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The aim of this study was to evaluate the greatest drivers for development of lower extremity peripheral artery disease (PAD) in relation to coronary, precerebral, or cerebral artery disease This prospective study (Malmö Diet and Cancer study) included 26,681 participants. The diagnosis of incident PAD, coronary artery disease (CoAD), atherothrombotic ischemic stroke (IS) free from atrial fibrillation or flutter, and carotid artery disease (CaAD) was validated. A modified Lunn-McNeil competing risk analysis was performed to compare the Hazard Ratio (HR) strength of PAD in relation to CoAD, IS, or CaAD. The estimated population attributable risk fractions (PAF) for each atherosclerotic manifestation were estimated by first fit an age and sex adjusted Cox proportional hazard regression, and then estimate the PAF using the Direct method. Male sex, age, and hypertension were risk factors for development of all atherosclerotic manifestations. Current smoking accounted for 45.6% (95% CI 41.1–47.2), 16.1%, 14.0%, and 23.3% of the risk for development of PAD, CoAD, IS, and CaAD, respectively. Hypertension was more associated with development of PAD than CoAD (p = 0.009). Smoking and diabetes mellitus were positively associated with all four manifestations, but these associations were significantly stronger for PAD than the other three manifestations. Smoking and diabetes mellitus had a larger impact on incident PAD than incident coronary, cerebral or precerebral artery manifestations. Since the lower extremity arteries are the easiest to access and examine, they may be considered as the first arterial bed to examine in patients at increased risk for atherosclerotic manifestations. [ABSTRACT FROM AUTHOR]

Background: Acute mesenteric venous thrombosis (MVT) is rarely suspected as primary diagnosis in emergency departments and still carries an in-hospital mortality rate of above 20%. Objectives: The aim of this study was to find differences in clinical and laboratory markers between patients with acute MVT and a control group of suspected but confirmed as not having any type of acute mesenteric ischaemia (AMI). Design: Data was retrieved from the AMESI (Acute MESenteric Ischaemia) study. This international, multicenter prospective case-control study from 32 sites collected data on patients with suspected AMI during a 10-month period. Methods: Independent factors associated with acute MVT were evaluated in a multivariable logistic regression analysis and expressed as odds ratios (OR) with 95% confidence intervals (CI). Results: D-dimer was not significantly higher in MVT (n = 73) compared to non-AMI (n = 287) patients (median 7.0 mg/L vs 4.5 mg/L, P =.092). After entering BMI, atherosclerotic disease, history of venous thromboembolism, CRP, and D-dimer as covariates in a multi-variable logistic regression analysis, absence of atherosclerotic disease (OR 0.096, 95% CI 0.011-0.84; P =.034) and elevated D-dimer (OR 2.59/one SD increment, 95% CI 1.07-6.28; P =.034) were associated with MVT. The discriminative ability of D-dimer for MVT as assessed by area under the curve in the receiver operating characteristics analysis was 0.63 (95% CI 0.49-0.78). Conclusion: Elevated D-dimer was associated with MVT, but the discriminative ability of D-dimer was poor. There is an urgent need to find a more accurate plasma biomarker for this condition. TRIAL REGISTRATION: NCT05218863 (registered 19.01.2022). Plain Language Summary: Acute mesenteric vein thrombosis is rare, but life-threatening. The symptoms are abdominal pain and are not distinct from other acute abdominal conditions. A blood test identifying or leading to easier diagnosis is warranted. This multicenter international study has included patients with thrombosis in the mesenteric veins as well as suspected diseases, but not confirmed conditions, of disturbed circulation to the gastrointestinal tract. Elevation of the blood marker D-dimer was found to be associated with the condition of acute mesenteric vein thrombosis, but was not enough discriminative in relation to those patients with suspected disease only. There is an urgent need to find a more accurate blood marker for deep vein thrombosis of the abdomen. [ABSTRACT FROM AUTHOR]

Introduction: The potential utility of inflammatory and hemodynamic plasma biomarkers for the prediction of incident lower extremity arterial disease (LEAD), carotid artery stenosis (CAS), isolated atherosclerotic disease without concomitant abdominal aortic aneurysm (AAA), and isolated AAA without concomitant atherosclerotic disease has not yet been integrated in clinical practice. The main objective of this prospective study was to find predictive plasma biomarkers for cardiovascular disease and to evaluate differences in plasma biomarker profiles between asymptomatic and symptomatic CAS, as well as between isolated atherosclerotic disease and isolated AAA. Methods: Blood samples collected at baseline from participants in the prospective Malmö Diet and Cancer study (MDCS) cardiovascular cohort (n = 5550 middle-aged individuals; baseline 1991–1994) were used for plasma biomarker analysis. Validation of each incident cardiovascular diagnosis was performed by random sampling. Cox regression analysis was used to calculate hazard ratios (HRs) per one standard deviation increment of each respective log-transformed plasma biomarker with 95% confidence intervals (CI). Results: Adjusted lipoprotein-associated phospholipase A2 (Lp-PLA2) activity (HR 1.33; CI 1.17–1.52) and mass (HR 1.20; CI 1.05–1.37), C-reactive protein (CRP) (HR 1.55; CI 1.36–1.76), copeptin (HR 1.46; CI 1.19–1.80), N-terminal pro-B-type natriuretic peptide (N-BNP) (HR 1.28; 1.11–1.48), and cystatin C (HR 1.19; 95% 1.10–1.29) were associated with incident symptomatic LEAD. Adjusted N-BNP (HR 1.59; CI 1.20–2.11), mid-regional proadrenomedullin (HR 1.40; CI 1.13–1.73), cystatin C (HR 1.21; CI 1.02–1.43), and CRP (HR 1.53; CI 1.13–1.73) were associated with incident symptomatic but not asymptomatic CAS. Adjusted HR was higher for Lp-PLA2 (mass) for incident isolated AAA compared to for isolated atherosclerotic disease. Conclusions: Plasma biomarker profile data support that subclinical vascular inflammation and cardiovascular stress seem to be relevant for the development of atherosclerotic disease and AAA. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate outcomes of management without surgical revascularization in patients with acute lower limb ischemia (ALI) in a population-based setting. Design: Retrospective observational population-based study. Materials: Patients from Malmö, Sweden, hospitalized for ALI between 2015 and 2018. Methods: In-hospital, surgical, radiological, and autopsy registries were scrutinized for descriptive data on ALI patients managed by endovascular and open vascular surgery, conservative vascular therapy, primary major amputation, and palliative care. Results: Among 161 patients, 73 (45.3%) did not undergo any operative revascularization. Conservative vascular therapy, primary amputation, and palliative care were conducted in 25 (15.5%), 26 (16.1%), and 22 (13.7%) patients, respectively. Conservatively treated patients had Rutherford class ≥ IIb ischemia and embolic occlusion in 33% and 68% of cases, respectively. Their median C-reactive protein level at admission was 7 mg/L (interquartile range 2 – 31 mg/L). Among conservatively treated patients, anticoagulation therapy in half to full dose was given to 22 (88%) patients for six weeks or longer, and analgesics in low or moderate doses were given to twelve (48%) patients at discharge. The major amputation rate at 1 year was 8% among conservatively treated patients, and four patients with foot embolization had not undergone amputation at 1 year. Conclusion: Patients selected for initial conservative therapy of ALI with anticoagulation alone may have a good outcome, even when admitted with Rutherford class IIb ischemia. A low C-reactive protein level at admission seems to be a favorable marker when choosing conservative therapy. A prospective, preferably multicenter, study with a predefined protocol in these conservatively treated patients is warranted to better define the dose and length of anticoagulation therapy. [ABSTRACT FROM AUTHOR]

Atherosclerosis constitutes the leading cause of death worldwide, surpassing violence. Given the physiopathological complexity it presents, it is important to recognize the genetic and atherogenic alterations associated with its development biology, which is useful for the prevention and control of obstructive vascular disease. The genetic inheritance pattern and the availability of candidate genes, such as PCSK9, APOB, APOA5, APOC3, ApoE, ABCA1, LPA, involved in the synthesis and metabolism of lipoproteins, show the possibility of establishing biomarkers related to alterations in plasma levels, demonstrating their risk association in different populations, which allows the identification of potential therapeutic targets. [ABSTRACT FROM AUTHOR]

Aim: To establish outcomes of a priority setting partnership between participants with diabetes mellitus and clinicians to identify the top 10 research priorities for preventing and treating diabetic foot ulcers (DFUs). Methods: Due to the COVID‐19 pandemic, the James Lind Alliance Priority Setting Partnership process was adapted into a digital format which involved a pilot survey to identify understandable uncertainties with high relevance for participants tested by calculating the content validity index; a main survey answered by 53 participants living with diabetes and 49 clinicians; and a final digital workshop to process and prioritise the final top 10 research priorities. Results: The content validity index was satisfactory for 20 out of 25 uncertainties followed by minor changes and one additional uncertainty. After we processed the 26 uncertainties from the main survey and seven current guidelines, a list of 28 research uncertainties remained for review and discussion in the digital workshop. The final top 10 research priorities included the organisation of diabetes care; screening of diabetes, impaired blood circulation, neuropathy, and skin properties; vascular surgical treatment; importance of self‐care; help from significant others; pressure relief; and prevention of infection. Conclusion: The top 10 research priorities for preventing and treating DFUs represent consensus areas from persons living with diabetes and clinicians to guide future research. These research priorities can justify and inform strategic allocation of research funding. The digitalisation of James Lind Alliance methodology was feasible. [ABSTRACT FROM AUTHOR]

Background: Subjects exposed to risk factors such as age, gender, hypertension, diabetes mellitus, and smoking are prone to atherosclerotic events. Aims: The main aim of this longitudinal cohort study was to determine whether the role of novel plasma biomarkers for atherosclerotic carotid artery disease is different in subjects developing symptomatic carotid artery stenosis (CAS), as opposed to those with incident asymptomatic CAS. Methods: The following biomarkers were measured in 5,550 middle-aged subjects in a population-based cohort study: C-reactive protein (CRP), lipoprotein-associated phospholipase A2 mass and activity, proneurotensin, midregional proadrenomedullin (MR-proADM), midregional proatrial natriuretic peptide (MR-proANP), N-terminal pro-B-type natriuretic peptide (NT pro-BNP), copeptin, and cystatin C. After exclusion of those with prevalent CAS, subjects were thereafter followed in national patient registers for 23.4 (interquartile range 19.5–24.3) years regarding incident symptomatic and asymptomatic CAS. Results: Among 110 patients with confirmed incident CAS, 56 were symptomatic and 54 were asymptomatic. When including conventional risk markers in a Cox regression analysis, NT pro-BNP (hazard ratio [HR] 1.59; 95% confidence interval [CI]: 1.20–2.11), MR-proADM (HR 1.40; CI: 1.13–1.73), cystatin C (HR 1.21; CI: 1.02–1.43), and CRP (HR 1.53; CI: 1.13–1.73) were independently associated with incident symptomatic CAS, whereas no plasma biomarker was associated with incident asymptomatic CAS. Conclusion: Plasma biomarkers NT pro-BNP, MR-proADM, cystatin C, and CRP were independently associated with incident symptomatic CAS, whereas no such association could be demonstrated with incident asymptomatic CAS. As these biomarkers indicate future development of clinically relevant atherosclerotic CAS, their potential utility in relation to intensified preventive measures and selection of potential candidates for carotid surgery should be further evaluated. [ABSTRACT FROM AUTHOR]

This document is a comment on an article about the diagnostic performance of computed tomography angiography (CTA) and colonoscopy in suspected colon ischemia. The authors agree that colonoscopy is useful for early diagnosis of acute colon ischemia, but it does not assess the entire small bowel and there can be a mismatch between endoscopy and surgery findings. The nomenclature for acute mesenteric ischemia (AMI) is evolving, with different guidelines considering different definitions. The authors suggest a broader view that includes all subtypes of AMI and emphasizes the need for interdisciplinary consensus. CTA is recommended as a frontline diagnostic tool for AMI, while the utility of colonoscopy in suspected non-occlusive mesenteric ischemia (NOMI) remains to be proven. [Extracted from the article]

• Most suicide victims were dead at the scene, and most homicide victims died during hospital care. • In suicides, stab injuries involving the heart and/or injuries considered unsurvivable (NISS 75) were more often observed. • In homicides, injuries involving vessels were more often observed. • Only suicides died of the minor injuries (NISS ≤ 8) causing pneumothorax, intraabdominal bleeding or incarcerated abdominal wall hernia. Homicides using knives or other sharp objects are the most common type of homicide in Europe, and the second most common type of homicide worldwide. In contrast, suicides using sharp objects are rarer, constituting only a few per cent of all suicides in western countries. We investigated single stab injuries to the trunk in both homicides and suicides to assess differences in extent of injuries and in medical care, which could be of value for trauma management, public health and forensic assessment. We identified all cases in Sweden between 2010 and 2021 that died of a single stab to the trunk, in either a homicide (n = 94) or a suicide (n = 45), and that were the subject of a forensic autopsy. We obtained data on demographics, hospital care and injured structures. To assess the severity of injuries, we applied AIS (Abbreviated Injury Score) and NISS (New Injury Severity Score). The inter-rater reliability of NISS between two raters was evaluated with intra-class correlation (ICC), with 95 % confidence intervals (CI). The data was analysed using Fisher's exact test, Mann-Whitney U test and logistic regression models. The inter-rater reliability between the two NISS raters showed an ICC of 0.87 (95 % CI 0.68−0.95). We observed a larger variation of injuries in suicides, with a higher proportion of both unsurvivable (NISS 75) and minor injuries (NISS ≤ 8) (66.7 % and 8.9 % respectively) compared to in homicides (46.8 % and 0 % respectively). We observed a larger proportion of injuries to the heart in suicides (68.9% vs. 46.8 %, p = 0.018). In homicides, injuries involving vessels (52.1% vs. 13.3 %, p < 0.001) and hospital care (56.4 % vs. 8.9 %, p < 0.001) were significantly more common compared to suicides. Causation (self-inflicted or assaults) seems to be associated with characteristics of injury and the likelihood of receiving hospital care. These findings could potentially be valuable for trauma management and forensic assessment of manner of death, however, determining the mortality of the injuries would require a comparison group comprising injured survivors. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to investigate fibre, and plant foods, and its association with AAA risk. Methods: In this prospective cohort study, Malmö Diet and Cancer Study, baseline data collection was carried out 1991–1996. The study participants' (n = 26,133) dietary habits were extensively recorded at baseline. The specific diagnosis of AAA in the in-hospital registry was found valid in 95%. The association between plant foods, such as cereals and types of vegetables, and AAA was assessed by using Cox regression analysis expressed as hazard ratios (HR) with 95% confidence intervals (CI). Results: A high intake of fibre was independently associated with AAA risk (HR per quintile 0.87, 95% CI 0.79–0.97). High intake of vegetables (HR 0.91, 95% CI 0.84–0.98), specifically leaf vegetables (HR 0.87, 95% CI 0.81–0.94), and fruits and berries (HR 0.89, 95% CI 0.82–0.96), citrus (HR 0.91, 95% CI 0.85–0.98) and non-citrus fruits (HR 0.87, 95% CI 0.81–0.95) were independently associated with a decreased AAA risk. Conclusions: A high intake of fruits and berries and vegetables, in particular leaf vegetables, are associated with a decreased risk of developing AAA. [ABSTRACT FROM AUTHOR]

Background: Stroke is one of the leading causes of death, and out of all stroke cases, 10–15% originate from a previously asymptomatic stenosis in the internal carotid artery. Aims: The aim of the study was to investigate whether dietary and lifestyle habits were associated with future risk of incident carotid artery disease (CAD). Methods: Baseline examinations on middle-aged individuals (n = 30,447) in the Malmö Diet and Cancer study (MDCS), a prospective cohort study, took place between 1991 and 1996 in Malmö, Sweden. Individuals with cardiovascular disease and diabetes mellitus were excluded at baseline, resulting in a total study population of 25,952 patients. Information on dietary intake was gathered through a 7-day food diary, a detailed questionnaire, and a 1-h interview. A diet quality index was calculated from adherence to recommended intake of 6 dietary components (saturated fat, polyunsaturated fat, fish and shellfish, fiber, vegetables and fruit, and sucrose). Individuals with a first registered diagnosis of CAD were identified from the Swedish National Patient register. Results: During a median follow-up of 21.8 years, 469 participants (1.8%) developed CAD. The diagnosis of incident CAD was validated and confirmed in 99% of a random sample of 100 individuals. Higher intake of vegetables and fruit was associated with a trend of decreased risk of CAD in a Cox regression analysis (hazard ratio of 0.76, 95% confidence interval 0.56–1.03; p = 0.080). Conclusions: In conclusion, the present study found a trend toward a protective effect of higher intake of vegetables and fruit against incident CAD. More prospective studies investigating the association between diet and CAD and stroke are needed in order to give firm recommendations. [ABSTRACT FROM AUTHOR]

Background. Aortic dissection (AD) and abdominal aortic aneurysm (AAA) share the same risk factors. Whereas the incidence of AAA is falling, it is unclear whether population-based incidences of acute type A and B AD have changed. The aim of this study was to investigate incidences of AD subtypes over time. Methods. Citizens in the municipality of Malmö, Sweden, diagnosed with AD in 2000-2004 and 2014-2016 were identified through the in-patient, clinical, and forensic autopsy registers. Results. The overall and gender-specific incidences of acute type A and B AD were stable over time. The overall autopsy rate declined from 25.2% in 2000-2004 to 16.1% in 2014-2016 (p = .0001) and patients with acute type A AD were more often encountered at autopsy (78% of cases) during the first time period, compared to 43% of cases during the second time period (p = .005), when the ratio of acute type A: acute type B AD was 2.6: 1. The proportion of individuals <65 years of age tended to be higher in acute type A AD compared to acute type B AD (p = .07). The frequencies of hypertension and smoking were 90% and 91%, respectively, in type A AD, and 86% and 86%, respectively in type B AD. Conclusions. Population-based incidences of acute type A and type B AD were stable over time, but the decreasing autopsy rate has led to a lower proportion of AD diagnosed at autopsy. Primary prevention towards hypertension and smoking seem necessary to reduce AD incidence. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study is to evaluate plasma biomarkers as predictors for peripheral arterial disease (PAD). Materials and methods: Prospective longitudinal cohort study of middle-aged individuals from the cardiovascular cohort of the Malmö Diet and Cancer study (MDCS) (n = 5550; 1991–94). Cystatin C, copeptin, N-terminal pro-B-type natriuretic peptide (N-BNP), midregional proatrial natriuretic peptide (MR-proANP), mid-regional proadrenomedullin (MR-proADM), and conventional risk factors were measured at baseline. The diagnosis of symptomatic PAD was validated in 97% of the cases. Results: Cumulative incidence of PAD during median follow up of 23.4 years was 4.4% (men 5.9%, women 3.3%). Adjusted for age, sex, smoking, body mass index, hypertension, diabetes mellitus and total cholesterol, copeptin (hazard ratio [HR] 1.46; 95% confidence interval [CI] 1.19–1.80), N-BNP (HR 1.28; 95% CI 1.11–1.48), and cystatin C (HR 1.19; 95% CI 1.10–1.29) were independently associated with incident PAD. Subjects with the three biomarkers copeptin, N-BNP, and cystatin C in the highest quartiles, ran a high risk of incident PAD (HR 3.29; 95% CI 1.76–6.17) compared to those with no biomarker in the highest quartile. Conclusion: Copeptin, N-BNP, and cystatin C were associated with incident symptomatic PAD, implying that these biomarkers are sensitive indicators of early subclinical PAD. First prospective longitudinal cohort study evaluating Cystatin C, copeptin, N-terminal pro-B-type natriuretic peptide (N-BNP), midregional proatrial natriuretic peptide (MR-proANP), and mid-regional proadrenomedullin (MR-proADM) as predictors for peripheral arterial disease (PAD). Copeptin, N-BNP, and Cystatin C where independently associated with incident symptomatic PAD after adjustment for conventional risk factors. Copeptin, N-BNP, and Cystatin C seem to be sensitive indicators of early subclinical PAD. [ABSTRACT FROM AUTHOR]

Forensic pathologists are frequently confronted with questions about whether an injury is likely to have been inflicted by an assault or be self-inflicted. However, little is known of the epidemiological variables that might be applicable to differentiate between homicides and suicides in deaths caused by single stab injuries to the trunk. Using the Swedish forensic autopsy register, we identified 94 homicides and 45 suicides between 2010 and 2021 in which death followed a single stab injury to the trunk. We extracted characteristics from the cases and performed statistical analyses using the Mann-Whitney U test, Chi-square test and logistic regression model. Victims of homicides were younger than suicide victims (median age 33 years vs. 52 years, p < 0.05), and males were in the majority in both groups (93% vs. 82%). In numerous homicide victims, stab wounds were placed in the back and in axillar regions, unlike in suicides victims in which the stabs were all placed on the medial part of the anterior trunk. Vertical entrance wounds in the skin combined with a medially running injury channel (n = 13) showed a positive predictive value of 100% (95% CI 75.3–100) for homicide, although the sensitivity was low. Homicides were conclusively associated with an outdoor death scene (OR 19.0, 95% CI 7.6–47.1), injury to thoracic bone/cartilage (OR 3.8, 95% CI 1.6–9.0), influence of alcohol (OR 7.1, 95% Cl 2.9–17.7) and illicit drugs (OR 4.3, 95% CI 1.5–11.9). The observed forensic characteristics of stab injuries could be used as a tool when assessing the manner of death in single stabs. Further research on variables associated with manner of death are needed and we suggest also including characteristics of surviving victims in such analyses. • Homicide victims were predominately young males and often found outdoors. • All suicidal stabs were located on the medial part of the anterior trunk. • Homicidal stabs were scattered on all sides of the trunk. • Alcohol and illicit narcotics were more often proved in homicides. [ABSTRACT FROM AUTHOR]

Prospective clinical plasma biomarker studies in abdominal aortic aneurysm (AAA) pathogenesis have been hampered by the need for very large cohorts and long follow-up time. The main aim of the present study was to evaluate the association of adrenomedullin, a cardiovascular (CV) stress marker, and incident AAA risk. Prospective longitudinal cohort of middle-aged individuals from the CV cohort of the Malmö Diet and Cancer Study (n = 5551; 1991-1994) was assessed. Plasma concentrations of midregional proadrenomedullin (MR-proADM), C-reactive protein (CRP), and conventional risk factors were measured at baseline. Incidence of AAA was studied up to December 31, 2013. Cumulative incidence of AAA was 1.5% (men 2.9%, women 0.5%). Mean age of individuals with incident AAA was 59.7 years at study entry, and AAA was diagnosed on average 14 years later. Adjusting for age, gender, smoking, body mass index, hypertension, diabetes mellitus, and CRP, MR-proADM (hazard ratio: 1.28; 95% confidence interval: 1.01-1.62) was independently associated with incident AAA. The plasma biomarker MR-proADM seems to be a marker of AAA risk, implying that AAA development may be driven by long-standing CV stress on the aortic wall. [ABSTRACT FROM AUTHOR]

Acute mesenteric ischaemia (AMI) is a condition that can lead to necrosis of the bowel and potentially fatal outcomes. This article provides an overview of recent evidence related to the diagnosis, management, and outcomes of AMI. Timely diagnosis of AMI is challenging due to its different causes and nonspecific symptoms. It is important for healthcare professionals, especially those in intensive care units, to be aware of AMI as it is often underrecognized and underdiagnosed. The ultimate goal of managing AMI is to restore blood flow to the bowel before irreversible damage occurs. Different treatment options are available depending on the subtype of AMI. Mortality rates for AMI remain high, but early revascularization has been associated with improved survival. More research is needed to improve the diagnosis and treatment of AMI. [Extracted from the article]

Pathogenesis of abdominal aortic aneurysm (AAA) is unclear. The aim of this study was to evaluate inflammatory and hemodynamic plasma biomarkers as predictors for AAA in the prospective longitudinal cohort of middle-aged individuals from the cardiovascular cohort of the Malmö Diet and Cancer Study (n=5551; 1991-94). C-reactive protein, cystatin C, copeptin, N-terminal pro-B-type natriuretic peptide (N-BNP), midregional pro-atrial natriuretic peptide (MR-proANP) and conventional risk factors at baseline were measured in patients with incident AAA during follow-up and compared to individuals without a diagnosis of AAA. Subjects were followed until 31 December 2013. Multivariable analyses were expressed in terms of hazard ratios (HR) per 1 standard deviation increment of each respective log-transformed plasma biomarker in the Cox proportional hazard models. Mean follow-up time was 20.7 years. Cumulative incidence of AAA was 1.5% (men 2.9%, women 0.5%). Mean age of individuals with incident AAA was 59.7 years at study entry and AAA was diagnosed on average 14 years later. Adjusting for age, sex, smoking, body mass index, hypertension and diabetes mellitus, N-BNP (HR 1.29; 95% CI 1.03-1.62), but not MR-proANP (HR 1.20; 95% CI 0.95-1.50), was independently associated with incident AAA. In conclusion, the plasma biomarker N-BNP was associated with future development of AAA, which implies that this marker is a sensitive indicator of early subclinical cardiovascular disease. [ABSTRACT FROM AUTHOR]

Background and aims The pathogenesis of abdominal aortic aneurysm (AAA) shares several common pathways with atherosclerosis. Prospective clinical plasma biomarker studies in AAA have been hampered by the need for very large cohorts and long follow-up time. Methods We analyzed a prospective longitudinal cohort of middle-aged individuals from the cardiovascular cohort of the Malmö Diet and Cancer study (n = 5551; 1991-94). The plasma biomarkers lipoprotein-associated phospholipase A2 (Lp-PLA 2 activity and mass), proneurotensin and C-reactive protein, and conventional risk factors at baseline were measured in patients with incident AAA during follow-up, and compared to individuals without a diagnosis of AAA. Subjects were followed until December 31st, 2013. Multivariable analyses were expressed in terms of hazard ratios (HR) per 1 standard deviation increment of each respective log-transformed plasma biomarker in the Cox proportional hazard models. Results Cumulative incidence of AAA was 1.5% (men 2.9%, women 0.5%) during a median follow-up period of 20.7 years. Overall, 84 individuals had an incident AAA, of whom 22 (26.2%) were operated on and 16 (19.0%) had ruptured. Mean age of individuals with incident AAA was 59.7 years at study entry and AAA was diagnosed on average 14 years later. When adjusting for age, gender, smoking, body mass index, hypertension, and diabetes mellitus, Lp-PLA 2 activity (HR 1.40; 95% CI 1.15–1.72) and Lp-PLA 2 mass (HR 1.23; 95% CI 1.00–1.51) were independently associated with incident AAA. Conclusions The plasma biomarkers Lp-PLA 2 activity and mass were markers of AAA risk and this implies that AAA is an athero-thrombotic related disease. [ABSTRACT FROM AUTHOR]

Aims and objectives To explore experiences of negative pressure wound therapy at home, in patients with deep perivascular groin infection after vascular surgery and management in daily life. Background Deep surgical site infection after vascular surgery with exposed vessels often requires long-term treatment with negative pressure wound therapy, and continued therapy at home has become routine. Design An explorative qualitative study. Methods Nine men and six women with a deep surgical site infection in the groin after vascular surgery, treated in their home with negative pressure wound therapy, were interviewed. The interviews were analysed using manifest and latent content analysis. Results Undergoing negative pressure wound therapy at home meant a transition from being a dependent patient to a person who must have self-care competence and be involved in their own care. A need to feel prepared for this before discharge from hospital was expressed. Lack of information and feelings of uncertainty prolonged the time before feeling confident in managing the treatment. The informants gradually accepted the need to be tied up to a machine, became competent in its management and found solutions to perform everyday tasks. Overall, it was a relief to be treated at home. Conclusions Several benefits of negative pressure wound therapy at home were expressed. However, unnecessary stress and anxiety were experienced due to a lack of information on the treatment and instruction concerning the equipment. Adequate information and education must therefore be provided to facilitate the transition from a patient to a person with self-care competence and ability to manage this treatment at home. Relevance to clinical practice The findings revealed a need for more support and knowledge in their transition from hospital care to home care with negative pressure wound therapy. Routines must be established that ensure patient safety and security in treatment at home. [ABSTRACT FROM AUTHOR]

Introduction: The Basic Surgical Skills course uses an assessment score interval of 0-3. An extended score interval, 1-6, was proposed by the Swedish steering committee of the course. The aim of this study was to analyze the trainee scores in the current 0-3 scored version compared to a proposed 1-6 scored version. Methods: Sixteen participants, seven females and nine males, were evaluated in the current and proposed assessment forms by instructors, observers, and learners themselves during the first and second day. In each assessment form, 17 tasks were assessed. The inter-rater reliability between the current and the proposed score sheets were evaluated with intraclass correlation (ICC) with 95% confidence intervals (CI). Results: The distribution of scores for 'knot tying' at the last time point and 'bowel anastomosis side to side' given by the instructors in the current assessment form showed that the highest score was given in 31 and 62%, respectively. No ceiling effects were found in the proposed assessment form. The overall ICC between the current and proposed score sheets after assessment by the instructors increased from 0.38 (95% CI 0.77-0.78) on Day 1 to 0.83 (95% CI 0.51-0.94) on Day 2. Discussion: A clear ceiling effect of scores was demonstrated in the current assessment form, questioning its validity. The proposed score sheet provides more accurate scores and seems to be a better feedback instrument for learning technical surgical skills in the Basic Surgical Skills course. [ABSTRACT FROM AUTHOR]

Abstract: Background: Acute superior mesenteric artery (SMA) occlusion leads to acute intestinal ischemia and is associated with high mortality. Early diagnosis is often missed, and confounding factors leading to diagnostic delays need to be highlighted. Objectives: To identify potential diagnostic laboratory pitfalls at admission in patients with acute SMA occlusion. Methods: Fifty-five patients with acute SMA occlusion were identified from the in-hospital register during a 4-year period, 2005–2009. Results: The median age was 76 years; 78% were women. The occlusion was embolic in 53% and thrombotic in 47% of patients. At admission, troponin I was above the clinical decision level (> 0.06 μg/L) for acute ischemic myocardial injury in 9/19 (47%) patients with embolic occlusion. Elevated pancreas amylase and normal plasma lactate were found in 12/45 and 13/27, respectively. A troponin I (TnI) above the clinical decision level was associated with a high frequency of referrals from the general surgeon to a specialist in internal medicine (p = 0.011) or a cardiologist (p = 0.024). The diagnosis was established after computed tomography angiography in 98% of the patients. The overall in-hospital mortality rate was 33%. Attempting intestinal revascularization (n = 43; p < 0.001), with a 95% frequency rate of completion control of the vascular procedure, was associated with a higher survival rate, whereas referral to the cardiologist was associated with a higher mortality rate (p = 0.018). Conclusion: Elevated TnI was common in acute SMA occlusion, and referral to the cardiologist was found to be associated with adverse outcome. Elevated pancreas amylase and normal plasma lactate values are also potential pitfalls at admission in patients with acute SMA occlusion. [Copyright &y& Elsevier]

Background: Reports on trends in incidence and mortality of acute superior mesenteric artery (SMA) occlusion and evaluation of prognostic factors in recent years are lacking.Methods: Patients with acute SMA occlusion were identified through the in-patient and autopsy registry between 1970 and 1982 (n = 270), 1987 to 1996 (n = 135), and 2000 and 2006 (n = 100) in Malmö, Sweden.Results: The overall incidence rate decreased from 8.6 to 5.4/100,000 person years and the autopsy rate from 87% to 25% over time. A higher serum creatinine level was associated with a lower probability of undergoing multi-detector row computed tomography with intravenous contrast (MDCTiv) (p = 0.006). Not performing a MDCTiv (odds ratio 4.0; 95% confidence interval [1.0-16.0]) remained as independent prognostic factor for in-hospital mortality. General and vascular surgeons collaborated in 25 out of 61 patients that underwent an intervention, of which 21 (84%) (p < 0.001) survived.Conclusions: A close collaboration between radiologists and general and vascular surgeons seems to be most important to lower the mortality in patients with acute SMA occlusion. [ABSTRACT FROM AUTHOR]

Background: Plasma markers for intestinal ischemia have not proven to be accurate. The value of L-lactate is unclear. Experimental models based on open surgery confound the effects of surgical trauma with that of ischemia. The aim was to create an endovascular model for acute superior mesenteric artery thromboembolism, and then to study L-lactate and lactate dehydrogenase (LD) activity in plasma and peritoneal fluid in pigs with extensive, high-grade intestinal ischemia. Materials and methods: Nine pigs underwent full superior mesenteric artery embolization with 4 h of intended intestinal ischemia, whereas six were control animals. Sampling of central venous and arterial blood was performed throughout the experiment, ending with laparotomy to collect peritoneal fluid and segmental intestinal biopsies. A pathologist, blinded to the performed interventions, graded the ischemic lesions. Results: There were no differences in plasma L-lactate (P = 0.61) or LD activity levels (P = 0.69), measured at different time points from baseline to end of study, between animals with extensive, high-grade intestinal ischemia and sham. Intraperitoneal L-Lactate (P = 0.005) and LD activity (P = 0.018) levels were elevated compared with sham. There were differences in grades of ischemia in the duodenum (P = 0.003), small intestine (P < 0.001), proximal (P < 0.001), and sigmoid (P = 0.032) colon between experimental animals and sham. The grade of small bowel ischemia (n = 15) correlated to intraperitoneal fluid L-lactate (r = 0.80; P < 0.001) and LD activity levels (r = 0.72; P = 0.003). Conclusions: This endovascular study in a porcine model showed that L-lactate and LD activity levels in peritoneal fluid, not in plasma, reflect intestinal ischemia. The study suggests that plasma L-lactate not is a useful early marker in patients with suspicion of intestinal ischemia. [Copyright &y& Elsevier]

Open abdomen (OA) treatment often results in difficulties in closing the abdomen. Highest closure rates are seen with the vacuum-assisted wound closure (VAWC) technique. However, we have experienced occasional failures with this technique in cases with severe visceral swelling needing longer treatment periods with open abdomen. Feasibility and short-term outcome of a novel combination of techniques for managing the open abdomen are presented. The VAWC technique was combined with medial traction of the fasciae through a temporary mesh in seven consecutive patients. The VAWC-system was changed and the mesh tightened every 2–3 days. Median (range) age in the 7 men was 65 (17–78) years. The diagnoses were ruptured abdominal aortic aneurysm (AAA) (3), operation for juxtarenal AAA (1), iatrogenic aortic lesion (1), trauma (1) and abdominal abscesses (1). Four patients were decompressed due to abdominal compartment syndrome (ACS) or intra-abdominal hypertension, and 3 could not be closed after laparotomy. Intra-abdominal pressure prior to OA treatment was 24 (17–36) mmHg. Maximal separation of the fasciae was 16 (7 –30) cm. Delayed primary closure was achieved in all patients after 32 (12–52) days with OA. No recurrent ACS was seen. No technique-specific complication was observed. Two small incisional hernias, one intra-abdominal abscess and one wound infection occurred in three patients. Delayed primary closure in cases with severe visceral swelling and long periods of OA seems feasible with this technique. [ABSTRACT FROM AUTHOR]

Background: In 1992, there were major changes in Swedish law of the deceased, which had led to a dramatic decrease in autopsy rates. The aim of this study was to investigate the prevalence of fatal or potential fatal surgical diseases within a Swedish forensic autopsy cohort, before and after this change in legislation. Methods: Deaths referred for forensic autopsy at the Institution of Forensic Medicine, Lund University Hospital, Sweden, between 1970–1982 and 2000–2004, were studied regarding the prevalence of aorto-iliac diseases, acute abdomen and abdominal cancer. Results: The forensic autopsy rates in the population during the two time periods were 14.0% (29 399 patients) and 5.3% (4487 patients), respectively. The total prevalence of surgical diseases has increased significantly from 67.3 (95% confidence interval 64.3–70.2) to 83.4 (74.9–91.8) per 1000 autopsies, respectively. The cause-specific mortality ratios in patients with fatal acute abdomen increased significantly from 16.5 (15.1–18.0) to 39.0 (33.2–44.8) per 1000 autopsies, respectively, and there was almost a three-time increase in patients with fatal gastrointestinal haemorrhage and acute alcohol-related pancreatitis. Conclusion: Forensic autopsy data continues to be invaluable, despite changes in legislation in Sweden, for epidemiological studies on fatal or potential fatal surgical diseases. [ABSTRACT FROM AUTHOR]

Objectives. To estimate the incidence of fatal colonic ischaemia (CI) and the cause-specific mortality of CI, and to describe the localization and extension of colonic infarction and quantify the risk factors associated with CI.Material and methods. Between 1970 and 1982 the autopsy rate in Malmö, Sweden, was 87%, creating the possibilities for a population-based study. Out of 23,446 clinical autopsies, 997 cases were coded for intestinal ischaemia in a database. In addition, 7569 forensic autopsy protocols were analysed. In a case-control study nested in the clinical autopsy cohort, four CI-free controls, matched for gender, age at death and year of death, were identified for each fatal CI case in order to evaluate the risk factors.Results. The cause-specific mortality ratio was 1.7/1000 autopsies. The overall incidence of autopsy-verified fatal CI was 1.7/100,000 person years, increasing with age up to 23/100,000 person years in octogenarians. Fatal cardiac failure (odds ratio (OR) 5.2), fatal valvular disease (OR 4.3), previous stroke (OR 2.5) and recent surgery (OR 3.4) were risk factors for fatal CI. Narrowing/occlusion of the inferior mesenteric artery (IMA) at the aortic origin was present in 68% of the patients. The most common segments affected by transmural infarctions were the sigmoid (83%) and the descending (77%) colon.Conclusions. Heart failure, atherosclerotic occlusion/stenoses of the IMA and recent surgery were the main risk factors causing colonic hypoperfusion and infarction. Segments of transmural infarctions were observed within the left colon in 94% of the patients. Awareness of the diagnosis and its associated cardiac comorbidities might help to improve survival. [ABSTRACT FROM AUTHOR]

Background: The association between leisure-time physical activity and cardiovascular mortality has been previously studied, but few studies have focused on specific activities and intensities.Methods: The association between different leisure-time physical activities and cardiovascular mortality was investigated among 25,876 individuals without diabetes or cardiovascular disease from the population-based Malmö Diet and Cancer Study cohort. The individuals estimated the average duration spent on 17 physical activities at baseline in 1991-1996 and after 5 years. Cardiovascular mortality was obtained from a register during a mean of 20 years of follow-up.Results: A total leisure-time physical activity of 15-25 metabolic equivalent task (MET) hours/week was associated with a decreased risk of cardiovascular mortality (HR 15-25 vs < 7.5 MET-h/week =0.80, 95% CI 0.69-0.93), with no further risk reduction at higher levels. Several high-intensity activities (i.e., lawn tennis and running) and moderate-intensity activities (i.e., golf, cycling and gardening) were associated with a reduced risk. Individuals who engaged in high-intensity physical activity for an average of 2.29 MET h/week (30 min/week) had an 18% (95% CI 0.72-0.93) reduced risk of cardiovascular mortality compared with non-participants, and no further risk reductions were observed at higher levels. Decreased risk was observed among individuals who had started (HR 0.56, 95% CI 0.32-0.97) or continued (HR 0.49, 95% CI 0.36-0.66) high-intensity activities at the five-year follow-up.Conclusions: Moderate- and high-intensity leisure-time physical activities reduced the risk of cardiovascular mortality. With regard to total leisure-time physical activity, the largest risk reduction was observed for 15-25 MET-h/week (equivalent to walking for approximately 5 h/week). [ABSTRACT FROM AUTHOR]

Objective: To compare costs of transurethral prostatic resection (TURP) and transurethral microwave thermotherapy (TUMT) for symptomatic benign prostatic hyperplasia (BPH) in a randomized, controlled trial. Methods: In 70 BPH patients all costs were calculated for management, including complications and repeat treatment, during TURP or TUMT and 24-month follow-up. Clinical outcome was judged from Madsen-Iversen symptom score, peak urinary flow and residual urine. The effect of changes in some critical variables was assessed by sensitivity analysis. A cost-effectiveness analysis was carried out to compare the two methods. Results: Symptom reduction after 2 years was 92% in the TURP group and 83% in the TUMT group. The total costs over 2 years were SEK 24,234 and 14,830 in the respective groups. Costs for retreatments were higher after TUMT, while complication costs were higher in the TURP group. TUMT costs depend on the investment for the equipment, including disposable probes, and the degree of its utilization. TUMT was more cost-effective than TURP in relieving BPH-related symptoms during the 2-year follow-up. Conclusions: Primary treatment costs were lower for TUMT than for TURP. Complication costs were higher in the trial's TURP arm, while retreatment costs were greater in the TUMT arm. TUMT costs depend on investment in and utilization of the equipment and reuse of treatment probes. TUMT was more cost-effective than TURP in the 2-year study period. [ABSTRACT FROM AUTHOR]

The article discusses medical screenings for abdominal aortic aneurysms (AAAs) in older men in Sweden, and it mentions the Swedish National Board of Health and Welfare, as well as another article in the journal which examines the impact of AAA screening on disease-specific mortality, incidence, and surgery. An increase in AAA diagnosis is assessed, along with smoking-related diseases and issues such as overtreatment and overdiagnosis.

Background: The Abdominal Compartment Society (WSACS) established consensus definitions and recommendations for the management of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) in 2006, and they were last updated in 2013. The WSACS conducted an international survey between 2022 and 2023 to seek the agreement of healthcare practitioners (HCPs) worldwide on current and new candidate statements that may be used for future guidelines. Methods: A self-administered, online cross-sectional survey was conducted under the auspices of the WSACS to assess the level of agreement among HCPs over current and new candidate statements. The survey, distributed electronically worldwide, collected agreement or disagreement with statements on the measurement of intra-abdominal pressure (IAP), pathophysiology, definitions, and management of IAH/ACS. Statistical analysis assessed agreement levels, expressed in percentages, on statements among respondents, and comparisons between groups were performed according to the respondent's education status, base specialty, duration of work experience, role (intensivist vs non-intensivist) and involvement in previous guidelines. Agreement was considered to be reached when 80% or more of the respondents agreed with a particular statement. Results: A total of 1042 respondents from 102 countries, predominantly physicians (73%), of whom 48% were intensivists, participated. Only 59% of HCPs were aware of the 2013 WSACS guidelines, and 41% incorporated them into practice. Despite agreement in most statements, significant variability existed. Notably, agreement was not reached on four new candidate statements: "normal intra-abdominal pressure (IAP) is 10 mmHg in critically ill adults" (77%), "clinical assessment and estimation of IAP is inaccurate" (65.2%), "intragastric can be an alternative to the intravesical route for IAP measurement" (70.4%), and "measurement of IAP should be repeated in the resting position after measurement in a supine position" (71.9%). The survey elucidated nuances in clinical practice and highlighted areas for further education and standardization. Conclusion: More than ten years after the last published guidelines, this worldwide cross-sectional survey collected feedback and evaluated the level of agreement with current recommendations and new candidate statements. This will inform the consensus process for future guideline development. [ABSTRACT FROM AUTHOR]

This comment is a response to an article on non-occlusive mesenteric ischemia (NOMI), which is a challenging subtype of acute mesenteric ischemia (AMI). The authors acknowledge the importance of diagnosing and treating NOMI, but highlight the difficulties in doing so due to its similarity to other conditions and the lack of clear diagnostic criteria. They suggest that intra-arterial vasodilation could be a potential treatment for NOMI, but caution that current evidence is limited to retrospective studies. They propose a multi-center randomized controlled trial to further investigate this treatment option and are planning a prospective study on biomarkers. The authors invite interested parties to participate in their research. [Extracted from the article]

Background: The Hawthorne Effect is the change in behaviour by subjects due to their awareness of being observed and is evident in both research and clinical settings as a result of various forms of observation. When the Hawthorne effect exists, it is short-lived, and likely leads to increased productivity, compliance, or adherence to standard protocols. This study is a qualitative component of an ongoing multicentre study, examining the role of Incisional Negative Pressure Wound Therapy after vascular surgery (INVIPS Trial). Here we examine the factors that influence hygiene and the role of the Hawthorne effect on the adherence of healthcare professionals to standard hygiene precautions.Methods: This is a qualitative interview study, investigating how healthcare professionals perceive the observation regarding hygiene routines and their compliance with them. Seven semi-structured focus group interviews were conducted, each interview included a different staff category and one individual interview with a nurse from the Department for Communicable Disease Control. Additionally, a structured questionnaire interview was performed with environmental services staff. The results were analysed based on the inductive qualitative content analysis approach.Results: The analysis revealed four themes and 12 subthemes. Communication and hindering hierarchy were found to be crucial. Healthcare professionals sought more personal and direct feedback. All participants believed that there were routines that should be adhered to but did not know where to find information on them. Staff in the operating theatre were most meticulous in adhering to standard hygiene precautions. The need to give observers a clear mandate and support their work was identified. The staff had different opinions concerning the patient's awareness of the importance of hygiene following surgery. The INVIPS Trial had mediated the Hawthorne effect.Conclusion: The results of this study indicate that the themes identified, encompassing communication, behaviour, rules and routines, and work environment, influence the adherence of healthcare professionals to standard precautions to a considerable extent of which many factors could be mediated by a Hawthorne effect. It is important that managers within the healthcare system put into place an improved and sustainable hygiene care to reduce the rate of surgical site infections after vascular surgery. [ABSTRACT FROM AUTHOR]

Background: Previous reports have suggested higher rates of mortality and amputation for female patients in acute lower limb ischemia (ALI). The aims of the present study were to investigate if there is a difference in mortality, amputation, and fasciotomy between the sexes. Methods: A retrospective cohort study of consecutive patients undergoing index revascularization for ALI between 2001 and 2018 was conducted. A propensity score was created through a logistic regression with female/male sex as an outcome. Cox regression analyses for 90‐day and 1‐year mortality, combining major amputation/mortality, and logistic regression for major bleeding and fasciotomy, were performed. All analyses were performed with and without adjusting for propensity score. Results: A total of 709 patients were included in the study of which 45.9% were women. Mean age was 72.1 years. Females were older and had higher rates of atrial fibrillation, embolic disease, and lower estimated glomerular filtration rate, while men more often had anemia and chronic peripheral arterial disease. Mortality at 1 year was 21.2% for women and 14.7% for men. The adjusted hazard ratio for 1‐year mortality was 0.99 (95% CI 0.67–1.46). Fasciotomy was performed in 7.1% of female and 12.8% of male patients; the adjusted odds ratio was 0.52 (95% CI 0.29–0.91). Conclusion: Sex was not found to be an independent risk factor for mortality or combined major amputation/mortality after revascularization for acute lower limb ischemia, whereas women had lower odds of undergoing fasciotomy. Whether women are underdiagnosed or do not develop acute compartment syndrome in the lower leg as often as men should be evaluated prospectively. [ABSTRACT FROM AUTHOR]

Background: Open repair (OR) for popliteal artery aneurysm (PAA) has recently been challenged by endovascular repair (ER) as the primary choice of treatment. The aim of the present study was to evaluate time trends in treatment modality and compare outcomes between OR and ER among electively operated patients after start of screening in 2010 for abdominal aortic aneurysm (AAA), a disease highly associated with PAA. Methods: Between January 1, 2009, and April 30, 2017, 102 procedures and 36 acute and 66 elective repairs for PAA were identified. Results: Over time, a trend (P = .089) for an increasing elective to acute repair ratio of PAA and an increase in elective ER to OR ratio (P = .003) was found. Among electively repaired PAAs, the ER group was older (P = .047) and had a higher ankle–brachial index (ABI; P = .044). The ER group had fewer wound infections (P = .003), fewer major bleeding complications (P = .046), and shorter in-hospital stay (P < .001). After 1 year of follow-up, the ER group had a higher rate of major amputations (P = .037). Amputation-free survival at the end of follow-up did not differ between groups (P = .68). Among the 17 patients with PAA eligible for AAA screening, 4 (24%) were diagnosed with PAA through the screening program of AAA. Conclusion: The epidemiology of elective repair of PAA has changed toward increased ER, although ER showed a higher rate of major amputations at 1 year. Confounding was considerable and a randomized trial is needed for evaluation of the best therapeutic option. [ABSTRACT FROM AUTHOR]

Abstract: Purpose of the investigation: Scar formation is an important, permanent surrogate marker for wound healing. The main aim of this randomized trial was to evaluate the effects of incisional negative pressure wound therapy (iNPWT) on scar formation in uncomplicated wound healing with 3‐dimensional (3D) digital imaging. Basic procedures: Patients undergoing bilateral inguinal incisions after vascular surgery were randomized to receive iNPWT and standard dressing on separate sides. The incisional scars were documented at a median time of 808 days (range 394–1194) after surgery with 3D photography, which were objectively evaluated by two plastic surgeons using the Stony Brook scar evaluation scale (SBSES) and a 10‐point graded numeric ranking scale (NRS10). Subjective evaluation was performed with the patient observer scar assessment scale (POSAS). Patients with surgical site infection or other wound complications were excluded to minimize bias. The p‐values were calculated using McNemar's and Wilcoxon signed‐rank test for paired nominal and paired continuous data, respectively. Main findings: Among 33 patients, 32 patients had undergone endovascular aortic repair (EVAR) and 31 patients had transverse inguinal incisions. Objective and subjective scar evaluation showed no difference between iNPWT and standard dressing. In objective scorings, 18.8 and 21.9% received the highest possible SBSES total score in the iNPWT and standard dressing groups, while 43.8 and 37.5% received the highest possible NRS10 score, respectively. The inter‐rater reliability between the two assessors for SBSES total score and NRS10 showed an intra‐class correlation (ICC) of 0.78 and 0.68 for NPWT and 0.70 and 0.77 for traditional dressing, respectively. Principal conclusion: The present randomized trial showed that iNPWT and standard dressings on closed transverse inguinal incisions after EVAR resulted in equal subtle scar formation. Objective scar evaluation with 3D images showed good inter‐rater agreement. [ABSTRACT FROM AUTHOR]

Background: Surgical site infections (SSIs) and their prevention continue to be a major point of focus in all surgical specialties today. Antibiotic prophylaxis is one of the mainstays in their prevention. Due to the consistently high proportion of infections caused by intestinal flora from the start of our wound surveillance registry in 2005, we conducted a change in prophylactic antibiotic therapy from cloxacillin in 2012 to trimethoprim/sulfamethoxazole (TMP-SMX) in 2013. Methods: The study included all patients undergoing vascular surgery with groin incisions between March 1 and June 30 in 2012 and 2013, respectively, whereby the antibiotic regime was changed in between the 2 sampling periods. The diagnosis of SSI was based on clinical examination and microbiological results. Results: Two hundred nineteen patients with inguinal incisions were included in the analysis: 105 in the cloxacillin group of which 19% had SSI and 114 in the TMP-SMX group with an SSI rate of 18% (P = .77), without differences between the 2 groups regarding age, gender, proportion of emergency surgery, type of surgery, or frequency of concomitant foot ulcers. The high proportion of infections caused by intestinal flora between time periods was unchanged (67% vs 81%, P = .34). Conclusion: There was no difference between the 2 groups, suggesting that the choice of antibiotic prophylaxis had a limited role in preventing SSI at our center. Despite this, the lower cost and ease of the administration of TMP-SMX can be seen as convincing advantages. [ABSTRACT FROM AUTHOR]

Background: Surgical site infections (SSI) in the groin after vascular surgery are common. The aim of the study was to evaluate the effect of negative pressure wound therapy (NPWT) on SSI incidence when applied on closed inguinal incisions after endovascular aneurysm repair (EVAR). Methods: A multicenter randomized controlled trial (RCT). Between November 2013 and December 2020, 377 incisions (336 bilateral and 41 unilateral) from elective EVAR procedures with the primary intent of fascia closure were randomized and included, receiving either NPWT or a standard dressing. In bilateral incisions, each incision randomly received the opposite dressing of the other side, thereby becoming each other's control. The primary endpoint was SSI incidence at 90 days postoperatively, analyzed on an intention-to-treat basis. Uni and bilaterally operated incisions were analyzed separately, and their respective p-values combined using Fisher's method for combining P-values. Study protocol (NCT01913132). Results: The SSI incidence at 90 days postoperatively in bilateral incisions was 1.8% (n = 3/168) in the NPWT and 4.8% (n = 8/168) in the standard dressing group, and in unilateral incisions 13.3% (n = 2/15) and 11.5% (n = 3/26), respectively (combined p = 0.49). In all SSIs, bacteria were isolated from incisional wound cultures. No additional SSIs were diagnosed between 90 days and 1 year follow-up. Conclusions: No evidence of difference in SSI incidence was seen in these low-risk inguinal incisions when comparing NPWT with standard dressings after EVAR with the primary intent of fascia closure. Clinical Trials: NCT01913132. [ABSTRACT FROM AUTHOR]

Background: Classification of the open abdomen (OA) status is essential for clinical studies on the subject and may help to improve OA therapy. This is a validity and reliability analysis of the OA classification proposed by the World Society of the Abdominal Compartment Syndrome in 2013. Methods: Prospective data on 111 consecutive OA patients treated with vacuum-assisted wound closure and mesh-mediated fascial traction (VAWCM) was used. For validity analysis, OA grades were compared with fascial closure and mortality. For reliability analysis, operative reports were graded by three external raters on two different occasions and the results compared. Instructions for use of the classification were constructed and studied by the external raters beforehand. Results: The in-hospital mortality rate was 30 % (33/111). The delayed primary fascial closure rate was 89 % (85/95). Most complex grade ( p = 0.033), deteriorating grade ( p = 0.045), enteric leak ( p = 0.001), and enteroatmospheric fistula ( p = 0001) were associated with worse clinical outcomes, while initial grade, grade 1A only, contamination, fixation, and frozen abdomen were not. A floor effect was observed, with 20 % of patients receiving the lowest grade throughout OA period. Inter-rater reliability, expressed as intra-class correlation coefficient (ICC), was 0.77, 0.76, and 0.88 (95 % confidence interval 0.66-0.84, 0.65-0.84, and 0.81-0.92, respectively) and test-retest reliability 1.0, 0.99, and 0.95, respectively. Conclusions: More complex OA grades were associated with worse clinical outcomes. However, favorable clinical results with the VAWCM technique caused many patients to receive the lowest grade, thus causing a floor effect and lower validity. Inter-rater and test-retest reliability was 'good' to 'very good'. [ABSTRACT FROM AUTHOR]

Objective To evaluate patterns of inflammatory mediators before and after elective endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). Materials and methods Inflammatory mediators including soluble urokinase plasminogen activator (suPAR), endothelin (ET)-1, tumour necrosis factor (TNF)-α, interleukin (IL)-6, CD40 ligand (CD40L) and IgM antibodies against phosphorylcholine (IgM anti-PC), were evaluated before and after elective EVAR in 21 patients. Five patients undergoing open AAA repair (OR) were evaluated for comparison. Results SuPAR ( p < 0.001), ET-1 ( p = 0.003) and IL-6 ( p = 0.02) increased whereas IgM anti-PC decreased ( p < 0.001) after EVAR. Both suPAR ( p = 0.04) and IL-6 ( p = 0.03) increased in the five patients with unchanged/expanded aneurysm sac after EAR, whereas only suPAR increased ( p = 0.04) and IL-6 remained unchanged ( p = 0.2) among the 16 patients with shrinking aneurysm sac. No difference was noted between patients undergoing EVAR and OR regarding levels or changes of studied markers. Conclusions These changes in plasma biomarker profile are compatible with on-going inflammatory activation in AAA patients after EVAR. The potential role of IL-6 as a plasma biomarker for treatment failure in surveillance programs after EVAR needs to be further evaluated. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: To report contemporary outcomes, and evaluate differences after thrombolysis for occluded endoprosthesis, bypasses and native artery occlusion in patients with lower limb ischemia. Methods: Patients undergoing local intra-arterial thrombolysis for lower limb ischemia between 2001 and 2010 were identified in the prospective database for endovascular intervention, and analysis was performed retrospectively. Results: There was an increase in thrombolysis for occluded endoprosthesis and a decrease in thrombolysis for occluded bypasses during the study period (p=0.001). The technical success rate for thrombolysis in occluded endoprosthesis, bypasses and native artery occlusion was 91%, 89% and 73%, respectively. The overall major amputation rate, mortality rate and amputation-free survival rate at 1year was 19%, 14% and 73%, respectively, without differences between groups. The major amputation rate at long-term was highest, 45%, for patients with occluded synthetic bypass grafts. Female gender (HR 1.7; 95% CI 1.1–2.7), ischemic heart disease (HR 1.8; 95% CI 1.1–2.8), anemia at admission (HR 1.9; 95% CI 1.2–3.0), foot ulcer (HR 4.4; 95% CI 2.4–8.0), motor deficit at admission (HR 2.5; 95% CI 1.4–4.3), occluded synthetic bypass graft (HR 3.3; 95% CI 1.9–5.7) and failure of thrombolysis (HR 4.8; 95% CI 2.9–7.7) were independently associated with an increased long-term risk of major amputation. Conclusions: Thrombolysis for occluded endoprosthesis, bypasses and native artery occlusion was effective. Female gender, ischemic heart disease, anemia, foot ulcer, motor deficit, occluded synthetic bypass graft and failure of thrombolysis were independently associated with an increased risk of major amputation. [Copyright &y& Elsevier]

Background: General pathophysiological mechanisms regarding associations between fluid administration and intra-abdominal hypertension (IAH) are evident, but specific effects of type, amount, and timing of fluids are less clear. Objectives: This review aims to summarize current knowledge on associations between fluid administration and intra-abdominal pressure (IAP) and fluid management in patients at risk of intra-abdominal hypertension and abdominal compartment syndrome (ACS). Methods: We performed a structured literature search from 1950 until May 2021 to identify evidence of associations between fluid management and intra-abdominal pressure not limited to any specific study or patient population. Findings were summarized based on the following information: general concepts of fluid management, physiology of fluid movement in patients with intra-abdominal hypertension, and data on associations between fluid administration and IAH. Results: We identified three randomized controlled trials (RCTs), 38 prospective observational studies, 29 retrospective studies, 18 case reports in adults, two observational studies and 10 case reports in children, and three animal studies that addressed associations between fluid administration and IAH. Associations between fluid resuscitation and IAH were confirmed in most studies. Fluid resuscitation contributes to the development of IAH. However, patients with IAH receive more fluids to manage the effect of IAH on other organ systems, thereby causing a vicious cycle. Timing and approach to de-resuscitation are of utmost importance, but clear indicators to guide this decision-making process are lacking. In selected cases, only surgical decompression of the abdomen can stop deterioration and prevent further morbidity and mortality. Conclusions: Current evidence confirms an association between fluid resuscitation and secondary IAH, but optimal fluid management strategies for patients with IAH remain controversial. [ABSTRACT FROM AUTHOR]

Objective: To study the complications after cerebrospinal fluid (CSF) drainage and predictors of spinal cord ischemia (SCI) after advanced endovascular therapy with CSF drainage for complex aortic disease. Methods: Between 2009 and 2012, 88 attempts of CSF drainage insertions/84 operations/83 patients, of the 658 operations for aortoiliac diseases, were performed. Results: Indications for therapy were aortic dissection (n ¼ 13) and aortic aneurysm (n ¼ 70), of whom 38 had thoracoabdominal aortic aneurysm (TAAA). In all, 10 had ruptured aorta. The CSF drainages were inserted preoperatively (n ¼ 75) and postoperatively (n ¼ 9). In all, 14 CSF drainages were nonfunctioning. The SCI was present in 29 patients, transient/permanent in 12/17. Intraoperative circulatory instability (P ¼ .001) and operation for TAAA, type II (P ¼ .036), were associated with SCI. Meningitis (n ¼ 1), epidural (n ¼ 1), and subdural (n ¼ 2) hematoma and needle-mediated paresis in 1 leg (n ¼ 1) occurred after CSF drainage. Conclusions: Complication to CSF drainage occurred too frequently in this selected group of patients with high rate of SCI. [ABSTRACT FROM AUTHOR]

Objective: This study aims to analyze the diagnostic workup in patients referred for endovascular mesenteric revascularization for symptomatic mesenteric atherosclerotic disease. Material and Methods: Fifty-five patients were identified between 2006 and 2011. Median follow-up time was 24 months. Results: Median age was 71 years, 67 % were women. Forty patients had acute on chronic mesenteric ischemia, eight had acute mesenteric ischemia, and seven had chronic mesenteric ischemia. Other manifestations of atherosclerotic disease were present in 71 %. Body mass index (BMI) <20 kg/m was found in 37 %. Endoscopy diagnosed duodenitis (38 %; 13/34) and colitis in the right colon (57 %;12/21). All ulcers tested for Helicobacter pylori were negative ( n = 17). Patients received proton pump inhibitor, antibiotic, and cortisone therapy during diagnostic workup in 73, 42, and 29 % of the cases, respectively. Previous hospitalization for the same complaints had occurred in 78 %. CT angiography showed occlusion ( n = 30) and high-grade stenosis ( n = 25) of the superior mesenteric artery (SMA). Forty-eight patients were treated with stenting of the SMA. The BMI increased in both women ( p = 0.001) and men ( p = 0.03) after endovascular therapy. The in-hospital mortality rate was 18 %. Conclusion: Patients with abdominal pain, known atherosclerotic disease, right-sided colitis or H. pylori-negative duodenitis should undergo CT angiography immediately to be able to identify symptomatic mesenteric atherosclerotic disease. [ABSTRACT FROM AUTHOR]

Objective. Large-bore catheters for temporary haemodialysis are often placed via the internal jugular or femoral vein, guided by external landmarks or ultrasound techniques. Inadvertent femoral artery catheterization may occur during attempted placement of the dialysis catheter in the femoral vein. Material and methods. This investigation was carried out in Skåne University Hospital, Malmö, Sweden. Between 2008 and 2011, patients referred for consultation by a vascular specialist owing to inadvertent arterial catheterization after attempted placement of a dialysis catheter in the femoral vein were noted in a logbook and patients with iatrogenic arterial injuries undergoing vascular repair at Malmö-Lund Hospitals were identified through the Swedish vascular registry (Swedvasc). Results. The five included patients had a dialysis catheter (11-13.5 Fr) inserted, without ultrasound guidance, into the femoral artery. One patient suffered from circulatory shock. Two cases were managed with external compression, while three cases required surgical repair. Two patients had postoperative wound infection in the groin. Conclusions. Femoral dialysis catheters should be inserted using ultrasound guidance. Large-bore catheters suspected of being in an inadvertent arterial position should be fixed securely before further diagnostic or interventional considerations. A management algorithm for inadvertently placed catheters in the femoral artery is proposed. [ABSTRACT FROM AUTHOR]

Background: Patients with diabetes mellitus (DM) have a more extensive distal arterial occlusive disease compared to non-diabetic patients. Diagnostic imaging is a necessity to identify the location and extent of the arterial occlusion in acute limb ischemia (ALI). Computed tomography angiography (CTA) is the most commonly used modality and the diagnostic performance with CTA of calf arteries may be questioned. Purpose: To evaluate diagnostic performance of CTA of calf arteries in ALI and to compare patients with and without DM. Material and Methods: All thrombolytic treatments performed during 2001–2018 in patients with ALI were included. Initial digital subtraction angiography (DSA) and CTA of all patients were classified according to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) below-the-knee arteries and compared to CTA. Two raters assessed the CTA images independently. Inter-rater reliability was expressed as intraclass correlation (ICC) with 95% confidence intervals (CI). Results: Patients with (n = 23) and without (n = 85) DM had lower (P = 0.006) glomerular filtration rate. ICC between CTA and DSA was 0.33 (95% CI –0.22 to 0.56) and 0.71 (95% CI 0.38–0.68) in patients with and without DM, respectively. Sensitivity with CTA for TASC D lesions in patients with and without DM was 0.14 (95% CI –0.12 to 0.40) and 0.64 (95% CI 0.48–0.80), respectively. Conclusion: The sensitivity of CTA for assessment of infra-popliteal TASC D lesions in patients with ALI was not acceptable in patients with DM in contrast to those without DM. Another imaging option at present times should be considered for patients with DM. [ABSTRACT FROM AUTHOR]

Purpose: Repetitive iodinated contrast media exposure may be harmful for the kidneys. The aim of the present study was to evaluate if patients with diabetes mellitus (DM) undergoing CT angiography (CTA) and local continuous thrombolysis for acute lower limb ischemia (ALI) had an increased risk of developing contrast-associated acute kidney injury (CA-AKI) compared to patients without DM. Methods: This is a retrospective study of patients undergoing CTA and local continuous thrombolysis due to ALI between 2001 and 2018. CA-AKI was defined as a 25% increase in serum creatinine within 72 hours after latest contrast administration. Results: There was no difference (P =.30) in the frequency of CA-AKI between patients with (27.9%; n = 43) and without DM (20.6%; n = 170). Among patients with CA-AKI, patients with DM had a lower (P <.001) estimated glomerular filtration rate (eGFR) at discharge (55 ml/min/1.73 m2) than at admission (70 ml/min/1.73 m2), while no such difference was found in the group without DM (P =.20). The gram-iodine dose/eGFR ratio was higher (P <.001) in patients with CA-AKI (median 1.49, [IQR 1.34-1.81]) than in those who did not develop CA-AKI (median 1.05 [IQR 1.00-1.13]). There was a trend that gram-iodine dose/eGFR ratio (OR 1.42/standard deviation increment, 95% CI 1.00-2.02; P =.050) was associated with an increased risk of CA-AKI, after adjusting for DM, age, and gender. Conclusions: The frequency of CA-AKI was high after CTA and local continuous thrombolysis for ALI without shown increased frequency for the DM group. Among patients with CA-AKI, however, patients with DM had worse renal function at discharge than those without DM. The gram-iodine dose/eGFR ratio in these patients needs to be lower to improve renal outcomes, particularly in patients with DM. [ABSTRACT FROM AUTHOR]

The risk of major amputation is higher after urgently planned endovascular therapy for chronic limb-threatening ischemia (CLTI) in patients with diabetes mellitus (DM). The aim of this nationwide cohort study was to compare outcomes between patients with and without DM following urgently planned open revascularization for CLTI from 2010 to 2014. Out of 1537 individuals registered in the Swedish Vascular Registry, 569 were registered in the National Diabetes Register. A propensity score adjusted Cox regression analysis was conducted to compare outcome between the groups with and without DM. Median follow-up was 4.3 years and 4.5 years for patients with and without DM, respectively. Patients with DM more often had foot ulcers (p = 0.034) and had undergone more previous amputations (p = 0.001) at baseline. No differences in mortality, cardiovascular death, major adverse cardiovascular events (MACE), or major amputation were observed between groups. The incidence rate of stroke was 70% higher (95% CI: 1.11–2.59; p = 0.0137) and the incidence rate of acute myocardial infarction (AMI) 39% higher (95% CI: 1.00–1.92; p = 0.0472) among patients with DM in comparison to those without. Open vascular surgery remains a first-line option for a substantial number of patients with CLTI, especially for limb salvage in patients with DM. The higher incidence rates of stroke and AMI among patients with DM following open vascular surgery for infrainguinal CLTI require specific consideration preoperatively with the aim of optimizing medical treatment to improve cardiovascular outcome postoperatively. [ABSTRACT FROM AUTHOR]

We evaluated if plasma biomarkers can predict incident peripheral arterial disease (PAD) and mortality in a longitudinal cohort study. Men (n = 3618) and women (n = 1542) were included in the Malmö Preventive Project and underwent analysis of: C-terminal endothelin-1 (CT-proET-1), N-Terminal prosomatostatin (NT-proSST), midregional proatrial natriuretic peptide (MR-proANP), procalcitonin (PCT), and copeptin. Participants were followed up for incident PAD and mortality until December 31, 2016. Median follow-up was 11.2 years (interquartile range 9.4-12.2). Cumulative incidence of PAD was 4.3% (221/5160), 4.5% in men (164/3618) and 3.7% in women (57/1542; P =.174). In an adjusted Cox proportional hazards regression model, higher CT-proET-1 (hazard ratio [HR] 1.8; 95% confidence interval [CI] 1.4-2.3), NT-proSST (HR 1.5; 95% CI 1.2-2.0), and MR-proANP (HR 1.7; 95% CI 1.3-2.3) were independently associated with incident PAD, and higher CT-proET-1 (HR 1.3; 95% CI 1.2-1.5), NT-proSST (HR 1.2; 95% CI 1.1-1.3), MR-proANP (HR 1.4; 95% CI 1.3-1.6), PCT (HR 1.1; 95% CI 1.0-1.2), and copeptin (HR 1.2; 95% CI 1.1-1.4) were independently associated with mortality. Increased levels of CT-proET-1, NT-proSST, and MR-proANP were independently associated with incident PAD, whereas all the vasoactive biomarkers were independently associated with mortality during follow-up. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this prospective study was to validate the diagnostic performance of computed tomography angiography (CTA) in endoprosthesis stenosis in the superior mesenteric artery (SMA) using mean arterial pressure (MAP) gradients during angiography as a reference method. Methods: Twenty-nine patients with mesenteric atherosclerotic disease underwent 45 paired measurements of endoprosthesis stenosis in the SMA with CTA and MAP gradients between March 2009 and July 2015. The grade of endoprosthesis stenosis in the SMA at CTA using the TeraRecon Aquarius workstation was correlated with MAP gradients. Results: Grade of endoprosthesis stenosis in the SMA (r = 0.37, p = 0.013) correlated with MAP gradients. The intraclass correlations between the first and second CTA rater was 0.76 (95% CI 0.56–0.87) for estimation of grade of endoprosthesis stenosis in the SMA. The area under the receiver operating characteristics curve was 0.79 for diagnosis of significant endoprosthesis stenosis in the SMA at CTA for different threshold values using MAP gradient of ≥ 10 mmHg as reference. Sensitivity, specificity and positive predictive value for endoprosthesis stenosis in the SMA ≥ 50% at CTA were 52.4% (95% CI 31.0–73.7), 87.5% (95% CI 74.3–100.0) and 78.6 (95% CI 57.1–1.00), respectively. Conclusion: Grading endoprosthesis stenosis in the SMA with CTA performed fair when using trans-stenotic MAP gradient as reference. Software development towards reduction of endoprosthesis artefacts may result in more accurate CTA assessment of the narrowest part. [ABSTRACT FROM AUTHOR]

Even though abdominal aortic aneurysm (AAA) and coronary heart disease (CHD) are both related to atherosclerosis, there could be important differences in risk factors. Based on Malmö Diet and Cancer Cohort, the incidence of AAA and CHD was followed prospectively. Cox regression was used to calculate the association of each factor with AAA and CHD and hazards ratio were compared using a modified Lunn-McNeil method; 447 participants developed AAA and 3129 developed CHD. After multivariate adjustments, smoking, antihypertensive medications, lipid-lowing medications, systolic and diastolic blood pressures, apolipoprotein (Apo) A1 (inversely), ApoB, ApoB/ApoA1 ratio, total leukocyte count, neutrophil count, and neutrophil to lymphocyte ratio were associated with the risks of both AAA and CHD. When comparing risk factor profiles for the 2 diseases, smoking, diastolic blood pressure, ApoA1, and ApoB/ApoA1 ratio had stronger associations with risk of AAA than with risk of CHD, while diabetes and unmarried status showed increased risk of CHD, but not of AAA (all P values for equal association <.01). The results from this big population study confirm that the risk factor profiles for AAA and CHD show not only many similarities but also several important differences. [ABSTRACT FROM AUTHOR]