Endogenous calcitonin gene-related peptide in cerebrospinal fluid and early quality of life and mental health after good-grade spontaneous subarachnoid hemorrhage-a feasibility series.

The vasodilatory calcitonin gene-related peptide (CGRP) is excessively released after spontaneous subarachnoid hemorrhage (sSAH) and modulates psycho-behavioral function. In this pilot study, we prospectively analyzed the treatment-specific differences in the secretion of endogenous CGRP into cerebrospinal fluid (CSF) during the acute stage after good-grade sSAH and its impact on self-reported health-related quality of life (hrQoL). Twenty-six consecutive patients (f:m = 13:8; mean age 50.6 years) with good-grade sSAH were enrolled (drop out 19% (n = 5)): 35% (n = 9) underwent endovascular aneurysm occlusion, 23% (n = 6) microsurgery, and 23% (n = 6) of the patients with perimesencephalic SAH received standardized intensive medical care. An external ventricular drain was inserted within 72 h after the onset of bleeding. CSF was drawn daily from day 1-10. CGRP levels were determined via competitive enzyme immunoassay and calculated as "area under the curve" (AUC). All patients underwent a hrQoL self-report assessment (36-Item Short Form Health Survey (SF-36), ICD-10-Symptom-Rating questionnaire (ISR)) after the onset of sSAH (t1: day 11-35) and at the 6-month follow-up (t2). AUC CGRP (total mean ± SD, 5.7 ± 1.8 ng/ml/24 h) was excessively released into CSF after sSAH. AUC CGRP levels did not differ significantly when dichotomizing the aSAH (5.63 ± 1.77) and pSAH group (5.68 ± 2.08). aSAH patients revealed a higher symptom burden in the ISR supplementary item score (p = 0.021). Multiple logistic regression analyses corroborated increased mean levels of AUC CGRP in CSF at t1 as an independent prognostic factor for a significantly higher symptom burden in most ISR scores (compulsive-obsessive syndrome (OR 5.741, p = 0.018), anxiety (OR 7.748, p = 0.021), depression (OR 2.740, p = 0.005), the supplementary items (OR 2.392, p = 0.004)) and for a poorer performance in the SF-36 physical component summary score (OR 0.177, p = 0.001). In contrast, at t2, CSF AUC CGRP concentrations no longer correlated with hrQoL. To the best of our knowledge, this study is the first to correlate the levels of endogenous CSF CGRP with hrQoL outcome in good-grade sSAH patients. Excessive CGRP release into CSF may have a negative short-term impact on hrQoL and emotional health like anxiety and depression. While subacutely after sSAH, higher CSF levels of the vasodilator CGRP are supposed to be protective against vasospasm-associated cerebral ischemia, from a psychopathological point of view, our results suggest an involvement of CSF CGRP in the dysregulation of higher integrated behavior.

Hemodialysis patients' satisfaction and perspectives on complications associated with vascular access related interventions: are we listening?

PURPOSE: To understand the patient's perspective on complications associated with vascular access-related interventions. METHODS: A multi-stage comprehensive questionnaire of over 150 items was administered to 140 in-center hemodialysis patients in a large, Toronto-based academic-based facility from May 1, 2011 until July 1, 2014. The questionnaire was divided into three domains: physical complications, disruption to routine, and infection. For each of the 12 prespecified vascular access interventions, there were 9 items about the associated complications. The level of bother associated with complications was measured using a 5-point Likert scale. RESULTS: The mean Likert value (5 = extremely bothered) for the physical complications domain was highest for grafts at 1.92, followed closely by fistulas at 1.87, and catheters at 1.56. The mean Likert value for the "disruption of routine" domain was highest for catheters at 1.44, followed by grafts at 1.37, and fistulas at 1.33. For infectious complications of all vascular access-related interventions the mean Likert value was highest at 1.76 for catheters as compared to fistulas at 1.23 and grafts at 1.22. CONCLUSIONS: For hemodialysis patients, the physical complications associated with needle cannulation of fistulas and grafts are a major source of dissatisfaction, while infectious complications, including catheter-related infections, are not a significant source of their concerns. Future research should focus on developing methods to effectively: (i) reduce the fear and pain associated with cannulation and (ii) educate patients about the risks associated with vascular access-related infection.

[Informed consent for aortic pathology].

Obtaining informed consent from patients and their families before surgery, particularly for aortic pathology, is a necessary, and very important, step. This is because, although the risk of death from asymptomatic disease is underestimated in many cases, surgery for aortic pathology is generally associated with higher risks of mortality and morbidity than that in other fields. The importance of informed consent is the same in principle even in emergency cases. The surgeon must faithfully provide accurate medical information to the patient and family members, including a summary of the patient's condition, the purposes and necessity of treatment, alternatives, details of the procedure, risks, and possible postoperative complications. Extra consideration should be given to offering explanations at a level appropriate for the individual patient, according to factors such as age-group, philosophy, and comprehension ability, to ensure that patients fully understand and are in a position to make a decision of their own volition. The process of giving information and obtaining informed consent offers a prime opportunity to build a strong surgeon-patient relationship.

Attitude towards one's illness vs. attitude towards a surgical operation, displayed by patients diagnosed with asymptomatic abdominal aortic aneurysm and asymptomatic internal carotid artery stenosis.

AIM: Two most frequent asymptomatic diseases qualifying for vascular surgery are abdominal aortic aneurysm (AAA) and internal carotid artery stenosis (ICAS). Emotions experienced by the patient activate processes of dealing with the cognitive dissonance of asymptomatic disease. The aim of this paper was to compare the reasons involved in decision making on surgery in two asymptomatic vascular pathologies. METHODS: Fifty patients were divided into two groups: the ICAS group-27 (CAS or CEA) and the AAA group-23 (EVAR or open surgical operation (OSR). Specific questionnaire regarding: 1) self-image; 2) attitude to one's illness; 3) reasons for decision on surgery was applied for the study. The χ² test was used to for the analysis. RESULTS: The AAA patients reacted emotionally (88.2%) comparing to ICAS patients reacting "rationally" (59.3%) (α=0.05). In AAA patients attitude towards themselves had worsened (α=0.001) AAA patients were less likely to seek support in decision on surgery (α=0.01). ICAS patients are internally motivated (78.7%), whereas AAA patients are externally motivated (63.9%) (α=0.001). Reasons underlying the decision on surgery, were predominantly rational (55.8%). CONCLUSION: In the process of decision-making on surgery by asymptomatic patients, evolutionary transformation takes place - the emotional attitude to one's illness leads to rationally evaluated decision. Regardless of the causes the process of making a decision on surgical operation tended to run more smoothly in ICAS patients. The ICAS patients tended to display a rational attitude to their illness. AAA patients displayed a distinctly emotional attitude towards their illness.

Vascular access type, health-related quality of life, and depression in hemodialysis patients: a preliminary report.

PURPOSE: Arteriovenous fistulas (AVF) are the vascular access of choice for hemodialysis (HD) compared with arteriovenous grafts (AVG) and central venous catheters (CVC). In spite of increasing recognition of importance of a patient's perception of health-related quality of life (HRQOL) and depression, few studies have assessed the association of vascular access type with HRQOL and depression. The purpose of our study was to examine HRQOL and depression among patients with different vascular access. METHODS: Severity of symptoms of depression and HRQOL were assessed by Beck Depression Inventory (BDI) and Short Form-36 (SF-36), respectively. Vascular access was reported as one of three options; AVF, AVG, and CVC. RESULTS: In total, 136 patients were included; 104 had AVF, 15 had AVG, and 17 had CVC. BDI and HRQOL parameters differed among patients with different vascular access types. In post hoc analysis, BDI and HRQOL subscales were not different between patients with AVF and AVG. Patients with CVC had lower physical functioning (P:.001), role-physical limitation (P:.015), general health perception (P:.017), vitality (P:.010), social functioning (P:.004), role-emotional (P:.008), mental health (P:.001), physical component summary score (P:.017), and mental component summary score (P:.006) when compared to patients with AVF. Patients with CVC had lower physical functioning (P:.044), role-emotional (P:.044) and mental health scores (P:.04) when compared to patients with AVG. CONCLUSIONS: Having a CVC may negatively influence HRQOL in HD patients. Vascular access type does not seem to be related to depressed mood in HD.

Patients' perspective of functional outcome after elective abdominal aortic aneurysm repair: a questionnaire survey.

BACKGROUND: To evaluate patients' awareness, functional outcome, and satisfaction after abdominal aortic aneurysm (AAA) repair. METHODS: A study-specific questionnaire was developed with collaboration of a multidisciplinary team. Lists of patients who underwent elective open AAA repair and endovascular aneurysm repair (EVAR) between January 2006 and December 2008 were obtained from the departmental database and cross-checked against hospital database for survival status. Emergency AAA repairs were excluded. Study questionnaires were posted to 138 patients (113 open, 25 EVAR) with self-addressed stamped return envelopes. Statistical analysis was performed using SPSS v16.0. RESULTS: Response rate was 89% (n = 123; 102 open, 21 EVAR). Seventy-one percent (n = 88) were unaware of this condition before diagnosis. Ninety-seven percent (n = 120) indicated their understanding of the need for surgery. Ninety-two percent (n = 113) stated that the operation was adequately explained to them. Ninety percent (n = 111) reported full recovery after surgery, with 60% (n = 74) recovering within 6 months. Eighty-seven percent (n = 108) were satisfied with the overall experience, and 85% (n = 105) stated that they would recommend the operation to family and/or friends if required. CONCLUSIONS: There is a lack of awareness regarding AAA in elderly population. However, after being diagnosed, patients understand the implications and are satisfied with the overall results and would recommend AAA repair to family and/or friends if required.

Midterm outcomes and quality of life of aortic root replacement: mechanical vs biological conduits.

BACKGROUND: Aortic root replacement is a complex operation for severe aortic root pathology such as aneurysms and dissections with concomitant aortic valve disease. Biological and mechanical valve conduits are available. METHODS: Early and midterm results were analyzed in patients undergoing aortic root replacement. From January 1, 1998, to May 31, 2007, 144 patients underwent aortic root replacement (Bentall procedures) with either a mechanical (n = 51) or a biological (n = 93) valve conduit. Cox proportional hazard analysis was used to determine whether valve type was an independent predictor of all-cause mortality, and analysis of covariance was used to compare general and disease-specific health-related quality-of-life scores. RESULTS: Operative mortality was 2.1%. Median follow-up time was 40 months; 1- and 5-year survival rates for the mechanical group were 96.0% and 89.0%, respectively, vs 93.0% and 84.0% for the biological group. Valve type was not predictive of all-cause mortality, and valve-related complications were not significantly different between groups. At follow-up, 31.5% of patients in the biological group were on anticoagulant. General and disease-specific health-related quality-of-life scores were not significantly different between groups. CONCLUSIONS: Aortic root replacement with either mechanical or biological valved conduits is a safe procedure. Morbidity, mortality, and adverse quality of life were not associated with the type of valve conduit. Further studies are required to assess long-term durability of biological valve conduits used for aortic root replacement.

Quality of life in patients with small abdominal aortic aneurysm: the effect of early endovascular repair versus surveillance in the CAESAR trial.

OBJECTIVE: To evaluate and compare changes over time in health-related quality of life reported by patients with small (4.1-5.4 cm) abdominal aortic aneurysms (AAAs) undergoing endovascular aortic aneurysm repair (EVAR) or surveillance. METHODS: Participants were randomly assigned to receive either early EVAR or surveillance within a multicentre, randomised clinical trial on small AAA (Comparison of surveillance vs. Aortic Endografting for Small Aneurysm Repair, CAESAR). Patient-reported health-related quality of life was assessed before randomisation, at 6 months and yearly thereafter using the Short Form 36 (SF-36) Health Survey. RESULTS: Between 2004 and 2008, 360 patients (345 males, mean age 68.9 years) were randomised, 182 to early EVAR and 178 to surveillance. There was one perioperative death. Mean follow-up was 31.8 months. No significant difference in survival was found. At baseline, comparable quality of life scores were recorded in both treatment groups: Total SF-36: 73.0 versus 75.5 (p = 0.18), Physical domain: 71.4 versus 73.3 (p = 0.33); Mental health domain: 70.9 versus 72.7 (p = 0.33), in the EVAR arm versus the surveillance arm, respectively. Six months after randomisation, Total SF-36 and Physical and Mental domain scores were all significantly higher with respect to baseline in the EVAR group, while patients of the surveillance group scored lower. The differences between EVAR and surveillance arms in score changes at 6 months were significant and in favour of EVAR: Total score: difference 5.4; p = 0.0017; Physical: difference 3.8; p = 0.02; and Mental: difference 6.0; p = 0.0005. Differences between EVAR and surveillance diminished over time. At the last assessment, patients in both groups had decreased scores with a significant drop with respect to the baseline (-3.9 in EVAR, -6.3 in surveillance). There were no significant differences between the EVAR and surveillance arms: Total score: p = 0.25; Physical: p = 0.47; and Mental: p = 0.38. CONCLUSIONS: Patients with small AAA under surveillance compared with early EVAR had significant impaired functional health at 6 months after assignment. After a mean of 31.8 months, SF-36 health-related quality of life in patients allocated to early EVAR and surveillance was similar.

Quality of life after acute type B dissection in the era of thoracic endovascular aortic repair.

BACKGROUND: Conservative management of acute type B aortic dissection is currently being challenged by primary thoracic endovascular aortic repair. Aim was to assess outcome and quality of life after these different approaches using an adjusted standard population as benchmark. PATIENTS AND METHODS: Observational study of a prospectively collected (January 2000 to December 2005) consecutive series of 87 patients with acute type B aortic dissection. Patients were 63 +/- 13 years old and 68 were men (78.2 %). Seventy-two were managed conservatively (83 %) and 15 invasively (12 by endovascular aortic repair). Follow-up was 36 +/- 19 months. Endpoints were early and late morbidity and mortality, and long-term quality of life as assessed by the Short Form health survey questionnaire. RESULTS: Patient cohorts were similar regarding age, risk profile and local disease. In the conservative cohort, four patients died during early (5.6 %) and eight during long-term follow-up (cumulative four years survival rate 79 %). Thirty-two patients needed secondary surgical management (44 %), i.e. delayed aortic repair (n = 11), or interventions on adjacent aortic sections or major branches (n = 21). In the surgical cohort no patient died, and no repeated interventions were necessary after the peri-operative period. Long-term quality of life scores were 100 (69-115) in conservatively and 94 (75-124) in invasively managed patients. Normal scores range from 85 to 115. CONCLUSIONS: Primary endovascular management of uncomplicated acute type B dissection is safe and leads to excellent long-term results, whereas secondary interventions were required with high incidence after initial conservative management. Long-term quality of life, however, returned to normal with any successful treatment strategy.

Quality of life survey after endovascular abdominal aortic aneurysm repair in octogenarians.

AIM: The aim of this study was to assess health-related quality of life (HRQOL) after endovascular abdominal aortic aneurysm (AAA) repair in octogenarians compared to younger patients. In addition, a possible association between HRQOL, duration of hospitalisation and preoperative serum C-reactive protein (CRP) was studied. METHODS: 270 consecutive patients (249 men, mean age 73 years, range 52-89 years) with elective endovascular repair of AAA had been retrospectively evaluated. The Nottingham Health Profile (NHP) score was used to assess health related quality of life in 20 patients 80 years or older and in 25 younger patients. RESULTS: The only difference in the NHP score between the two groups was found in physical abilities, where octogenarians had a significant lower score (79.9%, range 32.8-100%) than the younger group (92.2%, range 36.8-100%, P=0.0003). The mean AAA diameter of the octogenarians was 6.4 cm (range 4.1-13.0 cm) and was significantly larger than in non-octogenarians (5.8 cm, range 3.6-12.5 cm, P=0.017). Duration of hospitalisation, CRP-level and prevalence of CAD and PAD were not different in the two groups. Higher preoperative CRP was associated with longer hospital stay. CONCLUSION: Perceived HRQOL in patients undergoing endovascular repair of AAA is equally good in octogenarians and non-octogenarians, however only the score for physical ability is lower in the older group.

The drama of being diagnosed with an aortic aneurysm and undergoing surgery for two different procedures: open repair and endovascular techniques.

The purpose of this study is to describe and interpret what it means for patients to be diagnosed with an abdominal aortic aneurysm (AAA) and how they experience treatment. AAA is usually asymptomatic and often discovered coincidentally in conjunction with a diagnostic workup for other medical problems. Twenty patients who had undergone 2 different surgical procedures were sequentially invited for interviews 1 month following surgery. A hermeneutic approach was used. For all patients three themes emerged: an inability to come to terms with a life-threatening condition, a sense of living on borrowed time, and a sense of being granted a new lease on life. The theme that emerged for patients with open repair was that diagnosis with AAA was an ordeal to endure, while the theme for patients who underwent endovascular treatment was a sense of gratitude, security, and insecurity. Once the aneurysm was discovered patients were convinced that they were both blessed and saved, along with a sense of gratitude. Pre- and postoperative nursing care strategies can be developed based on the findings from this study.

Prospective multicenter study of quality of life before and after lower extremity vein bypass in 1404 patients with critical limb ischemia.

BACKGROUND: Patients with critical limb ischemia (CLI) have multiple comorbidities and limited life spans. The ability of infrainguinal vein bypass to improve quality of life (QoL) in patients with CLI has therefore been questioned. Prospective preoperative and postoperative QoL data for patients undergoing lower extremity vein bypass for CLI are presented. METHODS: A validated, disease-specific QoL questionnaire (VascuQoL) with activity, symptom, pain, emotional, and social domains and responses scored 1 (lowest QoL) to 7 (best QoL) was administered before surgery and at 3 and 12 months after lower extremity vein bypass for CLI. Changes in QoL at 3 and 12 months after lower extremity vein bypass and multiple predetermined variables potentially influencing QoL after lower extremity vein bypass were analyzed to determine the effect of lower extremity vein bypass on QoL in CLI patients. RESULTS: A total of 1404 patients had lower extremity vein bypass for CLI at 83 centers in the United States and Canada as part of the PREVENT III clinical trial. Surveys were completed in 1296 patients at baseline, 862 patients at 3 months, and 732 patients at 12 months. The global QoL score (mean +/- SD) was 2.8 +/- 1.1 at baseline and was 4.7 +/- 1.4 and 5.1 +/- 1.4 at 3 and 12 months, respectively. Mean changes from baseline at 3 and 12 months were statistically significant (P < .0001). Improved QoL scores extended across all domains. Diabetes and the development of graft-related events were associated with decreased improvement in QoL scores, though the mean relative change from baseline remained positive. CONCLUSIONS: Patients with CLI have a low QoL at baseline that is improved at 3 and 12 months after lower extremity vein bypass. QoL improvements are lower in diabetic patients and those who develop graft-related events. Successful revascularization can be expected to improve QoL in patients with CLI, with benefits that are sustained to at least 1 year.