Die Behandlung von Thrombophlebitis in Israel

Die Behandlung von Thrombophlebitis in Israel

Die Behandlung von Thrombophlebitis in Israel

N Engl J Med ; Without strong evidence of benefit, the use of carotid endarterectomy for prophylaxis against stroke rose dramatically until the mids, then declined. Our investigation sought to determine whether carotid endarterectomy reduces the risk of stroke among patients with a recent adverse cerebrovascular event and ipsilateral carotid stenosis. Full Text of Background. We conducted a randomized trial at 50 clinical centers throughout the United States and Canada, in patients in two predetermined strata based on the severity of carotid stenosis—30 to 69 percent and 70 to 99 percent.

We report here the results in the patients in the latter stratum, who had had a hemispheric or retinal transient ischemic attack or a nondisabling stroke within the days before entry and had stenosis of 70 to 99 percent in the symptomatic carotid artery. All patients received optimal medical care, including antiplatelet therapy.

Those assigned to surgical treatment underwent carotid endarterectomy performed by neurosurgeons or vascular surgeons. All patients were examined by neurologists 1, 3, Die Behandlung von Thrombophlebitis in Israel, 6, 9, and 12 months after entry and then every 4 months.

End points were assessed by blinded, independent case review. No patient was lost to follow-up. Full Text of Methods.

For a major or fatal ipsilateral stroke, the corresponding estimates were Full Text of Results. Carotid endarterectomy is highly beneficial to patients with recent hemispheric and retinal transient ischemic attacks or nondisabling strokes and ipsilateral high-grade stenosis 70 to 99 percent of the internal carotid artery.

Full Text of Conclusions. CAROTID endarterectomy was introduced in as a logical procedure for the prevention of ischemic stroke distal to carotid-artery stenosis. The number of patients undergoing endarterectomy in hospitals in the United States other than Veterans Affairs hospitals rose from 15, in toin A full description of the methods of the study has been published elsewhere.

The study was conducted at 50 centers in the United States and Canada. Each center had a rate of less than 6 percent for stroke and death occurring within 30 days of operation for at least 50 consecutive carotid endarterectomies performed within the previous 24 months, and each had obtained approval of the research Die Behandlung von Thrombophlebitis in Israel from its local institutional review board.

To be eligible for the trial, patients had to give informed consent, be less than 80 years old, and have had a hemispheric transient ischemic attack distinct focal neurologic dysfunction or monocular blindness persisting less than 24 hours or a nondisabling stroke with persistence of symptoms or signs for more than 24 hours within the previous days, in association with stenosis of 30 to 99 percent in the ipsilateral internal carotid artery; the artery had to be technically suitable for endarterectomy, as assessed by selective carotid angiography.

Using a jeweler's eyepiece marked in tenths of a millimeter, the principal neuroradiologist measured on the angiograms of each patient the luminal diameter on two views at the point of greatest stenosis and at the normal part of the artery beyond the carotid bulb. The percent stenosis was determined by calculating the ratio of these two measurements, with use of the view showing the greatest degree of narrowing. If review by the Data Management Center Robarts Institute found the stenosis to be less than 30 percent, the angiograms were submitted for independent external adjudication.

Patients were categorized at entry as being in one of two predetermined strata: Patients were excluded from the study if they 1 were mentally incompetent or unwilling to give informed consent; 2 had no angiographic visualization of both carotid arteries and their intracranial branches; 3 had an intracranial lesion that was more severe than the surgically accessible lesion; 4 had organ failure of the kidney, liver, or lung, or had cancer judged likely to cause death within five years; 5 had a cerebral infarction on either side that deprived the patient of all useful function in the affected territory; 6 had symptoms that could be attributed to nonatherosclerotic disease e.

Patients were temporarily ineligible if they had uncontrolled hypertension, diabetes mellitus, or unstable angina pectoris; myocardial infarction within the previous 6 months; signs of progressive neurologic dysfunction; contralateral carotid endarterectomy within the previous 4 months; or a major surgical procedure within the previous 30 days. Such patients could become eligible if the disorder causing their temporary ineligibility resolved within days after their qualifying cerebrovascular event, Die Behandlung von Thrombophlebitis in Israel.

The data on all ineligible patients and all who were eligible but did not undergo randomization, including all patients undergoing carotid endarterectomy outside the trial, were reported to the Nonrandomized Data Center at the Mayo Clinic. Patients underwent standardized history taking, physical and neurologic examinations, a point assessment of functional Die Behandlung von Thrombophlebitis in Israel, laboratory tests, Die Behandlung von Thrombophlebitis in Israel electrocardiography, computerized tomography of the head, angiography and duplex ultrasonography of the carotid arteries, and chest roentgenography.

On transmission of base-line data to the Data Management Center, patients were randomly assigned to receive either medical care alone or medical care plus surgery, according to a computer-generated randomization schedule. Antiplatelet treatment usually mg of aspirin per day or a lower dose if necessitated by side effects and, as indicated, antihypertensive, Die Behandlung von Thrombophlebitis in Israel, antilipid, and antidiabetic therapy was prescribed for all patients.

Those assigned to surgery also underwent carotid endarterectomy. The surgical technique was left to the discretion of the surgeon, Die Behandlung von Thrombophlebitis in Israel, and the procedures have been described elsewhere.

Patients with bilateral stenosis who were assigned to surgery could undergo bilateral endarterectomy if the symptomatic side of the carotid was operated on first.

Study surgeons completed postoperative assessments 30 days after surgery or at the time of hospital discharge, whichever occurred first. Study neurologists performed medical, neurologic, and functional-status assessments of all patients one month after entry, then every three months for the first year, and every four months thereafter. The management of cardiovascular risk factors was monitored centrally, and reminders were sent to neurologists if necessary.

Computed tomography of the head was performed if cerebrovascular events were suspected. Duplex ultrasonography was repeated one month after entry and after any cerebrovascular event in the carotid distribution.

Carotid angiography was repeated after any cerebrovascular event when considered clinically appropriate, Die Behandlung von Thrombophlebitis in Israel. All deaths were assessed for their immediate, underlying, and contributing causes. Strokes were assessed for location, type, Die Behandlung von Thrombophlebitis in Israel, laterality, severity, and duration, according to the definitions published by the Committee on Classification of Cerebrovascular Disease of the National Institute of Neurological Disorders and Stroke.

Patient eligibility and events were assessed at three levels: The original calculations of sample size allowed for independent analyses in each of four angiographic subgroups defined by the degree of stenosis and angiographic evidence of ulceration. However, the comparison of base-line angiograms and surgical specimens confirmed the insensitivity of angiography in detecting ulceration. All analyses compared medical and surgical patients with respect to the Die Behandlung von Thrombophlebitis in Israel of time before treatment failure by means of the MantelHaenszel chi-square test and Kaplan—Meier survival curves.

All reported P values are two-tailed. The primary analysis defined treatment failure as any fatal or nonfatal stroke ipsilateral to the carotid lesion. Other definitions included all strokes and all deaths as well as consideration of the severity of stroke. Strokes producing functional deficits persisting beyond 90 days were considered major.

Each of these analyses included all strokes regardless of location and all deaths regardless of cause that occurred among surgical patients during the day postoperative period and among medical patients during a comparable period after randomization, Die Behandlung von Thrombophlebitis in Israel.

Patients found to be ineligible because they did not have either an appropriate carotid lesion or corresponding symptoms were excluded from the primary analysis. Patients who were crossed over to the other treatment group were included in the primary Die Behandlung von Thrombophlebitis in Israel up Die Behandlung von Thrombophlebitis in Israel the date of crossover, but not after that date.

As dictated in the protocol, monthly interim analyses were initiated in January two years after the randomization of the first patient. If the results of any of these monthly analyses, known only to the principal biostatistical investigator and a clinical epidemiologist, showed a difference between the medical and surgical groups that had reached a level of statistical significance of 0.

If this difference remained at the 0. The committee was also to be convened if it became possible to rule out, with a high level of confidence, a 10 percent reduction in relative risk as a result of Die Behandlung von Thrombophlebitis in Israel endarterectomy. Analyses were conducted to ascertain the importance of risk factors by dividing patients into three risk groups of approximately equal size according to a simple count of the commonly recognized risk factors with the use of arbitrary cutoff points: These risk factors and cutoff points were chosen in advance and were not derived through analysis of the data.

On February 1,the trial's preplanned rule for stopping randomization was invoked because of evidence of treatment efficacy among patients with high-grade stenosis 70 to 99 percent who underwent carotid endarterectomy.

On February 21, the monitoring and executive committees agreed that 1 randomization of patients with high-grade stenosis should be stopped, 2 a summary of the results in the patients with high-grade Die Behandlung von Thrombophlebitis in Israel should be communicated immediately to the participating clinicians, along with a list of all patients given medical treatment alone to whom the results might apply, 3 reports of all strokes and deaths and all patient assessments occurring before February 21 should be collected as quickly as possible for inclusion in this report, and 4 the parallel study dealing with symptomatic patients with medium-grade stenosis 30 to 69 percent should be continued.

The sponsoring agency, the National Institute of Neurological Disorders and Stroke, independently issued a peer-reviewed Clinical Alert to convey immediately a summary of these interim results to physicians across North America. Six hundred sixty-two patients with high-grade carotid stenosis determined by central radiologic review were enrolled between January 1,and February 21, Of these, three patients 0.

Randomization created Weinblatt mit Varizen treatment groups with respect to the qualifying cerebrovascular events, underlying vascular lesions, and important prognostic characteristics Table 1 Table 1 Base-Line Characteristics of the Treatment Groups.

The similarity between the patients included and those excluded, reported elsewhere, 19 confirmed that no subgroup of eligible patients was systematically excluded from the trial.

No patient was lost to follow-up and none withdrew; 98 percent of the surviving patients had their last follow-up examination within 4 months Die Behandlung von Thrombophlebitis in Israel the February 21 closing date, and the average duration of follow-up was 18 months. Twenty-one medical patients 6, Die Behandlung von Thrombophlebitis in Israel. Of the patients assigned to surgery, only 1 refused the operation and received medical treatment alone.

All the others underwent carotid endarterectomy, performed an average of two days after randomization. Medical regimens to reduce the risk of stroke were applied equally in both treatment groups. Over 99 percent of both medical and surgical patients were taking anti-thrombotic drugs at the last follow-up visit, most commonly aspirin, which was being used by 94 percent of the medical patients and 98 percent of the surgical patients.

The perioperative period was considered the time from randomization to 30 days after surgery which was performed a median of 2 days after randomization.

None of the surgical patients had a stroke or died between randomization and surgery. In the perioperative period, 18 surgical patients 5. In addition, one patient died suddenly after surgery, for a rate of 5.

Restricting the analysis to the most serious events resulted in a rate of 2. In the comparable day period after randomization among the medical patients, 11 3. This resulted in a rate of 3. Other surgical complications included cranialnerve injury 7. Of these complications, 81 percent were considered mild of no lasting consequence and not prolonging hospitalization and the rest were considered moderate of no lasting consequence but prolonging the hospital stay. Thus, for every patients treated surgically, 17 were spared an ipsilateral stroke over the next two years.

This represents a relative-risk reduction of 65 percent and shows that six such patients are the "number needed to be treated" 22 in order to prevent one adverse event by 24 months. The second through sixth rows of Table 2 show that carotid endarterectomy remained beneficial with respect Die Behandlung von Thrombophlebitis in Israel each of the five other definitions of outcome events, Die Behandlung von Thrombophlebitis in Israel.

The vast majority of first events were ipsilateral strokes 61 in medical patients vs. The inclusion of stroke in the distribution of the contralateral carotid and vertebral basilar arteries added only three events to those in the medical group and eight to those in the surgical group, and the further addition of death from any cause added another nine and seven events, respectively.

Survival curves for the values reflected in each of the rows in Table 2 are shown in Figure 1 Figure 1 Survival Curves for the Treatment Groups. These Kaplan—Meier survival curves show the probability of surviving six events indicating treatment failure after randomization. The number of patients who remained event-free in each treatment group is shown at six-month intervals at the bottom of each graph; the numbers at time zero are in the surgical group and in the medical group.

They reveal two additional points of interest. First, the early disadvantage to the surgical patients who faced a risk of perioperative stroke and death was rapidly overcome, with the curves for the medical and the surgical patients crossing about three months after randomization.

Second, there was no evidence of convergence of the two curves for as long as 30 months, indicating that the beneficial effects of surgery persisted at least this long.

Among the patients who did not die or have a major stroke during the first month after randomization, the risk of any major or fatal stroke within two years was Thus, the immediate postoperative increase in the risk of major stroke or death among the surgical patients, 1. Analyzing our results according to the intention-to-treat principle produced essentially the same levels of significance and standard errors for between-group differences.

This analysis, which included the three incorrectly randomized ineligible patients and counted events occurring in a patient after crossover according to the group to which the patient had originally been assigned, added just one event to those in the medical group and two events to those in the surgical group. The analyses reported in this paper include 30 patients found to be technically ineligible because of inadequate angiography 17 patientssevere intracranial stenosis 4cerebral aneurysms 3cardiac disorders 3and other medical problems 3.

Die Behandlung von Thrombophlebitis in Israel

Pilz gegen FuГcreme gegen Krampfadern ob den Varizen eine andere Erkrankung zugrunde liegt MГrz VerГdung von Krampfadern und Besenreiser. Wenn winterzeit ist grippezeit und verstopft dort ein gefГГ, fГhrt mit der Zeit zur SchwГchung des Jin.

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