Is there any impact of regular physical activity on weekly warfarin dose requirement? Yes there is !!

http://link.springer.com/article/10.1007/s11239-015-1248-9 

Warfarin is an oral anticoagulant agent with a narrow therapeutic index. There is a marked inter- and intra-patient variability in warfarin dose requirement. All factors influencing warfarin response are not known and this study aims to evaluate if regular physical activity (RPA) is a determining factor. RPA level was collected with the Stanford Brief Activity Survey in 1064 incident warfarin users, as part of the Quebec Warfarin Cohort (QWC), and with the Global Physical Activity Questionnaire in 618 patients from the Montreal Heart Institute (MHI) Biobank. Linear regression was performed to model relationship of warfarin dose after 3 months of therapy in the QWC with RPA, while controlling for height, weight, age, CYP2C9 (*2 and *3 alleles) and VKORC1 (*2 allele) genotype. Warfarin dose of prevalent users was modeled in the MHI Biobank for replication. A higher level of physical activity was associated with higher doses of warfarin in both cohorts. In the QWC, physical activity could explain 5.4 % (P < 0.001) and 0.9 % (P = 3.23 × 10−5) of variance in dose, in univariate and multivariable models, respectively. Similarly, RPA was found to be associated with 1.7 % (P = 0.0012) and 0.5 % (P = 0.0391) of inter-individual variability in warfarin dose requirement before and after adjustment for other covariables, respectively. 
RPA is associated with higher warfarin dose requirement. The relevance of clinical recommendations on RPA to maintain a steady response to warfarin should be assessed in further studies.

Conventional surgery, Endovenous laser ablation and Ultrasound-guided foam sclerotherapy in patients with great saphenous varicose veins, which is better?

Br J Surg. 2015 Sep;102(10):1184-94. doi: 10.1002/bjs.9867. Epub 2015 Jul 1.

Five-year results of a randomized clinical trial of conventional surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy in patients with great saphenous varicose veins.

van der Velden SK¹, Biemans AA², De Maeseneer MG^1,3, Kockaert MA¹, Cuypers PW⁴, Hollestein LM¹, Neumann HA¹, Nijsten T¹, van den Bos RR¹.

BACKGROUND:A variety of techniques exist for the treatment of patients with great saphenous vein (GSV) varicosities. Few data exist on the long-term outcomes of these interventions.

METHODS:Patients undergoing conventional surgery, endovenous laser ablation (EVLA) and ultrasound-guided foam sclerotherapy (UGFS) for GSV varicose veins were followed up for 5 years. Primary outcome was obliteration or absence of the treated GSV segment; secondary outcomes were absence of GSV reflux, and change in Chronic Venous Insufficiency quality-of-life Questionnaire (CIVIQ) and EuroQol - 5D (EQ-5D™) scores.

RESULTS: A total of 224 legs were included (69 conventional surgery, 78 EVLA, 77 UGFS), 193 (86.2 per cent) of which were evaluated at final follow-up. At 5 years, Kaplan-Meier estimates of obliteration or absence of the GSV were 85 (95 per cent c.i. 75 to 92), 77 (66 to 86) and 23 (14 to 33) per cent in the conventional surgery, EVLA and UGFS groups respectively. Absence of above-knee GSV reflux was found in 85 (73 to 92), 82 (72 to 90) and 41 (30 to 53) per cent respectively. CIVIQ scores deteriorated over time in patients in the UGFS group (0.98 increase per year, 95 per cent c.i. 0.16 to 1.79), and were significantly worse than those in the EVLA group (-0.44 decrease per year, 95 per cent c.i. -1.22 to 0.35) (P = 0.013). CIVIQ scores for the conventional surgery group did not differ from those in the EVLA and UGFS groups (0.44 increase per year, 95 per cent c.i. -0.41 to 1.29). EQ-5D™ scores improved equally in all groups.

CONCLUSION: EVLA and conventional surgery were more effective than UGFS in obliterating the GSV 5 years after intervention. UGFS was associated with substantial rates of GSV reflux and inferior CIVIQ scores compared with EVLA and conventional surgery.

REGISTRATION NUMBER: NCT00529672 (http://www.clinicaltrials.gov).

Combined assessment of thrombotic and haemorrhagic risk in acute medical patients

It is important to assess thrombosis risk and hemorrhage risk in our patients !

Online Supplementary Material

M. La Regina (1), F. Orlandini (1), F. Marchini (1), A. Marinaro (1), R. Bonacci (1), P. Bonanni (1), F. Corsini (1), A. M. Ceraudo (1), E. Pacetti (1), L. Scuotri (1), D. Costabile (2), F. Dentali

(1) Department of Internal Medicine, Ligurian East Hospital, La Spezia, Italy; (2) Elco S. r. l., Cairo Montenotte (Savona), Italy

venous thromboembolism, internal medicine, anticoagulants, prophylaxis, haemorrhage

Acute medical patients have a high risk of venous thromboembolic events (VTE). Unfortunately, the fear of bleeding complications limits the use of antithrombotic prophylaxis in this setting. To stratify the VTE and haemorrhagic risk, two clinical scores (PADUA, IMPROVE) have recently been developed. However, it is not clear how many patients have a concomitant high VTE and haemorrhagic risk and what is the use of prophylaxis in this situation. To clarify these issues we performed a prospective cohort study enrolling consecutive patients admitted to internal medicine. Patients admitted to internal medicine (January to December 2013) were included. VTE and haemorrhagic risk were evaluated in all the included patients. Use and type of anti-thrombotic prophylaxis was recorded. A total of 1761 patients (mean age 77.6 years) were enrolled; 76.8 % (95 % CI 74.7–78.7) were at high VTE risk and 11.9 % (95 % CI 10.4–13.5) were at high haemorrhagic risk. Anti-thrombotic prophylaxis was used in 80.5 % of patients at high VTE risk and in 6.5 % at low VTE risk (p< 0.001), and in 16.6 % at high haemorrhagic risk and in 72.5 % at low haemorrhagic risk (p< 0.001). Prophylaxis was used in 20.4 % at both high VTE and haemorrhagic risk and in 88.9 % at high VTE risk but low haemorrhagic risk. At multivariate-analysis, use of prophylaxis appeared highly influenced by the VTE risk (OR 68.2, 95 % CI 43.1 - 108.0). In conclusion, many patients admitted to internal medicine were at high risk of VTE. Since almost 90 % of them were at low haemorrhagic risk, pharmacological prophylaxis may be safely prescribed in most of these patients.

Intra-arterial Therapy in the Early Treatment of Acute Ischaemic Stroke

http://www.ejves.com/article/S1078-5884(15)00575-4/abstract

Intra-arterial Therapy in the Early Treatment of Acute Ischaemic Stroke

In 1995, intravenously administered recombinant tissue-type plasminogen activator (rtPA) was demonstrated to be effective as a treatment for acute ischaemic stroke provided it was commenced within 3 hours of stroke onset.1 In 2008, the ECASS-2 trial demonstrated that the time window for intravenous thrombolysis could be increased to 4.5 hours.2 More recently, intra-arterial thrombectomy (IAT), in addition to intravenous rtPA, has been shown to be highly beneficial when administered within 6 hours after acute stroke onset in six randomized clinical trials.

The introduction of IAT may also increase the need for expedited carotid interventions such as endarterectomy or stenting. It may be challenging for interventionists to stent a severe stenosis of the extracranial carotid artery at the same time as they treat an occluded intracranial artery. From a pragmatic point of view, this may seem a good approach, but it is unknown if the patient will benefit from a simultaneous procedure, or if it would be better to perform deferred carotid surgery after a few days. In the Mr Clean study, additional carotid interventions were performed in one out of eight patients (13%) who were treated with thrombolysis. It is well known that carotid endarterectomy should be performed within a few days after onset of a TIA or minor disabling stroke, but we know little about the safety of this procedure in patients with a severe carotid artery stenosis who only very recently suffered from a major stroke that was successfully treated with IAT. Expedited carotid surgery within 24 hours of lysis completion has shown promising results, but more data on stenting versus surgery and especially the optimal timing are still required.

In summary, 2015 will be remembered as the year in which IAT was established as a highly beneficial therapy for patients with acute ischaemic stroke affecting the anterior circulation. Stroke teams should now move to implement IAT in their treatment strategies and adapt their organization accordingly. More knowledge about the best indications for IAT and the need for additional carotid interventions will be forthcoming in the future.

Detection of Peripheral Arterial Disease Within the Foot Using Vascular Optical Tomographic Imaging: A Clinical Pilot Study

Happy New year 2016

Detection of Peripheral Arterial Disease Within the Foot Using Vascular Optical Tomographic Imaging: A Clinical Pilot Study

M.A. Khalil

http://www.ejves.com/article/S1078-5884(14)00578-4/fulltext

Vascular optical tomographic imaging (VOTI) is a novel imaging modality that is capable of detecting hemoglobin concentrations in tissue. VOTI is non-invasive, non-ionizing and does not require contrast injection. This technology was applied to the diagnosis of peripheral arterial disease (PAD) within lower extremities of diabetic patients with calcified arteries. This could be of substantial benefit as these patients suffer from comorbidities such as arterial incompressibility, which complicates diagnosis and monitoring.

The VOTI system with its sandal shaped measuring probe provides cross sectional images of hemoglobin concentrations in the foot.

This figure shows coronal cross sectional images from a healthy volunteer, a PAD patient, and a diabetic PAD patient. The five frames shown outline the hemodynamics during the thigh cuff occlusion and release. The healthy volunteer has a greater amount of blood pooling in the leg during the occlusion as well as a faster reaction to the application and release of the thigh cuff.

Conclusion

VOTI can effectively diagnose PAD independently of arterial compressibility, making it very useful for assessing vascular disease in diabetic patients.