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J Golledge

Publications and source records attributed to J Golledge.

At least 19 recordsLinked to original sources
PubMed2006

High risk plaque, high risk patient or high risk procedure?

SAPPHIRE, a randomised trial of endarterectomy versus angioplasty in 'high-risk' patients, concluded that angioplasty was 'not inferior' to surgery. This has subsequently been translated to mean that angioplasty was 'preferable' or 'advisable' in patients considered high-risk for surgery, with no further discrimination between symptomatic and asymptomatic individuals. Moreover, there have been suggestions that the accepted procedural risks may have to be increased in these patients. In fact, 71% of patients in SAPPHIRE were asymptomatic in whom there was an average 6% 30-day death/stroke rate. At this level of risk, neither surgery nor angioplasty could ever prevent long-term stroke. The concept of identifying high-risk patients is laudable, but they should be high risk for stroke (i.e. symptomatic). There is currently little systematic evidence to include asymptomatic patients within this definition.

Angioplasty↗
PubMed2005

Aortic calcification.

OBJECTIVES: Vascular calcification is a complicating factor observed in advanced atherosclerosis. This review summarises the present knowledge regarding abdominal aortic calcification. DESIGN: Literature review. METHODS: A literature review was carried using MEDLINE and PUBMED with the search terms 'abdominal', 'aortic' and 'calcification'. Articles were assessed for data regarding mechanisms, measurement, risk factors and outcomes of aortic calcification. RESULTS: Thirty relevant studies were identified. These demonstrated a positive correlation between abdominal aortic calcification and the following factors: older age, hypertension, and smoking. Further studies are required to critically assess other risk factors such as gender, diabetes mellitus and renal failure. Calcification of the abdominal aorta is associated with an increased risk of mortality, coronary heart disease and stroke. CONCLUSION: Aortic calcification predicts an increased incidence of cardiovascular events, however, the reasons for this association requires further investigation. Accurate measurement of aortic calcification is likely to be increasingly used to determine the risk of cardiovascular events.

Age Factors↗
PubMed2003

Pathogenesis of varicose veins.

BACKGROUND: varicose veins are present in up to 40% of the population. They may be associated with considerable morbidity. Around 70% of patients with chronic venous insufficiency have evidence of superficial venous incompetence on duplex imaging. METHODS: in this publication we review the evidence available regarding the pathogenesis of varicose veins. RESULTS: a number of theories have been suggested. The present data suggests that abnormalities in the venous endothelium and smooth muscle cells result in vein wall dilatation with secondary valvular incompetence. However, there is also evidence to support acquired venous valve failure. Congenital venous valve abnormalities have not been well studied. CONCLUSION: further work is required on this relatively neglected topic. The use of improved imaging such as high-resolution ultrasound is likely to significantly improve our understanding of venous valve function and pathology.

Adult↗
PubMed2001

Determinants of carotid microembolization.

PURPOSE: Earlier studies have highlighted risk factors for perioperative stroke after carotid endarterectomy, such as female sex, preoperative symptoms, and cerebral infarction. In this study, we investigated the relationship between these factors and perioperative microembolization. METHODS: A total of 235 patients were entered in the study at two centers. Transcranial Doppler ultrasound scanning was possible in 190 patients (81%) and was performed for 1 hour preoperatively and continuously intraoperatively as a means of detecting microemboli and monitoring mean middle cerebral artery velocity. The findings of transcranial Doppler ultrasound scanning were related to perioperative risk factors by means of univariate analysis. RESULTS: Microemboli were detected in 28 (15%), 79 (42%), and 98 (52%) patients preoperatively, during carotid artery dissection, and after closure of the artery, respectively. Having 10 or more emboli after carotid artery closure was more common in women (P = .04) and in patients with symptomatic carotid artery disease (P = .04) and was demonstrated in three of the six patients who had a perioperative stroke. These three patients also had preoperative evidence of cerebral infarction and an intraoperative middle cerebral artery velocity less than 40 cm/s. CONCLUSION: In this study, perioperative microembolization was more common in women and patients with symptomatic carotid artery disease. These findings may explain the increased risk of carotid surgery in these patients.

Adult↗
PubMed2001

Critical assessment of the outcome of infrainguinal vein bypass.

OBJECTIVE: To perform a more critical assessment of infrainguinal vein bypass. SUMMARY BACKGROUND DATA: Graft patency may give an unrealistic impression of the outcome of bypass surgery. METHODS: During a 6-year period, 236 patients undergoing primary vein grafts were entered into the study. An ideal outcome required the patient to have survived 12 months with a patent graft on duplex scanning, no perioperative complication, and no further related open or endovascular surgery or admission. RESULTS: At 12 months, the secondary graft patency rate was 82%; however, only 22% of patients had an ideal outcome. At 1 year, 44 (19%) patients died, 93 (39%) required further ipsilateral and 39 (17%) contralateral intervention, and a total of 108 (46%) were readmitted. An ideal outcome was more likely in patients receiving calcium channel blockers, principally because of improved primary patency, and less likely in those with cardiac failure requiring furosemide, principally because of worse survival in these patients. CONCLUSIONS: Few patients achieve an ideal result after infrainguinal vein bypass. Outcome may be improved by the use of calcium channel blockers. Careful consideration is required before performing revascularization in patients with cardiac failure.

Aged↗
PubMed2000

Age-related variation in the treatment and outcomes of patients with breast carcinoma.

BACKGROUND: There is controversy regarding the effect of age on breast carcinoma, and previous analyses have often excluded the most elderly patients as well as those with advanced cancers. This study assessed treatment variations and outcome in relation to age for a complete series of patients who presented with breast carcinoma within a defined geographic district. METHODS: Data were collected prospectively for all 784 patients who presented with breast carcinoma in North Bedfordshire, United Kingdom, from 1990 to 1996. Stage of disease, treatment, and outcome were compared for different age groups. RESULTS: Older patients had more advanced cancers: 14% of lymph node negative patients age > or = 60 years had T3 or T4 tumors compared with 4% of younger lymph node negative patients (P < 0. 0001). Treatment varied with age: 94% of lymph node negative patients age > or = 60 years received tamoxifen compared with 73% of younger lymph node negative patients (P < 0.0001). For lymph node positive patients, outcome was unaffected by age; however, for lymph node negative patients, outcome was best for patients ages 60-69 years: disease free survival was 91% compared with 78% for other ages at 3 years (P = 0.008), and the locoregional recurrence rate was 2% compared with 7% at 3 years (P = 0.04). The improvement in the locoregional recurrence rate applied to all lymph node negative patients age > or = 60 years: the recurrence rate was 2% compared with 9% for younger patients at 3 years (P = 0.04). CONCLUSIONS: These data support the theory that breast carcinomas are more aggressive in younger patients. The high prescription rate of tamoxifen for older lymph node negative women may have contributed to the low locoregional recurrence rate for this group.

Adult↗
PubMed2000

Effect of surgical subspecialization on breast cancer outcome.

BACKGROUND: There is increasing pressure for specialization of medical services. The effect of surgical specialization on the outcome of breast cancer in Bedford has been assessed. METHODS: The Bedford Breast Cancer Registry, which contains prospective diagnostic, treatment and follow-up data on all breast cancers treated in North Bedfordshire, was analysed to compare breast cancer outcome between 1990-1992 and 1993-1996, that is before and after the advent of surgical subspecialization. All 784 patients were analysed, including patients with metastases (4 per cent) and those treated by tamoxifen alone (8 per cent). Outcome was compared in terms of disease-free survival (DFS), locoregional and all (locoregional and metastases) recurrence rates assessed by Cox proportional hazard and Kaplan-Meier analyses. RESULTS: Overall DFS was 75 per cent and the locoregional recurrence rate was 8 per cent at 3 years. The tumour stage and grade at presentation and the proportion of screen-detected cancers were similar for both intervals. The outcome for patients before specialization (1990-1992; n = 329) was worse: hazard ratio (HR) for DFS 1.5 (95 per cent confidence interval 1.2-2.0) and HR for locoregional recurrence 2.0 (1.2-3.5). After subspecialization (1993-1996, n = 455) DFS improved from 70 to 79 per cent (P = 0.009) and the all recurrence rate fell from 22 to 12 per cent (P = 0.0004) at 3 years. The improvement in outcome was mainly in younger patients (aged less than 70 years), in whom DFS improved from 72 to 81 per cent (P = 0.02) and the all recurrence rate fell from 24 to 12 per cent (P = 0.001) at 3 years. The improvement was associated with increased axillary surgery (47 to 74 per cent; P < 0.0001), and more frequent use of tamoxifen (74 to 84 per cent; P = 0.004) and chemotherapy (10 to 27 per cent; P < 0.0001) in this age group. CONCLUSION: There was a significant improvement in outcome for patients with breast cancer after surgical subspecialization in Bedford. This may relate to the more frequent use of appropriate systemic therapy.

Adult↗
PubMed2000

Arterial flow induces changes in saphenous vein endothelium proteins transduced by cation channels.

OBJECTIVES: expression of leukocyte adhesins and proteins controlling thrombosis is likely to be an important determinant of graft patency early following vein bypass. We have previously demonstrated rapid increase in endothelial ICAM-1 and nitric oxide synthase (eNOS) concentrations in human saphenous vein exposed to arterial flow. The aim of this study was to investigate whether ion-channel-blocking drugs could alter these flow-induced changes. METHODS: human saphenous vein segments, freshly excised from patients, were placed in a validated in vitro circuit using flow conditions shown to simulate arterial or venous circulations for 90 min, in the presence or absence of ion-channel blockers. The concentrations of ICAM-1, VCAM-1, eNOS and tissue factor (TF) were assessed by quantitative immunohistochemistry in vein exposed to flow and compared with that in freshly excised vein from the same patient. The endothelial protein concentration was calculated as the mean area of staining as percentage of that for the control protein CD31, using computer-aided image analysis. RESULTS: after arterial flow conditions the area ratio of ICAM-1 increased from 21.4+/-1.4 to 44.6+/-2.0%, of eNOS increased from 50.0+/-5.6 to 70.1+/-5.0%, of VCAM-1 decreased from 16.6+/-3.4 to 3.6+/-1.0%, whereas TF staining area ratio was unchanged. Inclusion of the non-selective K(+)channel blocker, tetraethylammonium, in the arterial perfusion solution abolished all these arterial flow-induced changes. Inclusion of the K(+)ATP channel blocker, glibenclamide, selectively abolished the arterial flow-induced changes in ICAM-1 and VCAM-1. Inclusion of the calcium channel blocker, nifedipine, abolished the arterial flow-induced changes in eNOS and VCAM-1 but increased the TF staining area ratio from 3.0+/-0.4 to 8.5+/-0.7%, p=0.01. Inclusion of the stretch-activated cation-channel blocker, gadolinium, enhanced the arterial flow-induced increase in eNOS, but prevented the arterial flow-induced increase in ICAM-1. CONCLUSIONS: perfusion of veins under arterial flow conditions with gadolinium was associated with low endothelial concentrations of ICAM-1, VCAM-1 and TF, but high levels of eNOS. Such a concentration of endothelial proteins may be advantageous in newly implanted vein grafts. In contrast, nifedipine could have adverse effects by promoting increase in TF concentration.

Arteries↗
PubMed2000

Exercise therapy or angioplasty? A summation analysis.

OBJECTIVES: To compare the outcome of exercise therapy or angioplasty for the treatment of patients with intermittent claudication. DESIGN: A summation analysis. METHODS: A search using MEDLINE and PUBMED between 1966 and April 1999 followed by a review of the manuscripts yielded 54 studies involving angioplasty and 27 studies involving exercise therapy for intermittent claudication. Studies were only included (12 angioplasty and nine exercise series) when results were available for patients with intermittent claudication alone, and when outcome was assessed in terms of symptoms at a minimum of 6 months. RESULTS: The total number of claudicants undergoing exercise therapy was 294 patients, with a mean symptomatic success rate of 38. 4% and a mean improvement in maximum walking distance of 189.7% at 6 months. The total number of claudicants undergoing angioplasty was 2071, with a mean overall symptomatic success rate of 76.6%. The mean overall complication rate was 9% and mean major complication rate was 2.7% for the angioplasty studies. CONCLUSION: Although the result demonstrates an advantage of angioplasty over exercise therapy at 6 months, there is a small risk of major complications. However, comparison of studies was impaired due to disparity in patient numbers, limited follow-up time and lack of uniformity in outcome assessment. In order to achieve a valid comparison of these therapies in a future randomised study, a validated disease-specific instrument for the assessment of symptomatic outcome for claudicants is required.

Angioplasty, Balloon↗
PubMed2000

The symptomatic carotid plaque.

BACKGROUND: The natural histories of equally severe symptomatic and asymptomatic carotid stenoses are very different, which suggests dichotomy in plaque behavior. The vascular biology of the symptomatic carotid plaque is presented in this review. SUMMARY OF REVIEW: Histology studies comparing asymptomatic and symptomatic plaques were identified from MEDLINE. Reports in which stenosis severity was not stated or not similar for symptomatic and asymptomatic patients were excluded. In vitro studies and reports from the coronary circulation were reviewed with regard to the vascular biology of the plaque. Histology studies comparing carotid plaques removed from symptomatic and asymptomatic patients reveal characteristic features of unstable plaques: surface ulceration and plaque rupture (48% of symptomatic compared with 31% of asymptomatic, P<0.001), thinning of the fibrous cap, and infiltration of the cap by greater numbers of macrophages and T cells. In vitro studies suggest that macrophages and T cells release cytokines and proteinase, which stimulate breakdown of cap collagen and smooth muscle cell apoptosis and thereby promote plaque rupture. CONCLUSIONS: Infiltration of inflammatory cells to the surface of carotid plaques may be a critical step in promoting plaque rupture and resultant embolization or carotid occlusion. Further understanding of cell recruitment and behavior in carotid atherosclerosis may allow better detection of unstable plaques and therapeutic methods of plaque stabilization.

Carotid Arteries↗
PubMed2000

Systematic comparison of the early outcome of angioplasty and endarterectomy for symptomatic carotid artery disease.

BACKGROUND AND PURPOSE: Endoluminal treatment is being increasingly used for carotid artery disease. The aim of this study was to compare the stroke and death risk within 30 days of endovascular treatment or endarterectomy for symptomatic carotid artery disease. METHODS: systematic comparison of the 30-day outcome of angioplasty with or without stenting and endarterectomy for symptomatic carotid artery disease reported in single-center studies, published since 1990, was performed. RESULTS: Thirty-three studies (13 angioplasty and 20 carotid endarterectomy) were included in this analysis. Carotid stents were deployed in 44% of angioplasty patients. Mortality within 30 days of angioplasty was 0.8% compared with 1.2% after endarterectomy (OR 0.68, 95% CI 0.43 to 1.05; P=0.6). The stroke rate was 7.1% for angioplasty and 3.3% for endarterectomy (OR 2.22, CI 1.62 to 3.04; P<0.001), while the risk of fatal or disabling stroke was 3.2% and 1.6%, respectively (OR 2.09, CI 1.3 to 3.33; P<0.01). The risk of stroke or death was 7.8% for angioplasty and 4% for endarterectomy (OR 2.02, CI 1.49 to 2.75; P<0.001), while disabling stroke or death was 3.9% after angioplasty and 2.2% after endarterectomy (OR 1.86, CI 1.22 to 2.84; P<0.01). CONCLUSIONS: In the treatment of symptomatic carotid artery disease, the risk of stroke is significantly greater with angioplasty than carotid endarterectomy. At present, carotid angioplasty is not recommended for the majority of patients with symptomatic carotid artery disease.

Angioplasty, Balloon↗