Tibial vessel injuries (3) - Repair of the posterior tibial artery!

Fig: Spiral CT and Intra -Operative photo

 

Tibial vessel injuries are generally managed conservatively as one of the three is usually is patent and supplies adequate blood to the distal leg and foot. Rarely we see all the three vessels are injured and distal foot is ischemic. In such situations we do consider repair of one of the tibial vessels to save the ischemic foot. In this case ( fig) posterior tibial artery was repaired ( resection and anastomosis) and the other occluded vessels are not repaired. Nerve injury is left for the secondary repair. At the end of the procedure the repaired posterior tibial artery is pulsting well beyond the anastomosis. 

 

 

Cattle as MRSA reservoir? Can MRSA get transmitted in Milk?

Penicillin binding protein 2a is encoded by the gene mecA. It imparts the resistance to the bacteria against antibiotics. The resistance of the staphylococci is due to the acquisition of one of the several SCCmec elements carrying the gene mecA. PCR test can detect the mecA gene. PBP2a is detected by the agglutination assay.

A novel mecA homologue, mecALGA251, associated with resistance to β-lactam antibiotics was present in clinical MRSA isolates from the UK and Denmark, and bovine milk samples from the UK. This is giving raise to an alarm that the cattle can be a reservoir for the MRSA which can get transferred to the humans. In the recent past there was lot discussion about the NDM1 betalactamase producing MRSA infections and their spread across the continents. Now we are hearing that the milk and probably milk products also associated with risk of carrying the MRSA infections. It is alarming to note the ability of staphylococcus to spread with the capabilities of antibiotic resistance across the continents and species too.

Ref: The Lancet Infectious Diseases, Early Online Publication, 3 June 2011

Biomechanical properties of AAA – what does it mean to clinicians who are faced with dilemma  - To do or not to do an intervention based on the size of the AAA?

 

Abdominal aortic aneurysms are feared in the clinical practice as they are known to rupture without a prior notice and result in death. This clinical fear of rupture supports the treatment of the large aneurysms even though they are asymptomatic. But, open operative repair of the small AAA is associated with significant risks which are more in units which are not considered large volume centers. That means we have to be more selective in identifying the AAAs which are likely to rupture based on their wall ability to withstand the stress and strain.  The bio mechanical properties of the normal aortic wall and aneurysm wall are definitely going to help us in selecting the patients for early repair in addition to the diameter.

In the year 1966 Szilagyi et al observed that the aneurysms larger than 6 cm are at increased risk of rupture.  Later Foster and colleagues noted similar observations (< 6cm – 16% .,  >6cm 51%  rupture). For the next 4 decades the diameter of the aneurysm dictated the decision to operate. Now we are looking at the other parameters such as “wall stress”. 

Finite Element analysis (2002) was introduced by Fillinger colleagues was used to assess the wall stress in the aortic aneurysms (see fig). The figure shows stress as Newtons/ cm². The point of maximum stress need not be over the maximum diameter point. There are many factors in wall structure which could be deciding the strength of the wall to resist the breakdown. Finite element analysis method was used by engineers to study the elastic properties and strength the materials. The same is applied to the biological materials where the shapes are variable such as the aortic dilatation.  In women the aneuryms with small diameters are also risk of rupture (5cm). The measurement of wall stress with finite element analysis is not universally accepted and validated as a method for assessing risk of rupture. But in the coming years it may be available in our neighborhood and we may assess the aneurysms with this method to predict rupture. This is comparable to the foot pressures (pedobarograph) to assess the development of plantar foot ulcers. Probably we will be able to get this information along with CT scan report and imagine the ease with which the surgeon can tell his patients about the need for interventions.

 

HbA1c: an old friend in new clothes

Equivalent DCCT-aligned and IFCC-standardised values

DCCT=Diabetes Control and Complications Trial. 

IFCC=International Federation of Clinical Chemistry.

 

In the recent past the importance of measuring HBA1c is recognized at various levels in the management of diabetic people. But there is concern about the reliability of the HBA1c done from different laboratories which is variable between 3% to 14%. IFCC standardized the value as mmol/mol and said that it should be less than 48 mmol/mol to say some is non diabetic that is equal to <6.5gm%. It is said that in future we will be using this measure in all the studies and clinical practice to avoid the variations in the older measurement of HBA1c. We need to wait and see in India for this change. This paper is presented in the Lancet 30 April 2011

Vascular malformation in the left Supra Clavicular region

Tuberculosis in Vascular surgical patients: 

Peripheral Vascular disease patients are usually smokers and there is a good possibility that they had tuberculosis at some point of time in their life.  Recently a 50 year old smoker was referred to our clinic (emaciated  and BMI less than 18) with left upper limb ischemia.Clinically he looks like a patient of tuberculosis. X-ray showed changes of chronic both lung disease and fibrosis. The physicians are hesitating to admit the patients after Brachial artery thrombectomy in the TB hospital as they are not convinced of the active nature of the tuberculosis. Surgeons are hesitant to admit such a patient in the surgical ward where more than 15 Post operative patients are lodged with common toilet facilities.We can do the thrombectomy under local anesthesia in 15-20 minutes safely. After that it is advisable to treat such patients in outpatient departments safely. It took more than 1 hour to convince the patient and his relatives to accept and wear a face mask to prevent the spread of potential tuberculosis or other diseases to the neighbors. In a recent Lancet report it was mentioned that although tuberculosis prevails in mainly high-burden developing countries, cases in immigrants in many low-incidence countries are increasing substantially. This changing pattern of disease is clear in the UK where, between 1998 and 2009, tuberculosis notifications have risen by 46%, from 6167 cases to 9040, with much of this rise fueled by the 98% increase in cases from overseas.These individuals account for nearly three-quarters of all tuberculosis notifications in the UK with an incidence that is 20 times higher than in UK-born individuals (89 cases per 100 000 people per year vs 4 per 100 000). We have to note importance of these reports more seriously and provide or display information about tuberculosis to the patients in the high turnover hospitals (in notice boards or as wall posters) at regular intervals to sensitize the patients about the possibility of easy spread of Tuberculosis bacilli which are getting resistance to the currently available drugs. 

Medical Errors!

There is concern about the medical errors in the hospitals in developing countries and developed countries. India is going to increase the number of hospital beds. The number of hospital admissions will increase in the coming years and so are the medical errors. The US Institute of Medicine's landmark 1999 report, To Err is Human: Building a Safer Health System, estimated that avoidable medical errors contributed annually to 44 000—98 000 deaths in US hospitals. Hospital-based errors were reported as the eighth leading cause of death nationwide, ahead of breast cancer, AIDS, and motor-vehicle accidents. The report put medical errors under the national spotlight.
Who or what is to blame for medical errors and their consequences? Overworked providers, an unnecessarily complex medical system, or uninformed patients? Patients are often handed from one doctor to another and, in the process, communication between providers can break down. Time spent filling out paperwork is time not spent with patients improving the quality of their care. Decision making often does not involve informing a patient about the balance between benefits and harms of individual treatments, or incorporating patients' goals into planned treatment. And it does not help that existing guidelines allow medical residents in the USA to work on average 28 h more per week than junior doctors in countries of the European Union. In  India we need to follow the guidelines more strictly and teams should adhere to the standard protocols to reduce the medical errors.
The medical errors can turn out to be very expensive to the society and hospitals. Hospitals must develop protocols and check lists to prevent the medical errors. 

Transdermal cutaneous Oxygen therapy ( EPIFLO)

We are looking for the newer and simpler therapies for treating the chronic non healing ulcers. In the recent past negative pressure wound therapy (NPWT) has been made available in Indian hospitals. Hyperbaric oxygen therapy is used in very few centers in India for treating the non healing ulcers. But the new concept of delivering the oxygen (3 ml/hour) directly in to the wound through a small device which concentrates the oxygen from the atmosphere seems to have advantages over the other methods available to us.  This device ( Fig) is small and can be tied to the extremity very easily and patient can be mobile and expect good healing of wound within 15 to 30 days. There seems to be a definite place for this device in the vascular surgeon's clinical practice. 

World Malaria Day -25th April

According to World Health Organisation statistics, Malarial parasite infected around 225 million and killed nearly 800,000 people worldwide in 2009. They seem to be developing resistance to the available drugs. In the recent studies it was found that the parasite is dependent on the kinases in the cells ( liver, RBCs) for their survival and multiplication. If these kinases are inhibited then it becomes a halt for parasite. Now there is a new hope that the newer Cancer drugs can kill malaria parasite Plasmodium, which is transmitted via the bites of infected mosquitoes. In the human body, the parasites reproduce in the liver, and then infect and multiply in red blood cells. Joint research by few organizations showed that, in order to proliferate, the malaria parasite depends upon a signalling pathway present in the host's liver cells and in red blood cells. They demonstrated that the parasite hijacks the kinases (enzymes) that are active in human cells, to serve its own purposes. When the research team used cancer chemotherapy drugs called kinase inhibitors to treat red blood cells infected with malaria , the parasite was stopped in its tracks.

Endovascular repair of the aneurysms of descending thoracic aorta and abdominal aorta in the same sitting

We are concerned about many issues if there is a patient with Thoracic and abdominal aorta aneurysm asking for the Endo vascular repair of the aneurysms aneurysm in the same sitting. Paraplegia is always a concern when a large extent aorta is covered by the endograft. Recently I, myself along with a cardiologist repaired both the aneurysms in the same sitting but we preserved the left subclavian artery (Chimney) and left internal iliac artery with a hope to avoid the paraplegia. We noted that it was also done in  other centers, with minimal morbidity ( see the reference below). There is also concern about the amount of contrast injection and overload. But for the patient it may be convenient to get the both repaired in one sitting. Similarly groin exploration by the vascular surgeon may be difficult and time consuming during the second time.  One has to certainly weigh the benefits and risks of repairing the both aneurysms in one sitting.

Reference:

Interact Cardiovasc Thorac Surg. 2011 Feb 5. 

Stenting of the descending thoracic aorta: a 6-year single-center experience.Matsagkas MI, Kirou IE, Kouvelos G, Arnaoutoglou EM, Papakostas JC, Katsouras C, Papadopoulos G, Michalis LK. Department of Vascular Surgery Unit, School of Medicine, University of Ioannina, Ioannina, Greece. Objectives: The aim of this study was to review the six-year results of the endovascular repair of descending thoracic aortic pathologies, reporting the early perioperative outcomes as well as the mid-term follow-up of the treated patients. Methods: Fifty-five consecutive patients who underwent endovascular repair for thoracic aortic pathology (29 aneurysms, 17 acute thoracic aortic syndromes, and six traumatic aortic ruptures) during a six-year period were retrospectively reviewed. From these patients, 30 (54.5%) were treated electively and 25 (45.5%) on an emergency basis. In eight cases (14.5%) there was a need for left subclavian artery orifice overstenting. In seven patients (12.7%) an abdominal aortic lesion was simultaneously treated, while three more patients (5.5%) had previously had their abdominal aortic aneurysm repaired. Results: The primary technical success was 92.7%. Seven patients (12.7%) underwent some operation related complication, while postoperative complications occurred in five patients (9.1%), namely four myocardial infarctions, one acute respiratory distress syndrome and two delayed parapareses resulting in an overall incidence of neurological complications of 3.6%. The combined 30-day and in-hospital mortality was 9.1%, exclusively related to patients treated emergently (P=0.01). In a mean follow-up period of 34 months there were six deaths, and the overall cumulative survival at four years was estimated at 72.6%. Only one type II endoleak was observed one month after the procedure and it spontaneously disappeared 18 months later. Conclusions: The endovascular repair of descending thoracic aortic pathologies seems to be a well-established method, with favorable morbidity and mortality rates, at least for 30 days and in the mid-term. Taking into account the potential of a wide application of the endovascular technique in many vascular centers, stenting of the thoracic aorta might offer an overall better solution for patients suffering from these devastating pathologies. Keywords: Endovascular repair; Descending thoracic aortic pathology; Stent-graft.

Anticoagulant Options — Why the FDA Approved a Higher but Not a Lower Dose of Dabigatran for non valvular atrial fibrillation

NEJM | April 13, 2011 | Topics: Drugs, Devices, and the FDA

On October 19, 2010, the Food and Drug Administration (FDA) approved dabigatran for the reduction of the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. Approval was based on a multicenter, active-control trial, the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY), in which patients were randomly assigned to receive 150 mg of dabigatran, 110 mg of dabigatran, or warfarin. Dabigatran was given twice daily; warfarin was titrated to achieve an international normalized ratio (INR) of 2.0 to 3.0. Assignment to warfarin or dabigatran treatment was unblinded; assignment to a specific dabigatran dose was double-blind. RE-LY was a noninferiority study, attempting to rule out a hazard ratio of more than 1.38 for the primary end point, stroke or systemic embolism.

vascular ( blood vessels)

http://www.sciencedaily.com/

Increase in Deaths in Men With Type 2 Diabetes and Testosterone Deficiency May Be Prevented by Testosterone Replacement?

Professor Jones' team conducted a six year study of 587 men with type 2 diabetes, splitting them into three groups: those with normal total testosterone levels (above 10.4nmol/L, n=338), those with low testosterone levels (below 10.4nmol/L) that weren't treated with testosterone replacement therapy (n=182), and those with low testosterone levels treated with testosterone replacement therapy for two years or more during the follow up period (n=58).

The findings show for the first time that low testosterone puts diabetic men at a significantly increased risk of death (p=0.001 log rank): 36 of the 182 diabetic men with untreated low testosterone died during the six year study, compared to 31 of the 338 men with normal testosterone levels (20% vs 9%). Furthermore, only 5 of the 58 diabetic men that were given testosterone replacement therapy died during the study (8.6%), meaning they showed significantly better survival compared to the non-treated group (p=0.049 log rank).
This is the first study to show testosterone treatment can improve survival in men with type 2 diabetes and testosterone deficiency. Further studies now need to be carried out to fully investigate the potential therapeutic benefit of testosterone replacement in diabetic men with low testosterone.
Professor Hugh Jones, Consultant Endocrinologist and Hon. Professor of Andrology, Barnsley Hospital NHS Foundation Trust and the University of Sheffield, said: "This is potentially a very exciting finding. Whilst we have shown that low testosterone levels can put diabetic men at greater risk of dying, we have also demonstrated for the first time the potential benefit that testosterone replacement therapy holds for this group of patients.
"It is well known that men with type 2 diabetes often have low testosterone levels, so it is important that we investigate the health implications of this. We now need to carry out a larger clinical trial to confirm these preliminary findings. If confirmed, then many deaths could be prevented every year."
In another study, also presented at this year's Society for Endocrinology meeting, Professor Jones' group found for the first time that low testosterone and severity of erectile dysfunction are independently associated with a reduced health-related quality of life in men with type 2 diabetes. Health-related quality of life questionnaires, such as the one used in this study, measure how a person perceives their own general health in areas such as physical and social functioning, vitality and pain. The questionnaire does not measure how good a person's health actually is; it measures how good a person thinks their health is in daily life.
In the 356 men with type 2 diabetes tested, health related quality of life decreased as testosterone levels decreased (r=0.353 p=0.044). In the 126 patients who were also assessed for erectile dysfunction, health-related quality of life decreased in the areas including physical functioning (r=0.5, p=0.003), social functioning (r=0.445, p=0.022) vitality (r=0.383, p=0.025) and pain (r=0.428, p=0.012) as the severity of erectile dysfunction increased. Although severity of erectile dysfunction has been shown to be associated with lower testosterone levels, statistical analysis shows for the first time that these are both independently associated with a reduced health-related quality of life in these men.Lead researcher Prof Hugh Jones said: "Our research shows that low testosterone impacts on health-related quality of life in men with type 2 diabetes. This finding supports previous evidence suggesting that erectile dysfunction is a marker of ill health.
"Our next step is to assess whether offering testosterone replacement therapy to diabetic men with testosterone deficiency and erectile dysfunction may help to improve their health related quality of life."

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)