Cochrane Database Syst Rev. 2016 Mar 11;3:CD011033. doi: 10.1002/14651858.CD011033.pub3.
Sunday, October 02, 2016
Pharmacological treatment for Buerger's disease.
Sunday, May 08, 2016
Hepatitis C infections in the hospitalized patients requiring the interventions – Concern, attitude and care of the health care workers providing the services, How can we address them?
It is estimated that nearly 100,000
people die annually in India from HCV infection and co-morbidities. Around 25%
of 18 million HCV patients in India are infected by Hepatitis-C genotype 1
virus. This has become a concern in many hospitals, health care workers and more so in dialysis centers,
trauma care centers and intensive care units, who frequently deal with blood
and blood products during the course of the treatments.
 |
| Source of Hepatitis C infection |
This is a complex issue
observed in the state run hospitals with limited resources and at the same time
the risks of operating on such patients with chronic hepatitis C infection can’t
be ruled and one needs to organize themselves for these special situations with
special provisions and protection measures.
“Who would like to get exposed to
the risk of acquiring hepatitis C infection while operating on patients with chronic
hepatitis C infections in our elective operation theaters?” Said an anesthetist, defending his stand of
cancelling an operation in a government run tertiary care hospital. The patient
and the surgeon were left with no other option. The patient was asked to choose
another hospital which can take up such operations. The fear of Hepatitis C
infection, is significant due to the lack of availability of appropriate and
affordable treatment within reach of the hospitals. Similar situation was there
in the past for the patients infected with HIV.
This is a complex issue
observed in the state run hospitals with limited resources and at the same time
the risks of operating on such patients with chronic hepatitis C infection can’t
be ruled and one needs to organize themselves for these special situations with
special provisions and protection measures.
In the
recent past the hope of curing hepatitis C infection is on the cards in many countries with
introduction of the new drug treatments. Harvoni, the fixed-dose combination of
ledipasvir-sofosbuvir of 90mg and 400mg, respectively, is an improved version
of Gilead’s Hepatitis-C drug Sovaldi or sofosbuvir, seems to be playing a major
role in the coming years. Biocon will be selling the generic Harvoni under
brand name CIMIVIR-L. The potential market size for these drugs could be Rs.500
crore or even Rs. 1,000 crores in the foreseeable future. This type of
treatment would cost Rs.63 lakhs in USA today for one individual. But the
Indian company is determined to supply this medicine at an affordable price
(< Rs. 70,000). In the absence of vaccination for the Hepatitis C infection,
there should be provision for the supply of these medicines with the help of
insurance to the health care workers. Hospital management should take a lead
and assure the health care workers that there is support for them in any
exposed gets hepatitis C infection during their service.
Pinjala R K
Friday, May 06, 2016
Should we worry about the renal function loss in patients undergoing endovascular therapies?
This paper published in Jl of Vascular Surgery, needs attention from all those who would like to do Endovascular procedures for all the vascular lesions in the patients!
http://www.jvascsurg.org/article/S0741-5214(16)00822-3/abstract
Loss of kidney function in patients with critical limb
ischemia treated endovascularly or surgically
Tim A. Sigterman, MD et al
Wednesday, May 04, 2016
Supervised exercise program for the claudicants
Claudication is the common symptom in peripheral arterial disease. It can be progressive or stable. In those patients with stable claudication medical managements and supervised exercise programs may be helpful. But in our hospitals there are very few such programs encouraging the patients to follow these practices. Doctors tell their patients about the benefits of regular walking, but rarely they are able supervise such measures. Even in the physiotherapy departments there is no such provision in many hospitals. Very few trials are conducted in India in this direction. The Angioplasty and Stenting of superficial femoral artery, popliteal artery is advocated in some places to save the limbs. Open surgery is performed to bypass the occluded FP segments in some centers.
A systematic review of the uptake and adherence rates to supervised exercise programmes in patients with intermittent claudication was conducted by A.E. Harwood et al from Hull Royal infirmary and published in Annals of vascular surgery.
They said that reporting of SEP trials was poor with regard to the numbers of subjects screened and reasons for exclusions. Only approximately 1 in 3 screened IC patients was suitable for and willing to undertake SEP. Levels of adherence to SEPs and definitions of satisfactory adherence were also lacking in the majority of the current literature. Current clinical guidelines based upon this evidence base may not be applicable to the majority of IC patients and changes to SEPs may be needed to encourage/retain participants.
This type of papers should encourage us to do more detailed study on supervised exercise programs in Indian hospitals. This may help our patients and reduce burden of angioplasty or bypass surgery in Peripheral arterial disease patients.
Reference
http://www.annalsofvascularsurgery.com/article/S0890-5096(16)30174-1/abstract
 |
| Common site of Claudication in Femoral-Popliteal disease |
A systematic review of the uptake and adherence rates to supervised exercise programmes in patients with intermittent claudication was conducted by A.E. Harwood et al from Hull Royal infirmary and published in Annals of vascular surgery.
They said that reporting of SEP trials was poor with regard to the numbers of subjects screened and reasons for exclusions. Only approximately 1 in 3 screened IC patients was suitable for and willing to undertake SEP. Levels of adherence to SEPs and definitions of satisfactory adherence were also lacking in the majority of the current literature. Current clinical guidelines based upon this evidence base may not be applicable to the majority of IC patients and changes to SEPs may be needed to encourage/retain participants.
This type of papers should encourage us to do more detailed study on supervised exercise programs in Indian hospitals. This may help our patients and reduce burden of angioplasty or bypass surgery in Peripheral arterial disease patients.
Reference
http://www.annalsofvascularsurgery.com/article/S0890-5096(16)30174-1/abstract
Wednesday, April 27, 2016
Osteosarcoma
It originates more frequently in the metaphyseal
region of tubular long bones, with 42% occurring in the femur, 19% in
the tibia, and 10% in the humerus. About 8% of all cases occur in the
skull and jaw, and another 8% in the pelvis.
 |
| CT Angiogram in Sarcoma patient |
Tuesday, April 19, 2016
The impact of chronic renal insufficiency on vascular surgery patient outcomes
Renal insufficiency is associated with an increased incidence of poor
outcomes, including cardiovascular events and death, in the general
population. Renal dysfunction appears to have a particularly negative
impact in patients undergoing vascular surgery and endovascular therapy.
Although the exact mechanism is unknown, increased levels of
inflammatory and biochemical modulators associated with adverse
cardiovascular outcomes, as well as endothelial dysfunction, appear to
play a role in the association between renal insufficiency and adverse
outcomes. Outcomes after the surgical and endovascular treatment of
abdominal aortic aneurysms, carotid disease, and peripheral arterial
disease are all negatively affected by renal insufficiency. Patients
with renal dysfunction may warrant intervention for the treatment of
critical limb ischemia and symptomatic carotid stenosis, given the
comparatively worse outcomes associated with medical management. Open
repair of aortic aneurysms and carotid intervention for asymptomatic
disease in patients with severe renal dysfunction should be performed
with significant caution, as the risks of repair may outweigh the
benefits in this population. Further study is needed to better delineate
the risks of medical management for these conditions in patients with
coexisting severe renal dysfunction.
Lastly, current guidelines for the management of vascular diseases, including objective performance goals for critical limb ischemia, are likely not applicable in patients with severe renal insufficiency.
http://www.semvascsurg.com/article/S0895-7967%2815%2900007-1/fulltext
Lastly, current guidelines for the management of vascular diseases, including objective performance goals for critical limb ischemia, are likely not applicable in patients with severe renal insufficiency.
| CKD stage | Description | GFR (mL/min/1.73 m2) | |||
|---|---|---|---|---|---|
| I | Normal or mildly decreased GFR | ≥90 | |||
| II | Normal or mildly decreased GFR | 60−89 | |||
| III | Moderately decreased GFR | 30−59 | |||
| IV | Severely decreased GFR | 15−29 | |||
| V | Severely decreased GFR | <15 td=""> |
----------------------------------------------
Abbreviations: CKD, chronic kidney disease; GFR, glomerular filtration rate.
Saturday, March 26, 2016
Abdominal Aortic Aneurysm Repair by Principle of Exclusion and Aortic Bypass: Single Centre Experience
Abdominal
Aortic Aneurysm Repair by Principle of Exclusion and Aortic Bypass: Single
Centre Experience
Sandeep M* and Ramakrishna P
Department
of Vascular Surgery, Nizam’s Institute of Medical Sciences, Punjagutta,
Hyderabad, India
Abstract
Purpose: Non-respective treatment of the abdominal aortic aneurysm by proximal and distal ligation of the aneurysm sac (exclusion) combined with aortic bypass known as Debakey Procedure has been previously reported. A 2 year experience with 10 patients undergoing this procedure was reviewed.
Methods: From 2010 to 2012, 10 patients of abdominal aortic aneurysm underwent repair with the retroperitoneal exclusion technique. Preoperative morbidity and mortality, blood loss and transfusion requirements, naturally of the excluded aneurysm sac were all assessed.
Results: The operative mortality rate for patients undergoing exclusion and bypass was 10% (one out of 10 patients). The incidence of nonfatal preoperative complications was 5%. Blood loss requiring transfusion in the preoperative period measured 600 mL to 900 mL on an average. On follow-up, only one out of 10 patients was found to have patent aneurysm sacs as detected by duplex examination which required surgical Intervention. No cases of graft infection or Aorto-enteric fistula have been noted.
Conclusion: Retroperitoneal exclusion and bypass is a viable alternative to traditional open endoaneurysmorraphy in surgery for abdominal aortic aneurysm. Most excluded aneurysm sacs have thrombosis without any long or short-term complications; however, in a small number of patients delayed rupture of patent aneurysm occurs, thus emphasizing the need for diligent follow-up and appropriate intervention.
Monday, February 08, 2016
Incremental Health Care Burden of Bleeding Among Patients with Venous Thromboembolism in the United States.
J Manag Care Spec Pharm. 2015 Oct;21(10):965-72. Amin A1, Bruno A, Trocio J, Lin J, Lingohr-Smith M.1University of California, Irvine, UCIMC, 101 The City Drive South, Bldg. 58, Rm 110, ZC-4076H, Mail Code: 4076, Irvine, CA 92868. anamin@uci.edu.
The health care and economic burden of venous thromboembolism (VTE) has been evaluated in regard to acute VTE, VTE recurrence, and some VTE complications, such as postthrombotic syndrome, but the cost burden attributed to bleedings is not well understood.
OBJECTIVE: To evaluate health care resource utilization and costs associated with major bleeding (MB) and clinically relevant nonmajor bleeding (CRNMB) among a large U.S. commercially and Medicare-insured population with VTE.
METHODS: Patients (≥ 18 years of age, continuously insured) with a diagnosis of VTE between January 1, 2008, and December 31, 2011, were identified from the Truven Health Analytics Commercial and Medicare MarketScan databases. Patients who did not have any bleedings during the study period were grouped into a no-bleedings cohort and a random date after VTE diagnosis was selected as the index date. VTE patients who experienced MB within 1 year of the initial VTE diagnosis were grouped into a MB cohort, and patients without MB but with CRNMB were grouped into a CRNMB cohort. Baseline patient demographics and clinical characteristics were determined for study cohorts. All-cause and bleeding-related health care resource utilization and costs (inflation adjusted to 2013 level) during a 12-month follow-up period after the index date of the initial bleeding event were measured and compared. Descriptive statistics were used to evaluate differences in demographics, clinical characteristics, and unadjusted health care resource utilization and costs of patient cohorts. Multivariable generalized linear models were used to evaluate incremental health care costs of bleedings after adjusting for key patient characteristics.
RESULTS: Among the 112,885 patients identified with a VTE diagnosis, 14% (n = 15,897) had MB and 14% (n = 15,842) had CRNMB; 72% (n = 81,146) had neither of these events occur during the study period. The mean ages of the MB and CRNMB cohorts were both 63.6 years, while the mean age of the no-bleedings cohort was significantly lower at 59.6 years (P less than 0.001). Mean Charlson Comorbidity Index scores were highest for the MB cohort (3.2), followed by those of the CRNMB cohort (2.5) and the no-bleedings cohort (1.6). The MB cohort had the greatest proportion of patients with an initial VTE event of pulmonary embolism only (23.5%), followed by that of the CRNMB cohort (20.2%), and the no-bleedings cohort (16.7%). For MB and CRNMB cohorts, the total mean bleeding-related inpatient and outpatient costs during the follow-up period were $49,779 (SE = $820) and $2,187 ($89), respectively. After adjustment for key patient characteristics, the estimated mean differences in total bleeding-related medical costs were $45,367 ($1,853) for patients with MB and $2,140 ($88) for patients with CRNMB versus patients with no bleedings.
CONCLUSIONS: Among patients with VTE diagnosis in the United States, approximately 28% have a bleeding event within 1 year of VTE diagnosis, and about half of these patients experience MB. Patients with MB have greatly elevated health care costs.
Friday, January 29, 2016
Is there any impact of regular physical activity on weekly warfarin dose requirement? Yes there is !!
http://link.springer.com/article/10.1007/s11239-015-1248-9
Warfarin is an oral anticoagulant agent with a narrow therapeutic index. There is a marked inter- and intra-patient variability in warfarin dose requirement. All factors influencing warfarin response are not known and this study aims to evaluate if regular physical activity (RPA) is a determining factor. RPA level was collected with the Stanford Brief Activity Survey in 1064 incident warfarin users, as part of the Quebec Warfarin Cohort (QWC), and with the Global Physical Activity Questionnaire in 618 patients from the Montreal Heart Institute (MHI) Biobank. Linear regression was performed to model relationship of warfarin dose after 3 months of therapy in the QWC with RPA, while controlling for height, weight, age, CYP2C9 (*2 and *3 alleles) and VKORC1 (*2 allele) genotype. Warfarin dose of prevalent users was modeled in the MHI Biobank for replication. A higher level of physical activity was associated with higher doses of warfarin in both cohorts. In the QWC, physical activity could explain 5.4 % (P < 0.001) and 0.9 % (P = 3.23 × 10−5) of variance in dose, in univariate and multivariable models, respectively. Similarly, RPA was found to be associated with 1.7 % (P = 0.0012) and 0.5 % (P = 0.0391) of inter-individual variability in warfarin dose requirement before and after adjustment for other covariables, respectively.
RPA is associated with higher warfarin dose requirement. The relevance of clinical recommendations on RPA to maintain a steady response to warfarin should be assessed in further studies.
Warfarin is an oral anticoagulant agent with a narrow therapeutic index. There is a marked inter- and intra-patient variability in warfarin dose requirement. All factors influencing warfarin response are not known and this study aims to evaluate if regular physical activity (RPA) is a determining factor. RPA level was collected with the Stanford Brief Activity Survey in 1064 incident warfarin users, as part of the Quebec Warfarin Cohort (QWC), and with the Global Physical Activity Questionnaire in 618 patients from the Montreal Heart Institute (MHI) Biobank. Linear regression was performed to model relationship of warfarin dose after 3 months of therapy in the QWC with RPA, while controlling for height, weight, age, CYP2C9 (*2 and *3 alleles) and VKORC1 (*2 allele) genotype. Warfarin dose of prevalent users was modeled in the MHI Biobank for replication. A higher level of physical activity was associated with higher doses of warfarin in both cohorts. In the QWC, physical activity could explain 5.4 % (P < 0.001) and 0.9 % (P = 3.23 × 10−5) of variance in dose, in univariate and multivariable models, respectively. Similarly, RPA was found to be associated with 1.7 % (P = 0.0012) and 0.5 % (P = 0.0391) of inter-individual variability in warfarin dose requirement before and after adjustment for other covariables, respectively.
RPA is associated with higher warfarin dose requirement. The relevance of clinical recommendations on RPA to maintain a steady response to warfarin should be assessed in further studies.
Conventional surgery, Endovenous laser ablation and Ultrasound-guided foam sclerotherapy in patients with great saphenous varicose veins, which is better?
Br J Surg. 2015 Sep;102(10):1184-94. doi: 10.1002/bjs.9867. Epub 2015 Jul 1.
Five-year results of a randomized clinical trial of conventional surgery, endovenous laser ablation and ultrasound-guided foam sclerotherapy in patients with great saphenous varicose veins.
van der Velden SK1, Biemans AA2, De Maeseneer MG1,3, Kockaert MA1, Cuypers PW4, Hollestein LM1, Neumann HA1, Nijsten T1, van den Bos RR1.
BACKGROUND:A variety of techniques exist for the treatment of patients with great saphenous vein (GSV) varicosities. Few data exist on the long-term outcomes of these interventions.
METHODS:Patients undergoing conventional surgery, endovenous laser ablation (EVLA) and ultrasound-guided foam sclerotherapy (UGFS) for GSV varicose veins were followed up for 5 years. Primary outcome was obliteration or absence of the treated GSV segment; secondary outcomes were absence of GSV reflux, and change in Chronic Venous Insufficiency quality-of-life Questionnaire (CIVIQ) and EuroQol - 5D (EQ-5D™) scores.
RESULTS: A total of 224 legs were included (69 conventional surgery, 78 EVLA, 77 UGFS), 193 (86.2 per cent) of which were evaluated at final follow-up. At 5 years, Kaplan-Meier estimates of obliteration or absence of the GSV were 85 (95 per cent c.i. 75 to 92), 77 (66 to 86) and 23 (14 to 33) per cent in the conventional surgery, EVLA and UGFS groups respectively. Absence of above-knee GSV reflux was found in 85 (73 to 92), 82 (72 to 90) and 41 (30 to 53) per cent respectively. CIVIQ scores deteriorated over time in patients in the UGFS group (0.98 increase per year, 95 per cent c.i. 0.16 to 1.79), and were significantly worse than those in the EVLA group (-0.44 decrease per year, 95 per cent c.i. -1.22 to 0.35) (P = 0.013). CIVIQ scores for the conventional surgery group did not differ from those in the EVLA and UGFS groups (0.44 increase per year, 95 per cent c.i. -0.41 to 1.29). EQ-5D™ scores improved equally in all groups.
CONCLUSION: EVLA and conventional surgery were more effective than UGFS in obliterating the GSV 5 years after intervention. UGFS was associated with substantial rates of GSV reflux and inferior CIVIQ scores compared with EVLA and conventional surgery.
REGISTRATION NUMBER: NCT00529672 (http://www.clinicaltrials.gov).
Wednesday, January 27, 2016
Combined assessment of thrombotic and haemorrhagic risk in acute medical patients
It is important to assess thrombosis risk and hemorrhage risk in our patients !
Online Supplementary Material
M. La Regina (1), F. Orlandini (1), F. Marchini (1), A. Marinaro (1), R. Bonacci (1), P. Bonanni (1), F. Corsini (1), A. M. Ceraudo (1), E. Pacetti (1), L. Scuotri (1), D. Costabile (2), F. Dentali
(1) Department of Internal Medicine, Ligurian East Hospital, La Spezia, Italy; (2) Elco S. r. l., Cairo Montenotte (Savona), Italy
venous thromboembolism, internal medicine, anticoagulants, prophylaxis, haemorrhage
Acute medical patients have a high risk of venous thromboembolic events (VTE). Unfortunately, the fear of bleeding complications limits the use of antithrombotic prophylaxis in this setting. To stratify the VTE and haemorrhagic risk, two clinical scores (PADUA, IMPROVE) have recently been developed. However, it is not clear how many patients have a concomitant high VTE and haemorrhagic risk and what is the use of prophylaxis in this situation. To clarify these issues we performed a prospective cohort study enrolling consecutive patients admitted to internal medicine. Patients admitted to internal medicine (January to December 2013) were included. VTE and haemorrhagic risk were evaluated in all the included patients. Use and type of anti-thrombotic prophylaxis was recorded. A total of 1761 patients (mean age 77.6 years) were enrolled; 76.8 % (95 % CI 74.7–78.7) were at high VTE risk and 11.9 % (95 % CI 10.4–13.5) were at high haemorrhagic risk. Anti-thrombotic prophylaxis was used in 80.5 % of patients at high VTE risk and in 6.5 % at low VTE risk (p< 0.001), and in 16.6 % at high haemorrhagic risk and in 72.5 % at low haemorrhagic risk (p< 0.001). Prophylaxis was used in 20.4 % at both high VTE and haemorrhagic risk and in 88.9 % at high VTE risk but low haemorrhagic risk. At multivariate-analysis, use of prophylaxis appeared highly influenced by the VTE risk (OR 68.2, 95 % CI 43.1 - 108.0). In conclusion, many patients admitted to internal medicine were at high risk of VTE. Since almost 90 % of them were at low haemorrhagic risk, pharmacological prophylaxis may be safely prescribed in most of these patients.
Friday, January 22, 2016
Intra-arterial Therapy in the Early Treatment of Acute Ischaemic Stroke
http://www.ejves.com/article/S1078-5884(15)00575-4/abstract
Intra-arterial Therapy in the Early Treatment of Acute Ischaemic Stroke
In 1995, intravenously administered recombinant tissue-type plasminogen activator (rtPA) was demonstrated to be effective as a treatment for acute ischaemic stroke provided it was commenced within 3 hours of stroke onset.1 In 2008, the ECASS-2 trial demonstrated that the time window for intravenous thrombolysis could be increased to 4.5 hours.2 More recently, intra-arterial thrombectomy (IAT), in addition to intravenous rtPA, has been shown to be highly beneficial when administered within 6 hours after acute stroke onset in six randomized clinical trials.
Intra-arterial Therapy in the Early Treatment of Acute Ischaemic Stroke
In 1995, intravenously administered recombinant tissue-type plasminogen activator (rtPA) was demonstrated to be effective as a treatment for acute ischaemic stroke provided it was commenced within 3 hours of stroke onset.1 In 2008, the ECASS-2 trial demonstrated that the time window for intravenous thrombolysis could be increased to 4.5 hours.2 More recently, intra-arterial thrombectomy (IAT), in addition to intravenous rtPA, has been shown to be highly beneficial when administered within 6 hours after acute stroke onset in six randomized clinical trials.
The introduction of IAT may also increase the need for
expedited carotid interventions such as endarterectomy or stenting. It may be
challenging for interventionists to stent a severe stenosis of the extracranial
carotid artery at the same time as they treat an occluded intracranial artery.
From a pragmatic point of view, this may seem a good approach, but it is
unknown if the patient will benefit from a simultaneous procedure, or if it
would be better to perform deferred carotid surgery after a few days. In the Mr
Clean study, additional carotid interventions were performed in one out of
eight patients (13%) who were treated with thrombolysis. It is well known that carotid
endarterectomy should be performed within a few days after onset of a TIA or
minor disabling stroke, but we know little about the safety of this procedure
in patients with a severe carotid artery stenosis who only very recently
suffered from a major stroke that was successfully treated with IAT. Expedited
carotid surgery within 24 hours of lysis completion has shown promising
results, but more data on
stenting versus surgery and especially the optimal timing are still required.
In summary, 2015 will be remembered as the year in which IAT
was established as a highly beneficial therapy for patients with acute
ischaemic stroke affecting the anterior circulation. Stroke teams should now
move to implement IAT in their treatment strategies and adapt their
organization accordingly. More knowledge about the best indications for IAT and
the need for additional carotid interventions will be forthcoming in the
future.
Detection of Peripheral Arterial Disease Within the Foot Using Vascular Optical Tomographic Imaging: A Clinical Pilot Study
Happy New year 2016
Detection of Peripheral Arterial Disease Within the Foot Using Vascular Optical Tomographic Imaging: A Clinical Pilot Study
Vascular optical tomographic imaging (VOTI) is a novel
imaging modality that is capable of detecting hemoglobin concentrations in
tissue. VOTI is non-invasive, non-ionizing and does not require contrast
injection. This technology was applied to the diagnosis of peripheral arterial
disease (PAD) within lower extremities of diabetic patients with calcified
arteries. This could be of substantial benefit as these patients suffer from
comorbidities such as arterial incompressibility, which complicates diagnosis
and monitoring.
The VOTI system with its sandal shaped measuring probe
provides cross sectional images of hemoglobin concentrations in the foot.
This figure shows coronal cross sectional images from a
healthy volunteer, a PAD patient, and a diabetic PAD patient. The five frames
shown outline the hemodynamics during the thigh cuff occlusion and release. The
healthy volunteer has a greater amount of blood pooling in the leg during the
occlusion as well as a faster reaction to the application and release of the
thigh cuff.
Conclusion
Thursday, March 12, 2015
Venographic comparison of subcutaneous low–molecular weight heparin with oral anticoagulant therapy in the long-term treatment of deep venous thrombosis Jose A. Gonzalez-Fajardo, MD Carlos Vaquero, MD et al (J Vasc Surg 1999;30:283-92.)
Purpose: The primary objective of this study was to evaluate with venography the rate of thrombus regression after a fixed dose of low–molecular weight heparin (LMWH) per day for 3 months compared with oral anticoagulant therapy for deep venous thrombosis (DVT). Secondary endpoints were the comparisons of the efficacy and safety of both treatments.
Methods: This study was designed as an open randomized clinical study in a university hospital setting. Of the 165 patients finally enrolled in the study, 85 were assigned LMWH therapy and 80 were assigned oral anticoagulant therapy. In the group randomized to oral anticoagulant therapy, the patients first underwent treatment in the hospital with standard unfractionated heparin and then coumarin for 3 months. Doses were adjusted with laboratory monitoring to maintain the international normalized ratio between 2.0 and 3.0. Patients in the LMWH group were administered subcutaneous injections of fixed doses of 40 mg enoxaparin (4000 anti-Xa units) every 12 hours for 7 days, and after discharge from the hospital, they were administered 40 mg enoxaparin once daily at fixed doses for 3 months without a laboratory control assay. A quantitative venographic score (Marder score) was used to assess the extent of the venous thrombosis, with 0 points indicating no DVT and 40 points indicating total occlusion of all deep veins. The rate of thrombus reduction was defined as the difference in quantitative venographic scores after termination of LMWH or coumarin therapy as compared with the scores obtained on the initial venographic results. The efficacywas defined as the ability to prevent symptomatic extension or recurrence of venous thromboembolism (documented with venograms or serial lung scans). The safety was defined as the occurrence of hemorrhages.
Results: After 3 months of treatment, the mean Marder score was significantly decreased in both groups in comparison with the baseline score, although the effect of therapy was significantly better after LMWH therapy (49.4% reduction) than after coumarin therapy (24.5% reduction; P < .001). LMWH therapy and male gender were independently associated with an enhanced resolution of the thrombus. A lower frequency of symptomatic recurrent venous thromboembolism was also shown in patients who underwent treatment with LMWH therapy (9.5%) than with oral anticoagulant therapy (23.7%; P< .05), although this difference was entirely a result of recurrence of DVT. Bleeding complications were significantly fewer in the LMWH group than in the coumarin group (1.1% vs 10%; P < .05). This difference was caused by minor hemorrhages. Coumarin therapy and cancer were independently associated with an enhanced risk of complications. Subcutaneous heparin therapy was well tolerated by all patients.
Conclusion: The patients who were allocated to undergo enoxaparin therapy had a significantly greater improvement in their quantitative venographic score, a significantly lower recurrence rate of symptomatic venous thromboembolism, and a significantly lower incidence of bleeding than patients who underwent treatment with coumarin. LMWH can be used on an outpatient basis as a safer and more effective alternative to classical oral anticoagulant therapy for the secondary prophylaxis of selected patients with DVT. (J Vasc Surg 1999;30:283-92.)
Do you think we should give LMWH for the DVT patients for better results? Would you prefer giving the warfarin to patients? What are the reasons to choose Warfarin?
Methods: This study was designed as an open randomized clinical study in a university hospital setting. Of the 165 patients finally enrolled in the study, 85 were assigned LMWH therapy and 80 were assigned oral anticoagulant therapy. In the group randomized to oral anticoagulant therapy, the patients first underwent treatment in the hospital with standard unfractionated heparin and then coumarin for 3 months. Doses were adjusted with laboratory monitoring to maintain the international normalized ratio between 2.0 and 3.0. Patients in the LMWH group were administered subcutaneous injections of fixed doses of 40 mg enoxaparin (4000 anti-Xa units) every 12 hours for 7 days, and after discharge from the hospital, they were administered 40 mg enoxaparin once daily at fixed doses for 3 months without a laboratory control assay. A quantitative venographic score (Marder score) was used to assess the extent of the venous thrombosis, with 0 points indicating no DVT and 40 points indicating total occlusion of all deep veins. The rate of thrombus reduction was defined as the difference in quantitative venographic scores after termination of LMWH or coumarin therapy as compared with the scores obtained on the initial venographic results. The efficacywas defined as the ability to prevent symptomatic extension or recurrence of venous thromboembolism (documented with venograms or serial lung scans). The safety was defined as the occurrence of hemorrhages.
Results: After 3 months of treatment, the mean Marder score was significantly decreased in both groups in comparison with the baseline score, although the effect of therapy was significantly better after LMWH therapy (49.4% reduction) than after coumarin therapy (24.5% reduction; P < .001). LMWH therapy and male gender were independently associated with an enhanced resolution of the thrombus. A lower frequency of symptomatic recurrent venous thromboembolism was also shown in patients who underwent treatment with LMWH therapy (9.5%) than with oral anticoagulant therapy (23.7%; P< .05), although this difference was entirely a result of recurrence of DVT. Bleeding complications were significantly fewer in the LMWH group than in the coumarin group (1.1% vs 10%; P < .05). This difference was caused by minor hemorrhages. Coumarin therapy and cancer were independently associated with an enhanced risk of complications. Subcutaneous heparin therapy was well tolerated by all patients.
Conclusion: The patients who were allocated to undergo enoxaparin therapy had a significantly greater improvement in their quantitative venographic score, a significantly lower recurrence rate of symptomatic venous thromboembolism, and a significantly lower incidence of bleeding than patients who underwent treatment with coumarin. LMWH can be used on an outpatient basis as a safer and more effective alternative to classical oral anticoagulant therapy for the secondary prophylaxis of selected patients with DVT. (J Vasc Surg 1999;30:283-92.)
Do you think we should give LMWH for the DVT patients for better results? Would you prefer giving the warfarin to patients? What are the reasons to choose Warfarin?
Wednesday, February 18, 2015
Superficial phlebitis and Fondaparinux
Treatment for superficial thrombophlebitis of
the leg.
The optimal
treatment of superficial thrombophlebitis (ST) of the legs remains poorly
defined. While improving or relieving the local painful symptoms, treatment
should aim at preventing venous thromboembolism (VTE), which might complicate
the natural history of ST. This is the second update of a review first
published in 2007. To assess the efficacy and safety of topical, medical, and
surgical treatments in patients presenting with ST of the legs. For this
update, the Cochrane Peripheral Vascular Diseases Group Trials Search
Co-ordinator searched the Specialised Register (last searched November 2012)
and the Cochrane Central Register of Controlled Trials (CENTRAL) (2012, Issue
11). We handsearched the reference lists of relevant papers and conference
proceedings. Randomised controlled trials (RCTs) evaluating topical, medical,
and surgical treatments for ST of the legs that included participants with a
clinical diagnosis of ST of the legs or an objective diagnosis of a thrombus in
a superficial vein.
Two
authors assessed the trials for inclusion in the review, extracted the data,
and assessed the quality of the studies. Data were independently extracted from
the included studies and any disagreements resolved by consensus.
MAIN RESULTS:
We
identified four additional trials (986 patients), so this update considered 30
studies involving 6507 participants with ST of the legs.Treatment ranged from fondaparinux,
low molecular weight heparin (LMWH), unfractionated heparin (UFH),
non-steroidal anti-inflammatory agents (NSAIDs), topical treatment, oral
treatment, intramuscular treatment, and intravenous treatment to surgery. Only
a minority of trials compared treatment with placebo rather than an alternative
treatment, none evaluated the same treatment comparisons on the same study
outcomes (which precluded meta-analysis), and many of the studies were small
and of poor quality. In one large, placebo-controlled RCT of about 3000
patients, subcutaneous fondaparinux was
associated with a significant reduction in symptomatic VTE (RR 0.15; 95% CI
0.04 to 0.50), ST extension (RR 0.08; 95% CI 0.03 to 0.22), and ST recurrence
(RR 0.21; 95% CI 0.08 to 0.54) with comparable rates of major bleeding (RR
0.99; 95% CI 0.06 to 15.86) relative to placebo. In a further
placebo-controlled trial, both prophylactic and therapeutic doses of LMWH (RR
0.40; 95% CI 0.22 to 0.72 and RR 0.42; 95% CI 0.23 to 0.75, respectively) and
NSAIDs (RR 0.41; 95% CI 0.23 to 0.75) reduced the extension and recurrence of
ST in comparison to placebo, with no significant effects on symptomatic VTE nor
major bleeding. Overall, topical treatments improved local symptoms compared
with placebo but no data were provided on the effects on VTE and ST extension.
Surgical treatment combined with elastic stockings was associated with a lower
VTE rate and ST progression compared with elastic stockings alone. However, the
majority of studies that compared different oral treatment, topical treatment,
or surgery did not report VTE, ST progression, adverse events , or treatment side effects.
AUTHORS'
CONCLUSIONS:
Prophylactic
dose fondaparinux given for six weeks appears to be a
valid therapeutic option for ST of the legs. The evidence on oral treatments,
topical treatment, or surgery is too limited and does not inform clinical
practice about the effects of these treatments in terms of VTE and ST
progression. Further research is needed to assess the role of the new oral
direct thrombin and activated factor-X inhibitors, LMWH, and NSAIDs; the
optimal doses and duration of treatment; and whether a combination therapy may
be more effective than single treatment. Adequately designed and conducted
studies are required to clarify the role of topical and surgical treatments.
Update of Treatment for
superficial thrombophlebitis of the leg
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