Risk factors for the development of venous ulcers

Venous ulcers are the most common type of chronic lower extremity ulcers, affecting 1% to 3% of the U.S. population. Venous hypertension as a result of venous reflux (incompetence) or obstruction is thought to be the primary underlying mechanism for venous ulcer formation .

Risk factors for the development of venous ulcers include

1.Age 55 years or older,

2.Family history of Chronic venous insufficiency,

3. Higher body mass index,

4.History of pulmonary embolism or superficial/deep venous thrombosis,

5. Lower extremity skeletal or joint disease,

6.Higher number of pregnancies,

7.Parental history of ankle ulcers,

8.Physical inactivity,

9.History of ulcers,

10.Severe lipodermatosclerosis, and

11. Venous reflux in deep veins.

Bonkemeyer Millan S, Gan R, Townsend PE. Venous Ulcers: Diagnosis and Treatment.

Am Fam Physician. 2019 Sep 1;100(5):298-305

Effects of smoking on blood vessels – can we reverse them?

The effects of nicotine replacement therapy (NRT)-aided smoking cessation on vascular function are not fully clarified. We investigated 100 healthy smokers who were motivated to quit and received NRT for a 3-month period. Vascular endothelial function (measured by reactive hyperemia-peripheral arterial tonometry [RH-PAT]), arterial stiffness (measured by augmentation index [AI] and brachial-ankle pulse wave velocity [baPWV]), and systemic inflammation markers (including serum soluble intercellular adhesion molecule-1 [sICAM-1] and interleukin-1β [IL-1β]) were assessed at baseline and 3 and 12 months of follow-up. After 3 months of intervention, endothelial function, arterial stiffness, and inflammatory markers significantly improved (RH-PAT increased, AI and baPWV decreased, sICAM-1 and IL-1β decreased, all P < .05) for the participants who abstained from smoking completely, but for those who did not abstained completely, RH-PAT, AI, baPWV, and IL-1β remained unchanged. At 12 months follow-up, endothelial function (RH-PAT), arterial stiffness (AI and baPWV), and inflammatory markers (sICAM-1 and IL-1β) were further improved in participants who abstained from smoking (P < .001), while the above parameters deteriorated in continued smokers (P < .05). In conclusion, vascular dysfunction can be reversible after NRT-aided smoking cessation in healthy smokers and vascular function could be further damaged if they continue smoking[1].

---

[1]. Xue C1, Chen QZ1, Bian L1, Yin ZF1, Xu ZJ1, Zhang AL1, Xie YS1, Zhang HL1, Du R2, Wang CQ1. Effects of Smoking Cessation with Nicotine Replacement Therapy on Vascular Endothelial Function, Arterial Stiffness, and Inflammation Response in Healthy Smokers. Angiology. 2019 Sep;70(8):719-725

Inferior vena cava thrombosis

Inferior vena cava thrombosis (IVCT), although rare, has a potential for significant morbidity and mortality. IVCT is often a result of IVC filter thrombosis, but it can also occur de novo. Although anticoagulation remains the standard of care, endovascular techniques to restore IVC patency have become key adjunctive therapies in recent years. This study examines a single-center experience with diagnosis and management of IVCT.

https://www.annalsofvascularsurgery.com/article/S0890-5096(18)30842-2/pdf

Methods

A retrospective Institutional Review Board-approved review of a single-center institutional database was screened to identify IVCT thrombosis using International Classification of Diseases code 453.2 over a 3-year period. Etiology of IVCT was separated into 2 groups: those with IVC thrombosis in the setting of prior IVC filter place and those in whom IVCT occurred de novo. Patient demographics, presenting characteristics, and management of IVCT were examined. Treatment options included expectant management with anticoagulation versus catheter-directed thrombolysis (CDT), mechanical thrombectomy, stenting, or a combination. For those who underwent intervention, technical success, defined as restoration of IVC patency, was assessed.

Results

Forty-one unique patients were identified with radiographically confirmed diagnosis of ICVT (mean age 61, range 25-91; 21 female, 51.2%). Eighteen (43.9%) patients presented with thrombosed IVC filter. Risk factors for venous thromboembolism included tobacco usage, current or prior smoking (n = 17, 41.5%), history of prior deep vein thrombosis (n = 25, 61.0%), malignancy (n = 17, 41.5%), use of hormonal supplements (n = 3, 7.3%), known thrombophilia (n = 4, 9.8%), and obesity (body mass index: mean 29, range 18.8-58.53). Eleven patients (26.8%) presented with pulmonary embolism (PE), and of those 63.6% had IVC filter thrombosis (n = 7). Risk of PE was not significantly different between those patients presenting with a thrombosed IVC filter compared to those with de novo IVCT (38.9% vs. 17.4%, P = 0.12) Management of IVCT included anticoagulation alone (n = 27, 65.9%), CDT (n = 5, 12.2%), mechanical thrombolysis (n = 10, 24.4%), and adjunctive IVC stent (n = 3, 7.3%). Among the 14 (34.1%) patients who had intervention for IVCT, patency was restored in 12 patients (85.7%).

Conclusions

IVCT is a rare event and is associated with known risk factors for venous thromboembolism. PE can occur in roughly 25% of patients presenting with IVCT. Presence of a filter does not appear to confer an advantage in preventing PE when IVCT occurs. Although majority of IVCT is managed with anticoagulation alone, endovascular interventions, including lysis and stenting, can safely restore patency in most properly selected patients.

Carotid body tumors and the outcomes

A Systematic Review and Meta-Analysis of the Presentation and Surgical Management of Patients With Carotid Body Tumours.

Vaux Robertson

, 

Federica Poli

, 

Ben Hobson

, 

Athanasios Saratzis

, 

A. Ross Naylor∗,Correspondence information about the author A. Ross NaylorEmail the author A. Ross Naylor

The Leicester Vascular Institute, Glenfield Hospital, Leicester UK

Objectives

The aim was to determine the mode of presentation and 30 day procedural risks in 4418 patients with 4743 carotid body tumours (CBTs) undergoing surgical excision.

Methods

This is a systematic review and meta-analysis of 104 observational studies.

Results

Overall, 4418 patients with 4743 CBTs were identified. The mean age was 47 years, with the majority being female (65%). The commonest presentation was a neck mass (75%), of which 85% were painless. Dysphagia, cranial nerve injury (CNI), and headache were present in 3%, while virtually no one presented with a transient ischaemic attack (0.26%) or stroke (0.09%). The majority (97%) underwent excision, but only 21% underwent pre-operative embolisation. Overall, 27% were Shamblin I CBTs; 44% were Shamblin II; and 29% were Shamblin III. The mean 30 day mortality was 2.29% (95% CI 1.79–2.93). The mean 30 day stroke rate was 3.53% (95% CI 2.91–4.29), while the mean 30 day CNI rate was 25.4% (95% CI 24.5–31.22). The prevalence of persisting CNI at 30 days was 11.15% (95% CI 8.42–14.64). Twelve series (544 patients) correlated 30 day stroke with Shamblin status. Shamblin I CBTs were associated with a 1.89% stroke rate (95% CI 0.92–3.82), increasing to 2.71% (95% CI 1.43–5.07) for Shamblin II CBTs and 3.99% (95% CI 2.34–6.74) for Shamblin III tumours. Twenty-six series (1075 patients) correlated CNI rates with Shamblin status: 3.76% (95% CI 2.62–5.35) for Shamblin I CBTs, 14.14% (95% CI 11.94–16.68) for Shamblin II, and 17.10% (95% CI 14.82–19.65) for Shamblin III tumours. The prevalence of neck haematoma requiring re-exploration was 5.24% (95% CI 3.45–7.91). The proportion of patients with a neck haematoma requiring re-exploration was not reduced by pre-operative embolisation (5.92%; 95% CI 2.56–13.08) vs. no embolisation (5.82%; 95% CI 2.76–11.88). Pre-operative embolisation did not reduce drainage losses (639 mL vs. 653 mL).

Conclusions

This is the largest meta-analysis of outcomes after CBT excision. Procedural risks associated with tumour excision were considerable, especially with Shamblin III tumours where 4% suffered a peri-operative stroke and 17% suffered a CNI.

A National Goal: Prevent a Million Heart Attacks and Strokes by 2022

With your cooperation and the support of the medical profession, insurance companies, government agencies and communities throughout the country, the agency hopes to prevent a million heart attacks and strokes by the year 2022.As the centers’ experts estimated last year, if 2016 trends remain constant through 2021, an estimated 16.3 million potentially preventable life-threatening or fatal events, or 3.3 million a year, are projected to occur, including 2.2 million emergency department visits, 2.2 million deaths and 11.8 million hospitalizations, at a projected cost of $170 billion. A third of these preventable events are likely to afflict people aged 35 to 64, these experts, Dr. Janet S. Wright, Hilary K. Wall and Matthew D. Ritchey, calculated.He and his colleagues cited 213 million opportunities to improve cardiovascular risk among Americans by addressing behaviors that are currently standing in the way of progress: 71 million people are physically inactive, participating in no leisure-time exercise. 54 million people are still smoking combustible tobacco products. 40 million adults have uncontrolled high blood pressure.39 million with high cholesterol are not using medication to lower it. 9 million people for whom a daily baby aspirin is appropriate are not taking it.
The as-yet unstoppable epidemic of obesity is most likely the leading cause of preventable cardiovascular disease and deaths. Excess weight can result in high blood pressure, high cholesterol levels, Type 2 diabetes and a reluctance to be physically active, all of which contribute to cardiovascular risk.

Doctors and Disclosures

Doctors work hard not only in diagnosing diseases and treating them but also conduct research and help in improving the understanding of the diseases and their origins. This is possible through their association with other scientists, organizations and other medical industries. But this process needs to be transparent and one has to disclose conflict of interest. There can be serious objections if there are undisclosed links between the doctors and medical industries. In the Western countries this is taken seriously if the doctors at the helm of affairs fail to disclose search associations and especially when they are receiving honorariums. This is going to be considered equally seriously in the developing nations also soon. 

Academic journals are the way the world learns about medical breakthroughs, and companies benefit greatly when research about their products is published in them. Prestigious journals require authors to list any potential conflicts of interest. But dozens of doctors have failed to disclose significant relationships with health care and drug companies that pay them for consulting work, sitting on corporate boards and other roles.

https://www.nytimes.com/interactive/2018/12/08/health/journal-conflicts-of-interest.html 

Can we reduce the Cardiovascular risk and cancer risk by supplementing omega-3 fatty acids 1gm per day and Vitamin D3 2000 units/day-?

When we were medical students, omega-3 fatty acids were talked about among the senior citizens as better nutritional supplements to protect them from the illnesses. Now, we are aware that the higher intake of these omega-3 fatty acids has been associated with reduced risks of cardiovascular disease and cancer in several observational studies. Similarly, in the last few years, vitamin D levels were found to be very low in many people in our society. Some association was also noted between the low levels of Vitamin D and CV disease and cancer. This leads us to think that supplementation of these (omega-3 fatty acids and vitamin D) may be more effective in reducing the CV disease and cancers. If that is proved we may be finding new medication (fixed drug combinations)

A study was conducted and the results were published by J E Manson et al (2019). In this study the benefits of using the combination (Vitamin D₃ 2000units/day + Omega -3 fatty acids 1gm per day) were assessed. This is a randomized placebo-controlled trial. This study focuses a primary prevention of CV disease and cancer among men older than 50 years and women older than 55 years. Primary endpoints were major CV events (a composite of myocardial infarction, stroke or death from cardiovascular causes) and invasive cancer of any type. Secondary end points included individual components of the composite cardiovascular end point, the composite end point plus coronary revascularization (expanded composite of cardiovascular events), site-specific cancers, and death from cancer. A total of 25,871 people participated in this trial, out of them 5106 were blacks. All these patients were followed for 5.3 years.

At the end, it is disappointing to note that  supplementation of this combination did not result in lower incidence of major cardiovascular events or cancer than placebo.

https://www.nejm.org/doi/full/10.1056/NEJMoa1811403?query=featured_home

Myocardial injury after non-cardiac surgery

Perioperative myocardial injury in patients undergoing non-cardiac surgery is a major challenge in the vascular surgical practice. It can be missed if we don’t look for it, but it was found to be associated with early (30-day) and late (1 yr) morbidity and mortality. Puelacher C et al defined Perioperative Myocardial Infarction (PMI) as an absolute high-sensitivity cardiac troponin T increase of ≥14 ng/L from preoperative to postoperative measurements. In their large study (2546 surgeries) PMI occurred in 16%, but it was accompanied by chest pain only in 6%, any type of ischemic symptoms in 18%. Crude 30-day mortality was 8.9%  in patients with PMI versus 1.5% in patients without PMI. There is a potential to help many of the 8 million adults globally who have PMI(MINS) to reduce their risk of a major vascular complication. If only we can identify these patients and apply appropriate medications, we can prevent this mortality and morbidity.

Reference

Puelacher C, Lurati Buse G, Seeberger D, Sazgary L, Marbot S, Lampart A, Espinola J, Kindler C, Hammerer A, Seeberger E, Strebel I, Wildi K, Twerenbold R, du Fay de Lavallaz J, Steiner L, Gurke L, Breidthardt T, Rentsch K, Buser A, Gualandro DM, Osswald S, Mueller C; BASEL-PMI Investigators. Perioperative Myocardial Injury After Noncardiac Surgery: Incidence, Mortality, and Characterization. Circulation. 2018;137(12):1221-1232. 

Effect of polidocanol foam on pulmonary parenchyma?

Phlebology. 2018 Mar;33(2):122-127. doi: 10.1177/0268355516683922. Epub 2017 Jan 16.

Effect of polidocanol foam administration into rat peripheral veins 

on pulmonary parenchyma.

de Moraes Silva MA¹, Ferreira RG¹, de Jesus-Silva SG¹, Cardoso RS¹, Miranda F Jr.¹

Abstract

Background Sclerotherapy has been gaining increased acceptance and popularity as an effective therapy for the treatment of varicose veins. This attention has fed growing interest into the safety and potential complications of this procedure. There is no evidence of pulmonary complications from foam sclerotherapy in humans; however, animal studies have shown possible damage. The aim of this study is to show the changes in rat pulmonary parenchyma after the injection of 1% polidocanol Tessari foam into the peripheral vein using histological analysis of the inflammatory and fibrosis processes. Methods Twenty-four Wistar rats were divided into the following four groups: 24 h polidocanol, seven-day polidocanol, 28-day polidocanol, and control group. After the foam was injected into the lateral saphenous vein, the lungs of the rats were removed for histological analysis. Results Alveolar edema was observed in only the 24 h group (P < 0.005). Vessel thickening was observed in the seven-and 28-day groups (P < 0.001). Interstitial fibrosis was found in only the 28-day group (P = 0.006). There was no evidence of venous or arterial thrombosis in either group. Conclusion Polidocanol Tessari foam injection into rat peripheral veins causes alveolar edema, vessel thickening, and interstitial fibrosis.

Diosmin along with other active Flavanoids is more effective in treating the venous disease.

Eur J Vasc Endovasc Surg. 2018 Mar 24. pii: S1078-5884(18)30106-0. doi: 10.1016/j.ejvs.2018.02.009. [Epub ahead of print]

Protective Effects of Micronized Purified Flavonoid Fraction (MPFF)

on a Novel Experimental Model of Chronic Venous Hypertension.

das Graças C de Souza M¹, Cyrino FZ², de Carvalho JJ³, Blanc-Guillemaud V⁴, Bouskela E

CONCLUSION:

 MPFF was more effective than diosmin in improving all microvascular

variables. The superiority of MPFF over diosmin alone can be explained by the synergistic

beneficial effects of the association between diosmin and active flavonoids of MPFF.

PGE-1 infusion and PET Scan to see increase in the muscular blood flow!

Increase of blood flow in the ischaemic leg is believed to represent the main action of prostaglandin E1 (PGE1) in the therapy of peripheral vascular disease (PVD). There is no reliable data in man concerning the amount of increase in muscular blood flow (MBF) of the calf, and the difference between intra-arterial and intravenous application. We conducted a positron emission tomography (PET) study of MBF with 15O-water as flow tracer. Fifteen patients with PVD and three healthy volunteers were given 5 micrograms PGE1 intra-arterially over 50 min; PET scans were taken at 0, 25 and 50 min.  

Additionally, eight of the patients were investigated during an intravenous infusion of 40 micrograms PGE1 over 120 min; PET scans were taken at 0, 30, 60 and 120 min.  

Increase of muscular blood flow by intra-arterial PGE1 averaged 80%. A steal phenomenon was not observed. The amount of flow enhancement depended on whether or not the femoral artery was patent. During intravenous PGE1, muscular blood flow remained unchanged. In man, the pharmacodynamic profile of intra-arterial PGE1 differs clearly from intravenous PGE1. The flow-enhancing property is lost during metabolization in the lung. Since no difference exists between the therapeutic efficacy of intraarterial and intravenous PGE1, the impact on muscular blood flow is not as important as suggested previously.  Prostaglandin E1 in peripheral vascular disease: A PET study of muscular blood flow. Available from: https://www.researchgate.net/publication/13697266_Prostaglandin_E1_in_peripheral_vascular_disease_A_PET_study_of_muscular_blood_flow [accessed Sep 15, 2017]. 

Pinjala R K

Quality of life in patients with chronic venous disease in Turkey: influence of different treatment modalities at 6-month follow-up

Quality of Life Research  June 2016, Volume 25, Issue 6, pp 1527–1536

Kadir Çeviker Email author, Şahin Şahinalp, Erdinç Çiçek, Deniz Demir, Dinçer Uysal, Rasih Yazkan, Abdullah Akpınar, Turhan Yavuz, Kadir Çeviker

Abstract

Purpose  The main purpose of this study was to evaluate the influence of any of the four domains of the QoL score in CVD patients of classes C0–C4 and to analyze the correlation between the QoL and types of treatment modalities, and an additional aim of the present study was to compare QoL levels of patients with CVD and healthy participants and was to examine the factors associated with QoL in CVD patients.

Methods \The sample was composed of 501 patients with primary superficial venous reflux (28.5 % male and 71.5 % female) who answered 100 % of the questions in the World Health Organization Quality of Life (WHOQoL-BREF) questionnaire. After a clinical and duplex examination, the patients were categorized as C0–C4, according to the CEAP classification. The relationships between WHOQoL-BREF domains and gender, age, occupation, BMI, the clinical classes of the CEAP classification and four different treatment modalities according to guideline were analyzed.

Results For the WHOQOL-BREF test battery, the patients with CVD had worse values, as compared with the control group participants. The differences were significant for the physical (77.81 ± 12.75 vs. 59.18 ± 12.90, p < 0.001), the psychological (74.78 ± 11.37 vs. 60.21 ± 14.70, p < 0.001), the social relationships (76.56 ± 13.56 vs. 63.07 ± 21.37, p < 0.001) and the environmental (70.27 ± 13.36 vs. 50.16 ± 11.39, p < 0.001) health scores. The patients with CVD had worse WHOQOL-BREF scores at initial, compared with the 6-month follow-up scores.

Conclusion: This study shows that in spite of undergoing therapy, the subsequent QoL scores did not improve significantly, indicating that CVD continued to negatively affect the patient’s life.

J Vasc Surg. 2002 Jun;35(6):1197-203.

The effect of long saphenous vein stripping on quality of life.

MacKenzie RK1, Paisley A, Allan PL, Lee AJ, Ruckley CV, Bradbury AW.

Author information

Abstract

PURPOSE:

Long saphenous vein (LSV) stripping in the treatment of varicose veins may reduce the recurrence of varices but may also increase morbidity rates. The effect of stripping on health-related quality of life (HRQoL) is unknown. The aim of this study was to examine the effect of LSV surgery, with and without successful stripping, on HRQoL.

METHODS:

This prospective study comprises 102 consecutive patients who underwent varicose vein surgery that included attempted stripping of the LSV to the knee. HRQoL was assessed before surgery and at 4 weeks, 6 months, and 2 years after surgery with the Aberdeen varicose vein severity score (AVSS; disease-specific) and the Short-Form 36 (SF-36; generic). Patients defined as stripped were those in whom complete thigh stripping to the knee was confirmed with postoperative duplex scanning at 2 years. Patients defined as incompletely stripped were those in whom any LSV remnant was found in the thigh after surgery. Deep venous reflux (DVR) was defined as reflux of 0.5 seconds or more in at least the popliteal vein.

RESULTS:

Sixty-six of 102 patients (65%) provided complete HRQoL data at all four time points. At baseline, there was no significant difference between patients who were stripped (n = 25) and incompletely stripped (n = 41) in terms of AVSS, SF-36, age, gender, DVR, or CEAP grade. Significantly more patients in the incompletely stripped group underwent surgery for recurrent disease (29/41, 71%, versus 8/25, 32%; P =.002, with chi(2) test). Both groups gained significant improvements in AVSS scores for as much as 2 years. After adjustment for recurrent disease, stripping conferred additional benefit in terms of AVSS at 6 months (median [interquartile range]) (9 [4 to 16] versus 15 [9 to 24]; P =.031) and 2 years (7 [2 to 10] versus 9 [5 to 15]; P =.014), which was statistically significant in patients without preoperative DVR but not significant in patients with preoperative DVR. SF-36 scores were not affected by stripping.

CONCLUSION:

LSV surgery leads to a significant improvement in disease-specific HRQoL for as much as 2 years. In patients without DVR, stripping to the knee confers additional benefit.

Evolution of practices in carotid surgery: from 2006 to 2015

Carotid artery intervention or surgery is less often performed in our hospital for various reasons when compared to the more often performed coronary artery surgery and interventions.. Similarly in the last 10 years, this has not changed significantly. In addition the high dose statin therapy and best medical therapies are gaining popular in many hospital. Early initiation of best medical therapies helping the patients to prevent the next event. It is still very difficult to do carotid endarterectomy in the early window period (golden period is less than a week after indexed event TIA) due to many factors which delay the entry of the patient to the operation theatre. As the time passes the risk drops and patients also postpone it further.

An observational analysis showed stability in the number of carotid procedures performed during the period and a progressive modification of carotid surgery practices in France, in accordance with the recommendations of learned societies and major publications. We also feel that seems to be fact in many other hospitals.



Reference

Salomon du Mont, Lucie et al.. Evolution of practices in carotid surgery: observational study in France from 2006 to 2015.   Annals of Vascular Surgery , Volume 0 , Issue 0 ,

http://www.annalsofvascularsurgery.com/article/S0890-5096(17)30325-4/fulltext 

Smoking cessation rates amongst patients undergoing vascular surgery

Vascular surgeons and interventionists explain the patients and suggest them to stop smoking in the perioperative period. But some of them fail to stop smoking due to various reasons. Recurrence of the stenotic lesions and thrombosis is known to be higher in such people. In our hospital 25% of the patients stop smoking forever. 50% of patients stop smoking for some time and restart after discharge. 25% of smokers never stop smoking.

Smoking is the single most important modifiable risk factor for patients with vascular disease. A study was done in Canada with an aim to determine prevalence of smoking and cessation rates amongst patients undergoing vascular surgery.

Results  of that study - Overall 624 patients had complete follow up data. Of these, 209 (33.5%) were smokers pre-surgically. At 1 year follow up of those 209 patients who were smokers pre-op, 87 (41.6%) had stopped smoking while 122 (58.4%) had not. Patients who were male and aged >70 were more likely to be smokers pre-operatively (p=0.001 and p<0 .001="" aged="" cessation="" in="" increased="" rates="" respectively="" those="" were="">70 years (p=0.005), and in those with COPD (p=0.016). Gender was also statistically associated, with cessation rates higher in females (p=0.011).

They concluded by saying that,  more than one-third of patients who underwent surgery in a Canadian vascular center continue to smoke.  

May be, we should study the outcomes of vascular treatments after improving this difficult habit (smoking cessation) further. We should do a study targeting the smoking habit and then measuring the outcomes of the vascular procedures. The attention is needed in this direction at this hour.

Reference

McHugh, S.M. et al. Smoking cessation rates amongst patients undergoing vascular surgery in a Canadian center.  .Annals of Vascular Surgery , Volume 0 , Issue 0 ,  article in press

http://www.annalsofvascularsurgery.com/article/S0890-5096(16)31348-6/fulltext

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