hepPTFE AVGs failed to improve patency or decrease secondary interventions compared to standard PTFE grafts used as Arteriovenous grafts for dialysis

Vascular occlusions in the lower limbs require a bypass operation. A conduit is needed for the bypass operation. Autogenous vein graft from the contralateral limb or ipsilateral limb is considered as an ideal conduit for the bypass operations. But it is not available or inadequate in 20-30% of the patients requiring bypass operation. Then one has to use the synthetic vascular graft in the absence of autogenous vein graft. The synthetic vascular grafts are modified over a period of time to improve the patency and reduce the recurrent thrombosis and also reduce the need for reinterventions. Porous dacron grafts need preclotting and that is not needed in the PTFE grafts. The kinking and rotation of the synthetic grafts in the long subcutaneous tunnels is avoided  by external support (rings/spirals). In a similar way there were many attempts to make the inner surface of the graft less thrombogenic and heparin bonding (coating) was one of them. These grafts have initially shown better results in the literature and they are available in the market. But there were not many papers to establish the indications and evaluating the long term results. Now these vascular grafts are also used for creating AV fistula for  patients requiring hemodialysis and known as arterio-venous grafts. The long term patency of the A-Vgrafts without re-interventions is a boon for the patients. It was hoped that the heparin bonding to the internal luminal surface of the Arterio-Venous grafts may prevent the thrombosis.

Recently a paper is published saying that Heparin Bonding Does Not Improve Patency of Polytetrafluoroethylene Arterio-Venous Grafts by Matthew TA et al (Feb 2013). A total of 223 patients had 265 grafts placed. Of these, 62 (23%) were hepPTFE grafts. The average age was 66 ± 15 years in the hepPTFE group and 59 ± 17 years in the non–heparin-bonded control group (PTFE; P < 0.01). Of the hepPTFE group, 39% were men, 81% were African American, 63% were diabetic, and 81% had a tunneled catheter at the time of access placement. Of the PTFE group, 35% were men, 85% were African American, 56% were diabetic, and 83% had a tunneled catheter. HepPTFE grafts failed to improve rates of primary, assisted primary, or secondary patency based on univariate analysis (hazard ratio [HR]: 1.37 [95% confidence interval {CI}: 0.99–1.88]; HR: 1.39 [95% CI: 0.98–1.96]; and HR: 1.20 [95% CI: 0.73–1.96], respectively). The number of secondary interventions was similar in the 2 groups (1.1 interventions per person-year of follow-up PTFE versus 1.4 hepPTFE; P = 0.13). A multivariable model including age, diabetes, peripheral artery disease, tobacco use, previous access placement, and tunneled catheter found that the HR for hepPTFE was not significantly different than PTFE in primary, assisted primary, or secondary patency (HR: 1.32 [95% CI: 0.91–1.90]; HR: 1.35 [95% CI: 0.91–1.99]; and HR: 1.15 [95% CI: 0.62–2.16], respectively.
This probably indicates that the intraluminal thrombosis of Arterio-Venous Grafts (AVGs) in the patients undergoing Dialysis is dependent on many other factors other than less thrombogenisity of the intraluminal surface of the grafts.

A 15-fold increase in rates of mortality due to cardiovascular disease and coronary heart disease among subjects with large-vessel peripheral arterial disease !!! do you believe?

Peripheral arterial disease (PAD) is a widespread vascular disorder that has been addressed for over a century and continues to affect a large portion of the modernized world. Both symptomatic and asymptomatic PAD affects 4.3% of the U.S. population aged ≥40 years of age1 and is recognized as a chronic atherosclerotic progression of lower-extremity arterial obstruction, which eventually leads to limb-threatening ischemia. PAD is functionally defined as an occlusive disease that generates a resting ankle–brachial index (ABI) of ≤0.90,2 although an ABI of between 0.9 and 1 is considered borderline and may introduce diagnostic subjectivity. PAD is strongly associated with terminal coronary artery disease for patients both with and without a significant cardiovascular history.3 As defined by a history of cardiovascular events or interventions (abdominal aortic aneurysms, transient ischemic attacks, stroke, carotid endarterectomy, history of angina, myocardial infarction, coronary angioplasty, and/or coronary artery bypass graft surgery), general cardiovascular disease has been associated with 70% of patients with PAD, rendering its diagnosis a significant indication for pan-vascular risk.4 Thus, the timely detection of PAD permits treatment of the diseased limb and preemptive management of cardiovascular risks.5 Preliminary PAD screenings have evolved into routine, noninvasive vascular laboratory studies, which reduce the risks, time, and costs associated with angiography. 

In a 10 years followup study published in Annals of vascular surgery in 1992 it was found that  - Twenty-one of the 34 men (61.8 percent) and 11 of the 33 women (33.3 percent) with large-vessel peripheral arterial disease died during follow-up, as compared with 31 of the 183 men (16.9 percent) and 26 of the 225 women (11.6 percent) without evidence of peripheral arterial disease. After multivariate adjustment for age, sex, and other risk factors for cardiovascular disease, the relative risk of dying among subjects with large-vessel peripheral arterial disease as compared with those with no evidence of such disease was 3.1 (95 percent confidence interval, 1.9 to 4.9) for deaths from all causes, 5.9 (95 percent confidence interval, 3.0 to 11.4) for all deaths from cardiovascular disease, and 6.6 (95 percent confidence interval, 2.9 to 14.9) for deaths from coronary heart disease. The relative risk of death from causes other than cardiovascular disease was not significantly increased among the subjects with large-vessel peripheral arterial disease. After the exclusion of subjects who had a history of cardiovascular disease at base line, the relative risks among those with large-vessel peripheral arterial disease remained significantly elevated. Additional analyses revealed a 15-fold increase in rates of mortality due to cardiovascular disease and coronary heart disease among subjects with large-vessel peripheral arterial disease that was both severe and symptomatic.

1. Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999–2000. Circulation. 2004;110:738–743
2. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45(Suppl. S):S5–67
3. Criqui MH, Langer RD, Fronek A, et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992;326:381–386
4. Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286:1317–1324
5. Verhaeghe R. Prophylactic antiplatelet therapy in peripheral arterial disease. Drugs. 1991;42((Suppl. 5)):51–57

We should check the ABI in all patients at risk of peripheral arterial disease!

International ABI awareness as the next step in the PAD campaign

Coronary artery disease, cerebrovascular disease are well known in the society as the cause for heart attack (MI) and brain attack (stroke). Peripheral artery disease is the third most common manifestation of the atherosclerosis and one can lose lower limb if the critical ischemia is precipitated by other factors. The awareness of peripheral vascular disease is not adequate enough among the people in our society or general practioners to avoid complications and toe or limb loss in India and many other countries.

Peripheral artery disease (PAD) is common, underdiagnosed, and undertreated. Owing to the systemic nature of atherosclerosis, PAD patients are at risk for polyvascular disease. For example, 63% of patients with PAD have concomitant symptomatic cerebrovascular or coronary disease. Accordingly, PAD patients are at significantly increased risk for myocardial infarction, stroke, and vascular death over a 5-year period compared to age-matched cohorts.  

The ankle–brachial index (ABI) is the preferred initial test for PAD screening and diagnosis. It is relatively inexpensive, sensitive, and specific. Current guidelines provide clear recommendations on the indications for ABI testing. However, these guidelines may not have been fully implemented among practitioners.

In our practice we rarely see patients getting referred based on the ABI recorded in the clinics. The clinicians ask for Colour Doppler study (both legs costing Rs 2000 to 3000) and then send them with a report saying diffuse peripheral vascular disease in the diabetic and smoking population. Then we are doing the ankle brachial index in our clinic to classify degree of ischemia. One should practice checking the ankle brachial index routinely in patients with suspected peripheral arterial disease.

In a survey conducted in Australia, it was found that strikingly low 6% of GPs were aware of evidence-based guidelines on PAD screening, and only 5% were aware of guidelines on PAD diagnosis. The majority of GPs (58%) never perform ABIs. Most notably, 70% of the respondents choose arterial duplex (which is more costly and time-consuming) as the initial diagnostic tool in a patient with a history and physical exam consistent with PAD; younger GPs were more likely to choose the ABI. I think we are no better than the GPs in Australia in the evaluation of Peripheral vascular disease in the community.

The most common ‘moderate to major’ barriers to PAD screening and testing were (1) equipment availability, (2) time constraints, (3) lack of training and skills, and (4) staff availability. The time constraint barrier is not surprising, given that the time for an ABI could approach the 15-minute length of a typical primary care office visit. Other studies have also identified limited reimbursement and time as primary barriers to widespread use of the ABI in primary care practices.

I think, by increasing the awareness and improving staff ability more and more GPs will make an attempt to record the ABI in their practice and follow their patients for the CV events and extend better protection measures to avoid the amputations.

Surgical site infection in Diabetics- Is it related to preoperative HBA1c levels ?

We are all concerned about the surgical site infections in diabetic individuals. This is more important in patients undergoing surgery with implantable devices such as vascular surgery, orthopedic surgeries. It is probably better to correct the HBA1c prior to surgery in elective cases. Patients and their relatives should be informed and explained about the importance of metabolic control and correction of the HBA1c prior to the major elective operations. We prefer to correct the anemia before elective surgery in a similar manner it would be better to correct the metabolic problems.
In a recent paper published it was found that the surgical site infections were associated with high HBA1c. DM patients whose blood glucose levels were poorly controlled before surgery were at high risk for SSI. To prevent SSI in DM patients, we recommend lowering the HbA1c to <7 .="" font="">http://www.ncbi.nlm.nih.gov/pubmed/24368606  J Orthop Sci. 2013 Dec 25

What will happen to venous functions in 5 years, if iliofemoral deep vein thrombosis is treated with Anticoagulation only!

Akesson H et al (1990)examined 20 patients over period of 5 years who were treated for acute iliofemoral DVT with anticoagulation.

To determine the chronological changes of venous physiology following major thromboses, 20 patients were repeatedly examined for over 5 years after an acute ilio-femoral thrombosis which was treated with conventional anticoagulation. Radionuclide angiography showed that 70% of the patients had obstructive lesions of the iliac vein with only minor changes occurring from 6 months to 5 years. In spite of this, the plethysmographic maximum venous outflow increased from 31 to 45 ml/min/100 ml (P less than 0.001).
The foot volumetric reflux did not change with time and about half of the patients had abnormal values. Venous reflux assessed by the refill time of foot vein pressure, deteriorated with time (P less than 0.05), and at 5 years all but one patient had a refill time less than 20 s. The muscle pump function, examined by foot volumetry, was abnormally low in about half of the patients throughout the study.
The ambulatory foot vein pressure was constantly pathological (greater than 60 mmHg) in half of the patients and only two of 18 patients had normal values (less than 45 mmHg) at 5 years. Five patients with thromboses involving only the proximal veins had better physiological results than 15 patients with thromboses that extended to the peripheral veins. Three patients who developed venous claudication had iliac vein obstruction and an impaired venous outflow and three patients who developed venous ulcers had venous reflux and severe venous hypertension. Although venous outflow continuously improves following ilio-femoral thromboses, valvular competence and muscle pump function are constantly pathological, creating severe venous hypertension with a risk of post-thrombotic sequelae.
This study shows that -Obstruction can be over come after a period of time with recanalization and neovascularization.But the reflux is going to get worse with passage of time. People with venous reflux after 10 years will be showing the classical signs of venous hypertension.

Carotid artery intima media thickness (CIMT) is it a reliable marker of atherosclerosis?

In our county we do not measure the carotid artery intima media thickness in the routine clinical practice. But for the research trials this examination is done to know effect of drugs. This is a surrogate marker. There are doubts raised about the value of the CIMT measurement to know the CV risk. The CIMT may not give more information than that shown by traditional risk factors. A large number of prospective studies have demonstrated that carotid artery intima-medial wall thickening is predictive of major cardiovascular events, independently of traditional risk factors, with risk ratios ranging from 1.4 to 5.1 for coronary heart disease, and from 2.0 to 3.5 for stroke. Because of its established predictive value and its quantitative measurement with high precision and reproducibility rates, CIMT is also being employed as a surrogate endpoint in numerous clinical trials involving lipid-lowering or anti hypertensive drugs.
Simon A, Gariepy J, Chironi G, Megnien J, Levenson J. Intimamedia thickness: a new tool for diagnosis and treatment of cardiovascular risk. J Hypertens 2002;20:159—69.
Simon A, Megnien JL, Chironi G. The value of carotid intima media thickness for predicting cardiovascular risk. Arterioscler Thromb Vasc Biol 2010;30:182—5.
Lorenz MW, Markus HS, Bots ML, Rosvall M, Sitzer M. Prediction of clinical cardiovascular events with carotid intima-media thickness a systematic review and meta-analysis. Circulation 2007;115:459—67.
Den Ruijter HM, Peters SA, Anderson TJ, et al. Common carotid intima-media thickness measurements in cardiovascular risk prediction: a meta-analysis. JAMA 2012;308:796—803.

Carotid artery plaque may be a better predictive marker than CIMT. Indeed, when measured in the common carotid artery usually free from atherosclerotic plaque, CIMT is not a specific marker of the atherosclerotic process, but it reflects  medial hypertrophy, particularly as a consequence of hypertension or ageing. Accordingly, polled data from several longitudinal studies showed that the absolute risk of coronary
heart disease at 10 years associated with the presence of carotid plaque was 25% compared with 8% (low risk) in the absence of plaque, contrasting with an absolute risk of 11 to 15% (still intermediate risk) in subjects with CIMT > 95th percentile. However, the current recommendation to measure CIMT in order to reclassify intermediate-risk subjects  is not supported by its actual predictive value, which suffers established weakness beyond traditional risk factors compared with that of carotid plaque and coronary artery calcinosis.
http://ac.els-cdn.com/S1875213613000089/1-s2.0-S1875213613000089-main.pdf?_tid=dc099cf4-6bb5-11e3-93f6-00000aacb35d&acdnat=1387791637_b577dba96c2e307acb0ede59976abd00
In another study published in Lancet it was concluded that - The association between cIMT progression assessed from two ultrasound scans and cardiovascular risk in the general population remains unproven. No conclusion can be derived for the use of cIMT progression as a surrogate in clinical trials.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60441-3/abstract

Let us search and find new and better paths to reach, discover the ultimate truth and science behind management of Non-communicable diseases and facilitate the mankind to lead a better and healthy life. -Pinjala RK

Outcomes of Infra popliteal bypass in patients with gangrene of forefoot or toes!

J Vasc Surg. 1985 Sep;2(5):669-77.

Infrapopliteal bypass for established gangrene of the forefoot or toes.

Dalsing MC

Limb salvage by life-table analysis was 70% at 1 year, 60% at 3 years, and 28% at 5 years. The graft patency at 3 years was 65% for vein grafts and 30% for PTFE grafts.

In the entire series the operative mortality rate was 1.7%. Age, sex, hypertension, or diabetes mellitus did not influence the result of surgery. Similarly, failure of a previous femoro-popliteal or tibial graft did not reduce the likelihood of limb salvage. Graft patency, however, is prerequisite for limb salvage, and graft patency can be maintained by thrombectomy or repetitive bypass.

The present study suggests that limb salvage is possible in as many as two thirds of limbs with established gangrene. Although saphenous vein remains the graft material of choice, its absence should not preclude attempts at limb salvage. Repetitive grafting did not jeopardize patient safety but contributed significantly to extended limb survival.

From January 1977 through June 1983, 361 patients underwent infrapopliteal bypasses; 58 patients (59 limbs) had forefoot and/or toe gangrene. There were 33 men and 25 women (mean age 67.6 years), and 40 patients (69%) were diabetic. A total of 71 femorodistal bypass procedures were performed in these patients:A single bypass in 49, repeat procedure in eight, and multiple bypasses in two patients. Graft material was autogenous saphenous vein in 22 cases, polytetrafluoroethylene (PTFE) in 39 cases, and a composite graft in 10 procedures. After bypass 50 patients underwent limited toe or forefoot amputation with uncomplicated healing. 

There is always this question, should we do a bypass in a patient with forefoot or toe gangrene?  We should in a selected group of patients as this can be useful. 

Outcomes of Femoro-distal reconstruction in Diabetics and Non Diabetic patients -

Eur J Vasc Endovasc Surg. 2003 Mar;25(3):229-34.

Graft patency and clinical outcome of femorodistal arterial reconstruction in diabetic and non-diabetic patients: results of a multicentre comparative analysis.

Wölfle KD et al

Diabetes did not adversely affect graft function. For diabetics and non-diabetics primary cumulative patency rate at 1 year was found to be 66 and 56%, respectively (p=0.10) and a virtually identical limb salvage rate of 85 and 83% was achieved (p=0.76). 

With regard to healing of ischaemic foot ulcers a trend against diabetics was noted with a healing rate of 81% compared to 96% in non-diabetics at 1 year (p=0.067); gangrenous foot lesions could be equally remedied in 94% and in 87% among patients with and without diabetes (p=0.44). The survival rate of diabetics, however, was significantly lower with 78% at 1 year compared with 95% in non-diabetic patients (p=0.0004).

Infrainguinal bypass grafting can be safely done even in diabetics. Despite increased mortality in this group, liberal indication for reconstructive vascular surgery seems to be justified by favourable patency rates and clinical outcome in selected patients. I am not sure if the higher mortality is acceptable some of us!  The 17% higher mortality in diabetics compared to non diabetics after revascularisation at the end of 1 year may be too high!

Intermittent claudication

Intermittent claudication is a common condition affecting over 5% of the population over the age of 65 years.
Patients exhibit limited walking ability, but over recent years a number of studies have identified that claudication is also associated with significant impairments in overall physical function,1 including walking speed, lower limb strength, and balance. There is strong evidence that higher levels of daily activity in claudicants reduces functional decline and associated morbidity/mortality in the mid to long term. Furthermore, there is increasing evidence that claudicants have associated balance impairments that may predispose to an increased risk of falling and its associated physical and socio-economic consequences.

Percutaneous transluminal angioplasty results in improved physical function but not balance in patients with intermittent claudication - Risha Arun Gohil, et al
Objective: The aim of this study was to identify whether revascularization by percutaneous transluminal angioplasty (PTA) for patients with intermittent claudication improved measures of functional performance including balance.
Methods: A prospective observational study was performed at a single tertiary vascular center. Patients with symptomatic intermittent claudication (Rutherford grades 1-3) were recruited to the study. Participants were assessed at baseline (pre-PTA) and then, and 12 months post-PTA for markers of (1) lower limb ischemia (treadmill walking distances and ankle-brachial pressure index), (2) physical function (6-minute walk, Timed Up and Go, and chair stand time), (3) balance impairment using computerized dynamic posturography with the Sensory Organization Test, and (4) quality of life (VascuQoL and Short Form Health Survey [SF-36]).
Results: Forty-three participants underwent PTA. Over 12 months, a significant improvement was demonstrated in initial (P = .04) and maximum treadmill walking distance (P = .019). Physical functional ability improved across all outcome measures (P < .02), and some domains of both generic (P < .03) and disease-specific quality of life (P < .01). No significant improvement in balance was demonstrated by the Sensory Organization Test (P = .24).
Conclusions: Balance impairment is common in claudicants and does not improve with revascularization. Further research regarding effective treatment of balance impairment is required in this specific group of patients.

Journal of Vascular Surgery Volume 58, Issue 6, December 2013, Pages 1533–1539

Medial arterial calcification in the feet of diabetic patients

Diabetologia. 1993 Jul;36(7):615-21.

Medial arterial calcification in the feet of diabetic patients and matched non-diabetic control subjects.

Young MJ, Adams JE, Anderson GF, Boulton AJ, Cavanagh PR.

Author information

Abstract

The prevalence and distribution of medial arterial calcification was assessed in the feet of four subject groups; 54 neuropathic diabetic patients with previous foot ulceration (U), median age 60.5 (50.5-67 interquartile range) years, duration of diabetes 19.5 (9.9-29.9) years; 40 neuropathic diabetic patients without a foot ulcer history (N), age 68 (62-73) years, duration of diabetes 14.0 (8.0-28.0) years; 43 non-neuropathic diabetic patients (NN), age 60.5 (52-68.5) years, duration of diabetes 14.0 (8.0-28.0) years and 50 non-diabetic control subjects, age 62.5 (53.7-70) years. A single radiologist graded medial arterial calcification as absent, mild or severe, at the ankle, hind-foot, mid-foot, metatarsals and toes on standardised plain lateral and antero-posterior foot radiographs taken by a single radiographer. Diabetes history, vibration perception threshold, ankle systolic pressure and serum creatinine were also assessed. 

Medial arterial calcification was significantly greater (total score 18 [3-31]) in neuropathic diabetic patients with previous ulceration (U vs N p < 0.01, U vs NN p < 0.001). 

Non-neuropathic diabetic patients did not have significantly higher arterial calcification scores than age-matched non-diabetic control subjects. 

Medial arterial calcification correlated with vibration perception threshold (r = 0.35), duration of diabetes (r = 0.32) and serum creatinine (r = 0.41), (all p < 0.01). 

Logistic regression models showed vibration perception and duration of diabetes to predict the probability of any calcification. Serum creatinine level was added to predict severe calcification.

Percutaneous transluminal angioplasty results in improved physical function but not balance in patients with intermittent claudication

Intermittent claudication is a common condition affecting over 5% of the population over the age of 65 years. Patients exhibit limited walking ability, but over recent years a number of studies have identified that claudication is also associated with significant impairments in overall physical function,including walking speed,  lower limb strength, and balance. There is strong evidence that higher levels of daily activity in claudicants reduces functional decline and associated morbidity/mortality in the mid to long term. Furthermore, there is increasing evidence that claudicants have associated balance impairments that may predispose to an increased risk of falling and its associated physical and socio-economic consequences.

Percutaneous transluminal angioplasty results in improved physical function but not balance in patients with intermittent claudication  Risha Arun Gohil, et al  Objective: The aim of this study was to identify whether revascularization by percutaneous transluminal angioplasty (PTA) for patients with intermittent claudication improved measures of functional performance including balance. Methods: A prospective observational study was performed at a single tertiary vascular center. Patients with symptomatic intermittent claudication (Rutherford grades 1-3) were recruited to the study. Participants were assessed at baseline (pre-PTA) and then, and 12 months post-PTA for markers of (1) lower limb ischemia (treadmill walking distances and ankle-brachial pressure index), (2) physical function (6-minute walk, Timed Up and Go, and chair stand time), (3) balance impairment using computerized dynamic posturography with the Sensory Organization Test, and (4) quality of life (VascuQoL and Short Form Health Survey [SF-36]). Results: Forty-three participants underwent PTA. Over 12 months, a significant improvement was demonstrated in initial (P = .04) and maximum treadmill walking distance (P = .019). Physical functional ability improved across all outcome measures (P < .02), and some domains of both generic (P < .03) and disease-specific quality of life (P < .01). No significant improvement in balance was demonstrated by the Sensory Organization Test (P = .24). Conclusions: Balance impairment is common in claudicants and does not improve with revascularization. Further research regarding effective treatment of balance impairment is required in this specific group of patients.

Sleep and Quality of Life

“Appetite and Sleep” are very important to enjoy the quality of life. The sleeping patterns are variable depending on the physical condition and different kinds of diseases.  

Recently a new study showed that poor sleep quality is strongly associated with mood disturbance and lower quality of life among people with extreme obesity. The study involved 270 patients with a mean body mass index (BMI) of 47.0 kg/m2 who were consecutively enrolled in a regional specialist weight management service. They had a mean age of 43 years. Sleep disturbance, daytime sleepiness, mood and quality of life were assessed using standardized questionnaires. The medical personnel working on night duties in busy centers are usually missing that necessary sleep. In a big hospital when there shortage of staff it is still worse as they may be doing continuous duties for 24 to 48 hours (weekend).

Some time back people were concerned about the decisions one would make in absence of sleep for saving the lives of critically ill patients. One can also see the mood changes in people deprived of adequate sleep which can affect the interpersonal relationships. The results of this recent study showed that 74.8 percent of participants were poor sleepers, and their mean self-reported sleep duration was only six hours and 20 minutes. Fifty-two percent of study subjects were anxious, and 43 percent were depressed. After controlling for age, sex, hypertension, diabetes, and obstructive sleep apnea, sleep quality and daytime sleepiness were significantly associated with mood disturbance and quality of life impairment.

"There was a clear association between the sleep problems such as short sleep duration and the psychological disorders and with quality of life," said Dr. G. Neil Thomas, lead supervisor, study methodology lead and reader in epidemiology at the Department of Public Health, Epidemiology and Biostatistics at the University of Birmingham in the United Kingdom. "These associations remained significant even after adjusting for a range of potential confounders." According to the authors, the potential role of sleep in the health and well-being of individuals with severe obesity is underappreciated. Although the cross-sectional design of the study did not allow for an examination of causality, the results suggest that the early detection of disturbed sleep could prevent the potential development and perpetuation of psychological problems among people with extreme obesity. "Despite the very high levels of problems in these patients, those involved with their care usually don't ask about sleep problems and often pay little heed to the psychological issues underlying the obesity," said Thomas. "The focus is often on treating the obesity and its consequences, such as diet and exercise interventions, rather than addressing its underlying cause, which may be psychological in nature, such as an unhappy marriage or job stress."

According to the Centers for Disease Control and Prevention, 35.7 percent of U.S. adults are obese with a BMI of 30 or higher. The CDC estimates that the annual medical cost of obesity in the U.S. was $147 billion in 2008 dollars. Obesity is a huge burden on the society in developed countries; it is soon to be seen in the other countries too. We are already seeing the advertisements on the road side by the people providing the bariatric surgery for the obese people.

In mammals and birds, sleep is divided into two broad types: rapid eye movement (REM sleep) and non-rapid eye movement (NREM or non-REM sleep). Each type has a distinct set of associated physiological and neurological features. The American Academy of Sleep Medicine (AASM) further divides NREM into three stages: N1, N2, and N3, the last of which is also called delta sleep or slow-wave sleep.

Academic Paper publications:

1. Masson's Hemangioma of Proximal Radial Artery - Tumour like vascular lesions are rare. Here we report a rare case of tumor like vascular lesion from the radial artery. A pulsatile swelling in the forearm is usually diagnosed as a case of Aneurysm, AV fistul... Ramakrishna Pinjala in Indian Journal of Surgery (2012)

2. Thrombophilia – How Far and How Much to Investigate?- Thrombohemorrhagic balance is maintained by complicated interactions between the coagulation and fibrinolytic system, platelets, and the vessel wall. Dr. Virchow provided approach for investigating and managin...

R. K. Pinjala, L. R. C. Reddy, R. P. Nihar, G. V. A. Praveen… in Indian Journal of Surgery (2012)      

3. Leiomyosarcoma of the Inferior Vena Cava:Segment II- R. Pinjala  Received 20 November 2012; accepted 24 April 2013. published online 10 June 2013. PII: S1533-3167(13)00019-8 doi :10.1016/j.ejvsextra. 2013.04.002 © 2013 European Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.

4. Venous thromboembolism risk & prophylaxis in the acute hospital ... Ramakrishna Pinjala on behalf of all ENDORSE-India investigators*. Department of Vascular Surgery, Nizam's Institute of Medical Sciences, Hyderabad, India ...www.icmr.nic.in/ijmr/2012/july/0709.pdf - Cached - Similar

5. Retrospective evidence for clinical validity of expanded genetic model in warfarin dose optimization in a South Indian population Addepalli Pavani, Shaik Mohammad Naushad, Ramesh C Mishra, Amaresh Rao Malempati, Ramakrishna Pinjala, Takallapally Ramesh Kumar, Vijay Kumar Kutala  Pharmacogenomics, June 2012, Vol. 13, No. 8, Pages 869-878. 6. Optimization of warfarin dose by population-specific pharmacogenomic algorithm. Pavani A, Naushad SM, Rupasree Y, Kumar TR, Malempati AR, Pinjala RK, Mishra RC, Kutala VK. Source Department of Clinical Pharmacology and Therapeutics, Nizam's Institute of Medical Sciences, Hyderabad, India. Pharmacogenomics J. 2012 Aug;12(4):306-11. doi: 10.1038/tpj.2011.4. Epub 2011 Mar 1. Important functions During this year 2012-13: Elected President of the Vascular Society of India Received –  Fellowship from the Vascular society of India Promoted as Senior professor – in Nizam’s Institute of Medical Sciences Academic Associate Dean of the NIMS – Appointed Examiner for the National DNB-vascular surgery examination Examiner for MCh-Vascular surgery examination Theory Paper setting for the DNB and MCh vascular surgery examinations MCQs – for the entrance examinations for the vascular surgery MCh and DNB courses MCI – inspector  for examining the facilities at the centres to start the MCh vascular surgery. Attended the National and international conferences in India. Organizing chairman for the Annual meetings of Day care surgery, Diabetic foot society of India – Annual conferences in Hyderabad. Delivered Lectures on Deep vein thrombosis, Triple Combination therapy in Hypertension, Diabetic dysvascular foot, High dose statin therapy in the prevention of cardiovascular mortality, ischemia reperfusion syndrome, Diabetic foot infections, Newer anticoagulants.

Excess dietary sodium is a major public health problem worldwide

High Salt intake is common in some parts of the world. Excessive carbohydrate intake can lead to Diabetes and excessive salt intake can lead to the hypertension and the associated complications. Many drugs and formulations contain sodium and it was observed that that can be harmful too.

Exposure to sodium-containing formulations of effervescent, dispersible, and soluble medicines was associated with significantly increased odds of adverse cardiovascular events compared with standard formulations of those same drugs. Sodium-containing formulations should be prescribed with caution only if the perceived benefits outweigh these risks.

Excess dietary sodium is a major public health problem worldwide. In response to a 2010 report by the Institute of Medicine, the National Salt Reduction Initiative (NSRI) was established with a goal to reduce dietary sodium consumption in the United States by 20% in five years. Reducing sodium intake in the US to the recommended 2.3 g/day (100 mmol/L or one teaspoonful) could prevent 11 million cases of hypertension, save $18bn (£11bn, €13bn) healthcare dollars, and gain 312 000 quality adjusted life years (QALYs) valued at $32bn annually. In the United Kingdom, the Food Standards Agency also launched a campaign in 20023 to reduce salt intake in the estimated 26 million people in the UK who have high dietary sodium intake. It has been estimated that a 3 g/day reduction in salt (1.2 g/day reduction in sodium) could prevent 30 000 cardiovascular events and save the National Health Service (NHS) at least £40m/year (€48m, $64m).
The dispersible and effervescent formulations of paracetamol 500 mg, however, can contain 18.6 mmol and 16.9 mmol of sodium in each tablet, respectively, and therefore the maximum daily dose of eight tablets/day results in the ingestion of 148.8 mmol and 135.2 mmol of sodium, respectively. This exceeds the recommended total daily allowance of sodium for one drug alone. Added to a typical Western diet, these drugs could result in high sodium intake. Curiously, unlike foods, pharmaceutical manufacturers are not placed under any restrictions or obligations with regards to sodium content or labeling of these sodium-containing formulations.
Beware of Tablets with High sodium content especially in patients where you are restricting salt intake !!!

Varicose GSV and catheter directed foam sclerotherapy

In India, surgical therapies or endovenous ablative therapies for varicose veins are going to be more expensive than the sclerotherapy under local anesthesia. It is possible to treat more people if the sclerotherapy results are improved further with less primary or secondary failures. Sclerotherapy for the axial veins (GSV) is considered to be inadequate as they have a larger lumen and it is difficult to decide the concentration of the sclerosant solution prior to injection. Catheter directed foam sclerotherapy seems to be good in these patients to maintain the appropriate contact between the foam and venous endothelium. Some times we feel that the vein lumen reduction can help us to achieve better results. I noted a study in which vein (GSV) diameter was reduced by perivenous tumescent local anesthesia before the infection of foam sclerosant in the through a catheter. 8ml of 2% foam was used for occluding the GSV. Patients were followed 1, 6, 12 months period. No benefit could be found using additional TA to reduce the vein diameter before the treatment.

Eur J Vasc Endovasc Surg. 2013 Oct 30. pii: S1078-5884(13)00649-7. doi: 10.1016/j.ejvs.2013.10.017. [Epub ahead of print]

Catheter-directed Foam Sclerotherapy of Great Saphenous Veins in Combination with Pre-treatment Reduction of the Diameter Employing the Principals of Perivenous Tumescent Local Anesthesia.

Devereux N, Recke AL, Westermann L, Recke A, Kahle B.

Source

Department of Dermatology, University of Schleswig-Holstein, Campus Luebeck, Germany.

Abstract

OBJECTIVES:

The aim of this study was to evaluate occlusion rates of great saphenous veins (GSV) with a diameter between 5-10 mm that received a pre-treatment size reduction via perivenous tumescent application (TA) followed by catheter-directed foam sclerotherapy (CDFS).

METHODS:

A prospective blinded randomized clinical trial comparing the occlusion rates of GSV at 1-, 6-, and 12-month follow-up. Fifty patients were included and randomized into two groups. CDFS was performed accessing the GSV at knee level and applying 8 mL of 2% polidocanol-foam (EasyFoam) while the catheter was withdrawn. Strictly perivenous TA was performed in group 1 before applying the sclerosant agent. Occlusion rates and clinical scores were assessed by blinded examiners.

RESULTS:

After 12 months in group 1 full occlusion was achieved in 73.9%, partial occlusion in 8.7%, and 17.4% were classified as treatment failure. In group 2, 75% of the targeted GSV were fully occluded, 20% were partially occluded, and 5% were diagnosed as treatment failure. Both groups showed a significant reduction of the vein diameter. Patient's tolerance and satisfaction with the treatment was high in both groups.

CONCLUSION:

No benefit could be found using additional TA to reduce the vein diameter before the treatment.

Bacteria killing virus – this can be helpful to fight some of the superbugs!

http://www.medicalnewstoday.com/articles/267573.php

Bacteria killing virus – this can be helpful to fight some of the superbugs!

We are constantly looking for the ways and means to fight the superbugs. Now there seems to be a potential new victory in the war against antibiotic-resistant "superbugs" lies in the discovery of specific viruses that eat bacteria - called bacteriophages. Researchers in the UK have isolated certain phages, which have been shown to target the infectious hospital bug Clostridium difficile. C. diff, as the superbug is known, is responsible for 250,000 infections in the US each year and results in 14,000 deaths, the researchers say. Causing excess medical costs of $1 billion each year, finding a solution to this problem is one of both medical and economic importance. Dr. Martha Clokie, from the University of Leicester's Department of Infection, Immunity and Infection, has been studying how naturally occurring bacteriophages - which means "eaters of bacteria" - could serve as an alternative to antibiotics. Though Dr. Clokie gives credit to the important role antibiotics have played in saving lives, she says new treatments are needed: "Less than a century following their discovery, the future impact of antibiotics is dwindling at a pace that no one anticipated, with more and more bacteria out-smarting and 'out-evolving' these miracle drugs. This has re-energized the search for new treatments."Unlike antibiotics, Dr. Clokie says phages "are specific in what they kill," noting that they usually infect only one specific species or strain of bacteria.By injecting their DNA into the bacterium, she notes that phages then replicate and cause the bacterial cell to "burst open." Once the dead bacterium is opened, the phages can then repeat the process on other host cells. Maintaining gut bacteria balance: What is so remarkable about the research team's finding is that they were able to isolate and characterize 26 distinct phages - the biggest set of C. diff phages that are currently known.These phages infect strains of C. diff that are "clinically relevant," and they have been proven to be effective against 90% of the strains currently seen in the UK. Dr. Clokie says:"C. diff bacteria primarily affect our digestive system. Whilst relatively innocuous in individuals with a healthy gut flora, they pose a serious threat when our natural digestive environment is disrupted or depleted, such as after chronic antibiotic use." She notes that the ability of phages to only infect and kill a specific type of bacteria is "particularly important" when dealing with C. diff infections, because keeping the balance of gut bacteria "greatly reduces the chance of relapse."Clinical trials soon, Dr. Clokie's phages have been licensed by a US biopharmaceutical company called AmpliPhi Biosciences Corporation, and together, they aim to have a mixture of C. diff phages ready for phase I and II clinical trials in the near future. The company, which has developed phage-based therapeutics, is funding further development and testing of these phages. Dr. Clokie and colleagues from the University of Leicester will work with scientists from the University of Glasgow in Scotland to analyze the efficacy of the phages in treating infections. The work has been predominantly funded by the Medical Research Council (MRC), and Dr. Des Walsh, head of Infections and Immunity at the MRC, says that Dr. Clokie "has established an impressive collection of phage viruses and has developed strong partnerships to translate her research into potential new treatments for Clostridium difficile infection."

"Ultimately," says Dr. Clokie, "I hope this will pave the way for a greater use of bacteriophages in the wider, global fight against antibiotic-resistant bacteria." When asked how long until patients might begin to see benefits from her research, Dr. Clokie told  "If all goes well," she added, "we could see a product in 5-10 years."

Atherosclerotic intracranial arterial stenosis: risk factors, diagnosis, and treatment

Intracranial stenosis before and after angioplasty

Vascular surgeons are treating the extracranial carotid artery stenosis, neurosurgeons and interventionists are treating the intracranial stenotic lesions to reduce the cerebral ischemia which can lead to stroke. In india, intra cranial lesions are more common than the extra cranial artery lesions. So, the number of endarterectomies performed are less in India and few centers are providing these services. The recent developments in proving best medical therapies certainly reduced the risk of stoke in hypertensive patients, Diabetic people.
Intracranial atherosclerosis is one of the most common causes of stroke worldwide and is associated with a high risk of recurrent stroke. New therapeutic approaches to treat this high-risk disease include dual antiplatelet treatment, intensive management of risk factors, and endovascular therapy. Early data from randomised trials indicate that aggressive medical therapy is better than stenting for prevention of recurrent stroke in high-risk patients with atherosclerotic stenosis of a major intracranial artery. Nevertheless, there are subgroups of patients who remain at high risk of stroke despite aggressive medical therapy. Further research is needed to identify these high-risk subgroups and to develop more effective treatments. Non-invasive vascular imaging methods that could be used to identify high-risk patients include fractional flow on magnetic resonance angiography (MRA), quantitative MRA, and high-resolution MRI of the atherosclerotic plaque. Alternative therapies to consider for future clinical trials include angioplasty alone, indirect surgical bypass procedures, ischaemic preconditioning, and new anticoagulants (direct thrombin or Xa inhibitors).
http://www.thelancet.com/journals/laneur/article/PIIS1474-4422(13)70195-9/abstract
 

Pulmonary embolism after endovenous thermal ablation of the saphenous vein.

Semin Vasc Surg. 2013 Mar;26(1):14-22. 

Pulmonary embolism after endovenous thermal ablation of the saphenous vein.

Rosales-Velderrain A, Gloviczki P, Said SM, Hernandez MT, Canton LG, Kalra M.

Division of Vascular and Endovascular Surgery, Mayo Clinic, 200 1(st) Street, SW, Rochester, MN 55905.

Pulmonary embolism (PE) after venous procedures is fortunately rare. Our goal was to analyze the data of patients who developed PE after endovenous thermal ablation and phlebectomy for varicose veins and to review the literature on this subject. We report on three patients who developed PE after radiofrequency ablation of the great saphenous vein and mini phlebectomy for symptomatic primary lower-extremity varicose veins. Early postoperative duplex scans confirmed successful closure of the great saphenous vein in all. One patient presented with chest pain and dyspnea, one with blood-tinged sputum, and the third with symptoms of saphenous thrombophlebitis. Two patients had PE from the saphenous vein thrombus and the third had gastrocnemius vein thrombosis extending into the popliteal vein. One had previous deep vein thrombosis. Computed tomography of the chest confirmed PE in all. Two patients were treated with anticoagulation, but the third patient with small PE declined such treatment. One patient underwent temporary inferior vena cava filter placement because of recurrent PE. In conclusion, PE is very rare but it can occur after endovenous thermal ablation of lower-extremity varicose veins. Selective thrombosis prophylaxis and preoperative counseling of the patients about signs and symptoms of deep vein thrombosis and PE are warranted for early recognition and rapid treatment. 

Is it difficult to choose the cost effective mode of treatment for aortic aneurysms after the introduction of the endovascular therapies for the aneurysms?

The Cost of open and endovascular repair of the aortic aneurysms is comparable?

It is generally felt that the Endovascular vascular repairs of the aortic aneurysms is more expensive than the open repair in India. The duration of the hospital stay and other services are considered to be less expensive in India than in the other countries. There are some studies published in the EJVES and JVS saying that the Endovascular repair may be better than open in terms cost saving!  It may be surprising to some of us in India. 

The cost of the Endoprosthesis is more than Rs. 3,50,00 to 10,00,000 depending on the number of devices and hard ware used during the procedures. The multinational companies are trying to provide the necessary supports by extending concessions in some cases. 

In many Governments hospitals the surgeons don’t have privileges to enter the cath labs and at the same these procedures are not supported financially in government hospitals. So, majority of the cath lab procedures are done in private sector in our country. There are few govt. general hospitals performing these procedures maintaining a balance between the cost and the outcomes. We strongly feel that the Govt. should propose to establish the cath labs accessible to all the doctors treating the patients through endovascular methods. There is also need for the hybrid operation theatres to facilitate the minimally invasive operations to reduce the morbidity and mortality.  

VAC study group from USA says that Endovascular repair is a cost-effective alternative to open repair in the US VA healthcare system for at least the first two years Eur J Vasc Endovasc Surg. 2012 Dec;44(6):543-8. Stroupe KT et al say that In a multicenter randomized trial, endovascular AAA repair resulted in lower cost and better survival than open repair after the initial hospitalization for repair; but after 2 years, survival, quality of life, and costs were not significantly different between the two treatments. J Vasc Surg. 2012 Oct;56(4):901-9. Routine use of endovascular repair in patients also eligible for open repair does not result in a QALY gain at 1 year postoperatively, provides only a marginal overall survival benefit, and is associated with a substantial, if not prohibitive, increase in costs. Prinssen M et al J Vasc Surg. 2007 Nov;46(5):883-890.