Background
Intermittent claudication is associated with significant impairment of health‐related quality of life. The use of revascularization techniques to improve health‐related quality of life ...remains controversial.
Methods
Patients with intermittent claudication due to iliac or femoropopliteal peripheral artery disease were enrolled in the IRONIC trial. They were randomized to either best medical therapy (BMT), including a structured, non‐supervised exercise programme, or revascularization with either endovascular or open techniques in addition to BMT. The primary outcome was health‐related quality of life at 2 years assessed using the Short Form 36 (SF‐36®) questionnaire. Secondary outcomes included VascuQoL questionnaire results, treadmill walking distances and achievement of patient‐specified treatment goals.
Results
Both randomized groups had improved health‐related quality of life and treadmill walking distance at 2‐year follow‐up. Overall SF‐36® physical component summary score, three SF‐36® physical domain scores, overall VascuQoL score, and three of five VascuQoL domain scores showed significantly greater improvement in the group that also received invasive treatment. Intermittent claudication distance on a graded treadmill improved more in the revascularization + BMT group (117 versus 55 m; P = 0·003) whereas maximum walking distance and 6‐min walk test distance were similar. Some 44 per cent of patients in the revascularization + BMT group reported they had fully achieved their treatment goal versus 10 per cent in the BMT group.
Conclusion
A revascularization strategy with unsupervised exercise improved health‐related quality of life and intermittent claudication distance more than standard BMT and an unsupervised exercise programme in patients with lifestyle‐limiting claudication. Registration number: NCT01219842 (http://www.clinicaltrials.gov).
Revascularization better than unsupervised exercise alone
Single crystal CVD (scCVD) diamond is an attractive material for particle detection in high energy physics for its good time resolution and reported outstanding radiation tolerance. In addition to ...direct signal loss via charge carrier trapping, polarization effect, caused by non-homogeneous filling of trap defects, is a known cause of signal degradation in irradiated scCVD diamond. This phenomenon was studied by intentionally polarizing irradiated diamonds. Even the relatively lightly irradiated (1014 protons/cm2) diamonds exhibited strong enough polarization to collapse the electric field with moderate rate of 5 MeV alpha particles. The transient current measurements were reproduced with TCAD simulations. The hypothesis that the polarization is caused by single neutral defect type in the bulk, was tested using two generic models. Neither one has a satisfactory agreement with the measurement data, which indicates that trapping at the interfaces play a significant role in space charge polarization.
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•Space charge polarization was studied with irradiated single crystal diamond sensors.•Full collapse of the electric field was observed for all irradiated samples.•To remove polarization in low fluence samples switching bias voltage on-off effective•Polarization very likely cannot be explained by trapping in the bulk only.
The aim of the Carotid Alarm Study was to compare the procedural risk of carotid endarterectomy (CEA) performed within 48 hours with that after 48 hours to 14 days following an ipsilateral ...cerebrovascular ischaemic event.
Consecutive patients with symptomatic carotid stenosis undergoing CEA were prospectively recruited. Time to surgery was calculated as time from the most recent ischaemic event preceding surgery. A neurologist examined patients before and, after CEA. The primary endpoint was the composite endpoint of death and/or any stroke within 30 days of the surgical procedure. The study was designed to include 600 patients, with 150 operated on within 48 hours.
From October 2010 to December 2015, 418 patients were included, of whom 75 were operated within 48 hours of an ischaemic event. The study was prematurely terminated owing to the slow recruitment rate in the group operated on within 48 hours. Patients undergoing CEA within 48 hours had a higher risk of reaching the primary endpoint than those operated on later (8.0% vs. 2.9%). Multivariate logistic regression analyses showed that CEA performed within 48 h (odds ratio OR 3.07; 95% confidence interval CI 1.04–9.09), CEA performed out of office hours (OR 3.65; 95% CI 1.14–11.67), and use of shunt (OR 4.02; 95% CI 1.36–11.93) were all independently associated with an increased risk of reaching the primary endpoint.
CEA performed within 48 hours was associated with a higher risk of complications compared with surgery performed 48 hours–14 days after the most recent ischaemic event.
Objectives The use of an intraoperative shunt is an established technique used to reduce the ischemic time after acute arterial obstruction or in the prevention of hypoperfusion due to complex open ...vascular or endovascular operative procedures. To date, described methods of temporary extremity blood perfusion have required open surgical techniques. Methods An endovascular shunt (ES) was formed by connecting two introducer sheaths to each other, one positioned proximal and one distal to an arterial obstruction. The ES method was used in patients considered to be at high risk for prolonged lower limb ischemia in conjunction with a vascular procedure and where shunt creation by open surgical technique was not considered to be a practical alternative. The flow capacity of the ES was defined in a desktop model. Results The ES method was used clinically in 15 vascular interventions including eight complex endovascular aortic procedures, three open aortic operations, and four procedures for acute limb ischemia. The shunts were functional in all patients and there were no shunt occlusions. Postoperatively, there were no evident clinical reperfusion injuries. Flow analysis revealed that the ES had a flow capacity of 73% flow capacity compared to a Pruitt-Inahara shunt. Conclusion A new method of temporary blood shunting in connection to vascular procedures has been demonstrated.
Objectives The risk of recurrent stroke in patients with symptomatic carotid artery stenosis is highest in the first weeks after a transient ischemic attack (TIA) or minor stroke and can be reduced ...with carotid endarterectomy (CEA). The optimal timing of CEA remains a controversial issue since very urgent CEA is associated with an increased procedural risk. The aim of this study was to determine the risk of very early recurrent stroke in a population with symptomatic high grade carotid stenosis. Methods Data were analyzed on all patients with ocular TIA, TIA, or minor stroke with >70% carotid stenosis as assessed by carotid ultrasound at Sahlgrenska University Hospital during the periods 2004–2006 and 2010–2012. The two time periods were chosen to minimize selection bias and to analyze changes over time. The risk of recurrent stroke within 30 days of the referring event was assessed. Results 397 patients with symptomatic carotid stenosis were identified. The risk of recurrent stroke in the total cohort was 2.0% (CI 95% 0.6–3.4) by day 2, 4.0% (CI 95% 2.0–5.9) by day 7, and 7.5% (CI 95% 4.4–10.6) by day 30. There was no significant difference between the two time periods. Patients with minor stroke had a significantly higher risk of recurrent stroke than patients with TIA or ocular TIA as the referring event. Conclusions The data suggest that the early risk of recurrent stroke in symptomatic significant carotid stenosis is not as high as some earlier studies have shown. The risk is similar to several studies in which a modern medical treatment regime could be assumed.
Objective The objective of this study was to evaluate the risk of recurrent ischaemic stroke in patients with ultrasound assessed symptomatic mild carotid artery stenosis (20–49% NASCET) treated ...solely with modern medical treatment. Method This was a retrospective, observational register cohort study. Three groups of patients were recruited from a database of all carotid Doppler ultrasound examinations performed in the Gothenburg region between 2004 and 2009. Patients with symptomatic mild carotid artery stenosis ( n = 162) were compared with patients with asymptomatic carotid artery stenosis ( n = 301) of equal degree and a group of patients with surgically (CEA) treated symptomatic moderate or severe carotid artery stenosis ( n = 220). Kaplan-Meier estimates and Cox proportional hazard models were used to compare the primary outcome (ipsilateral ischaemic stroke) between groups. Results After a 3 year follow up, the cumulative incidence of recurrent ipsilateral stroke in patients with symptomatic mild carotid artery stenosis was 7.4%. Patients with symptomatic mild carotid artery stenosis had a substantially increased risk of recurrent ipsilateral stroke compared with asymptomatic patients with equal degree of stenosis (HR 5.5. 95% CI 1.8–17.1; p = .003) as also compared with patients with CEA treated symptomatic moderate or severe stenosis (HR 7.8. 95% CI 1.62–37.8; p = .011). Conclusions The present study on patients with symptomatic mild carotid artery stenosis, as determined by Doppler ultrasound, shows that there is still a substantial risk of recurrent stroke in this group.
The purpose of this study was to determine whether recovery from burnout is associated with improved cognitive functioning, and whether such improvement is associated with changes in ...hypothalamic-pituitary-adrenal axis activity and return to work. Forty-five former burnout patients were followed up after 1.5 years with a neuropsychological examination, diurnal salivary cortisol measurements, dexamethasone suppression test (DST), and self-ratings of cognitive problems. At follow-up, improved cognitive performance was observed on several tests of short-term memory and attention. Self-rated cognitive problems decreased considerably, but this decrease was unrelated to the improvement on neuropsychological tests. Diurnal salivary cortisol concentrations at awakening, 30 min after awakening, and in the evening, did not change from baseline to follow-up, nor did the cortisol awakening response. However, slightly, but significantly, stronger suppression of cortisol in response to the DST was observed at follow-up. Improvements in subjective or objective cognitive functioning and changes in diurnal cortisol concentration were unrelated to the extent of work resumption. However, a decreased DST response at follow-up was partially related to improved cognitive performance and work resumption. The clinical implications are that burnout seems to be associated with slight and significantly reversible cognitive impairment, and that self-rated cognitive change during recovery poorly reflects objective cognitive change.
This study investigated cognitive performance in patients with burnout, in relation to the flexibility of the hypothalamic-pituitary-adrenal (HPA) axis. Clinical cases with work stress-induced ...burnout (n = 65), and demographically matched, healthy reference subjects (n = 65), were given six neuropsychological tests and a self-rating scale for cognitive problems. Diurnal salivary cortisol was measured among burnout cases and an external reference group (n = 174), including a dexamethasone suppression test (DST) among burnout cases. Compared with referents, the burnout group under-performed in a cognitive speed test (Wechsler Adult Intelligence Scale-Revised (WAIS-R) Digit Symbol), but not in any other test of sustained attention, episodic memory, or vocabulary. Burnout cases had considerably more subjective cognitive problems, but ratings were unrelated to test performance. Compared with referents, burnout cases had similar morning salivary cortisol levels and similar awakening response, but lower evening cortisol. Among burnout cases, lower diurnal cortisol variability was related to slower performance in several tests. The DST response showed no consistent relationship with any cognitive parameter. Hence, despite considerable subjective cognitive problems, the burnout group showed only a partial, mild deviation in cognitive performance. A flatter diurnal cortisol profile was related to lower cognitive processing speed, but diurnal cortisol pattern and DST response were normal, suggesting a maintained HPA axis flexibility.
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