Low high-density lipoprotein cholesterol predicts cardiovascular events after carotid stenting: a long-term survey.

BACKGROUND: Apart from advanced age, little is known about predictors of the long-term outcome after carotid artery stenting (CAS). OBJECTIVE: We sought to determine whether atherosclerotic risk factors predict the long-term outcome after CAS. PATIENTS AND METHODS: We enrolled 532 patients assigned for CAS. The primary composite end-point, including stroke, myocardial infarction and all-cause mortality, was observed in 100 patients (19%) during the long-term follow-up (median 28 months, interquartile range 14-49 months). RESULTS: Cumulative event rates at 1, 3 and 5 years were 4.4%, 17.1% and 33.4%, respectively. High-density lipoprotein (HDL) cholesterol was an independent predictor of event-free survival. The adjusted hazard ratio for the primary end-point was 0.97 per increase of 1 mg dL(-1) HDL cholesterol [95% confidence interval (CI) 0.95-0.99, P = 0.002) and 2.7 (95% CI 1.6-4.4, P < 0.001) for low HDL cholesterol (< 40 mg dL(-1) in men and < 50 mg dL(-1) in women). Inflammatory activation (leukocyte count > 10,000 mL(-1) or fibrinogen > 450 mg dL(-1) or erythrocyte sedimentation rate > 20 mm h(-1)) was the only other independent atherosclerotic risk factor (P = 0.001). Patients with low HDL cholesterol and elevated inflammatory activation were at very high risk, with a 5-year event rate of 59.4% (95% CI 43.6-75.2%) as compared to 15.1% (95% CI 8.2-22.0%) in those without both risk factors (log rank, P < 0.001). Age, occlusion of the contralateral carotid artery and heart failure were further independent risk predictors (P < 0.01 for all). CONCLUSIONS: Low HDL cholesterol is an independent predictor of the long-term outcome after CAS. The combination of low HDL cholesterol and elevated inflammatory markers identified high-risk patients.

Transmission of methicillin-resistant Staphylococcus aureus among hospital staff in a German trauma centre: a problem without a current solution?

Between October 2001 and February 2002, 324 healthcare workers were screened for methicillin-resistant Staphylococcus aureus (MRSA) by nose and throat swabs. A positive finding led to activation of a standardised control programme for the affected person who was immediately excluded from work. Family members of those who were MRSA-positive were offered screening free of charge. An eradication programme was carried out in the permanent carriers. MRSA was found in 17 (5.3%) healthcare workers, 11 of whom proved to be permanent carriers, and six temporarily colonised. Three children of a positive healthcare worker showed nasopharyngeal MRSA, the acquisition of which occurred within the hospital. The standardised eradication programme for carriers was successful in most cases but failed in two individuals, whereupon systemic antibiotics were used successfully. The decolonised carriers, observed for more than one year, remained MRSA negative. Isolation precautions in hospitals do not always prevent hospital staff and their families from acquiring MRSA. The identification of affected employees is difficult because in most cases only asymptomatic colonisation occurs. Screening and eradication can be complicated and costly, and for the affected employees the occupational consequences can be far-reaching as they have no guaranteed legal protection.

In-stent restenosis after interventional treatment of carotid artery stenoses: a long-term follow-up of a single center cohort.

BACKGROUND: Whereas in-stent restenosis (ISR) is widely discussed after coronary stenting procedures, this phenomenon is a considerable problem after interventional treatment of carotid artery stenosis as well. We sought to quantify ISR rate and to identify important respective risk factors in our cohort. METHODS: We retrospectively analyzed data of our carotid artery stenting database comprising 1165 angiographically successful interventional procedures during the last 19 years. Significant ISR was assessed by Doppler ultrasound and defined as a flow velocity exceeding 300 cm/s representing a lumen narrowing >70%. Examinations were performed the day after intervention, at follow-up visits 1, 6 and 12 months after index hospitalization and once a year afterwards. RESULTS: Thirty-nine patients (3.4%) developed a significant ISR > 70% during the follow-up period (median 19.6 months, IQR 5.1-49.6 months). In 13 of them, restenosis was caused by a mechanical collapse (stent crush) of the implanted stent. All patients with significant ISR were free of neurological events during follow-up and 31 patients underwent a stent-in-stent implantation. We found a shorter stent length, a narrower stent diameter, performance of post-dilatation as well as stent type to significantly influence development of ISR. CONCLUSION: ISR > 70% after carotid artery stenting is a rare finding also during long-term follow-up. Especially in patients treated with balloon-expandable stents, post-dilatation reduced ISR significantly. As ISR was rare and clinically benign, this technique seems to remain a good therapy option in patients with significant carotid artery stenosis.