Očuvanje udova i preživljenje dijabetičnih bolesnika s ishemijom donjih udova

We retrospectively analyzed the results of treatment of lower limb ischemia in 63 diabetic patients (27 female and 36 male, mean age 73.5 years) who were identified in a group of 138 randomly selected patients among those who had undergone lower limb arteriography during hospitalization at the Department of Vascular Medicine, Department of Radiology, Clinical Centre Ljubljana, in the year 1998. The reason for lower limb arteriography was claudication in 18 (29%), chronic critical ischemia in 42 (66%), and acute ischemia in three (5%) patients. After arteriography, the procedure of a revascularization was performed in 32 (51%) patients, among whom three patients with acute ischemia had successful embolectomy, 24 were treated endovascularly, and five patients surgically. Thirty (47%) patients were treated conservatively, and one patient with primary amputation. The patient status was reassessed after an average of 24 months, range 19 to 33 months. Among the 18 patients with claudication, two patients died, one from stroke and the other due to worsening of chronic obstructive pulmonary disease with respiratory failure, however, all patients retained their limb during the survival or follow-up, 15 after revascularization procedure and 18 with conservative treatment. Nine (21%) patients had amputation, four below and five above the knee. One amputation was primary, 2 amputations followed endovascular treatment, and 6 were performed after conservative treatment. During the follow-up period, 13 (31%) patients with chronic critical ischemia died, five from stroke, three from acute myocardial infarction, and five due to unknown causes. Our results have confirmed that lower limb ischemia can be treated relatively successfully in diabetic patients, but that mortality remains high, especially in patients with chronic critical ischemia.Retrospektivno smo analizirali rezultate liječenja ishemije donjih udova u 63 bolesnika sa šećernom bolešću (27 žena i 36muškaraca, prosječne dobi 73,5 god.) izdvojenih iz skupine od 138 slučajno odabranih bolesnika me.u onima kojima je tijekom 1998. god. za vrijeme hospitalizacije na Odjelu vaskularne medicine Odjela za radiologiju Kliničkog centra u Ljubljani učinjena arteriografija donjih udova. Razlozi za arteriografiju donjih udova bili su: klaudikacija u 18 (29%), kronična kritična ishemija u 42 (66%) i akutna ishemija u 3 (5%) bolesnika. Poslije arteriografije, postupak revaskularizacije proveden je u 32 (51%) bolesnika, od kojih je u troje bolesnika s akutnom ishemijom uspješno provedena embolektomija, 24 bolesnika liječeno je endovaskularno, a 5 bolesnika liječeno je kirurški. Tridesetoro (47%) bolesnika liječeno je konzervativno, a u jednoga je učinjena primarna amputacija. Status bolesnika ponovno je ocijenjen u prosjeku nakon 24 mjeseca (raspon 19-33 mjeseca). Od 18 bolesnika s klaudikacijom dvoje je umrlo, jedan zbog moždanog udara, a drugi zbog pogoršanja kronične opstrukcijske plućne bolesti sa zatajenjem respiracije. U svih su bolesnika u razdoblju preživljenja ili tijekom praćenja udovi bili očuvani, u 15 nakon postupka revaskularizacije, a u 18 uz konzervativno liječenje. U 9 (21%) bolesnika učinjena je amputacija (u 4 bolesnika ispod koljena, a u 5 iznad koljena). Jedna je amputacija bila primarna, 2 su uslijedile poslije endovaskularnog liječenja, a 6 poslije konzervativne terapije. Tijekom razdoblja praćenja umrlo je 13 (31%) bolesnika s kroničnom kritičnom ishemijom (5 zbog moždanog udara, 3 zbog akutnog infarkta miokarda, a 5 zbog nepoznatih uzroka). Naši rezultati potvrđuju da se ishemija donjih udova u bolesnika sa šećernom bolešću može liječiti razmjerno uspješno, no smrtnost je i dalje visoka, poglavito među bolesnicima s kroničnom kritičnom ishemijom

Is Restenosis/Reocclusion after Femoropopliteal Percutaneous Transluminal Angioplasty (PTA) the Consequence of Reduced Blood Flow, Inflammation, and/or Hemostasis Disturbances?

Percutaneous transluminal angioplasty (PTA) is an established method for treatment of peripheral artery disease (PAD) of the femoropopliteal artery. However, in up to 50% of patients restenosis and/or reocclusion remain a frequent complication occurring in the first year after the procedure. In this study, we focused on the influence of compromised postprocedural infrapopliteal runoff of the affected limb, on the hypercoagulability as detected by a global hemostasis assay and on genetic predisposition to hypercoagulability and on the regulation of the inflammation through the nuclear receptor related 1 protein (NuRR1). Consecutive PAD patients treated by femoropopliteal PTA because of disabling claudication or critical limb ischemia were followed up by vascular ultrasound imaging at 1, 6, and 12 months after the procedure. Venous blood samples for hemostasis, inflammation, and gene analysis were obtained before and 24 h after PTA. One month after femoropopliteal PTA, 23% of patients with compromised runoff developed the combined end point restenosis/reocclusion in comparison to 11% with good runoff (p = 0.03). After 6 months, the differences were no longer significant. It was concluded that compromised postprocedural infrapopliteal runoff predisposes to early restenosis/reocclusion after femoropopliteal PTA and that the deterioration of infrapopliteal runoff in the year after femoropopliteal PTA is accompanied by worsening of long-term femoropopliteal patency. Patients were genotyped for the prothrombotic gene polymorphisms: platelet receptor glycoprotein IIIa T1565C, coagulation factor V G1691A, coagulation factor II G20210A, coagulation factor XII C(-4)T, and plasminogen activator inhibitor-1 4G5G. We were not able to show any association between these polymorphisms and the restenosis/reocclusion rate in patients treated with femoropopliteal PTA. Furthermore, no association between thrombin generation and restenosis/reocclusion rate was established. NuRR1 haplotypes significantly increased the restenosis/reocclusion rate after PTA (adjusted relative risks were 1.6, 95% CI 1.1–2.3 for haplotype 2 and 2.0, 95% CI 1.3–2.8 for haplotype 3). To conclude, this study suggested a significantly higher restenosis/reocclusion rate in patients with compromised runoff compared to patients with a good runoff 1 month after the procedure. Hypercoagulability was not associated with the restenosis/reocclusion rate, and the prothrombotic polymorphisms were equally distributed among patient with and without restenosis/reocclusion, suggesting minor or no role in restenosis/reocclusion. Haplotypes 2 and 3 in the NuRR1 gene significantly increased the restenosis/reocclusion rate, suggesting significant role of inflammation. In this ongoing study, further analysis on a larger group of patients is warranted

Airborne spread of SARS-CoV-2 – a commentary by the Division of Internal Medicine, University Medical Centre Ljubljana

Slovenia is one of the countries that have been most affected by the autumn/winter 2020/21 wave of the COVID-19 pandemic regarding the incidence and excess mortality among the general population as well as regarding the incidence among health care workers and nursing personnel. The World Health Organization has underestimated the importance of the airborne spread of SARS-CoV-2 and the recommended safety measures have not been entirely sufficient. When people breathe, talk, sing, cough, or sneeze, they emit respiratory droplets of various sizes, most of which are always smaller than 1 μm. Respiratory droplets smaller than 5 μm stay airborne in indoor spaces for a long time and travel over distances much longer than 2 m. Thus, an infected person in an indoor environment creates an infectious aerosol that may infect other people without close interpersonal contact. This short review presents the mathematical model and internet application by authors from the Massachusetts Institute of Technology for calculating the safe time before probable airborne infection occurs in indoor spaces. The importance of ventilation, air filtration, air humidity, and air disinfection by ultraviolet light is briefly discussed. The principles of preventing the airborne spread of SARS-CoV-2 are summarized

Microscopic clot fragment evidence of biochemo-mechanical degradation effects

Introduction: Although fibrinolytic treatment has been used for decades, the interactions between the biochemical mechanisms and the mechanical forces of the streaming blood remain incompletely understood. Analysis of the blood clot surface in vitro was employed to study the concomitant effect of blood plasma flow and recombinant tissue plasminogen activator (rt-PA) on the degradation of retracted, non-occlusive blood clots. Our hypothesis was that a faster tangential plasma flow removed larger fragments and resulted in faster overall thrombolysis. Materials and Methods: Retracted model blood clots were prepared in an optical microscopy chamber and connected to an artificial perfusion system with either no-flow, or plasma flow with a velocity of 3 cm/s or 30 cm/s with or without added rt-PA at 2 µg/ml. The clot surface was dynamically imaged by an optical microscope for 30 min with 15 s intervals. Results: The clot fragments removed during rt-PA mediated thrombolysis ranged in size from that of a single red blood cell to large agglomerates composed of more than a thousand red blood cells bound together by partly degraded fibrin. The average and the largest discrete clot area change between images in adjacent time frames were significantly higher with the faster flow than with the slow flow (14,000 μm 2 and 160,000 μm 2 vs. 2200 μm 2 and 10,600 μm 2 ). Conclusions: On the micrometer scale, thrombolysis consists of sequential removal of clot fragments from the clot surface. With increasing tangential plasma flow velocity, the size of the clot fragments and the overall rate of thrombolysis increases

Effectiveness and safety of anticoagulant versus antiplatelet therapy in patients after endovascular revascularisation of the lower limb

Background: After revascularisation, patients with peripheral arterial disease (PAD) are routinely prescribed antiplatelet treatment (APT). Patients who receive anticoagulant treatment (ACT) due to comorbidity are an exception. We set out to determine possible differences in the effectiveness and safety between ACT and APT in patients after endovascular revascularisation of the lower limb arteries. Methods: In a single-centre retrospective cohort study, we analysed the data of 1,587 PAD patients who underwent successful endovascular revascularisation of the lower limb arteries due to disabling intermittent claudication or chronic critical limb ischemia over a 5-year period. Patients were divided into the ACT and APT groups based on their prescribed treatment. After balancing both groups’ baseline characteristics with propensity score matching, we compared the effectiveness and safety of both treatment regimens in the first year after revascularisation. Results: Compared to patients with APT, patients with ACT were older, and more often reported arterial hypertension, diabetes, chronic kidney disease, congestive heart failure, ischaemic heart disease, and prior stroke or transient ischaemic attack. After matching, the odds ratio (OR) for an effective outcome with ACT versus APT was 0.78 (95% CI 0.39–1.59; p=0.502), while the OR for a safe outcome with ACT versus APT was 4.12 (95% CI 0.82–20.73; p=0.085). Conclusions: Patients who required ACT were elderly, had more cardiovascular risk factors and had more advanced PAD than patients with APT. After matching, we found no statistically significant difference in the effectiveness and safety of both treatment regimens; however the wide OR confidence intervals warrant further research

Practical Recommendations for Optimal Thromboprophylaxis in Patients with COVID-19: A Consensus Statement Based on Available Clinical Trials.

Coronavirus disease 2019 (COVID-19) has been shown to be strongly associated with increased risk for venous thromboembolism events (VTE) mainly in the inpatient but also in the outpatient setting. Pharmacologic thromboprophylaxis has been shown to offer significant benefits in terms of reducing not only VTE events but also mortality, especially in acutely ill patients with COVID-19. Although the main source of evidence is derived from observational studies with several limitations, thromboprophylaxis is currently recommended for all hospitalized patients with acceptable bleeding risk by all national and international guidelines. Recently, high quality data from randomized controlled trials (RCTs) further support the role of thromboprophylaxis and provide insights into the optimal thromboprophylaxis strategy. The aim of this statement is to systematically review all the available evidence derived from RCTs regarding thromboprophylaxis strategies in patients with COVID-19 in different settings (either inpatient or outpatient) and provide evidence-based guidance to practical questions in everyday clinical practice. Clinical questions accompanied by practical recommendations are provided based on data derived from 20 RCTs that were identified and included in the present study. Overall, the main conclusions are: (i) thromboprophylaxis should be administered in all hospitalized patients with COVID-19, (ii) an optimal dose of inpatient thromboprophylaxis is dependent upon the severity of COVID-19, (iii) thromboprophylaxis should be administered on an individualized basis in post-discharge patients with COVID-19 with high thrombotic risk, and (iv) thromboprophylaxis should not be routinely administered in outpatients. Changes regarding the dominant SARS-CoV-2 variants, the wide immunization status (increasing rates of vaccination and reinfections), and the availability of antiviral therapies and monoclonal antibodies might affect the characteristics of patients with COVID-19; thus, future studies will inform us about the thrombotic risk and the optimal therapeutic strategies for these patients

Perioperative Prevention of Venous Thromboembolism in Abdominal Surgery Patients Based on the Caprini or the Padua Risk Score—A Single Centre Prospective Observational Study

Surgical patients should receive perioperative thromboprophylaxis based on risk assessment, and the Caprini score is validated for this purpose. Whether the Padua score, originally devised for medical patients, can be useful in surgical patients remains to be fully clarified. This study aimed to evaluate perioperative thromboprophylaxis based on the Caprini or the Padua score in elective abdominal surgery. A total of 223 patients undergoing elective abdominal surgery for malignant or benign disease were prospectively evaluated. The patients were divided into two groups in which thromboprophylaxis was prescribed according to either the Caprini score (n = 122) or the Padua score (n = 101). Patients with high-risk scores in both groups received nadroparin. The alternate risk score in each group was calculated for evaluation purposes only. During a 3-month follow-up, we assessed patients for symptomatic venous thromboembolism (VTE), bleeding, or mortality. In the Caprini score group, 87 patients (71%) had a high risk for VTE (≥5 points), while 38 patients (38%) had a high risk for VTE (≥4 points) in the Padua score group; p < 0.00001. The overall correlation between the Caprini and Padua scores was moderate (r= 0.619), with 85 patients having high Caprini and discordant Padua scores. Ten patients died during follow-up (4.5%), and five developed non-fatal symptomatic VTE (2.2%). Among the five major bleeding incidents recorded (1.8%), two cases were possibly associated with pharmacological thromboprophylaxis. The incidence of adverse outcomes did not differ between the two groups. The odds ratio for adverse outcomes was significantly higher with a high Caprini or Padua risk score, malignant disease, age ≥65 years, and active smoking. We found no significant differences in adverse outcomes between abdominal surgical patients who received perioperative thromboprophylaxis based on either the Caprini or the Padua risk score. However, a discordant Padua score was noted in almost 40% of patients who had a high Caprini score, suggesting that the latter may be more sensitive than the Padua score in surgical patients

Razširjenost Covid-19 med zdravstvenim osebjem Univerzitetnega kliničnega centra Ljubljana do zaključka leta 2020 in koncentracija CO₂ v zraku bolniških sob, prezračevanih skozi okna, v letu 2021/22

In autumn and winter 2020/21 and again in 2021/22 Slovenia has ranked among countries with the highest incidence of COVID-19 per million inhabitants and high excess mortality over the average of previous years. Many patients on non-COVID-19 hospital wards were in fact infected by SARS-CoV-2. Health care personnel at the University Medical Centre Ljubljana (UMCL) were falling ill by Covid-19 in large numbers despite wearing surgical masks and eye protection when dealing with patients. We compared the prevalence of COVID-19 among health care personnel of the Division of Internal Medicine, UMCL by the end of December 2020 with the national average of Slovenia. After instructions had been issued to increase room ventilation by opening windows every hour for at least 10 minutes, ambient air CO₂ was measured in an intensive care room and in an outpatient clinic room during a 10-month period, from April 2021 to February 2022. The prevalence of COVID-19 by the end of December 2020 was 42 % among nurses, 21 % among registered nurses and 17 % among medical doctors, whereas the national of average of the population was significantly lower at 5.5 %. Between April 2021 and February 2022, the average CO₂ (ppm) in the intensive care was 633 (standard deviation 198, range 376 – 1540), while in the outpatient clinic the average was 552 (standard deviation 199, range 380 - 1910). During 2020, before the instructions for the use of personal protective equipment were up-graded and before regular window-opening was advised, the prevalence of Covid-19 among health care personnel at the Division of Internal medicine, UMCL exceeded the national average by 3- to 8-fold. After regular window-opening was advised, the peak CO₂ levels still often exceeded the recommended “safe” level of 750 ppm