Why the United States Center for Medicare and Medicaid Services (CMS) should not extend reimbursement indications for carotid artery angioplasty/stenting

In recent years, many important discoveries have been made to challenge current policy, guidelines, and practice regarding how best to prevent stroke associated with atherosclerotic stenosis of the origin of the internal carotid artery. The United States Center for Medicare and Medicaid Services (CMS), for instance, is calling for expert advice as to whether its current policies should be modified. Using a thorough review of literature, 41 leading academic stroke-prevention clinicians from the United States and other countries, have united to advise CMS not to extend current reimbursement indications for carotid angioplasty/stenting (CAS) to patients with asymptomatic carotid stenosis or to patients with symptomatic carotid stenosis considered to be at "low or standard risk from carotid endarterectomy (CEA)." It was concluded that such expansion of reimbursement indications would have disastrous health and economic consequences for the United States and any other country that may follow such inappropriate action. This was an international effort because the experts to best advise CMS are relatively few and scattered around the world. In addition, US health policy, practice, and research have tended to have strong influences on other countries.

Peginterferon alfa-2b plus weight-based ribavirin for 24 weeks in patients with chronic hepatitis C virus genotype 1 with low viral load who achieve rapid viral response

In chronic hepatitis C (CHC), treatment duration may be individualized according to time to first undetectable hepatitis C virus (HCV) RNA, with patients who attain undetectable HCV RNA early in treatment being candidates for shorter regimens. The aim of this study was to determine the relapse rate in patients with CHC genotype (G) 1 infection and low baseline viral load who achieved undetectable HCV RNA by week 4 [rapid virologic response (RVR)] when treated for 24 weeks. This was an open-label, multicentre, noninterventional study. Adult patients with G1 CHC infection and baseline viral load <600,000 IU/mL who attained RVR were treated with peginterferon alfa-2b (1.5 μg/kg/week) plus ribavirin (800-1200 mg/day) for 24 weeks, then followed for a further 24 weeks. The primary endpoint was relapse rate, defined as the proportion of patients with undetectable HCV RNA at treatment week 24 and detectable HCV RNA at week 24 follow-up. The secondary efficacy endpoint was sustained virologic response (SVR). Overall, 170 patients were included in the efficacy-evaluable population. The relapse rate was 9.7% (16/165, 95% confidence interval: 0.06-0.15), and SVR was attained by 149 of 170 patients (87.6%). Virologic outcomes were consistent regardless of age, gender, body weight and genotype. Seven patients reported treatment-emergent serious adverse events (AEs), and four patients discontinued treatment because of an AE. This study further demonstrates that peginterferon alfa-2b plus weight-based ribavirin for 24 weeks is an effective treatment strategy for treatment-naive patients with G1 CHC and low viral load who attain RVR.

Endovascular repair of a presumed aortoenteric fistula: late failure due to recurrent infection

PURPOSE

To describe a case of presumed aortoduodenal fistula that was treated by endovascular implantation of a stent-graft.

METHODS AND RESULTS

A 76-year-old man was transferred from another hospital where he had been treated for upper gastrointestinal hemorrhage over a 2-month period. Ten years previously, he had undergone aortobifemoral bypass, the right limb of which recently thrombosed. At the time of transfer, computed tomographic scanning showed a large false aneurysm between the aorta and the duodenum. Endoscopy disclosed mucosal erosions in the fourth portion of the duodenum. Following implantation of 2 overlapping stent-grafts, the bleeding ceased and the false aneurysm disappeared. At no time did the patient have a fever. The patient initially did well, but 8 months after treatment, he presented with fever and chills. Recurrent infection had caused erosion of the aorta so that a large portion of the stent-graft was visible from the duodenum. The infected graft and stent-grafts were removed in a two-part operation, from which the patient recovered satisfactorily.

CONCLUSIONS

Endovascular stent-grafts may have a role to play in the management of aortoduodenal fistula, if only as a temporary measure to control bleeding.

Endovascular repair of a presumed aortoenteric fistula: late failure due to recurrent infection

PURPOSE

To describe a case of presumed aortoduodenal fistula that was treated by endovascular implantation of a stent-graft.

METHODS AND RESULTS

A 76-year-old man was transferred from another hospital where he had been treated for upper gastrointestinal hemorrhage over a 2-month period. Ten years previously, he had undergone aortobifemoral bypass, the right limb of which recently thrombosed. At the time of transfer, computed tomographic scanning showed a large false aneurysm between the aorta and the duodenum. Endoscopy disclosed mucosal erosions in the fourth portion of the duodenum. Following implantation of 2 overlapping stent-grafts, the bleeding ceased and the false aneurysm disappeared. At no time did the patient have a fever. The patient initially did well, but 8 months after treatment, he presented with fever and chills. Recurrent infection had caused erosion of the aorta so that a large portion of the stent-graft was visible from the duodenum. The infected graft and stent-grafts were removed in a two-part operation, from which the patient recovered satisfactorily.

CONCLUSIONS

Endovascular stent-grafts may have a role to play in the management of aortoduodenal fistula, if only as a temporary measure to control bleeding.

Alpha-tocopherol inhibits agonist-induced monocytic cell adhesion to cultured human endothelial cells

Antioxidants have been proposed to be anti-atherosclerotic agents; however, the mechanisms underlying their beneficial effects are poorly understood. We have examined the effect of alpha-tocopherol (alpha-tcp) on one cellular event in atherosclerotic plaque development, monocyte adhesion to stimulated endothelial cells (ECs). Human umbilical vein ECs were pretreated with alpha-tcp before stimulation with known agonists of monocyte adhesion: IL-1 (10 ng/ml), LPS (10 ng/ml), thrombin (30 U/ml), or PMA (10 nM). Agonist-induced monocytic cell adhesion, but not basal adhesion, was inhibited in a time- and concentration-dependent manner by alpha-tcp. The IC50 of alpha-tcp on an IL-1-induced response was 45 microM. The inhibition correlated with a decrease in steady state levels of E-selectin mRNA and cell surface expression of E-selectin which is consistent with the ability of a monoclonal antibody to E-selectin to inhibit monocytic cell adhesion in this system. Probucol (50 microM) and N-acetylcysteine (20 mM) also inhibited agonist-induced monocytic cell adhesion; whereas, several other antioxidants had no significant effect. Protein kinase C (PKC) does not appear to play a role in the alpha-tcp effect since no suppression of phosphorylation of PKC substrates was observed. Activation of the transcription factor NF-kappa B is reported to be necessary but not sufficient for E-selectin expression in EC. Electrophoretic mobility shift assays failed to show an alpha-tcp-induced decrease in activation of this transcription factor after cytokine stimulation. It has been hypothesized that alpha-tcp acts as an anti-atherosclerotic molecule by inhibiting generation of oxidized LDL--a putative triggering molecule in the atherosclerotic process. Our results point to a novel alternative mechanism of action of alpha-tcp.

An audit of surgical emergencies in the very old

The surgical emergency admissions of patients over the age of 80 years at the hospitals of the West Berkshire Health Authority during 1989 have been analysed. The results were then compared with those of 1976 and 1966 in an attempt to identify any changing trends. The total number of admissions increased by almost 37% from 248 in 1976 to 339 in 1989. There was a dramatic increase in those patients admitted with gastrointestinal problems. The average length of stay was less in 1989, being 9 days compared with 15 days in 1976; this was despite the fact that the average length of stay for all ages was comparable for the 2 years in question. The overall mortality rate has not appreciably altered being 21.8% in 1976 and 22.4% in 1989. Excluding terminal disease the mortality rates were 12.5% and 15.9% for 1976 and 1989 respectively. Despite the increased numbers of patients admitted the total beds occupied by the over 80s has actually fallen between 1976 and 1989, due to their shorter hospital stay. Figures for the year 2000 predict a continuing increase in the number of elderly patients in the community. It is unlikely that we will be able to reduce hospital stay much further and therefore the total number of beds occupied by the very old in the acute surgical ward will rise steadily.