Outcome of selective patching following carotid endarterectomy

Objectives:Routine patch angioplasty has been advocated following carotid endarterectomy but patching can be associated with complications. This study assesses the effect of a selective patching policy based on distal internal carotid diameter on the rate of restenosis and outcome following carotid endarterectomy.Design, material and methods:A consecutive series of 213 patients underwent carotid endarterectomy performed by one surgeon. Preoperative carotid dimensions were measured intraoperatively using calipers. Following endarterectomy a 5mm Dacron patch was selectively employed if the distal internal carotid was 5mm or less (group 1, 95 patients) or 6mm or less (group 2, 118 patients). Patients underwent colour-coded Duplex scanning at 24 h, 1 week, 3, 6, 9, and 12 months, and yearly following this.Results:Overall 27 restenoses (5 residual) of 50% or greater and two occlusions developed. Patching was performed in 47% of group 1 and 61% of group 2 arteries. In group 1 14% of patched compared with 24% of non-patched arteries developed restenosis at 24 months (p = 0.4). In group 2 13% of patched compared to 11% of non-patched arteries developed restenosis at 12 months (p > 0.5). Stroke rate at 24 months were similar for patched and non-patched patients in groups 1 (p > 0.5) and 2 (p = 0.4).Conclusions:This study suggests that patch angioplasty of larger carotid arteries may be unnecessary. Randomisation of larger arteries between patch and primary closure would be required to confirm this

Fenofibrate in the management of AbdoMinal aortic anEurysm (FAME): Study protocol for a randomised controlled trial

Background: Abdominal aortic aneurysm (AAA) is a slowly progressive destructive process of the main abdominal artery. Experimental studies indicate that fibrates exert beneficial effects on AAAs by mechanisms involving both serum lipid modification and favourable changes to the AAA wall. Methods/design: Fenofibrate in the management of AbdoMinal aortic anEurysm (FAME) is a multicentre, randomised, double-blind, placebo-controlled clinical trial to assess the effect of orally administered therapy with fenofibrate on key pathological markers of AAA in patients undergoing open AAA repair. A total of 42 participants scheduled for an elective open AAA repair will be randomly assigned to either 145 mg of fenofibrate per day or identical placebo for a minimum period of 2 weeks prior to surgery. Primary outcome measures will be macrophage number and osteopontin (OPN) concentration within the AAA wall as well as serum concentrations of OPN. Secondary outcome measures will include levels of matrix metalloproteinases and proinflammatory cytokines within the AAA wall, periaortic fat and intramural thrombus and circulating concentrations of AAA biomarkers. Discussion: At present, there is no recognised medical therapy to limit AAA progression. The FAME trial aims to assess the ability of fenofibrate to alter tissue markers of AAA pathology. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12612001226897. Registered on 20 November 2012. © 2017 The Author(s)

Dilatation of saphenous vein grafts by nitric oxide

Objectives:To investigate firstly whether flow-dependent vasodilation is maintained in vein grafts, and secondly whether nitric oxide donors dilate vein grafts to improve the flow through graft stenoses.Design, materials and methods:The vasodilatation of mature patent vein grafts, in response to reactive hyperaemia and glyceryl trinitrate (GTN), was assessed by the change in external diameter using duplex ultrasonography. The severity (ratio of proximal systolic velocity, V1, to peak systolic velocity at the stenosis, V2, of vein graft stenoses was determined by duplex ultrasonography before and after 24 h of local application of GTN patches.Results:In post-occlusion hyperaemia the diameter of patent distal vein grafts (n = 7) increased to a maximum of 112±1.9% of resting diameter after 2 min, p = 0.026. The diameter increased further to 117±2.5% of the resting value 5 min after oral GTN (n = 5), p = 0.007. The velocity ratio, V2/V1, through graft stenoses (n = 6) decreased by 20 ± 5% after application of GTN patches, principally as a result of reduction in V2, mean difference 0.8, p = 0.15. The changes in response to GTN were more evident for proximal than distal vein graft stenoses.Conclusion:Flow-induced vasodilatation responses, which have been attributed to the endothelial release of nitric oxide, are maintained in patent vein grafts: the grafts dilate even further in response to GTN. The application of GTN patches close to a vein graft stenosis appears to reduce the velocity ratio through vein graft stenoses. GTN patches might be used to reduce the risk of graft occlusion when there is a delay between the detection and the treatment of haemodynamically significant graft stenoses

Depression as a modifiable factor to decrease the risk of dementia

Depression is an accepted risk factor for dementia, but it is unclear if this relationship is causal. This study investigated whether dementia associated with depression decreases with antidepressant use and is independent of the time between exposure to depression and the onset of dementia. We completed a 14-year longitudinal study of 4922 cognitively healthy men aged 71-89 years, and collected information about history of past depression, current depression and severity of depressive symptoms. Other measures included use of antidepressants, age, education, smoking and history of diabetes, hypertension, coronary heart disease, and stroke. The onset of dementia and death during follow-up was ascertained via the Western Australian Data Linkage System. A total of 682 men had past (n = 388) or current (n = 294) depression. During 8.9 years follow-up, 903 (18.3%) developed dementia and 1884 (38.3%) died free of dementia. The sub-hazard ratios (SHRs) of dementia for men with past and current depression were 1.3 (95% confidence interval (CI) = 1.0, 1.6) and 1.5 (95% CI = 1.2, 2.0). The use of antidepressants did not decrease this risk. Compared to men with no symptoms, the SHRs of dementia associated with questionable, mild-to-moderate and severe depressive symptoms were 1.2 (95% CI = 1.0, 1.4), 1.7 (95% CI = 1.4, 2.2) and 2.1 (95% CI = 1.4, 3.2), respectively. The association between depression and dementia was only apparent during the initial 5 years of follow-up. Older men with history of depression are at increased risk of developing dementia, but depression is more likely to be a marker of incipient dementia than a truly modifiable risk factor

Effectiveness of Remotely Delivered Interventions to Simultaneously Optimize Management of Hypertension, Hyperglycemia and Dyslipidemia in People With Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Remotely delivered interventions may be more efficient in controlling multiple risk factors in people with diabetes. Purpose: To pool evidence from randomized controlled trials testing remote management interventions to simultaneously control blood pressure, blood glucose and lipids. Data Sources: PubMed/Medline, EMBASE, CINAHL and the Cochrane library were systematically searched for randomized controlled trials (RCTs) until 20th June 2021. Study Selection: Included RCTs were those that reported participant data on blood pressure, blood glucose, and lipid outcomes in response to a remotely delivered intervention. Data Extraction: Three authors extracted data using a predefined template. Primary outcomes were glycated hemoglobin (HbA1c), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c), systolic and diastolic blood pressure (SBP & DBP). Risk of bias was assessed using the Cochrane collaboration RoB-2 tool. Meta-analyses are reported as standardized mean difference (SMD) with 95% confidence intervals (95%CI). Data Synthesis: Twenty-seven RCTs reporting on 9100 participants (4581 intervention and 4519 usual care) were included. Components of the remote management interventions tested were identified as patient education, risk factor monitoring, coaching on monitoring, consultations, and pharmacological management. Comparator groups were typically face-to-face usual patient care. Remote management significantly reduced HbA1c (SMD -0.25, 95%CI -0.33 to -0.17, p<0.001), TC (SMD -0.17, 95%CI -0.29 to -0.04, p<0.0001), LDL-c (SMD -0.11, 95%CI -0.19 to -0.03, p=0.006), SBP (SMD -0.11, 95%CI -0.18 to -0.04, p=0.001) and DBP (SMD -0.09, 95%CI -0.16 to -0.02, p=0.02), with low to moderate heterogeneity (I²= 0 to 75). Twelve trials had high risk of bias, 12 had some risk and three were at low risk of bias. Limitations: Heterogeneity and potential publication bias may limit applicability of findings. Conclusions: Remote management significantly improves control of modifiable risk factors

Review of harm-benefit analysis in the use of animals in research

This is the final version of the report. Available from the Home Office via the link in this recordReport of our review of the processes of harm-benefit analysis (HBA) carried out under the UK Animals (Scientific Procedures) Act 1986 (A(SP)A).Report of the Animals in Science Committee Harm-Benefit Analysis Sub-Group chaired by Professor Gail Davies. The Animals in Science Committee Harm-Benefit Analysis subgroup, chaired by Professor Gail Davies, has produced a review of the harm-benefit analysis (HBA). This review is an analysis of the underpinnings and implementation of the HBA which remains a crucial step in the justification of the use of animals in science. It is published in response to a ministerial commission.Animals in Science Committe

Cardiorespiratory Fitness Modulates The Acute Flow-Mediated Dilation Response Following High-Intensity But Not Moderate-Intensity Exercise In Elderly Men.

Impaired endothelial function is observed with ageing and with low cardiorespiratory fitness (VO2peak) whilst improvements in both are suggested to be reliant on higher-intensity exercise in the elderly. This may be due to the flow-mediated dilation (FMD) response to acute exercise of varying intensity. We examined the hypothesis that exercise-intensity alters the FMD response in healthy elderly adults, and would be modulated by VO2peak Forty-seven elderly men were stratified into lower- (VO2peak = 24.3±2.9 ml.kg(-1)min(-1), n=27) and higher-fit groups (VO2peak = 35.4±5.5 ml.kg(-1)min(-1), n=20) after a test of cycling peak power output (PPO). In randomised order, participants undertook 27 min moderate-intensity continuous (MICE; 40% PPO) or high-intensity interval cycling exercise (HIIE; 70% PPO), or no-exercise control. Brachial FMD was assessed at rest, 10 and 60 min after exercise. In control, FMD reduced in both groups (P=0.05). FMD increased after MICE in both groups [increase of 0.86 % (95% CI, 0.17 to 1.56), P=0.01], and normalised after 60 min. In the lower-fit, FMD reduced after HIIE [reduction of 0.85 % (95% CI, 0.12 to 1.58), P=0.02), and remained decreased at 60 min (P=0.05). In the higher-fit FMD was unchanged immediately after HIIE and increased after 60 min [increase of 1.52 % (95% CI, 0.41 to 2.62), P<0.01], which was correlated with VO2peak (r =0.41; P<0.01). Exercise-intensity alters the FMD response in elderly adults, and VO2peak modulates the FMD response following HIIE, but not MICE. The sustained decrease in FMD in the lower-fit may represent a signal for vascular adaptation or endothelial fatigue