Introduction: In the United States more than 6 million persons have chronic venous insufficiency and more than 500,000 have venous ulcers. Patients in whom conservative therapies fail may improve after surgical treatment of superficial and perforating venous disease, but the degree of this benefit is uncertain.Purpose: We performed a systematic review of health outcomes in patients with severe chronic venous insufficiency treated with surgical management that incorporated subfascial endoscopic perforator surgery (SEPS), to quantify, the overall rates of surgical outcomes.Methods: Published studies in English reporting venous ulcer healing and recurrence outcomes after SEPS were obtained from a MEDLINE search. Data regarding patient characteristics and surgical outcomes were abstracted from each study, and the outcomes were combined by using a random effects model.Results: Our search identified 20 studies, 1 randomized trial and 19 case series, involving 1140 treated limbs. CEAP classification was secondary cause (E-S) in 36%, deep venous involvement (A(D))in 56%, and obstructive (P-O) in 12%. Overall, after surgical treatment including SEPS, with or without concomitant superficial venous ablation, ulcers in 88% of limbs healed. Ulcers recurred in 13%, at mean time of 21 months. Risk factors for nonhealing and recurrence included postoperative incompetent perforator veins, pathophysiologic obstruction, secondary cause, and ulcer diameter greater than 2 cm. Complications and their overall rates after surgical treatment including SEPS were wound infection (6%), hematoma (9%), neuralgia (7%), and deep venous thrombosis (1%).Conclusion: Our results suggest that surgical management of venous ulcer including SEPS, with or without saphenous ablation, leads to an 88% chance of ulcer healing and a 13% chance of ulcer recurrence over the short term. Randomized controlled trials are needed to discern the contributions of compression therapy, superficial venous surgery, and SEPS in the treatment of venous ulcer disease.

Background: beta-Blocker therapy postmyocardial infarction is generally recommended because it reduces mortality. However, beta-blockers may increase anaphylaxis mortality in the growing population of patients with peanut-induced anaphylaxis.Objective: We sought to assess the risks and benefits of beta-blocker therapy among patients with peanut allergy and heart disease.Methods: We created a Markov model for patients with heart disease at risk for peanut-induced anaphylaxis to compare life expectancy with the following strategies: (1) beta-blocker and (2) no beta-blocker. Meta-analysis and a literature review were used to estimate model parameters. We performed sensitivity analysis to explore parameter uncertainty.Results: For peanut-allergic patients who are postmyocardial infarction or who have congestive heart failure, the heart disease benefit of beta-blockers outweighs the increased likelihood of dying from anaphylaxis, increasing life expectancy by 9.4 and 17.4 months, respectively. beta-Blocker was preferred unless (1) the annual rate of moderate to severe anaphylaxis exceeded 6.0% for postmyocardial infarction and 15% for congestive heart failure patients; (2) beta-blocker therapy increased the incidence of moderate to severe anaphylaxis >2.5-fold for postmyocardial infarction and >5.8-fold for congestive heart failure patients; (3) anaphylaxis case fatality exceeded 6.5% postmyocardial infarction; or (4) beta-blocker therapy increased anaphylaxis case fatality >25-fold postmyocardial infarction.Conclusion: Our results suggest that for patients postmyocardial infarction or with congestive heart failure who are at risk for peanut-induced anaphylaxis, beta-blocker use should still improve survival. However, the epidemiology of anaphylaxis and effects of beta-blocker therapy on anaphylaxis incidence and mortality require further study.

OBJECTIVES:We performed a meta-analysis of randomized trials comparing coronary artery bypass graft surgery (CABG) with percutaneous transluminal coronary angioplasty (PTCA) for the treatment of coronary artery disease, incorporating new trials and examining long-term outcomes. BACKGROUND:Previous meta-analyses of trials comparing CABG with PTCA have reported short- and intermediate-term outcomes, but since then longer term follow-up and newer trials have been published. METHODS:We performed a meta-analysis of 13 randomized trials on 7,964 patients comparing PTCA with CABG. RESULTS:We found a 1.9% absolute survival advantage favoring CABG over PTCA for all trials at five years (p < 0.02), but no significant advantage at one, three, or eight years. In subgroup analysis of multivessel disease, CABG provided significant survival advantage at both five and eight years. Patients randomized to PTCA had more repeat revascularizations at all time points (risk difference [RD] 24% to 38%, p < 0.001); with stents, this RD was reduced to 15% at one and three years. Stents also resulted in a significant decrease in nonfatal myocardial infarction at three years when compared with CABG. For diabetic patients, CABG provided a significant survival advantage over PTCA at 4 years but not at 6.5 years. CONCLUSIONS:Our results suggest that, when compared with PTCA, CABG is associated with a lower five-year mortality, less angina, and fewer revascularization procedures. For patients with multivessel disease, CABG provided a survival advantage at five to eight years, and for diabetics, a survival advantage at four years. The addition of stents reduced the need for repeat revascularization by about half.