Buerger’s disease - What progress has been made in the last decade in salvaging the ischemic limbs of the young smokers with TAO?

In the past we often considered minor or major amputations in ischemic legs of young smokers when the medical and surgical therapies failed to relieve the severe pain associated with non healing ulcers or gangrene. But now after the introduction of Prostaglandin E-1 infusions therapies for the below knee non re-constructable vascular disease we are able to relieve the rest pain and help in healing the ischemic ulcers with more certainty. We are following the patients for 6 months and so we are able to guide the patients and confirm their limb salvage for a long time. The cost of therapies has also been spread over a period of 6 months and so their affordability and compliance is surprisingly very good in these ill nourished patients. We have also been looking for features of systemic inflammatory responses (SIRS) in these patients who are groaning with ischemic rest pain. Low dose steroid therapy and immune modulators have been helpful in TAO patients with SIRS like features when added to the PGE-1 therapy. We did not use epidural analgesia for the relief of rest pain in the recent past when we are using the PGE1 + LDS + IMT. We do not routinely consider the wound swab cultures from the ulcers or dry gangrene with minimal wetting of the surface. These patients do not tolerate dressing over their feet and they loosely wrap gauze bandage over their ischemic ulcers, gangrene feet. Few patients are not able to abstain from smoking though they may reduce the number of cigarettes. Yet, we have noted the good response with the PGE1 + LDS + IMT in these people. We have not done major amputations in the last year in these patients. Only gangrenous toes which are failing to separate and fall off, on the request of the patients we consider surgical separation after completion of the PGE1 + LDS + IMT course.

Happy New year 2015

to you

with best wishes.

Pinjala R K

Pseudomonas aeruginosa - Touch or taste? which one should it like before infecting us?

Pseudomonas aeruginosa
Pseudomonas aeruginosa is a common bacterium that leads to a variety of diseases in plants, animals, and humans and is relatively impervious to antibiotics. For years, scientists remained perplexed at how a single species of bacteria was able to infect such a wide array of hosts. Typically, bacteria use chemical signals to “taste” their environment; if bacteria detect they are in a good place for their survival, they will infect and thrive. Bacteria also rely on “quorum sensing,” the ability to determine how many of their kind are present before mounting an infection. Researchers at Princeton have discovered for the first time that Pseudomonas aeruginosa relies on touch (not taste) for infection. It doesn’t necessarily matter if they’re “tasting” the right environment or not; it just matters if they are on any environment at all. Once attached to any host surface, the bacteria initiate quorum sensing before rapidly overwhelming nearby organisms, including the host.
Pinjala R K

Are we concerned about these micro bubble emboli in to the MCA after microfoam ablation of varicosities?

J Vasc Surg. 2011 Jan;53(1):131-7. doi: 10.1016/j.jvs.2010.06.179. Epub 2010 Sep 22.

Clinical significance of cerebrovascular gas emboli during polidocanol endovenous ultra-low nitrogen microfoam ablation and correlation with magnetic resonance imaging in patients with right-to-left shunt.

MCA bubble emboli were detected in 60 of 82 treated patients; 22 patients had no detectable emboli. Among patients with MCA bubbles detected, 49 (82%) had ≤ 15 bubbles. No patients developed magnetic resonance imaging abnormalities, neurological signs, or elevated cardiac troponin.

Carotid disease

Carotid endarterectomy (CEA) is still considered the "gold-standard" of the treatment of patients with significant carotid stenosis and has proven its value during past decades. However, endovascular techniques have recently been evolving. Carotid artery stenting (CAS) is challenging CEA for the best treatment in patients with carotid stenosis
Aspects-such as evolving best medical treatment, timely intervention, interventionalists' experience, and analysis of plaque composition-may have important influences on the future treatment of patients with carotid artery  stenosis.

Cochrane Database Syst Rev. 2012 Sep 12;9:CD000515. doi: 10.1002/14651858.CD000515.pub4.

Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis. Endovascular treatment is associated with an increased risk of peri-procedural stroke or death compared with endarterectomy. However, this excess risk appears to be limited to older patients. The longer term efficacy of endovascular treatment and the risk of restenosis are unclear and require further follow-up of existing trials. Further trials are needed to determine the optimal treatment for asymptomaticcarotid stenosis.

Vascular. 2009 Jul-Aug;17(4):183-9.

Carotid artery stenting may be losing the battle against carotid endarterectomy for the management of symptomatic carotid artery stenosis, but the jury is still out.

Paraskevas KI1, Mikhailidis DP, Veith FJ.

Author information

Abstract

Carotid artery stenting (CAS) has emerged as a potential alternative to carotid endarterectomy (CEA) for the management of carotid artery stenosis. The purpose of this article is to provide an evaluation and critical overview of the trials comparing the early and later results of CAS with CEA for symptomatic carotid stenosis. The CochraneControlled Trials Register, PubMed/Medline, and EMBASE databases were searched up to February 1, 2009, to identify trials comparing the long-term outcomes of CAS with CEA. The MeSH terms used were "carotid artery stenting," "carotidendarterectomy," "symptomatic carotid artery stenosis," "treatment," "clinical trial," "randomized," and "long-term results," in various combinations. One single-center and three multicenter randomized studies reporting their long-term results from the comparison of CAS with CEA for symptomaticcarotid stenosis were identified. All four studies independently reached the conclusion that CAS may not provide results equivalent to those of CEA for the management of symptomatic carotid stenosis. A higher incidence of recurrent stenosis and peri- and postprocedural events accounted for the inferior results reported for CAS compared with CEA. Current data from randomized studies indicate that CAS provides inferior long-term results compared with CEA for the management of symptomatic carotid artery stenosis. However, it can be argued that all of these trials were performed when both CAS equipment and CAS operators had not evolved to their current status. Given that current equipment and mature experience are required for CAS before comparing it with the current "gold standard" procedure (CEA), the results of soon-to-be reported trials (CarotidRevascularization Endarterectomy vs Stenting Trial [CREST], International Carotid Stenting Study [ICSS], or others) may alter the current impression that CAS is inferior to CEA for the treatment of symptomatic carotid stenosis.

Ann Thorac Surg. 2014 Jan;97(1):102-9. doi: 10.1016/j.athoracsur.2013.07.091. Epub 2013 Oct 1.

Meta-analysis of staged versus combined carotid endarterectomy and coronary artery bypass grafting.

Sharma V1, Deo SV2, Park SJ3, Joyce LD3.

meta-analysis of observational studies suggests comparable outcomes in combined and staged approach for synchronouscarotid and coronary artery disease. Hence, the 2 strategies can be used interchangeable in the clinical practice, with each having specific applications linked to specific clinical conditions. A randomized trial is warranted to answer this question definitively

J Vasc Surg. 2008 Aug;48(2):355-360; discussion 360-1. doi: 10.1016/j.jvs.2008.03.031. Epub 2008 Jun 24.

Trends and outcomes of concurrent carotid revascularization and coronary bypass.

Timaran CH1, Rosero EB, Smith ST, Valentine RJ, Modrall JG, Clagett GP. Although CAS may currently be performed for high-risk patients, it is still infrequently used in patients who require concurrent carotidand coronary interventions. In the United States, patients who undergo CAS-CABG have significantly decreased in-hospital stroke rates compared with patients undergoing CEA-CABG but similar in-hospital mortality. CAS may provide a safer carotid revascularization option for patients who require CABG.

Human Microbiome

How can we explain this after carotid endarterectomy?

Int Angiol. 2014 Aug;33(4):309-15.

The influence of carotid endarterectomy on cerebral blood flow in significant carotid stenosis-perfusion computed tomography study.

Lukasiewicz A1, Mindykowski R, Serafin Z.

Author information

Abstract

AIM:

Carotid endarterectomy (CEA) is well recognized procedure in the treatment of patients with significant symptomatic internal carotid artery (ICA)stenosis. Operation reconstitutes physiologic blood flow in the ICA. The influence of CEA on cerebral perfusion (CP) is not well established. Some data suggest increased CP after stenosis correction however evidence in post-endarterectomy patients is scarce. Our aim was to investigate the influence of CEA in patients with symptomatic carotid stenosis on CP parameters by means of perfusion computed tomography (PCT).

METHODS:

Thirty-four patients with symptomatic severe carotid stenosis qualified for CEA were included. The baseline PCT of the brain according to standardized protocol was performed within 3 weeks prior to surgical procedure. The follow-up PCT was performed between 30-60th day postop. The following perfusion parameters were analyzed: cerebral blood flow (CBF), cerebral blood volume (CBV), peak enhancement intensity (PEI) and time to peak (TTP). Pre- and postoperative average values of these parameters were compared. 

RESULTS:

No death/stroke occurred in the investigated group. Mean preoperative total CBF was 66.2 mL/100 g/min and was not dependent on the degree of the carotid stenosis or the presence of contralateral carotid artery stenosis. Mean postoperative total CBF was significantly lower (61.8 mL/100g/min, P<0 .05="" nbsp="" p="">

No significant changes in PEI, TTP and CBV were observed.

CONCLUSION:

PCT of the brain reveals that CEA in patients with symptomatic carotid stenosis decreased total CBF especially in the contralateral hemisphere.

new designs of carotid filter and stents

Revision of the CEAP classification for chronic venous disorders: Consensus statement

Revision of CEAP

Diagnosis and treatment of CVD is developing rapidly, and the need for an update of the classification logically follows. It is important to stress that CEAP is a descriptive classification. Venous severity scoring ⁴was developed to enable longitudinal outcomes assessment, but it became apparent that CEAP itself required updating and modification. In April 2002 an ad hoc committee on CEAP was appointed by AVF to review the classification and make recommendations for change by 2004, 10 years after its introduction . An international ad hoc committee was also established to ensure continued universal use. The 2 committees held 4 joint meetings, with key members contributing in the interim to the revised document. The following passages summarize the results of these deliberations by describing the new aspects of the revised CEAP.

In essence, basic CEAP applies 2 simplifications. First, in basic CEAP the single highest descriptor can be used for clinical classification. For example, in a patient with varicose veins, swelling, and lipodermatosclerosis the classification would be C_4b. The more comprehensive clinical description, in advanced CEAP, would be C_2,3,4b. Second, in basic CEAP, when duplex scanning is performed, E, A, and P should also be classified with the multiple descriptors recommended, but the complexity of applying these to the 18 possible anatomic segments is avoided in favor of applying the simple s, p, and d descriptors to denote the superficial, perforator and deep systems. Thus, in basic CEAP the previous example, with painful varicosities, lipodermatosclerosis, and duplex scan–determined reflux involving the superficial and perforator systems would be classified as C_4b,S, E_p,A_s,p, P_r, rather than C_2,4b,S, E_p,A_s,p, P_r2,3,18.

Revision of CEAP an ongoing process

With improvement in diagnostics and treatment there will be continued demand to adapt the CEAP classification to better serve future developments. There is a need to incorporate appropriate new features without too frequent disturbance of the stability of the classification. As one of the committee members (F. Padberg) stated in our deliberations, “It is critically important that recommendations for change in the CEAP standard be supported by solid research. While there is precious little that we are recommending which meets this standard, we can certainly emphasize it for the future. If we are to progress we should focus on levels of evidence for changes rather than levels of investigation. While a substantial portion of our effort will be developed from consensus opinion, we should still strive to achieve an evidence-based format.”

Example

A patient has painful swelling of the leg, and varicose veins, lipodermatosclerosis, and active ulceration. Duplex scanning on May 17, 2004, showed axial reflux of the great saphenous vein above and below the knee, incompetent calf perforator veins, and axial reflux in the femoral and popliteal veins. There are no signs of postthrombotic obstruction.

Classification according to basic CEAP: C_6,S, E_p,A_s,p,d, P_r.

Classification according to advanced CEAP: C_2,3,4b,6,S, E_p,A_s,p,d, P_{r2,3,18,13,14} (2004-05-17, L II).

Sclerotherapy is to be considered in our patients ?

In routine practice, a 0.5% or 1% concentration of foam sclerosant is preferred for vessels less than 5 mm in diameter, while 2% and 3% concentrations are used for vessels larger than 5 mm in diameter. In one ex-vivo study they were unable to demonstrate any statistically significant results among different foam concentrations on 5-10 mm diameter vessels in terms of pathological damage. However, due to the near significant difference between the outcomes of 0.5% and 1% foam sclerosants, the use of 1% foam sclerosant instead of 0.5% may be preferable. Again, 1% foam sclerosant may be preferred to 2% or 3% in larger vessels, as it exerts more severe damage on the vein wall. Further studies are necessary to validate these findings. We have been using the 1% sclerosant for vessels between 5 -10 mm diameters for the past few years without significant recanalizaiton or residual varicosities. Axial veins seem to be more resistant to obliteration by the sclerotherapy compared to the tributaries in clinical practice.

Compression Therapy Versus Surgery in the Treatment of Patients with Varicose Veins: A RCT, effect on HR QoL?

Varicose veins are common in the people in population groups. Many of them are afraid of operations and at the same time they do not want go for the stockings in the tropical countries. Some of them work in the wet surroundings and they would like to avoid the stockings and compression bandages. Some of them are keen to undergo interventional therapies but they are too expensive ( RF ablation/ Laser) for them. Some times they don't like to undergo surgical treatment after knowing about the recurrence rates.

So, the question before them would be - which is one is better to opt for,  stockings or varicose  vein interventional therapies?  In one study of two year follow up - it was observed that -
At 2 years, 70/76 patients in the surgery group and 11/77 patients in the compression group had been operated on. VCSS-S decreased from 4.6 to 3.5 in the compression group (p < .01) and from 4.8 to 0.6 in the surgery group (p < .001). VSDS decreased from 7.7 to 7.0 in the compression group and from 8.2 to 0.9 in the surgery group (p < .0001). HRQoL did not change in the compression group, but improved significantly in the surgery group. It was concluded that - The surgical elimination of non-complicated superficial venous reflux is an effective treatment when compared with providing compression stockings only. 

HRQoL did not change in the compression group, but improved significantly in the surgery group.

http://www.ejves.com/article/S1078-5884(14)00096-3/abstract 

Pinjala R K

Home therapy for Acute DVT in the leg! Is it safe in all countries?

Home therapy for DVT is convenient and it gives freedom with safety to treat the patients coming in the out patient clinic without admission in to the hospitals and additional burden hospital beds and expenditure to the family.

In patients with DVT, home treatment was associated with a better outcome than treatment in the hospital. Current guidelines of antithrombotic therapy recommend initial treatment of patients with acute deep venous thrombosis (DVT) with low-molecular-weight heparin (LMWH), fondaparinux, or unfractionated heparin (UFH) over no such initial therapy.¹ A number of studies comparing LMWH administered at home (without hospital admission or after early discharge) with UFH in the hospital suggested that home therapy may be associated with improved outcome and better quality of life.^{2, 3, 4, 5, 6, 7, 8, 9, 10, 11 and 12} Hence, in DVT patients with adequate home circumstances, current guidelines recommend that most patients with DVT be initially treated at home rather than in the hospital.¹ However, many physicians are still concerned about the safety of home therapy because even with adequate anticoagulation, some patients may present with symptomatic pulmonary embolism (PE), recurrent DVT, major bleeding complications, or even death.

The RIETE (Registro Informatizado de la Enfermedad TromboEmbólica) registry is an ongoing, international (Spain, France, Italy, Israel, Germany, Switzerland, Republic of Macedonia, and Brazil), multicenter, prospective registry of consecutive patients presenting with symptomatic acute venous thromboembolism (VTE). It started in Spain in 2001, and some years later, the database was translated into English to expand the Registry to other countries, with the aim to help physicians worldwide select the most appropriate therapy for their patients. Data from this registry have been used to evaluate outcomes after acute VTE, such as the frequency of recurrent VTE, major bleeding, and mortality, and risk factors for these outcomes.^{13, 14,15 and 16} The current analysis compared the outcome of outpatients with acute DVT of the lower limbs within the first week of anticoagulation according to initial therapy at home or in the hospital.

References

1. C. Kearon, E.A. Akl, A.J. Comerota, P. Prandoni, H. Bounameaux, S.Z. Goldhaber et al. American College of Chest Physicians. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest, 141 (Suppl) (2012), pp. e419S–e494S

2. M. Bakker, P.J. Dekker, E.A. Knot, P.F. van Bergen, J.J. Jonker Home treatment for deep venous thrombosis with low-molecular-weight heparinLancet, 2 (1988), p. 1142

3. M. Levine, M. Gent, J. Hirsh, J. Leclerc, D. Anderson, J. Weitz et al.A comparison of low-molecular-weight heparin administered primarily at home with unfractionated heparin administered in the hospital for proximal deep-vein thrombosis. N Engl J Med, 334 (1996), pp. 677–681

4.M.M. Koopman, P. Prandoni, F. Piovella, P.A. Ockelford, D.P. Brandjes, J. van der Meer et al. Treatment of venous thrombosis with intravenous unfractionated heparin administered in the hospital as compared with subcutaneous low-molecular-weight heparin administered at home. The TASMAN Study Group N Engl J Med, 334 (1996), pp. 682–687

5. I.G. Schraibman, A.A. Milne, E.M. Royle Home versus in-patient treatment for deep vein thrombosisCochrane Database Syst Rev, 2 (2001), p. CD003076

6. R. Othieno, M. Abu Affan, E. Okpo Home versus in-patient treatment for deep vein thrombosisCochrane Database Syst Rev, 3 (2007), p. CD003076

7. W. Ageno, R. Grimwood, S. Limbiati, F. Dentali, L. Steidl, P.S. Wells Home-treatment of deep vein thrombosis in patients with cancer Haematologica, 90 (2005), pp. 220–224

8. S. Siragusa, C. Arcara, A. Malato, R. Anastasio, M.R. Valerio, F. Fulfaro et al. Home therapy for deep vein thrombosis and pulmonary embolism in cancer patients Ann Oncol, 16 (Suppl 4) (2005), pp. 136–139

9. S.R. Kahn, V. Springmann, S. Schulman, J. Martineau, J.A. Stewart, N. Komari et al. Management and adherence to VTE treatment guidelines in a national prospective cohort study in the Canadian outpatient setting. The Recovery Study. Thromb Haemost, 108 (2012), pp. 493–498

10. M. Winter, D. Keeling, F. Sharpen, H. Cohen, P. Vallance, Haemostasis and Thrombosis Task Force of the British Committee for Standards in Haematology Procedures for the outpatient management of patients with deep venous thrombosis. Clin Lab Haematol, 27 (2005), pp. 61–66

11. V. Snow, A. Qaseem, P. Barry, E.R. Hornbake, J.E. Rodnick, T. Tobolic, American College of Physicians; American Academy of Family Physicians Panel on Deep Venous Thrombosis/Pulmonary Embolism et al. Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians Ann Intern Med, 146 (2007), pp. 204–210

12. J.D. Douketis. Treatment of deep vein thrombosis. What factors determine appropriate treatment?Can Fam Physician, 51 (2005), pp. 217–223

Oncolytic viruses

Oncolytic viruses are providing an interesting approach to treat cancers:

Some time back in the past, we postulated that the virus may cause the some types of cancers. But today we are postulating that viruses can be used to cure the cancers. Cancers tend to grow at the expense of the normal tissues and so are the viruses when they invade the body. Now, there are attempts to engineer the viruses to do the jobs favorable for the humans beings and that seems to be good. Some have engineered viruses to cure multiple myeloma and others are using the virus loaded stem cells to treat tumors. Recently herpes virus loaded stem cells are used to treat brain tumor (in mice) such as glioblastoma multiforme which is a difficult tumor to treat.  It said that “Further preclinical work will be needed to use the herpes-loaded stem cells for breast, lung and skin cancer tumours that metastasize to the brain. Shah predicts the approach will enter clinical trials within the next two to three years”.

What is CaVenT study?

Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial.

209 patients were randomly assigned to treatment groups (108 control, 101 CDT). At completion of 24 months' follow-up, data for clinical status were available for 189 patients (90%; 99 control, 90 CDT). At 24 months, 37 (41·1%, 95% CI 31·5—51·4) patients allocated additional CDT presented with PTS compared with 55 (55·6%, 95% CI 45·7—65·0) in the control group (p=0·047). The difference in PTS corresponds to an absolute risk reduction of 14·4% (95% CI 0·2—27·9), and the number needed to treat was 7 (95% CI 4—502). Iliofemoral patency after 6 months was reported in 58 patients (65·9%, 95% CI 55·5—75·0) on CDT versus 45 (47·4%, 37·6—57·3) on control (p=0·012). 20 bleeding complications related to CDT included three major and five clinically relevant bleeds.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61753-4/abstract

from University of Oslo.

Longterm outcomes after catheter directed thrombolysis in DVT

What is CaVenT study?

Long-term outcome after additional catheter-directed thrombolysis versus standard treatment for acute iliofemoral deep vein thrombosis (the CaVenT study): a randomised controlled trial. 209 patients were randomly assigned to treatment groups (108 control, 101 CDT). At completion of 24 months' follow-up, data for clinical status were available for 189 patients (90%; 99 control, 90 CDT). At 24 months, 37 (41·1%, 95% CI 31·5—51·4) patients allocated additional CDT presented with PTS compared with 55 (55·6%, 95% CI 45·7—65·0) in the control group (p=0·047). The difference in PTS corresponds to an absolute risk reduction of 14·4% (95% CI 0·2—27·9), and the number needed to treat was 7 (95% CI 4—502). Iliofemoral patency after 6 months was reported in 58 patients (65·9%, 95% CI 55·5—75·0) on CDT versus 45 (47·4%, 37·6—57·3) on control (p=0·012). 20 bleeding complications related to CDT included three major and five clinically relevant bleeds.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61753-4/abstract

from University of Oslo.

Transplantation of an allogeneic vein bioengineered with autologous stem cells

Vein segments are harvested and used for bypassing the arterial occlusions and these vein grafts have good long term patency. But when a vein has to be bypassed then we do not have an ideal graft available to us. In the recent past a 9 cm segment of allogeneic donor iliac vein was decellularised and subsequently recellularised with endothelial and smooth muscle cells differentiated from stem cells obtained from the bone marrow of the recipient. Such a graft may not require suppression for life time by sweedish team of doctors.

After one year a second stem-cell populated vein graft was used for relieving the compression of first graft graft and  to lengthen the previous graft which was used for replacing the portal vein in a patient with extra hepatic portal vein obstruction. With restored portal circulation the patient has substantially improved physical and mental function and growth. The patient has no anti-endothelial cell antibodies and is receiving no immunosuppressive drugs. An acellularised deceased donor vein graft recellularised with autologous stem cells can be considered for patients in need of vascular vein shunts without the need for immunosuppression.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60633-3/fulltext#article_upsell

Robert B. Rutherford 29 July 1931–22 November 2013

Bob Rutherford, for more than three decades, was arguably the best known and most respected vascular surgeon in the world. His textbook, VASCULAR SURGERY, has been “the textbook” and remains the premier source of information in the field since it first appeared in 1976. Since then, Rutherford's text gained in authority and respect as it went through its subsequent eight editions, just as vascular surgery grew and morphed into the defined specialty it is today. In 1996, Bob received an Honorary Fellowship from the Royal College of Surgeons and he delivered the prestigious Lister Lecture in Glasgow, Scotland. In 2005, Bob received the singular honor of the SVS Lifetime Achievement Award and, in 2006, he received the Julius H. Jacobson II Physician Excellence Award from the Vascular Disease Foundation for his exceptional leadership and contributions to vascular disease education and management.

Buerger's Disease - is still unresolved in Asian countries?

More than 100 years back the first paper on Buerger's disease was published. In many countries the disease prevalence is significantly reduced. But in the developing and poor countries where childhood smoking is uncontrolled this disease seems to be persistent. The disease is surprisingly less common in urban population and in those who have gone to proper schooling! probably this means these children are protected from the risk of childhood smoking. There are reports mentioning that autoimmunity plays an important role. The initial enthusiasm to do surgeries faded away slowly as the results are universally not satisfactory. Now, a new concept directed towards cell therapies (stem cells) renewed the interest in detecting the patients who can be benefited by them. Here is a report on endothelial progenitor cells and TAO.

Reduced circulating endothelial progenitor cells in thromboangiitis obliterans (Buerger’s disease)

Hyung Sub Park1 Kyung Hee Cho1 Koung Li Kim2 Duk-Kyung Kim2Taeseung Lee1
Taeseung Lee Department of Surgery Seoul National University Bundang Hospital Seoul National University College of Medicine 173-82 Gumi-ro, Bundang-gu, Seongnam-si Gyeonggi-do 463-707 Korea Email: tslee@snubh.org

Abstract

To determine the role of endothelial progenitor cells (EPCs) in the pathogenesis of thromboangiitis obliterans (TAO), EPC numbers and colony-forming units, migratory function and tubular structure formation in vitro were compared between 13 young male TAO patients and two age-matched healthy control groups: 11 smokers and 12 non-smokers. TAO patients had significantly lower numbers of EPCs and EPC colonies compared to both non-smokers [190 (97.0–229) vs 528 (380–556), p < 0.001 for EPCs and 0.80 (0.53–1.00) vs 2.80 (2.08–4.00) per mm2, p = 0.001 for EPC colonies] and smokers [190 (97.0–229) vs 272 (229–326), p = 0.012 for EPCs and 0.80 (0.53–1.00) vs 2.80 (1.80–3.93) per mm2, p = 0.001 for EPC colonies]. However, there were no significant differences in migratory function or tube formation between the three groups. These results suggest that TAO patients have an intrinsic decrease in EPCs not entirely associated with smoking, which may be the cause of endothelial dysfunction seen in TAO patients leading to the development of this disease at early ages.

How specific are venous symptoms for diagnosis of chronic venous disease?

I feel this is very important to know this fact, before we confirm and treat CVI patients based on only few symptoms. The recently introduced Endovenous ablative therapies are offered to lot of patients due to the safety and ease with which these procedures are performed. It would be useful to base our interventions with adequate supportive clinical features after exclude the other possible conditions. If we take these precautions there will be more satisfaction and improvement therapeutic effectiveness.

Pinjala R K
13th Jan 2014

Fruit juice - may be better to avoid concentrated juices!

Some of us like Fruit juices and believe they are safe. But are they safe?

Dear NIMS Doctor,

Fruits and fruit juices are considered to be safe and good for the health by many of us. Some of us take whole fruit while some prefer to take the readymade fruit juices. Now there are alerts to avoid the fruit juices and recommendations are in favour of whole fruit intake. If one would still like to take juices it is better to dilute them adequately.

Fruit juice should be removed from the recommended list of five-a-day portions of fruit or vegetables in the U.K. as it contained as much sugar as many soft drinks, an adviser to the government on obesity has said. Susan Jebb, head of diet and obesity research at the Medical Research Council’s Human Nutrition Research unit in Cambridge, said she did not see juice as a healthy option.

“I would support taking it out of the five-a-day guidance,” she said. “Fruit juice isn’t the same as intact fruit and it has got as much sugar as many classical sugar drinks. It is also absorbed very fast so by the time it gets to your stomach your body doesn’t know whether it’s Coca-Cola or orange juice, frankly,” she told Sunday Times.

“I have to say it is a relatively easy thing to give up. Swap it and have a piece of real fruit. If you are going to drink it, you should dilute it,” she said.

Ms. Jebb said she had herself stopped drinking orange juice and advised others to do so, or at least drink it diluted.

The paper quoted her as saying she would support a wider tax on sugar-heavy drinks.

Ms. Jebb works closely with the U.K. government on diet and obesity issues, and leads the government’s so-called health responsibility deal, which oversees voluntary pledges by the food and drink industry to improve public health. Her comments follow a similar warning in September by two U.S. scientists, Barry Popkin and George Bray, who exposed the health risks of fructose corn syrup in soft drinks in 2004.

Popkin, a professor of nutrition at the University of North Carolina, told the Guardian that fruit juices and fruit smoothies were “the new danger”.

“Think of eating one orange or two and getting filled. Now think of drinking a smoothie with six oranges and two hours later it does not affect how much you eat. The entire literature shows that we feel full from drinking beverages like smoothies but it does not affect our overall food intake, whereas eating an orange does,” he said. “So pulped-up smoothies do nothing good for us but do give us the same amount of sugar as four to six oranges or a large coke. It is deceiving,” Mr. Popkin said.

Smoking prevalence among Indian men decreased from 33.8 percent to 23 percent (1980-2012) !

A new research from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington has revealed that India has made progress in reducing the prevalence of daily smoking among men.Smoking is the third top risk for health loss in India, leading to nearly one million deaths each year in the country. Between 1980 and 2012, smoking prevalence among Indian men decreased from 33.8 percent to 23 percent.

According to the research India has more female smokers  over 12.1 million  than any country except the United States. In 2012, female smoking prevalence was 3.2 percent, which is virtually unchanged since 1980. "Smoking rates remain dangerously high for men and there is more work to be done to drive these rates lower," Dr. Srinath Reddy, President of the Public Health Foundation of India, said in response to the findings. "The high number of female smokers in India is also troubling," he said.These developments in India have taken place against an increasingly complex global backdrop.Trends in age standardized tobacco use vary greatly by country and gender, with places such as Mexico and Canada seeing rapid declines while others, such as Russia and China, seeing increases since 2006.Male smokers continue to outnumber female smokers and, since 1980, the global rate of decline in female smoking prevalence was consistently faster than in men.The study is published in the Journal of the American Medical Association.

Can we manage TIA patients safely in outpatient clinics?

Can lower risk patients presenting with transient ischemic attack be safely managed as outpatients? This is a question we need to answer during these days, where one would like to avoid hospitalization expenditure

A paper published by an Australian author said in conclusion, medical assessment, expedited investigation with immediate commencement of secondary prevention and outpatient neurology review may be a reasonable alternative to admission for low risk patients presenting to the Emergency Department with TIA.

Stroke is second only to ischemic heart disease as a leading cause of disease burden in Australia. Stroke places considerable strain on the public health system in Australia (length of stay averages 8 days and outcomes range from returning home to nursing home placement to death). There is a paucity of data regarding the best approach to care provision following a transient ischemic attack (TIA) in the Australian setting. The risk of stroke following a TIA is as high as 5–10% in the first 7 days depending on the population and clinical setting examined, with the lowest risks observed in the context of emergent management. Higher rates have been reported among high risk populations in the absence of protocol driven initiation of secondary prevention.

TIA represent a window of opportunity for effective secondary stroke prevention.7 Review in a daily (as opposed to weekly) TIA  clinic with no appointment necessary and immediate commencement of therapy has demonstrated an 80% reduction in risk of recurrent cerebrovascular accident within 90 days (10.3% versus 2.1%) in the EXPRESS study with demonstrated cost-savings in terms of bed days, acute costs, and 6 month disability.8 Risk reduction with early intervention is also supported by results of the SOSTIA study and other approaches, all of which involve immediate commencement of anti platelet therapy.

External validation studies have yielded inconsistent results with regard to predictability of the age, blood pressure, clinical features, duration of symptoms and diabetes (ABCD2) score at determining risk of stroke recurrence, thus, its clinical utility remains unclear. Two recent large population based studies have again raised questions about the clinical utility of the ABCD2 score. It is likely that the optimal approach to risk stratification incorporates the results of diffusion-weighted imaging (as examined by the more recently devised ABCD2–I and ABCD3–I scores) and early carotid imaging (as assessed by the ABCD3–I score), although prompt cerebral MRI may not be possible in many practice settings.

Stroke is a major cause for loss of life, limbs and speech in India, with the Indian Council of Medical Research estimating that in 2004, there were 9.3 lakh cases of stroke and 6.4 lakh deaths due to stroke in India, most of the people being less than 45 years old. Experts say that if deaths as well as disability are counted together, then India lost 63 lakh of disability-adjusted life years in 2004.WHO estimates suggest that by 2050, 80% stroke cases in the world would occur in low and middle income countries mainly India and China. Those with high blood pressure, diabetes, high blood fat (cholesterol) are specially at risk. The most important of these risk factors is high BP. In India, more than 16% of people above 20 years of age suffer from high BP. Fifty per cent of those with high BP are not even aware of it. Of those who are aware, only 50% take measures to control it, and of those who take these measures, only 50% are adequately controlled. "Thus, only 12.5% of patients with high BP are adequately controlled".  In the absence of high risk factors (low risk patients) one may consider the outpatient clinic protocol based therapies in India also!!

Cervical rib and thromboembolic stroke

Middle aged, overweight woman was admitted with critical ischemia in the right upper limb. She was symptomatic for more than a month. In our clinic (tertiary care hospital) it is uncommon to see patients with history shorter than 1 week. She required trans brachial thrombectomy (in emergency) and removal of the cervical rib (elective) and subclavian artery thrombectomy. The vertebral artery was close to the scalenous anticus muscle. Yet the thrombus in the subclavian artery rarely goes to the vertebral artery to cause the thromboembolic stroke. But we never came across such a patient in the last 25 years in our practice. It is possible that the neurologist treating the stroke patient may miss cervical rib,  if the patient has not been specifically examined and evaluated.

I came across a paper – where this information was published, I thought it will be useful to you, if you are looking for this type of information.

Thoracic outlet syndrome occurs due to compression of the neurovascular structures as they exit the thorax. Subclavian arterial compression is usually due to a cervical rib, and is rarely associated with thromboembolic stroke. The mechanism of cerebral embolization associated with the thoracic outlet syndrome is poorly understood, but may be due to retrograde propagation of thrombus or transient retrograde flow within the subclavian artery exacerbated by arm abduction. We report an illustrative patient and review the clinical features, imaging findings and management of stroke associated with thoracic outlet syndrome.

J Clin Neurosci. 2013 Oct 4. pii: S0967-5868(13)00514-6. doi: 10.1016/j.jocn.2013.07.030. [Epub ahead of print] Thromboembolic stroke associated with thoracic outlet syndrome. Meumann EM, Chuen J, Fitt G, Perchyonok Y, Pond F, Dewey HM.