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Biomedical subjects

J F Toole

Publications and source records attributed to J F Toole.

At least 181 records · Page 10Linked to original sources
PubMedDate not supplied

Individual variation in susceptibility to extracranial carotid atherosclerosis.

Risk factors for coronary disease were assessed and noninvasive methods were used to quantitate the extent of extracranial carotid atherosclerosis in 382 patients free of cerebrovascular symptoms. The ages of the participants ranged from 27 to 80 years. There were 183 men and 199 women, 30 black and 352 white persons. All patients had heart disease symptoms and were hospitalized for coronary angiography. Correlation of risk factors with extent of extracranial carotid atherosclerosis in this series of patients undergoing coronary angiography uncovered individual variability in relationships between risk factors and carotid atherosclerosis that depended on coronary status. Risk factors for carotid atherosclerosis in patients with and without coronary disease differed. Age and hypertension were independently related to carotid atherosclerosis in patients with, as well as those without, coronary disease. However, other risk factors were related to carotid atherosclerosis in only one group or the other. Risk factors correlated strongly with carotid atherosclerosis in patients with coronary disease (r2 = 0.41) but poorly in those with no coronary disease (r2 = 0.21). Certain risk factors (age, pack years of smoking, left ventricular hypertrophy) related differently to the extent of carotid atherosclerosis in patients with, than in those without, coronary disease. Clarification of the role of coronary status in the carotid atherosclerosis response to risk factors may partly explain the results of certain population-based studies that have related race, gender, and other risk factors to carotid atherosclerosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
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Comparison of Doppler ultrasonography with arteriography of the carotid artery bifurcation.

Continuous-wave (CW) Doppler ultrasound imaging for prediction of arteriogrphic abnormality at the carotid bifurcation was carried out in 195 arteries of 105 patients. The Doppler method had no predictive value when compared to angiographic findings in arteries classified as 0-50% stenosis by Doppler. In 50-75% stenosis by arteriography Doppler accuracy was 52%. With stenosis of 76-99% Doppler imaging correlated with 71% reliability. When an arteriogram was compared with Doppler imaging the latter gave a "false negative" reading in 56% and "false positive" readings in 19%. We conclude that Doppler ultrasound evaluation provides important information regarding the state of the carotid bifurcation, which supplements the bedside evaluation, but it does not substitute for arteriography.

Adult↗
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Management of patients with established ("completed") cerebral infarction.

Management of patients with sudden neurological deficit must be based on complete knowledge of the underlying cause. In about 80% of such patients, a careful history and examination will lead to a precise etiologic and anatomic diagnosis. If the deficit is vascular in etiology, therapy and prognosis depend on its stage of evolution.

Anticoagulants↗
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A case for cerebral thromboangiitis obliterans.

The existence of cerebral thromboangiitis obliterans (CTAO) has been controversial. The clinical, laboratory and angiographic features of a young woman with recurrent thrombophlebitis, digital gangrene and a bilateral anterior opercular syndrome (Foix-Chavany-Marie) are reported. The cerebral angiogram demonstrated significant narrowing of fronto-opercular branches of both middle cerebral arteries. Histology of small digital muscular arteries revealed segmental adventitial fibrosis, narrowing or occlusion of lumen and mild lymphocitic infiltrates; occasional veins showed phlebitis. An etiologic relationship between cerebral occlusive disease and peripheral thromboangitis obliterans (TAO) is suggested.

Adult↗
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Cerebral angiographic and clinical differences in carotid system transient ischemic attacks between American Caucasian and Japanese patients.

Cerebral angiographic findings of 32 Japanese patients with carotid system TIA's were compared with those of an equal number of age and sex matched American Caucasians. The end points included irregularity, ulceration, stenosis or occlusion of the carotid artery appropriate to the side of TIA. Atherosclerotic changes were found in 27 patients (84.4%) of the Japanese and 30 patients (93.7%) of the American patients. Mild lesions (49% stenosis and below) were similar in either frequency of topography between both groups; namely 25 intracranial and 17 extracranial lesions in Japanese as well as 29 intracranial and 10 extracranial in Caucasian patients. There was, however, an extra-intracranial difference in severe lesions (50% stenosis and above) between American Caucasian and Japanese patients; 10 of 12 severe lesions in Japanese were located intracranially, while 17 of 20 severe lesions present in the American group occurred in the extracranial portion of the internal or common carotid arteries.

Adult↗
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Asymptomatic bruit, carotid and vertebrobasilar transient ischemic attacks--a clinical and ultrasonic correlation.

One hundred patients with asymptomatic carotid bruit or transient ischemic attack (TIA) underwent continuous-wave Doppler (CWD) and real time ultrasound (RTU) testing of their cervical carotid arteries. After ultrasonic studies, 51 patients also underwent bilateral carotid angiography. There was 95% agreement between CWD and angiography for the diagnosis of a significant (greater than 50%) stenosis. The RTU diagnosis of a normal or occluded vessel was correct in 100% of cases. Seven plaques appreciated on RTU may not have been large enough for detection by angiography. In this small series, ulceration confirmed pathologically was more reliably predicted by RTU than by cerebral angiography. Significant ipsilateral carotid plaques occurred more often in patients with amaurosis fugax than in patients with hemispheric TIAs. Ipsilateral plaque ulceration occurred in 50% of symptomatic carotid bruits, but in only 10% of asymptomatic carotid bruits. Plasma concentrations of total cholesterol were significantly higher in TIA patients with carotid stenosis than in controls.

Adult↗
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Evaluation of a scoring system for extracranial carotid atherosclerosis extent with B-mode ultrasound.

We have developed a scoring system to quantify extent of extracranial carotid artery atherosclerosis using real-time ultrasound (B-mode). To evaluate repeatability of this scoring system we correlated repeat scores obtained within a short interval of one another (6 months) in 52 individuals. We compared repeatability of extent measurements with repeatability of a measure of severity (single most severe lesion). Correlations between first and second studies for severity were weak (r2 = 0.20) but significant (p less than 0.001). Extent scores correlated much better (r2 = 0.77, p less than 0.001). In another group of 22 patients we found that the extent of atherosclerosis decreased following endarterectomy. We used this method to determine changes in extent of carotid atherosclerosis with age in two sets of individuals. One consisted of a cohort of 22 patients who underwent repeat B-mode studies separated by 1 1/2-3 years. This cohort demonstrated an increase in carotid score with age (p less than 0.05). In a second group of volunteers undergoing cardiac catheterization and B-mode evaluation of the carotid system, carotid scores could be compared in individuals with age differences that averaged 15 years. Extent of carotid atherosclerosis was significantly greater in older individuals (p less than 0.01) and differences in extent with age were exaggerated in patients with coronary disease compared to coronary disease free controls.

Adult↗
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Community Hospital-based Stroke Programs: North Carolina, Oregon, and New York. I: Goals, objectives, and data collection procedures.

In order to assess the impact of variations in stroke care on outcomes, and to make geographic comparisons, the three Community Hospital-Based Stroke Programs in North Carolina, Oregon, and New York, aggregated their data on 4,132 hospitalized stroke patients. Complete demographic data or "Major Profile" were obtained on 2,390 (57.8%) of the 4,132 stroke patients. This includes those patients on whom informed patient and physician consents were obtained during the hospitalization. Of the major profile patients, 1,490 (62.3%) were followed for periods up to one year, 502 (21.0%) were lost to followup and 398 (16.6%) died within the one year followup period. Incomplete demographic data or "Minor Profile" were observed on 1,742 (42.1%) of the 4,132 patients. Minor profile includes those who died before comprehensive interviews were completed or those for whom informed consent for an interview could not be obtained. Of the minor profile group, 813 (46.7%) died in hospital, and 929 (53.3%) were alive when discharged from the hospital. This paper, which describes the programs, data collection procedures, and study cases, also highlights specific issues on stroke diagnosis, risk factors associated with stroke, and the influence of interventions on stroke outcomes. We conclude that: 1) the merging of data on hospitalized stroke cases from rural and urban hospitals in geographically distinct regions can be used in the study of stroke diagnosis, the use of diagnostic tests, and the effect of interventions on stroke outcomes; and 2) these data are consistent with the hypothesis that part of the national decline in mortality from stroke is due to a decline in stroke severity.

Adult↗
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Community Hospital-based Stroke Programs: North Carolina, Oregon, and New York. II: Description of study population.

The three Community Hospital-based Stroke Programs collected data on 4132 stroke patients admitted to acute care hospitals during 1979 and 1980. White female stroke patients were older than the white male, nonwhite female and nonwhite male stroke patients. Nearly one-fourth (23%) of stroke patients were employed at the time of the event. Most (77%) of the patients were hospitalized for first stroke episodes. Eighty-three percent of the patients had at least one of the four major risk factors for stroke, namely, hypertension, diabetes, transient ischemic attacks and cardiac disease. Half (49%) of the patients were alert at the time of admission. The three diagnostic categories included infarction (60%), stroke not otherwise specified (30%) and hemorrhage (10%). Fourteen days was the median length of hospitalization; 50% of the stroke patients were discharged to a home setting, 31% were institutionalized and 19% died while in the hospital. The mean Barthel Index score for 2400 patients at the time of discharge was 61.8 (normal is 100). Of those patients who were working at the time of the stroke, 22% returned to work. In comparison to the patients in the National Survey of Stroke, patients in this Study were less severe at the time of admission (49% of patients in the National Survey of Stroke were stuporous or comatose compared to 21% of the patients in the current Study). The inhospital fatality was 30.7% in the National Survey of Stroke, and 19.7% in the current Study.

Activities of Daily Living↗
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Community Hospital-based Stroke Programs: North Carolina, Oregon, and New York. III. Factors influencing survival after stroke: proportional hazards analysis of 4219 patients.

The possible effect of age, race, sex, consciousness upon admission, geographic location, and history of selected risk factors on the survival after stroke due to infarction or hemorrhage was determined using proportional hazards analysis (Cox regression). For each diagnostic category the most significant prognostic factor was consciousness upon admission. Increasing age, cardiac disease, or previous stroke also decreased the survival time of patients with infarctions. For patients with cerebral hemorrhage, no other variable was significant after control for consciousness level.

Adult↗
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Evaluation of the North Carolina Stroke Care Program.

A study of 774 patients in eastern North Carolina was undertaken to determine the effects of a coordinated program of care and follow-up on recovery from stroke. The program was designed to coordinate and improve in-hospital stroke care and rehabilitation, to provide for education and training of the family for post-hospital care, and to coordinate and facilitate continued access to services after discharge. As measured by the Barthel Index at discharge, three, six and 12 months, the impact of the program was found to be minimal. Patients' scores throughout follow-up were influenced by age, whether the stroke event was new or recurrent, and the state of consciousness at admission. Follow-up Barthel scores were also related to scores obtained at discharge.

Activities of Daily Living↗
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The sex difference in manifestations of carotid bifurcation disease.

One would think that risk factors for transient ischemic attack (TIA) and asymptomatic carotid bruit (ACB) would be similar. In our referral population and in several previously reported cohort populations, however, men outnumber women among patients with TIA. In contrast, women outnumber men among patients with ACB. We found in two independent populations that women with ACB are up to 5.7 times less likely than men to have carotid stenosis. Thus women are more prone than men to have ACB, but their bruits much less commonly reflect carotid stenosis. Women are probably predisposed to have carotid bruit even in the absence of carotid stenosis. In our referral population of ACB, this tendency among women for carotid bruit without stenosis does not seem to be related to lower hematocrit, higher prevalence of heart murmur, constitutionally smaller carotid arteries, or differences in pulse rate or body habitus.

Aged↗
PubMedDate not supplied

Factors influencing the survival of 451 transient ischemic attack patients.

Four hundred fifty-one patients with transient ischemic attacks (TIA) occurring within 1 month of hospitalization, admitted during 1977-1983, were analyzed to establish the effect on survival of age, race, sex, distribution of TIA, cigarette smoking, previous cerebral infarction or hemorrhage, previous TIA, or history of ischemic heart disease, valvular heart disease, cardiac dysrhythmia, hypertension, and diabetes mellitus. Proportional hazards analysis revealed that decreased survival was associated with increasing age, carotid artery distribution TIAs (compared with vertebrobasilar distribution TIAs), cigarette smoking, previous contralateral stroke, ischemic heart disease, and diabetes mellitus. We found great variation in the estimated survival of TIA patients, ranging from 5-year survivals of greater than 95% for 60-year-old patients with none of these risk factors to less than 25% for patients with all of these risk factors. Although the survival of the strata differed, the average mortality rates for this series of patients was about one-half of that observed for 225 patients accessed and followed by our center during 1961-1973.

Aged↗
PubMedDate not supplied

Extracranial carotid arterial disease in patients with familial hypercholesterolemia and coronary artery disease treated with colestipol and nicotinic acid.

Carotid bifurcation atherosclerosis was demonstrated in 34 of 108 patients with familial hypercholesterolemia and coronary artery disease by B-scan, continuous-wave Doppler sonography, and intravenous digital subtraction angiography. An intensive combined therapy of diet, colestipol, and nicotinic acid was mounted to control the hypercholesterolemia of these patients. Their serial sonographies and digital subtraction angiography were evaluated independently by technical specialists who served as coinvestigators. The data obtained suggest that extracranial arterial disease can develop concurrently with coronary artery disease in a significant proportion of patients with familial hypercholesterolemia, and amaurosis fugax, transient ischemic attack, cerebral infarction, and myocardial infarction did not recur during 58-72 months of control of familial hypercholesterolemia in this series of patients.

Adult↗
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Declining morbidity and mortality of carotid endarterectomy. The Wake Forest University Medical Center experience.

The 30-day mortality as well as morbidity for stroke and myocardial infarction were determined by review of the charts for every carotid endarterectomy (N = 389 operations on 356 patients) performed at Wake Forest University Medical Center from 1979 through 1983 to ascertain whether the 16% morbidity and 6% mortality documented in our previous report of 1978 had changed over time. For endarterectomies performed on asymptomatic patients (n = 155), major morbidity included 2 myocardial infarctions and 1 stroke (1.9%). There were 3 fatalities--2 myocardial infarctions and 1 stroke (1.9%). For the symptomatic group (n = 234), major morbidity was 2.1%, mortality 2.6%. The combined morbidity for asymptomatic and symptomatic carotid stenosis was 2%, mortality 2.3%. Perioperative stroke rate (morbidity plus mortality) was 2.6%, 9 ipsilateral to the carotid endarterectomy, suggesting distal embolism as its probable cause. We contend that quality control measures implemented to correct the unacceptable rates reported in 1978 have contributed to dramatic and sustained reductions in complication rates.

Academic Medical Centers↗
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Measurement variability of carotid atherosclerosis: real-time (B-mode) ultrasonography and angiography.

To quantify the within- and between-reader agreement of carotid B-mode ultrasonography and angiography interpretation, images from 117 patients examined by both modalities were read multiple times. Angiographic measurements were more reproducible than those of B-mode scans for all parameters except lesion width, but variations for B-mode scan measurements were similar to those for angiographic measurements. Within-reader agreement on the presence of ulceration was substantial for both modalities, whereas between-reader agreement was poor for B-mode scan and only moderate for angiography.

Carotid Artery Diseases↗