Pulsatile swelling in the forearm

A middle aged man presented with pulsatile swelling in the upper part of the right forearm. There was no history of trauma. There were no dilated pulsatile veins. Radial and ulnar arteries were palpable at the wrist. Duplex scan reported it as a vascular tumor. The Spiral CT angiogram showed lesion arising from the proximal 1/3 of the radial artery. Abnormal dilatations connected with normal radial artery. The picture was not typical of aneurysm. During surgery mass looking like thrombosed aneurysm was completely excised and sent for histopathological examination. The report came as Masson's hemangioma (benign condition) and complete excision is the curative treatment.

AP BlackBerry Client: WHO: Blood tests for tuberculosis are unreliable

A story from AP BlackBerry Client has been shared with you.

WHO: Blood tests for tuberculosis are unreliable
http://m.apnews.com/ap/db_15847/contentdetail.htm?contentguid=05aVXZKr

Sent from my BlackBerry® smartphone from !DEA

IMG-20110714-00197.jpg

Sent from my BlackBerry® smartphone from !DEA

Tuberous sclerosis is a group of two genetic disorders that affect the skin, brain/nervous system, kidneys, and heart, and cause tumors to grow. The diseases are named after a tuber- or root-shaped growth in the brain. Recently we have seen a young boy with acute ischemia of the left upper limb due to obstruction starting at the level of left axillary artery. Distally the vessel is diffusely narrowed. Incidentally we have noted abnormalities in the bones and face suggestive of tuberous sclerosis .  We evaluating the brain, kidneys, heart for any associated tumors.

IMG-20110713-00185.jpg

Sent from my BlackBerry® smartphone from !DEA

IMG-20110713-00190.jpg

Sent from my BlackBerry® smartphone from !DEA

Lymphatic malformation

Isolated lymphatic malformations are uncommon on the lateral side of the thigh. Completely excised.
Sent from my BlackBerry® smartphone from !DEA

Aneurysm at the level of the renal arteries ( occlusion of the right renal artery and left renal artery arising from the aneurysm)-

Infra renal abdominal aortic aneurysms are common and relatively they are considered to be straight forward operations technically. But when the renal arteries are involved we need to do the addition planning to preserve the kidneys (at least one kidney) and repair the aneurysm. In the patients (see figure CT angio) there is occlusion of the right renal artery and left renal artery is arising from the aneurysm. The origin of the superior mesentric artery is abutting on the upper margin of  the aneurysm. In such a situation we need to plan to re-implant the left renal artery to the graft or auto transplant the kidney. Preservation of the right kidney is questionable when the artery is already for a very long time.

PEPFAR and AIDS future

Dear APVASCULAR.BLOGSPOT.COM,
Pinjala (pinjala@hotmail.com) has sent you an article from The Economist
online
Pinjala has also included the following message for you:
-----------------------------------------------------------------------
This is important to know how the focus on the AIDS management is going to
change in the coming few years with the available funds from different
sources.
-----------------------------------------------------------------------

Well, I declare!
Jun 9th 2011
MORE money, probably. That was the bottom line of the declaration that came
out of the UN General Assembly's high-level meeting on AIDS, which closed
on June 10th. It was, however, accompanied by a promise of more money for
real by PEPFAR, the American President's Emergency Plan For AIDS Relief,
and a series of PEPFAR's allies.The UN "recognised", in the nuanced
argot of diplomacy, an estimate made by scientists at its agency, UNAIDS,
that the amount of money which needs to be spent on AIDS per year in poor and
middle-income countries should reach something between $22 billion and $24
billion by 2015. However that recognition was prefaced, in a phrase that bore
the hallmarks of arm-wrestling behind the scenes, by a commitment only to
reach a "significant level" of annual global expenditure on the
disease.Not quite a target, then, but perhaps the best that could be expected
in these stringent times.

AP BlackBerry Client: India health costs a crisis impoverishing millions

A story from AP BlackBerry Client has been shared with you.

India health costs a crisis impoverishing millions
http://m.apnews.com/ap/db_16052/contentdetail.htm?contentguid=0DbOrX25

Sent from my BlackBerry® smartphone from !DEA

Superficial Femoral Artery (SFA) aneurysm - Ruptured

Isolated aneurysms of superficial artery are less common. When this happens in the rural villages these people get access to the vascular centers very late and there are some complications associated with it.  This is a case of SFA aneurysm which has ruptured and presented to us very late. We operated this patient under the Rajiv Aarogyasri scheme. A vein graft was interposed to repair the SFA (proximal saphenous vein). Post operative out come uneventful. Pulses were palpable and there were no aneurysms at the other sites. This patient received  two antiplatelet drugs in the post operative period and advised to continue them for 6 months. Some surgeons may be using only one antiplatelet drug such as Tablet Aspirin 75 mg or 150 mg once daily.

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.