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- Svensson, Christina, 1964-
(författare)
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Ultrasound Assessment and Vascular Mechanics in Takayasu Arteritis and Systemic Lupus Erythematosus
- 2023
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Takayasu arteritis (TAK) and systemic lupus erythematosus (SLE) are inflammatory diseases that primarily affect young women. TAK is a rare vasculitis that affects the aorta and its main branches, whereas SLE is a chronic autoimmune disease that effects multiple organs. Both diseases are associated with premature cardiovascular disease (CVD), and a wish to understand these associations prompted the studies of this thesis.The macrocirculation, microcirculation and vascular haemodynamics were studied in patients with TAK (N=25 in Paper I, N=17 in Paper II) and SLE (N=60 in Papers III and IV), and compared with age- and gender-matched controls. Vessel wall thickness (intima-media thickness (IMT)), vessel wall appearance, and occurrence of atherosclerotic plaques were evaluated in multiple vascular areas using high-frequency ultrasound (US). Microcirculation in the skin was studied after induced ischaemia employing a new method that combines laser Doppler flowmetry (LDF) and diffuse reflectance spectroscopy (DRS). The measured microcirculatory value was defined as the peak oxygen saturation (OxyP). Pulse wave analysis was used for calculation of the central augmentation index (AIx). Cerebrovascular reserve capacity (CVR) was analysed using transcranial Doppler (TCD).Paper IIn this study, TAK patients were examined with US, including follow-up studies. Clinically active cases of TAK showed significantly increased IMT compared to stable patients with TAK and healthy controls. The arteries of patients with active disease showed signs of intra-mural micro-vessels, oedema, or increased vessel diameter, whereas these signs were not seen in cases of stable disease. The Takayasu US index (based on the summation of the IMT in three arterial areas) was higher in active disease than in stable disease, and was valuable for the assessment of relapse.Paper IIIn this study of vascular haemodynamics in patients with TAK we observed impaired microcirculation, as compared with controls. CVR was preserved regardless of proximal arterial stenosis. The AIx, reflecting arterial stiffness, was increased, also in the arms without proximal stenosis or occlusion.Papers III and IVIncreased IMT with predominantly medium echogenicity was observed in multiple arteries of the 60 patients with SLE, predominantly in vascular areas that are not usually part of the IMT measurements. The patients with SLE developed plaques more frequently and earlier in life compared to the controls. Correlation with traditional cardiovascular risk factors was observed, indicating atherosclerotic mechanisms rather than inflammation. The patients with SLE had higher AIx values and lower OxyP levels, even at younger ages, and both these methods correlated with the IMT and plaque occurrence.ConclusionsFor patients with TAK, US can be valuable both for the diagnosis of the disease and for distinguishing between the active and stable disease forms. The microcirculation and degree of arterial stiffness in the arms are affected also in patients with TAK without proximal stenosis/occlusion, indicating a more widespread arterial wall dysfunction.In patients with SLE, increased IMT, an affected microcirculation, increased arterial stiffness, and premature atherosclerotic plaques indicate vascular affection coupled with increased risk for cardiovascular disease. All these evaluated methods may be used for longitudinal studies with or without intervention.
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| 2. |
- Svensson, Christina, 1964-, et al.
(författare)
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Vascular ultrasound for monitoring of inflammatory activity in Takayasu arteritis
- 2020
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Ingår i: Clinical Physiology and Functional Imaging. - : WILEY. - 1475-0961 .- 1475-097X. ; 40:1, s. 37-45
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Tidskriftsartikel (refereegranskat)abstract
- Background Takayasu arteritis (TA) is a rare large-vessel arteritis that primarily affects the aorta and its major branches. The aim of this study was to describe the value of high frequency ultrasound for monitoring of inflammatory activity. Methods Twenty-five patients, range 11-71 years, diagnosed with TA were investigated with duplex ultrasound (DUS) including follow-up studies. Twenty-five healthy controls were also investigated. Nine patients had newly diagnosed active TA. Sixteen patients had stable/inactive disease at baseline DUS, and TA was diagnosed median 4 center dot 5 years previously. Intima-media thickness (IMT), vessel and lumen diameter were measured in the carotid arteries, central neck arteries and the aortic arch. The vessel walls were studied qualitatively. The Takayasu ultrasound index was created for inflammatory activity scoring. Results Intima-media thickness in common carotid artery (CCA) was (median and 25-75 percentile parenthetic) 2 center dot 3 mm (1 center dot 7-2 center dot 9) in clinically active TA, 1 center dot 2 mm (1 center dot 1-1 center dot 6) in clinically stable TA (Pamp;lt;0 center dot 001) and 0 center dot 5 mm (0 center dot 5-0 center dot 6) in healthy controls (Pamp;lt;0 center dot 001). Clinically active TA had prominent increase in IMT and/or increased vessel diameter, and/or intramural arteries, and/or hypoechogenic areas interpreted as oedema in the vessel wall. TA in clinical remission was characterized by increased IMT with medium to high echogenicity with or without fibrotic stripes. The Takayasu ultrasound index was higher in patients with active disease versus treated disease, 2 center dot 55 (1 center dot 60-3 center dot 05) versus 1 center dot 30 (1 center dot 00-1 center dot 58), (P = 0 center dot 003). Conclusion DUS is an excellent tool to monitor inflammatory changes in the vessel wall in TA. Further DUS studies in larger patient populations are warranted.
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| 4. |
- Eriksson, Heléne, 1964-
(författare)
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End of Life Stroke Care : perspectives of health-care professionals and family members
- 2019
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- IntroductionEven though medical improvements have reduced the mortality rates for patients afflicted by stroke, mortality during the first few days at hospital is significant. Today, there is an increasing recognition that the principles of palliative and supportive care are important components of meeting the needs of patients severely afflicted by stroke even in acute settings. However, there is limited knowledge about which factors have an impact on the end-of-life care (EoLC) for these patients or about how these last days of life are experienced from the family members’ perspective.AimThe overall aim of this thesis was to describe the EoLC of patients severely afflicted by stroke and to identify factors impacting upon EoLC for the patients and their family members in Sweden out of various contexts and methods.Design and MethodsThis thesis is based upon four papers employing qualitative, quantitative and mixed-method designs.Paper I is a qualitative study based on focus-group interviews with 41 health-care professionals (HCPs) in different professions related to stroke care at three stroke units. The aim was to study ethical dilemmas, different approaches and what consequences they had among health HCPs; the data was analysed using content analysis. The result inspired the design and conduct of the following studies.Paper II is a quantitative comparative study based on a retrospectively registered questionnaire from the Swedish Registry of Palliative Care (SRPC). Patients dying of stroke (n =1626) were compared with patients dying from cancer (n=1626), according to symptoms, symptom management and communication with the patient and family members during the last week of life. Data was statistically calculated using OR.Paper III is a mixed-method study employing a sequential explanatory design. In the first, quantitative, part, 995 stroke patients who died in hospital were compared with 631 stroke patients who died at nursing homes, according to symptoms, symptom management and communication with the patient and family members during the last week of life. The quantitative data was statistically calculated using OR and the qualitative data was analysed using content analysis. Nine significant differences drawn from the quantitative results regarding care were chosen to be discussed by twelve nurses working in stroke units.Paper IV is a qualitative interview study with the aim to study the family member descriptions of the trajectory from admission to the hospital until their loved one died. A semi-structured interview guide was used, and data was analysed using thematic analyses.ResultsFactors that had an impact on EoLC were consequences related to the difficulties around decision-making about withholding or withdrawing life-sustaining treatment. Non-decisions or not holding to the decision generated communication barriers causing obstacles in inter-professional collaboration and ethical dilemmas within the team (Study I). The absence of a mutual approach to care resulted in underprovided palliation, undignified medical treatment and ambiguity in care, generating feelings of distrust among the family members. The results described in Study I of underprovided palliation were further investigated in Study II. The differences in knowledge about whether symptoms were present or not in patients afflicted by stroke compared to patients with cancer were significant. For example, the HCPs in the stroke group did not know if pain was present nine times more frequently than in the cancer group. These differences in knowledge about whether symptoms were present of not were also identified in Study III. Here, HCPs at the nursing home more often had knowledge about whether a symptom was present in patients dying of stroke or not, compared to HCPs at hospitals. This study also identifies differences in the presence of the symptoms being compared and whether the patient’s suffering was fully relieved. The nurses working at stroke units explained that these differences were a consequence of the stroke unit’s aim (saving lives), no previous relationship to the patient and ambiguity in the evaluation of symptoms. The patient’s altered levels of consciousness increased the difficulties in evaluation. In addition, the hospital setting’s aim increased the risk of prolonged treatment, for example nutrition supplied during the last day of life, and underprovided palliation of for example, pain compared to nursing homes. In Study IV, family members were seeking trust through mutual collaboration and creating relationships with the HCPs. If the family did not feel that their search for trust was taken care of, it generated feelings of distrust allied with anxiety and memories of failing to do the best for their loved one at in the end of life. During the trajectory at the hospital, family members were “seeking trust in chaos”, “seeking clarity when deciding about living or dying” and finally they were “seeking trust in care as a final act of love”.Conclusions:The results of this thesis suggest that the absence of a coherent approach contributes to developing ethical dilemmas within the HCPs. The ambiguity in care had an impact on the quality on EoLC, with an increased risk of unnecessary suffering and questionable symptom management. The prevailing culture at acute-care hospitals affected the HCPs’ attitudes towards EoLC, with attention being predominantly on life-sustaining treatments. There is an increasing recognition of the need for improvement in the PC approach at acute-care hospitals in order to create equal quality of care during end of life, irrespective of the place of death for patients dying of stroke. Furthermore, family members need to feel trust, which is achieved through relationships and collaboration with HCPs. In the striving to accomplish a wholly compensatory care of quality during the trajectory, this thesis can be a source of knowledge and guidance for nurses and for teams at the stroke unit.
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| 5. |
- Werner, Helene, 1987, et al.
(författare)
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Psychological Interventions for Poor Oral Health: A Systematic Review
- 2016
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Ingår i: Journal of Dental Research. - : SAGE Publications. - 0022-0345 .- 1544-0591. ; 95:5, s. 506-514
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Tidskriftsartikel (refereegranskat)abstract
- The aim of this systematic review and meta-analysis was to study the effectiveness of psychological interventions in adults and adolescents with poor oral health. The review follows the PRISMA guidelines for systematic reviews. The PICO format (population, intervention, comparison, and outcome) was used to define eligible studies. The populations were adults or adolescents (13 y of age and independent of others) with poor oral health (defined as dental caries, periodontal disease, and/or peri-implantitis). The interventions were psychological and/or behavioral models and theories, in comparison with traditional oral health education/information. The primary outcomes were dental caries, periodontitis, gingivitis, and peri-implantitis. Secondary outcomes were dental plaque, oral health-related behavior, health-related quality of life, health beliefs and attitudes, self-perceived oral health, and complications/risks. The systematic literature search identified 846 articles in December 2013 and 378 articles in July 2015. In total, 11 articles on 9 randomized controlled trials were found to meet the inclusion criteria. These reported on adults with periodontal disease, and several used motivational interviewing (MI) as their mode of intervention. The CONSORT guidelines and the GRADE approach were used for study appraisal and rating of evidence. The meta-analysis showed no statistically significant differences in gingivitis or plaque presence. In addition, a meta-analysis on MI compared with education/information found no statistically significant differences in gingivitis presence. Only 1 meta-analysison psychological interventions versus education/information regarding the plaque indexshowed a small but statistically significant difference. There were also statistically significant differences reported in favor of psychological interventions in oral health behavior and self-efficacy in toothbrushing. However, the clinical relevance of these differences is difficult to estimate. The certainty of evidence was low. Future research needs to address several methodological issues and not only study adults with periodontal disease but also adolescents and patients with dental caries and peri-implantitis.
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| 6. |
- Zachrisson, Helene, et al.
(författare)
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An extended high-frequency ultrasound protocol for detection of vessel wall inflammation.
- 2018
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Ingår i: Clinical Physiology and Functional Imaging. - : John Wiley & Sons. - 1475-0961 .- 1475-097X. ; 38:4, s. 586-594
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVE: The aim of this study was to evaluate an extended protocol of the large vessels using high-frequency duplex ultrasound (DUS) for detection of vessel wall inflammation.METHODS: Fifty-eight patients performed a DUS examination where arteritis could not be excluded. All DUS examinations were performed using ACUSON S2000 TM ultrasound system (Siemens Medical Solutions USA, Inc.). High-frequency linear transducers were used (18L6 MHz, 9L4MHz) or curve linear for the aortic arch (6C2 MHz). Carotid, vertebral, central neck arteries (subclavian, axillary, innominate) arteries, aortic arch and femoral arteries were studied. Circumferential, homogenous wall thickening, with or without a hyperechogenic stripe lining the innermost layer, were regarded as typical signs of arteritis. Intima-media thickness (IMT) was measured in the patients and a normal control group. The latest clinical updated diagnosis was assessed at least 6 months after DUS.RESULTS: The DUS findings showed normal vessels (n = 14), arteritis and atherosclerosis (n = 13), atherosclerosis (n = 15) and arteritis (n = 16). The latter group had a significant increased IMT in the common femoral artery and the common carotid artery (mean 1·0 ± SD 0·3 mm versus 0·6 ± 0·2 mm in the normal group (n = 37), P<0·00001, 1·2 ± 0·5 mm versus 0·8 ± 0·2 mm in the normal group (n = 40), P<0·00001). In the groups with sonographic signs implying arteritis (n = 29), 20 patients had a clinical diagnosis of arteritis, whereas eight patients had another main diagnosis such as malignancy/other inflammatory or infectious disease complicated by inflammation of the vessel wall. One patient had multiple diagnoses and was not possible to classify.CONCLUSION: An extended ultrasound protocol for central neck and leg arteries could be of value for diagnosis of arteritis. In case of atypical vessel wall inflammation, other main diagnoses should be considered.
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