Vascular Dysfunction in Stroke and CADASIL

Cerebrovascular disease (CVD) is strongly linked to hypertension and generally occurs later in life than coronary artery disease (CAD). Three quarters of the patients with symptomatic CVD are above 65 years of age. The risk factors are the same for CVD and CAD, but the relative importance of the vascular risk factors differs greatly. Genetic causes of stroke are relatively rare. Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL) is a hereditary disease which causes CVD in young adults and middle-aged people, with migraine, stroke, psychiatric illness and dementia as clinical manifestations. The subject of this thesis is vascular function in stroke and CADASIL. Endothelium-dependent vasodilation (EDV) and arterial stiffness were investigated by different methods in stroke patients and CADASIL patients compared with healthy controls. Venous occlusion plethysmography with intra-arterial acetylcholine was used to evaluate EDV in the forearm resistance vessels. Flow-mediated vasodilation of the brachial artery was used to evaluate EDV in a conduit artery. Stroke patients displayed reduced EDV in resistance vessels compared with a healthy control group, but this reduction was not significant when, in a larger group of stroke patients, adjustments were made for blood pressure, antihypertensive treatment and other risk factors. Flow mediated vasodilation of the brachial artery was reduced in the stroke patients even after adjustment for risk factors. Compared with controls, the CADASIL patients showed similar EDV in the conduit artery, but reduced EDV in resistance vessels. Arterial compliance was evaluated by augmentation index from pulse wave analysis, by a ratio of cardiac stroke volume and pulse pressure, and by the distensibility of the carotid artery in relation to pulse pressure. Stroke patients and CADASIL patients did not display any significant increase in arterial stiffness when evaluated by these methods

Living with HIV : patients’ experience of encounter by health care providers

BAKGRUND: HIV (humant immunbristvirus) är en smittsam blodsjukdom vilket finns över stora delar av världen. Stigmatiseringen i samhället kring HIV är utbrett och kan därmed komma att påverka patientens vård. Från vårdpersonalens sida finns det både negativa och positiva attityder kring människor vilka lever med HIV. Det är viktigt att belysa problemet för att alla patienter ska få en likvärdig vård. SYFTE: Studiens syfte är att beskriva hur människor vilka är HIV-positiva upplever bemötandet från vårdpersonal. METOD: En litteraturbaserad studie där analys har gjorts av nio kvalitativa vetenskapliga artiklar. RESULTAT: Tre teman har tagits fram: Att bli bemött som en människa, att bli bemött på ett nytt sätt och att bli diskriminerad. Ett positivt bemötande från vårdpersonalen upplevs då det finns en känsla av delaktighet. Ett negativt bemötande kan upplevas genom att vårdpersonal till exempel använder överdrivna försiktighetsåtgärder, är avståndstagande och vägrar att vårda. KONKLUSION: Ökad kunskap hos vårdpersonal skapar en ökad förståelse för sjukdomen och dess smittspridning vilket leder till att rädslor minskar och vårdpersonalens bemötande förbättras.BACKGROUND: HIV (Human Immunodeficiency Virus) is an infectious blood disease found in large parts of the world. The stigma associated with HIV is widely spread in society and can therefore impact the efficacy of the patients’ treatment. Health care providers exhibit both positive and negative attitudes towards people living with HIV. It is important to highlight the problem in order for all patients to receive an equal treatment. AIM: The aim of this study is to describe how HIV-positive individuals experience the encounter with the health care providers. METHOD: A literature based study with analysis of nine qualitative scientific articles. RESULTS: Three themes have been researched: Being met as a human being, being met in a new way and being discriminated. A positive response from health care providers is perceived when there is a sense of participation. A negative response can be perceived for example when the health care provider uses excessive precautions, when they are distancing themselves or when the health care provider refuses to give treatment. CONCLUSIONS: Increased knowledge of health care providers creates a better understanding of HIV disease and its spread, leading to reduced fears and an improvement in the treatment offered by the health care providers

Celiprolol Treatment in Patients with Vascular Ehlers-Danlos Synurome

Objecti_ Vascular Ehlers-Danlos syndrome (vEDS) is a rare monogenetic disease caused by pathogenic variants in procollagen 3A1. Arterial rupture is the most serious clinical manifestation. A randomised controlled trial, the Beta-Blockers in Ehlers-Danlos Syndrome Treatment (BBEST) trial, reported a significant protective effect of the beta blocker celiprolol. The aim was to study the outcome of celiprolol treatment in a cohort of Swedish patients with vEDS. Methods: Uppsala is a national referral centre for patients with vEDS. They are assessed by vascular surgeons, angiologists, and clinical geneticists. Family history, previous and future clinical events, medication, and side effects are registered. Celiprolol was administered twice daily and titrated up to a maximum dose of 400 mg daily. Logistic regression was used to analyse predictors of vascular events. Results: Forty patients with pathogenic sequence variants in COL3A1 were offered treatment with celiprolol in the period 2011-2019. The median follow up was 22 months (range 1-98 months); total follow up was 106 patient years. In two patients, uptitration of the dose is ongoing. Of the remaining 38, 26 (65%) patients reached the target dose of 400 mg daily. Dose uptitration was unsuccessful in six patients because of side effects; one died before reaching the maximum dose, and five terminated the treatment. Five major vascular events occurred; four were fatal (ruptured ascending aorta; aortic rupture after type B dissection; ruptured cerebral aneurysm; and ruptured pulmonary artery). One bled from a branch of the internal iliac artery, which was successfully coiled endovascularly. The annual risk of a major vascular event was 4.7% (n = 5/106), similar to the treatment arm of the BBEST trial (5%) and lower than in the control arm of the same trial (12%). No significant predictor of vascular events was identified. Conclusion: Treatment with celiprolol is tolerated in most patients with vEDS. Despite fatal vascular events, these observations suggest that celiprolol may have a protective effect in vEDS

Results of renal artery revascularization in the post-ASTRAL era with 4 years mean follow-up

Purpose: To investigate contemporary results of percutaneous transluminal renal angioplasty (PTRA). Materials and Methods: A multicentre retrospective study analysing all patients treated with PTRA for primary symptomatic renal artery stenosis (RAS) between 2010 and 2013 at four tertiary centres. Procedures during the preceding four years were counted to evaluate for change in PTRA frequency. Results: The number of PTRA procedures decreased by approximately 50% from 2006 to 2013. Patients treated in the post-ASTRAL period (n = 224) had a significant reduction in mean systolic pressure (168 to 146 mmHg, p < 0.01), diastolic pressure (84 to 76 mmHg, p < 0.01), number of anti-hypertensive drugs (3.54 to 3.05, p < 0.01), and anti-hypertensive treatment index (21.75 to 16.92, p < 0.01) compared to before PTRA. These improvements were maintained at one year and at the last clinical evaluation after a mean follow-up of 4.31 years. Renal function increased transiently without sustained improvement, or deterioration, during later follow-up. Thirteen patients (5.8%) eventually required dialysis, nine of these had eGFR <20 ml/min/1.73 m2 before PTRA. There was no difference in outcomes between subgroups differentiated by different indications for PTRA. Conclusion: The frequency of PTRA has decreased, indicating a higher threshold for invasive treatment of RAS in recent years. The reduction in blood pressures, the reduced need for anti-hypertensive medication, and stabilization of renal function over time suggest a clinical benefit for most patients who are now being treated with PTRA