Niacin and mixed dyslipidemia

Niacin (nicotinic acid) lowers lipids by inhibiting very-low-density lipoprotein (VLDL) production in the liver and reducing the level of VLDL that can be converted into low-density lipoprotein (LDL). Niacin can lower LDL cholesterol by 10 to 25 percent and triglyceride levels by 20 to 50 percent, and can raise levels of high density lipoprotein (HDL) cholesterol by 15 to 35 percent. These effects may be even greater in patients with a predominance of small, dense LDL, which has been associated with greater coronary heart disease risk. For these reasons, niacin is considered a useful treatment in patients with mixed dyslipidemia. The adverse effects of immediate-acting niacin preparations, including flushing, itching, gastrointestinal upset and hepatotoxicity, have limited its use. An extended-release form of niacin has to be taken nightly to minimize liver toxicity and other side effects. The daily niacin dosage can be started at 375 mg taken nightly and slowly increased, to a maximum of 3,000 mg per day, at four-week intervals for a total of 25 weeks. Patients can take 325 mg of aspirin before Niacin to prevent flushing.In peripheral vascular surgery patients HDL levels are usually low in Inida. We need to increase the HDL levels in these patients and Niacin is a good  medication for these patients if the side effects such as flushing and other side effects are removed.

Patient self management of oral anticoagulation and patient self testing of INR -
Anticoagulation with vitamin K antagonists (for example, warfarin) reduces thromboembolic complications in patients with common chronic conditions, including atrial fibrillation, history of deep venous thrombosis and pulmonary embolism, and mechanical heart valves . In the United States, more than 5% of persons aged 65 to 74 years and more than 10% of persons aged 75 years or older receive long-term oral anticoagulants. In 2007, the cost of this medication alone was $905 million in USA. As the population ages, use and costs are likely to increase substantially. We find it very difficult to take care of the less educated people who are on oral anticoagulant medications. Many times the hospitals are not able to provide this care after major interventions and operations. Vitamin K antagonists have a narrow therapeutic window, and patients require frequent laboratory monitoring to ensure that they are neither excessively anticoagulated, which increases the risk for a bleeding event, or underanticoagulated, which increases the risk for thromboembolism. Recent trials have shown that direct thrombin inhibitors, which do not require intensive monitoring, may be as efficacious as vitamin K antagonists. We hope the new drugs will this simpler and safer until then we need to keep service active for the patients who are on oral anticoagulants for prevent of recurrent thrombotic complications. The review of these patients on oral anticoagulants indicated that compared with usual clinic care, Patient Self Testing with or without Patient Self Management is associated with significantly fewer deaths and thromboembolic events, without any increase in bleeding complications, for a selected group of motivated patients requiring long-term anticoagulation with vitamin K antagonists.
Ref : Annals of Inernal Medicine , April 5, 2011, 154 (7)

Carotidobrachial bypass in a Takayasu's disease patient - 7yrs follow up.

The surgical treatment of Takayasu's disease is complicated due to many reasons. It has been complicated by the extensive nature of the lesions, lack of accurate knowledge regarding the preferred sites and extent of the lesions, presence of skip lesions, and chances of reactivation. These patients are usually young, with an otherwise normal vascular system beyond the diseased area. Previously published reports expressing reservations about the efficacy of surgical treatment do not seem justified. Careful assessment of each patient as to his residual disability after conservative treatment and the haemodynamic status will make surgical treatment safe and rewarding for a large number of patients. Immunological investigations indicate the possibility of a mechanism  involving immune complex formation on a background of defective T-lymphocyte function in Takayasu's disease. Whereas the original antigenic trigger could be any one of a number of different possibilities, parasitic infestation and chronic infection in the intestines along with protein energy malnutrition may be possible etiological factors. The figure shows the patent right carotid brachial bypass with saphenous vein graft after 7 years, and she developed occlusive disease in the left subclavian artery in the recent past with symptoms of claudication in the left arm.

Trifurcation of the popliteal artery and Tibial vessel (3) occlusion with thrombosis.

In the recent few months we have seen and treated 7 men with severe pain, symptoms of ischemia due to below knee occlusion of  the popliteal artery and tibial (3) arteries. Initially they were given antiplatelet drugs and anticoagulation with no relief of symptoms. Thrombolytic therapy was started after angiogram and guide wire confirmation of the nature of the obstruction. In five patients Inj Tinectaplase and in two patients Inj Urokinase was given. All these patients were relieved of their symptoms with recanalization of the popliteal and tibial vessels and there was improvement of the ankle pressures above the critical levels.We feel that guide wire testing (ability to pass it through the occluded tibials) is crucial and determines the out comes of thrombolytic therapy.

World Health Day 7th April - 2011

Antimicrobial resistance: no action today, no cure tomorrow 

“Every government should have a national intersectoral plan on how to address the issue and respond to it.”Clinicians agree that one of the biggest challenges is finding out the true size of the problem of resistant infections in each country. “We need better microbiology labs to test antibiotic resistance to infections but above all we need better data to inform policies,” says Professor Nirmal Ganguly, Chair of the Global Antibiotic Resistance Partnership – India National Working Group. One of the most powerful measures globally to prevent antimicrobial resistance has been the ban of the use of antibiotics as growth promoters in livestock in the 27 European Union countries since 2006. The ban underlines the complex nature of the problem. “Antimicrobial resistance is a problem that goes beyond the health sector, so it is important to involve all sectors,” says Jakab. 

Spreading Antibiotic resistance and the role of hospitals in curtailing this problem - World Health Day 2011

Indian hospitals are going to need special precautions to prevent the spread of the antibiotic resistant bacteria across India. Over crowding, improper waste disposal, inappropriate use of antibiotic use without guidance will be focused more and more as the cause of spread of bacterial resistance. Frequent hand washing in the hospitals would be an important measure to reduce the spread of the resistant bacteria across the different wards in the hospitals. In the other countries such as USA and Europe Hospital-acquired infections are a major challenge to patient safety. It is estimated that in 2002, a total of 1.7 million hospital-acquired infections occurred (4.5 per 100 admissions), and almost 99,000 deaths resulted from or were associated with a hospital-acquired infection, making hospital-acquired infections the sixth leading cause of death in the United States; similar data have been reported from Europe. The estimated costs to the U.S. health care budget are $5 billion to $10 billion annually. Approximately one third or more of hospital-acquired infections are preventable.

Population in India
India added more than 181 million people to its swelling population in the past decade, growing to over 1.21 billion people, according to the latest census data released by officials on Thursday, 31st March 2011.
“We are now over 17 percent of the world population, and India is 2.4 percent of the world’s surface area,” said C. Chandramauli, India’s census commissioner. “We have added the population of Brazil to India’s numbers this time.”
The total population grew from 1.02 billion people in 2001 to 1.21 billion this year, according to the preliminary calculations of the massive census exercise that ended in February, costing over $492,000. The population of India now is almost equal to the combined population of United States, Indonesia, Brazil, Pakistan, Bangladesh and Japan

Alcohol consumption and cardiovascular disease outcomes - A systematic review and meta analysis.

The alcohol consumption is now socially accepted in more number of urban cities.The Indian alcoholic beverages market is dominated by whisky, which accounts for more than half of the total spirits consumed in the country.
The total consumption of whisky is estimated to be around 131 million cases in the current year, a rise of 10 per cent from 119 million cases in 2009. After whisky, rum is the most popular alcoholic beverage in India and the total consumption is estimated to be at 42.4 million cases in the current year, a rise of 8.7 per cent from 39 million cases in 2009.According to the IWSR report, consumption of beer — counted as a separate category — is likely to grow by 7 per cent to 195.5 million cases of 7.8 litres each (1.52 crore Hecto Litres) in the current year, as compared to 181.5 cases (1.41 crore Hecto Litres) in 2009.
IWSR is a London-headquartered market research firm that focuses exclusively on the global alcoholic beverage market.

The recent study in British Medical Journal is appealing to all those who are taking alcohol in a controlled manner. Possible cardioprotective effects of alcohol consumption seen in observational studies continue to be hotly debated in the medical literature and popular media. In the absence of clinical trials, clinicians must interpret these data when answering patients’ questions about taking alcohol to reduce their risk of cardiovascular disease. Systematic reviews and meta-analyses have addressed the association of alcohol consumption with cardiovascular disease outcomes but have not uniformly addressed associations between alcohol use and mortality from cardiovascular disease, as well as the incidence and mortality from coronary heart disease and stroke.

In a review of 84 studies of alcohol consumption and cardiovascular disease, alcohol consumption at 2.5–14.9 g/day (about ≤1 drink a day) was consistently associated with a 14–25% reduction in the risk of all outcomes assessed compared with abstaining from alcohol. Such a reduction in risk is potentially of clinical importance, but consumption of larger amounts of alcohol was associated with higher risks for stroke incidence and mortality.

The protective association of alcohol has been consistently observed in diverse patient populations and in both women and men. Fourthly, the association is specific: moderate drinking (up to 1 drink or 12.5 g alcohol per day for women and 2 drinks or 25 g alcohol per day for men is associated with lower rates of cardiovascular disease but is not uniformly protective for other conditions, such as cancer. But one should remember that hemorrhagic stroke in more in the alcoholics.
The focus  trials would shift from assessing the association between alcohol and disease outcomes to evaluating the receptivity of both physicians and patients to the recommended consumption of alcohol for therapeutic purposes and the extent to which it can be successfully and safely implemented. In support of implementation trials, our two papers show that alcohol consumption in moderation has reproducible and plausible effects on markers of coronary heart disease risk.The total consumption of alcoholic beverages in India is expected to touch 217.1 million cases in 2010, marking a growth of 8 per cent from the previous year, according to a report.
The Emerging Ideal
While alcohol consumption is low overall, it's even lower in women than in men in India, as in many countries. Though data is limited, studies through 2000 consistently estimated prevalence of alcohol use among Indian women at less than 5 percent. In addition, there is a persistent belief that women who drink alcohol are either less educated, rural women or members of the upper crust, leading to a stereotype that associates alcohol use with primitivism or privilege.
However, drinking is becoming more commonplace for India's professional women, causing the gap between drinking habits of women and men in India to narrow--a phenomenon also happening around the world. As women become more educated and more economically independent, women's alcohol use in some societies is rising. (And men's alcohol use, interestingly, is falling in some European countries.)
One contributor in India is employment. Though labor force participation dropped between 1999 and 2002 for rural females, rural males, and urban males, it rose for urban females. Contrary to the historical stereotype, these urban females now consume alcohol at twice the rate of their rural counterparts.

Sarah Bosa et al (European Jl of cardiovascular prevention and rehabilitation) concluded that moderate alcohol consumption is associated with a reduced risk of CHD among hypertensive women. Light alcohol consumption tended to be related to a lower risk of stroke. Current guidelines for alcohol consumption in the general population also apply to hypertensive women.

We can expect changes in the coming years in a country like India and that may depend on the many social  ethical and cultural issues.

Atorvastatin Linked to Small Increase in Risk for Type 2 Diabetes

Simvastatin, Atorvastatin, Rosuvastatin are now available in India. They have been found to be very effective in preventing the secondary cardiovascular complications. There are some complications such as reduction of HDL or inability to raise the HDL, new onset Diabetes ( physician reported diabetes). Atorvastatin seems to carry a "slight increase in the risk" for new-onset type 2 diabetes, according to an analysis of three large trials published in the Journal of the American College of Cardiology. (The trials, as well as this analysis, were sponsored by atorvastatin's manufacturer.)
Researchers were responding to a 2010 Lancet meta-analysis, which found a small but measurable risk for new-onset diabetes after all statin use. The current analysis focuses on atorvastatin's effects in the TNT, IDEAL, and SPARCL trials. It found that atorvastatin, when compared with placebo in the SPARCL trial, carries a higher risk for diabetes. In the other trials, there was a slightly increased risk when an 80-mg dose was compared with lower doses (10-mg atorvastatin in TNT, 20-mg simvastatin in IDEAL), but the differences did not achieve statistical significance.

The JACC authors conclude (as did the authors of the Lancet meta-analysis) that the benefits of statins "far outweigh the risks."

DVT awareness Month - March 2011

Photo: Melanie ( David Bloom NBC reporter) -National spokes person (USA) for Coalition against deep vein thrombosis

Venous thrombosis and pulmonary embolism are important clinical conditions that occur in the hospitalized patients. The mortality and morbidity associated with them can be prevented by precautions and medical therapies prior to their onset. Hospitals are encouraged to have written protocols to prevent venous thromboembolism in the hospitalized patients. Heparin, oral anticoagulants are regularly used in the prevention and treatment of VTE. The newer oral direct Xa inhibitors are undergoing phase III trials and soon there is a possibility that they are going to be released in to the market 2013. Riveroxaban, Apixaban, Edoxaban are going to be used in the treatment of deep vein thrombosis without much biochemical monitoring. Thrombolytic usage may increase in the coming years with an idea to prevent post thrombotic syndrome which is currently expected to be as high as 50%. During this month we organized many meetings in the hospitals to share the information and educate the hospital staff. DVT Awareness Meetings were conducted in all the major cities by doctors with lot of enthusiasm. The findings of ENDORSE study were discussed and it was stressed that 50% of the patients getting admitted in to the acute care hospitals are at risk of VTE and only 16% of the surgical and 19% of the medical patients who are at risk of the VTE received the thrombosis prophylaxis. More efforts are needed to identify the patients at risk with the help of RAMs ( risk assessment modules) and adequate prophylactic measures should be taken to reduce the DVT, PE related and deaths and post thrombotic syndrome.

World Health Day – 7 April 2011

Antimicrobial resistance and its global spread

• Antimicrobial resistance: no action today no cure tomorrow
  We live in an era of medical breakthroughs with new wonder drugs available to treat conditions that a few decades ago, or even a few years ago in the case of HIV/AIDS, would have proved fatal. For World Health Day 2011, WHO will launch a worldwide campaign to safeguard these medicines for future generations. Antimicrobial resistance and its global spread threaten the continued effectiveness of many medicines used today to treat the sick, while at the same time it risks jeopardizing important advances being made against major infectious killers.

Negative Pressure Wound Therapy With Integrated Irrigation for the Treatment of Diabetic Foot Ulcers

 In India, diabetic foot wound care is found to be expensive and usually neglected. That results in increased morbidity, mortality. Offloading is not routinely given in clinics  and patients are not adequately convinced that such a foot wear is helpful to them. Preventing diabetic foot ulcers from progressing in depth and becoming infected and developing into more serious conditions is not only clinically beneficial but also has a positive impact on health care resources.
Given the high costs of non healing wounds and the associated negative impact on patient quality of life, outpatient interventions that prevent ulcer progression and promote healing are of benefit to patients and clinicians. The recently introduced NPWT, is decreasing the healing time and effective too in controlling the infection. In Hyderabad, India- VAC (Vacum assisted closure) therapy is now available both in the hospitals and at the home. It is costing Rs.10,000 to Rs20,000 depending on the duration of the therapy.
In a prospective study conducted in a clinic setting, NPWT using the Svedman Wound Treatment System with irrigation was successful in facilitating wound closure and healing in both large and small wounds resulting from complications of diabetic neuropathy and pressure on the distal lower limb. Wound irrigation in addition to the negative pressure further facilitates the healing and control of infection. In other words after a long period of time the diabetic foot wound care is becoming more simpler and effective. This NPWT is added to the adequate and repeated debridements and skin grafting.

Can we treat the Aortic Aneurysms medically?

Abdominal aortic aneurysms (AAA) continue to provide an intractable clinical problem. As a disease that affects nearly 10% of the elderly population and claims over 15,000 lives/yr (USA), it is remarkable that treatment of a ruptured AAA is still associated with high mortality rates (in excess of 80%). Many would argue that physicians remain largely incapable of altering the natural history of this disease, despite our growing understanding of the pathophysiology of the vascular lesion. Several promising therapies, including statins, β-blockers, and antibiotics, have all failed to conclusively improve outcomes in large clinical trials, and no medicine is currently approved to treat AAA formation. In clinical management of Aortic Aneurysms, doctors and patients are often faced with the important decision of whether to perform invasive repair or to manage the condition conservatively. The mortality rate associated with reparative surgery has been reported to be as high as 5.5%.Current guidelines recommend endovascular repair or surgery if the aortic diameter exceeds 5.5 cm and the performance of anatomic imaging every 3 to 6 months for aneurysms above 4 cm. If growth is observed to exceed 1 cm per year in smaller aneurysms, surgical repair is also recommended. However, individual risk is also influenced by gender, age, smoking, and co-morbidities, but its assessment is rarely easy because reliable data regarding how best to evaluate these variables are not readily available. This situation often leaves one with a difficult decision, and many patients are unnecessarily exposed to the risks of reparative surgery when their aneurysm might never have ruptured if left untreated.
Aneurysms are complex entities that differ physiologically from stenotic and atherosclerotic vascular lesions. Although atheromas are dominated by neointimal proliferation and foam cell generation, the AAA is defined by the progressive loss of extracellular matrix and medial degeneration. Macrophages are recruited to the involved vessel in both conditions, but have differing roles in each case. Unlike the subendothelial lipid-laden cells of the fatty streak, macrophages of the abdominal aneurysm accumulate in the medial layer where they present antigens to other leukocytes, secrete collagenases, and elaborate proinflammatory cytokines and chemoattractants. Ultimately, they play a role in progressive aneurysmal dilation and clinical presentation. Novel therapies that can reverse this pathological course are eagerly sought.
A number of studies in patients have suggested that doxycycline can inhibit MMPs in aneurysm tissue. Curci et al66 treated a series of patients with a 3-week course of doxycycline before open aneurysm repair. Tissue levels of MMP-9 were significantly reduced by doxycycline compared with untreated patients. Baxter et al showed in a small series of 36 patients on a 6-month course of doxycycline that plasma MMP-9 levels decreased significantly compared with baseline levels. This work has been followed by a small, prospective, randomized trial of doxycycline in which 32 patients were randomized, with 17 receiving doxycycline (150 mg/d) for 3 months. Patients were followed up for 18 months. C pneumoniae titers were assessed but found not to be affected by doxycycline treatment. The calculated growth rate at the end of the 18-month period of observation was 1.5 mm per year in the doxycycline-treated group versus 3.0 mm per year in the placebo-treated group. This difference did not achieve statistical significance, but the 6- and 12-month time periods did show a significant difference in favor of doxycycline treatment. Level B evidence (from small randomized trials) suggests that roxithromycin or doxycycline will decrease the rate of aneurysm expansion.
A small study by Lindholt et al suggested that serological evidence of a C pneumoniae infection was associated with an increased rate of aneurysm expansion. This led to a randomized clinical trial in which 43 patients received a 1-month course of roxithromycin, whereas 49 patients received placebo.60 Patients in the treatment arm had an expansion rate at the end of the study of 1.56 mm per year compared with a rate of 2.75 mm per year in the placebo-treated group. The inhibition was greater in the first year than the second year. The study did not clarify the mechanism of effect because there was no correlation between Chlamydia titers and roxithromycin ability to inhibit aneurysm expansion.
We need more medical therapies which can alter the natural course of the small aneurysms and prevent the rupture of these Aortic aneurysms which are diagnosed when they are small and note taken up for the interventions.

Risk assessment for recurrent venous thrombosis

(Number of risk factors identified by laboratory screening for thrombophilia in 158 patients without cancer with two episodes of unprovoked venous thrombosis, 3 weeks after the incident event, patients were screened for deficiency of antithrombin, protein C, or protein S; presence of lupus anticoagulant, factor V Leiden, factor II G20210A; and high concentrations of homocysteine, factor VIII, or factor IX.)

Recurrent Thrombosis is going to increase the morbidity and mortality. If there are two episodes of unprovoked DVT  without cancer, we can expect that there is some kind of hypercoagulable condition with one or more risk factors.

FIELD study - Can we reduce the amputations in Diabetic population with Fenofibrate?

Diabetes mellitus is the leading cause of non-traumatic lower-extremity amputations in the developed world. In the USA in 2001, at least one amputation due to diabetes occurred every 2 h, with an annual cost exceeding US$1·6 billion.Despite rigorous management of reversible factors, probably around one in ten patients with diabetes will eventually need at least one amputation. Neither control of glycaemia or blood pressure nor lowering of cholesterol has prevented the risk of amputation, underscoring the importance of assessing the management of other potential risk factors. Any further therapeutic option to prevent the morbidity and mortality associated with amputation would be highly desirable. In the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study, 9795 patients aged 50—75 years with type 2 diabetes were randomly assigned by computer-generated randomisation sequence to receive fenofibrate 200 mg per day (n=4895) or matching placebo (n=4900) for 5 years' duration. Information about non-traumatic amputation—a prespecified tertiary endpoint of the study—was routinely gathered.The risks of first amputation (45 vs 70 events; hazard ratio [HR] 0·64, 95% CI 0·44—0·94; p=0·02) and minor amputation events without known large-vessel disease (18 vs 34 events; 0·53, 0·30—0·94; p=0·027) were lower for patients assigned to fenofibrate than for patients assigned to placebo, with no difference between groups in risk of major amputations (24 vs 26 events; 0·93, 0·53—1·62; p=0·79)

In POPADAD study, it was found that Aspirin is ineffective in Diabetics with Asymptomatic Peripheral Vascular Disease for primary prophylaxis! (BMJ 2008)

Peripheral arterial disease patients have an increased risk of subsequent myocardial infarction and stroke and are six times more likely to die from cardiovascular disease within10 years than patients without peripheral arterial disease. Patients with peripheral arterial disease have a 15 year accrued survival rate of about 22% compared with a survival rate of 78% in patients without such disease. So, there is always a question about beneficial effect and safety in giving Aspirin in the asymptomatic PAD patients to prevent the CV complications!

After this POPADAD study a question was asked as to whether these diabetic patients were at sufficient risk, in terms of peripheral arterial disease, as the cut-off point of an ankle brachial pressure index of 0.99 or less is higher than that used to define peripheral arterial disease in the population (<0.9). A subgroup analysis did not, however, find evidence of a difference in effect of aspirin between those with an index of 0.91-0.99 and those below this level.
Furthermore, one of the current major interventions in the specialty of diabetes mellitus is statin therapy. Calculations by two of the centres (DM and CK) in over 10 000 people with diabetes showed a mean total cholesterol level of 6.0 mmol/l in 1996 decreasing to 4.3 mmol/l in 2007. As aspirin was the first drug to have an evidence base for secondary prevention of cardiovascular disease it is always given to patients in subsequent trials and it might be asked if aspirin does indeed provide additional benefit when statins are used to good effect. The importance of the neutral effect of aspirin on cardiovascular events is that this drug is not without side effects. Aspirin is the most commonly prescribed drug in Scotland, with about 544 438 person years exposure per year in 2002. The number of prescriptions is increasing. The overwhelming majority of this, in the region of Tayside at least, is prescription based, with only about 7% being from over the counter use. Aspirin is one of the top 10 causes of adverse drug events reported to the Commission on Human Medicines. Gastrointestinal bleeding is associated ith general use of non-steroidal anti-inflammatory drugs in over 80%of reported cases, and 87%of that use is associated with aspirin, either alone or with other non-steroidal anti-inflammatory drugs. The risk of a bleeding event increases with age and also continuous exposure.
Although the calculated risk of major bleeding is relatively small, the number of people taking aspirin is relatively large and therefore in population terms aspirin induced bleeding is a major problem. In a meta-analysis the number needed to treat to cause an adverse event has been calculated as 248, and this is relevant to the large and increasing population with diabetes.
In addition, of concern was the fact that there was a tendency to harm in the antioxidant group. Anecdotally, many people with diabetes supplement with antioxidants after major publicity in the lay press of a deficiency in antioxidants in such people. It was also found there was no evidence for this perceived benefit in the studies.

Conclusion: Both Aspirin and Antioxidants are not useful in Diabetics with asymptomatic peripheral vascular disease in preventing the cardiovascular events!

Helicobacter pylori  in smokers with peripheral vascular disease - Shoud we consider quadruple therapy for eradication routinely?

Infection with Helicobacter pylori is a substantial public health problem that affects 20 to 50% of people in industrialised nations and up to 80% in less-developed countries. H pylori is associated with many gastroduodenal disorders, including peptic ulcer disease, gastric carcinoma, and gastric mucosa-associated lymphoid tissue lymphoma. In regions with high incidence of gastric carcinoma, eradication of H pylori is advocated to prevent the development of this disease. Further, patients benefit from eradication after endoscopic resection of early gastric carcinoma because it reduces the risk for metachronous gastric neoplasia.
A previous international study, which assessed the efficacy and safety of 10 days of omeprazole with a single (three-in-one) capsule containing bismuth subcitrate potassium, metronidazole, and tetracycline (quadruple therapy) for H pylori eradication in patients with peptic ulcer disease or non-ulcer dyspepsia, reported overall eradication rates greater than 90%.

Quadruple therapy should be considered for first-line treatment in view of the rising prevalence of clarithromycin-resistant H pylori, especially since quadruple therapy provides superior eradication with similar safety and tolerability to standard therapy.

Long term follow up (8 yrs) after Endorepair of Thoracic Aortic dissection.

This gentleman was admitted with acute ischemia in both the lower limbs in middle of the night and in emergency the resident on duty attempted thrombectomy but failed to retreive the thrombus. The next morning further investigations revealed dissection of aorta from the left subclavian origin to abdominal aortic bifurcation. After discussions it was decided to do the endorepair. Endorepair was successfully done and remained intact for the past 8 years. He has developed diabetes in the followup. His blood pressure was controlled with medications and he is advised to monitor blood pressure regularly at home.

Obesity and Venous disease (Varicose veins): Weight management in venous disease (varicose veins) patients is very difficult. It is becoming a common problem in the vascular surgery out patient clinics. Some may still feel that obesity is not a major problem in Indian hospitals. In the venous subset of population attending the vascular clinics this is a significant problem. A recent study by the University of Maryland and the National Council of Applied Economic Research found 22 per cent of Indians living in cities were overweight and 7 per cent were obese. The following is the typical presentation in our clinic. Here is a man weighing 107 Kgs with history of bleeding from the leg veins. He was advised to loose 5 kgs by adjusting diet and life styles along with class II stockings. He came back to the clinic after 4 weeks with a weight of 110Kgs. But he is regular with his stockings and there were no episodes of bleeding from the leg. This is a common problem to see weight gain when you advise them to loose weight. Weight management needs special attention to the details and it would not be sufficient if we simply advice the patients to loose weight. Very few patients (from low socioeconomic group) succeed in loosing the weight with a simple advice in the outpatient clinics. India has 70 million people who have been re-classified as overweight or obese, after a lowering of obesity thresholds. In India the BMI limits have been lowered to 23 for being overweight and 25 for being obese, to reflect the risks to the population. Indians also have lower thresholds for waist circumference measurements.

Changing Health care  in west (UK, USA), we need better understanding of medical health insurance and future needs ?

We did not  dream that this would be happening to health care industry in United Kingdom three decades back. It seems, Since its establishment in July, 1948, the aim of the NHS has been to offer a comprehensive service to improve health and prevent illness, available to all in England and Wales (and then extended throughout the UK), which is largely free of charge. Health care for all, for free, has been the common ethos and philosophy throughout the NHS. But in 60 years things changed, it has been forced to look for better ways to provide health care even in the countries like United kingdom and few others.The money barrier, of course is crucial in making decisions.Now, GPs will return to the market place and will decide what care they can afford to provide for their patients, and who will be the provider and insuring agent. There is fear that the emphasis will move from clinical need (GPs' forte) back to cost (not what GPs were trained to evaluate). The ethos will become that of the individual providers and insurers, and will differ accordingly throughout England, replacing the philosophy of a genuinely national health service. We in Andhrapradesh India, introduced a system to reach people known as "Aarogyasree" public(Govt) funded health insurance scheme, managed through the web (internet) approval of patient selection and procedures and release of money. I forsee that there is going to be a need for similar systems (with modifications) in the other countries also to reach the needy people. That means the robust medical insurance has come to the lime light in many parts of the world by force. We need to understand more about the Medical insurance and It should be a subject for study during undergraduate studies for Medical graduates.

Can we make the vascular access for hemodialysis through the neck lines (central lines) more safer and long lasting?

Vascular access for hemodialysis is known to frequently thrombose and force us to go for revision or create a new vascular access. Central lines are flushed with heparin to prevent the thrombosis but even then some catheters get blocked due to thrombosis and others develop the infection. Such catheters are treated with rtPA (1mg) to lyse the clots in the catheter. Loss of access can be expensive and one has to go for another one. In a recent study published in NEJM it was observed routine use of rtPA (1mg) once in a week in addition to twice a week Heparin irrigation of the catheter can prevent the thrombosis and bacteremia. Brenda RH ( preCLOT study group) did this study and it is very interesting to findout that elective use of rtPA can increase the patency and prevent the bacteremia in those patients undergoing dialysis through the central neck lines. Soon the 1mg rtPA prefilled syringes may be available in many countries to irrigate the the central lines for better patency. We can congratulate Brenda R H et al for conducting this study which can help the hemodialysis patients.

Economics and venous disease in the developing nations
In the coming years venous disease is going to be diagnosed more often and therapies will be suggested by doctors to the patients. It is due to the availability of the Ultrasound scans (doppler) in every medical centre. This can tremendously increase the demand for the treatments which are day care and minimally invasive. Endovenous ablative therapies are going to be popularised by the hospital based doctors. In India, the cost of varicose veins -ablative therapies will be around Rs 40,000/= in the coming years.

Chronic venous ulcers

Patients develop venous ulcers after sufferring from chronic venous hypertension over a period of time ( 8 to 10 years). The venous ulcers fail to heal and they also recur after healing. Patients also become indifferent to the treatments as they have seen failures more often than success with treatments. This patient had ulcer for more than 10 years. The skin around the ulcer is indurated and there are pale grannualtion tissues in the base of the ulcer.

Pulsatile swelling in the Hypothenar eminence

Traumatic(repeated) injury to the ulnar artery can result in aneurysm formation. The radial artery is patent and the palmar arch is also supplied by the radial artery. This patient is advised repair of the ulnar artery aneurysm under tourniquet.

Femoral artery Pseudo aneurysm (post traumatic) in middle aged man.

This gentleman sustained injury to the thigh (Bamboo stick) while working near the cattle at home 1 month back. He developed profuse bleeding and later swelling of the thigh. He waited for 1 month with local therapies. Then he came to our clinic under the Aarogyasri scheme. We operated on him in emergency after getting the approval from Aarogyasri insurance scheme. A short segment of saphenous vein graft was interposed to repair the damaged artery segment. The sartorius muscle (flap) was used to cover the graft. Usually patients from low socioeconomic status are able to reach the tertiary care hospital after a minimum of 2 to 4 weeks and Aarogysri is helping them to get the vascular surgical therapies in emergency situations.

Intra operative photograph showing the vein graft after excision of aneurysm

Post thrombotic syndrome and its prevention by early clearance of thrombus load from the DVT patients is going to attract the attention of doctors as it is promising to clear the vein load of thrombus. Catheter directed thrombolysis in combination with the percutaneous mechanical thrombectomy seem to be future mode of management  of the ilio-femoral deep vein thrombosis. However the cost of such treatment may not make it best choice of treatment for majority of the people who are living in India who can not afford such expensive therapies. The appropriate cost for such therapies will not be less than Rs 1,50,000/= . We donot know if the 3rd party insurance companies will be approving such expensive therapies for the ilio-femoral DVT!



Intraarterial Administration of Bone Marrow Mononuclear Cells in Patients With Critical Limb Ischemia

Critical limb ischemia due to peripheral arterial occlusive disease is associated with a severely increased morbidity and mortality. There is no effective pharmacological therapy available. Injection of autologous bone marrow-derived mononuclear cells (BM-MNC) is a promising therapeutic option in patients with critical limb ischemia, but double-blind, randomized trials are lacking. A Randomized-Start, Placebo-Controlled Pilot Trial (PROVASA) was published in Circulation - cardiovascular interventions.In this study Limb salvage and amputation-free survival rates did not differ between the control and study groups. However, cell therapy was associated with significantly improved ulcer healing (ulcer area, 3.2±4.7 cm² to 1.89±3.5 cm²P=0.014] versus placebo, 2.92±3.5 cm²² [P=0.5]) and reduced rest pain (5.2±1.8 to 2.2±1.3 [P=0.009] versus placebo, 4.5±2.4 to 3.9±2.6 [P=0.3]) within 3 months. 

We in India, need to be careful in jumping to conclusions without adequate  supportive evidence in favor of the cell therapies to treat the critical limb ischaemia for the present. If the strong evidence becomes available certainly and eagerly we are waiting to bring that in to our clinical practice.

What is optimum anticoagulation with Heparin in peripheral vascular treatments?

             Beyond the heparin dose ( initially up to 60 U/kg) and the ACT level (250 seconds) , in the multivariate analysis it was found that female sex, creatinine clearance <60 mL/min per 1.73m² age >70 years, preprocedural anemia, history of heart failure, hybrid vascular surgery, rest pain, and below-knee interventions were independent predictors of higher postprocedural bleeding risk. These findings are consistent with those from 2 large retrospective databases of patients undergoing PCI and a registry of 24 045 patients with acute coronary syndromes from the Global Registry of Acute Coronary Events (GRACE).Less aggressive anticoagulation, or use of an alternative anticoagulant strategy such as a direct thrombin inhibitor, may decrease the incidence of bleeding complications in these subgroups of high-risk patients.
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References

1. Moscucci M, Fox KA, Cannon CP et al. Predictors of major bleeding in acute coronary syndromes: the Global Registry of Acute Coronary Events (GRACE). Eur Heart J. 2003; 24: 1815– 1823
2. Shammas NW,Allie D,Hall P: Predictors of in-hospital and 30-day complications of peripheral vascular interventions using bivalirudin as the primary anticoagulant: results from the APPROVE Registry. J Invasive Cardiol. 2005; 17: 356– 359

Surgical site infections in the Hospital patients - Guidelines can prevent them?
American Journal of Surgery - Volume 201, Issue 1 (January 2011)

Surgical site infections (SSIs) occur in more than 500,000 patients annually and result in increased length of hospital stay, readmissions, costs, and mortality in USA. [1] , [2] Up to 60% of SSIs have been estimated to be preventable, [3] , [4] , [5] largely by using recommended evidence-based guidelines such as timely and appropriate administration of antibiotics for prophylaxis and maintenance of perioperative normothermia. [3] , [6] , [7] , [8] A number of hospitals have reported decreased infection rates by improving utilization of these guidelines. [9] , [10] Furthermore, lack of compliance with these guidelines is associated with a significant increase in mortality.[11] Despite the evidence that these measures improve outcome, compliance with these guidelines is suboptimal in many hospitals, as demonstrated by data from large administrative databases and cohort studies. [9] , [12] , [13] , [14] Bratzler et al evaluated a random sample of 34,133 Medicare patients and found that only 56% of patients received antimicrobial therapy within 1 hour before incision and that only 40% had appropriate discontinuation of prophylactic antibiotics after 24 hours.[13] Based on poor compliance with these guidelines and the high morbidity and mortality of postoperative complications, the Surgical Care Improvement Project (SCIP) was developed as a collaborative effort to prevent infectious, thromboembolic, cardiac, and respiratory complications.[15]



1 Kirkland K.B., Briggs J.P., Trivette S.L., et al: The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol 20. 725-730.1999; Abstract


2 Weinstein R.A.: Nosocomial infection update. Emerg Infect Dis 4. 416-420.1998; Abstract

3 Mangram A.J., Horan T.C., Pearson M.L., et al: Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory CommitteeAm J Infect Control 27. 97-132.1999; Full Text

4 Page C.P., Bohnen J.M., Fletcher J.R., et al: Antimicrobial prophylaxis for surgical wounds. Guidelines for clinical careArch Surg 128. 79-88.1993; Abstract

5 Platt R., Munoz A., Stella J., et al: Antibiotic prophylaxis for cardiovascular surgery. Efficacy with coronary artery bypassAnn Intern Med 101. 770-774.1984; Abstract

6 Chodak G.W., Plaut M.E.: Use of systemic antibiotics for prophylaxis in surgery: a critical review. Arch Surg 112. 326-334.1977; Abstract

7 Horan T.C., Gaynes R.P., Martone W.J., et al: CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol 13. 606-608.1992; Citation

8 Kurz A., Sessler D.I., Lenhardt R.: Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature GroupN Engl J Med 334. 1209-1215.1996; Abstract

9 Dellinger E.P., Hausmann S.M., Bratzler D.W., et al: Hospitals collaborate to decrease surgical site infections. Am J Surg 190. 9-15.2005; Full Text

10 Hedrick T.L., Heckman J.A., Smith R.L., et al: Efficacy of protocol implementation on incidence of wound infection in colorectal operations. J Am Coll Surg 205. 432-438.2007; Full Text

11 Mahid S.S., Polk , Jr , JrH.C., Lewis J.N., et al: Opportunities for improved performance in surgical specialty practice. Ann Surg 247. 380-388.2008; Abstract

12 Bratzler D.W., Houck P.M.: Antimicrobial prophylaxis for surgery: an advisory statement from the national surgical infection prevention project. Clin Infect Dis 38. 1706-1715.2004; Abstract

13 Bratzler D.W., Houck P.M., Richards C., et al: Use of antimicrobial prophylaxis for major surgery: baseline results from the national surgical infection prevention project. Arch Surg 140. 174-182.2005; Abstract

14 Silver A., Eichorn A., Kral J., et al: Timeliness and use of antibiotic prophylaxis in selected inpatient surgical procedures. The Antibiotic Prophylaxis Study GroupAm J Surg 171. 548-552.1996; Abstract

15 Bratzler D.W., Hunt D.R.: The surgical infection prevention and surgical care improvement projects: national initiatives to improve outcomes for patients having surgery. Clin Infect Dis 43. 322-330.2006; Abstract

Healing of Venous ulcers and cost of therapy


The treatment of venous leg ulcers (VLU) represents 23% of new patient visits and 36% of all patient visits in vascular surgery practice. Depending on the age of the patient cohort, VLU affects between 0.2% and 1% of the population.1 In first world countries, the treatment of VLU may represent a maximum of 3% of health care expenditures.2 Presently, the standard of care for VLU remains compression therapy, in many cases Unna’s boot, but ideally multilayer wraps.3 With this current treatment, healing rates in patients with normal arterial perfusion is reported to be between 63% at 10 weeks retrospectively and 33% at 12 weeks prospectively.[4] and [5] Overall, annual direct costs for the treatment of VLU are in the range of $30,000 per patient per annum, with only 60-80% of them healing at 6 months. Dr O’Donnell has accurately pointed out that “any treatment modality improving VLU healing time or proportion healed would reduce the burden of VLU care.”6


Others have noted that a maximum of 15% of the limbs affected by VLU observed in large volume vascular practices have an ankle–brachial index (ABI) of <0.8.4 Patients with an ABI of <0.8 were noted to take 19 weeks to heal 50% of their ulcers as compared with 9 weeks taken by the normally perfused group. In another study, which evaluated the closure rate of mixed arterial venous ulcers, the closure rate for the standard of care arm at 16 weeks was 46.2% as compared with the 82.6% in the cohort treated with porcine-derived intestinal submucosa (SIS) (Cook Medical Inc., Bloomington IN).7 A 2004 study conducted in the United Kingdom reported that 13.6% of patients presenting with VLU had an ABI of 0.5-0.85 and 2.2% had an ABI of <0.5.8 M.L. Humphreys, A.H. Stewart and M.S. Gohel et al., Management of mixed arterial and venous leg ulcer, Br J Surg 94 (2007), pp. 1104–1107. View Record in Scopus Cited By in Scopus (9)8 Therefore, to assess the effect of intervening percutaneously on the arterial circulation of patients with mixed arterial venous disease who were dependent on compression therapy. This therefore excluded the few patients who had mixed arterial venous disease with easily correctable, superficial-only venous reflux. The hypothesis was that improving or “normalizing” the lower extremity perfusion, as assessed by ABI and pulse volume recordings (PVRs), would normalize the healing trajectory of this hard-to-close patient subset. Few others have applied this protocol selectively but with a large proportion of patients who underwent arguably more morbid open procedures.8

Second - hand smoking and mortality

Worldwide, 40% of children, 33% of male non-smokers, and 35% of female non-smokers were exposed to second-hand smoke in 2004. This exposure was estimated to have caused 379 000 deaths from ischaemic heart disease, 165 000 from lower respiratory infections, 36 900 from asthma, and 21 400 from lung cancer. 603 000 deaths were attributable to second-hand smoke in 2004, which was about 1·0% of worldwide mortality. 47% of deaths from second-hand smoke occurred in women, 28% in children, and 26% in men. DALYs lost because of exposure to second-hand smoke amounted to 10·9 million, which was about 0·7% of total worldwide burden of diseases in DALYs in 2004. 61% of DALYs were in children. The largest disease burdens were from lower respiratory infections in children younger than 5 years (5 939 000), ischaemic heart disease in adults (2 836 000), and asthma in adults (1 246 000) and children (651 000).

The Lancet, Volume 377, Issue 9760, Pages 139 - 146, 8 January 2011