Diagnosis, treatment and evaluation of chronic venous disease

BACKGROUND AND AIMS: Varicose veins (VVs) are the most common manifestation of chronic venous disease (CVD) in the Western hemisphere. Recent research shows that the disease encompasses the global population and with similar prevalence. The most severe form of CVD is venous ulceration with a prevalence of about 1% that does not only cause great suffering but is also costly for the society. The aims of this thesis were to investigate ways in improving prioritization, diagnosis, and surgical treatment of patients with VV that have the potential risk of developing VU. METHODS: Cross-sectional (Studies I, III and IV) and follow-up (Study II) studies were carried out. Study I investigated the inter-observer reproducibility of the clinical class of CEAP and whether there was a medical indication for treatment. Seventy-eight patients (106 limbs) with varying degree of CVD were included. Three independent physicians assessed the patients. In study II, we assessed the ulcer recurrence rate in patients with healed or active venous ulcer (VU) that were treated with endovenous laser ablation (EVLA) for superficial venous incompetence. One hundred and seventy patients (195 limbs) of consecutively treated patients were followed-up. Study III investigated the association between the biomarker E-XDP in plasma and the presence or severity of CVD. Samples of blood were drawn from a total of 142 patients with CVD and were matched to VU patients. In Study IV, 112 patients with CVD were included. The VEINES-QOL/Sym questionnaire was translated into Swedish and evaluated with regards to its psychometric properties. RESULTS: In Study I, total agreement between the three observers for clinical class was obtained in 61% of all cases (κ 0.55-0.68 (95% CI)) and for medical indication 60% of all cases (κ 0.35-0.57 (95% CI)). Study II showed that all patients had healed their original ulcer and 84% of the limbs had no recurrence after 3.5 years. In Study III, E-XDP levels were elevated in patients with CVD compared with controls (p< 0.05) and increased with increasing disease severity (p = 0.02). Multiple linear regression confirmed that E-XDP was independently associated with CVI (p < 0.05) after adjustment for age and gender. Study IV showed excellent internal consistency for both VEINES-QOL (Cronbach’s alpha (α) = 0.93) and VEINES-Sym (α = 0.89). Both the VEINES-QOL and VEINES-Sym correlated well to all the RAND-36 domains, demonstrating good construct validity. Exploratory factor analysis confirmed both subscales of the VEINES-QOL/Sym. CONCLUSIONs: Diagnosis using the clinical class of CEAP has moderate reproducibility when deciding medical indication for treatment and EVLA in VU patients achieves good healing with low recurrence rates and low rates of complications. Further, the novel biomarker E-XDP appears to have a positive association with increasing disease severity. The Swedish version of the VEINES-QOL/Sym is valid in assessing health related quality of life in CVD, both clinically and in research

Cholecystostomy as Bridge to Surgery and as Definitive Treatment or Acute Cholecystectomy in Patients with Acute Cholecystitis

Purpose. Percutaneous cholecystostomy (PC) has increasingly been used as bridge to surgery as well as sole treatment for patients with acute cholecystitis (AC). The aim of the study was to assess the outcome after PC compared to acute cholecystectomy in patients with AC. Methods. A review of medical records was performed on all patients residing in Stockholm County treated for AC in the years 2003 and 2008. Results. In 2003 and 2008 altogether 799 and 833 patients were admitted for AC. The number of patients treated with PC was 21/799 (2.6%) in 2003 and 50/833 (6.0%) in 2008. The complication rate (Clavien-Dindo ≥ 2) was 4/71 (5.6%) after PC and 135/736 (18.3%) after acute cholecystectomy. Mean (standard deviation) hospital stay was 11.4 (10.5) days for patients treated with PC and 5.1 (4.3) days for patients undergoing acute cholecystectomy. After adjusting for age, gender, Charlson comorbidity index, and degree of cholecystitis, the hospital stay was significantly longer for patients treated with PC than for those undergoing acute cholecystectomy (P<0.001) but the risk for intervention-related complications was found to be significantly lower (P=0.001) in the PC group. Conclusion. PC can be performed with few serious complications, albeit with a longer hospital stay

Global hälsa på läkarutbildningen igår, idag och imorgon

Undervisning i global hälsa förekommer i olika former vid samtliga läkarutbildningar i Sverige, och på vissa håll har kursmoment med fokus på internationell hälsa funnits i över trettio år. I denna artikel presenteras utvecklingenav global hälsa vid Sveriges läkarutbildningar – från dåtid till nutid och framtid. Textbidrag har inkommit från respektive lärosäte och sammanställts av Helena Nordenstedt och Hampus Holmer.Global health education exists in different forms in all medical programs in Sweden, and in some places parts of courses with a focus on international health has existed for more than 30 years. In this article we the development of global health education in the medical programs in Sweden is presented – from then to now and into the future. Each university has contributed texts, and these contributions have then been compiled by Helena Nordenstedt and Hampus Holmer

Empowering districts to target priorities for improving child health service in Uganda using change management and rapid assessment methods

Background: Local health system managers in low- and middle-income countries have the responsibility to set health priorities and allocate resources accordingly. Although tools exist to aid this process, they are not widely applied for various reasons including non-availability, poor knowledge of the tools, and poor adaptability into the local context. In Uganda, delivery of basic services is devolved to the District Local Governments through the District Health Teams (DHTs). The Community and District Empowerment for Scale-up (CODES) project aims to provide a set of management tools that aid contextualised priority setting, fund allocation, and problem-solving in a systematic way to improve effective coverage and quality of child survival interventions. Design: Although the various tools have previously been used at the national level, the project aims to combine them in an integral way for implementation at the district level. These tools include Lot Quality Assurance Sampling (LQAS) surveys to generate local evidence, Bottleneck analysis and Causal analysis as analytical tools, Continuous Quality Improvement, and Community Dialogues based on Citizen Report Cards and U reports. The tools enable identification of gaps, prioritisation of possible solutions, and allocation of resources accordingly. This paper presents some of the tools used by the project in five districts in Uganda during the proof-of-concept phase of the project. Results: All five districts were trained and participated in LQAS surveys and readily adopted the tools for priority setting and resource allocation. All districts developed health operational work plans, which were based on the evidence and each of the districts implemented more than three of the priority activities which were included in their work plans. Conclusions: In the five districts, the CODES project demonstrated that DHTs can adopt and integrate these tools in the planning process by systematically identifying gaps and setting priority interventions for child survival

Global hälsa på läkarutbildningen igår, idag och imorgon

Undervisning i global hälsa förekommer i olika former vid samtliga läkarutbildningar i Sverige, och på vissa håll har kursmoment med fokus på internationell hälsa funnits i över trettio år. I denna artikel presenteras utvecklingenav global hälsa vid Sveriges läkarutbildningar – från dåtid till nutid och framtid. Textbidrag har inkommit från respektive lärosäte och sammanställts av Helena Nordenstedt och Hampus Holmer.Global health education exists in different forms in all medical programs in Sweden, and in some places parts of courses with a focus on international health has existed for more than 30 years. In this article we the development of global health education in the medical programs in Sweden is presented – from then to now and into the future. Each university has contributed texts, and these contributions have then been compiled by Helena Nordenstedt and Hampus Holmer