| 1. |
- Engert, Andreas, et al.
(författare)
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The European Hematology Association Roadmap for European Hematology Research : a consensus document
- 2016
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Ingår i: Haematologica. - Pavia, Italy : Ferrata Storti Foundation (Haematologica). - 0390-6078 .- 1592-8721. ; 101:2, s. 115-208
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Tidskriftsartikel (refereegranskat)abstract
- The European Hematology Association (EHA) Roadmap for European Hematology Research highlights major achievements in diagnosis and treatment of blood disorders and identifies the greatest unmet clinical and scientific needs in those areas to enable better funded, more focused European hematology research. Initiated by the EHA, around 300 experts contributed to the consensus document, which will help European policy makers, research funders, research organizations, researchers, and patient groups make better informed decisions on hematology research. It also aims to raise public awareness of the burden of blood disorders on European society, which purely in economic terms is estimated at (sic)23 billion per year, a level of cost that is not matched in current European hematology research funding. In recent decades, hematology research has improved our fundamental understanding of the biology of blood disorders, and has improved diagnostics and treatments, sometimes in revolutionary ways. This progress highlights the potential of focused basic research programs such as this EHA Roadmap. The EHA Roadmap identifies nine 'sections' in hematology: normal hematopoiesis, malignant lymphoid and myeloid diseases, anemias and related diseases, platelet disorders, blood coagulation and hemostatic disorders, transfusion medicine, infections in hematology, and hematopoietic stem cell transplantation. These sections span 60 smaller groups of diseases or disorders. The EHA Roadmap identifies priorities and needs across the field of hematology, including those to develop targeted therapies based on genomic profiling and chemical biology, to eradicate minimal residual malignant disease, and to develop cellular immunotherapies, combination treatments, gene therapies, hematopoietic stem cell treatments, and treatments that are better tolerated by elderly patients.
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| 2. |
- Björck, Fredrik, 1974-
(författare)
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Warfarin treatment quality in stroke prevention
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BackgroundIschemic stroke is a serious condition often associated to presence of atrial fibrillation (AF). Use of anticoagulants for AF patients greatly reduces the risk of stroke. Warfarin is the most commonly used anticoagulant in Sweden. The aim of this thesis was to study the impact of warfarin treatment quality in Swedish stroke prevention.MethodsStudy I, II and IV were relatively large multicentre, retrospective, cohort studies based on Swedish registries, especially AuriculA, a quality register for AF and anticoagulation. Background data as well as bleeding and thromboembolic complications were retrieved from the National Patient Register. The Cause of Death Register was used in study II and IV. The Swedish Prescribed Drug Register was used in study IV, for data on concomitant acetylsalicylic acid (ASA) use. Study period was January 1, 2006, to December 31, 2011. Study III enrolled all warfarin treated AF patients in Sundsvall, registered in AuriculA on January 1, 2010. This smaller cohort was followed until discontinuation or study-stop December 31, 2013. All used data were collected from each patient’s medical record.ResultsThe annual risk of major bleedings and thromboembolic events for warfarin treated patients, including all different indications for warfarin, was relatively low (2.24% and 2.66%), with incidence of intracranial bleeding of 0.37% per treatment year. The overall mean time in therapeutic range (TTR) was 76.5%. Patients started on warfarin due to AF had a mean TTR of 68.6%, with an annual risk of major bleeding and thromboembolic events of 2.23% and 2.95%, and with 0.44% annual risk of intracranial bleeding. No significant differences in overall complications were found when comparing treatment monitored in anticoagulation clinics (ACC) with treatment monitored in primary health care centers (PHCC). There were significantly increased risk of both overall major bleedings and thromboembolic events for those warfarin treated AF patients receiving additional ASA treatment, having individual TTR (iTTR) below 70%, or having high international normalized ratio (INR) variability. AF patients with low INR variability had generally lower complication rates, compared with patients with high INR variability. There were however no alteration on cumulative incidence of complications due to INR variability, for AF patients with iTTR ≥70%. The overall proportion of persistence to warfarin treatment for stroke patients with AF was found to be 0.69 after 2 years treatment and 0.47 after 5 years. Stroke patients with diagnosed dementia at baseline were more than two-times likely of discontinuing warfarin than others. Excessive alcohol use, chronic obstructive pulmonary disease, cancer and chronic heart failure were baseline diagnoses each associated with over 20% increased risk of treatment discontinuation. Lower persistence to treatment was linked to increasing start-age and CHA2DS2-VASc scores. As documented reasons for warfarin treatment discontinuation in AF patients, we found regained sinus rhythm as the most common addressed cause (31.2%), followed by problematic monitoring and bleedings. We estimated that only half (49.5%) of the treatment discontinuations were clinically well motivated.ConclusionsQuality of Swedish warfarin treatment in initiated stroke prevention is high, with generally low rates of complications and high TTRs, no matter treatment in ACC or PHCC, including high long time persistence to warfarin in secondary stroke prevention. For better outcome in future warfarin stroke prophylactic treatment clinicians should aim for iTTRs above 70%, avoid additional ASA therapy, support fragile patients like those with excessive alcohol use and dementia, and base decisions on treatment discontinuations on solid medical arguments.
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| 3. |
- Jashari, Fisnik, 1985-
(författare)
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Carotid artery disease : plaque features and vulnerability
- 2015
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Atherosclerosis is an important cause of stroke. Ultrasound offers the convenience of real-time and detailed assessment of carotid plaque features as well as arterial wall thickening and composition. Evaluation of these features is important for determining patients’ risk of suffering vascular events and also contributes to selecting the best treatment strategy.Methods: Using ultrasound data analysis we have determined plaque features in the bifurcation and internal carotid artery (ICA), including: surface plaque irregularities, calcification, echogenicity (grey scale median-GSM) and other textural plaque features (Juxtaluminal black area, entropy, coarseness). In addition, intima media thickens (IMT) and its grey scale median (IM-GSM) was measured in common carotid artery (CCA). Using Cone Beam CT (CBCT) we have quantified calcification volume of the carotid plaques extracted after carotid endarterectomy procedure. For the meta-analysis we have used comprehensive meta-analysis software version 3. Study I: We have included 39 patients and we compared carotid plaque features of the contralateral arteries with those located ipsilateral to symptomatic side and arteries of asymptomatic patients.Study II: The accuracy of US to detect atherosclerosis calcification was assessed against CBCT in 88 patients. Study III: Based on the previous vascular events in coronary, carotid and lower extremity arterial system, 87 patients were divided into three groups: asymptomatic, symptoms in one vascular system and symptoms in more that one vascular system. IMT, IM-GSM and plaque features were compared between groups.Study IV: We have meta-analyzed ten cohort prospective studies evaluating carotid plaque echogenicity for cerebrovascular symptoms prediction. Results: Study I. Plaques of the contralateral to symptomatic arteries had similar features to those in symptomatic and more vulnerable than asymptomatic arteries.Study II. Carotid ultrasound was accurate in detecting calcification volumes of ≥8mm3 with very high sensitivity but it was less accurate in detecting lower calcification volumes (<8mm3). Carotid calcification was not different between symptomatic and asymptomatic patients. Study III. Echogenicity of the intima-media complex (IM-GSM), but not its thickness (IMT), was significantly decreased with increasing number of arterial systems affected by atherosclerosis. IM-GSM was lower in patients with prior myocardial infarction and stroke.Study IV. Carotid plaque echogenicity evaluated by US could predict future cerebrovascular events in patients with asymptomatic, relative risk RR 2.72 (95% CI, 1.86 to 3.96), and recurrent symptoms in symptomatic patients, RR 2.97 (95% CI, 1.85-4.78). Conclusion: Plaques located in the contralateral to symptomatic arteries have similar features assymptomatic side and more vulnerable than asymptomatic arteries. Carotid ultrasound could accurately detect larger but not smaller carotid plaque calcification volumes (<8 mm3). Low IM- GSM could identify patients with multi-system atherosclerosis disease, suggesting a better marker for determining systemic atherosclerosis disease burden compared to conventional IMT. Finally, carotid plaque echogenicity predicts future cerebrovascular events in patients with symptomatic and asymptomatic carotid stenosis.
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| 4. |
- Johansson, Elias, 1984-, et al.
(författare)
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Vaskulärt ultraljud vid stroke
- 2013
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Ingår i: Läkartidningen. - 0023-7205 .- 1652-7518. ; 110
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Tidskriftsartikel (refereegranskat)abstract
- Den senaste tidens framsteg inom strokesjukvården ställer höga krav på snabb och säker diagnostik och monitorering av patienter som drabbats av stroke. Patienter med symtomgivande karotisstenos ska opereras kort tid efter att symtomen debuterat, och där kan ultraljudsteknik vara till hjälp i diagnostiken. Huruvida personer med asymtomatisk karotisstenos ska opereras är ett debatterat ämne, men ultraljudsteknik kan vara en framkomlig väg för att selektera vilka personer med asymtomatisk karotisstenos som ska opereras. Denna artikel är en översikt över vad vi i dag känner till om ultraljudets användbarhet och begränsning inom strokesjukvården, med fokus på patienter med karotisstenos.
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| 5. |
- Vanoli, Davide, 1972-
(författare)
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Vascular ultrasound for the assessment of carotid atherosclerosis
- 2017
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background: Atherosclerotic cardiovascular disease (CVD) is a common cause for mortality globally, and is expected to remain the single leading cause of death as the global population ages and as life expectancy increases.Cardiovascular screening models have been developed, and continue to be developed, to identify individuals at high-risk of CVD. This is necessary to establish prevention strategies to decrease the occurrence of an acute event or debilitating syndrome. These strategies largely take the form of lifestyle modification and pharmacological intervention. The Framingham risk score, NCEP/ATP II guidelines and SCORE risk assessment protocol are widely used screening models. Ultrasound based methods are non-invasive, affordable and have been suggested to improve assessment and definition of individual patients potential risk of CVD. Increased carotid artery intima-media thickness (cIMT) is a known and established sign of early atherosclerosis. The presence of plaque and the overall burden of atherosclerosis seems to have even greater value in predicting cerebrovascular and cardiovascular events. Ultrasound based texture characteristics of plaques such as entropy, grey scale median, discrete white area, coarseness and juxtaluminal hypoechoic black area have been proposed as useful possible predictors of plaque vulnerability. Moreover, ultrasound contrast agents have been developed to improve visualization and subsequent quantification of an atherosclerotic plaque. Considering the current available data and research, the importance of developing tools and techniques for detection and characterization of atherosclerotic changes, to indicate risk for CVD and the subsequent early intervention and prevention, appears clearly as an effort to improve public health. In this present collection of studies (4 papers) we aim to contribute to the development of clinically useful ultrasound methods and tools for the accurate assessment, understanding and management of atherosclerosis.Methods: To validate ultrasound-based methods for assessment of early signs of atherosclerosis, measured as cIMT, a total of 144 subjects underwent bilateral carotid ultrasound. In study I, the performance of an ultrasonography software capable of fully automated on-screen cIMT measurements was tested and compared with the traditional manual measurement approach. The coefficient of variation and the intraclass correlation coefficient for both methods were compared to verify the reliability and reproducibility of results generated by the new ultrasound software. To test the accessibility and possible clinical applications of this new technology tested in study I, the new software was used by novice’s scanners in study II, and the intraobserver variability of the cIMT measurements were assessed and compared with that of an expert operator. In study III, ultrasound texture characteristics of 327 plaques including entropy, grey scale median, discrete white area, coarseness and juxtaluminal hypoechoic black area were assessed as possible predictors of future cerebrovascular events in a cohort of 133 patients with symptomatic carotid stenosis waiting for carotid surgery. The reproducibility of measuring plaque area (expressed as intraclass correlation coefficient) using conventional ultrasound and contrast enhanced ultrasound was tested in study IV in an attempt to find a simple and reproducible parameter for monitoring changes in atherosclerotic burden.Results: The technology tested in study I was found to have good inter- and intra-system reproducibility compared with conventional methods. Moreover, it was found to produce reproducible results when used by expert and novice operators after a short period of training (study II), confirming the possibility for the employment of this technology in a large screening public health programs. Although such technology may have immediate practical application, other and more sophisticated ultrasound based plaque characteristics (such as grey scale median, entropy, coarseness, juxtaluminal hypoechoic black area) were not shown to be beneficial in predicting plaque vulnerability (study III). Contrast enhanced ultrasound technic tested in study IV did not improve quantification of atherosclerotic plaque burden. Conclusion: Medical ultrasound technology by using a automatically measure of carotid intima media thickness can be used with high reproducibility and also possible to be transferred to primary care by a well designed training program. Plaque characteristic using carotid ultrasound was not found to be useful in risk stratifying symptomatic patients with severe carotid stenosis. Furthermore, contrast enhanced ultrasound technique was found to have high reproducibility in plaque area assessment but not better than conventional b-mode based method in quantifying the atherosclerotic burden. Therefore, more sophisticated ultrasound based methods for assessment plaque characteristics was not found to be beneficial in predicting plaque vulnerability.
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