Predicting high risk of exacerbations in bronchiectasis: the E-FACED score.

BACKGROUND: Although the FACED score has demonstrated a great prognostic capacity in bronchiectasis, it does not include the number or severity of exacerbations as a separate variable, which is important in the natural history of these patients. OBJECTIVE: Construction and external validation of a new index, the E-FACED, to evaluate the predictive capacity of exacerbations and mortality. METHODS: The new score was constructed on the basis of the complete cohort for the construction of the original FACED score, while the external validation was undertaken with six cohorts from three countries (Brazil, Argentina, and Chile). The main outcome was the number of annual exacerbations/hospitalizations, with all-cause and respiratory-related deaths as the secondary outcomes. A statistical evaluation comprised the relative weight and ideal cut-off point for the number or severity of the exacerbations and was incorporated into the FACED score (E-FACED). The results obtained after the application of FACED and E-FACED were compared in both the cohorts. RESULTS: A total of 1,470 patients with bronchiectasis (819 from the construction cohorts and 651 from the external validation cohorts) were followed up for 5 years after diagnosis. The best cut-off point was at least two exacerbations in the previous year (two additional points), meaning that the E-FACED has nine points of growing severity. E-FACED presented an excellent prognostic capacity for exacerbations (areas under the receiver operating characteristic curve: 0.82 for at least two exacerbations in 1 year and 0.87 for at least one hospitalization in 1 year) that was statistically better than that of the FACED score (0.72 and 0.78, P<0.05, respectively). The predictive capacities for all-cause and respiratory mortality were 0.87 and 0.86, respectively, with both being similar to those of the FACED. CONCLUSION: E-FACED score significantly increases the FACED capacity to predict future yearly exacerbations while maintaining the score's simplicity and prognostic capacity for death.

No benefit of screening for abdominal aortic aneurysm among 70- instead of 65-year-old men.

AIM: Screening 65-year-old men for abdominal aortic aneurysm (AAA) reduces mortality from ruptured AAA (rAAA). Lower than expected prevalence of AAA is now found, why screening at a higher age and rescreening has been discussed. Our aim was to determine if screening at 70 years of age, instead of 65, increases clinical effectiveness. METHODS: Seven thousand nine hundred fifty-one and 5623 previously un-screened 65- and 70-year old men were invited to ultrasound screening. RESULTS: The attendance rate was 85.7% and 84.0%, P<0.01, for the 65- and 70-year old men respectively. The screening-detected prevalence did not differ, being 1.9% and 2.3%, P=0.15, respectively, probably due to the fact that 23.5% and 37.4% of all known AAA among 65- and 70-year-old men, were detected by other means prior to screening, P<0.01. However, the total known prevalence differed between the age-groups, being at least 2.1% and 3.0% respectively, P<0.001. CONCLUSION: The screening-detected AAA-prevalence did not differ between 65- and 70-year-old men, due to the greater number of AAA known prior to screening among 70- compared to 65-year-old men. Screening men at 70 instead of 65 years of age would not result in detection of substantially more previously unknown AAA, thus not preventing rAAA and consequently not more saved life-years. Further, data also indicates that it is questionable if re-screening the 65-year-old male population after five years would generate any important clinical effect.

Lower prevalence than expected when screening 70-year-old men for abdominal aortic aneurysm.

BACKGROUND: Screening 65-year-old men for abdominal aortic aneurysms (AAA) is a cost-effective method to reduce the mortality from ruptured AAA. However, contemporary results show a lower than expected prevalence of AAA, thus questioning the benefit of screening. Since the prevalence increases with age, a possible way to enhance the benefit of screening might be to screen older men. Our aim was to determine the contemporary screening-detected prevalence among 70-year-old men. METHODS: A total of 5,623 unscreened 70-year-old men were invited to ultrasound screening. Uni- and multivariable analyses were used to assess the risk factors for AAA. RESULTS: The attendance rate was 84.0%. The prevalence of previously unknown AAAs was 2.3%. When adding the 64 men with an already known AAA to the screening-detected ones, the total prevalence in the population was at least 3.0%, and the previously discovered AAAs constituted 37.4% of the total prevalence. "Ex smoker" and "Current smoker" were the most important risk factors. CONCLUSIONS: When screening 70-year-old men for AAA, the prevalence was less than half that expected, despite a high attendance rate. Smoking was the strongest risk factor. Almost 40% of the men with AAAs were already known from other means than screening.

Population-based survival rate with a one- or two-stop referral pattern for patients with ruptured abdominal aortic aneurysms.

AIM: Is there a difference in the population-based survival rate for patients with ruptured abdominal aortic aneurysms (rAAA), handled by a "one-stop" or a "two-stop" referral pattern? METHODS: Ten regions in Sweden were identified where clear-cut "one-stop" or "two-stop" referral-patterns prevailed. From the Swedvasc Registry we identified 849 patients operated on for rAAA, 1987 to 2004, living in any of these ten regions, and related the number of survivors to the whole population served by each hospital. RESULTS: The population-based survival rate was 14% lower for patients following a "two-stop" compared to a "one-stop" referral pattern (P=0.084). For the group 65-74 years-of-age the difference was significant (P=0.021), but no corresponding effect was seen regarding operative mortality rate or sex. CONCLUSION: Compared to a "one-stop" referral pattern for rAAA, a "two-stop" referral pattern results in a lower population-based survival rate for patients 65-74 years old, but the consequences would be small even if a "one-stop" referral pattern could be generally accomplished.

The effect on patency of type, shape and volume of a vein collar used at the distal anastomis of PTFE-bypass to arteries below-knee.

AIM: The aim of this paper was to study the effect on patency rate of different types of vein collar (Miller's original or St Mary's boot), different length/height shapes of vein collar, and different vein collar volumes at the distal anastomosis of PTFE-bypass grafts to below-knee arteries in patients with critical limb ischemia. METHODS: One hundred eighty patients operated on with PTFE-bypass to below-knee arteries with a vein collar at the distal anastomosis were analyzed. They were recruited from a prospective randomized trial evaluating the effect of adding a vein collar to the distal anastomosis. Primary patency rate of the reconstructions were assessed against three factors: the type, shape, and volume of the vein collar. Univariate analysis was performed with the help of plotted Kaplan-Meier lifetable curves and log-rank tests and multivariate analysis with Cox proportional hazards regression. RESULTS: Type of vein collar had no influence on primary patency (logrank-test, χ(2)=0.8, df=1, P=0.377, N.=180). A length/height ratio of the vein collar between 1.18 and 1.63 were advantageous for primary patency but the effect was not statistically significant (logrank-test, chisq=5.5, df=2, P=0.063, N.=177). A large volume of the vein collar enhanced primary patency (logrank-test, chisq=6, df=2, P=0.050, N.=173). In the multivariate analysis, however, a larger volume and a length/height ratio between 1.18 and 1.63 as well as > 1.63 reduce the risk of graft failure with 48% (P=0.00006), 58% (P=0.007), 58% (P=0.004), respectively, while vein collar type had no effect on primary patency. CONCLUSION: This prospective observational study indicates that if a vein collar is used at the distal anastomosis of a PTFE-bypass to below-knee arteries it should be long compared to height and large in volume to improve primary patency rate, while the type of vein collar does not appear to matter.

The vein collar: an anastomotic servant or a patency promoter? Re-analysis of a randomized trial.

AIM: Randomized studies evaluating the effect of a vein collar at the distal anastomosis of PTFE-grafts show conflicting results. The study of the Joint Vascular Research Group (JVRG) of UK found improved primary patency while the Scandinavian Miller Collar Study (SCAMICOS) found neither any effect on patency nor on limb salvage after bypass to below-knee arteries. It has been discussed whether the questioned positive effect of a vein collar is due to technical advantages when the anastomosis is made rather than on a positive influence on the long-term effect by less pseudointima formation. METHODS: Primary patency regarding the use of vein collar were re-analyzed in 345 patients from SCAMICOS with Kaplan-Meier life-table technique and Cox proportional hazards regression in a counting process notation to evaluate any interaction between time-period and the effect of a vein collar on the primary patency rate. RESULTS: No overall effect on primary patency of a vein collar at the distal anastomosis was found irrespective of the site anastomosis. However, during the first 30 days of follow-up the primary patency among the femoro-crural bypasses was 0.87 (0.79-0.95) and 0.72 (0.63-0.83) with and without vein collar respectively. The interaction between vein collar and time-period was not statistically significant (P=0.070) and neither was the Score test for the whole interaction analysis (P=0.091) for the patients with anastomosis to the crural arteries. No such initial differences were found for the patients with anastomosis to the popliteal artery below-knee. CONCLUSION: A clinically relevant but not statistically significant better primary patency during the first 30 days was found for patients with PTFE-bypass to the crural arteries with a vein collar at the distal anastomosis. There were no long-term advantages of the vein collar irrespective of the location of the anastomosis.

Does patency after a vein collar and PTFE-bypass depend on sex and age? Re-analysis of a randomised trial.

AIM: Randomized studies evaluating the effect of a vein collar at the distal anastomosis of PTFE-grafts show conflicting results. The study of the Joint Vascular Research Group (JVRG) of UK found improved primary patency while the Scandinavian Miller Collar Study (SCAMICOS) found neither any effect on patency nor on limb salvage after bypass to below-knee arteries. However, the Scandinavian patients were a decade older and predominately female compared to the British patients. Can this explain the conflicting result? METHODS: Primary patency with respect to sex, age and the use of vein collar were re-analysed in 345 patients from SCAMICOS with Kaplan-Meier life-table technique, log-rank test and Cox proportional hazards regression to evaluate any interaction between sex or age and the effect of a vein collar on the primary patency rate. RESULTS: Females had better patency than males (log-rank test, χ2=9.4, df=1, P=0.002) but age had no influence on patency (log-rank test, χ2=3.3, df=3, P=0.35). However, 47% of the males compared to 23% of the females were smokers (P=0.00002). No interaction effect between sex and vein collar (P-value=0.224) or age and vein collar (P-value=0.527) was established. CONCLUSION: The difference between the two randomised vein collar studies are unlikely to depend on the disparity in sex and age of the study populations.

Screening for abdominal aortic aneurysm, a one-year follow up: an interview study.

The purpose of the present study was to investigate whether screening for abdominal aortic aneurysm (AAA) and the finding of an enlarged aorta cause worries and affect the living situations of men with aneurysms or of their families within a 12-month follow-up period. Men invited to ultrasound screening and having an enlarged aorta (>or=30 mm) were invited for an interview. In total, 10 men were interviewed. The semi-structured interview was conducted by using an interview guide. Data was analyzed by using an interpretative phenomenological method. Three themes were identified: (i) feeling secure being under superintendence; (ii) living as usual, but repressing thoughts; and (iii) feeling disillusionment due to negative outcome. Being given the message that an enlarged aorta was discovered at the screening was manageable; hence, continuing growth of the aorta led to some unpleasant feelings. The men were living as usual; however, they all had some reflections about having an AAA and that something could happen when they least expected it. They reported thoughts about the consequences of the enlarged aorta itself and the surgery. In a one-year retrospective interview, men who have had an aneurysm detected in a screening program for AAA reported feeling secure being under superintendence. The one finding in our study concerning worries and effects on life situation could be interpreted as disillusionment due to negative outcomes. Decisions to introduce screening for AAA in Sweden and other countries with ongoing programs should be considered to include guidelines for how to handle disillusionment.

Invasive treatment for renovascular disease. A twenty year experience from a population based registry.

AIM: To analyze time trends in invasive treatment of renovascular disease in one country. METHODS: Data have been analyzed from registrations in the Swedish Vascular Registry. RESULTS: Invasive treatment for renovascular disease contributes around 1% of all vascular surgery within the Swedish Vascular Registry. Over the twenty-year period 1987-2006 the population-based frequency of invasive treatment for renovascular disease has increased; 1 597 procedures have been registered with an increase over time. The age of the treated patients has increased over the period (P<0.001). There has been a shift from open to endovascular procedure and from isolated percutaneous transluminal renal angioplasty (PTRA) to PTRA combined with a stent. Complications and mortality are significantly higher in patients undergoing open reconstruction (P<0.01). One year follow-up is incomplete and long-term results are therefore not possible to evaluate through registry-data only. CONCLUSION: Using nation-wide registry data it is possible to analyze time-trends also concerning rare diseases or interventions. The changing pattern toward endovascular treatment of renovascular disease is obvious. Follow-up data at one year are incomplete.

Cost-effectiveness of endarterectomy in patients with asymptomatic carotid artery stenosis.

BACKGROUND: Long-term health outcomes and costs are important when deciding whether a strategy of carotid endarterectomy in addition to best medical management should be recommended for patients with asymptomatic carotid artery stenosis. This study investigated the cost-effectiveness of such a strategy compared with a strategy of best medical management alone. METHODS: Based on data from the randomized Asymptomatic Carotid Surgery Trial (ACST), a national vascular database and other published sources, expected costs and health outcomes in terms of quality-adjusted life years (QALYs) of both treatment strategies were estimated using decision-analytical modelling. Cost-effectiveness was established for a Swedish setting from a societal perspective. RESULTS: Base-case analysis showed that the incremental cost per QALY of a strategy with carotid endarterectomy for 65- and 75-year-old men (women) was 34,557 euros (311,133 euros) and 58,930 euros (779,776 euros) respectively. Sensitivity analyses indicated that the duration of the treatment effect after 5 years of follow-up in the ACST was important for the cost-effectiveness results. CONCLUSION: Carotid endarterectomy in addition to best medical management can be considered cost-effective in men aged 73 years or less but is less likely to be cost-effective in older men or in women.

Decision-analytical model with lifetime estimation of costs and health outcomes for one-time screening for abdominal aortic aneurysm in 65-year-old men.

BACKGROUND: Abdominal aortic aneurysm (AAA) causes about 2 per cent of all deaths in men over the age of 65 years. A major improvement in operative mortality would have little impact on total mortality, so screening for AAA has been recommended as a solution. The cost-effectiveness of a programme that invited 65-year-old men for ultrasonographic screening was compared with current clinical practice in a decision-analytical model. METHODS: In a probabilistic Markov model, costs and health outcomes of a screening programme and current clinical practice were simulated over a lifetime perspective. To populate the model with the best available evidence, data from published papers, vascular databases and primary research were used. RESULTS: The results of the base-case analysis showed that the incremental cost per gained life-year for a screening programme compared with current practice was 7760, and that for a quality-adjusted life-year was 9700. The probability of screening being cost-effective was high. CONCLUSION: A financially and practically feasible screening programme for AAA, in which men are invited for ultrasonography in the year in which they turn 65, appears to yield positive health outcomes at a reasonable cost.

Prognostic factors for failure of primary patency within a year of bypass to the foot in patients with diabetes and critical ischaemia.

OBJECTIVE: To find out whether we could identify prognostic factors for early failure of bypass to the foot in diabetic patients with critical ischaemia. DESIGN: Retrospective series of consecutive patients. SETTING: County hospital, Sweden. PATIENTS: 43 diabetic patients who had 48 reconstructions for critical ischaemia between 1988 and 1994. INTERVENTIONS: 48 elective vein bypass procedures to the feet. MAIN OUTCOME MEASURES: Prognostic factors for primary patency. RESULTS: Primary and secondary patency rates at one year were 72% (95% confidence interval (CI) 58 to 85) and 83% (95% CI 71 to 95), respectively. Limb salvage and survival rates at one year were 85% (95% CI 74 to 96) and 86% (95% CI 75 to 96), respectively. Vein graft of questionable quality, major wound healing problems, use of the reversed vein technique, and a narrow lumen (< 1.5 mm) of the recipient artery increased the hazard for failed primary patency by 17.3 (p = 0.003), 6.0 (p = 0.02), 4.7 (p = 0.03), and 3.9 (p = 0.05) times, respectively. Short vein bypass (p = 0.70), translocated or composite veins (p = 0.61), major postoperative oedema of the leg (p = 0.46), or questionable quality of the wall of the recipient artery (p = 0.29), however, had no significant independent effect on the primary patency rate. CONCLUSION: Early primary patency after bypass to the foot in diabetic patients might improve if veins of questionable quality, major wound healing problems, thin reversed veins from the calf, and narrow recipient arteries can be avoided or handled more proficiently than in the present study.

Effects of frequent mouthrinses with palatinose and xylitol on dental plaque.

The aim was to evaluate the effects of frequent mouthrinses with palatinose, xylitol and a mixture of palatinose and xylitol on plaque pH, plaque formation and cariogenic microorganisms. 15 subjects refrained from toothbrushing during 3 test periods and rinsed 15 x daily for 4 d with 10 ml of: (1) 50% palatinose, (2) 37.5% palatinose + 12.5% xylitol, or (3) 50% xylitol. A contrast period with no mouthrinses was also carried out. The 4 periods were carried out in a randomized order with a cross-over design. After the 4-day periods, 3 parameters were measured: (1) plaque pH during the first 30 min after a mouthrinse with palatinose, a mixture of palatinose and xylitol or xylitol alone, directly followed by a 2nd rinse with 10% sucrose; (2) number of mutans streptococci and lactobacilli in plaque and saliva; (3) plaque index. The most pronounced pH drop for the sugar substitutes was found when rinsing with 50% palatinose after the palatinose period, and the least pH drop with 50% xylitol after the xylitol period. The sucrose rinse gave similar pH fall after all 4 periods. The microbial data showed no differences between the 4 periods, but the mutans streptococcus counts in saliva decreased after the xylitol period in contrast to the 3 other periods. Regarding the plaque index, xylitol gave lower scores compared to the other 3 periods.

Vein bypass surgery to the foot in patients with diabetes and critical ischaemia.

The feasibility of vein bypass surgery to the arteries of the foot was studied in a diabetic population with critical ischaemia; whether or not such reconstruction leads to an independent lifestyle was assessed 1 year later. Thirty-three reconstructions were performed on 32 limbs in 31 patients. The mortality and reoperation rates within 1 month were both 6 per cent. Primary and secondary patency, limb salvage and survival rates at 1 year were 76, 89, 89 and 82 per cent respectively. Good results in the form of combined survival, patency, limb salvage, walking ability, relief of pain and residence at home were achieved in 64 per cent of patients after 1 year. Reconstructive vascular surgery to the foot in diabetics is feasible and affords two-thirds of patients an independent lifestyle 1 year after surgery.

Chronic lower limb ischaemia. A prospective randomised controlled study comparing the 1-year results of vascular surgery and percutaneous transluminal angioplasty (PTA).

In a prospective randomised study, performed over a 6-year period, 102 patients with severe lower limb ischaemia or claudication resistant to exercise training were randomised either to percutaneous transluminal angioplasty (PTA) or vascular surgery. Only patients who could be treated by both methods were included, constituting only 5% of the total number of patients treated during this period. The two groups were similar regarding age, severity of symptoms and diabetes. The immediate and 1-year results showed similar success and complication rates. There was, however, a significantly shorter hospital stay for patients treated with PTA. Due to early complications and initial failures PTA should, however, only be used in institutions where vascular surgical facilities are available since PTA demands access to such treatment.

Insulin time-dependent effects on the leg exchange of glucose and amino acids in man.

Time-dependent effects of insulin on the leg exchange of glucose, lactate, glycerol, free fatty acids (FFA) and amino acids were measured in relation to oxygen uptake (leg and whole body) and whole body glucose assimilation including oxidation. Seven healthy males (58 +/- 3 years of age) were investigated before operation of uncomplicated inguinal hernia or varicose veins. Euglycaemic glucose clamp investigations with systemic hyperinsulinaemia between 100-120 mU1(-1) were used. Metabolic measurements were performed before and during hyperinsulinaemia at 2 and 6 h following the start of glucose clamp to evaluate the time-dependency of insulin actions. Whole body glucose uptake increased continuously for up to 6 h (from 4.7 +/- 0.7 to 8.0 +/- 0.8 mg/kg/min, P less than 0.01) despite stable plasma concentrations of glucose and insulin. This was also true for glucose oxidation. Whole body oxygen uptake did not change significantly during the clamp while the leg exchange of oxygen uptake did (from 5.9 +/- 0.86 mumol/100 g/min to 11.6 +/- 2.4, P less than 0.01). Insulin effect on leg blood flow was time-dependent and increased two-fold (2.3 +/- 0.4 ml/100 g/min to 4.4 +/- 0.9, P less than 0.001) during clamp. The leg production of lactate increased continuously, accounting for approximately 15% of the glucose uptake across the leg, but the rise in arterial lactate did not reach the level of statistical significance. Plasma FFA concentrations decreased in a time-dependent manner during clamp, while the leg exchange of FFA switched rapidly to a stable net uptake.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of coumarin treatment on patency and limb salvage after peripheral arterial reconstructive surgery.

The effect of coumarin on patency, limb salvage, and survival after primary femoro-popliteal and femoro-distal reconstructions was studied in 116 randomized patients (61 in the study group and 55 in the control group). All patients were treated postoperatively with heparin. Patients allocated to the study group received dicumarol (a coumarin derivative) orally postoperatively. The overall patency after 1 year was 75 +/- 6%, compared with 74 +/- 6%, after 2 years 65 +/- 9 compared with 57 +/- 8%, and after 3 years 46 +/- 11% compared with 42 +/- 9% (mean +/- SE) in the study and control groups, respectively. There were no statistically significant differences in limb salvage or survival rates between the two groups. In contrast, coumarin treatment was associated with serious bleeding complications in 4% to 5% of the study patients. As expected, limb salvage was lower in patients with critical ischemia (p less than 0.03), and this was also true for survival (p less than 0.04), which was also influenced by the level of the reconstruction; survival was lower in patients with femoro-distal reconstructions (p less than 0.001). Our results demonstrate that coumarin treatment does not improve outcome in routine femoro-popliteal and femoro-distal reconstructive surgery.

Muscle enzyme adaptation in patients with peripheral arterial insufficiency: spontaneous adaptation, effect of different treatments and consequences on walking performance.

1. The activities of phosphofructokinase (PFK), citrate synthetase (CS), lactate dehydrogenase (LDH), 3-hydroxyacyl-CoA dehydrogenase (ACDH) and cytochrome-c oxidase(Cyt-ox) in the calf muscle tissue were compared in subjects with intermittent claudication (n = 38) and controls (n = 20). The activities of CS, ACDH and Cyt-ox were increased and the activity of Cytox was positively correlated to the maximal walking distance (MWD) in the patients. 2. Thirty-three patients with intermittent claudication were randomized to three treatment groups: (1) operative surgery, (2) operative surgery supplemented with physical training and (3) physical training alone. Before and after 6-12 months of treatment, symptom-free walking distance (SFWD), MWD, ankle-brachial blood pressure quotient (ankle index), maximal plethysmographic calf blood flow (MPBF) and the activities of PFK, CS, LDH, ACDH and Cyt-ox were measured. 3. SFWD and MWD increased in all three groups. Ankle index and MPBF increased in groups 1 and 2, but were unchanged in group 3. The activities of Cyt-ox and CS decreased with operation, but the activity of Cyt-ox was further augmented with training in group 3. Overall, the change in ankle index explained 80-90% of the variability in walking performance. In a separate analysis, the increased activity of Cyt-ox in group 3 was positively correlated to, and explained 31% of the variability in, the improvement in SFWD. 4. These findings indicate that both physical activity and a reduced calf blood flow are necessary conditions for the enzymatic adaptation to take place. A causal relationship between metabolic adaptation in the muscle tissue and walking performance is suggested.(ABSTRACT TRUNCATED AT 250 WORDS)