RESUMO
BACKGROUND AND AIM: Resection of the distal part of the urethra is performed in 15% to 55% of women with vulvar cancer to achieve radicality of vulvectomy. Urinary reconstruction in these women may be complicated by urethral stenosis resulting from circular inset of the meatus. We report on our experience with 2 surgical techniques of noncircular inset to prevent such stenosis. METHODS: From January 2005 to January 2020, 42 urethral meatus reconstructions were performed in 41 women after vulvectomy for (pre)malignant skin disorders by a "limited" (n = 17) or "extended" (n = 25) anterior vaginal wall advancement technique, including V-Y insertion of part of the vaginal flap in a posterior longitudinal urethrotomy. Preoperative characteristics, procedural details, and surgical outcomes were reviewed. RESULTS: We observed 1 neomeatal stenosis and 1 case of partial vaginal wall flap necrosis as major complications following the "limited" technique and 1 circumferential neomeatal dehiscence and occlusion as major complication after the "extended" technique. Both the neomeatal stenosis and the dehiscence/occlusion are felt to have been preventable and not caused by a flaw of design of the advancement technique. CONCLUSIONS: We advocate applying these vaginal wall advancement techniques to prevent circular inset of the neomeatus. The "extended" technique offers a solution in cases where the periurethral vulvar defect cannot be closed by transpositioning of labial skin.
Assuntos
Procedimentos de Cirurgia Plástica , Vulvectomia , Constrição Patológica/cirurgia , Feminino , Humanos , Masculino , Procedimentos de Cirurgia Plástica/métodos , Retalhos Cirúrgicos/cirurgia , Uretra/cirurgiaRESUMO
BACKGROUND: Therapeutic immune intervention is highly dependent on the T-cell priming and boosting capacity of tumor-draining lymph nodes (TDLN). In vulvar cancer, in-depth studies on the immune status of (pre)metastatic TDLN is lacking. METHODS: We have phenotyped and enumerated various T-cell and myeloid subsets in tumor-free (LN-, n=27) and metastatic TDLN (LN+, n=11) using flow cytometry. Additionally, we studied chemokine and cytokine release profiles and assessed expression of indoleamine 2,3-dioxygenase (IDO) in relation to plasmacytoid dendritic cell (pDC) or myeloid subsets. RESULTS: Metastatic involvement of TDLN was accompanied by an inflamed microenvironment with immune suppressive features, marked by hampered activation of migratory DC, increased cytokine/chemokine release, and closely correlated elevations of pDC and LN-resident conventional DC (LNR-cDC) activation state and frequencies, as well as of terminal CD8+ effector-memory T-cell (TemRA) differentiation, regulatory T-cell (Treg) rates, T-cell activation, and expression of cytotoxic T-lymphocyte protein-4 (CTLA-4) and programmed cell death protein-1 (PD-1) immune checkpoints. In addition, high indoleamine 2,3-dioxygenase (IDO) expression and increased frequencies of monocytic myeloid-derived suppressor cells (mMDSC) were observed. Correlation analyses with primary and metastatic tumor burden suggested respective roles for Tregs and suppression of inducible T cell costimulator (ICOS)+ T helper cells in early metastatic niche formation and for CD14+ LNR-cDC and terminal T-cell differentiation in later stages of metastatic growth. CONCLUSIONS: Metastatic spread in vulvar TDLN is marked by an inflamed microenvironment with activated effector T cells, which are likely kept in check by an interplay of suppressive feedback mechanisms. Our data support (neoadjuvant) TDLN-targeted therapeutic interventions based on CTLA-4 and PD-1 blockade, to reinvigorate memory T cells and curb early metastatic spread and growth.
Assuntos
Linfonodos/patologia , Metástase Linfática/imunologia , Neoplasias Vulvares/imunologia , Adulto , Idoso , Feminino , Humanos , Pessoa de Meia-Idade , Metástase Neoplásica , Microambiente TumoralRESUMO
PURPOSE: Adenocarcinoma of the uterine cervix is the second most common type of cervical cancer after squamous cell carcinoma (SCC). Although both subtypes are treated similarly, patients with adenocarcinoma have a worse prognosis. In this study, immunologic features of the tumor microenvironment in these two subsets were pursued with potential therapeutic implications. EXPERIMENTAL DESIGN: The immune microenvironment of primary tumors and nonmetastatic tumor-draining lymph nodes (TDLN) was compared between patients with cervical adenocarcinoma (n = 16) and SCC (n = 20) by polychromatic flow cytometry and by transcriptional profiling of the primary tumors (n = 299) using publicly available data from The Cancer Genome Atlas (TCGA). RESULTS: Flow cytometric analyses revealed intact T-cell differentiation in TDLNs, but hampered effector T-cell trafficking to the primary tumors in adenocarcinoma, as compared with SCC. TCGA analysis demonstrated higher expression of chemokines involved in effector T-cell homing (CXCL9/10/11) in SCC primary tumors as compared with adenocarcinoma primary tumors, which was highly correlated to a transcriptional signature for type I conventional dendritic cells (cDC1). This was consistent with elevated frequencies of CD141/BDCA3+cDC1 in primary tumor SCC samples relative to adenocarcinoma and correspondingly elevated levels of CXCL9 and CXCL10 in 24-hour ex vivo cultures. Hampered cDC1 recruitment in adenocarcinoma was in turn related to lower transcript levels of cDC1-recruiting chemokines and an elevated ß-catenin activation score and was associated with poor overall survival. CONCLUSIONS: Our data have identified an opportunity for the investigation of potentially novel therapeutic interventions in adenocarcinoma of the cervix, that is, ß-catenin inhibition and cDC1 mobilization.
Assuntos
Adenocarcinoma/imunologia , Linfócitos T CD8-Positivos/imunologia , Carcinoma de Células Escamosas/imunologia , Células Dendríticas/imunologia , Neoplasias do Colo do Útero/imunologia , Adenocarcinoma/tratamento farmacológico , Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/farmacologia , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinoma de Células Escamosas/tratamento farmacológico , Carcinoma de Células Escamosas/mortalidade , Carcinoma de Células Escamosas/patologia , Colo do Útero/imunologia , Colo do Útero/patologia , Conjuntos de Dados como Assunto , Células Dendríticas/efeitos dos fármacos , Resistencia a Medicamentos Antineoplásicos/efeitos dos fármacos , Resistencia a Medicamentos Antineoplásicos/imunologia , Feminino , Perfilação da Expressão Gênica , Humanos , Inibidores de Checkpoint Imunológico/farmacologia , Inibidores de Checkpoint Imunológico/uso terapêutico , Ativação Linfocitária , Linfócitos do Interstício Tumoral/imunologia , Pessoa de Meia-Idade , Microambiente Tumoral/imunologia , Neoplasias do Colo do Útero/tratamento farmacológico , Neoplasias do Colo do Útero/mortalidade , Neoplasias do Colo do Útero/patologia , beta Catenina/antagonistas & inibidores , beta Catenina/metabolismoRESUMO
PD-1/PD-L1 immune checkpoint inhibitors show potential for cervical cancer treatment. However, low response rates suggest that patient selection based on PD-L1 protein expression is not optimal. Here, we evaluated different PD-L1 detection methods and studied transcriptional regulation of PD-L1/PD-L2 expression by The Cancer Genome Atlas (TCGA) mRNAseq analysis. First, we determined the copy number of the PD-L1/PD-L2 locus by fluorescence in situ hybridization (FISH), PD-L1 mRNA expression by RNA in situ hybridization (RNAish), and PD-L1/PD-L2 protein expression by immunohistochemistry (IHC) on tissue microarrays containing a cohort of 60 patients. Additionally, distribution of PD-L1/PD-L2 was visualized based on flow cytometry analysis of single-cell suspensions (n = 10). PD-L1/PD-L2 locus amplification was rare (2%). PD-L1 mRNA expression in tumor cells was detected in 56% of cases, while 41% expressed PD-L1 protein. Discordant scores for PD-L1 protein expression on tumor cells between cores from one patient were observed in 27% of cases. Interestingly, with RNAish, PD-L1 heterogeneity was observed in only 11% of the cases. PD-L2 protein expression was found in 53%. PD-L1 mRNA and protein expression on tumor cells were strongly correlated (p < 0.001). PD-L1 and PD-L2 protein expression showed no correlation on tumor cells (p = 0.837), but a strong correlation on cells in stromal fields (p < 0.001). Co-expression of PD-L1 and PD-L2 on macrophage-like populations was also observed with flow cytometry analysis. Both PD-L1 and PD-L2 TCGA transcript levels strongly correlated in the TCGA data, and both PD-L1 and PD-L2 strongly correlated with interferon gamma (IFNG) expression/transcript levels (p < 0.0001). Importantly, patients with high PD-L1/PD-L2/IFNG transcript levels had a survival advantage over patients with high PD-L1/PD-L2 and low IFNG expression. Based on these findings, we conclude that PD-L1/PD-L2 expression in cervical cancer is mainly associated with interferon induction and not gene amplification, which makes FISH unsuitable as biomarker. The heterogeneous PD-L1 and PD-L2 expression patterns suggest IHC unreliable for patient selection. RNAish, in conjunction with interferon signaling evaluation, seems a promising technique for immune checkpoint detection. These results warrant further investigation into their prognostic and predictive potential.
Assuntos
Antígeno B7-H1/genética , Biomarcadores Tumorais , Expressão Gênica , Proteína 2 Ligante de Morte Celular Programada 1/genética , Neoplasias do Colo do Útero/genética , Adulto , Antígeno B7-H1/metabolismo , Variações do Número de Cópias de DNA , Feminino , Loci Gênicos , Sequenciamento de Nucleotídeos em Larga Escala , Humanos , Imuno-Histoquímica , Imunofenotipagem , Hibridização in Situ Fluorescente , Pessoa de Meia-Idade , Proteína 2 Ligante de Morte Celular Programada 1/metabolismo , Neoplasias do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/metabolismoRESUMO
BACKGROUND: Usual type vulvar intraepithelial neoplasia (uVIN) is caused by HPV, predominantly type 16. Several forms of HPV immunotherapy have been studied, however, clinical results could be improved. A novel intradermal administration route, termed DNA tattooing, is superior in animal models, and was tested for the first time in humans with a HPV16 E7 DNA vaccine (TTFC-E7SH). METHODS: The trial was designed to test safety, immunogenicity, and clinical response of TTFC-E7SH in twelve HPV16+ uVIN patients. Patients received six vaccinations via DNA tattooing. The first six patients received 0.2 mg TTFC-E7SH and the next six 2 mg TTFC-E7SH. Vaccine-specific T-cell immunity was evaluated by IFNγ-ELISPOT and multiparametric flow cytometry. RESULTS: Only grade I-II adverse events were observed upon TTFC-E7SH vaccination. The ELISPOT analysis showed in 4/12 patients a response to the peptide pool containing shuffled E7 peptides. Multiparametric flow cytometry showed low CD4+ and/or CD8+ T-cell responses as measured by increased expression of PD-1 (4/12 in both), CTLA-4 (2/12 and 3/12), CD107a (5/12 and 4/12), or the production of IFNγ (2/12 and 1/12), IL-2 (3/12 and 4/12), TNFα (2/12 and 1/12), and MIP1ß (3/12 and 6/12). At 3 months follow-up, no clinical response was observed in any of the twelve vaccinated patients. CONCLUSION: DNA tattoo vaccination was shown to be safe. A low vaccine-induced immune response and no clinical response were observed in uVIN patients after TTFC-E7SH DNA tattoo vaccination. Therefore, a new phase I/II trial with an improved DNA vaccine format is currently in development for patients with uVIN.
Assuntos
DNA/genética , Papillomavirus Humano 16/genética , Proteínas Oncogênicas Virais/imunologia , Vacinas de DNA/imunologia , Neoplasias Vulvares/genética , Adulto , Feminino , Humanos , Pessoa de Meia-Idade , Neoplasias Vulvares/terapiaRESUMO
ASiT has long maintained that in order to provide the best quality care to patients in the UK and Republic of Ireland, it is critical that surgeons are trained to the highest standards. In addition, it is imperative that surgery remains an attractive career choice, with opportunities for career progression and job satisfaction to attract and retain the best candidates. In 2013, the Shape of Training review report set out recommendations for the structure and delivery of postgraduate training in light of an ever increasingly poly-morbid and ageing population. This consensus statement outlines ASIT's position regarding recommendations for improving surgical training and aims to help guide discussions with regard to future proposed changes to surgical training.
Assuntos
Escolha da Profissão , Educação de Pós-Graduação em Medicina/organização & administração , Sociedades Médicas , Especialidades Cirúrgicas/educação , Instituições de Caridade , Humanos , Irlanda , Reino UnidoRESUMO
Current vascular-targeted therapies in colorectal cancer (CRC) have shown limited benefit. The lack of novel, specific treatment in CRC has been hampered by a dearth of specific endothelial markers. Microarray comparison of endothelial gene expression in patient-matched CRC and normal colon identified a panel of putative colorectal tumour endothelial markers. Of these the glutamate dependent NMDA receptor GRIN2D emerged as the most interesting target. GRIN2D expression was shown to be specific to colorectal cancer vessels by RTqPCR and IHC analysis. Its expression was additionally shown be predictive of improved survival in CRC. Targeted knockdown studies in vitro demonstrated a role for GRIN2D in endothelial function and angiogenesis. This effect was also shown in vivo as vaccination against the extracellular region of GRIN2D resulted in reduced vascularisation in the subcutaneous sponge angiogenesis assay. The utility of immunologically targeting GRIN2D in CRC was demonstrated by the vaccination approach inhibiting murine CRC tumour growth and vascularisation. GRIN2D represents a promising target for the future treatment of CRC.
Assuntos
Biomarcadores Tumorais/metabolismo , Neoplasias Colorretais/metabolismo , Endotélio Vascular/patologia , Neovascularização Patológica/metabolismo , Receptores de N-Metil-D-Aspartato/metabolismo , Animais , Apoptose , Movimento Celular , Proliferação de Células , Neoplasias Colorretais/irrigação sanguínea , Neoplasias Colorretais/patologia , Endotélio Vascular/metabolismo , Humanos , Camundongos , Camundongos Endogâmicos BALB C , Prognóstico , Taxa de Sobrevida , Células Tumorais Cultivadas , Ensaios Antitumorais Modelo de XenoenxertoRESUMO
The structure and molecular signature of tumor-associated vasculature are distinct from those of the host tissue, offering an opportunity to selectively target the tumor blood vessels. To identify tumor-specific endothelial markers, we performed a microarray on tumor-associated and nonmalignant endothelium collected from patients with renal cell carcinoma (RCC), colorectal carcinoma, or colorectal liver metastasis. We identified a panel of genes consistently upregulated by tumor blood vessels, of which melanoma cell adhesion molecule (MCAM) and its extracellular matrix interaction partner laminin alpha 4 (LAMA4) emerged as the most consistently expressed genes. This result was subsequently confirmed by immunohistochemical analysis of MCAM and LAMA4 expression in RCC and colorectal carcinoma blood vessels. Strong MCAM and LAMA4 expression was also shown to predict poor survival in RCC, but not in colorectal carcinoma. Notably, MCAM and LAMA4 were enhanced in locally advanced tumors as well as both the primary tumor and secondary metastases. Expression analysis in 18 different cancers and matched healthy tissues revealed vascular MCAM as highly specific in RCC, where it was induced strongly by VEGF, which is highly abundant in this disease. Lastly, MCAM monoclonal antibodies specifically localized to vessels in a murine model of RCC, offering an opportunity for endothelial-specific targeting of anticancer agents. Overall, our findings highlight MCAM and LAMA4 as prime candidates for RCC prognosis and therapeutic targeting. Cancer Res; 76(8); 2314-26. ©2016 AACR.
Assuntos
Carcinoma de Células Renais/irrigação sanguínea , Neoplasias Renais/irrigação sanguínea , Laminina/metabolismo , Animais , Antígeno CD146/metabolismo , Carcinoma de Células Renais/metabolismo , Carcinoma de Células Renais/terapia , Células Endoteliais da Veia Umbilical Humana , Humanos , Neoplasias Renais/metabolismo , Neoplasias Renais/terapia , Camundongos , Metástase Neoplásica , Resultado do Tratamento , Fator A de Crescimento do Endotélio Vascular/farmacologiaRESUMO
INTRODUCTION: Frequent visitors of psychiatric emergency wards are an important health care problem. Previous studies underlined that 2 % to 9 % of patients induce 15 % to 33 % of total clinical activity. Those patients have chronic and severe mental illness such as schizophrenia, associated with social and financial difficulties. OBJECTIVE: The aim of this study was to describe demographic and clinical characteristics of frequent visitors to a psychiatric emergency ward in a French Academic hospital over 6years in comparison to non-frequent visitors. METHODS: The study is based on a retrospective review of the psychiatric emergency wards' administrative and medical computer databases; data that included demographic, financial, clinical, and management information. During this 6-year study, the psychiatric ward recorded 16,754 care episodes for 8800 different patients. We compared frequent visitors with other visitors using univariate and multivariate analyses. Frequent visitors were defined by a number of visits greater than 2 of the mean standard deviation. RESULTS: Two percent of patients (n=192) had nine or more visits during the period. These patients caused 21 % of the total number of the visits. In the univariate analysis, the most significant reasons for referral in frequent visitors versus others (P<0.001) were: more frequent anxiety (37.6 % vs. 32.1 %), less frequent disruptive behavior (8.4 % vs. 12.9 %), depression (7.8 % vs. 17.2 %) and suicide attempt (4.5 % vs. 11.1 %). Factors associated with frequent visitors (P<0.001), after including all significant or confounding variables (multivariate analysis), were: schizophrenia and schizophrenia spectrum disorders (OR=29.5, IC: 11.4-76), DSM-IV cluster B personality disorders (OR=5.5, IC: 3.6-8.4), mental and behavioral disorders due to psychoactive substance use (OR=4.6, IC: 3.1-7), financial assistance through social government programs (OR range: 9.1-2.4, all significant) and being homeless (OR=2.7, IC: 1.8-4). Factors associated with non-frequent visitors were mood disorders (OR=0.07, IC: 0.03-0.19) and neurotic, stress-related, and somatoform disorders (OR=0.14, IC: 0.05-0.4). Sex and age were not significant in multivariate analysis. DISCUSSION: This study identifies significant demographic and clinical factors associated with frequent visits in psychiatric emergency ward in accordance with the large majority of previous studies. We found that psychotic disorders or schizophrenia were the main diagnosis of these patients. Moreover, precariousness (homeless, financial assistance) is an important demographic factor associated with recurrence. However, contrary to numerous studies, we found no effect of sex or age. Due to this important economical and clinical burden, more specific care and alternative solutions to emergency care have to be proposed to this population of patients.
Assuntos
Serviços de Emergência Psiquiátrica/estatística & dados numéricos , Mau Uso de Serviços de Saúde/estatística & dados numéricos , Transtornos Mentais/epidemiologia , Transtornos Mentais/psicologia , Centros Médicos Acadêmicos/estatística & dados numéricos , Adolescente , Adulto , Idoso , Criança , Doença Crônica , Feminino , França , Pessoas Mal Alojadas/psicologia , Pessoas Mal Alojadas/estatística & dados numéricos , Humanos , Masculino , Transtornos Mentais/diagnóstico , Transtornos Mentais/terapia , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Transtornos da Personalidade/diagnóstico , Transtornos da Personalidade/epidemiologia , Transtornos da Personalidade/psicologia , Transtornos da Personalidade/terapia , Psicotrópicos/efeitos adversos , Assistência Pública/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Esquizofrenia/diagnóstico , Esquizofrenia/epidemiologia , Esquizofrenia/terapia , Psicologia do Esquizofrênico , Fatores Socioeconômicos , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/psicologia , Transtornos Relacionados ao Uso de Substâncias/terapia , Revisão da Utilização de Recursos de Saúde/estatística & dados numéricos , Adulto JovemRESUMO
OBJECTIVE: Many suicide victims had contacts with an emergency department before their attempt. We aimed to determine whether patients coming to a psychiatric emergency department were well assessed concerning their suicidal risk, and to test an easy to fill in scale rapidly assessing suicidal risk. METHOD: We conducted a descriptive epidemiological survey in Marseille. The source population was all patients admitted to the psychiatric emergency department. We used a booklet containing three questionnaires for "nurse", "psychiatrist" and "patient". We estimated the suicidal risk using both a visual analogue scale (similar for patients and caregivers), and validated scales on self-assessment (scale of suicidality SBQ-R and the Beck Hopelessness Scale). RESULTS AND DISCUSSION: The questionnaire results have shown that people who visited a psychiatric emergency department presented a significant suicidal risk on several criteria: socio-demographic criteria (social isolation, low level of education, low number of people with a job), psychiatric history (rate of pre-existing psychiatric disorders significantly higher than in the general population, high proportions of family and personal history of suicide attempts, psychiatric hospitalizations, and people with a psychiatrist). Six percent of patients claimed to have come to an emergency unit for suicidal ideas but they were ten times more with a suicidal risk, according to the SBQ-R score. The suicidal risk self-assessed by patients on our visual analogue scale was well correlated with SBQ-R scale and Beck Hopelessness scale, but was not well correlated with the evaluation of caregivers. CONCLUSION: Hence, the analog scale we created is easy to use and seems to be a good tool for suicidal risk estimation when it is self-assessed by patients in our study population.
Assuntos
Serviços de Emergência Psiquiátrica , Equipe de Assistência ao Paciente , Medição de Risco , Autoavaliação (Psicologia) , Ideação Suicida , Adolescente , Adulto , Idoso , Cuidadores/psicologia , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Estudos Prospectivos , Reprodutibilidade dos Testes , Estatística como Assunto , Inquéritos e Questionários , Escala Visual Analógica , Adulto JovemRESUMO
BACKGROUND: There is evidence to suggest that patients undergoing treatment at weekends may be subject to different care processes and outcomes compared with weekdays. This study aimed to determine whether clinical outcomes from weekend appendicectomy are different from those performed on weekdays. METHOD: Multicentre cohort study during May-June 2012 from 95 centres (89 within the UK). The primary outcome was the 30-day adverse event rate. Multilevel modelling was used to account for clustering within hospitals while adjusting for case mix to produce adjusted ORs and 95% CIs. RESULTS: When compared with Monday, there were no significant differences for other days of the week considering 30-day adverse events in adjusted models. On Sunday, rates of simple appendicitis were highest, and rates of normal (OR 0.62, 95% CI 0.42 to 0.90) and complex appendicitis (OR 0.65, 95% CI 0.46 to 0.93) lowest. This was accompanied by a 43% lower likelihood in use of laparoscopy on Sunday (OR 0.47, 95% CI 0.32 to 0.69), accompanied by the lowest level of consultant presence for the week. When pooling weekends and weekdays, laparoscopy use remained less likely at the weekend (OR 0.68, 95% CI 0.55 to 0.83), with no significant difference for 30-day adverse event rate (OR 1.01, 95% CI 0.80 to 1.29). CONCLUSIONS: This study found that weekend appendicectomy was not associated with increased 30-day adverse events. It cannot rule out smaller increases that may be shown by larger studies. It further illustrated that patients operated on at weekends were subject to different care processes, which may expose them to risk.
Assuntos
Apendicectomia/efeitos adversos , Serviços Médicos de Emergência/estatística & dados numéricos , Adolescente , Adulto , Apendicectomia/estatística & dados numéricos , Estudos de Coortes , Emergências , Serviços Médicos de Emergência/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Resultado do Tratamento , Reino Unido/epidemiologia , Adulto JovemAssuntos
Anticoagulantes/história , Revascularização Cerebral/história , Ensaios Clínicos como Assunto/história , Medicina Preventiva/história , Acidente Vascular Cerebral/história , Anticoagulantes/uso terapêutico , História do Século XX , História do Século XXI , Humanos , Acidente Vascular Cerebral/prevenção & controleAssuntos
Distinções e Prêmios , Neurologia , Universidades , Inglaterra , História do Século XX , História do Século XXI , Humanos , MasculinoAssuntos
Endarterectomia das Carótidas/métodos , Neurologia/métodos , Neurologia/normas , Stents , Acidente Vascular Cerebral/prevenção & controle , Acidente Vascular Cerebral/terapia , Centros Médicos Acadêmicos , Fatores Etários , Idoso , Estenose das Carótidas/terapia , Centers for Medicare and Medicaid Services, U.S. , Humanos , Saúde Pública , Risco , Estados UnidosAssuntos
Angioplastia Coronária com Balão/economia , Doenças das Artérias Carótidas/terapia , Reembolso de Seguro de Saúde , Medicaid/economia , Medicare/economia , Stents/economia , Centers for Medicare and Medicaid Services, U.S. , Humanos , Acidente Vascular Cerebral/prevenção & controle , Estados UnidosAssuntos
Estenose das Carótidas/complicações , Estenose das Carótidas/diagnóstico por imagem , Embolia/diagnóstico por imagem , Embolia/etiologia , Endarterectomia das Carótidas/métodos , Imageamento Tridimensional/métodos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/cirurgia , Úlcera/diagnóstico por imagem , Ultrassonografia Doppler Transcraniana/métodos , Feminino , Humanos , MasculinoRESUMO
Carotid angioplasty and stenting has become a popular alternative to carotid endarterectomy for the treatment of carotid stenosis in stroke. Evidence from early randomized controlled trials comparing these interventions revealed mixed results. The largest such trial, the Carotid Revascularization Endarterectomy vs. Stenting Trial recently showed equivalence of the procedures in a mixed cohort of both symptomatic and asymptomatic patients. These results have been heralded in North America as definitively demonstrating the safety and efficacy of carotid angioplasty and stenting, making it an attractive alternative to carotid endarterectomy. It is therefore probable that many more asymptomatic patients will be subjected to Carotid angioplasty and stenting, perceived by many to be less invasive than carotid endarterectomy. The authors argue that the design of Carotid Revascularization Endarterectomy vs. Stenting Trial was flawed by the mixture of two dissimilar patient groups, thus violating the principle of ceteris paribus, essential for the validity of a randomized controlled trials. The evidence for any invasive treatment of asymptomatic carotid disease is weak, with recent data favouring purely medical management. The authors believe that carotid angioplasty and stenting in asymptomatic patients should cease until better evidence is available.