Happy new year 2013

Professor Pinjala Ramakrishna, MS.,FRCSEd.,FICS
Head of the department of Vascular surgery
Nizams's Institute of Medical Sciences
Hyderabad - AP, India 
Tel No 0091 40 3317115

Drug Eluting stents and disadvantages- can we overcome these?

Drug Eluting Stents for coronary arteries

The use of metal Drug Eluting Stents (DES) presents some potential drawbacks. These include a predisposition to late stent thrombosis, prevention of late vessel adaptive or expansive remodeling, hindrance of surgical re-vascularization, and impairment of imaging with multi slice CT. That means we need some thing better than this in future. Are we there yet? However, it has been hypothesized that stents placed in many atherosclerotic arteries may require only about 3–6 months of mechanical integrity for scaffolding. Bioabsorbable or biodegradable stents that provide mechanical support during vascular wall repair and then harmlessly erode after the vascular wall has stabilized may eliminate some of the potential chronic risks of permanent stents and may mitigate the complexity of repeat stenting at the same site in the event of restenosis.

Smart phone based Ultrasound device

Smart phone based ultrasound for bed side use

We  would like to get the diagnosis  in patients as early as possible with the use of small gadget. We would like to get all the information needed to take a decision or start a treatment. 

In the beginning stethoscope and knee hammer were useful to examine the patients with cardiovascular and neurological problems. In recent past after the emergence of CT and MRI scans they basic tools have fallen out of fashion. We are looking for new devices which are simpler but provide more crucial information on the bed side to change the medications or start new treatment. 

CME - Management of Varicose Veins and Venous Insufficiency

Varicose veins in both legs - marking on left side

Varicose veins are common as the age advances. Chronic venous disease presents with a spectrum of signs and symptoms, including cosmetic spider veins, asymptomatic varicosities, large painful varicose veins, edema, hyperpigmentation and lipodermatosclerosis of skin, and ulceration. But there is no definitive stepwise progression from spider veins to ulcers and, in fact, severe skin complications of varicose veins are not seen in some with extensive varicose veins.

1. Precipitating factor for varicose veins include 

A. nulligravida pregnancy status. 

B. normotension.  

C. prolonged standing. 

D. autosomal-recessive genotype with complete penetrance.

2. Symptoms of chronic venous insufficiency 

A. include swelling, restlessness, limb heaviness and fatigue, aching/throbbing sensation, burning, tingling, direct tenderness, itch, and nocturnal leg cramps. 

B. are usually worse at the beginning of the day. 

C. decrease during the menstrual cycle and in cold weather. 

D. are not relieved by elevation.

3. In varicose veins patients, what can compression stockings do?

A. control pain and edema.  

B. help patients lose weight. 

C. are most practical for patients who are elderly, are obese, or have skin damage. 

D. slow the progression of venous insufficiency.

4.  When there are cosmetic spider angiomas (≤3 mm) any of one these therapies - sclerotherapy, thermocoagulation, or cutaneous laser therapy will 

A. seldom necessitates more than 1 treatment. 

B. leads to complete resolution of varicosities in most patients.  

C. induces endothelial damage leading to venous thrombosis and fibrosis.  

D. All of the above

5. When high volumes of dilute local anesthetic is injected into a treatment area of VVs, it  is called 

A. truncal reflux.  

B. transilluminated powered phlebectomy.  

C. tumescent anesthesia. 

D. micronized purified flavonoid fraction. 

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 Answers

C,A,A,C,C

Govt funded Health Insurance schemes

Age, BMI determine the severity of chronic venous disease?

Age, body mass index and severity of primary chronic venous disease.

Chronic venous disease

The severity of CVI is linked with the age and BMI of the individuals. A study confirmed the relationship between age, CEAP clinical class and extent of the venous reflux severity of CVD. Older age means an increased number of insufficient venous segments and increased risk of the clinical progression of CVD from varicose veins to chronic venous insufficiency (C(3)-C(6), trophic skin changes and venous ulcers). The results in this study support the BMI, in term of frequency of venous reflux, as a risk factor in the whole group of patients but only in women but not in men. Multiple linear regression showed BMI together with age as significant predictors of clinical grade of CVD according to the CEAP classification. As regards the influence of BMI on clinical severity/grade of CVD, the results of our study support BMI as an important risk factor.  Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2011 Dec;155(4):367-71. doi: 10.5507/bp.2011.054.

http://www.ncbi.nlm.nih.gov/pubmed/22336650

Obesity and Venous thrombosis

Obesity is a world wide problem. It is now common to see obese diabetic or obese person with venous disorders. It would be a good habit to measure the BMI of patients in the clinics and give them necessary precautionary advices when they are getting admitted to the hospitals for various therapies.

Carotid interventions in severe CKD patients

carotid artery disease and outcomes in CKD

Carotid artery stenotic disease is treated by endarterectomy and angioplasty/ stenting. The trials have shown that the incidence of MI is more after surgical endarterectomy in patients in the first few months.

Biochemical MI seems to be high after endarterectomy. In renal failure patients contrast injection may be a concern and surgery may be safer than the angioplasty and stenting. In a recent study this fact has been observed. Arch Surg. 2011;146(10):1135-1141. Published online June 20, 2011.

Clinical Image of the week

Fig: Femoro-popliteal angiogram of lower limb

Clinical information- This is the lower limb angiogram of the leg of a patient who is complaining of a pulsatile swelling on the back of the knee.

What is your diagnosis based on the findings in angiogram?

Answer:

Popliteal artery aneurysm with occlusion of distal popliteal artery

Comments:

Repair of popliteal artery aneurysm with revascularization of the tibial arteries.

Revascularization in octogenarians

In people above 80 years, we are generally hesitant to advice surgical revascularizations even though there are reports suggesting good results are possible in some of them. Critical limb ischaemia (CLI) defines a very advanced stage of chronic arterial insufficiency associated with high risk of major amputation and high risk of reduced quality of life. The estimated prevalence of CLI is 0.24%, and increases with patients’ ages. With ageing population, vascular physicians have to treat an increasing number of octogenarians suffering from CLI. For these patients, the main objective of revascularisation procedure is limb salvage and also improve the quality of life so that they become independent to attend to all their daily activities.In one of the recent studies 167 octogenarians under going open and endovascular surgery were examined for the degree of autonomy after the interventions. It was concluded that endovascular surgery is justified in octogenarians, as this is restoring higher autonomy with limb salvage and patency rates comparable to open surgery. 

Reference:
EJVES 2012 Dec; 44(6):562-567

Neglected diseases and mortality

There are concern about the way the medical diseases are perceived and the attention is given to them in terms of detection tests, treatments and  research spending in the recent past. Biomedical progress on neglected diseases seems to be very slow and limited. The neglected diseases account for 2.6 million deaths a year. 756 new drugs are approved for use in Europe and USA and only 3.8.% of them are going to be useful for the neglected diseases. That means these diseases are truly neglected as their name says.

The neglected group of diseases includes malaria, tuberculosis, lethal childhood diarrhoea, and other diseases that kill impoverished people around the world, who tend to lack clean water, secure housing, sanitary waste disposal, and access to healthcare. People who live on less than $2 per day cannot afford high-priced drugs, and therefore drug companies have little incentive to spend millions to develop the drugs and bring them to market.

This is going to be an important issue for many countries to address in the coming years. Prioritisation of the research funding and health care expenditure allocation in the health budgets needs to appropriate to the needs of the society.  Although drugs and vaccines are an essential step in saving the millions who die each year of neglected diseases, public health experts point out that they can only help if they reach the most vulnerable populations. Almost 2 million children under five years old die each year worldwide from diseases which existing vaccines could prevent.
    

Trauma induced left upper llimb DVT and hiccups due to suspected phrenic nerve injury

Hiccups - physiology

Young man (25 years)  tried to avoid hitting a buffalo while riding a two wheeler and fell on the outstretched hand. Initially he did not find any problem. He got up and went home. After one week he noticed a swelling of the arm and forearm. He went to the local doctor (general surgeon) and he suspected deep vein thrombosis and confirmed it on colour doppler scan. In the scan left internal jugular vein thrombosis, subclavian vein, axillary vein and upper brachial vein thrombosis was noted. He gave antibiotics and analgesics and referred him to the vascular surgery clinic for further management. Based on the clinical and colour doppler scan findings the patient was given Injection Heparin 1000 units per hour and APTT was monitored. There was no prolongation of the APTT after 2 days of anticoagulation. Then the dose was increased to 1250 units per hour. The dull aching pain and swelling was persisting in the arm and forearm. So, to relieve the pain and inflammation (traumatic) he was put on Deflazacort 4 mg x daily. The pain, swelling significantly reduced and APTT was prolonged to therapeutic levels.
He developed hiccups which bothered him throughout the day. We were not able to associate hiccups with any known medical condition and physical examination was normal, there were no neurological deficits in him. We suspected it could be due to partial injury to the phrenic nerve on the left side. We considered various pharmacological therapies for the hiccups such as chlorpromazine, haloperidol, valproic acid, gabapentin, and pregabalin. He was given Tab Pregabalin and reassured that hiccups are generally temporary and subside in couple of weeks.

Reference: 
Cymet TC. Retrospective analysis of hiccups in patients at a community hospital from 1995-2000. J Natl Med Assoc. 2002;94:480–3. [PMC free article] [PubMed]

Patient safety in India

The recent Editorial in The National Medical journal of India, discussed about the patient safety in India. The hospitals are now busy places with so many patients undergoing many different treatments and tests. It is very essential that all the precautions are taken in to account to avoid the problems or complications. It is important to realize that hospitals and members of the profession are held accountable for the short falls in care.The 1995 Supreme Court declaration bringing hospitals under the purview of the Consumers Protection Act (CPA) of 1986 was possibly the start of the movement for the safety of the patient in India. The WHO launched the World Alliance on Patient Safety (WAPS) to help stimulate further research to ascertain the extent and root causes of the problem and, more importantly, develop innovative solutions to reduce the burden of harm due to unsafe healthcare. Much progress has since been made, in the past decade, but it is equally clear from some high-profile instances, for example, in the National Health Service (NHS) in the UK that a lot more needs to be done (http://www.midstaffsinquiry.com/). India is a signatory to the WAPS and institutions such as the Quality Council of India have been set up. There are also other initiatives, such as the National Initiative on Patient Safety at the All India Institute of Medical Sciences and the Indian Confederation for Healthcare Accreditation, to promote action. We need to build on these developments. We could start with a five-pronged approach.
1. Lobbying and assisting institutions and the government with the creation of systems for recording, learning and reporting on the quality of services and adverse events in a ‘balanced’ manner (neither too heavy-handed, nor too light), and making it possible to set up such systems given the concerns of such documentation.
2. Accelerating the implementation of proven patient safety interventions, such as the Global Patient Safety Challenges work on hand hygiene and surgical checklist, andTHE NATIONAL MEDICAL JOURNAL OF INDIA VOL. 25, NO. 3, 2012 131 by the introduction of mandatory compliance with ‘Never Events’ (http://www.telegraph.co.uk/health/healthnews/4933949/List-of-eight-blunders-the-NHSmust-never-commit-released-by-watchdog.html).
3. Empowering patients to question and work with professionals, for example through the Patient Safety Alliance (www.patientsafetyalliance.in), which also draws on the work being done by the Health Education Library for Patients (www.healthlibrary.com).
4. Capacity-building through education and training at the undergraduate level by using the WHO curriculum on patient safety and for established professionals through distance learning, for example through the  people’s Open Access Education Initiative (www.peoples-uni.org).
5. Undertaking further research by building on the work started by the INCLEN.

So, patient safety is clearly a major public health issue in India, and some would argue that the problem is likely to be much more serious, given the concerns about counterfeit drugs, faulty medical equipment, unsafe blood banks or unregulated organ donation, for example. There is lot of work to do in the coming years in this direction!!!

Missing early diagnosis of Diabetes!

It is generally felt that the diagnosis is often missed or delayed in remote areas where the medical facilities are not available and medical insurance facilities are not able to reach. In India, it is common to see medical camps being conducted in the rural areas to detect the non communicable diseases such as diabetes and hypertension. In some countries even though there are all the medical facilities available the diagnosis of diabetes is often delayed due to many reasons. Limited access to health care, especially being uninsured and going without insurance for a long period, was significantly associated with being a “missed patient” with diabetes. Efforts to increase detection of diabetes may need to address issues of access to care. In the coming years more and more attention will be given to the non communicable diseases and we can reduce the number of undetected diabetes people and improve their health care through the insurance systems.
Reference: Diabetes Care. 2008 September; 31(9): 1748–1753.

Vitamian K antagonists (OACs) are harmful?

 Can we safeguard coronaries from micro calcification?

As Weijs et al.^[1] have described, most patients diagnosed with paroxysmal atrium fibrillation (AF) are currently treated by prescribing life-long use of vtamin K antagonists (VKAs) to prevent thrombo-embolic complications.[2] By applying minimal invasive multislice computed tomography (MSCT) imaging, the authors found a possible adverse treatment effect in patients who were receiving VKAs for relatively longer, showing significant higher levels of calcium in their coronary arteries compared with patients with a shorter time on VKAs. This could have serious consequences for current clinical practice.[2]

 1. Weijs B, Blaauw Y, Rennenberg RJMW, Schurgers LJ et al. Patients using vitamin K antagonists show increased levels of coronary calcification: an observational study in low-risk atrial fibrillation patients. Eur Heart J 2011;32:2555-2562. First published on 20 July 2011. doi:10.1093/eurheartj/ehr226. 

2. Fuster V, Ryden LE,Cannom DS,Crijns HJ et al.. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation—executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation). Eur Heart J 2006;27:1979-2030.

1. 
   

Lower extremities amputaitons are decreasing!

Amputations can be prevented -  amputation rates are decreasing!!!
It is important to know that the methods to reduce amputation and improve the quality of life are measurably effective in some countries such as America. During the last 25 years of our service at our institution in Hyderabad, the amputation rate has come down, but still the patients are coming for advice very late. That means we need to encourage the govt hospital doctors at primary care centers to recognize these problems early and treat the risk factors before they are unmanageable. That is the best way to control the epidemic cardiovascular diseases. Bypasses and balloon angioplasties will help to some extent but the larger populations can be benefited by the identification and modification of the risk factors. It may be worth developing risk modification clinics across the state to address this issue and improve the quality of life. The Aarogyasree scheme is very helpful to the people but it is going to be better if they also spend money for the development of the risk modification clinics.


Temporal Trends and Geographic Variation of Lower-Extremity Amputation in Patients With Peripheral Artery DiseaseResults From U.S. Medicare 2000–2008
W. Schuyler Jones, MD; Manesh R. Patel, MD; David Dai, PhD; Sumeet Subherwal, MD, MBA; Judith Stafford, MS; Sarah Calhoun, BS; Eric D. Peterson, MD, MPH
J Am Coll Cardiol. 2012;60(21):2230-2236. doi:10.1016/j.jacc.2012.08.983
Abstract
Objectives This study sought to characterize temporal trends, patient-specific factors, and geographic variation associated with amputation in patients with lower-extremity peripheral artery disease (LE PAD) during the study period.
Background Amputation represents the end-stage failure for those with LE PAD, and little is known about the rates and geographic variation in the use of LE amputation.
Methods By using data from the Centers for Medicare & Medicaid Services (CMS) from January 1, 2000, to December 31, 2008, we examined national patterns of LE amputation among patients age 65 years or more with PAD. Multivariable logistic regression was used to adjust regional results for other patient demographic and clinical factors.
Results Among 2,730,742 older patients with identified PAD, the overall rate of LE amputation decreased from 7,258 per 100,000 patients with PAD to 5,790 per 100,000 (p < 0.001 for trend). Male sex, black race, diabetes mellitus, and renal disease were all independent predictors of LE amputation. The adjusted odds ratio of LE amputation per year between 2000 and 2008 was 0.95 (95% CI: 0.95–0.95, p < 0.001).
Conclusions From 2000 to 2008, LE amputation rates decreased significantly among patients with PAD. However, there remains significant patient and geographic variation in amputation rates across the United States.

Obesity and deep vein thrombosis

Obesity and Deep vein thrombosis

Obesity is measured as body mass index above 30. The body mass index (BMI) is measured as weight in kilograms divided by the square of height in meter. Obesity is associated with venous thromboembolism (VTE). Body mass index is a marker of excess weight and correlates well with body fat content in adults. Body mass index fails to consider the importance of the distribution of body fat. All measurements of obesity are predictors of the risk for VTE. Positive associations were found between VTE and body weight, body mass index, waist circumference, hip circumference, and total body fat mass (1). The fact is that the fat distribution is not uniform in all the people and so there are different shapes of individuals. Basically obesity is differentiated as central or peripheral depending on the degree of fat accumulation in the central part of the body or extremities. Studies were done to find out the differences in risk associated with these types of fat distribution. The distribution of body fat predicts the risk of arterial thrombotic events, such as coronary heart disease (CHD). Central obesity is a better predictor of CHD than general obesity as measured with BMI.  Central obesity is measured as waist circumference or waist-to-hip ratio. It is important note that peripheral obesity is not a predictor of coronary heart disease. The peripheral obesity is measured as hip circumference (2,3). One study evaluated the association between VTE and central obesity in men and found that a waist circumference >100 cm was associated with a higher risk of VTE than a waist circumference  less than 100 cm (4).It is also important know the benefit of thrombo-prophylaxis in obese people who are undergoing major surgeries such as total knee arthroplasty. In a case-control study, they studied (130, 463) patient with and patients without acute VTE (within 9 days of surgery) and BMI ranging from 17 to 61.  Multivariable logistic regression was used to analyze risk factors for postoperative VTE, adjusted for age and gender. Thromboprophylaxis was LMWH in 284 (48%), warfarin in 189 (32%), both in 55 (10%), and mechanical prophylaxis alone in 120 (20%). Overall, 77% ambulated on day 1 or 2 after surgery. Severe obesity was not a significant independent predictor for VTE and did not modify the beneficial effect of FDA-approved pharmacological thromboprophylaxis. Bilateral TKA and failure to ambulate by the second day after surgery were significant risk factors (5). 

References:

1.   Knut H. Borch, Sigrid K. Brækkan, Ellisiv B. Mathiesen, Inger Njølstad, Tom Wilsgaard, Jan Størmer, and John-Bjarne Hansen. Anthropometric Measures of Obesity and Risk of Venous Thromboembolism: The Tromsø Study. Arterioscler Thromb Vasc Biol. 2010;30:121-12.   

2.   Canoy D, Boekholdt SM, Wareham N, Luben R, Welch A, Bingham S, Buchan I, Day N, Khaw KT. Body fat distribution and risk of coronary heart disease in men and women in the European Prospective Investigation Into Cancer and Nutrition in Norfolk cohort: a population-based prospective study. Circulation. 2007; 116: 2933–2943. 

3.   Yang L, Kuper H, Weiderpass E. Anthropometric characteristics as predictors of coronary heart disease in women. J Intern Med. 2008; 264: 39–49 

4.   Hansson PO, Eriksson H, Welin L, Svardsudd K, Wilhelmsen L. Smoking and abdominal obesity: risk factors for venous thromboembolism among middle-aged men: “the study of men born in 1913.” Arch Intern Med. 1999; 159: 1886–1890.

5.   Sadeghi B, Romano PS, Maynard G, Strater AL, Hensley L, Cerese J, White RH. Mechanical and suboptimal pharmacologic prophylaxis and delayed mobilization but not morbid obesity are associated with venous thromboembolism after total knee arthroplasty: A case-control study. J Hosp Med. 2012 Oct 5. doi: 10.1002/jhm.1962. [Epub ahead of print]