of Gynecology and Obstetrics (FIGO) grade 3 tumors and high-risk histology (serous, clear cell, and adenosquamous carcinoma and carcinosarcoma) than those with atypical glandular cells of uncertain significance (n = 33) or those with cytology not suspicious for malignancy (n = 63). Patients with malignant smears were also significantly more likely to have cervical extension, malignant peritoneal cytology, and FIGO stage II, III, or IV than those with atypical glandular cells of uncertain significance or those with cytology not suspicious for malignancy. CONCLUSION: Papanicolaou smears obtained within 1 year of histologic diagnosis of endometrial malignancy and interpreted using the Bethesda system were suspicious for (atypical glandular cells of uncertain significance) or diagnostic of malignancy in nearly half of all cases (29 and 15%, respectively). Patients having malignant glandular cells were more likely to have poor prognostic pathologic findings.

Physical activity, obesity, and diabetes in pregnancy.

Gestational diabetes mellitus (GDM) is the most common medical complication of pregnancy. Women with GDM are at elevated for numerous maternal health complications, and their infants are at elevated risk for death and morbidity. Management of GDM has traditionally been through diet and close monitoring of glucose levels, with initiation of insulin therapy when diet alone fails to maintain euglycemia. Recently, however, it has been suggested that alternative treatment modalities, such as exercise, may overcome a peripheral resistance to insulin, thus preventing GDM or controlling hyperglycemia in women with GDM. In this study, conducted from October 1995 to July 1996, the authors used a population-based birth registry to determine whether exercise has a preventive role in the development of GDM in women living in central New York State. They used contingency tables and chi-square statistics to examine bivariate differences among maternal and demographic variables and the occurrence of GDM. When stratified by prepregnancy body mass index category, exercise was associated with reduced rates of GDM only among women with a body mass index greater than 33 (odds ratio = 1.9, 95% confidence interval 1.2-3.1). The effect of exercise in obese women was further complicated by insurance status. When the data were stratified by insurance status, it appeared that women of higher socioeconomic status who were obese and did not exercise were at a significantly elevated risk of GDM compared with their counterparts of lower socioeconomic status. The results of this study suggest that for some women exercise may play a role in reducing the risk that they will develop GDM during pregnancy.

Biopsy findings in five hundred thirty-one patients with atypical glandular cells of uncertain significance as defined by the Bethesda system.

OBJECTIVES: Histologic findings in biopsy specimens obtained from patients with atypical glandular cells of uncertain significance were studied to define the utility and limitations of this category. STUDY DESIGN: Computerized records over a 3-year period were retrospectively analyzed. The most significant histologic diagnosis from all biopsy specimens submitted was compared with the subcategory of the first Papanicolaou smear obtained showing atypical glandular cells of uncertain significance. RESULTS: Biopsy results were available for 531 of 1117 patients with atypical glandular cells of uncertain significance (48%). Biopsy-proved preinvasive (83%) or invasive (17%) lesions were present in 191 patients (36%). Eighty-nine percent of the preinvasive lesions were squamous, whereas 97% of the invasive lesions were glandular. Glandular lesions were more likely to be invasive, whereas squamous lesions were more likely to be preinvasive (p < 0.001). Twenty-eight patients had endometrial carcinoma, which represents 88% of all invasive carcinomas detected. CONCLUSIONS: Almost three fourths of patients with atypical glandular cells of uncertain significance and with lesions have squamous lesions, not glandular as suggested by the name of the category. Unlike patients with atypical squamous cells of uncertain significance, patients with atypical glandular cells of uncertain significance have a significant risk of malignant lesions, which are nearly all glandular and predominantly arise from the endometrium.

Unintended pregnancy and breast-feeding behavior.

OBJECTIVES: This study assessed the effect of unintended pregnancy on breast-feeding behavior. METHODS: All women delivering a live birth between January 1, 1995, and July 31, 1996 (n = 33,735), in the 15-county central New York region were asked whether they had intended to become pregnant and their breast-feeding plans. RESULTS: Women with mistimed pregnancies, and pregnancies that were not wanted were significantly less likely to breast-feed than were women whose pregnancies were planned. After adjustment for confounding variables and contraindications for breast-feeding, the odds ratios of not breast-feeding remained significant. CONCLUSIONS: Promoting breast-feeding among women with unintended pregnancies is important to improve health status.

Incidence of atypical glandular cells of uncertain significance in cervical cytology following introduction of the Bethesda System.

OBJECTIVE: To establish the frequency of the atypical glandular cells of uncertain significance (AGCUS) category, and its subcategories, as defined by the Bethesda System (TBS). METHODS: Our computerized records of cervical/vaginal cytology specimens submitted from January 1, 1993, through December 31, 1995, were retrospectively reviewed for specimens diagnosed as AGCUS. When appropriate, our subcategory of "AGCUS favor premalignant/malignant lesion" was further qualified as "favor endocervical adenocarcinoma in situ" or "suspicious for endometrial carcinoma." The number of specimens and patients diagnosed for each subcategory were grouped by calendar year. Differences in frequency between time periods were tested for statistical significance using chi 2 analysis. RESULTS: AGCUS was diagnosed in 1181 of 177,715 submitted specimens (0.66%). The frequency of subcategories was as follows: "favor reactive" (65%), "unable to further classify" (30%), "favor premalignant/malignant" (2.9%), "suspicious for endometrial carcinoma" (1.9%), and "favor endocervical adenocarcinoma in situ" (0.4%). From 1993 to 1995 there was an increase in the rate of diagnosis of AGCUS (0.55 to 0.73%; P < 0.001) and a decrease in the percentage of specimens with AGCUS subclassified as "favor premalignant/malignant" (6.2 to 0.5%; P < 0.001). Other subcategories showed no significant change in frequency over this time period. The rate of biopsy-proven preinvasive or invasive lesions in AGCUS patients also showed no significant change from year to year over this time period. CONCLUSION: The AGCUS diagnosis can be anticipated at a low but consistent rate from a cytology laboratory using TBS. Any comparison of laboratories should take into consideration the change in reporting frequencies that occurs as part of the "learning curve" following introduction of TBS reporting. Uniform diagnostic criteria and additional reports with large numbers of cytologic specimens will be needed to establish the expected frequency of AGCUS and its subcategories.

The Bird's Nest inferior vena caval filter: review of a single-center experience.

PURPOSE: To examine a large single-center experience with Bird's Nest vena caval filters for indications, clinically evident recurrent thromboembolic disease, and other filter-related complications. MATERIALS AND METHODS: During a 6-year period, 308 patients underwent percutaneous placement of an inferior vena caval filter. The 267 patients who received a Bird's Nest filter are the subject of this retrospective review. The series included 162 men and 105 women who ranged in age from 16 to 88 years (mean, 57.1 +/- 17.0 standard deviation). RESULTS: Indications for filter placement included contraindication to anticoagulation (n = 141), complication of anticoagulation (n = 23), failure of anticoagulation (n = 30), failure of previously placed filter (n = 1), and prophylaxis (n = 82). Ten patients had more than one indication. Acute lower extremity deep venous thrombosis was confirmed in 133 patients, pulmonary embolism (PE) was found in 44 patients, and both were positively diagnosed in 37 other patients. Fifty-three patients had no documented acute thromboembolic disease at the time of insertion. Mean follow-up was 13 months. Thirty-day mortality was 9.7%, including one death from recurrent PE and one major puncture-site bleeding episode that may have contributed to death. Recurrent PE was found at radionuclide scanning or autopsy in three patients (1.1%), whereas another eight patients (3.0%) had suspected recurrent PE without confirmatory studies. Eight patients (3.0%) developed early venous access site thrombosis, including two who progressed to phlegmasia cerulea dolens with fatal complications. Significant nonthromboembolic problems were encountered in 1.9% of patients. CONCLUSIONS: The Bird's Nest filter is a safe and effective device for patients with complicated venous thromboembolic disease.

A cost evaluation of implementing a quality-oriented, regional perinatal data system.

We evaluated the cost impact of implementing a perinatal data system (PDS) on birth certificate (BC) processing and perinatal quality improvement (QI) reporting. Relevant staff in all birthing hospitals in the 15-county Central New York region (N = 23) were interviewed at baseline prior to implementation of the PDS and one year after implementation of the PDS to ascertain the time and costs of BC processing and of QI report generation. The average time and cost to collect and complete BCs did not change significantly from baseline to year 1. The time and costs to complete QI reports decreased significantly by 70 percent during this same period. Hospitals fully using the PDS for QI reporting purposes took, on average, six percent of the time it took other hospitals to generate comparable QI reports. The PDS significantly reduced the time and cost of generating perinatal reports from a consolidated database over what hospitals had done previously. Given the richness of the reports and the efficiency with which they are produced, hospitals are encouraged to adopt electronic means of BC processing and accessing these data for QI reporting purposes.

Malpractice, defensive medicine, and obstetric behavior.

OBJECTIVES: The authors examine 58,441 obstetric deliveries in New York State outside New York City to test for the existence of defensive medicine in obstetrics. METHODS: The data consist of merged vital statistics and hospital discharge records from the New York State Department of Health, together with other merged variables. Physician fear of malpractice is proxied by cumulative obstetric malpractice suits by county for 1975 through 1986. A generalized probit analysis is used. RESULTS: Malpractice exposure is shown to influence slightly the use of the electronic fetal monitor (EFM), a major diagnostic tool. Use of the EFM is shown to influence the diagnosis of fetal distress; fear of malpractice influences this diagnosis both directly and through the EFM. The diagnosis of fetal distress significantly affects the choice of cesarean section (c-section) as a method of delivery; hence, fear of malpractice influences the choice of a c-section both directly and through the diagnosis of fetal distress. Failure to include indirect effects via diagnostic procedures and diagnosis would result in an underestimate of the effect of fear of malpractice. Of an overall c-section rate of 27.6% in the data set, fear of malpractice accounts for an estimated 6.6 percentage points, of which 4.4 percentage points reflect a direct effect, and the remaining 2.2 percentage points reflect the effect of malpractice exposure on the use of the EFM and, directly and indirectly, the diagnosis of fetal distress. CONCLUSIONS: The results appear to confirm the existence of defensive medicine in obstetrics. Whether this is a desirable or undesirable effect remains ambiguous, but it is costly.

Association between pre-pregnancy obesity and the risk of cesarean delivery.

OBJECTIVE: To explore the relationship between pre-pregnancy obesity and the risk for cesarean delivery. METHODS: The population studied included 20,130 women with live births after 20 weeks' gestation in central New York state between June 1, 1994, and May 31, 1995. Women who were obese before pregnancy were compared with nonobese women with regard to mode of delivery. Obesity was defined as body mass index (BMI) greater than 29. Separate analyses were conducted on the entire sample and on a subset of women with singleton pregnancies and no prior cesarean deliveries, as an estimate of the risk of primary cesarean delivery in obese women. Statistical analyses included chi 2 test, crude odds ratio (OR) with 95% confidence interval (CI), and adjusted OR with 95% CI, using logistic regression to control for confounding variables. RESULTS: The adjusted OR was 1.64 (95% CI 1.46, 1.83) for obese women with singleton pregnancies and no prior cesarean deliveries to undergo cesarean delivery. The adjusted OR was 1.66 (95% CI 1.51, 1.82) for obese women in the entire sample to undergo cesarean delivery. In addition, increasing BMI was associated with increased risk for cesarean delivery. CONCLUSION: Compared with nonobese women, women who are obese before pregnancy are at increased risk for cesarean delivery. Preconceptional counseling regarding dietary and life-style modifications may alter this pattern.

Female alloimmunization with antibodies known to cause hemolytic disease.

OBJECTIVE: To determine the current frequency of red blood cell antigen alloimmunizations that are capable of causing hemolytic disease and would be suitable for prenatal DNA studies. METHODS: We reviewed blood-bank records at a single large tertiary center to identify patients with a positive antibody screen between January 1993 and June 1995. Data were analyzed based on age, gender, and specific blood-group alloimmunizations. The incidence of antibodies as published in the literature was reviewed and compared with our data. RESULTS: We identified 452 women who had a positive antibody screen. The frequencies of specific alloimmunization relevant to the development of fetal hemolytic disease were: anti-D, 18.4%; anti-E, 14%; anti-c, 5.8%; anti-C, 4.7%; Kell group, 22%; anti-MNS, 4.7%; anti-Fya (Duffy), 5.4%; and anti-Jka, 1.5%. Compared with other populations, in our group the frequency of antibodies to RhD decreased and Kell alloimmunization increased between 1967 and 1996. CONCLUSIONS: Despite the use of rhesus immune globulin, anti-D is still a common antibody identified in women presenting to a tertiary care center. The frequency of the Kell-group alloimmunization is higher among the central New York female population than in other populations. Rhesus and Kell antigen status can be determined by DNA studies. Research in prenatal determination of fetal antigen status should continue, as alloimmunization to these antigens is common.

Thrombolysis versus surgery as the initial management for native artery occlusion: efficacy, safety, and cost.

BACKGROUND: A controversy has evolved as to which therapy, thrombolysis or thromboembolectomy, represents the optimal initial treatment for acute native artery occlusion. METHODS: Forty-eight cases of acute class I or II limb ischemia caused by native artery occlusion were retrospectively analyzed between 1988 and 1993. Nineteen of the patients were initially treated with thrombolysis (group 1), and 29 underwent thromboembolectomy (group 2). RESULTS: Initial clinical improvement was seen in 11 (57.9%) of 19 extremities in group 1, with complete clot resolution in 21%, partial lysis in 47.4%, and no angiographic improvement in 31.6%. Significantly superior results were achieved in group 2; 28 (97%) of 29 limbs showed clinical improvement after initial surgical therapy (p = 0.001). Limb salvage was 88.2% in group 1 and 96.6% in group 2 (p = 0.5). Adjunctive procedures for limb salvage were necessary in 10 (52.6%) of 19 limbs in group 1 compared with only five (17.2%) of 29 limbs in group 2 (p = 0.013). Perioperative mortality was 10.5% and 10.3% (p = 1.0), whereas major postoperative complications occurred in 63.2% and 37% of patients in groups 1 and 2, respectively (p = 0.14). Hospital and professional patient charges were analyzed for the 12 most recent patients from each group. Total mean charges per patient were higher in group 1 ($45,171) than in group 2 ($24,898) (p = 0.046). CONCLUSIONS: Patients initially treated surgically achieved better immediate clinical results with significant cost savings and without significant differences in morbidity, mortality, or limb salvage compared with patients treated initially by thrombolysis.