Clinically Significant Prostate Cancer Detection Following Transrectal and Transperineal Biopsy: Results of the Prostate Biopsy Efficacy and Complications Randomized Clinical Trial.

PURPOSE: The comparative effectiveness of transrectal and transperineal prostate biopsy in detecting clinically significant prostate cancer is not well understood. We conducted a randomized clinical trial to determine whether transperineal biopsy improves the detection of clinically significant prostate cancer. MATERIALS AND METHODS: Of the 840 men randomized, 93% were White, 44% had a previous biopsy, with a median age of 66 years and median PSA density of 0.14. Of these, 384 underwent transrectal and 398 underwent transperineal prostate biopsy. Prebiopsy prostate MRI was performed in 96% of men. Grade Group ≥ 2 prostate cancer was classified as clinically significant. Odds ratios were calculated using logistic regression to evaluate the effect of biopsy procedures on cancer detection rates. RESULTS: The detection rates of clinically significant prostate cancer were 47.1% and 43.2% (odds ratio 1.17; 95% CI, 0.88-1.55) for transrectal and transperineal biopsy, respectively. Age, PSA density, clinical stage and Prostate Imaging Reporting and Data System score were associated with the diagnosis of clinically significant cancer, whereas history of previous biopsy, anterior tumors, and biopsy procedure (transrectal or transperineal) were not. Clinically significant cancer detection rates in biopsy-naïve men undergoing MRI-targeted transrectal or transperineal biopsy were 59% and 62%, respectively. The overall cancer detection rates following transrectal and transperineal biopsy were 72.1% and 70.4%, respectively. CONCLUSIONS: There was no significant difference noted in the detection of clinically significant prostate cancer following transrectal or transperineal prostate biopsy. Urologists may utilize either biopsy procedure that best suits their patients' needs and practice setting.

Complications Following Transrectal and Transperineal Prostate Biopsy: Results of the ProBE-PC Randomized Clinical Trial.

PURPOSE: Transrectal prostate biopsy has come under scrutiny due to potential for postbiopsy infections and transperineal prostate biopsy is being offered as the safer alternative. However, there is a lack of randomized comparative studies. Our goal was to directly evaluate infectious and noninfectious complications following the 2 biopsy procedures. MATERIALS AND METHODS: We conducted a prospective, pragmatic, randomized clinical study in men undergoing prostate biopsy. The participants underwent either transrectal or transperineal prostate biopsy in the office under local anesthesia. The primary outcome was a 30-day composite infectious complication rate, comprising of 1 or more components including fever, genitourinary infection, antibiotic prescriptions, office or emergency visits, hospitalization, or sepsis. Secondary outcomes included 30-day composite noninfectious complications (urinary or hemorrhagic). RESULTS: Of the 763 randomized participants, 718 underwent either transrectal (351) or transperineal (367) prostate biopsy. A composite infectious complication event occurred in 9 participants (2.6%) in the transrectal and 10 participants (2.7%) in the transperineal group (odds ratio, 1.06; 95% CI, 0.43 to 2.65; P = .99). None of the participants developed sepsis in either group. There were no between-group differences in any of the individual component infectious events. A composite noninfectious complication occurred in 6 (1.7%) and 8 (2.2%) participants in the transrectal and transperineal groups, respectively (odds ratio, 1.28; 95% CI, 0.44 to 3.73; P = .79). No participants required hospitalization or other interventions. CONCLUSIONS: Among men undergoing transperineal or transrectal prostate biopsy, we could not demonstrate any difference in the infectious or noninfectious complications. Both biopsy approaches remain clinically viable and safe.

Do You Bleed? A 1-Year FOBT Case-Series Study.

GOALS: The goal of this study is to investigate fecal occult blood test's (FOBT) usage in cases of suspected gastrointestinal bleeding and how it may affect hospitalization length and inpatient endoscopy procedures. BACKGROUND: FOBT is an approved modality used in colorectal cancer screening but is often used inappropriately for the investigation of suspected gastrointestinal bleeding (GIB) in the hospital setting. The efficiency of FOBT when used for this purpose is questionable. STUDY: This study was performed at a 766-bed tertiary academic medical center. All FOBT performed during a 12-month period were identified and 678 cases were analyzed. The results of FOBT were collected along with information regarding patients' hemoglobin levels, rectal examination frequency, performance of endoscopy, length of hospital stay, and presence/absence of gastrointestinal lesions. RESULTS: There were no findings on endoscopy in 13.5% of cases with positive FOBT, demonstrating weak test sensitivity. Low percentage (14.6%) of patients having negative FOBT results underwent endoscopy, even with negative FOBT results, whereas less than 50% of positive FOBT patients were offered procedural evaluation, demonstrating the inefficiency of FOBT in guiding management. Patients with positive FOBT had longer hospitalization periods. Even in the absence of GIB symptoms, critically anemic patients would still undergo endoscopy for GIB investigation even without FOBT being performed. CONCLUSIONS: FOBT is inappropriately used in the hospital setting for GIB investigation. This study shows the inefficiency of FOBT to guide management and the high frequency of positive inpatient FOBT tests leading to unnecessary endoscopic investigation, longer hospitalizations, and delays in care. FOBT should be limited to the outpatient setting and be avoided while investigating GIB, anemia, etc. in the hospital.

Investigation of non-invasive focused ultrasound efficacy on depressive-like behavior in hemiparkinsonian rats.

Depression is a common non-motor symptom in Parkinson's disease (PD) that includes anhedonia and impacts quality of life but is not effectively treated with conventional antidepressants clinically. Vagus nerve stimulation improves treatment-resistant depression in the general population, but research about its antidepressant efficacy in PD is limited. Here, we administered peripheral non-invasive focused ultrasound to hemiparkinsonian ('PD') and non-parkinsonian (sham) rats to mimic vagus nerve stimulation and assessed its antidepressant-like efficacy. Following 6-hydroxydopamine (6-OHDA) lesion, akinesia-like immobility was assessed in the limb-use asymmetry test, and despair- and anhedonic-like behaviors were evaluated in the forced swim test and sucrose preference test, respectively. After, tyrosine hydroxylase immuno-staining was employed to visualize and quantify dopaminergic degeneration in the substantia nigra pars compacta, ventral tegmental area, and striatum. We found that PD rats exhibited akinesia-like immobility and > 90% reduction in tyrosine hydroxylase immuno-staining ipsilateral to the lesioned side. PD rats also demonstrated anhedonic-like behavior in the sucrose preference test compared to sham rats. No 6-OHDA lesion effect on immobility in the forced swim test limited conclusions about the efficacy of ultrasound on despair-like behavior. However, ultrasound improved anhedonic-like behavior in PD rats and this efficacy was sustained through the end of the 1-week recovery period. The greatest number of animals demonstrating increased sucrose preference was in the PD group receiving ultrasound. Our findings here are the first to posit that peripheral non-invasive focused ultrasound to the celiac plexus may improve anhedonia in PD with further investigation needed to reveal its potential for clinical applicability.

Unique inflammatory profile is associated with higher SARS-CoV-2 acute respiratory distress syndrome (ARDS) mortality.

The COVID19 pandemic has caused more than a million of deaths worldwide, primarily due to complications from COVID19-associated acute respiratory distress syndrome (ARDS). Controversy surrounds the circulating cytokine/chemokine profile of COVID19-associated ARDS, with some groups suggesting that it is similar to patients without COVID19 ARDS and others observing substantial differences. Moreover, although a hyperinflammatory phenotype associates with higher mortality in non-COVID19 ARDS, there is little information on the inflammatory landscape's association with mortality in patients with COVID19 ARDS. Even though the circulating leukocytes' transcriptomic signature has been associated with distinct phenotypes and outcomes in critical illness including ARDS, it is unclear whether the mortality-associated inflammatory mediators from patients with COVID19 are transcriptionally regulated in the leukocyte compartment. Here, we conducted a prospective cohort study of 41 mechanically ventilated patients with COVID19 infection using highly calibrated methods to define the levels of plasma cytokines/chemokines and their gene expressions in circulating leukocytes. Plasma IL1RA and IL8 were found positively associated with mortality, whereas RANTES and EGF negatively associated with that outcome. However, the leukocyte gene expression of these proteins had no statistically significant correlation with mortality. These data suggest a unique inflammatory signature associated with severe COVID19.

Spinal Cord Stimulation to Treat Low Back Pain in Patients With and Without Previous Spine Surgery.

OBJECTIVES: Little is known about the effects of spinal cord stimulation (SCS) on chronic low back pain (CLBP) patients with no history of previous spine surgery. Using our prospectively collected database, we evaluate improvements in patients with and without previous spine surgery one-year post SCS implantation. MATERIALS AND METHODS: Subjects completed outcome metrics pre-operatively and one-year post-implantation including Numeric Rating Scale (NRS), McGill Pain Questionnaire (MPQ), Oswestry Disability Index (ODI), Beck's Depression Inventory (BDI), and Pain Catastrophizing Scale (PCS). RESULTS: We enrolled 134 patients; 82 patients had previous spine surgery and 52 patients did not. At one-year post-SCS implantation, patients with previous spine surgery showed improvements in worst pain experienced, least pain experienced, average pain experienced, pain felt currently, MPQ, MPQ sensory, MPQ affective, PCS, PCS helplessness, PCS rumination, PCS magnification, ODI, and BDI scores (p < 0.001, p = 0.005, p < 0.001, p < 0.001, p < 0.001, p < 0.001, p = 0.03, p = 0.01, p = 0.02, p < 0.001, p = 0.05, p < 0.001, p = 0.017, respectively). Likewise, patients without previous spine surgery showed improvements in worst pain experienced, least pain experienced, average pain experienced, pain felt currently, MPQ, MPQ sensory, PCS, PCS helplessness, PCS rumination, PCS magnification, ODI, and BDI scores (p < 0.001, p = 0.005, p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001, p < 0.001, p = 0.008, p < 0.001, p < 0.001, respectively). Patients without previous spine surgery showed greater improvements for average pain PCS helplessness (p = 0.01). CONCLUSIONS: Patients with and without previous spine surgery showed similar improvements in pain intensity, pain quality, feelings of rumination and magnification, functional disability, and depression severity. SCS can improve CLBP regardless of whether patients have had previous spine surgery.

Obesity reduces the requirement for subsequent esophageal stricture dilation in adults with eosinophilic esophagitis.

BACKGROUND: Eosinophilic esophagitis (EoE) causes esophageal narrowing and strictures, but factors that modify the severity of strictures and requirement for subsequent dilation are not well described. The aim of this study was to identify characteristics that impact the need for repeat (> 1) esophageal dilations in EoE patients. METHODS: This was a single center retrospective cohort study over a 12-year period (September 2005-October 2017). Patients were identified using ICD9, ICD10, and CPT codes for esophageal dilation, eosinophilic esophagitis, and esophageal obstruction. Data for EoE clinical characteristics, treatments, and BMI were extracted and correlated to the number of esophageal dilations and time elapsed between dilations. RESULTS: Of the 21 patients who met inclusion criteria, 11 (52%) had at least two dilations and 9 (43%) had three dilations. There was no differences baseline demographics between patients who needed ≥ 2 vs. those who needed one dilation. However, patients with a BMI > 30 had a significantly longer median time to second dilation compared to non-obese patients (4.9 years vs. 1.8 years; p = 0.027). Stratification by either high dose PPI or inhaled steroid use did not change this result. CONCLUSIONS: EoE patients with strictures who are obese have a reduced requirement for subsequent esophageal dilation. While the mechanism for this is not clear, increased attention of non-obese patients with fibrostenotic EoE is indicated as they are at higher risk for recurrent strictures.

Effects of endovascular first strategy on spliced vein bypass outcomes.

OBJECTIVE: Aggressive endovascular interventions for patients without adequate full-length venous conduit have gained popularity. The purpose of this study is to evaluate the outcomes of spliced vein bypass (SVB) as primary treatment versus treatment after failed endovascular intervention (endovascular SVB [ESVB]) for infrainguinal revascularization. METHODS: A retrospective analysis of a single vascular group's database of all SVBs was queried for demographics, indications, intraoperative details, and outcomes. Exclusion criteria included acute ischemia, aneurysm, dual outflow, bypass revisions, and patients lost to immediate follow-up. SPSS software was used for statistical analysis. RESULTS: Two hundred thirty-five infrainguinal SVBs were performed between January 2011 and March 2017. There were 182 SVB (77%) and 53 ESVB (23%) with a mean follow-up of 488 days (range, 1-2140). Demographics between the SVB and ESVB groups were similar in all categories recorded: diabetes, hypertension, coronary artery disease, current smoker, chronic obstructive pulmonary disease, hyperlipidemia, and renal disease (P = .29). Indications for bypass were not statistically significant between SVB and ESVB (P = .48). The study included Rutherford class 3 (14 vs 2), class 4 (51 vs 20), class 5 (67 vs 18), and class 6 (50 vs 13). Inflow was grouped into iliac (2.6%), femoral (88%), and popliteal (9.8%). Outflow arteries were grouped into below knee popliteal (14.9%) and infrapopliteal (85.1%). Inflow and outflow arteries, as well as number of spliced pieces per bypass were not different between groups. Major amputation rates were not different between SVB and ESVB for the entire study period. There was no statistical difference with patency outcomes based on Kaplan-Meier survival analysis (P = .84). CONCLUSIONS: An aggressive endovascular first strategy for treatment of patients without adequate autogenous conduit seems to offer benefit without negatively affecting future bypass options. SVB patency and major amputation rates in this series were not affected by a prior endovascular treatment.

ICU admission body composition: skeletal muscle, bone, and fat effects on mortality and disability at hospital discharge-a prospective, cohort study.

BACKGROUND: Reduced body weight at the time of intensive care unit (ICU) admission is associated with worse survival, and a paradoxical benefit of obesity has been suggested in critical illness. However, no research has addressed the survival effects of disaggregated body constituents of dry weight such as skeletal muscle, fat, and bone density. METHODS: Single-center, prospective observational cohort study of medical ICU (MICU) patients from an academic institution in the USA. Five hundred and seven patients requiring CT scanning of chest or abdomen within the first 24 h of ICU admission were evaluated with erector spinae muscle (ESM) and subcutaneous adipose tissue (SAT) areas and with bone density determinations at the time of ICU admission, which were correlated with clinical outcomes accounting for potential confounders. RESULTS: Larger admission ESM area was associated with decreased odds of 6-month mortality (OR per cm2, 0.96; 95% CI, 0.94-0.97; p < 0.001) and disability at discharge (OR per cm2, 0.98; 95% CI, 0.96-0.99; p = 0.012). Higher bone density was similarly associated with lower odds of mortality (OR per 100 HU, 0.69; 95% CI, 0.49-0.96; p = 0.027) and disability at discharge (OR per 100 HU, 0.52; 95% CI, 0.37-0.74; p < 0.001). SAT area was not significantly associated with these outcomes' measures. Multivariable modeling indicated that ESM area remained significantly associated with 6-month mortality and survival after adjusting for other covariates including preadmission comorbidities, albumin, functional independence before admission, severity scores, age, and exercise capacity. CONCLUSION: In our cohort, ICU admission skeletal muscle mass measured with ESM area and bone density were associated with survival and disability at discharge, although muscle area was the only component that remained significantly associated with survival after multivariable adjustments. SAT had no association with the analyzed outcome measures.

Criteria positive and criteria negative anaphylaxis, with a focus on undifferentiated somatoform idiopathic anaphylaxis: A review and case series.

Background: Undifferentiated somatoform (US) idiopathic anaphylaxis (IA) is considered a psychogenic disorder characterized by a lack of observable physical findings and poor response to treatment. Although failure to diagnose true anaphylaxis can have disastrous consequences, identification of US-IA is crucial to limit unnecessary expenses and use of health care resources. Objective: To better define the presentation and understand the potential relationship between US-IA and underlying psychiatric comorbidities. Methods: We retrospectively reviewed 110 visits by 107 patients to our institution for evaluation and management of anaphylaxis over a 1-year period. The patients were classified as having either criteria positive (CP) or criteria negative (CN) anaphylaxis based on whether they met Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium criteria for the clinical diagnosis of anaphylaxis. Patient characteristics, including objective and subjective signs and symptoms, and the presence of psychiatric diagnoses were collected and analyzed. Statistical significance was assessed by using the Fisher exact test. A literature review of US-IA and other psychogenic forms of anaphylaxis was performed. Results: Patients with CP anaphylaxis were more likely to present with hypotension, wheezing, urticaria, and vomiting than were patients with CN anaphylaxis. The patients with CN anaphylaxis were more likely to present with subjective symptoms of sensory throat tightness or swelling compared with patients with CP anaphylaxis. No significant difference was detected in the prevalence of psychiatric conditions between the two groups. Conclusion: Patients who met previously established diagnostic criteria for anaphylaxis were more likely to present with objective physical findings than those who did not meet criteria for true anaphylaxis. CN patients who presented for treatment of anaphylaxis were more likely to present with subjective symptoms. Formal diagnostic criteria should be used by clinicians when evaluating patients with suspected anaphylaxis.

Correlations Between Family History of Psychiatric Illnesses and Outcomes of Spinal Cord Stimulation.

OBJECTIVES: Spinal cord stimulation (SCS) is a well-established procedure for chronic neuropathic pain. Research has established patients with personal psychiatric history do not fare as well as their correspondents following SCS surgery. We explored whether a documented psychiatric family history (PFH) correlated with worse outcomes following SCS surgery. MATERIALS AND METHODS: We retrospectively reviewed our single-center, prospectively collected database of patients who received permanent SCS implants over the past eight years. Subjects were separated into those with documented PFH and those without. Subjects completed validated scales at preoperative, 6 ± 2 postoperative, and 12 ± 3 months postoperative visits. The percent change in scores from preoperative to postoperative timepoints was compared between subjects with PFH vs. controls. RESULTS: SCS subjects reporting a PFH demonstrated significantly worse 6-month outcomes on Pain Catastrophizing Scale-rumination subscale (p = 0.02), numeric rating scale (NRS) scores on "pain at its least" (p = 0.04) and NRS "pain right now" (p = 0.02). This group also endorsed greater disability as measured by the Oswestry Disability Index (ODI) throughout the follow-up period (p = 0.04 at 6 ± 2 months, p = 0.001 at 12 ± 3 months). CONCLUSIONS: Subjects with PFH may experience less improvement in disability following SCS as compared to subjects without PFH. They may take longer to achieve the same outcomes, including pain relief and decrease in pain rumination. Our findings show that improvements in the PFH cohort are equivalent to that of the no PFH cohort on all measures except ODI at 12-month follow-up. Thus obtaining a detailed PFH prior to performing SCS is important in order to implement pre-operative coping training for PFH patients, rather than exclusion from SCS.

A Comparison of Unilateral Deep Brain Stimulation (DBS), Simultaneous Bilateral DBS, and Staged Bilateral DBS Lead Accuracies.

BACKGROUND: Accuracy of lead placement within the brain can affect the outcome of deep brain stimulation (DBS) surgery. Whether performing unilateral lead implantation, simultaneous bilateral lead implantation, or staged bilateral lead implantation affects accuracy has not yet been assessed. We compare lead placement errors to evaluate whether one approach affords greater lead accuracy. METHODS: We retrospectively reviewed 205 leads placed in 125 DBS surgeries. The accuracy of lead placement, defined by differences in x, y, and z coordinates and error vector magnitudes, was compared between three surgery groups: unilateral leads, bilateral leads placed simultaneously, and bilateral leads placed in staged surgeries. We also compared accuracies between first and second leads within each bilateral cohort and between second leads of the bilateral cohorts. Finally, we examined the effect of target and age on accuracy. RESULTS: The accuracy of lead placement was comparable among unilateral, simultaneous bilateral, and staged bilateral leads. Timing of placement of the second lead in bilateral cases was not found to affect accuracy. The mean number of microelectrode trajectories was greater for first leads in simultaneous bilateral DBS (p = 0.032). No significant correlation between either age or target and accuracy was found. CONCLUSION: Although there may be other important reasons for performing DBS in a staged fashion, our study finds that neither laterality nor timing of second lead placement, patient age, or target site have significant impact on DBS lead accuracy, a finding that indicates with appropriate approach selection based on patient factors, accuracy does not have to be significantly compromised.

Impact of elimination diets on growth and nutritional status in children with multiple food allergies.

BACKGROUND: Impairment of growth has been reported in food-allergic children. It is not known whether this is related to the extent of food allergies. We sought to compare growth, nutritional status, and nutrient intake in children with food allergy either avoiding cow's milk or avoiding cow's milk and wheat, which are staples of the diet in young children. METHODS: Infants and young children with challenge-proven allergy were recruited to this prospective study. They were strictly avoiding their allergic food triggers, either cow's milk, or cow's milk and wheat. They were counseled by a dietitian specialized in food allergies on food avoidance diets and nutritionally adequate supplementation at regular intervals. A 3-day food diary was kept. Children's height, weight, and laboratory data for nutritional parameters were monitored at 8-month intervals. RESULTS: A total of 18 patients avoiding milk and 28 patients avoiding milk and wheat were evaluated at an average of 12, 21, and 28 months of age. During the follow-up, the markers of nutritional status, nutrient intake or height for age, and weight for height were comparable between the two groups, although the means for anthropometric measures were below the average for age in both groups. CONCLUSIONS: The extent of food elimination diet has no impact on growth or nutritional status of food-allergic children, when diet is adequately supplemented. Close physician and dietitian follow-up are essential for food-allergic children when avoiding one or more foods, which are staples of the diet.

High recurrence rate at 5-year followup in children after upper urinary tract stone surgery.

PURPOSE: Pediatric urolithiasis has been treated with shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy with high success rates during short-term followup. We studied our success rate and modifiable risk factors in patients with at least 5 years of followup postoperatively. MATERIALS AND METHODS: Retrospective chart review was performed for patients younger than 18 years who underwent upper tract stone surgery between 1999 and 2007, were stone-free afterward and had at least 5 years of followup. Recurrence rate, and anatomical and metabolic abnormalities were assessed. RESULTS: Of 60 eligible children 30 (33 kidneys) had at least 5 years of followup. Average patient age at surgery was 10 years, 17 patients were female and 20 kidneys had anatomical abnormalities. Overall recurrence rate at 5 years was 55% (95% CI 38%-70%). Ureteral stones had a lower recurrence rate than renal stones (5 of 19 and 13 of 14, respectively, p <0.001). Patients with abnormal anatomy had a 65% (95% CI 43%-82%) chance of recurrence within 5 years vs 38% (95% CI 18%-65%) in those with normal anatomy (p = 0.17). Of the 18 recurrences 10 required a second operation, 7 demonstrated abnormal anatomy and 14 involved calcium based stones. A 24-hour urine test in 13 children revealed 10 with hypercalciuria and 11 with hypocitraturia, with 9 patients exhibiting both conditions. CONCLUSIONS: We found a high recurrence rate in children with stones requiring surgical intervention, particularly those with abnormal anatomy. This finding should be confirmed in a larger multicenter study of recurrence rates. In the meantime our results suggest a need for aggressive diagnosis and treatment of metabolic abnormalities.

Standardized protocols enable stroke recognition and early treatment of carotid stenosis.

OBJECTIVE: This study examined the effect of acute ischemic stroke (AIS) care coordination between vascular surgery and stroke neurology services with primary focus on acute patient stabilization and expeditious carotid endarterectomy (CEA). METHODS: A standardized AIS protocol was instituted between vascular surgery and stroke neurology services in an academic hospital (group I) that included: (1) rapid patient evaluation and imaging inclusive of brain and carotid computed tomography/magnetic resonance angiography, carotid duplex ultrasound imaging or conventional arteriogram, or both; (2) patient admission to a dedicated stroke unit with minimum 1:2 intensive care nurse-to-patient staffing and a 24-hour available neurointensivist; (3) treatment of all patients with ipsilateral moderate or severe carotid stenosis by CEA with cervical block (158 [81%]) or general anesthesia (38 [19%]). Patient exclusion from undergoing expeditious CEA included (1) stroke in evolution, and (2) dense neurologic deficit or National Institutes of Health Stroke Scale score >15 (severe), or both. Comparisons of data were performed between group I patients and those treated in outlying hospitals (group II) for similar indications. All data were prospectively collected in a computerized database and outcomes evaluated retrospectively. RESULTS: From November 2002 to November 2012, 369 patients underwent CEA for AIS ≤1 week of presentation. There were 192 patients in group I and 177 in group II. There were no differences in group I and II in mean stroke-to-CEA interval (3.4 vs 3.9 days) or in the performance of eversion CEA (94% vs 97%), respectively. Intraoperative shunt use was greater in group I (28%) than in group II (18%; P = .021). Fewer total neurologic events (stroke or transient ischemic attack) occurred in group I (6 [3.1%] vs 14 [7.3%]; P = .03). No patients died in either group. Postoperative National Institutes of Health Stroke Scale scores available in group I patients showed improvement from preoperative baseline in mild and moderate stroke patients (P < .001). CONCLUSIONS: In patients with stable acute stroke, early CEA is feasible and relatively safe. Stroke or death occurs in only 1%, and most complications are of nonfatal cardiac origin. A standardized stroke team protocol that is inclusive of stroke neurologists and vascular surgeons allows for expeditious and safe CEA in the setting of an acute stroke.