Tratamiento actual de las venas varicosas. Importancia de la calidad de vida / Current treatment of varicose veins. The importance of quality of life

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¿Por qué tiene sentido obtener la certificación europea en cirugía vascular? / Why is it worth obtaining European certificate in vascular surgery?

La Unión Europea de Médicos Especialistas (UEMS) fue creada en 1958, y desde el año 2005 posee una sección independiente para la cirugía vascular (Section and Board of Vascular Surgery [SBVS]). Según sus estatutos el objetivo principal de la SBVS es garantizar los más altos estándares de atención en el campo de la cirugía vascular en los países de la Unión Europea y asegurar que la formación del médico especialista se eleva al nivel más alto posible. El presente artículo expone los medios para lograr dicho objetivo principal, centrándose en el examen europeo y en los criterios para la obtención del título europeo (Fellow European Board of Vascular Surgery [FEBVS]: criterios de selección, diario y definiciones, examen oral y de habilidades: análisis de casos clínicos, trabajo académico, evaluación global, evaluación de habilidades en técnicas quirúrgicas abiertas y de habilidades endovasculares). Finalmente se exponen los puntos clave para el futuro (AU)

The European Union of Medical Specialists (UEMS) was established in 1958 and since 2005 it has a separate section for vascular surgery (Section and Board of Vascular Surgery [SBVS]). According to its statutes the main objective of the SBVS is to ensure the highest standards of care in the field of vascular surgery in the countries of the European Union, ensuring that the training in specialised medicine rises to the highest possible level. This article outlines the means to achieve this main objective, focusing on the European examination and the criteria for obtaining the European title (Fellow European Board of Vascular Surgery [FEBVS]: selection criteria, daily work and definitions, oral examination and skills, analysis of clinical cases, academic work, overall assessment, evaluation of skills in open surgical techniques, and endovascular skills). Finally, the key points are set out for the future (AU)

Tratamiento y gestión del pie diabético / Treatment and management of diabetic foot

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Linguistic validation of the 20 item-chronic venous disease quality-of-life questionnaire (CIVIQ-20).

Our objective was to review the linguistic validation of the 20 item-ChronIc Venous dIsease quality-of-life Questionnaire (CIVIQ-20) in the countries that have used it since its publication in 1996. Seventeen linguistic versions of CIVIQ-20 were validated using forward/backward methodology in patients presenting with chronic venous disease, stages C0s to C4 of the CEAP (clinical, aetiological, anatomical and pathological) classification (patients with venous ulcers were excluded). Most obstacles in the cross-cultural validation of CIVIQ-20 related to content and semantic equivalence. Confirmation of cultural relevance by experts with the native language as their mother tongue and the use of forward/backward translation methodology partly resolved these difficulties. CIVIQ-20 is valid for the assessment of treatment effects in multinational studies.

Guidelines for treatment of patients with diabetes and infected ulcers.

Diabetic foot ulcers and their consequences do not only represent a major tragedy for the patient and his/her family, but also place a significant burden on the healthcare systems and society in general. Diabetic patients may develop foot ulcers due to neuropathy (autonomic, sensory, and motor deficits), angiopathy or both. As a result of the additional immunopathy associated with diabetes, the probability of these wounds to become infected is extremely high. Diabetic foot infections can be classified in mild, moderate and severe according to local and systemic signs. Their identification should lead to a prompt and systematic evaluation and treatment, ideally performed by a multidisciplinary team. Decisions concerning empirical initial antibiotic agent(s), desirable route of administration, duration and need of hospitalization should be based on the more likely involved pathogen(s), the severity of the infection, the ulcer chronicity and the presence of significant ischemia. Wound cultures, ideally from ulcer tissue, are strongly advisable and can help guiding and narrowing the antibiotic spectrum. Appropriate wound care and off-loading should not be neglected. When revascularization is required, the correct timing can be crucial for limb salvage. Since the recurrence of ulcer and infection is high, the implementation of appropriate preventive measures can be critical. Ultimately, the definitive goal in the treatment of diabetic foot infections is to prevent the amputation catastrophe.

Construction and international validation of CIVIQ-14 (a short form of CIVIQ-20), a new questionnaire with a stable factorial structure.

BACKGROUND: The factorial instability of the CIVIQ-20 social dimension in different populations has necessitated the development of a new stable questionnaire to interpret results from international studies. OBJECTIVE: Construction of a stable and psychometrically validated questionnaire from CIVIQ-20. METHODS AND MAJOR FINDINGS: A prospective, international study was used to construct a stable CIVIQ scale and to validate its psychometric properties. An iterative process was implemented to eliminate the more unstable items (six), and the social and physical dimensions were combined. The resulting instrument comprised 14 items, split into three dimensions (pain, physical, and psychological), and was named CIVIQ-14. The stability of the CIVIQ-14 factorial structure was confirmed in Polish, Czech, Spanish, and French populations using principal component analysis and multitrait/multimethod analysis. Psychometric assessment demonstrated that CIVIQ-14 was reliable (intra-class coefficient >0.8; weighted kappa >0.8), valid (correlation coefficients between dimension scores and clinical severity scores between 0.3 and 0.6), and sensitive (effect sizes >0.6 for psychological dimension; >0.8 for the other dimensions). CONCLUSION: CIVIQ-14 is a reliable, valid, and sensitive instrument applicable to international studies of patients with chronic venous disease.

International psychometric validation of the Chronic Venous Disease quality of life Questionnaire (CIVIQ-20).

OBJECTIVE: To review the psychometric validation of the Chronic Venous dIsease quality of life Questionnaire (CIVIQ-20) in the countries that have used it since 1996. DESIGN: Prospective, clinical, international study in 18 countries. PATIENTS: Patients with venous disease of the lower limb in the clinical, aetiological, anatomical and pathophysiological (CEAP) clinical stages C0s to C4 presenting to surgical outpatient departments and general practices and receiving drug treatment for 6 months. METHODS: Quantification of symptoms on a four-point scale and pain on a visual analogue scale, and self-administration of CIVIQ-20 to patients before visit (baseline, 2, 4 and 6 months). RESULTS: In 3956 patients, CIVIQ-20 showed good internal consistency and reliability (above 0.80) through test-retest correlations. The discriminating power of items was good in known groups of patients. Factor analysis identified physical, psychological and pain factors as important, but revealed instability of the social factor. CIVIQ-20 was highly sensitive to changes in the quality of life of patients clinically improved after drug treatment. CONCLUSION: CIVIQ-20 is valuable in assessing treatment effects in longitudinal, multinational studies, but comparisons of different populations should use the global score rather than scores per dimension.

The association between the VAL34LEU mutation in the factor XIII gene and deep venous thrombosis in young people

Background. A mutation in the coagulation FXIII has been described: a G to T transition in exon 2 of the FXIII A-subunitgene, which results in the substitution of Leucine for Valine at amino acid position 34 (FXIII Val34Leu). The higher level ofactivity of the Leu34 enzyme would be expected to be associated with increased resistance of the fibrin clot to plasmin degradation. Evidence is conflicting regarding the association of FXIII Val34Leu polymorphism with risk of venous thrombosis. The aim of this study was to evaluate the association of the Val34Leu mutation in the Factor XIII gene with deep venous thrombosis(DVT) in young people. Methods. The prevalence of the FXIII Val34Leu mutation was investigated in a population of 50 consecutive and unrelated patients with an objectively documented first episode of DVT under 40 years old and in a random control group of 45 healthy subjects, using DNA analysis. Results. The distribution of genotypes amongst patients was 64% Val/Val, 36% Val/Leu and 0% Leu/Leu, corresponding to a frequency of 18% for the Leu allele. In the control group the results were respectively 48.9%, 46.7% and 4.4%, corresponding to a frequency of 27.8% for the Leu allele (p= 0.150). The odds ratio (OR) was 0.54 (95% CI: 0.24-1.22 ).Conclusion. Data from this study suggests that the Val34Leu polymorphism offers a protective effect against a first episode of deep venous thrombosis in young people (AU)

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The association between the C677T mutation in the 5.10 methylenetertrahydrofolate reductase gene and deep venous thrombosis in young people

PURPOSE. To evaluate the association between the C677T mutation in the 5,10-methylenetetrahydrofolate reductase (MTHFR) gene and deep venous thrombosis (DVT) in young people. METHODS. The prevalence of the C677T mutation in the MTHFR gene was investigated in a population of 97 consecutive and unrelated patients with an objectively documented first episode of DVT under 40 years old and in a control group of 100 healthy subjects, using DNA analysis. FINDINGS. The frequency of genotypes amongst patients was 0.10 TT, 0.44 CT and 0.46 CC and in the control group the results were respectively 0.11, 0.40 and 0.49. The odds ratio (OR) for homozygous genotype 677TT was 1.0 (95% CI: 0.4- 2.6), which was not statistically significant (p=0.86). CONCLUSION. In this study, the C677T mutation in the MTHFR gene, including the homozygous mutant genotype, was not associated with an increased risk of deep venous thrombosis in young people (AU)

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Genetic polymorphisms and risk of recurrent deep venous thrombosis in young people: prospective cohort study.

OBJECTIVE: To determine the incidence of deep venous thrombosis (DVT) recurrence in young people, and its association with some genetic polymorphisms (FV G1691A, FII G20210A, MTHFR C677T, PAI-1 4G/5G). DESIGN: Prospective cohort study. METHODS: A database was established prospectively to follow-up a cohort of unselected patients who had had a first episode of objectively proven DVT under the age of 40 years. All patients had DNA analysis for heritable thrombophilia. We excluded patients with deficiency of antithrombin, protein C or protein S, malignant disease, antiphospholipid syndrome, or a requirement for long-term antithrombotic treatment. The end-point was objective evidence of symptomatic DVT recurrence. RESULTS: Eighty-seven patients were enrolled in the study. Mean duration of follow-up was 4.07 years. At 2 years, the cumulative recurrence rate was 19.3%. The risk of risk was not related to presence or absence of laboratory evidence of genetic polymorphisms: FV G1619A (HR 1.26 [95%CI: 0.64-2.46]; p = 0.51), FII G20210A (HR 0.81 [95%CI: 0.35-1.89]; p = 0.62), MTHFR C677T (HR 1.26 [95%CI: 0.56-2.81]; p = 0.58), PAI-1 4G/5G (0.84 [95%CI: 0.35-2.05]; p = 0.71). CONCLUSION: In this study, the risk of recurrent deep venous thrombosis in young people was not related with the presence of FV G1691A, FII G20210A, MTHFR C677T or PAI-1 4G/5G polymorphisms.

The PORtromb Project: prothrombin G20210A mutation and venous thromboembolism in young people.

Recently a new identified genetic variant in the 3'-untranslated region of the prothrombin gene (G20210A allele) associated with increased plasma prothrombin levels has been linked to an increased risk of venous thromboembolism (VTE). To determine the importance of this G20210A allele as a causative risk factor for VTE in the general population, we analysed the data of an epidemiologic investigation on thrombophilia in young people, the Oporto Thrombophilia Study (PORtromb). Forty cases (mean age: 27 yr old) with a first episode of VTE under 40 yr old, and 100 healthy subjects, were evaluated. Heterozygosity for the G20210A allele was present in 12.5% of VTE cases and in 5% of controls, indicating a possible marginal increase of VTE risk in carriers of the allele (odds ratio: 2.71: 95% CI 0.74-9.95).