Carotid Artery Stenting

According to the authors, treatment options for patients with significant carotid atherosclerosis include carotid endarterectomy (CEA), carotid artery stenting (CAS), and medical therapy. This is an analysis of results from the Stenting and Angioplasty with Protection in Patients at High-Risk for Endarterectomy (SAPPHIRE) randomized trial, which examined patients at higher surgical risk to determine factors predictive of death or stroke within 30 days of CAS. A new study gives guidance on patient features that identify patients at high and low risk for stroke or death after  carotid artery stenting - CAS. Using a population of patients at high surgical risk undergoing stenting (the SAPPHIRE worldwide study), researchers identified variables that were independently associated with higher risk, including demographic, clinical history, and lesion anatomy features, with the aim of developing a bedside tool for risk prediction. "We developed and validated a predictive model and integer-based tool to predict the occurrence of death or stroke within 30 days of CAS," Neil J. Wimmer, MD, from the Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts, and colleagues conclude. The tool was validated internally by statistical methods, but the investigators are also in the process of validating it externally in a new dataset, told senior author Laura Mauri, MD, also from the Division of Cardiovascular Medicine, Brigham and Women’s Hospital, and Harvard Medical School. "That being said, it's pretty robust," she said of the tool. "It's been constructed in over 10,000 patients and is already in a form that's easy to use, so we hope it will be able to be used right away by clinicians to estimate risk in individual patients." Their report was published online November 5 in Stroke to coincide with its presentation at the American Heart Association Scientific Sessions 2012 in Los Angeles, California.  The  SAPPHIRE  trial was a randomized comparison of CEA (carotid endarterectomy) vs carotid angioplasty and stenting in patients deemed at high surgical risk. However, with only 334 patients, it was not large enough to determine the features strongly associated with periprocedural risk, the authors write. For this analysis, they used data from SAPPHIRE, a single-group prospective study of higher-risk patients undergoing CAS using distal protection. The goal was to develop and internally validate a model and bedside tool to predict death or stroke within 30 days of stenting in patients at higher surgical risk by using variables that could be collected easily during clinical practice, the authors write. "The prediction model generated here can be used to support decision-making." Only patients with at least a single anatomic or comorbid factor associated with elevated surgical risk were included; in all, 10,186 patients were included in the analysis. The overall rate of stroke or death was 3.6% at 30 days after carotid stenting, which, Dr. Mauri said, is "interesting, because the patients who were included in the study were selected for having a high risk for undergoing carotid endarterectomy. And there are certain consensus opinion variables that surgeons feel increase the risk of carotid endarterectomy. Well, those variables are different from the ones that pertain to carotid artery stenting." They found that elevated age, history of stroke, history of transient ischemic attack (TIA), recent myocardial infarction (MI), the need for both cardiac surgery and carotid revascularization, dialysis treatment, the presence of a type 2 or 3 aortic arch, a right-sided carotid stenosis, a longer carotid plaque, and a severely tortuous carotid arterial system were all important risk factors for the development of stroke or death within 30 days of CAS.

·         Increased age

·         History of stroke

·         History of TIA presentation

·         Recent (<4 weeks) MI

·         Dialysis treatment

·         Need for cardiac surgery as well as carotid revascularization

·         Right-sided carotid stenosis

·         Longer carotid plaque

·         Type 2 or 3 aortic arch

·         Tortuous carotid arterial system

Using these factors, the researchers developed a model and integer-based risk score for predicting stroke or death within 30 days. The model was calibrated and internally validated, using bootstrap resampling. The risk score, included in the article, assigns points for each risk factor. The sum of the points relates to the level of risk, ranging from a less than 3% risk with 8 or fewer points to a greater than 10% risk with 16 or more points. "If you just look at the table for the risk score, the most powerful predictors obviously are the ones that give you the most points, and patients who needed to have carotid surgery together with coronary revascularization were at very high risk; patients with a recent MI, patients undergoing dialysis, those were really strong predictors, in addition to patients with advanced age, particularly those who were over 70 years of age," Dr. Mauri said.

Beautiful people

Despite the widely accepted ‘What is beautiful is good’ stereotype, our findings suggest that the beautiful strive for conformity rather than independence, and for self-promotion rather than tolerance,” writes a research team led by Lihi Segal-Caspi of the Open University of Israel.

In other words, the positive traits we attribute to good-looking people are simply a matter of stereotyping. But this study, published in the journal Psychological Science, suggests the unusually attractive have a distinct set of values—and they’re not, well, pretty.

The experiment featured 236 university students (mean age 29), all of whom completed detailed questionnaires designed to uncover their personality traits and deeply held values. Half the participants—118 women—were then videotaped for roughly one minute apiece as they walked around a table and read a weather forecast while looking into the camera.
The other 118 (a mixed group, 59 percent female and 41 percent male) subsequently watched the tapes. They rated each woman for attractiveness (passing judgment on her body, voice, degree of refinement and stylishness of dress), and offered their perception of her traits and values.
In line with prior research, “perceiving a target as physically attractive was associated with perceiving her as agreeable, open to experience, extroverted, conscientious and emotionally stable,” the researchers write. In contrast, on their self-assessment forms, attractive and less-attractive women did not significantly differ on these traits.
However, attractive and less-attractive women did differ on their self-reported values. “Attractiveness correlated with values that express the motivation to conform and submit to social expectations,” the researchers write, “and with values that express a focus on self-promotion rather than on concern for others.”
This is, of course, one small sample from one small country, but the results make intuitive sense. If beautiful people get doted on from a young age, they surely get the sense that society values them highly; it follows that they’d be more likely to be conformists than rebels.
Similarly, a focus on self-promotion as opposed to empathy may suggest narcissism—but isn’t being treated as special the perfect incubator for such an attitude?

Vision and Hearing Loss in Older Adults

Among 446 older adults (mean age, 79.9 years) screened, 3 measures of low-contrast visual acuity were significantly associated with moderate bilateral hearing loss in analyses controlling for age and comorbid conditions, report Marilyn E. Schneck, PhD, and colleagues at the Smith-Kettlewell Eye Research Institute in San Francisco, California. "It is suggested that audiologists consider including a brief test of low contrast vision, such as low contrast acuity. Likewise, eye care practitioners should consider performing a screening test of hearing on their patients. Depending on the severity of the dual sensory loss, referral for rehabilitation may be called for," they write. Although most people can adapt well to moderate loss of either vision or hearing, dual sensory impairment can lead to significant decline in quality of life, said Dr. Schneck, a scientist at Smith-Kettlewell and a research scientist at the University of California at Berkeley School of Optometry. "If someone has a vision impairment and is more likely to have a hearing impairment, it has implications for things like speech reading, which we all do to some extent, but people with hearing impairment come to rely on more and more. 

If they're compromised in their low-contrast visual acuity, that could pose a problem to them when they try to make up with vision the information lost to hearing. The investigators cite evidence that dual sensory loss can have greater effects on depression, cognitive function, and quality of life compared with sensory hearing or vision loss alone. Although the study has substantial design flaws, it draws attention to the fact that older adults frequently have sensory deficits that may get overlooked, commented William J. Hall, MD, Fine Professor of Medicine at the Center for Healthy Aging at the University of Rochester School of Medicine in New York. "All healthcare providers who deal with older people need to be aware of the potential for multiple morbidities at the same time. Frankly, what I find is that we commonly miss hearing loss in older people," said Dr. Hall . However, he questioned the investigators' choice to control for age by 5- to 8-year groups rather than as a continuum, and he noted that it would be a mistake to infer from the data that a single mechanism might be responsible for both hearing and vision loss. Johanna M. Seddo, MD, ScM, director of the Ophthalmic Epidemiology and Genetics Service at the New England Eye Center at Tufts Medical Center in Boston, Massachusetts, agrees with Dr. Hall that the authors should have looked at age as a continuous variable. She also noted that the study sample was small, with only 57 of the 446 participants having moderate hearing loss. "It might also have been helpful if the authors had looked at cardiovascular risk factors [other than stroke]. For example, smoking has been shown to be a risk factor for hearing loss in some studies, and we know that it's related to diseases that cause visual loss, both macular degeneration and cataract," she said. Dr. Schneck and colleagues looked at a cohort of older adults enrolled in a longitudinal study of vision and function in Marin County, California. The participants were screened for visual function with both high-contrast and low-contrast visual acuity tests. Moderate visual impairment was defined as binocular high-contrast visual acuity worse than 0.54 logarithm of the minimum angle of resolution, equivalent to 6/21 or 20/70 or worse on a Snellen chart. The authors defined moderate hearing impairment as the inability to hear pure tones presented twice to each ear by an audioscope set to deliver 500-, 2000-, and 4000-Hz frequencies at 40 decibels. As might be expected, the investigators found that prevalence of hearing loss, visual impairment, and dual sensory deficits increased with age. For example, only 1.6% of 67- to 74-year-olds had moderate hearing impairment, compared with 32.7% of those aged 85 years and older. Similarly, although no participants in the 67- to 74-year-old age range met the vision impairment criteria, 19.1% of those aged 85 and up had at least moderate vision loss. No participants younger than age 75 had dual hearing and vision loss, compared with less than 1% of those aged 75 to 79 and 11.8% of those aged 85 and older. In multivariate logistic regression analysis controlling for age, hearing impairment was significantly positively associated with a history of cataract surgery (odds ratio [OR], 1.97; 95% confidence interval [CI], 1.01 - 3.85; P < .05) and self-reported stroke (OR, 2.69; 95% CI, 1.18 - 6.15; P < .05) and was negatively associated with a history of glaucoma (OR, 0.37; 95% CI, 0.15 - 0.88; P < .05). The overall rate of moderate visual impairment was 5.4%, and the rate of moderate, bilateral hearing impairment was 12.8%, suggesting that the conditions are linked in at least some participants, the investigators say. "If vision and hearing impairments were independent, the probability of having both would be the product of the separate impairment probabilities. In this case, we would expect dual sensory loss in 0.7% of people. In fact, the prevalence of dual sensory loss was over four times higher (3.1%), indicating that the two kinds of impairment are associated," they write. The vision measures that were significantly associated with hearing loss were overall low contrast (10%) acuity (OR, 1.50; 95% CI, 1.02 - 2.22; P < .05), low contrast acuity at low luminance (OR, 1.46; 95% CI, 1.07 - 1.98; P < .05), and low contrast and acuity in glare (OR, 1.40; 95% CI, 1.02 - 1.91; P < .05). "For any of these three measures, those who perform poorly were 40-50% more likely to have moderate bilateral hearing loss than those who scored well on that measure," the investigators write. Normal or high-contrast acuity measures were not significantly associated with hearing loss, however.