Monday, January 27, 2014

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.
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 trial209 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.

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

Sunday, January 26, 2014

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.

Thursday, January 23, 2014

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.

Sunday, January 12, 2014

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.
quick_facts
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.

Wednesday, January 08, 2014

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.

Tuesday, January 07, 2014

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 EMChuen JFitt GPerchyonok YPond FDewey HM.

Saturday, January 04, 2014

$25 billion is spent annually in the United States treating chronic skin wounds related mostly to poor blood circulation?

The research review team, led by investigators at the Johns Hopkins Evidence-Based Practice Center and the Johns Hopkins Wound Healing Center, noted than an estimated $25 billion is spent annually in the United States treating chronic skin wounds related mostly to poor blood circulation, disorders known as venous ulcers. Their prevalence is rising along with rates of diabetes and obesity, and the review was undertaken in an effort to inform physicians about the treatment options.
Probably we should take them ( tiny and giant ulcerations)  more seriously and every effort should be made to prevent them and heal them early. - Pinjala R K