Editor's Choice - Very Urgent Carotid Endarterectomy is Associated with an Increased Procedural Risk: The Carotid Alarm Study.

OBJECTIVE/BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSION: 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.

Risk of Recurrent Stroke in Patients with Symptomatic Mild (20-49% NASCET) Carotid Artery Stenosis.

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.

Two-year results from a randomized clinical trial of revascularization in patients with intermittent claudication.

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).

Calibration of Fourier domain short coherence interferometer for absolute distance measurements.

We calibrated and determined the measurement uncertainty of a custom-made Fourier domain short coherence interferometer operated in laboratory conditions. We compared the optical thickness of two thickness standards and three coverslips determined with our interferometer to the geometric thickness determined by SEM. Using this calibration data, we derived a calibration function with a 95% confidence level system uncertainty of (5.9×10(-3)r+2.3) µm, where r is the optical distance in µm, across the 240 µm optical measurement range. The confidence limit includes contributions from uncertainties in the optical thickness, geometric thickness, and refractive index measurements as well as uncertainties arising from cosine errors and thermal expansion. The results show feasibility for noncontacting absolute distance characterization with micrometer-level accuracy. This instrument is intended for verifying the alignment of the discs of an accelerating structure in the possible future compact linear collider.

Risk of early recurrent stroke in symptomatic carotid stenosis.

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.

Endovascular technique for arterial shunting to prevent intraoperative ischemia.

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.

Introduction of embryonic stem cells into vein grafts reduces intimal hyperplasia in mice.

AIM: Atherosclerosis with its cardiovascular events including cardiac and peripheral ischemia represents the main cause of death in the developed countries. Although interventional treatments like percutaneous transluminal angioplasty or stents are increasingly applied for the treatment of peripheral arterial disease, they are not always technically applicable or durable and bypass surgery is needed. Compared to synthetic grafts, vein grafts show a better patency especially when used for the lower leg as well as a lower risk for infection compared to synthetic grafts. Still the long-term patency rates are unsatisfactory due to accelerated intimal hyperplasia, a thickening of the vessel wall. The aim of this study was to elucidate, if the implantation of embryonic stem cells into vein grafts can reduce the development of intimal hyperplasia in a mouse in vivo model. METHODS: In this study we implanted LacZ-tagged (ROSA26) murine embryonic stem cells into decellularized vein grafts. Control groups were: 1) untreated veins; 2) decellularized veins; 3) decellularized veins with gel and plastic film; and 4) decellularized veins with smooth muscle cells in gel surrounded by plastic film. Six weeks after insertion into the carotid artery of mice, the grafts were excised and analyzed immunohistochemically, morphologically, and by x-gal staining and compared to the control groups. The Mann-Whitney U test was used to compare groups. Statistical significance was indicated by a value of P<0.05. RESULTS: Decellularized veins with implanted stem cells showed significantly less intimal thickening compared to all control groups (intimal hyperplasia vs. luminal circumference mean±SD 7.3±3.5 µm, median 8 µm). The control groups: 1) untreated veins (60.3±25.5 µm, median 58.5 µm); 2) decellularized veins (53.9±22.4 µm, median 48.4 µm); 3) decellularized veins with gel and plastic film (70.6±22.4 µm, median 72.6 µm); and 4) decellularized veins with smooth muscle cells in gel surrounded by plastic film (73.5±18.1 µm, median 73.6 µm) all showed the same high degree of intimal hyperplasia. CONCLUSION: This study demonstrates that embryonic stem cells have a therapeutic competence to favourably modulate intimal hyperplasia in vivo.

A follow-up of cognitive performance and diurnal salivary cortisol changes in former burnout patients.

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.

Walking performance and health-related quality of life after surgical or endovascular invasive versus non-invasive treatment for intermittent claudication--a prospective randomised trial.

OBJECTIVES: Despite limited scientific evidence for the effectiveness of invasive treatment for intermittent claudication (IC), revascularisation procedures for IC are increasingly often performed in Sweden. This randomised controlled trial compares the outcome after 2 years of primary invasive (INV) versus primary non-invasive (NON) treatment strategies in unselected IC patients. MATERIALS/METHODS: Based on arterial duplex and clinical examination, IC patients were randomised to INV (endovascular and/or surgical, n = 100) or NON (n = 101). NON patients could request invasive treatment if they deteriorated during follow-up. Primary outcome was maximal walking performance (MWP) on graded treadmill test at 2 years and secondary outcomes included health-related quality of life (HRQL), assessed with Short Form (36) Health Survey (SF-36). RESULTS: MWP was not significantly (p = 0.104) improved in the INV versus the NON group. Two SF-36 physical subscales, Bodily Pain (p < 0.01) and Role Physical (p < 0.05) improved significantly more in the INV versus the NON group. There were 7% crossovers against the study protocol in the INV group. CONCLUSIONS: Although invasive treatment did not show any significant advantage regarding MWP, the HRQL improvements associated with invasive treatment tentatively suggest secondary benefits of this regimen. On the other hand, a primary non-invasive treatment strategy seems to be accepted by most IC patients.

Cognitive performance in patients with burnout, in relation to diurnal salivary cortisol.

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.

Effects of lifestyle factors on concentrations of salivary cortisol in healthy individuals.

OBJECTIVE: Salivary cortisol is widely used in occupational health research. However, many ordinary daily activities can influence the concentrations of cortisol and the interpretation of field studies. The aim of the present study was to evaluate the effect of lifestyle factors on salivary cortisol in everyday settings. MATERIAL AND METHODS: Healthy employees participated in one or more sub-studies on the effect of eating a vegetable salad versus protein-rich mid-day meal (n = 40), drinking coffee and smoking (n = 12), drinking alcohol (n = 32), awakening at different times (n = 29) and exercising (n = 21). Cortisol in saliva was measured by radioimmunoassay (RIA). RESULTS: When eating a mid-day meal, salivary cortisol was increased by 10 % (CI -1 % to 24 %) 1 h after eating compared to before eating in the case of both types of meal. Salivary cortisol increased by 80 % (CI 9 % to 199 %) after exercising compared to before exercise. The relative awakening response was approximately 100 % when using an alarm clock on both work-days and days off. However, the awakening response was 39 % (CI 10 % to 75 %) on a day off with spontaneous awakening. No effects of alcohol, coffee or smoking were observed. DISCUSSION: In field studies, the biological variation in salivary cortisol may be reduced by restricting physical exercise and in collecting pre-meal samples. However, the protein content of food and moderate consumption of alcohol had no effect on concentrations of cortisol. Differences in relative awakening responses on work-days and days off are related to time and mode of awakening.

Personality, mental distress, and subjective health complaints among persons with environmental annoyance.

The aim of this study was to assess possible early determinants of idiopathic environmental intolerance (IEI), contributing to an integrated model for the development of IEI. Questionnaires concerning personality traits, current mental distress, subjective health complaints, work load and satisfaction, and options for recovery, were given to 84 persons from the general population attributing annoyance to (i) chemicals/smells (smell-annoyed (SA) n= 29); (ii) electrical equipment (electrically annoyed (EA) n= 16); and (iii) both smells and electricity (generally annoyed (GA) n= 39), but otherwise healthy and in active work. Compared to referents (n= 54), the EA and GA groups showed strongly elevated scores on 5/6 scales within the trait anxiety/neuroticism personality dimension, while the SA group had a slight elevation on only one anxiety scale. Current mental distress and subjective health complaints scores were generally elevated in the EA and GA groups, but only partially in the SA group. Higher proportions of the EA, GA, and SA groups reported low satisfaction with their work situation, including more frequent fatigue after work and a higher, and often unfulfilled, need for recovery. The findings suggest that trait anxiety is prominent already at prodromal stages of IEI, possibly indicating that trait anxiety facilitates the acquisition of attribution of health complaints to environmental factors.

Psychological distress and coping in women married to men with a diagnosis of solvent-induced chronic toxic encephalopathy.

BACKGROUND: Solvent-induced chronic toxic encephalopathy (TE) is a slowly developing brain disorder associated with both a direct effect on the nervous system and as indirect experienced psychological distress. It can presumably also imply negative influence on the subject's social surroundings. METHODS: Seventeen women married to men diagnosed with TE (WTE) and 51 referent women of the same age married to healthy husbands were examined. Symptoms, social network and coping style were measured by questionnaires. RESULTS: The WTE reported slightly more psychological distress and fewer social contacts than did the referents. The WTE did not report affected stress management. Retired women in the WTE group accounted for most of the deviances from the referents. CONCLUSIONS: The conclusion is that becoming a WTE does not necessarily imply more psychological distress, social isolation or poorer stress management capability if they continue with their work and social activities.

Prevalence of annoyance attributed to electrical equipment and smells in a Swedish population, and relationship with subjective health and daily functioning.

BACKGROUND: Self-reported annoyance from electrical equipment has been in evidence since the mid-1980s, and the first reports of illness from everyday chemicals arose in the 1960s. However, the extent of the problem has not yet been fully established. AIMS: The aim of this study was to estimate the prevalence of annoyance related to electrical and chemical factors in a Swedish general population, and to assess possible relationships with subjective health and daily functioning. METHODS: In total, 13,604 subjects, representative of the population of Scania, Sweden, answered a survey containing five questions regarding annoyance from five environmental factors: fluorescent tube lighting, visual display units, other electrical equipment, air that smells of chemicals, and other smells. The survey also obtained data on self-reported health (SRH-7), mental well-being [General Health Questionnaire (GHQ)-12], work situation and daily functioning. RESULTS: Almost one-third of the respondents reported annoyance from at least one environmental factor. Annoyance was more frequent among women, subjects of working age and immigrants. Subjects who reported environmental annoyance scored higher on GHQ-12 and lower on SRH-7, indicating impaired subjective physical and mental well-being. They were also more likely to report deteriorated daily functioning. CONCLUSIONS: Annoyance related to electrical and/or chemical factors was common in a Swedish population. Subjects reporting environmental annoyance rated their overall health significantly poorer than the general population. The association with subjective health and functional capacity increased with severity of annoyance, which suggests that there is some connection between environmental annoyance, well-being and functional capacity.

Soluble and insoluble oxalate content of mushrooms.

Six different cultivars of edible fungi were bought from a local supermarket in Uppsala, Sweden and three different cultivars of wild growing fungi were harvested from the forest adjoining the city. The edible portions of the raw fungi were then analysed for total and soluble oxalate content. A portion of each fungi was then cooked by first boiling in a small amount of water followed by frying in a small amount of butter. The total oxalate content of the raw, commercially grown mushrooms ranged from 58.9 to 104.1 mg/100 g DM while the values for the total oxalate content of the cooked mushrooms ranged from 48.9 to 124.6 mg/100 g DM. Apart from cultivars ostronskivling and piopino the cultivated mushrooms contained mostly insoluble oxalates. Mushrooms harvested from the forest contained only soluble oxalate with the levels ranging from 29.3 to 40.2 mg/100 g DM in the raw tissue. Cooking marginally lowered the soluble oxalate content of these mushrooms. The levels of soluble and insoluble oxalates of all the mushrooms analysed were low compared to other common oxalate-containing vegetables.

Intakes of most nutrients remain at acceptable levels during a weight management program using the food exchange system.

OBJECTIVE: The purpose of this study was to determine if the food exchange system allows subjects' nutrient intake to remain at recommended levels during a weight-loss program. DESIGN: Subjects in an intervention were prescribed an energy-restriction diet and exercise program lasting 32 weeks, and nutrient intake was measured prestudy and after 12, 16, and 32 weeks. SUBJECTS/SETTING: Healthy but overweight and obese premenopausal women (n = 219) were recruited at 6 university sites into community-based weight loss programs. One hundred fifteen women completed all aspects of the study. INTERVENTION: Energy intake was set at 0.8 x resting metabolic rate (RMR) for weeks 1 through 12, 1.0 x RMR for weeks 13 through 20, and 1.2 x RMR for weeks 21 through 32. Energy intake was based on food exchange tables, with the number of food exchanges adjusted to encourage a distribution of 55% carbohydrate, 30% fat, and 15% protein. Subjects increased their daily walking distance to 3.2 km above prestudy levels. MAIN OUTCOME MEASURES: Nutrient intake was measured from four 3-day food records. STATISTICAL ANALYSES PERFORMED: Repeated measures analysis of variance, with specific time point changes assessed from paired t tests adjusted for multiple comparisons. RESULTS: Body mass decreased by a mean +/- SD of 6.7 +/- 3.2 kg at week 12 and 7.8 +/- 6.2 kg by week 32. Walking distance increased by an average of 17.2 +/- 10.0 km/week during the first 12 weeks, and 12.4 +/- 12.4 km/week during the last 20 weeks. Despite a 23% to 36% reduction in energy intake during the study, intake of most nutrients was maintained. Intake of vitamin E, calcium, iron, and zinc decreased significantly from prestudy levels during the first 16 weeks of the intervention, but not at week 32. APPLICATIONS/CONCLUSIONS: Intake of most nutrients can remain at recommended levels when overweight and obese women follow the American Diabetes Association/American Dietetic Association food exchange system during a community-based weight-loss program.

Influence of personality traits on neuropsychological test performance in toxic encephalopathy cases and healthy referent subjects.

The relationship between personality traits and cognitive performance was studied in two groups: men with symptoms and neuropsychological test results compatible with toxic encephalopathy (TE) and demographically similar healthy men (N=57 per group). Personality traits were assessed with the Karolinska Scales of Personality (KSP). The neuropsychological examination included 13 tests covering various functional domains. The TE group displayed elevated scores on all three KSP anxiety scales as well as an elevated impulsiveness score. Furthermore, the TE group had a lower score on the socialization scale than did the referent group. Different relationships between personality dispositions and cognitive functioning emerged in the two groups. Within the referent group the highest correlations were observed between KSP anxiety and socialization scale scores and reaction times measures. This pattern did not appear in the TE group; instead, divergent and a few weak relationships emerged. These relationships involved correlations between the KSP monotony avoidance score and some motor speed scores. By dividing the referent group into low anxiety and high anxiety subgroups on the basis of the multi-component anxiety scale score, it was shown that the test scores in the high anxiety subgroup mostly were indistinguishable from the scores in the TE group. In contrast, the low anxiety group had higher test scores than the TE group in 8 of the 13 tests. In conclusion, the expected relationship between anxiety and cognitive vigilance is absent in TE cases. This indicates that the neuropsychological performance decrement in TE cases is not primarily related to elevated mental distress, but is probably dominated by the effects of organic brain impairment. Thus, in TE cases low neuropsychological test scores should not be regarded as a consequence of emotional symptoms. Furthermore, personality traits may be considered as potential confounders even if traditional matching by demographic criteria has been successfully implemented.