vascular ( blood vessels)

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Increase in Deaths in Men With Type 2 Diabetes and Testosterone Deficiency May Be Prevented by Testosterone Replacement?

Professor Jones' team conducted a six year study of 587 men with type 2 diabetes, splitting them into three groups: those with normal total testosterone levels (above 10.4nmol/L, n=338), those with low testosterone levels (below 10.4nmol/L) that weren't treated with testosterone replacement therapy (n=182), and those with low testosterone levels treated with testosterone replacement therapy for two years or more during the follow up period (n=58).

The findings show for the first time that low testosterone puts diabetic men at a significantly increased risk of death (p=0.001 log rank): 36 of the 182 diabetic men with untreated low testosterone died during the six year study, compared to 31 of the 338 men with normal testosterone levels (20% vs 9%). Furthermore, only 5 of the 58 diabetic men that were given testosterone replacement therapy died during the study (8.6%), meaning they showed significantly better survival compared to the non-treated group (p=0.049 log rank).
This is the first study to show testosterone treatment can improve survival in men with type 2 diabetes and testosterone deficiency. Further studies now need to be carried out to fully investigate the potential therapeutic benefit of testosterone replacement in diabetic men with low testosterone.
Professor Hugh Jones, Consultant Endocrinologist and Hon. Professor of Andrology, Barnsley Hospital NHS Foundation Trust and the University of Sheffield, said: "This is potentially a very exciting finding. Whilst we have shown that low testosterone levels can put diabetic men at greater risk of dying, we have also demonstrated for the first time the potential benefit that testosterone replacement therapy holds for this group of patients.
"It is well known that men with type 2 diabetes often have low testosterone levels, so it is important that we investigate the health implications of this. We now need to carry out a larger clinical trial to confirm these preliminary findings. If confirmed, then many deaths could be prevented every year."
In another study, also presented at this year's Society for Endocrinology meeting, Professor Jones' group found for the first time that low testosterone and severity of erectile dysfunction are independently associated with a reduced health-related quality of life in men with type 2 diabetes. Health-related quality of life questionnaires, such as the one used in this study, measure how a person perceives their own general health in areas such as physical and social functioning, vitality and pain. The questionnaire does not measure how good a person's health actually is; it measures how good a person thinks their health is in daily life.
In the 356 men with type 2 diabetes tested, health related quality of life decreased as testosterone levels decreased (r=0.353 p=0.044). In the 126 patients who were also assessed for erectile dysfunction, health-related quality of life decreased in the areas including physical functioning (r=0.5, p=0.003), social functioning (r=0.445, p=0.022) vitality (r=0.383, p=0.025) and pain (r=0.428, p=0.012) as the severity of erectile dysfunction increased. Although severity of erectile dysfunction has been shown to be associated with lower testosterone levels, statistical analysis shows for the first time that these are both independently associated with a reduced health-related quality of life in these men.Lead researcher Prof Hugh Jones said: "Our research shows that low testosterone impacts on health-related quality of life in men with type 2 diabetes. This finding supports previous evidence suggesting that erectile dysfunction is a marker of ill health.
"Our next step is to assess whether offering testosterone replacement therapy to diabetic men with testosterone deficiency and erectile dysfunction may help to improve their health related quality of life."

Niacin and mixed dyslipidemia

Niacin (nicotinic acid) lowers lipids by inhibiting very-low-density lipoprotein (VLDL) production in the liver and reducing the level of VLDL that can be converted into low-density lipoprotein (LDL). Niacin can lower LDL cholesterol by 10 to 25 percent and triglyceride levels by 20 to 50 percent, and can raise levels of high density lipoprotein (HDL) cholesterol by 15 to 35 percent. These effects may be even greater in patients with a predominance of small, dense LDL, which has been associated with greater coronary heart disease risk. For these reasons, niacin is considered a useful treatment in patients with mixed dyslipidemia. The adverse effects of immediate-acting niacin preparations, including flushing, itching, gastrointestinal upset and hepatotoxicity, have limited its use. An extended-release form of niacin has to be taken nightly to minimize liver toxicity and other side effects. The daily niacin dosage can be started at 375 mg taken nightly and slowly increased, to a maximum of 3,000 mg per day, at four-week intervals for a total of 25 weeks. Patients can take 325 mg of aspirin before Niacin to prevent flushing.In peripheral vascular surgery patients HDL levels are usually low in Inida. We need to increase the HDL levels in these patients and Niacin is a good  medication for these patients if the side effects such as flushing and other side effects are removed.

Patient self management of oral anticoagulation and patient self testing of INR -
Anticoagulation with vitamin K antagonists (for example, warfarin) reduces thromboembolic complications in patients with common chronic conditions, including atrial fibrillation, history of deep venous thrombosis and pulmonary embolism, and mechanical heart valves . In the United States, more than 5% of persons aged 65 to 74 years and more than 10% of persons aged 75 years or older receive long-term oral anticoagulants. In 2007, the cost of this medication alone was $905 million in USA. As the population ages, use and costs are likely to increase substantially. We find it very difficult to take care of the less educated people who are on oral anticoagulant medications. Many times the hospitals are not able to provide this care after major interventions and operations. Vitamin K antagonists have a narrow therapeutic window, and patients require frequent laboratory monitoring to ensure that they are neither excessively anticoagulated, which increases the risk for a bleeding event, or underanticoagulated, which increases the risk for thromboembolism. Recent trials have shown that direct thrombin inhibitors, which do not require intensive monitoring, may be as efficacious as vitamin K antagonists. We hope the new drugs will this simpler and safer until then we need to keep service active for the patients who are on oral anticoagulants for prevent of recurrent thrombotic complications. The review of these patients on oral anticoagulants indicated that compared with usual clinic care, Patient Self Testing with or without Patient Self Management is associated with significantly fewer deaths and thromboembolic events, without any increase in bleeding complications, for a selected group of motivated patients requiring long-term anticoagulation with vitamin K antagonists.
Ref : Annals of Inernal Medicine , April 5, 2011, 154 (7)

Carotidobrachial bypass in a Takayasu's disease patient - 7yrs follow up.

The surgical treatment of Takayasu's disease is complicated due to many reasons. It has been complicated by the extensive nature of the lesions, lack of accurate knowledge regarding the preferred sites and extent of the lesions, presence of skip lesions, and chances of reactivation. These patients are usually young, with an otherwise normal vascular system beyond the diseased area. Previously published reports expressing reservations about the efficacy of surgical treatment do not seem justified. Careful assessment of each patient as to his residual disability after conservative treatment and the haemodynamic status will make surgical treatment safe and rewarding for a large number of patients. Immunological investigations indicate the possibility of a mechanism  involving immune complex formation on a background of defective T-lymphocyte function in Takayasu's disease. Whereas the original antigenic trigger could be any one of a number of different possibilities, parasitic infestation and chronic infection in the intestines along with protein energy malnutrition may be possible etiological factors. The figure shows the patent right carotid brachial bypass with saphenous vein graft after 7 years, and she developed occlusive disease in the left subclavian artery in the recent past with symptoms of claudication in the left arm.

Trifurcation of the popliteal artery and Tibial vessel (3) occlusion with thrombosis.

In the recent few months we have seen and treated 7 men with severe pain, symptoms of ischemia due to below knee occlusion of  the popliteal artery and tibial (3) arteries. Initially they were given antiplatelet drugs and anticoagulation with no relief of symptoms. Thrombolytic therapy was started after angiogram and guide wire confirmation of the nature of the obstruction. In five patients Inj Tinectaplase and in two patients Inj Urokinase was given. All these patients were relieved of their symptoms with recanalization of the popliteal and tibial vessels and there was improvement of the ankle pressures above the critical levels.We feel that guide wire testing (ability to pass it through the occluded tibials) is crucial and determines the out comes of thrombolytic therapy.

World Health Day 7th April - 2011

Antimicrobial resistance: no action today, no cure tomorrow 

“Every government should have a national intersectoral plan on how to address the issue and respond to it.”Clinicians agree that one of the biggest challenges is finding out the true size of the problem of resistant infections in each country. “We need better microbiology labs to test antibiotic resistance to infections but above all we need better data to inform policies,” says Professor Nirmal Ganguly, Chair of the Global Antibiotic Resistance Partnership – India National Working Group. One of the most powerful measures globally to prevent antimicrobial resistance has been the ban of the use of antibiotics as growth promoters in livestock in the 27 European Union countries since 2006. The ban underlines the complex nature of the problem. “Antimicrobial resistance is a problem that goes beyond the health sector, so it is important to involve all sectors,” says Jakab. 

Spreading Antibiotic resistance and the role of hospitals in curtailing this problem - World Health Day 2011

Indian hospitals are going to need special precautions to prevent the spread of the antibiotic resistant bacteria across India. Over crowding, improper waste disposal, inappropriate use of antibiotic use without guidance will be focused more and more as the cause of spread of bacterial resistance. Frequent hand washing in the hospitals would be an important measure to reduce the spread of the resistant bacteria across the different wards in the hospitals. In the other countries such as USA and Europe Hospital-acquired infections are a major challenge to patient safety. It is estimated that in 2002, a total of 1.7 million hospital-acquired infections occurred (4.5 per 100 admissions), and almost 99,000 deaths resulted from or were associated with a hospital-acquired infection, making hospital-acquired infections the sixth leading cause of death in the United States; similar data have been reported from Europe. The estimated costs to the U.S. health care budget are $5 billion to $10 billion annually. Approximately one third or more of hospital-acquired infections are preventable.

Population in India
India added more than 181 million people to its swelling population in the past decade, growing to over 1.21 billion people, according to the latest census data released by officials on Thursday, 31st March 2011.
“We are now over 17 percent of the world population, and India is 2.4 percent of the world’s surface area,” said C. Chandramauli, India’s census commissioner. “We have added the population of Brazil to India’s numbers this time.”
The total population grew from 1.02 billion people in 2001 to 1.21 billion this year, according to the preliminary calculations of the massive census exercise that ended in February, costing over $492,000. The population of India now is almost equal to the combined population of United States, Indonesia, Brazil, Pakistan, Bangladesh and Japan

Alcohol consumption and cardiovascular disease outcomes - A systematic review and meta analysis.

The alcohol consumption is now socially accepted in more number of urban cities.The Indian alcoholic beverages market is dominated by whisky, which accounts for more than half of the total spirits consumed in the country.
The total consumption of whisky is estimated to be around 131 million cases in the current year, a rise of 10 per cent from 119 million cases in 2009. After whisky, rum is the most popular alcoholic beverage in India and the total consumption is estimated to be at 42.4 million cases in the current year, a rise of 8.7 per cent from 39 million cases in 2009.According to the IWSR report, consumption of beer — counted as a separate category — is likely to grow by 7 per cent to 195.5 million cases of 7.8 litres each (1.52 crore Hecto Litres) in the current year, as compared to 181.5 cases (1.41 crore Hecto Litres) in 2009.
IWSR is a London-headquartered market research firm that focuses exclusively on the global alcoholic beverage market.

The recent study in British Medical Journal is appealing to all those who are taking alcohol in a controlled manner. Possible cardioprotective effects of alcohol consumption seen in observational studies continue to be hotly debated in the medical literature and popular media. In the absence of clinical trials, clinicians must interpret these data when answering patients’ questions about taking alcohol to reduce their risk of cardiovascular disease. Systematic reviews and meta-analyses have addressed the association of alcohol consumption with cardiovascular disease outcomes but have not uniformly addressed associations between alcohol use and mortality from cardiovascular disease, as well as the incidence and mortality from coronary heart disease and stroke.

In a review of 84 studies of alcohol consumption and cardiovascular disease, alcohol consumption at 2.5–14.9 g/day (about ≤1 drink a day) was consistently associated with a 14–25% reduction in the risk of all outcomes assessed compared with abstaining from alcohol. Such a reduction in risk is potentially of clinical importance, but consumption of larger amounts of alcohol was associated with higher risks for stroke incidence and mortality.

The protective association of alcohol has been consistently observed in diverse patient populations and in both women and men. Fourthly, the association is specific: moderate drinking (up to 1 drink or 12.5 g alcohol per day for women and 2 drinks or 25 g alcohol per day for men is associated with lower rates of cardiovascular disease but is not uniformly protective for other conditions, such as cancer. But one should remember that hemorrhagic stroke in more in the alcoholics.
The focus  trials would shift from assessing the association between alcohol and disease outcomes to evaluating the receptivity of both physicians and patients to the recommended consumption of alcohol for therapeutic purposes and the extent to which it can be successfully and safely implemented. In support of implementation trials, our two papers show that alcohol consumption in moderation has reproducible and plausible effects on markers of coronary heart disease risk.The total consumption of alcoholic beverages in India is expected to touch 217.1 million cases in 2010, marking a growth of 8 per cent from the previous year, according to a report.
The Emerging Ideal
While alcohol consumption is low overall, it's even lower in women than in men in India, as in many countries. Though data is limited, studies through 2000 consistently estimated prevalence of alcohol use among Indian women at less than 5 percent. In addition, there is a persistent belief that women who drink alcohol are either less educated, rural women or members of the upper crust, leading to a stereotype that associates alcohol use with primitivism or privilege.
However, drinking is becoming more commonplace for India's professional women, causing the gap between drinking habits of women and men in India to narrow--a phenomenon also happening around the world. As women become more educated and more economically independent, women's alcohol use in some societies is rising. (And men's alcohol use, interestingly, is falling in some European countries.)
One contributor in India is employment. Though labor force participation dropped between 1999 and 2002 for rural females, rural males, and urban males, it rose for urban females. Contrary to the historical stereotype, these urban females now consume alcohol at twice the rate of their rural counterparts.

Sarah Bosa et al (European Jl of cardiovascular prevention and rehabilitation) concluded that moderate alcohol consumption is associated with a reduced risk of CHD among hypertensive women. Light alcohol consumption tended to be related to a lower risk of stroke. Current guidelines for alcohol consumption in the general population also apply to hypertensive women.

We can expect changes in the coming years in a country like India and that may depend on the many social  ethical and cultural issues.

Atorvastatin Linked to Small Increase in Risk for Type 2 Diabetes

Simvastatin, Atorvastatin, Rosuvastatin are now available in India. They have been found to be very effective in preventing the secondary cardiovascular complications. There are some complications such as reduction of HDL or inability to raise the HDL, new onset Diabetes ( physician reported diabetes). Atorvastatin seems to carry a "slight increase in the risk" for new-onset type 2 diabetes, according to an analysis of three large trials published in the Journal of the American College of Cardiology. (The trials, as well as this analysis, were sponsored by atorvastatin's manufacturer.)
Researchers were responding to a 2010 Lancet meta-analysis, which found a small but measurable risk for new-onset diabetes after all statin use. The current analysis focuses on atorvastatin's effects in the TNT, IDEAL, and SPARCL trials. It found that atorvastatin, when compared with placebo in the SPARCL trial, carries a higher risk for diabetes. In the other trials, there was a slightly increased risk when an 80-mg dose was compared with lower doses (10-mg atorvastatin in TNT, 20-mg simvastatin in IDEAL), but the differences did not achieve statistical significance.

The JACC authors conclude (as did the authors of the Lancet meta-analysis) that the benefits of statins "far outweigh the risks."

DVT awareness Month - March 2011

Photo: Melanie ( David Bloom NBC reporter) -National spokes person (USA) for Coalition against deep vein thrombosis

Venous thrombosis and pulmonary embolism are important clinical conditions that occur in the hospitalized patients. The mortality and morbidity associated with them can be prevented by precautions and medical therapies prior to their onset. Hospitals are encouraged to have written protocols to prevent venous thromboembolism in the hospitalized patients. Heparin, oral anticoagulants are regularly used in the prevention and treatment of VTE. The newer oral direct Xa inhibitors are undergoing phase III trials and soon there is a possibility that they are going to be released in to the market 2013. Riveroxaban, Apixaban, Edoxaban are going to be used in the treatment of deep vein thrombosis without much biochemical monitoring. Thrombolytic usage may increase in the coming years with an idea to prevent post thrombotic syndrome which is currently expected to be as high as 50%. During this month we organized many meetings in the hospitals to share the information and educate the hospital staff. DVT Awareness Meetings were conducted in all the major cities by doctors with lot of enthusiasm. The findings of ENDORSE study were discussed and it was stressed that 50% of the patients getting admitted in to the acute care hospitals are at risk of VTE and only 16% of the surgical and 19% of the medical patients who are at risk of the VTE received the thrombosis prophylaxis. More efforts are needed to identify the patients at risk with the help of RAMs ( risk assessment modules) and adequate prophylactic measures should be taken to reduce the DVT, PE related and deaths and post thrombotic syndrome.

World Health Day – 7 April 2011

Antimicrobial resistance and its global spread

• Antimicrobial resistance: no action today no cure tomorrow
  We live in an era of medical breakthroughs with new wonder drugs available to treat conditions that a few decades ago, or even a few years ago in the case of HIV/AIDS, would have proved fatal. For World Health Day 2011, WHO will launch a worldwide campaign to safeguard these medicines for future generations. Antimicrobial resistance and its global spread threaten the continued effectiveness of many medicines used today to treat the sick, while at the same time it risks jeopardizing important advances being made against major infectious killers.

Negative Pressure Wound Therapy With Integrated Irrigation for the Treatment of Diabetic Foot Ulcers

 In India, diabetic foot wound care is found to be expensive and usually neglected. That results in increased morbidity, mortality. Offloading is not routinely given in clinics  and patients are not adequately convinced that such a foot wear is helpful to them. Preventing diabetic foot ulcers from progressing in depth and becoming infected and developing into more serious conditions is not only clinically beneficial but also has a positive impact on health care resources.
Given the high costs of non healing wounds and the associated negative impact on patient quality of life, outpatient interventions that prevent ulcer progression and promote healing are of benefit to patients and clinicians. The recently introduced NPWT, is decreasing the healing time and effective too in controlling the infection. In Hyderabad, India- VAC (Vacum assisted closure) therapy is now available both in the hospitals and at the home. It is costing Rs.10,000 to Rs20,000 depending on the duration of the therapy.
In a prospective study conducted in a clinic setting, NPWT using the Svedman Wound Treatment System with irrigation was successful in facilitating wound closure and healing in both large and small wounds resulting from complications of diabetic neuropathy and pressure on the distal lower limb. Wound irrigation in addition to the negative pressure further facilitates the healing and control of infection. In other words after a long period of time the diabetic foot wound care is becoming more simpler and effective. This NPWT is added to the adequate and repeated debridements and skin grafting.

Can we treat the Aortic Aneurysms medically?

Abdominal aortic aneurysms (AAA) continue to provide an intractable clinical problem. As a disease that affects nearly 10% of the elderly population and claims over 15,000 lives/yr (USA), it is remarkable that treatment of a ruptured AAA is still associated with high mortality rates (in excess of 80%). Many would argue that physicians remain largely incapable of altering the natural history of this disease, despite our growing understanding of the pathophysiology of the vascular lesion. Several promising therapies, including statins, β-blockers, and antibiotics, have all failed to conclusively improve outcomes in large clinical trials, and no medicine is currently approved to treat AAA formation. In clinical management of Aortic Aneurysms, doctors and patients are often faced with the important decision of whether to perform invasive repair or to manage the condition conservatively. The mortality rate associated with reparative surgery has been reported to be as high as 5.5%.Current guidelines recommend endovascular repair or surgery if the aortic diameter exceeds 5.5 cm and the performance of anatomic imaging every 3 to 6 months for aneurysms above 4 cm. If growth is observed to exceed 1 cm per year in smaller aneurysms, surgical repair is also recommended. However, individual risk is also influenced by gender, age, smoking, and co-morbidities, but its assessment is rarely easy because reliable data regarding how best to evaluate these variables are not readily available. This situation often leaves one with a difficult decision, and many patients are unnecessarily exposed to the risks of reparative surgery when their aneurysm might never have ruptured if left untreated.
Aneurysms are complex entities that differ physiologically from stenotic and atherosclerotic vascular lesions. Although atheromas are dominated by neointimal proliferation and foam cell generation, the AAA is defined by the progressive loss of extracellular matrix and medial degeneration. Macrophages are recruited to the involved vessel in both conditions, but have differing roles in each case. Unlike the subendothelial lipid-laden cells of the fatty streak, macrophages of the abdominal aneurysm accumulate in the medial layer where they present antigens to other leukocytes, secrete collagenases, and elaborate proinflammatory cytokines and chemoattractants. Ultimately, they play a role in progressive aneurysmal dilation and clinical presentation. Novel therapies that can reverse this pathological course are eagerly sought.
A number of studies in patients have suggested that doxycycline can inhibit MMPs in aneurysm tissue. Curci et al66 treated a series of patients with a 3-week course of doxycycline before open aneurysm repair. Tissue levels of MMP-9 were significantly reduced by doxycycline compared with untreated patients. Baxter et al showed in a small series of 36 patients on a 6-month course of doxycycline that plasma MMP-9 levels decreased significantly compared with baseline levels. This work has been followed by a small, prospective, randomized trial of doxycycline in which 32 patients were randomized, with 17 receiving doxycycline (150 mg/d) for 3 months. Patients were followed up for 18 months. C pneumoniae titers were assessed but found not to be affected by doxycycline treatment. The calculated growth rate at the end of the 18-month period of observation was 1.5 mm per year in the doxycycline-treated group versus 3.0 mm per year in the placebo-treated group. This difference did not achieve statistical significance, but the 6- and 12-month time periods did show a significant difference in favor of doxycycline treatment. Level B evidence (from small randomized trials) suggests that roxithromycin or doxycycline will decrease the rate of aneurysm expansion.
A small study by Lindholt et al suggested that serological evidence of a C pneumoniae infection was associated with an increased rate of aneurysm expansion. This led to a randomized clinical trial in which 43 patients received a 1-month course of roxithromycin, whereas 49 patients received placebo.60 Patients in the treatment arm had an expansion rate at the end of the study of 1.56 mm per year compared with a rate of 2.75 mm per year in the placebo-treated group. The inhibition was greater in the first year than the second year. The study did not clarify the mechanism of effect because there was no correlation between Chlamydia titers and roxithromycin ability to inhibit aneurysm expansion.
We need more medical therapies which can alter the natural course of the small aneurysms and prevent the rupture of these Aortic aneurysms which are diagnosed when they are small and note taken up for the interventions.

Risk assessment for recurrent venous thrombosis

(Number of risk factors identified by laboratory screening for thrombophilia in 158 patients without cancer with two episodes of unprovoked venous thrombosis, 3 weeks after the incident event, patients were screened for deficiency of antithrombin, protein C, or protein S; presence of lupus anticoagulant, factor V Leiden, factor II G20210A; and high concentrations of homocysteine, factor VIII, or factor IX.)

Recurrent Thrombosis is going to increase the morbidity and mortality. If there are two episodes of unprovoked DVT  without cancer, we can expect that there is some kind of hypercoagulable condition with one or more risk factors.

FIELD study - Can we reduce the amputations in Diabetic population with Fenofibrate?

Diabetes mellitus is the leading cause of non-traumatic lower-extremity amputations in the developed world. In the USA in 2001, at least one amputation due to diabetes occurred every 2 h, with an annual cost exceeding US$1·6 billion.Despite rigorous management of reversible factors, probably around one in ten patients with diabetes will eventually need at least one amputation. Neither control of glycaemia or blood pressure nor lowering of cholesterol has prevented the risk of amputation, underscoring the importance of assessing the management of other potential risk factors. Any further therapeutic option to prevent the morbidity and mortality associated with amputation would be highly desirable. In the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study, 9795 patients aged 50—75 years with type 2 diabetes were randomly assigned by computer-generated randomisation sequence to receive fenofibrate 200 mg per day (n=4895) or matching placebo (n=4900) for 5 years' duration. Information about non-traumatic amputation—a prespecified tertiary endpoint of the study—was routinely gathered.The risks of first amputation (45 vs 70 events; hazard ratio [HR] 0·64, 95% CI 0·44—0·94; p=0·02) and minor amputation events without known large-vessel disease (18 vs 34 events; 0·53, 0·30—0·94; p=0·027) were lower for patients assigned to fenofibrate than for patients assigned to placebo, with no difference between groups in risk of major amputations (24 vs 26 events; 0·93, 0·53—1·62; p=0·79)

In POPADAD study, it was found that Aspirin is ineffective in Diabetics with Asymptomatic Peripheral Vascular Disease for primary prophylaxis! (BMJ 2008)

Peripheral arterial disease patients have an increased risk of subsequent myocardial infarction and stroke and are six times more likely to die from cardiovascular disease within10 years than patients without peripheral arterial disease. Patients with peripheral arterial disease have a 15 year accrued survival rate of about 22% compared with a survival rate of 78% in patients without such disease. So, there is always a question about beneficial effect and safety in giving Aspirin in the asymptomatic PAD patients to prevent the CV complications!

After this POPADAD study a question was asked as to whether these diabetic patients were at sufficient risk, in terms of peripheral arterial disease, as the cut-off point of an ankle brachial pressure index of 0.99 or less is higher than that used to define peripheral arterial disease in the population (<0.9). A subgroup analysis did not, however, find evidence of a difference in effect of aspirin between those with an index of 0.91-0.99 and those below this level.
Furthermore, one of the current major interventions in the specialty of diabetes mellitus is statin therapy. Calculations by two of the centres (DM and CK) in over 10 000 people with diabetes showed a mean total cholesterol level of 6.0 mmol/l in 1996 decreasing to 4.3 mmol/l in 2007. As aspirin was the first drug to have an evidence base for secondary prevention of cardiovascular disease it is always given to patients in subsequent trials and it might be asked if aspirin does indeed provide additional benefit when statins are used to good effect. The importance of the neutral effect of aspirin on cardiovascular events is that this drug is not without side effects. Aspirin is the most commonly prescribed drug in Scotland, with about 544 438 person years exposure per year in 2002. The number of prescriptions is increasing. The overwhelming majority of this, in the region of Tayside at least, is prescription based, with only about 7% being from over the counter use. Aspirin is one of the top 10 causes of adverse drug events reported to the Commission on Human Medicines. Gastrointestinal bleeding is associated ith general use of non-steroidal anti-inflammatory drugs in over 80%of reported cases, and 87%of that use is associated with aspirin, either alone or with other non-steroidal anti-inflammatory drugs. The risk of a bleeding event increases with age and also continuous exposure.
Although the calculated risk of major bleeding is relatively small, the number of people taking aspirin is relatively large and therefore in population terms aspirin induced bleeding is a major problem. In a meta-analysis the number needed to treat to cause an adverse event has been calculated as 248, and this is relevant to the large and increasing population with diabetes.
In addition, of concern was the fact that there was a tendency to harm in the antioxidant group. Anecdotally, many people with diabetes supplement with antioxidants after major publicity in the lay press of a deficiency in antioxidants in such people. It was also found there was no evidence for this perceived benefit in the studies.

Conclusion: Both Aspirin and Antioxidants are not useful in Diabetics with asymptomatic peripheral vascular disease in preventing the cardiovascular events!

Helicobacter pylori  in smokers with peripheral vascular disease - Shoud we consider quadruple therapy for eradication routinely?

Infection with Helicobacter pylori is a substantial public health problem that affects 20 to 50% of people in industrialised nations and up to 80% in less-developed countries. H pylori is associated with many gastroduodenal disorders, including peptic ulcer disease, gastric carcinoma, and gastric mucosa-associated lymphoid tissue lymphoma. In regions with high incidence of gastric carcinoma, eradication of H pylori is advocated to prevent the development of this disease. Further, patients benefit from eradication after endoscopic resection of early gastric carcinoma because it reduces the risk for metachronous gastric neoplasia.
A previous international study, which assessed the efficacy and safety of 10 days of omeprazole with a single (three-in-one) capsule containing bismuth subcitrate potassium, metronidazole, and tetracycline (quadruple therapy) for H pylori eradication in patients with peptic ulcer disease or non-ulcer dyspepsia, reported overall eradication rates greater than 90%.

Quadruple therapy should be considered for first-line treatment in view of the rising prevalence of clarithromycin-resistant H pylori, especially since quadruple therapy provides superior eradication with similar safety and tolerability to standard therapy.

Long term follow up (8 yrs) after Endorepair of Thoracic Aortic dissection.

This gentleman was admitted with acute ischemia in both the lower limbs in middle of the night and in emergency the resident on duty attempted thrombectomy but failed to retreive the thrombus. The next morning further investigations revealed dissection of aorta from the left subclavian origin to abdominal aortic bifurcation. After discussions it was decided to do the endorepair. Endorepair was successfully done and remained intact for the past 8 years. He has developed diabetes in the followup. His blood pressure was controlled with medications and he is advised to monitor blood pressure regularly at home.