Long-term follow-up of patients with ANCA-associated vasculitis

This thesis is based on long-term follow-up results from two cohorts of patients with ANCA-associated vasculitis; one cohort with 535 patients originally included in 4 European randomized clinical trials (papers I and II) and one Swedish population-based cohort including 195 patients (papers III and IV). Two areas are covered in the two cohorts, respectively; the assessment of mortality, prognostic factors and causes of death in the two cohorts (paper I and III) and the assessment of malignancy risk compared with a matched general population (papers II and IV).ResultsPaper I: 1-, 2-, and 5-year survival was 88%, 85% and 78%. Predictors of death were age, gender, kidney function and disease activity at presentation. Main causes of death were active vasculitis and infection during the first year, and after the first year, malignancy and cardiovascular disease. Paper II: Higher risk for malignancy at all sites and non-melanoma skin cancer. Paper III: 1-, 2-, 5-, and 10-year survival was 87%, 82%, 70% and 55%, respectively. Predictors of death were age, gender, kidney function and organ involvement at diagnosis. Main causes of death were active vasculitis and infection during the first year, and after the first year, malignancy and cardiovascular disease. Paper IV: Higher risk for malignancy at all sites, non-melanoma skin cancer, bladder cancer and pancreatic cancer.Conclusions: The mortality and malignancy risks in patients treated for AAV with current treatment protocols are higher than in the general population. However, the mortality in the group of patients with AAV without gastrointestinal, cardiovascular, or renal involvement at presentation is not significantly increased compared with the general population

Diurnal IOP fluctuation: not an independent risk factor for glaucomatous visual field loss in high-risk ocular hypertension.

Purpose: To establish whether intraocular pressure (IOP) fluctuations contribute to the risk of developing glaucoma in patients with high-risk ocular hypertension. Methods: Ninety patients included in the Malmo Ocular Hypertension Study were examined every 3 months with office-hours diurnal tension curves and computerised perimetry. Patients were followed up prospectively for 10 years or until glaucomatous visual field loss could be demonstrated. Poststudy data were included in the analyses, extending maximum follow-up to 17 years. Results: After 17 years, 37 patients had developed glaucomatous visual field defects. When applying univariate Cox regression analyses, mean IOP of all measurements during the prospective part of the study was a significant risk factor for developing glaucoma (95% confidence interval [CI] 1.08 - 1.39), while IOP fluctuations were almost significant ( 95% CI 0.98 - 1.93). When separating effects of mean IOP level and mean IOP fluctuation using Cox multiple regression analysis, only IOP level came out as significant ( 95% CI 1.09 - 1.38), and IOP fluctuations did not contribute to the risk ( 95% CI 0.80 - 1.60). IOP fluctuation depended linearly on IOP level ( p< 0.0001), i.e. IOP fluctuation was larger in eyes with higher IOP levels. Conclusion: IOP fluctuations were not an independent risk factor for the incidence of glaucomatous visual field loss in subjects with ocular hypertension

Lifetime Risk of Blindness in Open-Angle Glaucoma.

To determine the lifetime risk and duration of blindness in patients with manifest open-angle glaucoma (OAG)

The effect of different criteria on the number of patients blind from open-angle glaucoma

<p>Abstract</p> <p>Background</p> <p>The prevalence of blindness and visual impairment from glaucoma is influenced by the criteria used to define these entities, which differ between countries and regions, as well as among published reports. The objective of the present study was to ascertain the extent to which different criteria of blindness and visual impairment influence estimates of the number of patients classified as blind or visually impaired by glaucoma in a clinic-based population.</p> <p>Methods</p> <p>We conducted a retrospective chart review of 914 patients with open-angle glaucoma to compare numbers of patients identified as visually impaired with and without considering visual field status. We also compared proportions classified using World Health Organisation (WHO) and United States (US) blindness criteria, and applying a new US Social Security Administration (SSA) disability criterion: perimetric mean deviation (MD) ≤ -22 dB.</p> <p>Results</p> <p>Forty patients (4.4%) were bilaterally blind from glaucoma by the WHO criteria. Fifty-two (5.7%) were blind by the the US criterion. Assessing only visual acuity, 14 (1.5%) patients were blind by the WHO criteria and 24 (2.6%) by the US definition. Eighty-five (9.3%) met the US SSA disability criterion. Among those, 52 were impaired also by the WHO definition. No patients impaired according to the WHO criteria had MD values better than -22 dB.</p> <p>Conclusions</p> <p>Excluding visual field status will seriously underestimate the prevalence of glaucoma blindness. In our patient population, 30% more patients were classified as blind by the US than by the WHO definition. Also, 60% more were identified as visually impaired by the US SSA criterion than by the WHO criteria. Visual field assessment is vital to determine visual impairment caused by glaucoma.</p

Prehospitale triage bij traumapatiënten

The prehospital trauma triage system consisting of regional ambulance services and overarching availability of mobile medical teams, the level criteria for trauma centres and in-hospital care for trauma patients are well-organised in the Netherlands.- However, the quality of prehospital triage in the Netherlands is inadequate at the moment, with an average under-triage rate of more than 30%. There is, thus, much room for improvement in the quality of prehospital triage.- Research in this area is now taking off, partly because of the arrival of a new quality indicator from the Netherlands National Health Care Institute, which states that at least 90% of multiple-trauma patients should be primarily taken to a level 1 trauma centre

Thermoelectric properties of Ba8Ga16Ge30 with TiO2 nanoinclusions

The effects on thermal and electrical properties of adding small amounts of TiO2 nanoinclusions to bulk Ba8Ga16Ge30 clathrate have been investigated. The thermal properties were analysed using the transient plane source technique and the analysis showed a significant decrease in thermal conductivity as the volume fraction of TiO2 increased from 0 vol. % to 1.2 vol. %. The introduction of TiO2 nanoparticles caused a shift in the peak value of the Seebeck coefficient towards lower temperatures. The maximum value of the Seebeck coefficient was, however, only little affected. The introduction of TiO2 nanoparticles into the bulk Ba8Ga16Ge30 resulted in an increased electrical resistivity of the sample, thus simultaneously reducing the charge carrier contribution to the thermal conductivity, partly explaining the decrease in total thermal conductivity. Due to the large increase in resistivity of the samples, ZT was only somewhat improved for the material with 0.4 vol. % TiO2 while the ZT values of the other materials were lower than for the reference Ba8Ga16Ge30 material without TiO2 nanoparticles. The combined results are consistent with a scenario where the nanoparticle introduction causes a light doping of the semiconductor matrix and an increased concentration of phonon scattering centres

The Effect of Education on the Assessment of Optic Nerve Head Photographs for the Glaucoma Diagnosis

Background: To evaluate the effect of one lesson of continuing medical education (CME) of subjective assessment of optic nerve head appearance on sensitivity and specificity for the diagnosis of glaucoma. Methods: Ophthalmologists and residents in ophthalmology attending an international glaucoma meeting arranged at Malmo University Hospital, Malmo, Sweden, were asked to grade optic nerve head (ONH) photographs of healthy and glaucomatous subjects at two sessions separated by a lecture on glaucoma diagnosis by ONH assessment. Each grader had access to an individual portfolio of 50 ONH photographs randomly selected from a web-based data bank including ONH photographs of 73 glaucoma patients and 123 healthy subjects. The individual portfolio of photographs was graded before and after the lecture, but in different randomized order. Results: Ninety-six doctors, 91% of all attending the meeting, completed both assessment sessions. The number of correct classifications increased from 69 to 72% on the average. Diagnostic sensitivity increased significantly (p < 0.0001) from 70% to 80%, and the number of photographs classified as uncertain decreased significantly (p < 0.0001) from 22% to 13%. Specificity remained at 68%, and intra-grader agreement decreased. Conclusion: CME had only a small effect on the assessment of ONH for the glaucoma diagnosis. Sensitivity increased and the amount of uncertain classifications decreased, while specificity was unchanged

Effects of Argon Laser Trabeculoplasty in the Early Manifest Glaucoma Trial.

PURPOSE: To analyze reduction of intraocular pressure (IOP) by argon laser trabeculoplasty (ALT) in the Early Manifest Glaucoma Trial and factors influencing the effect of such treatment. DESIGN: Cohort study based on 127 patients from the treatment group of the Early Manifest Glaucoma Trial, a randomized clinical trial. METHODS: Patients randomized to the treatment arm of the Early Manifest Glaucoma Trial received a standard treatment protocol (topical betaxolol hydrochloride followed by 360-degree ALT) and then were followed up prospectively at 3-month intervals for up to 8 years. One eye per patient was included in the analyses. We investigated the relationship between IOP before ALT and subsequent IOP reduction and other factors that might have influenced the effect of ALT, including stage of the disease, trabecular pigmentation, presence of exfoliation syndrome, and treating surgeon. RESULTS: The mean ± standard deviation IOP before ALT and after betaxolol treatment was 18.1 ± 3.9 mm Hg, and the mean ± standard deviation short-term IOP reduction 3 months after ALT was 2.8 ± 3.9 mm Hg (12.6 ± 20.5%). The IOP before ALT strongly affected IOP reduction (P < .001); each 3-mm Hg higher IOP before ALT value was associated with an additional mean IOP reduction of approximately 2 mm Hg. The treating surgeons also had a significant impact on IOP reduction (P = 0.001), with mean values ranging from 5.8 to -1.3 mm Hg. CONCLUSIONS: In this cohort, which included many patients with low IOP levels, IOP before ALT markedly influenced the IOP reduction induced by ALT, seen as a much larger decrease in eyes with higher IOP before ALT. The treating surgeon also had a significant impact on ALT outcome