Neuromuscular electrical stimulation for the prevention of venous thromboembolism

Methods: The Medline and Embase databases were systematically searched, adhering to PRISMA guidelines, for articles relating to electrical stimulation and thromboprophylaxis. Articles were screened according to a priori inclusion and exclusion criteria.

Results:  The search strategy identified 10 randomised controlled trials, which were used in three separate meta-analyses: five trials compared neuromuscular electrical stimulation to control, favouring neuromuscular electrical stimulation (odds ratio of deep vein thrombosis 0.29, 95% confidence interval 0.13–0.65; P = .003); three trials compared neuromuscular electrical stimulation to heparin, favouring heparin (odds ratio of deep vein thrombosis 2.00, 95% confidence interval 1.13–3.52; P = .02); three trials compared neuromuscular electrical stimulation as an adjunct to heparin versus heparin only, demonstrating no significant difference (odds ratio of deep vein thrombosis 0.33, 95% confidence interval 0.10–1.14; P = .08).

Neuromuscular electrical stimulation significantly reduces the risk of deep vein thrombosis compared to no prophylaxis. It is inferior to heparin in preventing deep vein thrombosis and there is no evidence for its use as an adjunct to heparin.

Reference:

Article first published online: June 13, 2017 DOI: https://doi.org/10.1177/0268355517710130

Raveena Ravikumar, Katherine J Williams, Adarsh Babber, Hayley M Moore, Tristan RA Lane, Joseph Shalhoub, Alun H Davies

Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, London, UK

Corresponding Author: Alun H Davies, Room 4E04, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK. Email: a.h.davies@imperial.ac.uk

Platinum age for rheumatology

Hi, we all should note this progress to help our patients

Diabetic foot

Infected wound after repeated
Operations

Diabetic foot

Infected

Neuro-ischemic foot

Very often people think that the Diabetic foot is always infection but they forget to recognise the underlying neuropathy as the main cause precipitating infections so the surgeons are asked to drain the pus and debride wounds. It is true that all the diabetic foot problems are complicated by infection with 1or 2 other organism.

Diet and health both are important but there is always a second opinion.

My visit to Medanta Hospital, new delhi

Hi, this is a photo taken when I was visiting Medanta hospital

Intra aortic thrombosis and peripheral arterial thrombosis in a person taking antipsychotic drugs

Fig: Angiogram films before and after therapy.

This patient was admitted with history of B/L lower limb ischemic pain ( sub acute ) while he was taking anti psychotic medications. Angiogram showed multi segmental thrombosis of the lower limb arteries. He was informed about the options - Thrombectomy and Medical therapies or combination. He opted for only medical therapies with Heparin, Prostaglandin E1 therapies. He was given monthly infections of PGE1 and antiplatelet drugs along with other antipsychotic medications. His symptoms disappeared. Now, he is able to walk freely for 2 km and after that he develops calf claudication due to the residual ischemia ( popliteal, tibial arterial residual occlusions)

Reference

http://onlinelibrary.wiley.com/doi/10.1111/pcn.12001/abstract

Duration of anti coagulation in patients who had thrombosis – Are we sure about it?

The recommended duration of anticoagulation in the VTE patients is dependent on the persisting risk of re-thrombosis and bleeding.  It was noted that in 10 years follow up after cessation of the anticoagulation nearly 50% of the patients develop a recurrent VTE episode. This indicates that there is hidden risk of thrombosis in these patients. It may be due to underlying known or unknown, old or new risk factors. In these patients may have persistent old factors (of varying intensity) or newly added risk factors. So, in the beginning it was felt that the anticoagulation should be continued even after discharge from the hospital, but they were not sure about the duration. Now, the prophylaxis guidelines recommend us to extend the thrombo-prophylaxis after hip replacement surgery for at least 35 days.  Similarly, in the treatment segment also, there was discussion about continuation anti coagulation beyond 6 months after the indexed event. Placebo controlled trials were done and they showed 82% relative risk reduction of VTE (Einstein II).  In the recent past (Einstein Choice study) in another study, the anticoagulation was extended for another 1 year to its to study effect on prevention of rec VTE! It was again found that there is benefit of anticoagulation (Relative risk reduction of recurrent VTE up to 60%) without increasing the significant bleeding risk. The relative risk reduction can be as high as 60% with rivaroxaban. That leaves us with a question that is - how far is far enough with anticoagulation therapy?  Someone can consider giving anticoagulation for 10 years with annual reviews of the risk factors for re-thrombosis and bleeding.  This means, we need to use the existing drugs optimally or find out drugs which are effective and safe across all subsets of patients with thrombotic (VTE) complications, for a period of one decade after the indexed event of VTE.

Increase in the Incidence of Diabetes and Its Implications.

Diabetes mellitus is among the most prevalent and morbid chronic diseases, affecting the health of millions of persons worldwide. According to the Global Burden of Disease (GBD) report for 2015, the prevalence of diabetes rose from approximately 333 million persons in 2005 to approximately 435 million persons in 2015, an increase of 30.6%.1 During the same interval, the annual number of deaths from diabetes rose from 1.2 million to 1.5 million.2 This increase is attributed in the GBD report to population growth and aging, with small decreases in age-specific and cause-specific mortality over the same period.

The investigators examined changes in mortality and the incidence of cardiovascular disease over time. Mortality and the incidence of cardiovascular disease both decreased significantly over the study period. All-cause mortality decreased by 31.4 deaths per 10,000 person-years among persons with type 1 diabetes and by 69.6 deaths per 10,000 person-years among those with type 2 diabetes. The incidence of death from cardiovascular disease decreased by 26.0 deaths per 10,000 person-years among persons with type 1 diabetes and by 110.0 deaths per 10,000 person-years among those with type 2 diabetes. However, the rates of fatal outcomes decreased significantly less among patients with type 2 diabetes than among matched controls.

What is the solution for this increasing prevalence of Diabetes and the associated problems! It is clear that we are far from controlling the negative effects of diabetes on health worldwide. As the prevalence increases, we clearly need new approaches to reduce the burden of this disease on public health.

Reference: Julie R. Ingelfinger, M.D.,  John A. Jarcho, M.D : Increase in the Incidence of Diabetes and Its Implications. N Engl J Med 2017; 376:1473-1474  April 13, 2017

Which one is more expensive? Is it Thrombo-prophylaxis or Treatment for VTE?

Sometimes a question is raised about the cost benefit of thromboprophylaxis over the treatment of confirmed VTE in our hospitalized patients. In one study Gualberto Gussoni et al (2013) from Italy showed that the VTE management costs 4 times more than the prophylaxis.

They have examined in-hospital paths of 160 patients with VTE (VTE group) and 160 patients receiving prophylaxis and without VTE (NO-VTE group) retrospectively within 26 internal medicine units in Italy. The total median costs for VTE management were around four-times higher than those for prophylaxis (€ 1,348.68 vs € 373.03). Human resources were the most important cost-driver (55.5% and 65.7% in the VTE and NO-VTE groups), followed by instrumental (24.6% in VTE and 15.5% in NO-VTE) and haematologic tests (12.6% in VTE patients and 13.3% in controls). In the NO-VTE group the direct costs for prophylaxis accounted for 4.5% of total.  The real-world data of this study confirm the economic burden of in-hospital treatment of VTE, and the relatively low costs of thromboprophylaxis. A greater adherence to evidence-based protocols for VTE prevention could probably reduce the current financial burden of VTE on healthcare systems

The post-thrombotic syndrome after upper extremity deep venous thrombosis in adults

PTS is a frequent complication of UEDVT, yet little is known regarding risk factors and optimal management. A standardized means of diagnosis would help to establish better management protocols. The impact of upper extremity PTS on quality of life should be further quantified.
Seven studies were reviewed. The frequency of PTS after UEDVT ranges from 7- 46% (weighted mean 15%). Residual thrombosis and Axillo-Subclavian vein thrombosis appear to be associated with an increased risk of PTS, whereas catheter-associated UEDVT may be associated with a decreased risk. There is currently no validated, standardized scale to assess upper extremity PTS, and little consensus regarding the optimal management of this condition. Quality of life is impaired in patients with upper extremity PTS, especially after DVT of the dominant arm.

In our clinical practice, we generally recommend heparin therapy for the  upper limb DVT,  which is less expensive and easy to administer. We do not have  cost benefit evaluation studies comparing the thrombolytic and heparin therapies for upper limb DVT. It is possible to expect the results of thrombolysis in the Upper limb DVT, similar to lower limb DVT. It is also common to see the upper limb DVT in the patients who are on IJV or subclavian catheter for the hemodialysis. In our hospital this aspect of the DVT in the upper limb can be studied further to understand the significance of the PTS in the upper limb DVT associated with central venous catheters.


References:

Elman E E, Kahn SR.The post-thrombotic syndrome after upper extremity deep venous thrombosis in adults: a systematic review. Thromb Res.2006;117(6):609-14. Epub 2005 Jul 6.

Impact of the Initial High Dose of Rivaroxaban on Thrombus Resolution in VTE patients

Initial heparin therapy followed by oral anticoagulation for 3 to 6 month has been standard therapy for DVT in many clinics. The recently introduced Rivaroxaban, Apixaban are given without initial heparin therapy. So, few doctors are still comfortable giving initial heparin therapy and later oral anticoagulation. The question is about the effectiveness of the high dose of Rivaroxaban or Apixaban given initially? Can resolution of the thrombus in those who received Rivaroxaban and Apixaban  can be comparable to that in patients who received the Inj. Heparin? 

Bauersachs R et al (Feb 2017) presented Data accumulating on the use of non-VKA oral anticoagulants, such as Rivaroxaban. He is of the opinion that these may provide greater thrombus resolution compared with VKAs. Data from the phase III Rivaroxaban studies discussed showed that a 21-day intensive dosing regimen of Rivaroxaban 15 mg twice daily is effective during the acute treatment phase for VTE, with similar recurrence rates and thrombus resolution to standard anticoagulation.

Probably one may need some more time, studies and availability of the antidote to reverse these drug effects, before he or she can consider recommending the high dose initial therapies of NOACs with more confidence.

References:

1). Bauersachs R¹, Koitabashi N. Overview of Current Evidence on the Impact of the Initial High Dose of the Direct Factor Xa Inhibitor Rivaroxaban on Thrombus Resolution in the Treatment of Venous Thromboembolism. Int Heart J. 2017 Feb 7;58(1):6-15.

https://www.ncbi.nlm.nih.gov/pubmed/28123163

Cardiovascular Disease and mortality- Is it changing in Type 1 and Type 2 Diabetes, Now ?

It is our hope that the morbidity and mortality should be much less with introduction of many antidiabetic, antihypertensive and anti lipidemic therapies in the past few decades. In one recent study published in the NEJM.org the absolute changes in the incidence rates of sentinel outcomes per 10,000 person-years were observed in the type 1 and type 2 diabetes patients 198-2012.

Patients with type 1 diabetes had roughly 40% greater reduction in cardiovascular outcomes (CVOs) than controls, and patients with type 2 diabetes had roughly 20% greater reduction than controls. Reductions in fatal outcomes were similar in patients with type 1 diabetes and controls, "whereas patients with type 2 diabetes had smaller reductions in fatal outcomes than controls".

This finding of Swedish doctors from 1998 through 2014, mortality and the incidence of cardiovascular outcomes declined substantially among persons with diabetes, although fatal outcomes declined less among those with type 2 diabetes than among controls, makes us think what could be reason for failure to reduce the fatal outcomes more significantly ? we have introduced so many new ways to treat these patients medically with drugs and interventions! Why these are adding up to reduce the fatal outcomes! in type 2 diabetes.  May be we have not understood the pathophysiology adequately and so the corrective measures are not effective too!

Reference: 

1). Aidin Rawshani,., Araz Rawshani, Stefan Franzén, Björn Eliasson,, Ann-Marie Svensson, Mervete Miftaraj, Darren K. McGuire, Naveed Sattar, Annika Rosengren, and Soffia Gudbjörnsdottir. Mortality and Cardiovascular Disease in Type 1 and Type 2 Diabetes. N Engl J Med 2017; 376:1407-1418

Is there Risk of Bleeding After Carotid Endarterectomy with dual antiplatelet therapy?

May of us are concerned about the unexpected bleeding after carotid endarterectomy. Some times suture needle puncture bleeds for a long time after endarterectomy. Some of  us assume that this could be more if the patient is on two or more anti platelet drugs preoperatively. Most of these patients might have already undergone coronary stenting procedures earlier. The cardiologist would like to  continue the antiplatelet drugs in perioperative period as there is risk of stent thrombosis in the absence of these drugs. Giulio Illuminati et al recently published their data related to the safety of using dual antiplatelet therapy in the carotid endarterectomy patients. 188 patients received dual anti platelet drugs (Aspirin 100mg, Clopidogrel 75mg) and Inj. LMWH- 2000 units B.D (till discharge) in the post operative period, started 6 hours after surgery without any complications. There were no postoperative cervical hematomas requiring surgical evacuation. There was one hypoglossal nerve palsy, which regressed within 2 weeks. There was no postoperative mortality and neurologic and cardiac morbidity.
This study is too good to believe and I am sure some surgeons will be still apprehensive to use this regimen after carotid endarterectomy in their practice.

Reference:
1) Giulio Illuminati, Fabrice Schneider, Giulia Pizzardi, Federica Masci, Francesco G. Calio', Jean-Baptiste Ricco. Dual Antiplatelet Therapy Does Not Increase the Risk of Bleeding After Carotid Endarterectomy: Results of a Prospective Study. Annals of Vascular Surgery. 2017; 40:39 - 43

x

Giulio Illuminati

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Affiliations

• The Department of Surgical Sciences, University of Rome “La Sapienza”, Rome, Italy

Correspondence

• Correspondence to: Giulio Illuminati, MD, The Department of Surgical Sciences, University of Rome “La Sapienza”, Via Vincenzo Bellini 14, Rome 00198, Italy

Real-world economic burden of VTE and VTE prophylaxis in clinical practice

It is a general opinion that the treatment of VTE will be more expensive than the prevention of VTE with prophylactic measures. So, there is need to consider the thromboprophylaxis in our patients who are at high risk of VTE to reduce the overall economic burden in the world. In their study, Gussoni G et al (1) noticed that costs for VTE management (the total median) were around four-times higher than those for VTE prophylaxis (€ 1,348.68 vs € 373.03). This means if we follow the evidence-based protocols for VTE prevention, it could limit the current financial burden of VTE on our health budgets. Many clinicians may not feel this net clinical benefit in their small group of patients to get convinced about the larger role of thromboprophylaxis in the health care systems. 

Reference

1). Gussoni G, Foglia E, Frasson S, Casartelli L, Campanini M, Bonfanti M, Colombo F, Porazzi E, Ageno W, Vescovo G, Mazzone A; FADOI Permanent Study Group on Clinical Governance. A real-world economic burden of venous thromboembolism and antithrombotic prophylaxis in medical inpatients. Thromb Res. 2013 Jan;131(1):17-23

Can Arterio-Venous Fistula (AVF) precipitate or worsen congestive heart failure in ESRD patients going for initiation of hemodialysis?

The chronic kidney disease patients are referred to vascular surgeons for creating an arterio-venous fistula for hemodialysis with different types of hidden cardio-vascular problems. We have noted that those patients with sub clinical congestive heart failure are at greater risk of worsening of the cardiac condition after creation of the arterio-venous fistula for hemodialysis. In general, it was observed that patients with CHF and ESRD have poor prognosis. Optimizing the hemodynamics is crucial in both these conditions. Adding the AVF as a third factor in these patients can also make the optimization of hemodynamics more difficult. When an AVF is created, it reduces peripheral resistance, increases the preload and the stroke volume and cardiac output are increased. In 7 to 10 days the cardiac output is increased by 15% to 20%, left ventricular end diastolic pressure is increased by 5% to 10%. The Atrial naturietic and brain naturietic factors (ANP, BNP) are elevated.  The higher flows throughs the AVF was not seem to be linked to the incidence of high output failure. The fistula flows will be twice higher in the upper limb than those at the wrist. The upper arm AVF flows (Q_a) will be between 1.13 to 1.72 Lit/min. The fistula flow can be higher than 2 lit/min (Q_a) in 15% of the patients. Generally, the ratio between cardiac output and fistula flow (Q_a) is 22% in the upper limbs. The risk of high output heart failure is high when CO/Q_a is more than 40%. It was observed that 17% of the patients developed de novo congestive heart failure in the HEMO study. Median time to develop high output heart failure will be 51 days and it is noted in 40% of the upper limb Brachio-cephalic and 8% of the Radio-cephalic arteriovenous fistula.

Dr. Pinjala R K

14 April 2017

Role of adjunctive surgical therapies during or after Injection PGE-1 infusion therapies (cycles) for relieving the residual symptoms (pain), ulcer healing and limb salvage.

In the past we were doing procedures (operations) which were less often described in the literature as a last resort to save the ischemic limbs in young smokers with occlusion of the superficial femoral and popliteal arteries with no or poor distal runoffs. There were earlier or delayed failures in this group of patients with clinical diagnosis of Buerger’s disease based on the Shionoya criteria.  He have improved the ischemic limb salvage with the improved medical therapies utilizing Intravenous Injection PGE -1 infusions and dual anti platelet drugs given over period of 6 months in monthly cycles.

We are now facing a small but a difficult group of young patients with ischemic limbs (TAO- based on Shionoya criteria) where there is partial relief of the pain symptoms with non-healing or poor healing of toe ulcers. They have atrophy of the calf muscles. The ankle pressures are 30-40 mmHg with portable Doppler probe testing. The ulcers are usually 0.5 cm in diameter with gangrenous margins and dirty pale looking base. Some of them have shown dilated veins in the ischemic leg. They are not active functionally and find it difficult to go for long periods. This group of patients has shown long or short multi segmental arterial occlusive disease at more than 3 places.

Here, in such group of patients we are re-looking at the role of surgical intervention for improvement of the quality of life, healing of ulcers and complete relief of pain. Profundoplasty, sympathectomy, Thrombo-endarterectomy with vein patch or bypass with a vein graft of proximal occlusions are the possibilities. It is well known from the previous studies that intra arterial thrombolytic therapies downsized (limited) the operations and achieved attractive limb salvage rates. We are of the opinion that in similar way, this group of patients with residual symptoms and pain after Injection PGE-1 infusion therapies (6 cycles) may be benefited by the limited surgical therapies based on the angiographic findings.

In the recent past we have performed short segment bypass with vein grafts, limited thrombectomy, lumbar sympathectomy, Profundoplasty as adjunctive procedures to Injection Prostaglandin infusion therapies with relief of symptoms and limb salvage.

Conclusion:  Adjunctive surgical procedures will help a sub group of patients receiving Injection   PGE-1 infusion therapies (6 cycles) with residual ischemia associated symptoms or ulcers. There is a need to characterize such patients and objectively evaluate these selection methods with the help of some kind of clinical score. There is a need to develop a score for selecting the patients for such adjunctive procedures.

Critical limb ischemia (CLI), defined as ischemic rest pain or the presence of a nonhealing arterial ulcer or gangrene, is the most advanced and debilitating form of peripheral artery disease (PAD). An estimated 10% of patients with PAD progress to CLI within 5 years, with the annual incidence of CLI ranging between 500 and 1,000 new cases per 1 million individuals (1). Within 3 months from the time of diagnosis, 9% of CLI patients will die and 12% will require major amputation. One- and 2-year mortality rates of 21% and 31.6% have been reported (1). Collectively, CLI substantially affects patient quality of life and exerts a substantial economic burden to the overall health care system (1,2).

High explosive treatment for ultra Acute Stroke

High explosive treatment for ultra Acute Stroke - is it a hype or hope?

Treatments for acute stroke can be categorized in to four groups. They are 1. Target population based(Ischemic stroke, Intra Cerebral Hemorrhage), 2. Utility ( Proportion of patients who can be treated), 3. magnitude of efficacy and 4.cost.  We can also divide them as High cost therapies and low cost therapies. High cost therapies can be justified of there is high efficacy ( intravenous alteplase, mechanical thrombectomy, hemicraniectomy). Aspirin, the cost therapy typically will have low efficacy. Is it not reasonable to expect and see that medium to high efficacy therapies which are inexpensive are available to our patients.

Intensive blood pressure control has been found to be beneficial in ICH (INTERACT- II trial), but we are not clear if intensive blood pressure is helpful in ischemic stroke patients!

In the recent studies (ENOS trial, RIGHT trial) early GTN therapy has shown benefits in ICH, Ischemic stroke patients. This may change the future of the early stroke management even before the patients are shifted to the hospitals. GTN, the explosive may change the future game plan! Is it a hype or hope? we have to see !! 

Alberta stroke program early CT score ( ASPECTS)

What is Alberta stroke program early CT score?

Dr Owen Kang and Dr Haris Sair et al.

The Alberta stroke programe early CT score (ASPECTS) is a 10-point quantitative topographic CT scan score used in patients with middle cerebral artery (MCA) stroke. Segmental assessment of the MCA vascular territory is made and 1 point is deducted from the initial score of 10 for every region involved:

• caudate
• putamen
• internal capsule
• insular cortex
• M1: "anterior MCA cortex," corresponding to frontal operculum
• M2: "MCA cortex lateral to insular ribbon" corresponding to anterior temporal lobe
• M3: "posterior MCA cortex" corresponding to posterior temporal lobe
• M4: "anterior MCA territory immediately superior to M1"
• M5: "lateral MCA territory immediately superior to M2"
• M6: "posterior MCA territory immediately superior to M3"

Important points

1. the initial paper ¹ specifically referred to the internal capsule only involving the posterior limb, however subsequent articles indicate any portion of the internal capsule may be included
2. M1 to M3 are at the level of the basal ganglia
3. M4 to M6 are at the level of the ventricles immediately above the basal ganglia

Clinical use

An ASPECTS score less than or equal to 7 predicts worse functional outcome at 3 months as well as symptomatic haemorrhage.
According to study done by R.I Aviv et al ³ patients with ASPECTS score less than 8 treated with thrombolysis did not have a good clinical outcome.

Treatment of thromboangiitis obliterans (Buerger's disease) with high-potency vasodilators

Treatment of thromboangiitis obliterans (Buerger's disease) with high-potency vasodilators

David -,JiménezGallo et al

Thromboangiitis obliterans (TAO) or Buerger's disease is a vascular inflammatory thrombotic occlusive and segmental disease affecting distal small and medium-sized arteries of the limbs. Tobacco is the main trigger factor and avoiding it is the main treatment. Frequently, it is necessary to use high-potency vasodilators, such as iloprost, bosentan, sildenafil, or alprostadil, to relieve symptoms and reduce the risk of amputation. Iloprost is the only one that has been shown to be effective in randomized clinical trials. We report the third case of TAO treated with sildenafil and a new case treated with bosentan. This condition can be diagnosed and treated by a dermatologist. We would like to highlight the excellent clinical response despite the fact that patients continued to smoke. This finding may have important therapeutic implications because early treatment may prevent amputation and can be effective even during the process of giving up smoking.

We are expecting more medical therapies in the coming years to compete with the existing endovascular and surgical therapies.