Diabetes Care for Patients with Peripheral Arterial Disease

The number of diabetics will increase almost 70% in developed countries during the next 20 years: peripheral arterial disease is a common and costly complication. The incidence of cardiovascular disease (mortality and morbidity) due to atherosclerosis, is higher among patients with diabetes than in those without diabetes. Intensive management of diabetes, including glycaemic control, treatment of hypertension and dyslipidemia, as well as nonpharmacological interventions, decreases both micro- and macrovascular complications. Aspirin and clopidogrel have less antiplatelet effect in patients with diabetes. Metformin therapy is considered a risk factor for lactic acidosis if not withdrawn 2 days before angiography, but this risk is extremely low in patients with normal renal function. Peri-operative hyperglycaemia and large fluctuations in plasma glucose increase postoperative mortality and morbidity and careful measures are required to minimise these effects

Response to Dr Herbert Dardik

Farrando Sicilia, Jordi; Lecea, Ignasi de; Fuente Fuente, Carlos; Ribas Seix, Anna; Masana Padrós, Judit; Delgado, José L

Outcome of unreconstructed chronic critical leg ischaemia

Objective:To assess the outcome of unreconstructed chronic critical leg ischaemia with a special reference to the definition of CLI.Design and Setting:A retrospective study with 1 year follow-up in an academic referral centre (Fourth Department of Surgery, Helsinki University Central Hospital).Material:105 consecutive unreconstructed patients with 136 critically ischaemic legs as defined by the European Consensus Document on Chronic Critical Leg Ischaemia.Main outcome measures:Major amputations and mortality.Results:81% of the 136 critically ischaemic legs survived 1 month, 70% three months and 54% one year. Of the 105 patients 93%, 77% and 46% were alive at 1, 3 and 12 months, respectively, whereas survival of patients with nonamputated leg was only 71%, 56% and 28%. Patients with bilateral CLI had a worse prognosis in terms of survival and leg salvage. The leg outcome was not worsened by the presence of diabetes nor by the distal extent of arterial changes.Conclusion:Although the selection of the present material is likely to cause some bias, unreconstructed CLI seemed to predict a very poor outcome in terms of survival and limb salvage

Deep infection of infrapopliteal autogenous vein grafts—Immediate use of muscle flaps in leg salvage

AbstractPurpose: The purpose of this study was to determine the efficacy of an aggressive management of infrapopliteal autogenous vein graft infection. Methods: Among 341 consecutive infrapopliteal autogenous vein bypass grafts performed at the Helsinki University Central Hospital, 14 patients (4%) had infragenicular wound infection that involved the vein graft. Six of these patients had graft rupture and bleeding. An extensive débridement was performed in all patients. Seven of the grafts had to be partially removed and replaced. The wound and the graft immediately were covered with local muscle flaps in 4 patients and with free muscle flaps in 10 patients. Results: One patient died, and another patient underwent above-knee amputation as a result of a persistent infection and necrosis of the local muscle flap during the 30-day postoperative period. No graft rupture occurred after the treatment of the infected conduit. Graft occlusion occurred in 4 patients who underwent regrafting because of graft rupture and in 1 patient with an infected intact conduit. One patient underwent amputation 15 months later because of an uncontrollable infection despite a patent graft and a functioning flap. At the 1-month, 6-month, 1-year, and 2-year follow-up periods, the leg salvage rates were 92%, 75%, 55%, and 44%, respectively. At the same intervals, 92%, 92%, 70%, and 70% of the patients survived and 85%, 68%, 34%, and 34% of the patients were alive without the loss of their legs. Conclusion: Radical surgical débridement and immediate muscle flap coverage seem to offer an effective alternative method to preserve an infected infrapopliteal autogenous vein graft and to achieve leg salvage. Poor results are expected when a regrafting procedure is necessary for the rupture of an infected vein graft. (J Vasc Surg 1998;28:611-6.

Antikoagulaatiohoidon seuranta ja verenvuotokomplikaatiot

Antikoagulaatiohoitoa saavat potilaat tarvitsevat seurantaa 1–4 kertaa vuodessa. Seurannassa tarkastellaan riskitekijöitä ja optimoidaan hoidon turvallisuus. Vuototilanteessa kartoitetaan vuodon sijainti sekä riskiä lisäävät lääkitykset ja sairaudet.Vuoto hoidetaan paikallisesti. Merkittävässä vuodossa annetaan tukihoitoa (verensiirto, traneksaamihappo). Antikoagulaatiohoito tauotetaan tai kumotaan

Verihiutaleiden estolääkityksen tehon yksilöllinen vaihtelu : aspiriini ja klopidogreeli

Antiplatelet medication is known to decrease adverse effects in patients with atherothrombotic disease. However, despite ongoing antiplatelet medication considerable number of patients suffer from atherothrombotic events. The aims of the study were 1) to evaluate the individual variability in platelet functions and compare the usability of different methods in detecting it, 2) to assess variability in efficacy of antiplatelet medication with aspirin (acetylsalicylic acid) or the combination of aspirin and clopidogrel and 3) to investigate the main genetic and clinical variables as well as potential underlying mechanisms of variability in efficacy of antiplatelet medication. In comparisons of different platelet function tests in 19 healthy individuals PFA-100® correlated with traditional methods of measuring platelet function and was thus considered appropriate for testing individual variability in platelet activity. Efficacy of ongoing 100mg aspirin daily was studied in 101 patients with coronary artery disease (CAD). Aspirin response was measured with arachidonic acid (AA)-induced platelet aggregation, which reflects cyclo-oxygenase (COX)-1 dependent thromboxane (Tx) A2 formation, and PFA-100®, which evaluates platelet activation under high shear stress in the presence of collagen and epinephrine. Five percent of patients failed to show inhibition of AA-aggregation and 21% of patients had normal PFA-100® results despite aspirin and were thus considered non-responders to aspirin. Interestingly, the two methods of assessing aspirin efficacy, platelet aggregation and PFA-100®, detected different populations as being aspirin non-responders. It could be postulated that PFA-100® actually measures enhanced platelet function, which is not directly associated with TxA2 inhibition exerted by aspirin. Clopidogrel efficacy was assessed in 50 patients who received a 300mg loading dose of clopidogrel 2.5 h prior to percutaneous coronary intervention (PCI) and in 51 patients who were given a loading dose of 300mg combined with a five day treatment of 75mg clopidogrel daily mimicking ongoing treatment. Clopidogrel response was assessed with ADP-induced aggregations, due to its mechanism of action as an inhibitor of ADP-induced activation. When patients received only a loading dose of clopidogrel prior to PCI, 40% did not gain measurable inhibition of their ADP-induced platelet activity (inhibition of 10% or less). Prolongation of treatment so that all patients had reached a plateau of inhibition exerted by clopidogrel, decreased the incidence of non-responders to 20%. Polymorphisms of COX-1 and GP VI, as well as diabetes and female gender, were associated with decreased in vitro aspirin efficacy. Diabetes also impaired the in vitro efficacy of short-term clopidogrel. Decreased response to clopidogrel was associated with limited inhibition by ARMX, an antagonist of P2Y12-receptor, suggesting the reason for clopidogrel resistance to be receptor-dependent. Conclusions: Considerable numbers of CAD patients were non-responders either to aspirin, clopidogrel or both. In the future, platelet function tests may be helpful to individually select effective and safe antiplatelet medication for these patients.Sydän- ja verisuonisairaudet ovat yleisin kuolinsyy länsimaissa. Niiden nykyinen lääkehoito perustuu sairauden eri riskitekijöiden, kuten korkean kolesterolin, kohonneen verenpaineen ja liiallisen verihiutaleiden aktiivisuuden laskemiseen. Verihiutaleiden normaalina tehtävänä on osallistua veren hyytymiseen paikkaamalla verisuonen seinämän vauriokohta, oli vaurio sitten ulkoisen vamman tai valtimonkovettuman aiheuttama. Sydän- ja verisuonitaudeissa verihiutaleiden aktiivisuus on lisääntynyt. Verihiutaleilla on keskeinen rooli äkillisen verisuonitukoksen aiheuttajina, silla ne aloittavat veritulpan muodostumistapahtuman valtimonkovettumataudin vaurioittamassa suonenseinässä. Tällöin verihiutaleet yhdessä muiden hyytymistekijöiden kanssa saattavat tukkia koko suonen, aiheuttaen tukoksen sijainnista riippuen esimerkiksi sydäninfarktin, aivohalvauksen tai alaraajojen vakavan hapenpuutteen. Suomessa pitkäaikaisessa hoidossa käytettävät verihiutaleiden estolääkkeet ovat asetyylisalisyylihappo l. aspiriini (ASA), dipyridamoli sekä uusimpana klopidogreeli. Näiden lääkkeiden käytöstä huolimatta osalle potilaista tulee äkillisiä verisuonitapahtumia ja verihiutaleiden estolääkityksen tehostamisen on ajateltu vähentävän näitä tapahtumia. Tässä väitöskirjatyössä tutkittiin yksilöiden vasteita verihiutaleiden estolääkitykselle ja arvioitiin eri menetelmiä niiden tehon mittaamiseksi. Työssä arvioitiin yleisimmin käytetyn aspiriinin ja uusimman estolääkkeen, klopidogreelin, tehoa sepelvaltimotautipotilailla. Tutkimuksessa todettiin, että kun verihiutaleiden aktiivisuutta mitattiin verihiutaleiden toimintatesteillä, kaikki potilaat eivät hyötyneet verihiutaleiden estolääkityksestä odotetusti. Osalla potilaista verihiutaleiden toiminta ei toivotusti vähentynyt aspiriinilla, klopidogreelilla tai niiden yhdistelmällä. Tietyt verihiutale-reseptorien genotyypit ja diabetes vaikuttivat estolääkityksen tehoon. Estolääkitykseen huonosti reagoivien potilaiden kohdalla tehostetusta lääkityksestä saattaa olla hyötyä. Koska tehostettuun verihiutaleiden estolääkitykseen voi liittyä myös suurentunut verenvuodon riski, tulisi tulevaisuudessa potilaille määritellä yksilöllinen estolääkitys verihiutaleiden toimintatestejä hyödyntäen. Toistaiseksi luotettavia testejä ei ole vielä käytettävissä ja sellaisten kehittäminen on tulevaisuuden haaste

Comparing modular and personal service delivery in specialised outpatient care : A survey of haematology and oncology patient preferences

Background Oncology and haematology are shifting from inpatient to outpatient care, requiring new care delivery models. This study compares preferences of oncology patients treated by named nurses in a traditional specialty-focused day hospital and haematology patients treated without named nurses in a modularised day hospital. Methods Questionnaires to explore patient preferences on number of treating nurses and named nurses, and satisfaction in day hospital care were distributed to 300 haematology and 410 oncology patients. Binomial logistic regressions were performed to study how background variables influenced preferences for having (i) a named nurse or (ii) maximum three treating nurses in the day hospital. Results In 2016, 156 (52%) haematology and 289 (70%) oncology surveys were completed and returned. Both groups were satisfied with day hospital care. Haematology patients preferred named nurses less often than oncology patients (odds ratio (OR) = 0.09, p <0.0005). Haematology patients were less likely to prefer a maximum of three treating nurses (OR = 0.12, p <0.0005). Conclusion This study suggests that patients can be satisfied with outpatient care with or without named nurses. However, as several factors affect patient satisfaction and experience, more in-depth research is needed to understand how modularisation and patient preferences may be linked.Peer reviewe

Terveyskeskuslääkärien työhön sitoutuminen ja työstälähtöaikeet sekä niihin yhteydessä olevat työn psykososiaaliset riskitekijät

Terveyskeskuslääkärien työhön ja työhyvinvointiin on kiinnitetty entistä enemmän huomiota terveyskeskuksien pahenevan lääkärivajeen vuoksi. Tämän tutkimuksen tarkoituksena oli arvioida lääkärien työhön sitoutumiseen ja työpaikan vaihtoaikeisiin yhteydessä olevia lääkärin työn riskitekijöitä sekä psykososiaalisia tekijöitä. Aineistona oli 585 Lääkärien työolot ja terveys 2006-kyselyyn vastannutta terveyskeskuslääkäriä. Terveyskeskuslääkärien työstälähtöaikeisiin olivat yhteydessä heikentynyt työtyytyväisyys ja epäoikeudenmukaisuuden kokemukset, jotka molemmat keskeisimmin yhdistyivät ryhmätyö- ja ihmissuhdeongelmiin. Työtyytyväisyyteen olivat yhteydessä myös työn yksinäisyys ja konsultaatiomahdollisuuksien heikkoudet sekä lääkärien kokema kiire ja resurssipula. Lääkärit, joiden työtyytyväisyys oli heikentynyt tai jotka kokivat ryhmätyö- ja ihmissuhdeongelmia, olivat muita huonommin sitoutuneita organisaatioonsa. Työvoimapulan tilanteessa lääkärien työstälähtöaikeisiin voitaneen vaikuttaa puuttumalla työtyytyväisyyteen ja oikeudenmukaisuuden kokemuksiin keskeisesti liittyviin tekijöihin

PTFE Bypass or Thrupass for Superficial Femoral Artery Occlusion? A Randomised Controlled Trial

AbstractEarly results of a thrupass endograft in the treatment of femoral lesions are promising. Less morbidity and better cost-effectiveness are suggested to be achieved in the treatment of chronic lower limb ischaemia with endovascular treatment compared to surgical treatment.Patients and methodsThis randomised multicentre trial aimed to enroll a group of 60+60 patients for the treatment of 5–25-cm occlusions of superficial femoral artery (SFA) to be followed up for 3 years. Patients were treated either with endoluminal PTFE thrupass (WL Gore & Ass) or with surgical polytetrafluoroethylene (PTFE) bypass to proximal popliteal artery. Primary patency at 3 years was scheduled to be the primary end-point and secondary patency, functional success, costs and quality of life the secondary end-points.ResultsA sample of 100 consecutive SFA occlusions in one of the centres revealed that only 4% of the lesions were amenable for the study. The trial was prematurely terminated due to the results of an interim analysis at the time when 44 patients were recruited: the 1-year primary patency (excluding technical failures) was 48% for thrupass and 95% for bypass (p=0.02). The patency difference in favour of surgical bypass over endovascular thrupass was also sustained after completion of 1-year follow-up, the primary patencies being 46% and 84% at 1 year with grossly equilinear life-table curves thereafter (p=0.18), respectively. The corresponding secondary patencies were 63% and 100% (p=0.05) when excluding technical failures and 58% and 100% (p=0.02) according to intention-to-treat analysis. Secondary outcomes were thus not analysed.ConclusionTreatment of SFA occlusions (TASC IIB and C or Imelda Ia and II) should be done by PTFE bypass rather than by PTFE thrupass, as thrupass is connected with worse early outcome. These results represent only a small category of femoral disease