Mark S. Lesney

The majority of patients receiving endovascular repair for an aortic abdominal aneurysm failed to meet criteria for intervention as opposed to surveillance, and more than 58% of these patients failed to meet conservative criteria for device use based on manufacturer instructions, according to a large retrospective database study.

In addition, at 5 years post EVAR, 41% of the patients showed aneurysm sac enlargement, an outcome considered a surrogate for potential aneurysm rupture, according to a report.

This is an important issue because “in 2006, 21,725 EVAR procedures were performed in the United States, exceeding for the first time the number of open surgical AAA repairs,” according to Dr. Andres Schanzer of the University of Massachusetts, Worcester, and his colleagues at the Harvard School of Public Health, Boston, and the Cleveland Clinic Foundation.

In addition, although studies have demonstrated substantially lower morbidity and mortality after EVAR than after open repair, “late survival of these cohorts has demonstrated that the early survival advantage of patients undergoing EVAR disappears with time and a significant proportion of late deaths after EVAR are due to aneurysm rupture.”

Dr. Schanzer and his colleagues conducted a retrospective analysis of patients in M2S Inc.'s imaging database. M2S has served as the core imaging laboratory for several large aneurysm management trials and provides these services to both public and private academic hospitals globally. The study population consisted of 10,228 patients who underwent EVAR for AAA repair in 1999-2008, and who had a baseline CT scan before EVAR and at least one follow-up CT scan. The patients were primarily men (84.1%) with a mean age of 73.9 years, and represented all regions of the United States.

Key anatomical measurements included maximum AAA sac diameter, aortic diameter at the lowest renal artery, aortic neck length (distance between the lowest renal artery and the origin of the aneurysm, indicated by a 10% increase in diameter), aortic neck angulation (angle calculated between the lowest renal artery, the origin of the aneurysm, and the aortic bifurcation), conical neck (aortic diameter at 15 mm below the lowest renal artery greater than or equal to 10% larger than the aortic diameter at the lowest renal artery), AAA volume, maximum common iliac diameter, and length from the lowest renal artery to the aortic bifurcation. Data on the exact endovascular device used were not available, and there were no data available regarding secondary interventions (Circulation 2011 April 10 [doi:10.1161/CIRCULATIONAHA.110.014902]).

The instructions for use (IFU) for each approved device was reviewed, and these criteria were incorporated into three descriptive variables: conservative IFU (most restrictive), liberal IFU (least restrictive), and time-dependent IFU (reflecting the most liberal IFU at each time point during the study period).

The primary end point was AAA sac enlargement (defined as a growth of 5 mm or more in the AAA maximal diameter from before EVAR to any post-EVAR CT scan, based on Society for Vascular Surgery reporting standards). The secondary end point was endoleak (defined as the presence of contrast-opacified blood within the aneurysm sac and outside the endovascular stent graft).

The average preoperative AAA maximum diameter was 54.8 mm, with 6,075 patients (59%) having an AAA maximum diameter of less than 55 mm. The average neck diameter was 23.1 mm, with a mean length of 20.7 mm and a mean angle of 36.9 degrees. In addition, 11.9% were found to have at least one common iliac aneurysm greater than 20 mm in diameter.

When all patients were classified according to IFU criteria, 5,983 patients (58.5%) were outside compliance with the conservative IFU, 3,178 patients (31.1%) were outside the liberal IFU, and 4,507 patients (44.1%) were outside the time-dependent IFU.

Population characteristics changed over the 10-year study period. An increasing number of patients undergoing EVAR were 80 years of age or older; the maximum AAA diameter before EVAR did not significantly change over time, but the average diameter of the AAA neck did increase significantly; and significantly more patients undergoing EVAR had highly angulated aortic necks (7.0% in 1999-2003 vs. 9.5% in 2008) or conical aortic necks (30% vs. 35.7%). In addition, the external iliac diameter in patients decreased significantly over the study period, with 14.8% having both external iliac arteries measuring less than 6 mm in 1999-2003, compared with 17.5% in 2008. Mean follow-up was 31 months, with an average of three postoperative CT scans per patient. At 1, 3, and 5 years after EVAR, AAA sac enlargement was seen in 3%, 17%, and 41% of patients, respectively.

“The rate of AAA sac enlargement was significantly higher in patients who underwent EVAR outside the IFU, regardless of whether lack of compliance was on the basis of conservative IFU, liberal IFU, or time-dependent IFU,” the researchers stated. In addition, the rate of AAA sac enlargement was significantly greater in the group undergoing EVAR more recently (2004-2008), compared with the group who underwent EVAR in 1999-2003.

Multivariate analysis showed that the primary determinate of AAA sac enlargement was the presence of an endoleak on any postop CT scan (hazard ratio, 2.70). Additional significant predictors were a patient age of 80 years or older, an aortic neck diameter of 28 mm or larger, a neck angle greater than 60 degrees, and a common iliac artery diameter less than 20 mm.

Liberalization of the anatomical characteristics “deemed suitable for EVAR has occurred, and several of these factors, including aortic neck diameter, aortic neck angle, and common iliac artery diameter, were independently associated with aortic aneurysm sac enlargement. These observations raise the question as to whether such liberalization is justified with current device designs,” the authors suggested.

“In this multicenter patient population, compliance with published EVAR device IFU guidelines was low, and post-EVAR aneurysm sac enlargement was high, raising concern for long-term risk of aneurysm rupture,” the researchers stated. In addition, the liberalization in the anatomical criteria deemed appropriate for EVAR, observed throughout the study period, “was associated with worse outcomes.”

The authors suggested the need for a prospective EVAR registry incorporating an independent imaging registry to define more precisely the specific aortic and iliac artery anatomy suitable for EVAR with available commercial devices.

Although this is the largest investigation of this question to date, the authors noted several limitations to their study, beyond the lack of device identification and information on secondary interventions. They pointed out that current research indicates that the standard definition of maximum diameter growth of 5 mm or more may be a less-sensitive criterion for sac enlargement than are volume assessments.

Their study indicated a greater need for concern for proper patient selection for EVAR, they concluded.

An improved understanding of these anatomical characteristics “will ultimately improve the effectiveness and durability of EVAR to protect patients against AAA rupture,” Dr. Schanzer and his colleagues said.

The authors reported that they had no disclosures.

The majority of patients receiving endovascular repair for an aortic abdominal aneurysm failed to meet criteria for intervention as opposed to surveillance, and more than 58% of these patients failed to meet conservative criteria for device use based on manufacturer instructions, according to a large retrospective database study.

In addition, at 5 years post EVAR, 41% of the patients showed aneurysm sac enlargement, an outcome considered a surrogate for potential aneurysm rupture, according to a report.

This is an important issue because “in 2006, 21,725 EVAR procedures were performed in the United States, exceeding for the first time the number of open surgical AAA repairs,” according to Dr. Andres Schanzer of the University of Massachusetts, Worcester, and his colleagues at the Harvard School of Public Health, Boston, and the Cleveland Clinic Foundation.

In addition, although studies have demonstrated substantially lower morbidity and mortality after EVAR than after open repair, “late survival of these cohorts has demonstrated that the early survival advantage of patients undergoing EVAR disappears with time and a significant proportion of late deaths after EVAR are due to aneurysm rupture.”

Dr. Schanzer and his colleagues conducted a retrospective analysis of patients in M2S Inc.'s imaging database. M2S has served as the core imaging laboratory for several large aneurysm management trials and provides these services to both public and private academic hospitals globally. The study population consisted of 10,228 patients who underwent EVAR for AAA repair in 1999-2008, and who had a baseline CT scan before EVAR and at least one follow-up CT scan. The patients were primarily men (84.1%) with a mean age of 73.9 years, and represented all regions of the United States.

Key anatomical measurements included maximum AAA sac diameter, aortic diameter at the lowest renal artery, aortic neck length (distance between the lowest renal artery and the origin of the aneurysm, indicated by a 10% increase in diameter), aortic neck angulation (angle calculated between the lowest renal artery, the origin of the aneurysm, and the aortic bifurcation), conical neck (aortic diameter at 15 mm below the lowest renal artery greater than or equal to 10% larger than the aortic diameter at the lowest renal artery), AAA volume, maximum common iliac diameter, and length from the lowest renal artery to the aortic bifurcation. Data on the exact endovascular device used were not available, and there were no data available regarding secondary interventions (Circulation 2011 April 10 [doi:10.1161/CIRCULATIONAHA.110.014902]).

The instructions for use (IFU) for each approved device was reviewed, and these criteria were incorporated into three descriptive variables: conservative IFU (most restrictive), liberal IFU (least restrictive), and time-dependent IFU (reflecting the most liberal IFU at each time point during the study period).

The primary end point was AAA sac enlargement (defined as a growth of 5 mm or more in the AAA maximal diameter from before EVAR to any post-EVAR CT scan, based on Society for Vascular Surgery reporting standards). The secondary end point was endoleak (defined as the presence of contrast-opacified blood within the aneurysm sac and outside the endovascular stent graft).

The average preoperative AAA maximum diameter was 54.8 mm, with 6,075 patients (59%) having an AAA maximum diameter of less than 55 mm. The average neck diameter was 23.1 mm, with a mean length of 20.7 mm and a mean angle of 36.9 degrees. In addition, 11.9% were found to have at least one common iliac aneurysm greater than 20 mm in diameter.

When all patients were classified according to IFU criteria, 5,983 patients (58.5%) were outside compliance with the conservative IFU, 3,178 patients (31.1%) were outside the liberal IFU, and 4,507 patients (44.1%) were outside the time-dependent IFU.

Population characteristics changed over the 10-year study period. An increasing number of patients undergoing EVAR were 80 years of age or older; the maximum AAA diameter before EVAR did not significantly change over time, but the average diameter of the AAA neck did increase significantly; and significantly more patients undergoing EVAR had highly angulated aortic necks (7.0% in 1999-2003 vs. 9.5% in 2008) or conical aortic necks (30% vs. 35.7%). In addition, the external iliac diameter in patients decreased significantly over the study period, with 14.8% having both external iliac arteries measuring less than 6 mm in 1999-2003, compared with 17.5% in 2008. Mean follow-up was 31 months, with an average of three postoperative CT scans per patient. At 1, 3, and 5 years after EVAR, AAA sac enlargement was seen in 3%, 17%, and 41% of patients, respectively.

“The rate of AAA sac enlargement was significantly higher in patients who underwent EVAR outside the IFU, regardless of whether lack of compliance was on the basis of conservative IFU, liberal IFU, or time-dependent IFU,” the researchers stated. In addition, the rate of AAA sac enlargement was significantly greater in the group undergoing EVAR more recently (2004-2008), compared with the group who underwent EVAR in 1999-2003.

Multivariate analysis showed that the primary determinate of AAA sac enlargement was the presence of an endoleak on any postop CT scan (hazard ratio, 2.70). Additional significant predictors were a patient age of 80 years or older, an aortic neck diameter of 28 mm or larger, a neck angle greater than 60 degrees, and a common iliac artery diameter less than 20 mm.

Liberalization of the anatomical characteristics “deemed suitable for EVAR has occurred, and several of these factors, including aortic neck diameter, aortic neck angle, and common iliac artery diameter, were independently associated with aortic aneurysm sac enlargement. These observations raise the question as to whether such liberalization is justified with current device designs,” the authors suggested.

“In this multicenter patient population, compliance with published EVAR device IFU guidelines was low, and post-EVAR aneurysm sac enlargement was high, raising concern for long-term risk of aneurysm rupture,” the researchers stated. In addition, the liberalization in the anatomical criteria deemed appropriate for EVAR, observed throughout the study period, “was associated with worse outcomes.”

The authors suggested the need for a prospective EVAR registry incorporating an independent imaging registry to define more precisely the specific aortic and iliac artery anatomy suitable for EVAR with available commercial devices.

Although this is the largest investigation of this question to date, the authors noted several limitations to their study, beyond the lack of device identification and information on secondary interventions. They pointed out that current research indicates that the standard definition of maximum diameter growth of 5 mm or more may be a less-sensitive criterion for sac enlargement than are volume assessments.

Their study indicated a greater need for concern for proper patient selection for EVAR, they concluded.

An improved understanding of these anatomical characteristics “will ultimately improve the effectiveness and durability of EVAR to protect patients against AAA rupture,” Dr. Schanzer and his colleagues said.

The authors reported that they had no disclosures.

The majority of patients receiving endovascular repair for an aortic abdominal aneurysm failed to meet criteria for intervention as opposed to surveillance, and more than 58% of these patients failed to meet conservative criteria for device use based on manufacturer instructions, according to a large retrospective database study.

In addition, at 5 years post EVAR, 41% of the patients showed aneurysm sac enlargement, an outcome considered a surrogate for potential aneurysm rupture, according to a report.

This is an important issue because “in 2006, 21,725 EVAR procedures were performed in the United States, exceeding for the first time the number of open surgical AAA repairs,” according to Dr. Andres Schanzer of the University of Massachusetts, Worcester, and his colleagues at the Harvard School of Public Health, Boston, and the Cleveland Clinic Foundation.

In addition, although studies have demonstrated substantially lower morbidity and mortality after EVAR than after open repair, “late survival of these cohorts has demonstrated that the early survival advantage of patients undergoing EVAR disappears with time and a significant proportion of late deaths after EVAR are due to aneurysm rupture.”

Dr. Schanzer and his colleagues conducted a retrospective analysis of patients in M2S Inc.'s imaging database. M2S has served as the core imaging laboratory for several large aneurysm management trials and provides these services to both public and private academic hospitals globally. The study population consisted of 10,228 patients who underwent EVAR for AAA repair in 1999-2008, and who had a baseline CT scan before EVAR and at least one follow-up CT scan. The patients were primarily men (84.1%) with a mean age of 73.9 years, and represented all regions of the United States.

Key anatomical measurements included maximum AAA sac diameter, aortic diameter at the lowest renal artery, aortic neck length (distance between the lowest renal artery and the origin of the aneurysm, indicated by a 10% increase in diameter), aortic neck angulation (angle calculated between the lowest renal artery, the origin of the aneurysm, and the aortic bifurcation), conical neck (aortic diameter at 15 mm below the lowest renal artery greater than or equal to 10% larger than the aortic diameter at the lowest renal artery), AAA volume, maximum common iliac diameter, and length from the lowest renal artery to the aortic bifurcation. Data on the exact endovascular device used were not available, and there were no data available regarding secondary interventions (Circulation 2011 April 10 [doi:10.1161/CIRCULATIONAHA.110.014902]).

The instructions for use (IFU) for each approved device was reviewed, and these criteria were incorporated into three descriptive variables: conservative IFU (most restrictive), liberal IFU (least restrictive), and time-dependent IFU (reflecting the most liberal IFU at each time point during the study period).

The primary end point was AAA sac enlargement (defined as a growth of 5 mm or more in the AAA maximal diameter from before EVAR to any post-EVAR CT scan, based on Society for Vascular Surgery reporting standards). The secondary end point was endoleak (defined as the presence of contrast-opacified blood within the aneurysm sac and outside the endovascular stent graft).

The average preoperative AAA maximum diameter was 54.8 mm, with 6,075 patients (59%) having an AAA maximum diameter of less than 55 mm. The average neck diameter was 23.1 mm, with a mean length of 20.7 mm and a mean angle of 36.9 degrees. In addition, 11.9% were found to have at least one common iliac aneurysm greater than 20 mm in diameter.

When all patients were classified according to IFU criteria, 5,983 patients (58.5%) were outside compliance with the conservative IFU, 3,178 patients (31.1%) were outside the liberal IFU, and 4,507 patients (44.1%) were outside the time-dependent IFU.

Population characteristics changed over the 10-year study period. An increasing number of patients undergoing EVAR were 80 years of age or older; the maximum AAA diameter before EVAR did not significantly change over time, but the average diameter of the AAA neck did increase significantly; and significantly more patients undergoing EVAR had highly angulated aortic necks (7.0% in 1999-2003 vs. 9.5% in 2008) or conical aortic necks (30% vs. 35.7%). In addition, the external iliac diameter in patients decreased significantly over the study period, with 14.8% having both external iliac arteries measuring less than 6 mm in 1999-2003, compared with 17.5% in 2008. Mean follow-up was 31 months, with an average of three postoperative CT scans per patient. At 1, 3, and 5 years after EVAR, AAA sac enlargement was seen in 3%, 17%, and 41% of patients, respectively.

“The rate of AAA sac enlargement was significantly higher in patients who underwent EVAR outside the IFU, regardless of whether lack of compliance was on the basis of conservative IFU, liberal IFU, or time-dependent IFU,” the researchers stated. In addition, the rate of AAA sac enlargement was significantly greater in the group undergoing EVAR more recently (2004-2008), compared with the group who underwent EVAR in 1999-2003.

Multivariate analysis showed that the primary determinate of AAA sac enlargement was the presence of an endoleak on any postop CT scan (hazard ratio, 2.70). Additional significant predictors were a patient age of 80 years or older, an aortic neck diameter of 28 mm or larger, a neck angle greater than 60 degrees, and a common iliac artery diameter less than 20 mm.

Liberalization of the anatomical characteristics “deemed suitable for EVAR has occurred, and several of these factors, including aortic neck diameter, aortic neck angle, and common iliac artery diameter, were independently associated with aortic aneurysm sac enlargement. These observations raise the question as to whether such liberalization is justified with current device designs,” the authors suggested.

“In this multicenter patient population, compliance with published EVAR device IFU guidelines was low, and post-EVAR aneurysm sac enlargement was high, raising concern for long-term risk of aneurysm rupture,” the researchers stated. In addition, the liberalization in the anatomical criteria deemed appropriate for EVAR, observed throughout the study period, “was associated with worse outcomes.”

The authors suggested the need for a prospective EVAR registry incorporating an independent imaging registry to define more precisely the specific aortic and iliac artery anatomy suitable for EVAR with available commercial devices.

Although this is the largest investigation of this question to date, the authors noted several limitations to their study, beyond the lack of device identification and information on secondary interventions. They pointed out that current research indicates that the standard definition of maximum diameter growth of 5 mm or more may be a less-sensitive criterion for sac enlargement than are volume assessments.

Their study indicated a greater need for concern for proper patient selection for EVAR, they concluded.

An improved understanding of these anatomical characteristics “will ultimately improve the effectiveness and durability of EVAR to protect patients against AAA rupture,” Dr. Schanzer and his colleagues said.

The authors reported that they had no disclosures.

Ernest Stanley Crawford (1922-1992) was an internationally renowned cardiovascular surgeon whose greatest technical work involved innovative surgical techniques in the treatment of complex aortic diseases and diseases of the heart. He was a tremendous innovator who became the co-inventor of the Baylor Rapid Autologous Transfusion System, a machine that recycles a patient's own red blood cells during surgery. The transfusion system reduced the amount of blood and blood products needed during complex aortic and other arterial surgeries, greatly increasing safety and lowering the costs of surgery. One of his specialty areas was the treatment of vascular complications of Marfan syndrome.

Dr. Crawford received his medical degree from Harvard Medical School in 1946, served in the U.S. Navy from 1947 to 1949, and completed his postgraduate surgical training at Massachusetts General Hospital. He then joined the faculty at Baylor University, becoming a full professor in 1956, and remained at Baylor until the end of his career.

One of Dr. Crawford's most important contributions to vascular surgery was the clamp-and-sew method of thoracic aortic aneurysm repair, which he developed in the 1970s. His technique involved the use of intraluminal Dacron tube grafts and the reimplantation of visceral and renal arteries. This treatment was considered to have vastly improved the efficacy of thoracic aortic aneurysm repair, but it required considerable skill on the part of the surgeon in order to avoid complications from extended cross-clamping of the aorta.

“Thousands of patients are living happy, productive lives as the result of Dr. Crawford's contributions, both directly [he was their personal surgeon] and indirectly through his teachings to other cardiovascular surgeons,” stated Dr. Calvin B. Ernst in a memorial paper published in the Journal of Vascular Surgery in 1993, several months after Dr. Crawford's death in October 1992.

Dr. Crawford also was intimately involved in the development of the first artificial heart assist devices, working with Dr. Michael DeBakey and Dr. Domingo Liotta at Baylor University.

“During 1961-62,” Dr. Liotta reminisced, “our lab at Baylor developed a small, intrathoracic, pneumatic-driven pump that partly bypassed the left ventricle from the left atrium to the thoracic aorta . . . .On 18 July 1963 one of Dr. E. Stanley Crawford's patients underwent an aortic valve replacement. The calcified stenotic valve was replaced with a Starr-Edwards prosthetic valve.

“Early the next morning, the patient had a cardiac arrest and was resuscitated by means of the open-chest technique. After the chest was closed, it was evident that severe brain damage had occurred. The patient remained in a coma, with low cardiac output and anuria. Subsequently, a rather severe pulmonary edema developed and was refractory to standard treatment.

“The first clinical VAD, bypassing the left ventricle from the left atrium to the descending aorta through a left thoracotomy, was implanted in this patient on the evening of 19 July by Dr. Crawford and me.

“The pump was regulated to bypass with 1,800 to 2,500 mL of blood per minute. Although the anuria that had been present since cardiac arrest persisted, the pulmonary edema cleared, as indicated by plain chest x-ray and auscultation. We discontinued mechanical support after 4 days of continuous use, but the patient remained in a coma and died,” said Dr. Liotta.

Among Dr. Crawford's accomplishments were 300 peer-reviewed publications and book chapters, and the much-valued textbook “Diseases of the Aorta,” which he co-authored with his son, John Lloyd Crawford II, M.D.

But Dr. Crawford is perhaps most known for his contributions to professional medical associations and education.

For E. Stanley Crawford was a tireless advocate of vascular surgery as a unique and autonomous profession. As part of these efforts, Dr. Crawford made significant contributions to the evolution and development of the nuts and bolts of the Society for Vascular Surgery and the journals that serve as the bedrock of the field. He was treasurer of the Society for Vascular Surgery from 1977 to 1980 and president from 1987 to 1988, and served as a member of the editorial board of the Journal of Vascular Surgery.

Dr. Crawford was also firmly committed to vascular surgery education, and much of what the profession is today was made possible by his years of teaching and mentoring some of the finest practitioners to grace the field. He served as president of the Lifeline Foundation of the SVS, working to implement the foundation's objective of enhancing the careers of young academic surgeons.

Among these key educational accomplishments was the development of the Society for Vascular Surgery Forum on Critical Issues in Vascular Surgery, which today bears his name. He convened the first Society for Vascular Surgery Forum on Critical Issues in Vascular Surgery at the SVS annual meeting in Chicago on June 11, 1988, and at the 1988 SVS Council Meeting, under his aegis, it was decided that one of the responsibilities of the president-elect would be to organize and orchestrate future Critical Issues meetings.

Sources and Suggested Readings
1) J. Vasc. Surg. 1996;23:1081-7.
2) J. Vasc. Surg. 1993;17:618-19.
3) Tex. Heart Inst. J. 2002;29:229-30.
4) Vascular Surgery Principles and Practice, R. W. Hobson II, S. E. Wilson, F. J. Veith, Eds.; Marcel Dekker: New York, 2003.

Ernest Stanley Crawford (1922-1992) was an internationally renowned cardiovascular surgeon whose greatest technical work involved innovative surgical techniques in the treatment of complex aortic diseases and diseases of the heart. He was a tremendous innovator who became the co-inventor of the Baylor Rapid Autologous Transfusion System, a machine that recycles a patient's own red blood cells during surgery. The transfusion system reduced the amount of blood and blood products needed during complex aortic and other arterial surgeries, greatly increasing safety and lowering the costs of surgery. One of his specialty areas was the treatment of vascular complications of Marfan syndrome.

Dr. Crawford received his medical degree from Harvard Medical School in 1946, served in the U.S. Navy from 1947 to 1949, and completed his postgraduate surgical training at Massachusetts General Hospital. He then joined the faculty at Baylor University, becoming a full professor in 1956, and remained at Baylor until the end of his career.

One of Dr. Crawford's most important contributions to vascular surgery was the clamp-and-sew method of thoracic aortic aneurysm repair, which he developed in the 1970s. His technique involved the use of intraluminal Dacron tube grafts and the reimplantation of visceral and renal arteries. This treatment was considered to have vastly improved the efficacy of thoracic aortic aneurysm repair, but it required considerable skill on the part of the surgeon in order to avoid complications from extended cross-clamping of the aorta.

“Thousands of patients are living happy, productive lives as the result of Dr. Crawford's contributions, both directly [he was their personal surgeon] and indirectly through his teachings to other cardiovascular surgeons,” stated Dr. Calvin B. Ernst in a memorial paper published in the Journal of Vascular Surgery in 1993, several months after Dr. Crawford's death in October 1992.

Dr. Crawford also was intimately involved in the development of the first artificial heart assist devices, working with Dr. Michael DeBakey and Dr. Domingo Liotta at Baylor University.

“During 1961-62,” Dr. Liotta reminisced, “our lab at Baylor developed a small, intrathoracic, pneumatic-driven pump that partly bypassed the left ventricle from the left atrium to the thoracic aorta . . . .On 18 July 1963 one of Dr. E. Stanley Crawford's patients underwent an aortic valve replacement. The calcified stenotic valve was replaced with a Starr-Edwards prosthetic valve.

“Early the next morning, the patient had a cardiac arrest and was resuscitated by means of the open-chest technique. After the chest was closed, it was evident that severe brain damage had occurred. The patient remained in a coma, with low cardiac output and anuria. Subsequently, a rather severe pulmonary edema developed and was refractory to standard treatment.

“The first clinical VAD, bypassing the left ventricle from the left atrium to the descending aorta through a left thoracotomy, was implanted in this patient on the evening of 19 July by Dr. Crawford and me.

“The pump was regulated to bypass with 1,800 to 2,500 mL of blood per minute. Although the anuria that had been present since cardiac arrest persisted, the pulmonary edema cleared, as indicated by plain chest x-ray and auscultation. We discontinued mechanical support after 4 days of continuous use, but the patient remained in a coma and died,” said Dr. Liotta.

Among Dr. Crawford's accomplishments were 300 peer-reviewed publications and book chapters, and the much-valued textbook “Diseases of the Aorta,” which he co-authored with his son, John Lloyd Crawford II, M.D.

But Dr. Crawford is perhaps most known for his contributions to professional medical associations and education.

For E. Stanley Crawford was a tireless advocate of vascular surgery as a unique and autonomous profession. As part of these efforts, Dr. Crawford made significant contributions to the evolution and development of the nuts and bolts of the Society for Vascular Surgery and the journals that serve as the bedrock of the field. He was treasurer of the Society for Vascular Surgery from 1977 to 1980 and president from 1987 to 1988, and served as a member of the editorial board of the Journal of Vascular Surgery.

Dr. Crawford was also firmly committed to vascular surgery education, and much of what the profession is today was made possible by his years of teaching and mentoring some of the finest practitioners to grace the field. He served as president of the Lifeline Foundation of the SVS, working to implement the foundation's objective of enhancing the careers of young academic surgeons.

Among these key educational accomplishments was the development of the Society for Vascular Surgery Forum on Critical Issues in Vascular Surgery, which today bears his name. He convened the first Society for Vascular Surgery Forum on Critical Issues in Vascular Surgery at the SVS annual meeting in Chicago on June 11, 1988, and at the 1988 SVS Council Meeting, under his aegis, it was decided that one of the responsibilities of the president-elect would be to organize and orchestrate future Critical Issues meetings.

Sources and Suggested Readings
1) J. Vasc. Surg. 1996;23:1081-7.
2) J. Vasc. Surg. 1993;17:618-19.
3) Tex. Heart Inst. J. 2002;29:229-30.
4) Vascular Surgery Principles and Practice, R. W. Hobson II, S. E. Wilson, F. J. Veith, Eds.; Marcel Dekker: New York, 2003.

Ernest Stanley Crawford (1922-1992) was an internationally renowned cardiovascular surgeon whose greatest technical work involved innovative surgical techniques in the treatment of complex aortic diseases and diseases of the heart. He was a tremendous innovator who became the co-inventor of the Baylor Rapid Autologous Transfusion System, a machine that recycles a patient's own red blood cells during surgery. The transfusion system reduced the amount of blood and blood products needed during complex aortic and other arterial surgeries, greatly increasing safety and lowering the costs of surgery. One of his specialty areas was the treatment of vascular complications of Marfan syndrome.

Dr. Crawford received his medical degree from Harvard Medical School in 1946, served in the U.S. Navy from 1947 to 1949, and completed his postgraduate surgical training at Massachusetts General Hospital. He then joined the faculty at Baylor University, becoming a full professor in 1956, and remained at Baylor until the end of his career.

One of Dr. Crawford's most important contributions to vascular surgery was the clamp-and-sew method of thoracic aortic aneurysm repair, which he developed in the 1970s. His technique involved the use of intraluminal Dacron tube grafts and the reimplantation of visceral and renal arteries. This treatment was considered to have vastly improved the efficacy of thoracic aortic aneurysm repair, but it required considerable skill on the part of the surgeon in order to avoid complications from extended cross-clamping of the aorta.

“Thousands of patients are living happy, productive lives as the result of Dr. Crawford's contributions, both directly [he was their personal surgeon] and indirectly through his teachings to other cardiovascular surgeons,” stated Dr. Calvin B. Ernst in a memorial paper published in the Journal of Vascular Surgery in 1993, several months after Dr. Crawford's death in October 1992.

Dr. Crawford also was intimately involved in the development of the first artificial heart assist devices, working with Dr. Michael DeBakey and Dr. Domingo Liotta at Baylor University.

“During 1961-62,” Dr. Liotta reminisced, “our lab at Baylor developed a small, intrathoracic, pneumatic-driven pump that partly bypassed the left ventricle from the left atrium to the thoracic aorta . . . .On 18 July 1963 one of Dr. E. Stanley Crawford's patients underwent an aortic valve replacement. The calcified stenotic valve was replaced with a Starr-Edwards prosthetic valve.

“Early the next morning, the patient had a cardiac arrest and was resuscitated by means of the open-chest technique. After the chest was closed, it was evident that severe brain damage had occurred. The patient remained in a coma, with low cardiac output and anuria. Subsequently, a rather severe pulmonary edema developed and was refractory to standard treatment.

“The first clinical VAD, bypassing the left ventricle from the left atrium to the descending aorta through a left thoracotomy, was implanted in this patient on the evening of 19 July by Dr. Crawford and me.

“The pump was regulated to bypass with 1,800 to 2,500 mL of blood per minute. Although the anuria that had been present since cardiac arrest persisted, the pulmonary edema cleared, as indicated by plain chest x-ray and auscultation. We discontinued mechanical support after 4 days of continuous use, but the patient remained in a coma and died,” said Dr. Liotta.

Among Dr. Crawford's accomplishments were 300 peer-reviewed publications and book chapters, and the much-valued textbook “Diseases of the Aorta,” which he co-authored with his son, John Lloyd Crawford II, M.D.

But Dr. Crawford is perhaps most known for his contributions to professional medical associations and education.

For E. Stanley Crawford was a tireless advocate of vascular surgery as a unique and autonomous profession. As part of these efforts, Dr. Crawford made significant contributions to the evolution and development of the nuts and bolts of the Society for Vascular Surgery and the journals that serve as the bedrock of the field. He was treasurer of the Society for Vascular Surgery from 1977 to 1980 and president from 1987 to 1988, and served as a member of the editorial board of the Journal of Vascular Surgery.

Dr. Crawford was also firmly committed to vascular surgery education, and much of what the profession is today was made possible by his years of teaching and mentoring some of the finest practitioners to grace the field. He served as president of the Lifeline Foundation of the SVS, working to implement the foundation's objective of enhancing the careers of young academic surgeons.

Among these key educational accomplishments was the development of the Society for Vascular Surgery Forum on Critical Issues in Vascular Surgery, which today bears his name. He convened the first Society for Vascular Surgery Forum on Critical Issues in Vascular Surgery at the SVS annual meeting in Chicago on June 11, 1988, and at the 1988 SVS Council Meeting, under his aegis, it was decided that one of the responsibilities of the president-elect would be to organize and orchestrate future Critical Issues meetings.

Sources and Suggested Readings
1) J. Vasc. Surg. 1996;23:1081-7.
2) J. Vasc. Surg. 1993;17:618-19.
3) Tex. Heart Inst. J. 2002;29:229-30.
4) Vascular Surgery Principles and Practice, R. W. Hobson II, S. E. Wilson, F. J. Veith, Eds.; Marcel Dekker: New York, 2003.

The majority of patients receiving endovascular repair for an aortic abdominal aneurysm failed to meet criteria for intervention as opposed to surveillance, and more than 58% of these patients failed to meet conservative criteria for device use based on manufacturer instructions, according to a large retrospective database study.

In addition, at 5 years post EVAR, 41% of the patients showed aneurysm sac enlargement, an outcome considered a surrogate for potential aneurysm rupture, according to a report published online April 10 in Circulation.

This is an important issue because "in 2006, 21,725 EVAR procedures were performed in the United States, exceeding for the first time the number of open surgical AAA repairs," according to Dr. Andres Schanzer of the University of Massachusetts, Worcester, and his colleagues at the Harvard School of Public Health, Boston, and the Cleveland Clinic Foundation.

In addition, although studies have demonstrated substantially lower morbidity and mortality after EVAR than after open repair, "late survival of these cohorts has demonstrated that the early survival advantage of patients undergoing EVAR disappears with time and a significant proportion of late deaths after EVAR are due to aneurysm rupture."

Dr. Schanzer and his colleagues conducted a retrospective analysis of patients in M2S Inc.’s imaging database. M2S has served as the core imaging laboratory for several large aneurysm management trials and provides these services to both public and private academic hospitals globally. The study population consisted of 10,228 patients who underwent EVAR for AAA repair in 1999-2008, and who had a baseline CT scan before EVAR and at least one follow-up CT scan. The patients were primarily men (84.1%) with a mean age of 73.9 years, and represented all regions of the United States.

Key anatomical measurements included maximum AAA sac diameter, aortic diameter at the lowest renal artery, aortic neck length (distance between the lowest renal artery and the origin of the aneurysm, indicated by a 10% increase in diameter), aortic neck angulation (angle calculated between the lowest renal artery, the origin of the aneurysm, and the aortic bifurcation), conical neck (aortic diameter at 15 mm below the lowest renal artery greater than or equal to 10% larger than the aortic diameter at the lowest renal artery), AAA volume, maximum common iliac diameter, and length from the lowest renal artery to the aortic bifurcation. Data on the exact endovascular device used were not available, and there were no data available regarding secondary interventions (Circulation 2011 April 10 [doi:10.1161/CIRCULATIONAHA.110.014902]).

The instructions for use (IFU) for each approved endovascular device was reviewed, and these criteria were incorporated into three descriptive variables: conservative IFU (most restrictive), liberal IFU (least restrictive), and time-dependent IFU (reflecting the most liberal IFU at each time point during the study period).

The primary end point was AAA sac enlargement (defined as a growth of 5 mm or more in the AAA maximal diameter from before EVAR to any post-EVAR CT scan, based on Society for Vascular Surgery reporting standards). The secondary end point was endoleak (defined as the presence of contrast-opacified blood within the aneurysm sac and outside the endovascular stent graft).

The average preoperative AAA maximum diameter was 54.8 mm, with 6,075 patients (59%) having an AAA maximum diameter of less than 55 mm. The average neck diameter was 23.1 mm, with a mean length of 20.7 mm and a mean angle of 36.9 degrees. In addition, 11.9% were found to have at least one common iliac aneurysm greater than 20 mm in diameter.

When all patients were classified according to IFU criteria, 5,983 patients (58.5%) were outside compliance with the conservative IFU, 3,178 patients (31.1%) were outside the liberal IFU, and 4,507 patients (44.1%) were outside the time-dependent IFU.

Population characteristics changed over the 10-year study period. An increasing number of patients undergoing EVAR were 80 years of age or older; the maximum AAA diameter before EVAR did not significantly change over time, but the average diameter of the AAA neck did increase significantly; and significantly more patients undergoing EVAR had highly angulated aortic necks (7.0% in 1999-2003 vs. 9.5% in 2008) or conical aortic necks (30% vs. 35.7%). In addition, the external iliac diameter in patients decreased significantly over the study period, with 14.8% having both external iliac arteries measuring less than 6 mm in 1999-2003, compared with 17.5% in 2008.

Mean follow-up was 31 months, with an average of three postoperative CT scans per patient. At 1, 3, and 5 years after EVAR, AAA sac enlargement was seen in 3%, 17%, and 41% of patients, respectively.

"The rate of AAA sac enlargement was significantly higher in patients who underwent EVAR outside the IFU, regardless of whether lack of compliance was on the basis of conservative IFU, liberal IFU, or time-dependent IFU," the researchers stated. In addition, the rate of AAA sac enlargement was significantly greater in the group undergoing EVAR more recently (2004-2008), compared with the group who underwent EVAR in 1999-2003.

Multivariate analysis showed that the primary determinate of AAA sac enlargement was the presence of an endoleak on any postop CT scan (hazard ratio, 2.70). Additional significant predictors were a patient age of 80 years or older, an aortic neck diameter of 28 mm or larger, a neck angle greater than 60 degrees, and a common iliac artery diameter less than 20 mm.

Liberalization of the anatomical characteristics "deemed suitable for EVAR has occurred, and several of these factors, including aortic neck diameter, aortic neck angle, and common iliac artery diameter, were independently associated with aortic aneurysm sac enlargement. These observations raise the question as to whether such liberalization is justified with current device designs," the authors suggested.

"In this multicenter patient population, compliance with published EVAR device IFU guidelines was low, and post-EVAR aneurysm sac enlargement was high, raising concern for long-term risk of aneurysm rupture," the researchers stated. In addition, the liberalization in the anatomical criteria deemed appropriate for EVAR, observed throughout the study period, "was associated with worse outcomes."

The authors suggested the need for a prospective EVAR registry incorporating an independent imaging registry to define more precisely the specific aortic and iliac artery anatomy suitable for EVAR with available commercial devices.

Although this is the largest investigation of this question to date, the authors noted several limitations to their study, beyond the lack of device identification and information on secondary interventions. They pointed out that current research indicates that the standard definition of maximum diameter growth of 5 mm or more may be a less-sensitive criterion for sac enlargement than are volume assessments.

Their study indicated a greater need for concern for proper patient selection for EVAR, they concluded.

An improved understanding of these anatomical characteristics "will ultimately improve the effectiveness and durability of EVAR to protect patients against AAA rupture," Dr. Schanzer and his colleagues said.

The authors reported that they had no disclosures. The study was funded by the William Rogers Family Foundation.

The majority of patients receiving endovascular repair for an aortic abdominal aneurysm failed to meet criteria for intervention as opposed to surveillance, and more than 58% of these patients failed to meet conservative criteria for device use based on manufacturer instructions, according to a large retrospective database study.

In addition, at 5 years post EVAR, 41% of the patients showed aneurysm sac enlargement, an outcome considered a surrogate for potential aneurysm rupture, according to a report published online April 10 in Circulation.

This is an important issue because "in 2006, 21,725 EVAR procedures were performed in the United States, exceeding for the first time the number of open surgical AAA repairs," according to Dr. Andres Schanzer of the University of Massachusetts, Worcester, and his colleagues at the Harvard School of Public Health, Boston, and the Cleveland Clinic Foundation.

In addition, although studies have demonstrated substantially lower morbidity and mortality after EVAR than after open repair, "late survival of these cohorts has demonstrated that the early survival advantage of patients undergoing EVAR disappears with time and a significant proportion of late deaths after EVAR are due to aneurysm rupture."

Dr. Schanzer and his colleagues conducted a retrospective analysis of patients in M2S Inc.’s imaging database. M2S has served as the core imaging laboratory for several large aneurysm management trials and provides these services to both public and private academic hospitals globally. The study population consisted of 10,228 patients who underwent EVAR for AAA repair in 1999-2008, and who had a baseline CT scan before EVAR and at least one follow-up CT scan. The patients were primarily men (84.1%) with a mean age of 73.9 years, and represented all regions of the United States.

Key anatomical measurements included maximum AAA sac diameter, aortic diameter at the lowest renal artery, aortic neck length (distance between the lowest renal artery and the origin of the aneurysm, indicated by a 10% increase in diameter), aortic neck angulation (angle calculated between the lowest renal artery, the origin of the aneurysm, and the aortic bifurcation), conical neck (aortic diameter at 15 mm below the lowest renal artery greater than or equal to 10% larger than the aortic diameter at the lowest renal artery), AAA volume, maximum common iliac diameter, and length from the lowest renal artery to the aortic bifurcation. Data on the exact endovascular device used were not available, and there were no data available regarding secondary interventions (Circulation 2011 April 10 [doi:10.1161/CIRCULATIONAHA.110.014902]).

The instructions for use (IFU) for each approved endovascular device was reviewed, and these criteria were incorporated into three descriptive variables: conservative IFU (most restrictive), liberal IFU (least restrictive), and time-dependent IFU (reflecting the most liberal IFU at each time point during the study period).

The primary end point was AAA sac enlargement (defined as a growth of 5 mm or more in the AAA maximal diameter from before EVAR to any post-EVAR CT scan, based on Society for Vascular Surgery reporting standards). The secondary end point was endoleak (defined as the presence of contrast-opacified blood within the aneurysm sac and outside the endovascular stent graft).

The average preoperative AAA maximum diameter was 54.8 mm, with 6,075 patients (59%) having an AAA maximum diameter of less than 55 mm. The average neck diameter was 23.1 mm, with a mean length of 20.7 mm and a mean angle of 36.9 degrees. In addition, 11.9% were found to have at least one common iliac aneurysm greater than 20 mm in diameter.

When all patients were classified according to IFU criteria, 5,983 patients (58.5%) were outside compliance with the conservative IFU, 3,178 patients (31.1%) were outside the liberal IFU, and 4,507 patients (44.1%) were outside the time-dependent IFU.

Population characteristics changed over the 10-year study period. An increasing number of patients undergoing EVAR were 80 years of age or older; the maximum AAA diameter before EVAR did not significantly change over time, but the average diameter of the AAA neck did increase significantly; and significantly more patients undergoing EVAR had highly angulated aortic necks (7.0% in 1999-2003 vs. 9.5% in 2008) or conical aortic necks (30% vs. 35.7%). In addition, the external iliac diameter in patients decreased significantly over the study period, with 14.8% having both external iliac arteries measuring less than 6 mm in 1999-2003, compared with 17.5% in 2008.

Mean follow-up was 31 months, with an average of three postoperative CT scans per patient. At 1, 3, and 5 years after EVAR, AAA sac enlargement was seen in 3%, 17%, and 41% of patients, respectively.

"The rate of AAA sac enlargement was significantly higher in patients who underwent EVAR outside the IFU, regardless of whether lack of compliance was on the basis of conservative IFU, liberal IFU, or time-dependent IFU," the researchers stated. In addition, the rate of AAA sac enlargement was significantly greater in the group undergoing EVAR more recently (2004-2008), compared with the group who underwent EVAR in 1999-2003.

Multivariate analysis showed that the primary determinate of AAA sac enlargement was the presence of an endoleak on any postop CT scan (hazard ratio, 2.70). Additional significant predictors were a patient age of 80 years or older, an aortic neck diameter of 28 mm or larger, a neck angle greater than 60 degrees, and a common iliac artery diameter less than 20 mm.

Liberalization of the anatomical characteristics "deemed suitable for EVAR has occurred, and several of these factors, including aortic neck diameter, aortic neck angle, and common iliac artery diameter, were independently associated with aortic aneurysm sac enlargement. These observations raise the question as to whether such liberalization is justified with current device designs," the authors suggested.

"In this multicenter patient population, compliance with published EVAR device IFU guidelines was low, and post-EVAR aneurysm sac enlargement was high, raising concern for long-term risk of aneurysm rupture," the researchers stated. In addition, the liberalization in the anatomical criteria deemed appropriate for EVAR, observed throughout the study period, "was associated with worse outcomes."

The authors suggested the need for a prospective EVAR registry incorporating an independent imaging registry to define more precisely the specific aortic and iliac artery anatomy suitable for EVAR with available commercial devices.

Although this is the largest investigation of this question to date, the authors noted several limitations to their study, beyond the lack of device identification and information on secondary interventions. They pointed out that current research indicates that the standard definition of maximum diameter growth of 5 mm or more may be a less-sensitive criterion for sac enlargement than are volume assessments.

Their study indicated a greater need for concern for proper patient selection for EVAR, they concluded.

An improved understanding of these anatomical characteristics "will ultimately improve the effectiveness and durability of EVAR to protect patients against AAA rupture," Dr. Schanzer and his colleagues said.

The authors reported that they had no disclosures. The study was funded by the William Rogers Family Foundation.

The majority of patients receiving endovascular repair for an aortic abdominal aneurysm failed to meet criteria for intervention as opposed to surveillance, and more than 58% of these patients failed to meet conservative criteria for device use based on manufacturer instructions, according to a large retrospective database study.

In addition, at 5 years post EVAR, 41% of the patients showed aneurysm sac enlargement, an outcome considered a surrogate for potential aneurysm rupture, according to a report published online April 10 in Circulation.

This is an important issue because "in 2006, 21,725 EVAR procedures were performed in the United States, exceeding for the first time the number of open surgical AAA repairs," according to Dr. Andres Schanzer of the University of Massachusetts, Worcester, and his colleagues at the Harvard School of Public Health, Boston, and the Cleveland Clinic Foundation.

In addition, although studies have demonstrated substantially lower morbidity and mortality after EVAR than after open repair, "late survival of these cohorts has demonstrated that the early survival advantage of patients undergoing EVAR disappears with time and a significant proportion of late deaths after EVAR are due to aneurysm rupture."

Dr. Schanzer and his colleagues conducted a retrospective analysis of patients in M2S Inc.’s imaging database. M2S has served as the core imaging laboratory for several large aneurysm management trials and provides these services to both public and private academic hospitals globally. The study population consisted of 10,228 patients who underwent EVAR for AAA repair in 1999-2008, and who had a baseline CT scan before EVAR and at least one follow-up CT scan. The patients were primarily men (84.1%) with a mean age of 73.9 years, and represented all regions of the United States.

Key anatomical measurements included maximum AAA sac diameter, aortic diameter at the lowest renal artery, aortic neck length (distance between the lowest renal artery and the origin of the aneurysm, indicated by a 10% increase in diameter), aortic neck angulation (angle calculated between the lowest renal artery, the origin of the aneurysm, and the aortic bifurcation), conical neck (aortic diameter at 15 mm below the lowest renal artery greater than or equal to 10% larger than the aortic diameter at the lowest renal artery), AAA volume, maximum common iliac diameter, and length from the lowest renal artery to the aortic bifurcation. Data on the exact endovascular device used were not available, and there were no data available regarding secondary interventions (Circulation 2011 April 10 [doi:10.1161/CIRCULATIONAHA.110.014902]).

The instructions for use (IFU) for each approved endovascular device was reviewed, and these criteria were incorporated into three descriptive variables: conservative IFU (most restrictive), liberal IFU (least restrictive), and time-dependent IFU (reflecting the most liberal IFU at each time point during the study period).

The primary end point was AAA sac enlargement (defined as a growth of 5 mm or more in the AAA maximal diameter from before EVAR to any post-EVAR CT scan, based on Society for Vascular Surgery reporting standards). The secondary end point was endoleak (defined as the presence of contrast-opacified blood within the aneurysm sac and outside the endovascular stent graft).

The average preoperative AAA maximum diameter was 54.8 mm, with 6,075 patients (59%) having an AAA maximum diameter of less than 55 mm. The average neck diameter was 23.1 mm, with a mean length of 20.7 mm and a mean angle of 36.9 degrees. In addition, 11.9% were found to have at least one common iliac aneurysm greater than 20 mm in diameter.

When all patients were classified according to IFU criteria, 5,983 patients (58.5%) were outside compliance with the conservative IFU, 3,178 patients (31.1%) were outside the liberal IFU, and 4,507 patients (44.1%) were outside the time-dependent IFU.

Population characteristics changed over the 10-year study period. An increasing number of patients undergoing EVAR were 80 years of age or older; the maximum AAA diameter before EVAR did not significantly change over time, but the average diameter of the AAA neck did increase significantly; and significantly more patients undergoing EVAR had highly angulated aortic necks (7.0% in 1999-2003 vs. 9.5% in 2008) or conical aortic necks (30% vs. 35.7%). In addition, the external iliac diameter in patients decreased significantly over the study period, with 14.8% having both external iliac arteries measuring less than 6 mm in 1999-2003, compared with 17.5% in 2008.

Mean follow-up was 31 months, with an average of three postoperative CT scans per patient. At 1, 3, and 5 years after EVAR, AAA sac enlargement was seen in 3%, 17%, and 41% of patients, respectively.

"The rate of AAA sac enlargement was significantly higher in patients who underwent EVAR outside the IFU, regardless of whether lack of compliance was on the basis of conservative IFU, liberal IFU, or time-dependent IFU," the researchers stated. In addition, the rate of AAA sac enlargement was significantly greater in the group undergoing EVAR more recently (2004-2008), compared with the group who underwent EVAR in 1999-2003.

Multivariate analysis showed that the primary determinate of AAA sac enlargement was the presence of an endoleak on any postop CT scan (hazard ratio, 2.70). Additional significant predictors were a patient age of 80 years or older, an aortic neck diameter of 28 mm or larger, a neck angle greater than 60 degrees, and a common iliac artery diameter less than 20 mm.

Liberalization of the anatomical characteristics "deemed suitable for EVAR has occurred, and several of these factors, including aortic neck diameter, aortic neck angle, and common iliac artery diameter, were independently associated with aortic aneurysm sac enlargement. These observations raise the question as to whether such liberalization is justified with current device designs," the authors suggested.

"In this multicenter patient population, compliance with published EVAR device IFU guidelines was low, and post-EVAR aneurysm sac enlargement was high, raising concern for long-term risk of aneurysm rupture," the researchers stated. In addition, the liberalization in the anatomical criteria deemed appropriate for EVAR, observed throughout the study period, "was associated with worse outcomes."

The authors suggested the need for a prospective EVAR registry incorporating an independent imaging registry to define more precisely the specific aortic and iliac artery anatomy suitable for EVAR with available commercial devices.

Although this is the largest investigation of this question to date, the authors noted several limitations to their study, beyond the lack of device identification and information on secondary interventions. They pointed out that current research indicates that the standard definition of maximum diameter growth of 5 mm or more may be a less-sensitive criterion for sac enlargement than are volume assessments.

Their study indicated a greater need for concern for proper patient selection for EVAR, they concluded.

An improved understanding of these anatomical characteristics "will ultimately improve the effectiveness and durability of EVAR to protect patients against AAA rupture," Dr. Schanzer and his colleagues said.

The authors reported that they had no disclosures. The study was funded by the William Rogers Family Foundation.

The majority of patients receiving endovascular repair for an aortic abdominal aneurysm failed to meet criteria for intervention as opposed to surveillance, and more than 58% of these patients failed to meet conservative criteria for device use based on manufacturer instructions, according to a large retrospective database study.

In addition, at 5 years post EVAR, 41% of the patients showed aneurysm sac enlargement, an outcome considered a surrogate for potential aneurysm rupture, according to a report published online April 10 in Circulation.

This is an important issue because "in 2006, 21,725 EVAR procedures were performed in the United States, exceeding for the first time the number of open surgical AAA repairs," according to Dr. Andres Schanzer of the University of Massachusetts, Worcester, and his colleagues at the Harvard School of Public Health, Boston, and the Cleveland Clinic Foundation.

In addition, although studies have demonstrated substantially lower morbidity and mortality after EVAR than after open repair, "late survival of these cohorts has demonstrated that the early survival advantage of patients undergoing EVAR disappears with time and a significant proportion of late deaths after EVAR are due to aneurysm rupture."

Dr. Schanzer and his colleagues conducted a retrospective analysis of patients in M2S Inc.’s imaging database. M2S has served as the core imaging laboratory for several large aneurysm management trials and provides these services to both public and private academic hospitals globally. The study population consisted of 10,228 patients who underwent EVAR for AAA repair in 1999-2008, and who had a baseline CT scan before EVAR and at least one follow-up CT scan. The patients were primarily men (84.1%) with a mean age of 73.9 years, and represented all regions of the United States.

Key anatomical measurements included maximum AAA sac diameter, aortic diameter at the lowest renal artery, aortic neck length (distance between the lowest renal artery and the origin of the aneurysm, indicated by a 10% increase in diameter), aortic neck angulation (angle calculated between the lowest renal artery, the origin of the aneurysm, and the aortic bifurcation), conical neck (aortic diameter at 15 mm below the lowest renal artery greater than or equal to 10% larger than the aortic diameter at the lowest renal artery), AAA volume, maximum common iliac diameter, and length from the lowest renal artery to the aortic bifurcation. Data on the exact endovascular device used were not available, and there were no data available regarding secondary interventions (Circulation 2011 April 10 [doi:10.1161/CIRCULATIONAHA.110.014902]).

The instructions for use (IFU) for each approved endovascular device was reviewed, and these criteria were incorporated into three descriptive variables: conservative IFU (most restrictive), liberal IFU (least restrictive), and time-dependent IFU (reflecting the most liberal IFU at each time point during the study period).

The primary end point was AAA sac enlargement (defined as a growth of 5 mm or more in the AAA maximal diameter from before EVAR to any post-EVAR CT scan, based on Society for Vascular Surgery reporting standards). The secondary end point was endoleak (defined as the presence of contrast-opacified blood within the aneurysm sac and outside the endovascular stent graft).

The average preoperative AAA maximum diameter was 54.8 mm, with 6,075 patients (59%) having an AAA maximum diameter of less than 55 mm. The average neck diameter was 23.1 mm, with a mean length of 20.7 mm and a mean angle of 36.9 degrees. In addition, 11.9% were found to have at least one common iliac aneurysm greater than 20 mm in diameter.

When all patients were classified according to IFU criteria, 5,983 patients (58.5%) were outside compliance with the conservative IFU, 3,178 patients (31.1%) were outside the liberal IFU, and 4,507 patients (44.1%) were outside the time-dependent IFU.

Population characteristics changed over the 10-year study period. An increasing number of patients undergoing EVAR were 80 years of age or older; the maximum AAA diameter before EVAR did not significantly change over time, but the average diameter of the AAA neck did increase significantly; and significantly more patients undergoing EVAR had highly angulated aortic necks (7.0% in 1999-2003 vs. 9.5% in 2008) or conical aortic necks (30% vs. 35.7%). In addition, the external iliac diameter in patients decreased significantly over the study period, with 14.8% having both external iliac arteries measuring less than 6 mm in 1999-2003, compared with 17.5% in 2008.

Mean follow-up was 31 months, with an average of three postoperative CT scans per patient. At 1, 3, and 5 years after EVAR, AAA sac enlargement was seen in 3%, 17%, and 41% of patients, respectively.

"The rate of AAA sac enlargement was significantly higher in patients who underwent EVAR outside the IFU, regardless of whether lack of compliance was on the basis of conservative IFU, liberal IFU, or time-dependent IFU," the researchers stated. In addition, the rate of AAA sac enlargement was significantly greater in the group undergoing EVAR more recently (2004-2008), compared with the group who underwent EVAR in 1999-2003.

Multivariate analysis showed that the primary determinate of AAA sac enlargement was the presence of an endoleak on any postop CT scan (hazard ratio, 2.70). Additional significant predictors were a patient age of 80 years or older, an aortic neck diameter of 28 mm or larger, a neck angle greater than 60 degrees, and a common iliac artery diameter less than 20 mm.

Liberalization of the anatomical characteristics "deemed suitable for EVAR has occurred, and several of these factors, including aortic neck diameter, aortic neck angle, and common iliac artery diameter, were independently associated with aortic aneurysm sac enlargement. These observations raise the question as to whether such liberalization is justified with current device designs," the authors suggested.

"In this multicenter patient population, compliance with published EVAR device IFU guidelines was low, and post-EVAR aneurysm sac enlargement was high, raising concern for long-term risk of aneurysm rupture," the researchers stated. In addition, the liberalization in the anatomical criteria deemed appropriate for EVAR, observed throughout the study period, "was associated with worse outcomes."

The authors suggested the need for a prospective EVAR registry incorporating an independent imaging registry to define more precisely the specific aortic and iliac artery anatomy suitable for EVAR with available commercial devices.

Although this is the largest investigation of this question to date, the authors noted several limitations to their study, beyond the lack of device identification and information on secondary interventions. They pointed out that current research indicates that the standard definition of maximum diameter growth of 5 mm or more may be a less-sensitive criterion for sac enlargement than are volume assessments.

Their study indicated a greater need for concern for proper patient selection for EVAR, they concluded.

An improved understanding of these anatomical characteristics "will ultimately improve the effectiveness and durability of EVAR to protect patients against AAA rupture," Dr. Schanzer and his colleagues said.

The authors reported that they had no disclosures. The study was funded by the William Rogers Family Foundation.

The majority of patients receiving endovascular repair for an aortic abdominal aneurysm failed to meet criteria for intervention as opposed to surveillance, and more than 58% of these patients failed to meet conservative criteria for device use based on manufacturer instructions, according to a large retrospective database study.

In addition, at 5 years post EVAR, 41% of the patients showed aneurysm sac enlargement, an outcome considered a surrogate for potential aneurysm rupture, according to a report published online April 10 in Circulation.

This is an important issue because "in 2006, 21,725 EVAR procedures were performed in the United States, exceeding for the first time the number of open surgical AAA repairs," according to Dr. Andres Schanzer of the University of Massachusetts, Worcester, and his colleagues at the Harvard School of Public Health, Boston, and the Cleveland Clinic Foundation.

In addition, although studies have demonstrated substantially lower morbidity and mortality after EVAR than after open repair, "late survival of these cohorts has demonstrated that the early survival advantage of patients undergoing EVAR disappears with time and a significant proportion of late deaths after EVAR are due to aneurysm rupture."

Dr. Schanzer and his colleagues conducted a retrospective analysis of patients in M2S Inc.’s imaging database. M2S has served as the core imaging laboratory for several large aneurysm management trials and provides these services to both public and private academic hospitals globally. The study population consisted of 10,228 patients who underwent EVAR for AAA repair in 1999-2008, and who had a baseline CT scan before EVAR and at least one follow-up CT scan. The patients were primarily men (84.1%) with a mean age of 73.9 years, and represented all regions of the United States.

Key anatomical measurements included maximum AAA sac diameter, aortic diameter at the lowest renal artery, aortic neck length (distance between the lowest renal artery and the origin of the aneurysm, indicated by a 10% increase in diameter), aortic neck angulation (angle calculated between the lowest renal artery, the origin of the aneurysm, and the aortic bifurcation), conical neck (aortic diameter at 15 mm below the lowest renal artery greater than or equal to 10% larger than the aortic diameter at the lowest renal artery), AAA volume, maximum common iliac diameter, and length from the lowest renal artery to the aortic bifurcation. Data on the exact endovascular device used were not available, and there were no data available regarding secondary interventions (Circulation 2011 April 10 [doi:10.1161/CIRCULATIONAHA.110.014902]).

The instructions for use (IFU) for each approved endovascular device was reviewed, and these criteria were incorporated into three descriptive variables: conservative IFU (most restrictive), liberal IFU (least restrictive), and time-dependent IFU (reflecting the most liberal IFU at each time point during the study period).

The primary end point was AAA sac enlargement (defined as a growth of 5 mm or more in the AAA maximal diameter from before EVAR to any post-EVAR CT scan, based on Society for Vascular Surgery reporting standards). The secondary end point was endoleak (defined as the presence of contrast-opacified blood within the aneurysm sac and outside the endovascular stent graft).

The average preoperative AAA maximum diameter was 54.8 mm, with 6,075 patients (59%) having an AAA maximum diameter of less than 55 mm. The average neck diameter was 23.1 mm, with a mean length of 20.7 mm and a mean angle of 36.9 degrees. In addition, 11.9% were found to have at least one common iliac aneurysm greater than 20 mm in diameter.

When all patients were classified according to IFU criteria, 5,983 patients (58.5%) were outside compliance with the conservative IFU, 3,178 patients (31.1%) were outside the liberal IFU, and 4,507 patients (44.1%) were outside the time-dependent IFU.

Population characteristics changed over the 10-year study period. An increasing number of patients undergoing EVAR were 80 years of age or older; the maximum AAA diameter before EVAR did not significantly change over time, but the average diameter of the AAA neck did increase significantly; and significantly more patients undergoing EVAR had highly angulated aortic necks (7.0% in 1999-2003 vs. 9.5% in 2008) or conical aortic necks (30% vs. 35.7%). In addition, the external iliac diameter in patients decreased significantly over the study period, with 14.8% having both external iliac arteries measuring less than 6 mm in 1999-2003, compared with 17.5% in 2008.

Mean follow-up was 31 months, with an average of three postoperative CT scans per patient. At 1, 3, and 5 years after EVAR, AAA sac enlargement was seen in 3%, 17%, and 41% of patients, respectively.

"The rate of AAA sac enlargement was significantly higher in patients who underwent EVAR outside the IFU, regardless of whether lack of compliance was on the basis of conservative IFU, liberal IFU, or time-dependent IFU," the researchers stated. In addition, the rate of AAA sac enlargement was significantly greater in the group undergoing EVAR more recently (2004-2008), compared with the group who underwent EVAR in 1999-2003.

Multivariate analysis showed that the primary determinate of AAA sac enlargement was the presence of an endoleak on any postop CT scan (hazard ratio, 2.70). Additional significant predictors were a patient age of 80 years or older, an aortic neck diameter of 28 mm or larger, a neck angle greater than 60 degrees, and a common iliac artery diameter less than 20 mm.

Liberalization of the anatomical characteristics "deemed suitable for EVAR has occurred, and several of these factors, including aortic neck diameter, aortic neck angle, and common iliac artery diameter, were independently associated with aortic aneurysm sac enlargement. These observations raise the question as to whether such liberalization is justified with current device designs," the authors suggested.

"In this multicenter patient population, compliance with published EVAR device IFU guidelines was low, and post-EVAR aneurysm sac enlargement was high, raising concern for long-term risk of aneurysm rupture," the researchers stated. In addition, the liberalization in the anatomical criteria deemed appropriate for EVAR, observed throughout the study period, "was associated with worse outcomes."

The authors suggested the need for a prospective EVAR registry incorporating an independent imaging registry to define more precisely the specific aortic and iliac artery anatomy suitable for EVAR with available commercial devices.

Although this is the largest investigation of this question to date, the authors noted several limitations to their study, beyond the lack of device identification and information on secondary interventions. They pointed out that current research indicates that the standard definition of maximum diameter growth of 5 mm or more may be a less-sensitive criterion for sac enlargement than are volume assessments.

Their study indicated a greater need for concern for proper patient selection for EVAR, they concluded.

An improved understanding of these anatomical characteristics "will ultimately improve the effectiveness and durability of EVAR to protect patients against AAA rupture," Dr. Schanzer and his colleagues said.

The authors reported that they had no disclosures. The study was funded by the William Rogers Family Foundation.

The majority of patients receiving endovascular repair for an aortic abdominal aneurysm failed to meet criteria for intervention as opposed to surveillance, and more than 58% of these patients failed to meet conservative criteria for device use based on manufacturer instructions, according to a large retrospective database study.

In addition, at 5 years post EVAR, 41% of the patients showed aneurysm sac enlargement, an outcome considered a surrogate for potential aneurysm rupture, according to a report published online April 10 in Circulation.

This is an important issue because "in 2006, 21,725 EVAR procedures were performed in the United States, exceeding for the first time the number of open surgical AAA repairs," according to Dr. Andres Schanzer of the University of Massachusetts, Worcester, and his colleagues at the Harvard School of Public Health, Boston, and the Cleveland Clinic Foundation.

In addition, although studies have demonstrated substantially lower morbidity and mortality after EVAR than after open repair, "late survival of these cohorts has demonstrated that the early survival advantage of patients undergoing EVAR disappears with time and a significant proportion of late deaths after EVAR are due to aneurysm rupture."

Dr. Schanzer and his colleagues conducted a retrospective analysis of patients in M2S Inc.’s imaging database. M2S has served as the core imaging laboratory for several large aneurysm management trials and provides these services to both public and private academic hospitals globally. The study population consisted of 10,228 patients who underwent EVAR for AAA repair in 1999-2008, and who had a baseline CT scan before EVAR and at least one follow-up CT scan. The patients were primarily men (84.1%) with a mean age of 73.9 years, and represented all regions of the United States.

Key anatomical measurements included maximum AAA sac diameter, aortic diameter at the lowest renal artery, aortic neck length (distance between the lowest renal artery and the origin of the aneurysm, indicated by a 10% increase in diameter), aortic neck angulation (angle calculated between the lowest renal artery, the origin of the aneurysm, and the aortic bifurcation), conical neck (aortic diameter at 15 mm below the lowest renal artery greater than or equal to 10% larger than the aortic diameter at the lowest renal artery), AAA volume, maximum common iliac diameter, and length from the lowest renal artery to the aortic bifurcation. Data on the exact endovascular device used were not available, and there were no data available regarding secondary interventions (Circulation 2011 April 10 [doi:10.1161/CIRCULATIONAHA.110.014902]).

The instructions for use (IFU) for each approved endovascular device was reviewed, and these criteria were incorporated into three descriptive variables: conservative IFU (most restrictive), liberal IFU (least restrictive), and time-dependent IFU (reflecting the most liberal IFU at each time point during the study period).

The primary end point was AAA sac enlargement (defined as a growth of 5 mm or more in the AAA maximal diameter from before EVAR to any post-EVAR CT scan, based on Society for Vascular Surgery reporting standards). The secondary end point was endoleak (defined as the presence of contrast-opacified blood within the aneurysm sac and outside the endovascular stent graft).

The average preoperative AAA maximum diameter was 54.8 mm, with 6,075 patients (59%) having an AAA maximum diameter of less than 55 mm. The average neck diameter was 23.1 mm, with a mean length of 20.7 mm and a mean angle of 36.9 degrees. In addition, 11.9% were found to have at least one common iliac aneurysm greater than 20 mm in diameter.

When all patients were classified according to IFU criteria, 5,983 patients (58.5%) were outside compliance with the conservative IFU, 3,178 patients (31.1%) were outside the liberal IFU, and 4,507 patients (44.1%) were outside the time-dependent IFU.

Population characteristics changed over the 10-year study period. An increasing number of patients undergoing EVAR were 80 years of age or older; the maximum AAA diameter before EVAR did not significantly change over time, but the average diameter of the AAA neck did increase significantly; and significantly more patients undergoing EVAR had highly angulated aortic necks (7.0% in 1999-2003 vs. 9.5% in 2008) or conical aortic necks (30% vs. 35.7%). In addition, the external iliac diameter in patients decreased significantly over the study period, with 14.8% having both external iliac arteries measuring less than 6 mm in 1999-2003, compared with 17.5% in 2008.

Mean follow-up was 31 months, with an average of three postoperative CT scans per patient. At 1, 3, and 5 years after EVAR, AAA sac enlargement was seen in 3%, 17%, and 41% of patients, respectively.

"The rate of AAA sac enlargement was significantly higher in patients who underwent EVAR outside the IFU, regardless of whether lack of compliance was on the basis of conservative IFU, liberal IFU, or time-dependent IFU," the researchers stated. In addition, the rate of AAA sac enlargement was significantly greater in the group undergoing EVAR more recently (2004-2008), compared with the group who underwent EVAR in 1999-2003.

Multivariate analysis showed that the primary determinate of AAA sac enlargement was the presence of an endoleak on any postop CT scan (hazard ratio, 2.70). Additional significant predictors were a patient age of 80 years or older, an aortic neck diameter of 28 mm or larger, a neck angle greater than 60 degrees, and a common iliac artery diameter less than 20 mm.

Liberalization of the anatomical characteristics "deemed suitable for EVAR has occurred, and several of these factors, including aortic neck diameter, aortic neck angle, and common iliac artery diameter, were independently associated with aortic aneurysm sac enlargement. These observations raise the question as to whether such liberalization is justified with current device designs," the authors suggested.

"In this multicenter patient population, compliance with published EVAR device IFU guidelines was low, and post-EVAR aneurysm sac enlargement was high, raising concern for long-term risk of aneurysm rupture," the researchers stated. In addition, the liberalization in the anatomical criteria deemed appropriate for EVAR, observed throughout the study period, "was associated with worse outcomes."

The authors suggested the need for a prospective EVAR registry incorporating an independent imaging registry to define more precisely the specific aortic and iliac artery anatomy suitable for EVAR with available commercial devices.

Although this is the largest investigation of this question to date, the authors noted several limitations to their study, beyond the lack of device identification and information on secondary interventions. They pointed out that current research indicates that the standard definition of maximum diameter growth of 5 mm or more may be a less-sensitive criterion for sac enlargement than are volume assessments.

Their study indicated a greater need for concern for proper patient selection for EVAR, they concluded.

An improved understanding of these anatomical characteristics "will ultimately improve the effectiveness and durability of EVAR to protect patients against AAA rupture," Dr. Schanzer and his colleagues said.

The authors reported that they had no disclosures. The study was funded by the William Rogers Family Foundation.

Lesbian, gay, bisexual, and transgender individuals face disparities in health care and health status, compared with their heterosexual counterparts, caused in part by social stigmatization and exacerbated by limited data and research on the unique medical needs of the LGBT community, according to a report released by the Institute of Medicine.

The report, "The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding," was requested by the National Institutes of Health (NIH). It was designed to assess current knowledge of the health status of the LGBT population, to identify research gaps and opportunities, and to propose specific research goals for NIH to implement in future.

The authors proposed seven specific recommendations, with the long-term goal of improving the status of health care in the LGBT community:

• NIH should implement a research agenda designed to advance knowledge of LGBT health.

• Data on sexual orientation and gender identity should be collected in federally funded surveys administered by the Department of Health and Human Services and other relevant federally funded surveys.

• Data on sexual orientation and gender identity should be collected in electronic health records.

• NIH should support the development and standardization of sexual orientation and gender identity measures.

• NIH should support methodological research that relates to LGBT health issues.

• A comprehensive research training approach should be created to strengthen LGBT health research at NIH.

• NIH should encourage grant applicants to explicitly address the inclusion or exclusion of sexual and gender minorities in their samples.

To back up these recommendations, the report detailed the broad historical and current difficulties faced by the LGBT community with regard to health care, citing small studies and anecdotal evidence of specific known issues for different age groups.

In childhood and adolescence, "LGB youth are at increased risk for suicidal ideation and attempts as well as depression. Small studies suggest the same may be true for transgender youth," according to the report. In addition, rates of smoking, alcohol consumption, and substance abuse may be higher among LGB youth, and the homeless youth population comprises a disproportionate number of LGB youth and transgender women. There are also increased levels of violence, victimization, and harassment reported by LGBT youth, compared with heterosexual and non–gender-variant youth.

Importantly, "the burden of HIV falls disproportionately on young men, particularly young black men who have sex with men."

These issues were found to continue throughout the lifetimes of LGBT individuals. The report is careful to point out that the disparities in mental and physical health seen in LGBT youth, compared with their heterosexual counterparts, "are influenced largely by their experiences of stigma and discrimination during the development of their sexual orientation and gender identity throughout the life course."

In early/middle adulthood, LGB individuals "appear to experience more mood and anxiety disorders, more depression, and an elevated risk for suicidal ideation and attempts, compared with heterosexual adults," the report noted.

Adult lesbian and bisexual women might use preventative health services less, be at greater risk of obesity, have higher rates of smoking and alcohol use, and have higher rates of breast cancer than do heterosexual women.

Compared with their heterosexual peers, gay and lesbian individuals are less likely to be parents, "although children of gay and lesbian parents are well adjusted and developmentally similar to children of heterosexual parents."

In this age group, "HIV/AIDS continues to enact a severe toll on men who have sex with men, with black men and Latino men being disproportionately affected."

Only limited studies look at this population in later adulthood. Transgender elders may experience negative health outcomes from long-term hormone use. HIV/AIDS is also a growing problem for older individuals, although there are few prevention programs targeting elder adults.

The report was frank in its approach, pointing out that many of the current medical difficulties faced by the LGBT community (and problems faced by researchers of that community) were brought about by social stigmatization in part created by the medical profession itself, which provided ostensible scientific rationales for social prejudice and punitive legislation and attempted to "cure" so-called sexual deviants through methods ranging from psychotherapy to shock treatments to castration and lobotomy.

This created a climate of mistrust that inhibits individual disclosure in studies already impeded by the statistical and recruitment difficulties intrinsic to minority studies.

Today, it still is difficult to accurately assess the percentage of lesbian, gay, bisexual, and transgender individuals in the general population, according to the report. The 2010 National Survey of Sexual Health and Behavior, the most recent large study cited in the report, found that 6.8% of men and 4.5% of women identify themselves as homosexual, gay, lesbian, or bisexual.

But relying on self-identification is problematic and might impede research. For example, in the 2008 General Social Survey, only 2.2% of men identified themselves as gay and 0.7% as bisexual, despite the fact that about 10% of men reported same-sex sexual behavior as adults. Most nonwhite men appear to be far less likely to self-identify as gay or bisexual than do white men, despite reporting that they have sex with men.

Data on the proportion of transgendered individuals are based almost exclusively on those who have sought medical intervention, whether instigated by their parents in their youth or by themselves as adults, according to the report.

A full prepublication copy of the report is available online.

The IOM Board on the Health of Select Populations, which was responsible for the report, indicated no financial disclosures; however, several of the participants had associations with or were employed by organizations that might benefit by increased monies for LGBT research, either from direct client service or increased grant funding.

Lesbian, gay, bisexual, and transgender individuals face disparities in health care and health status, compared with their heterosexual counterparts, caused in part by social stigmatization and exacerbated by limited data and research on the unique medical needs of the LGBT community, according to a report released by the Institute of Medicine.

The report, "The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding," was requested by the National Institutes of Health (NIH). It was designed to assess current knowledge of the health status of the LGBT population, to identify research gaps and opportunities, and to propose specific research goals for NIH to implement in future.

The authors proposed seven specific recommendations, with the long-term goal of improving the status of health care in the LGBT community:

• NIH should implement a research agenda designed to advance knowledge of LGBT health.

• Data on sexual orientation and gender identity should be collected in federally funded surveys administered by the Department of Health and Human Services and other relevant federally funded surveys.

• Data on sexual orientation and gender identity should be collected in electronic health records.

• NIH should support the development and standardization of sexual orientation and gender identity measures.

• NIH should support methodological research that relates to LGBT health issues.

• A comprehensive research training approach should be created to strengthen LGBT health research at NIH.

• NIH should encourage grant applicants to explicitly address the inclusion or exclusion of sexual and gender minorities in their samples.

To back up these recommendations, the report detailed the broad historical and current difficulties faced by the LGBT community with regard to health care, citing small studies and anecdotal evidence of specific known issues for different age groups.

In childhood and adolescence, "LGB youth are at increased risk for suicidal ideation and attempts as well as depression. Small studies suggest the same may be true for transgender youth," according to the report. In addition, rates of smoking, alcohol consumption, and substance abuse may be higher among LGB youth, and the homeless youth population comprises a disproportionate number of LGB youth and transgender women. There are also increased levels of violence, victimization, and harassment reported by LGBT youth, compared with heterosexual and non–gender-variant youth.

Importantly, "the burden of HIV falls disproportionately on young men, particularly young black men who have sex with men."

These issues were found to continue throughout the lifetimes of LGBT individuals. The report is careful to point out that the disparities in mental and physical health seen in LGBT youth, compared with their heterosexual counterparts, "are influenced largely by their experiences of stigma and discrimination during the development of their sexual orientation and gender identity throughout the life course."

In early/middle adulthood, LGB individuals "appear to experience more mood and anxiety disorders, more depression, and an elevated risk for suicidal ideation and attempts, compared with heterosexual adults," the report noted.

Adult lesbian and bisexual women might use preventative health services less, be at greater risk of obesity, have higher rates of smoking and alcohol use, and have higher rates of breast cancer than do heterosexual women.

Compared with their heterosexual peers, gay and lesbian individuals are less likely to be parents, "although children of gay and lesbian parents are well adjusted and developmentally similar to children of heterosexual parents."

In this age group, "HIV/AIDS continues to enact a severe toll on men who have sex with men, with black men and Latino men being disproportionately affected."

Only limited studies look at this population in later adulthood. Transgender elders may experience negative health outcomes from long-term hormone use. HIV/AIDS is also a growing problem for older individuals, although there are few prevention programs targeting elder adults.

The report was frank in its approach, pointing out that many of the current medical difficulties faced by the LGBT community (and problems faced by researchers of that community) were brought about by social stigmatization in part created by the medical profession itself, which provided ostensible scientific rationales for social prejudice and punitive legislation and attempted to "cure" so-called sexual deviants through methods ranging from psychotherapy to shock treatments to castration and lobotomy.

This created a climate of mistrust that inhibits individual disclosure in studies already impeded by the statistical and recruitment difficulties intrinsic to minority studies.

Today, it still is difficult to accurately assess the percentage of lesbian, gay, bisexual, and transgender individuals in the general population, according to the report. The 2010 National Survey of Sexual Health and Behavior, the most recent large study cited in the report, found that 6.8% of men and 4.5% of women identify themselves as homosexual, gay, lesbian, or bisexual.

But relying on self-identification is problematic and might impede research. For example, in the 2008 General Social Survey, only 2.2% of men identified themselves as gay and 0.7% as bisexual, despite the fact that about 10% of men reported same-sex sexual behavior as adults. Most nonwhite men appear to be far less likely to self-identify as gay or bisexual than do white men, despite reporting that they have sex with men.

Data on the proportion of transgendered individuals are based almost exclusively on those who have sought medical intervention, whether instigated by their parents in their youth or by themselves as adults, according to the report.

A full prepublication copy of the report is available online.

The IOM Board on the Health of Select Populations, which was responsible for the report, indicated no financial disclosures; however, several of the participants had associations with or were employed by organizations that might benefit by increased monies for LGBT research, either from direct client service or increased grant funding.

Lesbian, gay, bisexual, and transgender individuals face disparities in health care and health status, compared with their heterosexual counterparts, caused in part by social stigmatization and exacerbated by limited data and research on the unique medical needs of the LGBT community, according to a report released by the Institute of Medicine.

The report, "The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding," was requested by the National Institutes of Health (NIH). It was designed to assess current knowledge of the health status of the LGBT population, to identify research gaps and opportunities, and to propose specific research goals for NIH to implement in future.

The authors proposed seven specific recommendations, with the long-term goal of improving the status of health care in the LGBT community:

• NIH should implement a research agenda designed to advance knowledge of LGBT health.

• Data on sexual orientation and gender identity should be collected in federally funded surveys administered by the Department of Health and Human Services and other relevant federally funded surveys.

• Data on sexual orientation and gender identity should be collected in electronic health records.

• NIH should support the development and standardization of sexual orientation and gender identity measures.

• NIH should support methodological research that relates to LGBT health issues.

• A comprehensive research training approach should be created to strengthen LGBT health research at NIH.

• NIH should encourage grant applicants to explicitly address the inclusion or exclusion of sexual and gender minorities in their samples.

To back up these recommendations, the report detailed the broad historical and current difficulties faced by the LGBT community with regard to health care, citing small studies and anecdotal evidence of specific known issues for different age groups.

In childhood and adolescence, "LGB youth are at increased risk for suicidal ideation and attempts as well as depression. Small studies suggest the same may be true for transgender youth," according to the report. In addition, rates of smoking, alcohol consumption, and substance abuse may be higher among LGB youth, and the homeless youth population comprises a disproportionate number of LGB youth and transgender women. There are also increased levels of violence, victimization, and harassment reported by LGBT youth, compared with heterosexual and non–gender-variant youth.

Importantly, "the burden of HIV falls disproportionately on young men, particularly young black men who have sex with men."

These issues were found to continue throughout the lifetimes of LGBT individuals. The report is careful to point out that the disparities in mental and physical health seen in LGBT youth, compared with their heterosexual counterparts, "are influenced largely by their experiences of stigma and discrimination during the development of their sexual orientation and gender identity throughout the life course."

In early/middle adulthood, LGB individuals "appear to experience more mood and anxiety disorders, more depression, and an elevated risk for suicidal ideation and attempts, compared with heterosexual adults," the report noted.

Adult lesbian and bisexual women might use preventative health services less, be at greater risk of obesity, have higher rates of smoking and alcohol use, and have higher rates of breast cancer than do heterosexual women.

Compared with their heterosexual peers, gay and lesbian individuals are less likely to be parents, "although children of gay and lesbian parents are well adjusted and developmentally similar to children of heterosexual parents."

In this age group, "HIV/AIDS continues to enact a severe toll on men who have sex with men, with black men and Latino men being disproportionately affected."

Only limited studies look at this population in later adulthood. Transgender elders may experience negative health outcomes from long-term hormone use. HIV/AIDS is also a growing problem for older individuals, although there are few prevention programs targeting elder adults.

The report was frank in its approach, pointing out that many of the current medical difficulties faced by the LGBT community (and problems faced by researchers of that community) were brought about by social stigmatization in part created by the medical profession itself, which provided ostensible scientific rationales for social prejudice and punitive legislation and attempted to "cure" so-called sexual deviants through methods ranging from psychotherapy to shock treatments to castration and lobotomy.

This created a climate of mistrust that inhibits individual disclosure in studies already impeded by the statistical and recruitment difficulties intrinsic to minority studies.

Today, it still is difficult to accurately assess the percentage of lesbian, gay, bisexual, and transgender individuals in the general population, according to the report. The 2010 National Survey of Sexual Health and Behavior, the most recent large study cited in the report, found that 6.8% of men and 4.5% of women identify themselves as homosexual, gay, lesbian, or bisexual.

But relying on self-identification is problematic and might impede research. For example, in the 2008 General Social Survey, only 2.2% of men identified themselves as gay and 0.7% as bisexual, despite the fact that about 10% of men reported same-sex sexual behavior as adults. Most nonwhite men appear to be far less likely to self-identify as gay or bisexual than do white men, despite reporting that they have sex with men.

Data on the proportion of transgendered individuals are based almost exclusively on those who have sought medical intervention, whether instigated by their parents in their youth or by themselves as adults, according to the report.

A full prepublication copy of the report is available online.

The IOM Board on the Health of Select Populations, which was responsible for the report, indicated no financial disclosures; however, several of the participants had associations with or were employed by organizations that might benefit by increased monies for LGBT research, either from direct client service or increased grant funding.

Lesbian, gay, bisexual, and transgender individuals face disparities in health care and health status, compared with their heterosexual counterparts, caused in part by social stigmatization and exacerbated by limited data and research on the unique medical needs of the LGBT community, according to a report released by the Institute of Medicine.

The report, "The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding," was requested by the National Institutes of Health (NIH). It was designed to assess current knowledge of the health status of the LGBT population, to identify research gaps and opportunities, and to propose specific research goals for NIH to implement in future.

The authors proposed seven specific recommendations, with the long-term goal of improving the status of health care in the LGBT community:

• NIH should implement a research agenda designed to advance knowledge of LGBT health.

• Data on sexual orientation and gender identity should be collected in federally funded surveys administered by the Department of Health and Human Services and other relevant federally funded surveys.

• Data on sexual orientation and gender identity should be collected in electronic health records.

• NIH should support the development and standardization of sexual orientation and gender identity measures.

• NIH should support methodological research that relates to LGBT health issues.

• A comprehensive research training approach should be created to strengthen LGBT health research at NIH.

• NIH should encourage grant applicants to explicitly address the inclusion or exclusion of sexual and gender minorities in their samples.

To back up these recommendations, the report detailed the broad historical and current difficulties faced by the LGBT community with regard to health care, citing small studies and anecdotal evidence of specific known issues for different age groups.

In childhood and adolescence, "LGB youth are at increased risk for suicidal ideation and attempts as well as depression. Small studies suggest the same may be true for transgender youth," according to the report. In addition, rates of smoking, alcohol consumption, and substance abuse may be higher among LGB youth, and the homeless youth population comprises a disproportionate number of LGB youth and transgender women. There are also increased levels of violence, victimization, and harassment reported by LGBT youth, compared with heterosexual and non–gender-variant youth.

Importantly, "the burden of HIV falls disproportionately on young men, particularly young black men who have sex with men."

These issues were found to continue throughout the lifetimes of LGBT individuals. The report is careful to point out that the disparities in mental and physical health seen in LGBT youth, compared with their heterosexual counterparts, "are influenced largely by their experiences of stigma and discrimination during the development of their sexual orientation and gender identity throughout the life course."

In early/middle adulthood, LGB individuals "appear to experience more mood and anxiety disorders, more depression, and an elevated risk for suicidal ideation and attempts, compared with heterosexual adults," the report noted.

Adult lesbian and bisexual women might use preventative health services less, be at greater risk of obesity, have higher rates of smoking and alcohol use, and have higher rates of breast cancer than do heterosexual women.

Compared with their heterosexual peers, gay and lesbian individuals are less likely to be parents, "although children of gay and lesbian parents are well adjusted and developmentally similar to children of heterosexual parents."

In this age group, "HIV/AIDS continues to enact a severe toll on men who have sex with men, with black men and Latino men being disproportionately affected."

Only limited studies look at this population in later adulthood. Transgender elders may experience negative health outcomes from long-term hormone use. HIV/AIDS is also a growing problem for older individuals, although there are few prevention programs targeting elder adults.

The report was frank in its approach, pointing out that many of the current medical difficulties faced by the LGBT community (and problems faced by researchers of that community) were brought about by social stigmatization in part created by the medical profession itself, which provided ostensible scientific rationales for social prejudice and punitive legislation and attempted to "cure" so-called sexual deviants through methods ranging from psychotherapy to shock treatments to castration and lobotomy.

This created a climate of mistrust that inhibits individual disclosure in studies already impeded by the statistical and recruitment difficulties intrinsic to minority studies.

Today, it still is difficult to accurately assess the percentage of lesbian, gay, bisexual, and transgender individuals in the general population, according to the report. The 2010 National Survey of Sexual Health and Behavior, the most recent large study cited in the report, found that 6.8% of men and 4.5% of women identify themselves as homosexual, gay, lesbian, or bisexual.

But relying on self-identification is problematic and might impede research. For example, in the 2008 General Social Survey, only 2.2% of men identified themselves as gay and 0.7% as bisexual, despite the fact that about 10% of men reported same-sex sexual behavior as adults. Most nonwhite men appear to be far less likely to self-identify as gay or bisexual than do white men, despite reporting that they have sex with men.

Data on the proportion of transgendered individuals are based almost exclusively on those who have sought medical intervention, whether instigated by their parents in their youth or by themselves as adults, according to the report.

A full prepublication copy of the report is available online.

The IOM Board on the Health of Select Populations, which was responsible for the report, indicated no financial disclosures; however, several of the participants had associations with or were employed by organizations that might benefit by increased monies for LGBT research, either from direct client service or increased grant funding.

Lesbian, gay, bisexual, and transgender individuals face disparities in health care and health status, compared with their heterosexual counterparts, caused in part by social stigmatization and exacerbated by limited data and research on the unique medical needs of the LGBT community, according to a report released by the Institute of Medicine.

The report, "The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding," was requested by the National Institutes of Health (NIH). It was designed to assess current knowledge of the health status of the LGBT population, to identify research gaps and opportunities, and to propose specific research goals for NIH to implement in future.

The authors proposed seven specific recommendations, with the long-term goal of improving the status of health care in the LGBT community:

• NIH should implement a research agenda designed to advance knowledge of LGBT health.

• Data on sexual orientation and gender identity should be collected in federally funded surveys administered by the Department of Health and Human Services and other relevant federally funded surveys.

• Data on sexual orientation and gender identity should be collected in electronic health records.

• NIH should support the development and standardization of sexual orientation and gender identity measures.

• NIH should support methodological research that relates to LGBT health issues.

• A comprehensive research training approach should be created to strengthen LGBT health research at NIH.

• NIH should encourage grant applicants to explicitly address the inclusion or exclusion of sexual and gender minorities in their samples.

To back up these recommendations, the report detailed the broad historical and current difficulties faced by the LGBT community with regard to health care, citing small studies and anecdotal evidence of specific known issues for different age groups.

In childhood and adolescence, "LGB youth are at increased risk for suicidal ideation and attempts as well as depression. Small studies suggest the same may be true for transgender youth," according to the report. In addition, rates of smoking, alcohol consumption, and substance abuse may be higher among LGB youth, and the homeless youth population comprises a disproportionate number of LGB youth and transgender women. There are also increased levels of violence, victimization, and harassment reported by LGBT youth, compared with heterosexual and non–gender-variant youth.

Importantly, "the burden of HIV falls disproportionately on young men, particularly young black men who have sex with men."

These issues were found to continue throughout the lifetimes of LGBT individuals. The report is careful to point out that the disparities in mental and physical health seen in LGBT youth, compared with their heterosexual counterparts, "are influenced largely by their experiences of stigma and discrimination during the development of their sexual orientation and gender identity throughout the life course."

In early/middle adulthood, LGB individuals "appear to experience more mood and anxiety disorders, more depression, and an elevated risk for suicidal ideation and attempts, compared with heterosexual adults," the report noted.

Adult lesbian and bisexual women might use preventative health services less, be at greater risk of obesity, have higher rates of smoking and alcohol use, and have higher rates of breast cancer than do heterosexual women.

Compared with their heterosexual peers, gay and lesbian individuals are less likely to be parents, "although children of gay and lesbian parents are well adjusted and developmentally similar to children of heterosexual parents."

In this age group, "HIV/AIDS continues to enact a severe toll on men who have sex with men, with black men and Latino men being disproportionately affected."

Only limited studies look at this population in later adulthood. Transgender elders may experience negative health outcomes from long-term hormone use. HIV/AIDS is also a growing problem for older individuals, although there are few prevention programs targeting elder adults.

The report was frank in its approach, pointing out that many of the current medical difficulties faced by the LGBT community (and problems faced by researchers of that community) were brought about by social stigmatization in part created by the medical profession itself, which provided ostensible scientific rationales for social prejudice and punitive legislation and attempted to "cure" so-called sexual deviants through methods ranging from psychotherapy to shock treatments to castration and lobotomy.

This created a climate of mistrust that inhibits individual disclosure in studies already impeded by the statistical and recruitment difficulties intrinsic to minority studies.

Today, it still is difficult to accurately assess the percentage of lesbian, gay, bisexual, and transgender individuals in the general population, according to the report. The 2010 National Survey of Sexual Health and Behavior, the most recent large study cited in the report, found that 6.8% of men and 4.5% of women identify themselves as homosexual, gay, lesbian, or bisexual.

But relying on self-identification is problematic and might impede research. For example, in the 2008 General Social Survey, only 2.2% of men identified themselves as gay and 0.7% as bisexual, despite the fact that about 10% of men reported same-sex sexual behavior as adults. Most nonwhite men appear to be far less likely to self-identify as gay or bisexual than do white men, despite reporting that they have sex with men.

Data on the proportion of transgendered individuals are based almost exclusively on those who have sought medical intervention, whether instigated by their parents in their youth or by themselves as adults, according to the report.

A full prepublication copy of the report is available online.

The IOM Board on the Health of Select Populations, which was responsible for the report, indicated no financial disclosures; however, several of the participants had associations with or were employed by organizations that might benefit by increased monies for LGBT research, either from direct client service or increased grant funding.

Lesbian, gay, bisexual, and transgender individuals face disparities in health care and health status, compared with their heterosexual counterparts, caused in part by social stigmatization and exacerbated by limited data and research on the unique medical needs of the LGBT community, according to a report released by the Institute of Medicine.

The report, "The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding," was requested by the National Institutes of Health (NIH). It was designed to assess current knowledge of the health status of the LGBT population, to identify research gaps and opportunities, and to propose specific research goals for NIH to implement in future.

The authors proposed seven specific recommendations, with the long-term goal of improving the status of health care in the LGBT community:

• NIH should implement a research agenda designed to advance knowledge of LGBT health.

• Data on sexual orientation and gender identity should be collected in federally funded surveys administered by the Department of Health and Human Services and other relevant federally funded surveys.

• Data on sexual orientation and gender identity should be collected in electronic health records.

• NIH should support the development and standardization of sexual orientation and gender identity measures.

• NIH should support methodological research that relates to LGBT health issues.

• A comprehensive research training approach should be created to strengthen LGBT health research at NIH.

• NIH should encourage grant applicants to explicitly address the inclusion or exclusion of sexual and gender minorities in their samples.

To back up these recommendations, the report detailed the broad historical and current difficulties faced by the LGBT community with regard to health care, citing small studies and anecdotal evidence of specific known issues for different age groups.

In childhood and adolescence, "LGB youth are at increased risk for suicidal ideation and attempts as well as depression. Small studies suggest the same may be true for transgender youth," according to the report. In addition, rates of smoking, alcohol consumption, and substance abuse may be higher among LGB youth, and the homeless youth population comprises a disproportionate number of LGB youth and transgender women. There are also increased levels of violence, victimization, and harassment reported by LGBT youth, compared with heterosexual and non–gender-variant youth.

Importantly, "the burden of HIV falls disproportionately on young men, particularly young black men who have sex with men."

These issues were found to continue throughout the lifetimes of LGBT individuals. The report is careful to point out that the disparities in mental and physical health seen in LGBT youth, compared with their heterosexual counterparts, "are influenced largely by their experiences of stigma and discrimination during the development of their sexual orientation and gender identity throughout the life course."

In early/middle adulthood, LGB individuals "appear to experience more mood and anxiety disorders, more depression, and an elevated risk for suicidal ideation and attempts, compared with heterosexual adults," the report noted.

Adult lesbian and bisexual women might use preventative health services less, be at greater risk of obesity, have higher rates of smoking and alcohol use, and have higher rates of breast cancer than do heterosexual women.

Compared with their heterosexual peers, gay and lesbian individuals are less likely to be parents, "although children of gay and lesbian parents are well adjusted and developmentally similar to children of heterosexual parents."

In this age group, "HIV/AIDS continues to enact a severe toll on men who have sex with men, with black men and Latino men being disproportionately affected."

Only limited studies look at this population in later adulthood. Transgender elders may experience negative health outcomes from long-term hormone use. HIV/AIDS is also a growing problem for older individuals, although there are few prevention programs targeting elder adults.

The report was frank in its approach, pointing out that many of the current medical difficulties faced by the LGBT community (and problems faced by researchers of that community) were brought about by social stigmatization in part created by the medical profession itself, which provided ostensible scientific rationales for social prejudice and punitive legislation and attempted to "cure" so-called sexual deviants through methods ranging from psychotherapy to shock treatments to castration and lobotomy.

This created a climate of mistrust that inhibits individual disclosure in studies already impeded by the statistical and recruitment difficulties intrinsic to minority studies.

Today, it still is difficult to accurately assess the percentage of lesbian, gay, bisexual, and transgender individuals in the general population, according to the report. The 2010 National Survey of Sexual Health and Behavior, the most recent large study cited in the report, found that 6.8% of men and 4.5% of women identify themselves as homosexual, gay, lesbian, or bisexual.

But relying on self-identification is problematic and might impede research. For example, in the 2008 General Social Survey, only 2.2% of men identified themselves as gay and 0.7% as bisexual, despite the fact that about 10% of men reported same-sex sexual behavior as adults. Most nonwhite men appear to be far less likely to self-identify as gay or bisexual than do white men, despite reporting that they have sex with men.

Data on the proportion of transgendered individuals are based almost exclusively on those who have sought medical intervention, whether instigated by their parents in their youth or by themselves as adults, according to the report.

A full prepublication copy of the report is available online.

The IOM Board on the Health of Select Populations, which was responsible for the report, indicated no financial disclosures; however, several of the participants had associations with or were employed by organizations that might benefit by increased monies for LGBT research, either from direct client service or increased grant funding.

Lesbian, gay, bisexual, and transgender individuals face disparities in health care and health status, compared with their heterosexual counterparts, caused in part by social stigmatization and exacerbated by limited data and research on the unique medical needs of the LGBT community, according to a report released by the Institute of Medicine.

The report, "The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding," was requested by the National Institutes of Health (NIH). It was designed to assess current knowledge of the health status of the LGBT population, to identify research gaps and opportunities, and to propose specific research goals for NIH to implement in future.

The authors proposed seven specific recommendations, with the long-term goal of improving the status of health care in the LGBT community:

• NIH should implement a research agenda designed to advance knowledge of LGBT health.

• Data on sexual orientation and gender identity should be collected in federally funded surveys administered by the Department of Health and Human Services and other relevant federally funded surveys.

• Data on sexual orientation and gender identity should be collected in electronic health records.

• NIH should support the development and standardization of sexual orientation and gender identity measures.

• NIH should support methodological research that relates to LGBT health issues.

• A comprehensive research training approach should be created to strengthen LGBT health research at NIH.

• NIH should encourage grant applicants to explicitly address the inclusion or exclusion of sexual and gender minorities in their samples.

To back up these recommendations, the report detailed the broad historical and current difficulties faced by the LGBT community with regard to health care, citing small studies and anecdotal evidence of specific known issues for different age groups.

In childhood and adolescence, "LGB youth are at increased risk for suicidal ideation and attempts as well as depression. Small studies suggest the same may be true for transgender youth," according to the report. In addition, rates of smoking, alcohol consumption, and substance abuse may be higher among LGB youth, and the homeless youth population comprises a disproportionate number of LGB youth and transgender women. There are also increased levels of violence, victimization, and harassment reported by LGBT youth, compared with heterosexual and non–gender-variant youth.

Importantly, "the burden of HIV falls disproportionately on young men, particularly young black men who have sex with men."

These issues were found to continue throughout the lifetimes of LGBT individuals. The report is careful to point out that the disparities in mental and physical health seen in LGBT youth, compared with their heterosexual counterparts, "are influenced largely by their experiences of stigma and discrimination during the development of their sexual orientation and gender identity throughout the life course."

In early/middle adulthood, LGB individuals "appear to experience more mood and anxiety disorders, more depression, and an elevated risk for suicidal ideation and attempts, compared with heterosexual adults," the report noted.

Adult lesbian and bisexual women might use preventative health services less, be at greater risk of obesity, have higher rates of smoking and alcohol use, and have higher rates of breast cancer than do heterosexual women.

Compared with their heterosexual peers, gay and lesbian individuals are less likely to be parents, "although children of gay and lesbian parents are well adjusted and developmentally similar to children of heterosexual parents."

In this age group, "HIV/AIDS continues to enact a severe toll on men who have sex with men, with black men and Latino men being disproportionately affected."

Only limited studies look at this population in later adulthood. Transgender elders may experience negative health outcomes from long-term hormone use. HIV/AIDS is also a growing problem for older individuals, although there are few prevention programs targeting elder adults.

The report was frank in its approach, pointing out that many of the current medical difficulties faced by the LGBT community (and problems faced by researchers of that community) were brought about by social stigmatization in part created by the medical profession itself, which provided ostensible scientific rationales for social prejudice and punitive legislation and attempted to "cure" so-called sexual deviants through methods ranging from psychotherapy to shock treatments to castration and lobotomy.

This created a climate of mistrust that inhibits individual disclosure in studies already impeded by the statistical and recruitment difficulties intrinsic to minority studies.

Today, it still is difficult to accurately assess the percentage of lesbian, gay, bisexual, and transgender individuals in the general population, according to the report. The 2010 National Survey of Sexual Health and Behavior, the most recent large study cited in the report, found that 6.8% of men and 4.5% of women identify themselves as homosexual, gay, lesbian, or bisexual.

But relying on self-identification is problematic and might impede research. For example, in the 2008 General Social Survey, only 2.2% of men identified themselves as gay and 0.7% as bisexual, despite the fact that about 10% of men reported same-sex sexual behavior as adults. Most nonwhite men appear to be far less likely to self-identify as gay or bisexual than do white men, despite reporting that they have sex with men.

Data on the proportion of transgendered individuals are based almost exclusively on those who have sought medical intervention, whether instigated by their parents in their youth or by themselves as adults, according to the report.

A full prepublication copy of the report is available online.

The IOM Board on the Health of Select Populations, which was responsible for the report, indicated no financial disclosures; however, several of the participants had associations with or were employed by organizations that might benefit by increased monies for LGBT research, either from direct client service or increased grant funding.

Lesbian, gay, bisexual, and transgender individuals face disparities in health care and health status, compared with their heterosexual counterparts, caused in part by social stigmatization and exacerbated by limited data and research on the unique medical needs of the LGBT community, according to a report released by the Institute of Medicine.

The report, "The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding," was requested by the National Institutes of Health (NIH). It was designed to assess current knowledge of the health status of the LGBT population, to identify research gaps and opportunities, and to propose specific research goals for NIH to implement in future.

The authors proposed seven specific recommendations, with the long-term goal of improving the status of health care in the LGBT community:

• NIH should implement a research agenda designed to advance knowledge of LGBT health.

• Data on sexual orientation and gender identity should be collected in federally funded surveys administered by the Department of Health and Human Services and other relevant federally funded surveys.

• Data on sexual orientation and gender identity should be collected in electronic health records.

• NIH should support the development and standardization of sexual orientation and gender identity measures.

• NIH should support methodological research that relates to LGBT health issues.

• A comprehensive research training approach should be created to strengthen LGBT health research at NIH.

• NIH should encourage grant applicants to explicitly address the inclusion or exclusion of sexual and gender minorities in their samples.

To back up these recommendations, the report detailed the broad historical and current difficulties faced by the LGBT community with regard to health care, citing small studies and anecdotal evidence of specific known issues for different age groups.

In childhood and adolescence, "LGB youth are at increased risk for suicidal ideation and attempts as well as depression. Small studies suggest the same may be true for transgender youth," according to the report. In addition, rates of smoking, alcohol consumption, and substance abuse may be higher among LGB youth, and the homeless youth population comprises a disproportionate number of LGB youth and transgender women. There are also increased levels of violence, victimization, and harassment reported by LGBT youth, compared with heterosexual and non–gender-variant youth.

Importantly, "the burden of HIV falls disproportionately on young men, particularly young black men who have sex with men."

These issues were found to continue throughout the lifetimes of LGBT individuals. The report is careful to point out that the disparities in mental and physical health seen in LGBT youth, compared with their heterosexual counterparts, "are influenced largely by their experiences of stigma and discrimination during the development of their sexual orientation and gender identity throughout the life course."

In early/middle adulthood, LGB individuals "appear to experience more mood and anxiety disorders, more depression, and an elevated risk for suicidal ideation and attempts, compared with heterosexual adults," the report noted.

Adult lesbian and bisexual women might use preventative health services less, be at greater risk of obesity, have higher rates of smoking and alcohol use, and have higher rates of breast cancer than do heterosexual women.

Compared with their heterosexual peers, gay and lesbian individuals are less likely to be parents, "although children of gay and lesbian parents are well adjusted and developmentally similar to children of heterosexual parents."

In this age group, "HIV/AIDS continues to enact a severe toll on men who have sex with men, with black men and Latino men being disproportionately affected."

Only limited studies look at this population in later adulthood. Transgender elders may experience negative health outcomes from long-term hormone use. HIV/AIDS is also a growing problem for older individuals, although there are few prevention programs targeting elder adults.

The report was frank in its approach, pointing out that many of the current medical difficulties faced by the LGBT community (and problems faced by researchers of that community) were brought about by social stigmatization in part created by the medical profession itself, which provided ostensible scientific rationales for social prejudice and punitive legislation and attempted to "cure" so-called sexual deviants through methods ranging from psychotherapy to shock treatments to castration and lobotomy.

This created a climate of mistrust that inhibits individual disclosure in studies already impeded by the statistical and recruitment difficulties intrinsic to minority studies.

Today, it still is difficult to accurately assess the percentage of lesbian, gay, bisexual, and transgender individuals in the general population, according to the report. The 2010 National Survey of Sexual Health and Behavior, the most recent large study cited in the report, found that 6.8% of men and 4.5% of women identify themselves as homosexual, gay, lesbian, or bisexual.

But relying on self-identification is problematic and might impede research. For example, in the 2008 General Social Survey, only 2.2% of men identified themselves as gay and 0.7% as bisexual, despite the fact that about 10% of men reported same-sex sexual behavior as adults. Most nonwhite men appear to be far less likely to self-identify as gay or bisexual than do white men, despite reporting that they have sex with men.

Data on the proportion of transgendered individuals are based almost exclusively on those who have sought medical intervention, whether instigated by their parents in their youth or by themselves as adults, according to the report.

A full prepublication copy of the report is available online.

The IOM Board on the Health of Select Populations, which was responsible for the report, indicated no financial disclosures; however, several of the participants had associations with or were employed by organizations that might benefit by increased monies for LGBT research, either from direct client service or increased grant funding.

Lesbian, gay, bisexual, and transgender individuals face disparities in health care and health status, compared with their heterosexual counterparts, caused in part by social stigmatization and exacerbated by limited data and research on the unique medical needs of the LGBT community, according to a report released by the Institute of Medicine.

The report, "The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding," was requested by the National Institutes of Health (NIH). It was designed to assess current knowledge of the health status of the LGBT population, to identify research gaps and opportunities, and to propose specific research goals for NIH to implement in future.

The authors proposed seven specific recommendations, with the long-term goal of improving the status of health care in the LGBT community:

• NIH should implement a research agenda designed to advance knowledge of LGBT health.

• Data on sexual orientation and gender identity should be collected in federally funded surveys administered by the Department of Health and Human Services and other relevant federally funded surveys.

• Data on sexual orientation and gender identity should be collected in electronic health records.

• NIH should support the development and standardization of sexual orientation and gender identity measures.

• NIH should support methodological research that relates to LGBT health issues.

• A comprehensive research training approach should be created to strengthen LGBT health research at NIH.

• NIH should encourage grant applicants to explicitly address the inclusion or exclusion of sexual and gender minorities in their samples.

To back up these recommendations, the report detailed the broad historical and current difficulties faced by the LGBT community with regard to health care, citing small studies and anecdotal evidence of specific known issues for different age groups.

In childhood and adolescence, "LGB youth are at increased risk for suicidal ideation and attempts as well as depression. Small studies suggest the same may be true for transgender youth," according to the report. In addition, rates of smoking, alcohol consumption, and substance abuse may be higher among LGB youth, and the homeless youth population comprises a disproportionate number of LGB youth and transgender women. There are also increased levels of violence, victimization, and harassment reported by LGBT youth, compared with heterosexual and non–gender-variant youth.

Importantly, "the burden of HIV falls disproportionately on young men, particularly young black men who have sex with men."

These issues were found to continue throughout the lifetimes of LGBT individuals. The report is careful to point out that the disparities in mental and physical health seen in LGBT youth, compared with their heterosexual counterparts, "are influenced largely by their experiences of stigma and discrimination during the development of their sexual orientation and gender identity throughout the life course."

In early/middle adulthood, LGB individuals "appear to experience more mood and anxiety disorders, more depression, and an elevated risk for suicidal ideation and attempts, compared with heterosexual adults," the report noted.

Adult lesbian and bisexual women might use preventative health services less, be at greater risk of obesity, have higher rates of smoking and alcohol use, and have higher rates of breast cancer than do heterosexual women.

Compared with their heterosexual peers, gay and lesbian individuals are less likely to be parents, "although children of gay and lesbian parents are well adjusted and developmentally similar to children of heterosexual parents."

In this age group, "HIV/AIDS continues to enact a severe toll on men who have sex with men, with black men and Latino men being disproportionately affected."

Only limited studies look at this population in later adulthood. Transgender elders may experience negative health outcomes from long-term hormone use. HIV/AIDS is also a growing problem for older individuals, although there are few prevention programs targeting elder adults.

The report was frank in its approach, pointing out that many of the current medical difficulties faced by the LGBT community (and problems faced by researchers of that community) were brought about by social stigmatization in part created by the medical profession itself, which provided ostensible scientific rationales for social prejudice and punitive legislation and attempted to "cure" so-called sexual deviants through methods ranging from psychotherapy to shock treatments to castration and lobotomy.

This created a climate of mistrust that inhibits individual disclosure in studies already impeded by the statistical and recruitment difficulties intrinsic to minority studies.

Today, it still is difficult to accurately assess the percentage of lesbian, gay, bisexual, and transgender individuals in the general population, according to the report. The 2010 National Survey of Sexual Health and Behavior, the most recent large study cited in the report, found that 6.8% of men and 4.5% of women identify themselves as homosexual, gay, lesbian, or bisexual.

But relying on self-identification is problematic and might impede research. For example, in the 2008 General Social Survey, only 2.2% of men identified themselves as gay and 0.7% as bisexual, despite the fact that about 10% of men reported same-sex sexual behavior as adults. Most nonwhite men appear to be far less likely to self-identify as gay or bisexual than do white men, despite reporting that they have sex with men.

Data on the proportion of transgendered individuals are based almost exclusively on those who have sought medical intervention, whether instigated by their parents in their youth or by themselves as adults, according to the report.

A full prepublication copy of the report is available online.

The IOM Board on the Health of Select Populations, which was responsible for the report, indicated no financial disclosures; however, several of the participants had associations with or were employed by organizations that might benefit by increased monies for LGBT research, either from direct client service or increased grant funding.

Major Finding: Survival was best in patients who were transplanted for cardiomyopathy (1-, 3-, 5-, and 10-year survival of 90%, 84%, 81%, and 81%, respectively) and worst in patients with failed palliations for SV anomalies, especially failed Fontan procedures (1-, 3-, 5-, and 10-year survival of 66%, 61%, 61%, and 53%, respectively).

Data Source: A retrospective study of 307 pediatric heart transplants over a 24-year period at St. Louis Children's Hospital.

Disclosures: Dr. Voeller reported that none of the authors had any financial disclosures.

SAN DIEGO – Over the past 24 years, the prevalence of indications for pediatric heart transplantation resulting from congenital heart disease has changed. Transplantation for failed single-ventricle palliation, including failed Fontan procedure, has now become the predominant indication, according to the observations of a single-center experience reported in the J. Maxwell Chamberlain Memorial Paper for Congenital Heart Surgery at the meeting.

Heart transplantation is the only viable treatment for children with end-stage heart failure resulting from congenital heart disease (CHD) or cardiomyopathy. The purpose of this study by Dr. Rochus K. Voeller and his colleagues at Washington University in St. Louis was to review the trends in the indications for transplant and survival following transplant, using a retrospective review of all 307 orthotopic heart transplants performed at St. Louis Children's Hospital from January 1986 to December 2009. Combined heart-lung transplants were excluded from the study.

The indications for transplantation in 1986–2009 were 39% cardiomyopathy, 57% CHD, and 4% retransplant. Of the 174 patients with CHD, 80% had single-ventricle (SV) anomalies. In the CHD group, transplantation for failed SV palliation, including the failed Fontan procedure, became the predominant indication in the latest 8-year interval of their program (increasing from 11% during 1984–1993 to 60% during 2002–2009). The retransplantation rate remained low and unchanged across the various time periods, Dr. Voeller reported.

The mean recipient age was 6.1 years, with 41% of the recipients aged younger than 1 year at the time of transplantation. Nearly one-third of all patients had prior surgical procedures or surgery ranging from banding to Fontan operations; 55% of the patients were boys; 8% of patients were bridged with either ECMO (extracorporeal circulation membrane oxygenation) or VAD (ventricular assist devices).

Overall survival of transplant patients was 81%, 76%, 72%, and 65% at 1, 3, 5, and 10 years, respectively. Survival was best in those patients who were transplanted for cardiomyopathy (1-, 3-, 5-, and 10-year survival of 90%, 84%, 81%, and 81%, respectively) and worst in patients with failed palliations for SV anomalies, especially failed Fontan procedures (1-, 3-, 5-, and 10-year survival of 66%, 61%, 61%, and 53%, respectively).

“As the survival with early palliation for SV anomaly patients improves, more centers will be referred with these patients who will require transplantation at some point,” Dr. Voeller said in an interview. This will impact not only pediatric transplant programs, but also adult programs, he added. Risk factor analysis will determine which patients can benefit from earlier transplant referral and how to better prepare these patients for the procedure, he concluded.

As survival with early palliation for SV anomaly improves, more patients will require transplantation.

Source DR. VOELLER

Major Finding: Survival was best in patients who were transplanted for cardiomyopathy (1-, 3-, 5-, and 10-year survival of 90%, 84%, 81%, and 81%, respectively) and worst in patients with failed palliations for SV anomalies, especially failed Fontan procedures (1-, 3-, 5-, and 10-year survival of 66%, 61%, 61%, and 53%, respectively).

Data Source: A retrospective study of 307 pediatric heart transplants over a 24-year period at St. Louis Children's Hospital.

Disclosures: Dr. Voeller reported that none of the authors had any financial disclosures.

SAN DIEGO – Over the past 24 years, the prevalence of indications for pediatric heart transplantation resulting from congenital heart disease has changed. Transplantation for failed single-ventricle palliation, including failed Fontan procedure, has now become the predominant indication, according to the observations of a single-center experience reported in the J. Maxwell Chamberlain Memorial Paper for Congenital Heart Surgery at the meeting.

Heart transplantation is the only viable treatment for children with end-stage heart failure resulting from congenital heart disease (CHD) or cardiomyopathy. The purpose of this study by Dr. Rochus K. Voeller and his colleagues at Washington University in St. Louis was to review the trends in the indications for transplant and survival following transplant, using a retrospective review of all 307 orthotopic heart transplants performed at St. Louis Children's Hospital from January 1986 to December 2009. Combined heart-lung transplants were excluded from the study.

The indications for transplantation in 1986–2009 were 39% cardiomyopathy, 57% CHD, and 4% retransplant. Of the 174 patients with CHD, 80% had single-ventricle (SV) anomalies. In the CHD group, transplantation for failed SV palliation, including the failed Fontan procedure, became the predominant indication in the latest 8-year interval of their program (increasing from 11% during 1984–1993 to 60% during 2002–2009). The retransplantation rate remained low and unchanged across the various time periods, Dr. Voeller reported.

The mean recipient age was 6.1 years, with 41% of the recipients aged younger than 1 year at the time of transplantation. Nearly one-third of all patients had prior surgical procedures or surgery ranging from banding to Fontan operations; 55% of the patients were boys; 8% of patients were bridged with either ECMO (extracorporeal circulation membrane oxygenation) or VAD (ventricular assist devices).

Overall survival of transplant patients was 81%, 76%, 72%, and 65% at 1, 3, 5, and 10 years, respectively. Survival was best in those patients who were transplanted for cardiomyopathy (1-, 3-, 5-, and 10-year survival of 90%, 84%, 81%, and 81%, respectively) and worst in patients with failed palliations for SV anomalies, especially failed Fontan procedures (1-, 3-, 5-, and 10-year survival of 66%, 61%, 61%, and 53%, respectively).

“As the survival with early palliation for SV anomaly patients improves, more centers will be referred with these patients who will require transplantation at some point,” Dr. Voeller said in an interview. This will impact not only pediatric transplant programs, but also adult programs, he added. Risk factor analysis will determine which patients can benefit from earlier transplant referral and how to better prepare these patients for the procedure, he concluded.

As survival with early palliation for SV anomaly improves, more patients will require transplantation.

Source DR. VOELLER

Major Finding: Survival was best in patients who were transplanted for cardiomyopathy (1-, 3-, 5-, and 10-year survival of 90%, 84%, 81%, and 81%, respectively) and worst in patients with failed palliations for SV anomalies, especially failed Fontan procedures (1-, 3-, 5-, and 10-year survival of 66%, 61%, 61%, and 53%, respectively).

Data Source: A retrospective study of 307 pediatric heart transplants over a 24-year period at St. Louis Children's Hospital.

Disclosures: Dr. Voeller reported that none of the authors had any financial disclosures.

SAN DIEGO – Over the past 24 years, the prevalence of indications for pediatric heart transplantation resulting from congenital heart disease has changed. Transplantation for failed single-ventricle palliation, including failed Fontan procedure, has now become the predominant indication, according to the observations of a single-center experience reported in the J. Maxwell Chamberlain Memorial Paper for Congenital Heart Surgery at the meeting.

Heart transplantation is the only viable treatment for children with end-stage heart failure resulting from congenital heart disease (CHD) or cardiomyopathy. The purpose of this study by Dr. Rochus K. Voeller and his colleagues at Washington University in St. Louis was to review the trends in the indications for transplant and survival following transplant, using a retrospective review of all 307 orthotopic heart transplants performed at St. Louis Children's Hospital from January 1986 to December 2009. Combined heart-lung transplants were excluded from the study.

The indications for transplantation in 1986–2009 were 39% cardiomyopathy, 57% CHD, and 4% retransplant. Of the 174 patients with CHD, 80% had single-ventricle (SV) anomalies. In the CHD group, transplantation for failed SV palliation, including the failed Fontan procedure, became the predominant indication in the latest 8-year interval of their program (increasing from 11% during 1984–1993 to 60% during 2002–2009). The retransplantation rate remained low and unchanged across the various time periods, Dr. Voeller reported.

The mean recipient age was 6.1 years, with 41% of the recipients aged younger than 1 year at the time of transplantation. Nearly one-third of all patients had prior surgical procedures or surgery ranging from banding to Fontan operations; 55% of the patients were boys; 8% of patients were bridged with either ECMO (extracorporeal circulation membrane oxygenation) or VAD (ventricular assist devices).

Overall survival of transplant patients was 81%, 76%, 72%, and 65% at 1, 3, 5, and 10 years, respectively. Survival was best in those patients who were transplanted for cardiomyopathy (1-, 3-, 5-, and 10-year survival of 90%, 84%, 81%, and 81%, respectively) and worst in patients with failed palliations for SV anomalies, especially failed Fontan procedures (1-, 3-, 5-, and 10-year survival of 66%, 61%, 61%, and 53%, respectively).

“As the survival with early palliation for SV anomaly patients improves, more centers will be referred with these patients who will require transplantation at some point,” Dr. Voeller said in an interview. This will impact not only pediatric transplant programs, but also adult programs, he added. Risk factor analysis will determine which patients can benefit from earlier transplant referral and how to better prepare these patients for the procedure, he concluded.

As survival with early palliation for SV anomaly improves, more patients will require transplantation.

Source DR. VOELLER

Long-term behavioral and emotional outcomes after congenital heart surgery can be predicted by medical history and therapeutic intervention, according to a study of 114 congenital heart disease patients.

Patients who received cardiac medication (diuretics or prostaglandin E₁ before surgery or intervention had significantly worse long-term psychological outcomes compared with those who received palliative treatment (a Rashkind procedure) before undergoing surgery or intervention.

As long-term survival from congenital heart interventions becomes more and more common, outcomes beyond mortality and physical morbidity are receiving more attention; these outcomes include behavioral and emotional well-being, according to Dr. Alinda W. Spijkerboer of the Erasmus Medical Centre – Sophia Children's Hospital, Rotterdam, the Netherlands, and her colleagues.

The researchers used the Child Behavior Checklist (CBC) to determine the extent of behavioral and emotional problems in 7- to 17-year-old participants (64 boys, 50 girls) with congenital heart disease who underwent invasive treatment between 1990 and 1995.

Analyses were performed to correlate the behavioral and emotional outcomes with medical history; therapeutic intervention and direct postinterventional course; long-term medical course; present contact with physicians; and present medical status. The participants were also assessed as to whether problems were internalizing or externalizing. The General Health Questionnaire (GHQ) was used to assess parental distress, especially anxiety (J. Ped. Surg. 2010;45:2146–53).

The four diagnostic categories of congenital heart disease were surgical closure of atrial septal defect (27 patients), surgical closure of a ventricular septal defect (43 patients), arterial switch operation of transposition of the great arteries (31 patients), and balloon dilatation for pulmonary stenosis (13 patients).

“The only significant predictors found in this study all seemed to originate from the cluster medical history,” the authors stated. Use of cardiac medication before therapeutic intervention significantly predicted a higher CBC total problems score. Earlier palliative intervention with the Rashkind procedure before treatment was significantly associated with lower scores in total problems and externalizing (the Rashkind procedure is a catheter-based intervention to enlarge an opening in the cardiac septum between the right and left atria for improved blood oxygenation).

Mothers who reported more long-term behavioral and emotional problems for their children also showed significantly more anxiety and psychological distress in their own scores. Fathers showed a similar trend, but it did not reach significance.

The authors speculated that because cardiac medication before therapeutic intervention is usually related to the severity of an infant's clinical state, this could be one explanation for their results. However, if patients received both prior cardiac medications and palliative treatment, they did not show increased problems, something which they could not explain.

“Our results indicate that, overall, the use of cardiac medication before surgical or interventional treatment was associated with unfavorable long-term behavioral and emotional outcomes. A palliative intervention before therapeutic intervention was associated with favorable long-term outcomes,” the researchers stated.

The study was financially supported by Doctors for Children. The authors reported having no conflicts which the journal deemed relevant.

Long-term behavioral and emotional outcomes after congenital heart surgery can be predicted by medical history and therapeutic intervention, according to a study of 114 congenital heart disease patients.

Patients who received cardiac medication (diuretics or prostaglandin E₁ before surgery or intervention had significantly worse long-term psychological outcomes compared with those who received palliative treatment (a Rashkind procedure) before undergoing surgery or intervention.

As long-term survival from congenital heart interventions becomes more and more common, outcomes beyond mortality and physical morbidity are receiving more attention; these outcomes include behavioral and emotional well-being, according to Dr. Alinda W. Spijkerboer of the Erasmus Medical Centre – Sophia Children's Hospital, Rotterdam, the Netherlands, and her colleagues.

The researchers used the Child Behavior Checklist (CBC) to determine the extent of behavioral and emotional problems in 7- to 17-year-old participants (64 boys, 50 girls) with congenital heart disease who underwent invasive treatment between 1990 and 1995.

Analyses were performed to correlate the behavioral and emotional outcomes with medical history; therapeutic intervention and direct postinterventional course; long-term medical course; present contact with physicians; and present medical status. The participants were also assessed as to whether problems were internalizing or externalizing. The General Health Questionnaire (GHQ) was used to assess parental distress, especially anxiety (J. Ped. Surg. 2010;45:2146–53).

The four diagnostic categories of congenital heart disease were surgical closure of atrial septal defect (27 patients), surgical closure of a ventricular septal defect (43 patients), arterial switch operation of transposition of the great arteries (31 patients), and balloon dilatation for pulmonary stenosis (13 patients).

“The only significant predictors found in this study all seemed to originate from the cluster medical history,” the authors stated. Use of cardiac medication before therapeutic intervention significantly predicted a higher CBC total problems score. Earlier palliative intervention with the Rashkind procedure before treatment was significantly associated with lower scores in total problems and externalizing (the Rashkind procedure is a catheter-based intervention to enlarge an opening in the cardiac septum between the right and left atria for improved blood oxygenation).

Mothers who reported more long-term behavioral and emotional problems for their children also showed significantly more anxiety and psychological distress in their own scores. Fathers showed a similar trend, but it did not reach significance.

The authors speculated that because cardiac medication before therapeutic intervention is usually related to the severity of an infant's clinical state, this could be one explanation for their results. However, if patients received both prior cardiac medications and palliative treatment, they did not show increased problems, something which they could not explain.

“Our results indicate that, overall, the use of cardiac medication before surgical or interventional treatment was associated with unfavorable long-term behavioral and emotional outcomes. A palliative intervention before therapeutic intervention was associated with favorable long-term outcomes,” the researchers stated.

The study was financially supported by Doctors for Children. The authors reported having no conflicts which the journal deemed relevant.

Long-term behavioral and emotional outcomes after congenital heart surgery can be predicted by medical history and therapeutic intervention, according to a study of 114 congenital heart disease patients.

Patients who received cardiac medication (diuretics or prostaglandin E₁ before surgery or intervention had significantly worse long-term psychological outcomes compared with those who received palliative treatment (a Rashkind procedure) before undergoing surgery or intervention.

As long-term survival from congenital heart interventions becomes more and more common, outcomes beyond mortality and physical morbidity are receiving more attention; these outcomes include behavioral and emotional well-being, according to Dr. Alinda W. Spijkerboer of the Erasmus Medical Centre – Sophia Children's Hospital, Rotterdam, the Netherlands, and her colleagues.

The researchers used the Child Behavior Checklist (CBC) to determine the extent of behavioral and emotional problems in 7- to 17-year-old participants (64 boys, 50 girls) with congenital heart disease who underwent invasive treatment between 1990 and 1995.

Analyses were performed to correlate the behavioral and emotional outcomes with medical history; therapeutic intervention and direct postinterventional course; long-term medical course; present contact with physicians; and present medical status. The participants were also assessed as to whether problems were internalizing or externalizing. The General Health Questionnaire (GHQ) was used to assess parental distress, especially anxiety (J. Ped. Surg. 2010;45:2146–53).

The four diagnostic categories of congenital heart disease were surgical closure of atrial septal defect (27 patients), surgical closure of a ventricular septal defect (43 patients), arterial switch operation of transposition of the great arteries (31 patients), and balloon dilatation for pulmonary stenosis (13 patients).

“The only significant predictors found in this study all seemed to originate from the cluster medical history,” the authors stated. Use of cardiac medication before therapeutic intervention significantly predicted a higher CBC total problems score. Earlier palliative intervention with the Rashkind procedure before treatment was significantly associated with lower scores in total problems and externalizing (the Rashkind procedure is a catheter-based intervention to enlarge an opening in the cardiac septum between the right and left atria for improved blood oxygenation).

Mothers who reported more long-term behavioral and emotional problems for their children also showed significantly more anxiety and psychological distress in their own scores. Fathers showed a similar trend, but it did not reach significance.

The authors speculated that because cardiac medication before therapeutic intervention is usually related to the severity of an infant's clinical state, this could be one explanation for their results. However, if patients received both prior cardiac medications and palliative treatment, they did not show increased problems, something which they could not explain.

“Our results indicate that, overall, the use of cardiac medication before surgical or interventional treatment was associated with unfavorable long-term behavioral and emotional outcomes. A palliative intervention before therapeutic intervention was associated with favorable long-term outcomes,” the researchers stated.

The study was financially supported by Doctors for Children. The authors reported having no conflicts which the journal deemed relevant.

SAN DIEGO - The Society of Thoracic Surgeons Predicted Risk of Mortality score is a well-validated predictor of mortality during the first 30 days after cardiac surgery. The PROM score's role in predicting longer-term survival, however, has not been investigated, according to Dr. John D. Puskas at the annual meeting of the Society of Thoracic Surgeons.

To fill this void, Dr. Puskas and his colleagues from Emory University, Atlanta, undertook a study to statistically validate PROM at 1, 3, 5, and 10 years after cardiac surgery. He presented the study's results at the meeting.

The investigators found that the STS PROM algorithm accurately predicted mortality both at 30 days and during 12 years of follow-up with almost equally strong discriminatory power. "This may have profound implications for informed consent as well as for longitudinal comparative effectiveness studies," Dr. Puskas said in an interview.

"The STS Predicted Risk of Mortality models are probably underutilized and underappreciated in their power to predict short and long-term outcomes for our patients. The STS provides this service free of charge, and it is available online 24/7. I am hopeful that this newfound ability to predict longer-term survival after cardiac surgery will find utility in comparative effectiveness research and ultimately in shaping health policy," he added.

Dr. Puskas and his colleagues evaluated the survival rates for 24,222 patients who underwent cardiac surgery at a single academic center during 1996-2009. Long-term all-cause mortality was determined by referencing the national Social Security Death Master File. Logistic and Cox survival regression analyses were used to evaluate the long-term predictive utility of PROM.

The AUROC (area under the receiver operator characteristic) curve measured the discrimination of PROM at 1, 3, 5, and 10 years. Kaplan-Meier curves were stratified by quartiles of PROM risk to compare long-term survival. All analyses were performed for both the whole sample and 30-day survivors.
The investigators found an overall 30-day mortality rate of 2.78%.

Among all patients and 30-day survivors, AUROC values for PROM at 1, 3, 5, and 10 years were remarkably similar to the 30-day end point for which PROM is calibrated.

Moreover, PROM was highly predictive of Kaplan-Meier survival, even when this analysis was restricted to patients surviving beyond 30 days, he added.

Among 30-day survivors, each percent increase in PROM score was significantly associated with a 9.6% increase in instantaneous hazard of death (P less than .001).

Dr. Puskas and his colleagues reported no relevant disclosures with regard to their study.

SAN DIEGO - The Society of Thoracic Surgeons Predicted Risk of Mortality score is a well-validated predictor of mortality during the first 30 days after cardiac surgery. The PROM score's role in predicting longer-term survival, however, has not been investigated, according to Dr. John D. Puskas at the annual meeting of the Society of Thoracic Surgeons.

To fill this void, Dr. Puskas and his colleagues from Emory University, Atlanta, undertook a study to statistically validate PROM at 1, 3, 5, and 10 years after cardiac surgery. He presented the study's results at the meeting.

The investigators found that the STS PROM algorithm accurately predicted mortality both at 30 days and during 12 years of follow-up with almost equally strong discriminatory power. "This may have profound implications for informed consent as well as for longitudinal comparative effectiveness studies," Dr. Puskas said in an interview.

"The STS Predicted Risk of Mortality models are probably underutilized and underappreciated in their power to predict short and long-term outcomes for our patients. The STS provides this service free of charge, and it is available online 24/7. I am hopeful that this newfound ability to predict longer-term survival after cardiac surgery will find utility in comparative effectiveness research and ultimately in shaping health policy," he added.

Dr. Puskas and his colleagues evaluated the survival rates for 24,222 patients who underwent cardiac surgery at a single academic center during 1996-2009. Long-term all-cause mortality was determined by referencing the national Social Security Death Master File. Logistic and Cox survival regression analyses were used to evaluate the long-term predictive utility of PROM.

The AUROC (area under the receiver operator characteristic) curve measured the discrimination of PROM at 1, 3, 5, and 10 years. Kaplan-Meier curves were stratified by quartiles of PROM risk to compare long-term survival. All analyses were performed for both the whole sample and 30-day survivors.
The investigators found an overall 30-day mortality rate of 2.78%.

Among all patients and 30-day survivors, AUROC values for PROM at 1, 3, 5, and 10 years were remarkably similar to the 30-day end point for which PROM is calibrated.

Moreover, PROM was highly predictive of Kaplan-Meier survival, even when this analysis was restricted to patients surviving beyond 30 days, he added.

Among 30-day survivors, each percent increase in PROM score was significantly associated with a 9.6% increase in instantaneous hazard of death (P less than .001).

Dr. Puskas and his colleagues reported no relevant disclosures with regard to their study.

SAN DIEGO - The Society of Thoracic Surgeons Predicted Risk of Mortality score is a well-validated predictor of mortality during the first 30 days after cardiac surgery. The PROM score's role in predicting longer-term survival, however, has not been investigated, according to Dr. John D. Puskas at the annual meeting of the Society of Thoracic Surgeons.

To fill this void, Dr. Puskas and his colleagues from Emory University, Atlanta, undertook a study to statistically validate PROM at 1, 3, 5, and 10 years after cardiac surgery. He presented the study's results at the meeting.

The investigators found that the STS PROM algorithm accurately predicted mortality both at 30 days and during 12 years of follow-up with almost equally strong discriminatory power. "This may have profound implications for informed consent as well as for longitudinal comparative effectiveness studies," Dr. Puskas said in an interview.

"The STS Predicted Risk of Mortality models are probably underutilized and underappreciated in their power to predict short and long-term outcomes for our patients. The STS provides this service free of charge, and it is available online 24/7. I am hopeful that this newfound ability to predict longer-term survival after cardiac surgery will find utility in comparative effectiveness research and ultimately in shaping health policy," he added.

Dr. Puskas and his colleagues evaluated the survival rates for 24,222 patients who underwent cardiac surgery at a single academic center during 1996-2009. Long-term all-cause mortality was determined by referencing the national Social Security Death Master File. Logistic and Cox survival regression analyses were used to evaluate the long-term predictive utility of PROM.

The AUROC (area under the receiver operator characteristic) curve measured the discrimination of PROM at 1, 3, 5, and 10 years. Kaplan-Meier curves were stratified by quartiles of PROM risk to compare long-term survival. All analyses were performed for both the whole sample and 30-day survivors.
The investigators found an overall 30-day mortality rate of 2.78%.

Among all patients and 30-day survivors, AUROC values for PROM at 1, 3, 5, and 10 years were remarkably similar to the 30-day end point for which PROM is calibrated.

Moreover, PROM was highly predictive of Kaplan-Meier survival, even when this analysis was restricted to patients surviving beyond 30 days, he added.

Among 30-day survivors, each percent increase in PROM score was significantly associated with a 9.6% increase in instantaneous hazard of death (P less than .001).

Dr. Puskas and his colleagues reported no relevant disclosures with regard to their study.