IVC filters in Trauma Patients for thromboprophylaxis ?

Prophylactic IVCFs should be inserted within 48 hours of injury in specific trauma patients at high risk for PE and with contraindications to anticoagulation.

INFERIOR VENA cava filters (IVCFs) are being used with increasing frequency in trauma patients because of the heightened risk of deep vein thrombosis (DVT) and threat of subsequent pulmonary embolism (PE). The incidence of DVT in trauma patients may be as high as 20% to 58%, and the true incidence of PE is unknown. Unfortunately, some investigators have found that routine thromboembolism prophylaxis with sequential compression devices (SCDs), and low-dose heparin sodium is relatively ineffective in high-risk trauma patients. Additionally, many patients are not candidates for anticoagulation because of their associated traumatic injuries, and SCDs may be difficult to place on patients with major long-bone fractures.

Clinical signs of DVT are generally absent, and fatal PE frequently occurs without prior warning, with only a third of fatal PE cases diagnosed before death. Thus, insertion of IVCFs in high-risk trauma patients prior to DVT and/or PE should be able to reduce the incidence of lethal PE. The development of safe and effective, percutaneously placed IVCFs has stimulated an increase in the use of prophylactic IVCFs in high-risk trauma patients in an effort to reduce the incidence of PE.Some institutions have noted a decreased incidence of PE in trauma patients with prophylactic IVCFs.Others, however, have demonstrated conflicting results, noting no difference or an actual increase in the incidence of PE with prophylactic IVCFs.

http://archsurg.jamanetwork.com/article.aspx?articleid=212470

Guidelines for the treatment of antiphospholipid syndrome

The antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized
by arterial and venous thrombosis, gestational morbidity and presence of elevated and
persistently positive serum titers of antiphospholipid antibodies. The treatment of APS is
still controversial, because any therapeutic decision potentially faces the risk of an insuffi cient or excessive antithrombotic coverage associated with anticoagulation and its major
adverse effects. This guideline was elaborated from nine relevant clinical questions related
to the treatment of APS by the Committee of Vasculopathies of the Brazilian Society of
Rheumatology. Thus, this study aimed at establishing a guideline that included the most
relevant and controversial questions in APS treatment, based on the best scientifi c evidence available. The questions were structured by use of the PICO (patient, intervention or
indicator, comparison and outcome) process, enabling the generation of search strategies
for evidence in the major primary scientifi c databases (MEDLINE/PubMed, Embase, Lilacs,
Scielo, Cochrane Library, Premedline via OVID). A manual search for evidence and theses
was also conducted (BDTD and IBICT). The evidence retrieved was selected based on critical assessment by using discriminatory instruments (scores) according to the category of
the therapeutic question (JADAD scale for randomized clinical trials and Newcastle-Ottawa
scale for non-randomized studies). After defining the potential studies to support the recommendations, they were selected according to level of evidence and grade of recommendation, according to the Oxford classification.
http://www.scielo.br/pdf/rbr/v53n2/en_v53n2a05.pdf

Thromboprophylaxis for Orthopedic patients in Turkey

Fracture neck of femur surgery, total hip replacement, total knee replacement patients are at high risk of developing VTE as seen in western population. In India, there are still mixed opinions among the orthopedic surgeons about the increased risk of VTE in Indian population going for orthopedic surgeries.

It is interesting to note the results of the study from Turkey given below. this is a large study and worth to note their findings.

J Bras Pneumol. 2013 Jun;39(3). 

Does thromboprophylaxis prevent venous thromboembolism after major orthopedic surgery?Akpinar EE, Hosgün D, Akan B, Ates C, Gülhan M. Source  Ufuk University, Department of Chest Diseases, Ankara, Turkey.Abstract

OBJECTIVE:

Pulmonary embolism (PE) is an important complication of major orthopedic surgery. The aim of this study was to evaluate the incidence of venous thromboembolism (VTE) and factors influencing the development of VTE in patients undergoing major orthopedic surgery in a university hospital.

METHODS:

Patients who underwent major orthopedic surgery (hip arthroplasty, knee arthroplasty, or femur fracture repair) between February of 2006 and June of 2012 were retrospectively included in the study. The incidences of PE and deep vein thrombosis (DVT) were evaluated, as were the factors influencing their development, such as type of operation, age, and comorbidities.

RESULTS:

We reviewed the medical records of 1,306 patients. The proportions of knee arthroplasty, hip arthroplasty, and femur fracture repair were 63.4%, 29.9%, and 6.7%, respectively. The cumulative incidence of PE and DVT in patients undergoing major orthopedic surgery was 1.99% and 2.22%, respectively. Most of the patients presented with PE and DVT (61.5% and 72.4%, respectively) within the first 72 h after surgery. Patients undergoing femur fracture repair, those aged ≥ 65 years, and bedridden patients were at a higher risk for developing VTE.

CONCLUSIONS:

Our results show that VTE was a significant complication of major orthopedic surgery, despite the use of thromboprophylaxis. Clinicians should be aware of VTE, especially during the perioperative period and in bedridden, elderly patients (≥ 65 years of age).

RIETE registry and COPD with PE

Pulmonary embolism is a life threatening complication and it is known to recur in some patients. The diagnosis of pulmonary embolism is difficult in chronic pulmonary obstructive disease patients. There can be delay or difficulty due to overlap of the clinical symptoms in these conditions. If the PE is recurrent then also it can be missed in some patients. So, the morbidity and mortality in COPD patients with PE or recurrent PE is higher than those with Leg DVT. So, it is mandatory to look after patients of COPD with PE more closely to avoid the mortality.

Respir Res. 2013 Jul 18;14:75. doi: 10.1186/1465-9921-14-75.

Pulmonary embolism and 3-month outcomes in 4036 patients with venous thromboembolism and chronic obstructive pulmonary disease: data from the RIETE registry. Bertoletti L, Quenet S, Laporte S, Sahuquillo JC, Conget F, Pedrajas JM, Martin M, Casado I, Riera-Mestre A, Monreal M; RIETE Investigators. Thrombosis Research Group, EA3065, University Saint-Etienne, Jean Monnet, Saint-Etienne F-42023, France. laurent.bertoletti@gmail.com.

Abstract: Patients with chronic obstructive pulmonary disease (COPD) have a modified clinical presentation of venous thromboembolism (VTE) but also a worse prognosis than non-COPD patients with VTE. As it may induce therapeutic modifications, we evaluated the influence of the initial VTE presentation on the 3-month outcomes in COPD patients.

COPD patients included in the on-going world-wide RIETE Registry were studied. The rate of pulmonary embolism (PE), major bleeding and death during the first 3 months in COPD patients were compared according to their initial clinical presentation (acute PE or deep vein thrombosis(DVT)).

Of the 4036 COPD patients included, 2452 (61%; 95% CI: 59.2-62.3) initially presented with PE. PE as the first VTE recurrence occurred in 116 patients, major bleeding in 101 patients and mortality in 443 patients (Fatal PE: first cause of death). Multivariate analysis confirmed that presenting with PE was associated with higher risk of VTE recurrence as PE (OR, 2.04; 95% CI: 1.11-3.72) and higher risk of fatal PE (OR, 7.77; 95% CI: 2.92-15.7).

COPD patients presenting with PE have an increased risk for PE recurrences and fatal PE compared with those presenting with DVT alone. More efficient therapy is needed in this subtype of patients. 

PE recurrences according to initial presentation as DVT or PE.

Mortality according to initial presentation as DVT or PE

Pinjala R K

Delays in the management of venous thromboembolism

Delays in diagnosis and treatment of venous thromboembolism in a developing country setting

It is important to promptly suspect, confirm the diagnosis of venous thrombosis to avoid or reduce the risk of venous thrombosis and its complications. Every physician would generally make an effort to achieve the early anticoagulation in these patients as soon as the diagnosis is confirmed. In a recent paper published from the Iran it was observed that the delay in the diagnosis and treatment is related to the delayed presentation of the patient to the clinics and hospitals. Probably it is the same reason in many other countries where the general awareness of the problem is not there in the public and peripheral medical centers.


Tuberk Toraks. 2013 Jun;61(2):96-102. Rahimi-Rad MH, Rahimi-Rad S, Zarrin S. Source Department of Respiratory Medicine, Faculty of Medicine, Urmia University, Urmia, Iran. rahimirad@hotmail.com.Abstract : Introduction: Rapid diagnosis and treatment of deep vein thrombosis and pulmonary thromboembolism reduce mortality and morbidity. The aim of this study is to investigate delays in treatment of deep vein thrombosis and pulmonary thromboembolism and related factor in a developing country. Materials and Methods: We prospectively investigated 353 patients with diagnosis deep vein thrombosis and/or pulmonary thromboembolism in Urmia, Iran. We recorded dates of symptom onset, initial visit by a clinician, initiation of treatment, and confirmation of diagnosis. We also analyzed relation with some factors. Results: The mean interval from symptoms onset to initiation of treatment was 4.70 days, 89% of this interval was between onset of symptoms to first medical evaluation (mean= 4.19 days). Mean time from onset of symptoms to confirmation of diagnosis was 6.29 days. Of 353 patients with venous thromboembolism 185 (52.4%) visited by a physician within two days of onset of symptoms and 168 (47.6%) patients after two days. Factors that was associated with earlier seeking with p value < 0.05 were pulmonary thromboembolism patients earlier than deep veinthrombosis, higher education, recent surgery, presence of cast, entire leg swelling. There was no association between age, gender, number of symptoms, and presence familial history of venous thromboembolism (all p value > 0.05). The delays time from first visit to final diagnosis was significantly shorter in patients with high probability score. Conclusion: Most patients with venous thromboembolism received anti-coagulation and diagnosis with delay. The main cause of delay is related to patient's delays. There is a need to improve people awareness about venous-thromboembolism and to develop strategies to reduce delays.

Vasculo-Behcet's Disease

Successful Treatment of Vasculo-Behcet's Disease Presenting as Recurrent Pseudoaneurysms: the Importance of Medical Treatment.

Li S, Chen AJ, Huang K, Li H.

Source

The Department of Dermatology, The First Affiliated Hospital, Chongqing Medical University, No. 1 Youyi Road, Chongqing, 400016 China.

Abstract

INTRODUCTION:

Vasculo-Behcet's disease is a subtype of Behcet's disease, characterized by cases in which vascular complications are present and often dominate the clinical features. In this disease, there are four different vascular complications: arterial occlusion, arterial aneurysm or pseudoaneurysm, venous thrombosis, and variceal formation. It is rare that arterial lesions are multiple, but without venous involvement. So far, the optimal treatment of the disease has not been established.

CASE REPORT:

The authors report a rare case of vasculo-Behcet's disease with multiple and recurrent pseudoaneurysms in large arteries, but without affecting the venous system. The patient underwent three rounds of surgery, but developed a new pseudoaneurysm after each operation in short term. However, the patient was successfully treated with a combination of prednisone and immunosuppressive agents.

CONCLUSION:

For Vasculo-Behcet's disease, surgical and endovascular interventions alone increased the incidence of pseudoaneurysm. Early diagnosis and early initiation of prednisone in combination with immunosuppressive therapy are critical for inhibiting the progression of vascular lesions and provide a good prognosis.

Cytokine interleukin-17 as a signal can stabilize plaques

Do we know the role of inflammation and inflammatory cytokines in the stabilization of the atherosclerotic plaques?

We know that the plaques become unstable due to cytokines released by the macrophages in the plaques. In a recent study it was observed that there can be some cytokines released by the cells which can help in stabilization of the plaques.  Cytokine interleukin-17 as a signal can stabilize plaques.
  
"Traditionally, scientists and physicians have viewed atherosclerosis as merely a buildup of cholesterol in the arteries, and the influence of inflammation has not been fully attributed", says Göran K. Hansson, team leader of the Experimental Cardiovascular Research group at the Center for Molecular Medicine, and principal investigator of the study. "We need to explore the inflammatory pathways to find new therapies aside from lowering lipids. We have effective statin therapy, but a substantial risk of heart attacks still remains for treated individuals."
There is need to understand more about the cytokines which can protect or propagate the inflammation in the plaques to prevent cardiovascular events.

External iliac artery endofibrosis - male cyclists

Exercise-induced external iliac artery endofibrosis (EIAE) is rare and has been described primarily in endurance male cyclists. This is difficult to recognize and investigate in the clinical practice. Clinically, it presents as claudication during maximal exercise with quick resolution after exercise. Most patients have fibrotic changes within the external iliac artery (EIA). This can be easily confused as a case of vasculitis or proximal vessel involvement in TAO.

This series highlights a possible mechanism to explain the claudication associated with EIAE. Vasospasm may be more important than wall thickening for the reduction of blood flow during extreme exercise in affected athletes. Routine duplex ultrasound imaging to measure EIA diameter and flow velocities before and after maximal exercise is needed to confirm this phenomenon. Exercise-induced external iliac artery endofibrosis (EIAE) is an uncommon condition affecting high-end endurance athletes in the absence of classic risk factors for atherosclerosis. These athletes are asymptomatic at rest and become symptomatic, with complaints of thigh claudication and loss of power during maximal effort. This was first reported in 1984 in two competition cyclists. 

Since then, EIAE has been described not only among cyclists but also in long-distance runners, triathletes, and speed skaters. EIAE has been described mostly in men, with women accounting for only 7% of the cases. The diagnosis is made by having the athlete exercise to the point of symptoms and obtaining ankle-brachial indices (ABIs) and duplex scanning after exercise. Multiple mechanisms have been proposed to explain EIAE, including increased cardiac output and adaptive systolic hypertension during strenuous effort, psoas muscle hypertrophy, presence of collaterals from the EIA to the psoas muscle, and repeated direct mechanical trauma on the fixed iliac arterial segment by the psoas muscle during hip flexion, and kinking as a result of excessive iliac arterial length. The final pathway is wall thickening, reduction in arterial lumen caliber, and restriction of blood flow during maximal exertion. We describe our experience with EIAE, our method of diagnosis, and propose a hypothesis for the mechanism involved in claudication associated with EIAE.

Re-admissions after lower extremity revascularization procedures

Less invasive endovascular procedures were not associated with decreased readmission rates compared with open surgery. The overall readmission rate for claudicant patients was 10.7%, which was unexpectedly high. Predictors of readmission included male sex, longer hospital stays, hospital infection, elevated aspartate aminotransferase, and high numbers of medications ordered and dispensed. Further examination exploring reasons for readmission are required to decrease readmission rates in the vascular surgery population.

Dramatic changes in health care delivery and rising interest in cost containment have increased concern regarding readmission and its cost to the health care system. In USA, in the Medicare population, the readmission rate after vascular surgical procedures is almost 24%, substantially higher than the average rate of 15.6% for other surgical procedures.¹ At the same time there has been a dramatic shift in the use of endovascular procedures for the management of lower extremity (LE) occlusive disease.² Endovascular interventions are now performed much more commonly than bypass surgery in the treatment of LE peripheral artery disease (PAD), and the use of percutaneous transluminal angioplasty (PTA) for claudication has dramatically increased.^2 and 3

Despite increased use of more minimally invasive procedures, there is a paucity of information evaluating if less invasive procedures are associated with decreased morbidity and also specifically with decreased use in the form of readmission. This analysis evaluated the readmission rates after LE interventions to specifically compare rates between procedure type and to evaluate factors associated with readmission, because identifying patients with increased risk for readmission after vascular procedures may lead to more effective, higher-quality care. 

We are facing this problem in providing the vascular surgical care for the patients under the ARSR scheme. They are not understanding this fact that the readmission rate is much higher in vascular surgery patients compared to the other surgical patients in the hospitals. I am sure papers of this nature will help us make the administrators of the ARSR scheme in andhra pradesh to recognize these difficulties in providing care to vascular patients.

• http://dx.doi.org/10.1016/j.jvs.2012.12.031, How to Cite or Link Using DOI
• Jl of Vascular surgery Volume 58, Issue 1, July 2013, Pages 90–97.e4

Drug Eluting Stents and Bare metal stents - which one? What about the longterm results? Are we there still to decide which one is better ?

We know that  the Angioplasty alone is helpful in some lesions, angioplasty and stenting is helpful in some patients. But now we have an option to use the drug eluting stents or bare metal stents. The consensus is evolving and there seem to be still serious concerns about the use of the drug eluting stents and long term results. Recently long term results comparing the DES and BMS are examined and published in the JACC interventions.

DEDICATION trial showed that

Complete clinical status was available in 623 patients (99.5%) at 5 years follow-up. The combined MACE rate was insignificantly lower in the DES group (16.9% vs. 23%), mainly driven by a lower need of repeat revascularization (p = 0.07). Whereas the number of deaths from all causes tended to be higher in the DES group (16.3% vs. 12.1%, p = 0.17), cardiac mortality was significantly higher (7.7% vs. 3.2%, p = 0.02). The 5-year stent thrombosis rates were generally low and similar between the DES and the BMS groups. No cardiac deaths occurring within 1 month could be clearly ascribed to stent thrombosis, whereas stent thrombosis was involved in 78% of later-occurring deaths.

Conclusions  The 5-year MACE rate was insignificantly different, but the cardiac mortality was higher after DES versus BMS implantation in patients with STEMI. Stent thrombosis was the main cause of late cardiac deaths.

So, in the coming periods, how one can make an informed decision about using the drug eluting stents in clinical practice if these results are taken seriously. The drug eluting stents are expensive and we may say that BMS ( the less expensive) may be getting preference in the developing nations. But does that means there is a possibility that the absorbable drug eluting stents may stand a good chance as they not be associated with the late effects of drug eluting non absorbable stents. 

Long-Term Outcome After Drug-Eluting Versus Bare-Metal Stent Implantation in Patients With ST-Segment Elevation Myocardial Infarction5 Years Follow-Up From the Randomized DEDICATION Trial (Drug Elution and Distal Protection in Acute Myocardial Infarction)

Lene Holmvang, MD; Henning Kelbæk, MD; Anne Kaltoft, MD; Leif Thuesen, MD; Jens Flensted Lassen, MD; Peter Clemmensen, MD; Lene Kløvgaard, RN; Thomas Engstrøm, MD; Hans E. Bøtker, MD; Kari Saunamäki, MD; Lars R. Krusell, MD; Erik Jørgensen, MD; Hans-Henrik Tilsted, MD; Evald H. Christiansen, MD; Jan Ravkilde, MD; Lars Køber, MD; Klaus Fuglsang Kofoed, MD; Christian J. Terkelsen, MD; Steffen Helqvist, MD

J Am Coll Cardiol Intv. 2013;6(6):548-553. doi:10.1016/j.jcin.2012.12.129

Venous thrombosis in Cancer patients - are there any special features!

The risk of venous thrombosis is higher in cancer patients. But we do not know if there are specific features for the venous thrombosis in cancer patients. We believe that the thrombosis is dependent on the circulating procoagulant factors associated with or released by the cancer tissues. Is the proximal deep vein thrombosis  (iliac vein) more common in cancer patients? 

In a study conducted on - For 3263 patients with cancer, the venous thrombosis incidence was: total 31.4% (n=1026), proximal 14.5% (n=472), bilateral 8.5% (n=278) and multiple venous sites 4.6% (n=149). The rate of clinical suspicion of pulmonary embolism was 49.9% (n=1628). For 1026 patients withthrombosis, proximal thrombi were nearly as frequent as distal thrombi, with 17.6% (n=181) iliocaval thrombi. Gastrocnemial, popliteal and femoral veins were almost equally concerned by thrombosis with respective rates of 28.7% (n=278), 27.1% (n=294) and 25.6% (n=263). Superficial veins were concerned in 23.5% (n=241). Partial or floating clots occurred frequently in 4 localizations: common femoral, external iliac, femoral and popliteal veins. J Mal Vasc. 2013 Jun 18. pii: S0398-0499(13)00131-5. doi: 10.1016/j.jmv.2013.05.001. [Epub ahead of print]

This results of this study point out that - Proximal, multiple, partial, mobile thrombi, and such unusual locations as gastrocnemial or superficial thromboses, are potentially indicators for selecting patients that may benefit from a cancer check-up because their venous thrombosis could be due to cancer.

It may not be cost effective to screen all patients for cancer in our clinical practice - in addition to the above factors related to venous thrombosis, we should remember that recurrence of DVT requiring admissions ( 2 or 3 times) in last 6 months should also prompt us to think and investigate for the cryptogenic malignancies. We found this very useful in our clinical practice not to miss the hidden malignancies.  

30th June 2013

Will there be a role for Atorvastatin in acute deep vein thrombosis?

In the recent past it was observed that aspirin would be beneficial in the prevention of recurrent DVT and cardiovascular events if given as a secondary thromboprophylactic agent after initial anticoagulation. It was opined that this benefit of aspirin in the long run is due to the protection from the actions of cytokines circulating in the blood which seem to be higher in the group of patients. 
Can we consider that the statins such as Atorvastatin, Rosuvastatin are helpful in the acute DVT to protect the patients from effects of cytokines?
In a recent study it was observed that IL-6, IL-8, P selectin were reduced by the 3 day course of 40 mg of atorvastatin. Thromb Res. 2013 Jun 20. pii: S0049-3848(13)00183-7. doi: 10.1016/j.thromres.2013.04.026. [Epub ahead of print]
This  point needs to be studied further to determine role of statins in the acute deep vein thrombosis patients. If it is proved that we may be adding the statin to the heparin in the management of venous thromboembolism.

Can we patent Human Genes?

Superficial venous thrombosis (SVT)

Superficial vein thrombosis (SVT) is regarded a self-limiting disorder, although the authors of recent studies showed that ultrasonographically diagnosed SVT is a precursor for venous thrombosis. We would like to know whether the same holds true for clinically diagnosed SVT and to what extent it is associated with thrombophilia in a population-based case-control study (ie, Multiple Environmental and Genetic Assessment of risk factors for venous thrombosis). 
It was found that a history of clinical SVT was associated with a 6.3-fold (95% confidence interval [CI] 5.0-8.0) increased risk of deep-vein thrombosis and a 3.9-fold (95% CI 3.0-5.1) increased risk of pulmonary embolism. Blood group non-O and factor V Leiden showed a small increase in SVT risk in controls, with odds ratios of 1.3 (95% CI 0.9-2.0) and 1.5 (95% CI 0.7-3.3), respectively. 

In conclusion, clinically diagnosed SVT was a risk factor for venous thrombosis. Given that thrombophilia was only weakly associated with SVT, it is likely that other factors (varicosis, obesity, stasis) also play a role in its etiology.

http://bloodjournal.hematologylibrary.org/content/118/15/4239.full?sid=78553d12-afe0-439a-bc3c-e96aa64324a1

"Hormonal contraception and venous thrombosis."

Background. New studies about the influence of hormonal contraception (HC) on the risk of venous thromboembolism (VTE) have been published. 

Material and methods. Studies assessing the risk of specific types of hormonal contraception were evaluated, compared and set into a clinical perspective. 

Results. The majority of newer studies have demonstrated a three fold increased risk of VTE in current users of middle- and low-dose combined oral contraceptives (COCs) with norethisterone, levonorgestrel or norgestimate compared with non-users. 

The same studies have demonstrated a six-fold increased risk of VTE in users of combined pills with desogestrel, gestodene, drospirenone or cyproteroneacetate, and in users of the contraceptive vaginal ring, compared with non-users. The rate ratio of VTE between COCs with newer progestogens as compared with users of COCs with levonorgestrel was 1.5-2.8 in seven and 1.0 in two studies. Progestogen-only contraception did not confer an increased risk of VTE in any study.

The incidence rate of VTE in non-pregnant non-HC using women 15-49 years is 4 per 10 000 years. 

Recommendations. For starters on hormonal contraception, we recommend middle or low-dose combined pills with norethisterone, levonorgestrel or norgestimate as 1(st) choice preparations. For the many women who are users of COCs with newer progestogens, although the absolute risk of VTE is low, a change to combined pills with norethisterone, levonorgestrel or norgestimate may half their risk of VTE. Finally, we recommend COCs with 20 μg estrogen combined with the older progestogens to be launched in the Scandinavian countries. Women at an increased risk of VTE should consider progestogen-only contraception or non-hormonal contraception.

DVT in Orthopedic and Abdominal surgery patients - is due to different types of pathophysiological changes?

Why should there be a difference in the incidence of DVT in Orthopedic and abdominal surgery patients in post operative period?

Lower preoperative fibrinolytic activation observed in patients undergoing orthopedic surgery compared with abdominal surgery might have pathophysiological consequences. This may explain why Without prophylaxis, patients subjected to major abdominal surgery have a risk of deep vein thrombosis of approximately 30%, while the rate varies between 40% and 60% in orthopedic surgery. Pinjala R K

http://link.springer.com/article/10.1007/BF02912463

Vein grafts are often used for bypassing the occluded arterial segments in diabetic people and those who are habituated to smoking. Thrombosis of the vein grafts occur in some patients though the veins look healthy from out side and it is often considered to be a technical problem and revision of the vein grafting is often done especially in peripheral vascular surgical patients. Hyperglycemia is known to effect the endothelial functions and endothelial derived relaxation is abnormal in the diabetic people to varying degrees depending on the exposure of the patient to the glycemic variability in the previous times. Now there seems to evidence to support that BMP-4 is probably responsible for this impaired EDR ( endothelium derived relaxations) which is not linked to cyclooxygenase-2 pathway.   

Can we develop specific ischemia resist muscle fibers in chronic stable ischemia people?

The answer to this question can solve some of the problems faced by lower limb ischemia patients who are not suitable for interventional therapies or after failure of all the existing therapies?

This year slogan on world health day is control your blood pressure. We are aware of the importance of controlling high blood pressure in people attending our outpatient clinics. This is chosen with an aim to prevent the morbidity and mortality associated with the hypertension related cardiovascular outcomes.
The governments should take notice of the importance of implementation of the blood pressure control programs and support them to see that blood pressure of the people at large is kept under control health education and also providing basic medicinal supplies to the people. Ideally it would be helpful to train more paramedical people record the blood pressure and register hypertensive patients e-register so, that necessary supports can reach them to prevent complications.
In our world 9 million death are attributed to the hypertension related complications. That means they are potentially preventable with active implementation of the antihypertensive programs.
from  Pinjala R K,  7th April 2013

AV grafting for Vascular Access