Breast Cancer and Venous disease is there an association ?

Pathophysiology of Charcot's disease

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3733015/

Charcot arthropathy of the foot is a rare but devastating complication of diabetes that remains to be a challenging issue for the foot and ankle surgeons. Charcot foot fails to be an obvious diagnostic option that comes to mind, even in a pathognomonic clinical appearance. The rarity of the disorder, more common pathologies that mimic the condition, and the self-limiting prognosis deviate the clinician from the right diagnosis. The clinical challenges in the diagnosis of Charcot foot require in-depth investigations of its enigmatic nature to establish useful guidelines. Yet, this goal seems to be beyond reach, without a holistic view of the immense literature concerning the pathophysiology of the disorder.

In recent studies, many authors have emphasized the disturbance of the inflammatory cycle in the core of Charcot foot pathophysiology. Usually minor injuries which are even unrecognized, local infection or a minor surgery may prompt this sequence of events. Without the protective behavior ensured by the pain, in the insensate, neuropathic foot of a diabetic patient this cycle is flared up by repeated traumatic events. Genetic variations that affect the balance between pre- and anti-inflammatory chemo-attractants may predispose a patient to Charcot foot . This theory which has been proposed by two different studies conducted in different populations is a breakthrough for researchers who dedicated their work to Charcot foot. Genetic variations can explain a patient's tendency to pro-inflammatory status, and ultimately may put forth a solid answer why a majority of neuropathic patients are spared from Charcot arthropathy.

Finally, it is often difficult to isolate and experiment the contribution of a single factor in this complex and multifactorial phenomenon. This fact precludes the construction of experimental models to reveal single factor contributions or gathering of adequate (appropriate) control groups for blinded control studies. This suggestion can be adapted to Charcot foot that develops as a result of a subsequent dysfunction concerning different systems which cannot be separated and observed solely. This stalemate can be addressed with prospective studies and a larger number of patients.

18F-FDG PET and PET/CT for the diagnosis of diabetic foot osteomyelitis

Early detection of the grade of diabetic foot infections helps in planning and treating the infections and also helps in assessing the prognosis and risk of limb loss. 

X-ray of foot, CT scan or MRI scan are helpful to detect the infections in the depths of the wound and bone involvement. But we would like to know the infection much earlier more accurately. PET scans may of some help in detecting the septic complications in the foot, but we don't know if PET CT is any better than the available methods. Recently as study was done and found that PET is no better than the available methods. The accuracy of 18F-FDG-PET and PET/CT for the diagnosis of diabetic foot osteomyelitis is, at the moment, far from encouraging. However, results should still be perhaps described as only preliminary. Indeed, additional investigation is needed, and future works should include more patients and be more precise in the reference method for the confirmation of osteomyelitis. More caution is also required in patient selection, to avoid those with excessive hyper- or hypoglycaemia. Indeed, such glucose fluctuations may, in theory, affect 18F-FDG tissue uptake, although this remains to be quantified. Further work towards standardisation of technological details and options of interpretation is urgently awaited, as well. In Greece, these modalities are only available on a very restricted basis, emphasising the need for further experience. Moreover, their use should be reasonable and affordable, in harmony with the financial restraints due to the current economic crisis. There is, certainly, still a long way to go, but improved early diagnosis of diabetic foot infections is a goal worth pursuing.

Varicose veins - Surgery is no poor cousin to Laser at 5 years follow-up

The newer varicose therapies are looking attractive for many, butWe all should think of the cost of these therapies in India and reach the majority in India!

Randomized clinical trial comparing endovenous laser ablation and stripping of the great saphenous vein with clinical and duplex outcome after 5 years - Journal of Vascular Surgery Volume 58, Issue 2 , Pages 421-426, August 2013 - Presented at the Annual Meeting of The American College of Phlebology (winner of best abstract), Hollywood, Fla, November 15-18, 2012.

Lars Rasmussen, MD  Reprint requests: Lars Rasmussen, MD, The Danish Vein Centers, Eskadronsvej 4A, 4700 Naestved, Denmark., Martin Lawaetz, MB, Lars Bjoern, MD, Allan Blemings, MSc, Bo Eklof, MD, PhD
Danish Vein Centers, Åreknudeklinikken, and Surgical Center Roskilde, Naestved, Denmark

Abstract  This is the first randomized controlled trial with a 5-year follow-up comparing endovenous laser ablation (EVLA) with high ligation and pin-stripping in patients with great saphenous vein (GSV) incompetence.

Methods : One hundred twenty-one consecutive patients (137 legs) with GSV incompetence were randomized to EVLA (980 nm bare fiber) or high ligation and stripping using tumescent local anesthesia with light sedation. Mini-phlebectomies were performed in all patients. The patients were examined with duplex scanning before treatment and after 12 days, and then after 1, 3, and 6 months, and yearly thereafter for up to 5 years. The primary end point was open refluxing GSV. Secondary end points were recurrent varicose veins, frequency of reoperations, Venous Clinical Severity Score, and quality of life scores (Aberdeen Varicose Vein Symptoms Severity Score and Short Form-36).

Results : In the EVLA and stripping group, nine (Kaplan-Meier [KM] estimate, 17.9%) and four (KM estimate, 10.1%) of GSVs had open refluxing segments of 5 cm or more (ns). Clinical recurrence was recorded in 24 (KM estimate, 46.6%) and 25 (KM estimate, 54.6%), whereas reoperations were performed in 17 (KM estimate, 38.6%) and 15 (KM estimate, 37.7%) legs (ns). Venous Clinical Severity Score and Aberdeen Varicose Vein Symptoms Severity Score improved whereas Medical Outcomes Study Short Form-36 quality of life score improved in several domains in both groups with no difference between the groups.

Conclusions : Five-year follow-up of our randomized controlled trial comparing EVLA with open surgery in patients with GSV incompetence did not show any significant difference between the two groups in primary or secondary end points, perhaps because of the small sample size. EVLA seems to be a valid alternative to open surgery.

Unexpected cause of thrombotic complications

Case Report

A 51-year-old woman was admitted to the internal medicine department in a state of shock of unclear etiology. She was hypotensive, tachycardic, and dyspneic, with incipient blue mask. On ECG the typical signs of pulmonary embolism were detected (Figure 1) and according to the CT-pulmo-angiographic examination, bilateral massive pulmonary embolism was clearly confirmed (Figure 2). The shock was immediately treated with volume expanders (Gelafundine 500 ml intravenously 6 times) and vasoactive therapy (Noradrenaline 8 mg in 5% glucose 500 ml, 1ml/hour intravenously) was begun.

After getting the patient´s condition under control, thrombolytic therapy was initiated. According to current guidelines, the thrombolytic therapy was started with an intravenous bolus of alteplase 10 mg and then 40 mg intravenously during the first hour and 50 mg intravenously during the second hour. Intravenous anticoagulation with heparin was initiated after alteplase treatment to complete the treatment (Heparin 10 000 j. bolus and consequently 1000 units/hour intravenously). This therapy was administrated with a positive effect and led to the stabilization of patient´s condition. After stabilization of patient´s condition, the cause of pulmonary embolism was investigated, but there was nothing in the history suggesting a cause. The patient was normostenic, with BMI 23, a non-smoker, without hormonal therapy or contraception.

Except of a simple infection of the upper airways last month, she was healthy, without any history of serious internal diseases, trauma, or surgery. According to the differential diagnosis of pulmonary embolism, the patient underwent deep venous system ultrasonography, but no thrombosis was found. To exclude inflammation as an etiologic agent, a search for all focuses was subsequently conducted.

The patient was examined by a stomatologist and an otorhinolaryngologist; cultivation of nasal and throat swabs was done and gastrofibroscopy was also preformed, but no pathology was found. Gynecological examination was without any pathological finding, except for a hematoma of the right breast as a side effect of thrombolysis. Screening for oncologic diseases (hemoccult testing of stool, onco markers – CA 19-9, 125, 15-3, CEA, alpha-phetoprotein, CT of lungs and abdomen) was also negative; therefore, after this step the complete hematological examination for excluding the hereditary coagulation disorder was performed, but all results were normal (Table 1). Only a slight elevation of coagulation factor VIII was detected, but was most likely reactive. In DNA analysis, only the heterozygote form of MTHFR mutation was found.

Fig 1 :  ECG of patient

Fig 2: Spiral CT angiography shoing Bilateral PE

showed bilateral PE 

Table 1

Haematological screening for the thrombophilic state.

PCR DNA analysis	Coagulation factors function	Natural coagulation inhibitors
Methyl Tetrahydrofolate Reductase C677T: C/T Factor V Leiden R506Q: G/G Factor II ntG20210A: G/G CYP4V2 p.Q259K: K/K (*cytochrome P450, family 4, subfamily V, polypeptide 2) Factor XI: c.56-282T>c: C/T Factor XI: c.1481-188C>T: C/T	Factor VIII function: 1,883 IU/ml Factor XI function: 1,35 IU/ml	Antithrombin III function: 104,2% Protein C function: 135% Protein S function: 84%
Screening for antiphospholipid syndrome
1.) Anti-β2-glycoprotein I: 1,8 IU/ml 2.) Kaolin clotting time - ratio: 0,87 3.) Dilute Russell’s Viper Venom Time - ratio: 1,12
4.) Tissue thromboplastin inhibition (TTI) * TTI 1: 50 ratio: 1,28 * TTI 1: 500 ratio: 1,62
5.) Partial thromboplastin time - lag time (PTT-LT) * PTT – LT control: 33s * PTT - LT patient: 35s * PTT – LT ratio: 1,061
6.) Partial thromboplastin time – lupus anticoagulans (PTT-LA) * PTT – LA control: 30s * PTT – LA patient: 34,4s * PTT-LA ratio: 1,14

^*DNA CYP4 and DNA factor XI were examined just in frame of the research of importance of these polymorphisms for venous thrombembolism incidence.

After completion of all screening examinations to clarify the etiology of pulmonary embolism, we decided to examine the platelet aggregometry. Although SPS does not typical cause pulmonary embolism, in our patient we confirmed SPS type I using optical aggregometry

Discussion: SPS is a hereditary thrombophilia, first described in the literature in 1983, but for a long time it has been primarily just a theoretical term with little practical basis. In 1995 it was proposed as a possible cause of unexplained arterial and venous thromboses [1]. According to Bick et al. [1] SPS is responsible for 21% of arterial and 13.2% of venous thromboembolic events that are otherwise unexplainable. However, in the literature it is predominantly known as a hematologic disorder connected with arterial thrombosis. There are just a few publications about the venous complications of this syndrome.

This hereditary, probably autosomally dominant, platelet disorder can be diagnosed by using platelet aggregometry, which makes confirmation easy if the hyperaggregability of platelets is induced by subliminal concentrations of adenosine diphosphate (ADP) and epinephrine (type I), epinephrine alone (type II), or ADP alone (type III) [2,5]. After activated protein C resistance, it is the second most frequent hereditary thrombophilia, and it has been suggested that it is connected with other hereditary thrombophilic states [3]. Clinically, patients may present with symptoms of acute coronary syndrome, transient cerebral ischemic attacks, stroke, retinal thrombosis, peripheral arterial thrombosis, and venous thrombosis [5].

In this case, the SPS was also the only found risk factor explaining why a quite healthy young woman with no coagulation-influencing treatment had a highly fatal pulmonary embolism. After stabilizing the patient’s condition and providing thrombolytic therapy, we started to search for the etiology of the thromboembolic event. But all basal examinations – exclusion of inflammatory and oncologic disease, and deep vein thrombosis – were negative. We continued with the screening of hereditary thrombophilia. A slight elevation of coagulation factor VIII was detected, which was most likely reactive (factor VIII is the reactant of acute phase reaction) [10], and its role as an important risk factor for venous thromboembolism is not generally accepted [11]. DNA analysis revealed the heterozygote form of methylenetetrahydrofolate reductase (MTHFR) mutation. This hereditary disorder is often connected to folic acid and vitamin B12 metabolism, and if patient has a normal level of homocysteine it is not clinically significant for the hemostatic disorder [12,13].

Nowadays, the examination of SPS is a standard part of thrombophilic screening in some hemostasis and thrombosis centres, especially in patients under age 35 years after an attack of arterial thrombosis and in patients with repeated or progressive occurrence of vein thrombosis despite anticoagulation therapy [5]. These requirements were not met by our patient

But when all performed examinations seemed to yield negative results, we decided to try platelet aggregometry, with a positive result for SPS type I. In the literature, the combination of SPS with other hereditary thrombophilic states has been described in patients with arterial and venous thrombosis, but in our case a single SPS seems to have caused the thromboembolic event.

Conclusions

Although sticky platelets syndrome has been known since 1983 [1], it is still a new phenomenon, and few clinicians have practical experience in dealing with it. Clinically, this syndrome can be silent, or it can be presented by stroke, transient cerebral ischemic attacks, acute coronary syndrome, and arterial or venous thrombosis [5]. Although some previous reports found that SPS can be responsible for 21% of arterial thrombosis and 13.2% of venous thrombosis unexplainable by another reason, most data in the literature associates it with arterial thromboembolism [1,14]. However, the results from recently a published study suggest that it may be a more frequent cause of venous thrombosis/pulmonary embolism than is traditionally thought [15]. The criteria for its screening are limited and include only patients under age 35 and who have had arterial thrombosis, as well as patients with repeating or progressive occurrence of vein thrombosis despite anticoagulation therapy [5]. In the routine hematological screening of hereditary thrombophilia, this examination is not included. SPS testing is known and easy, but perhaps due to lack of practical experience with this thrombophilia, it is not part of the routine examination of hereditary thrombophilia. Despite this lack of clinical experience, SPS is serious risk factor for patient health and thus the benefit of SPS testing for the standard screening of thrombophilia deserves consideration.

References:

1. Bick RL. Sticky platelet syndrome: a common cause of unexplained arterial and venous thrombosis.Clin Appl Thromb Hemost. 1998;2:77–81.

2. Bartošová L, Dobrotová M, Hollý P, et al. Sticky platelet syndrome – its diagnostics and therapy. Lek Obz. 2008;7–8:512–13. [in Slovak]

3. Kubisz P, Ivanková J, Hollý P, et al. The glycoprotein IIIa PLA1/A2 polymorphism – a defect responsible for Sticky platelet syndrome? Clin Appl Thromb Hemost. 2006;1:117–19. [PubMed]

4. Muňoz X, Obach V, Hurtado B, et al. Association of specific haplotypes of GAS6 gene with stroke.Thromb Haemost. 2007;2:406–12. [PubMed]

5. Mammen EF. Ten years’ experience with the “Sticky platelet syndrome” Clin Appl Thromb Hemost.1995;1:66–72.

6. Šimonová R, Bartošová L, Chudý P, et al. Nine kindreds of familiar Sticky platelet syndrome phenotype. Clin Appl Thromb Hemost. 2012 [Epub ahead of print] [PubMed]

7. Rac MW, Minns Crawford N, Worley KC. Extensive thrombosis and first trimester pregnancy loss caused by sticky platelet syndrome. Obstet Gynecol. 2011;117:501–3. [PubMed]

8. Kahles H, Trobisch H, Kehren H. Disseminated coronary oclusion and massive pulmonary embolism in a 40-year-old women. Dtsch Med Wochenschr. 2006;131(13):672–75. [PubMed]

9. Muhlfeld AS, Kettcher M, Schwamborn K, et al. Sticky platelet syndrome: an unrrecognised cause of graft dysfunction and thromboembolic complications in renal transplant recipients. Am J Transplant.2007;7:1865–68. [PubMed]

10. Cucuianu M, Plesca Z, Bodizs G, et al. Acute phase reaction and the hemostatic balance. Rom J Intern Med. 1996;34:13–18. [PubMed]

11. Kyrle PA. High factor VIII and the risk of venous thromboembolism. Hämostaseologie. 2003;23:41–44. [PubMed]

12. Yin G, Yan Z, Chen K, Jin X. C677T methylentetrahydrofolate reductase polymorphism as a risk factor involved in venous thromboembolism: A population based case – control study. Mol Med Report.2012;6:1271–75. [PubMed]

13. Gouvela LO, Canhao P. MTHFR and the risk for cerebral venous thrombosis – a meta – analysis.Thromb Res. 2010;125:153–58. [PubMed]

14. Kannan S, Dhanasegaran S, Raji V. Recurrent arterial thrombosis In a young male: Sticky Platelet Syndrome. The Internet Journal of Hematology. 2008;4(1) 10.5580/d76.

15. Kotuličová D, Chudý P, Škereňová M, et al. Variability of GP6 gene in patients with sticky platelet syndrome and deep venous thrombosis and/or pulmonary embolism. Blood Coagul Fibrinolysis.2012;23:543–47. [PubMed]

Abdominal aortic aneurysm at the level of renal arteries

Death declaration in AP govt hospitals is going to be mandatory !

AP govt hospitals should make brain death declaration mandatory: medical experts

Our Bureau, Hyderabad Friday, August 09, 2013, 08:00 Hrs  [IST]

Medical experts stress that a ‘brain-dead’ declaration must be made mandatory in government hospitals in Andhra Pradesh. This will help to identify potential organ donors. On Organ Donation Day, observed on August 6, health counsellors and doctors explained that currently they are struggling to identify brain-dead patients, which is proving to be an uphill task. The Jeevandan Scheme has had 114 organs donated from 26 people between January and July 2013, but there is a strong need for more work. The problem is lack of awareness among the public and sensitisation of the medical fraternity. Neurologists responsible for declaring an individual brain-dead are not always sensitive about connecting the families to the government counselors for organ donation, claim members of the scheme. A senior official of the Jeevandan Scheme said, “The priority of a neurologist is to try and save the patient. But when they find that the patient is brain-dead, they ask the family to take the patient away. It’s here that the counselors for organ donation need to be introduced to sensitise the family to retrieve the organs. In 60 per cent of the cases, family members are found to agree.” The benefit of the declaration will be that hospitals can work faster towards sensitising the relatives than they do at present. Lalitha Raghuram, country director for Mohan Foundation said, “A declaration does not mean compulsory donation. It simply means that the government and organ donation committee is aware and can try their best to get consent for donation. Often people are willing to come forward to help.” Apart from technical reasons like neurologists, another important aspect is the abysmally low number of hospitals registered with the scheme. Currently, only 25 hospitals are registered, of which 18 have facilities for organ transplants. For other small hospitals and nursing homes, the quotient of benefit needs to be identified to motivate them. As the scheme struggles with the ground realities of organ donation, the scene in the country is no different with only 1,000 organs donated in the 2012, of which Chennai topped the list with 216. With changes in lifestyle, diseases are increasing, indicating dependency on organ donation to be a major need for the future.

IVC filters in Trauma Patients for thromboprophylaxis ?

Prophylactic IVCFs should be inserted within 48 hours of injury in specific trauma patients at high risk for PE and with contraindications to anticoagulation.

INFERIOR VENA cava filters (IVCFs) are being used with increasing frequency in trauma patients because of the heightened risk of deep vein thrombosis (DVT) and threat of subsequent pulmonary embolism (PE). The incidence of DVT in trauma patients may be as high as 20% to 58%, and the true incidence of PE is unknown. Unfortunately, some investigators have found that routine thromboembolism prophylaxis with sequential compression devices (SCDs), and low-dose heparin sodium is relatively ineffective in high-risk trauma patients. Additionally, many patients are not candidates for anticoagulation because of their associated traumatic injuries, and SCDs may be difficult to place on patients with major long-bone fractures.

Clinical signs of DVT are generally absent, and fatal PE frequently occurs without prior warning, with only a third of fatal PE cases diagnosed before death. Thus, insertion of IVCFs in high-risk trauma patients prior to DVT and/or PE should be able to reduce the incidence of lethal PE. The development of safe and effective, percutaneously placed IVCFs has stimulated an increase in the use of prophylactic IVCFs in high-risk trauma patients in an effort to reduce the incidence of PE.Some institutions have noted a decreased incidence of PE in trauma patients with prophylactic IVCFs.Others, however, have demonstrated conflicting results, noting no difference or an actual increase in the incidence of PE with prophylactic IVCFs.

http://archsurg.jamanetwork.com/article.aspx?articleid=212470

Guidelines for the treatment of antiphospholipid syndrome

The antiphospholipid syndrome (APS) is a systemic autoimmune disease characterized
by arterial and venous thrombosis, gestational morbidity and presence of elevated and
persistently positive serum titers of antiphospholipid antibodies. The treatment of APS is
still controversial, because any therapeutic decision potentially faces the risk of an insuffi cient or excessive antithrombotic coverage associated with anticoagulation and its major
adverse effects. This guideline was elaborated from nine relevant clinical questions related
to the treatment of APS by the Committee of Vasculopathies of the Brazilian Society of
Rheumatology. Thus, this study aimed at establishing a guideline that included the most
relevant and controversial questions in APS treatment, based on the best scientifi c evidence available. The questions were structured by use of the PICO (patient, intervention or
indicator, comparison and outcome) process, enabling the generation of search strategies
for evidence in the major primary scientifi c databases (MEDLINE/PubMed, Embase, Lilacs,
Scielo, Cochrane Library, Premedline via OVID). A manual search for evidence and theses
was also conducted (BDTD and IBICT). The evidence retrieved was selected based on critical assessment by using discriminatory instruments (scores) according to the category of
the therapeutic question (JADAD scale for randomized clinical trials and Newcastle-Ottawa
scale for non-randomized studies). After defining the potential studies to support the recommendations, they were selected according to level of evidence and grade of recommendation, according to the Oxford classification.
http://www.scielo.br/pdf/rbr/v53n2/en_v53n2a05.pdf

Thromboprophylaxis for Orthopedic patients in Turkey

Fracture neck of femur surgery, total hip replacement, total knee replacement patients are at high risk of developing VTE as seen in western population. In India, there are still mixed opinions among the orthopedic surgeons about the increased risk of VTE in Indian population going for orthopedic surgeries.

It is interesting to note the results of the study from Turkey given below. this is a large study and worth to note their findings.

J Bras Pneumol. 2013 Jun;39(3). 

Does thromboprophylaxis prevent venous thromboembolism after major orthopedic surgery?Akpinar EE, Hosgün D, Akan B, Ates C, Gülhan M. Source  Ufuk University, Department of Chest Diseases, Ankara, Turkey.Abstract

OBJECTIVE:

Pulmonary embolism (PE) is an important complication of major orthopedic surgery. The aim of this study was to evaluate the incidence of venous thromboembolism (VTE) and factors influencing the development of VTE in patients undergoing major orthopedic surgery in a university hospital.

METHODS:

Patients who underwent major orthopedic surgery (hip arthroplasty, knee arthroplasty, or femur fracture repair) between February of 2006 and June of 2012 were retrospectively included in the study. The incidences of PE and deep vein thrombosis (DVT) were evaluated, as were the factors influencing their development, such as type of operation, age, and comorbidities.

RESULTS:

We reviewed the medical records of 1,306 patients. The proportions of knee arthroplasty, hip arthroplasty, and femur fracture repair were 63.4%, 29.9%, and 6.7%, respectively. The cumulative incidence of PE and DVT in patients undergoing major orthopedic surgery was 1.99% and 2.22%, respectively. Most of the patients presented with PE and DVT (61.5% and 72.4%, respectively) within the first 72 h after surgery. Patients undergoing femur fracture repair, those aged ≥ 65 years, and bedridden patients were at a higher risk for developing VTE.

CONCLUSIONS:

Our results show that VTE was a significant complication of major orthopedic surgery, despite the use of thromboprophylaxis. Clinicians should be aware of VTE, especially during the perioperative period and in bedridden, elderly patients (≥ 65 years of age).

RIETE registry and COPD with PE

Pulmonary embolism is a life threatening complication and it is known to recur in some patients. The diagnosis of pulmonary embolism is difficult in chronic pulmonary obstructive disease patients. There can be delay or difficulty due to overlap of the clinical symptoms in these conditions. If the PE is recurrent then also it can be missed in some patients. So, the morbidity and mortality in COPD patients with PE or recurrent PE is higher than those with Leg DVT. So, it is mandatory to look after patients of COPD with PE more closely to avoid the mortality.

Respir Res. 2013 Jul 18;14:75. doi: 10.1186/1465-9921-14-75.

Pulmonary embolism and 3-month outcomes in 4036 patients with venous thromboembolism and chronic obstructive pulmonary disease: data from the RIETE registry. Bertoletti L, Quenet S, Laporte S, Sahuquillo JC, Conget F, Pedrajas JM, Martin M, Casado I, Riera-Mestre A, Monreal M; RIETE Investigators. Thrombosis Research Group, EA3065, University Saint-Etienne, Jean Monnet, Saint-Etienne F-42023, France. laurent.bertoletti@gmail.com.

Abstract: Patients with chronic obstructive pulmonary disease (COPD) have a modified clinical presentation of venous thromboembolism (VTE) but also a worse prognosis than non-COPD patients with VTE. As it may induce therapeutic modifications, we evaluated the influence of the initial VTE presentation on the 3-month outcomes in COPD patients.

COPD patients included in the on-going world-wide RIETE Registry were studied. The rate of pulmonary embolism (PE), major bleeding and death during the first 3 months in COPD patients were compared according to their initial clinical presentation (acute PE or deep vein thrombosis(DVT)).

Of the 4036 COPD patients included, 2452 (61%; 95% CI: 59.2-62.3) initially presented with PE. PE as the first VTE recurrence occurred in 116 patients, major bleeding in 101 patients and mortality in 443 patients (Fatal PE: first cause of death). Multivariate analysis confirmed that presenting with PE was associated with higher risk of VTE recurrence as PE (OR, 2.04; 95% CI: 1.11-3.72) and higher risk of fatal PE (OR, 7.77; 95% CI: 2.92-15.7).

COPD patients presenting with PE have an increased risk for PE recurrences and fatal PE compared with those presenting with DVT alone. More efficient therapy is needed in this subtype of patients. 

PE recurrences according to initial presentation as DVT or PE.

Mortality according to initial presentation as DVT or PE

Pinjala R K

Delays in the management of venous thromboembolism

Delays in diagnosis and treatment of venous thromboembolism in a developing country setting

It is important to promptly suspect, confirm the diagnosis of venous thrombosis to avoid or reduce the risk of venous thrombosis and its complications. Every physician would generally make an effort to achieve the early anticoagulation in these patients as soon as the diagnosis is confirmed. In a recent paper published from the Iran it was observed that the delay in the diagnosis and treatment is related to the delayed presentation of the patient to the clinics and hospitals. Probably it is the same reason in many other countries where the general awareness of the problem is not there in the public and peripheral medical centers.


Tuberk Toraks. 2013 Jun;61(2):96-102. Rahimi-Rad MH, Rahimi-Rad S, Zarrin S. Source Department of Respiratory Medicine, Faculty of Medicine, Urmia University, Urmia, Iran. rahimirad@hotmail.com.Abstract : Introduction: Rapid diagnosis and treatment of deep vein thrombosis and pulmonary thromboembolism reduce mortality and morbidity. The aim of this study is to investigate delays in treatment of deep vein thrombosis and pulmonary thromboembolism and related factor in a developing country. Materials and Methods: We prospectively investigated 353 patients with diagnosis deep vein thrombosis and/or pulmonary thromboembolism in Urmia, Iran. We recorded dates of symptom onset, initial visit by a clinician, initiation of treatment, and confirmation of diagnosis. We also analyzed relation with some factors. Results: The mean interval from symptoms onset to initiation of treatment was 4.70 days, 89% of this interval was between onset of symptoms to first medical evaluation (mean= 4.19 days). Mean time from onset of symptoms to confirmation of diagnosis was 6.29 days. Of 353 patients with venous thromboembolism 185 (52.4%) visited by a physician within two days of onset of symptoms and 168 (47.6%) patients after two days. Factors that was associated with earlier seeking with p value < 0.05 were pulmonary thromboembolism patients earlier than deep veinthrombosis, higher education, recent surgery, presence of cast, entire leg swelling. There was no association between age, gender, number of symptoms, and presence familial history of venous thromboembolism (all p value > 0.05). The delays time from first visit to final diagnosis was significantly shorter in patients with high probability score. Conclusion: Most patients with venous thromboembolism received anti-coagulation and diagnosis with delay. The main cause of delay is related to patient's delays. There is a need to improve people awareness about venous-thromboembolism and to develop strategies to reduce delays.

Vasculo-Behcet's Disease

Successful Treatment of Vasculo-Behcet's Disease Presenting as Recurrent Pseudoaneurysms: the Importance of Medical Treatment.

Li S, Chen AJ, Huang K, Li H.

Source

The Department of Dermatology, The First Affiliated Hospital, Chongqing Medical University, No. 1 Youyi Road, Chongqing, 400016 China.

Abstract

INTRODUCTION:

Vasculo-Behcet's disease is a subtype of Behcet's disease, characterized by cases in which vascular complications are present and often dominate the clinical features. In this disease, there are four different vascular complications: arterial occlusion, arterial aneurysm or pseudoaneurysm, venous thrombosis, and variceal formation. It is rare that arterial lesions are multiple, but without venous involvement. So far, the optimal treatment of the disease has not been established.

CASE REPORT:

The authors report a rare case of vasculo-Behcet's disease with multiple and recurrent pseudoaneurysms in large arteries, but without affecting the venous system. The patient underwent three rounds of surgery, but developed a new pseudoaneurysm after each operation in short term. However, the patient was successfully treated with a combination of prednisone and immunosuppressive agents.

CONCLUSION:

For Vasculo-Behcet's disease, surgical and endovascular interventions alone increased the incidence of pseudoaneurysm. Early diagnosis and early initiation of prednisone in combination with immunosuppressive therapy are critical for inhibiting the progression of vascular lesions and provide a good prognosis.

Cytokine interleukin-17 as a signal can stabilize plaques

Do we know the role of inflammation and inflammatory cytokines in the stabilization of the atherosclerotic plaques?

We know that the plaques become unstable due to cytokines released by the macrophages in the plaques. In a recent study it was observed that there can be some cytokines released by the cells which can help in stabilization of the plaques.  Cytokine interleukin-17 as a signal can stabilize plaques.
  
"Traditionally, scientists and physicians have viewed atherosclerosis as merely a buildup of cholesterol in the arteries, and the influence of inflammation has not been fully attributed", says Göran K. Hansson, team leader of the Experimental Cardiovascular Research group at the Center for Molecular Medicine, and principal investigator of the study. "We need to explore the inflammatory pathways to find new therapies aside from lowering lipids. We have effective statin therapy, but a substantial risk of heart attacks still remains for treated individuals."
There is need to understand more about the cytokines which can protect or propagate the inflammation in the plaques to prevent cardiovascular events.

External iliac artery endofibrosis - male cyclists

Exercise-induced external iliac artery endofibrosis (EIAE) is rare and has been described primarily in endurance male cyclists. This is difficult to recognize and investigate in the clinical practice. Clinically, it presents as claudication during maximal exercise with quick resolution after exercise. Most patients have fibrotic changes within the external iliac artery (EIA). This can be easily confused as a case of vasculitis or proximal vessel involvement in TAO.

This series highlights a possible mechanism to explain the claudication associated with EIAE. Vasospasm may be more important than wall thickening for the reduction of blood flow during extreme exercise in affected athletes. Routine duplex ultrasound imaging to measure EIA diameter and flow velocities before and after maximal exercise is needed to confirm this phenomenon. Exercise-induced external iliac artery endofibrosis (EIAE) is an uncommon condition affecting high-end endurance athletes in the absence of classic risk factors for atherosclerosis. These athletes are asymptomatic at rest and become symptomatic, with complaints of thigh claudication and loss of power during maximal effort. This was first reported in 1984 in two competition cyclists. 

Since then, EIAE has been described not only among cyclists but also in long-distance runners, triathletes, and speed skaters. EIAE has been described mostly in men, with women accounting for only 7% of the cases. The diagnosis is made by having the athlete exercise to the point of symptoms and obtaining ankle-brachial indices (ABIs) and duplex scanning after exercise. Multiple mechanisms have been proposed to explain EIAE, including increased cardiac output and adaptive systolic hypertension during strenuous effort, psoas muscle hypertrophy, presence of collaterals from the EIA to the psoas muscle, and repeated direct mechanical trauma on the fixed iliac arterial segment by the psoas muscle during hip flexion, and kinking as a result of excessive iliac arterial length. The final pathway is wall thickening, reduction in arterial lumen caliber, and restriction of blood flow during maximal exertion. We describe our experience with EIAE, our method of diagnosis, and propose a hypothesis for the mechanism involved in claudication associated with EIAE.

Re-admissions after lower extremity revascularization procedures

Less invasive endovascular procedures were not associated with decreased readmission rates compared with open surgery. The overall readmission rate for claudicant patients was 10.7%, which was unexpectedly high. Predictors of readmission included male sex, longer hospital stays, hospital infection, elevated aspartate aminotransferase, and high numbers of medications ordered and dispensed. Further examination exploring reasons for readmission are required to decrease readmission rates in the vascular surgery population.

Dramatic changes in health care delivery and rising interest in cost containment have increased concern regarding readmission and its cost to the health care system. In USA, in the Medicare population, the readmission rate after vascular surgical procedures is almost 24%, substantially higher than the average rate of 15.6% for other surgical procedures.¹ At the same time there has been a dramatic shift in the use of endovascular procedures for the management of lower extremity (LE) occlusive disease.² Endovascular interventions are now performed much more commonly than bypass surgery in the treatment of LE peripheral artery disease (PAD), and the use of percutaneous transluminal angioplasty (PTA) for claudication has dramatically increased.^2 and 3

Despite increased use of more minimally invasive procedures, there is a paucity of information evaluating if less invasive procedures are associated with decreased morbidity and also specifically with decreased use in the form of readmission. This analysis evaluated the readmission rates after LE interventions to specifically compare rates between procedure type and to evaluate factors associated with readmission, because identifying patients with increased risk for readmission after vascular procedures may lead to more effective, higher-quality care. 

We are facing this problem in providing the vascular surgical care for the patients under the ARSR scheme. They are not understanding this fact that the readmission rate is much higher in vascular surgery patients compared to the other surgical patients in the hospitals. I am sure papers of this nature will help us make the administrators of the ARSR scheme in andhra pradesh to recognize these difficulties in providing care to vascular patients.

• http://dx.doi.org/10.1016/j.jvs.2012.12.031, How to Cite or Link Using DOI
• Jl of Vascular surgery Volume 58, Issue 1, July 2013, Pages 90–97.e4

Drug Eluting Stents and Bare metal stents - which one? What about the longterm results? Are we there still to decide which one is better ?

We know that  the Angioplasty alone is helpful in some lesions, angioplasty and stenting is helpful in some patients. But now we have an option to use the drug eluting stents or bare metal stents. The consensus is evolving and there seem to be still serious concerns about the use of the drug eluting stents and long term results. Recently long term results comparing the DES and BMS are examined and published in the JACC interventions.

DEDICATION trial showed that

Complete clinical status was available in 623 patients (99.5%) at 5 years follow-up. The combined MACE rate was insignificantly lower in the DES group (16.9% vs. 23%), mainly driven by a lower need of repeat revascularization (p = 0.07). Whereas the number of deaths from all causes tended to be higher in the DES group (16.3% vs. 12.1%, p = 0.17), cardiac mortality was significantly higher (7.7% vs. 3.2%, p = 0.02). The 5-year stent thrombosis rates were generally low and similar between the DES and the BMS groups. No cardiac deaths occurring within 1 month could be clearly ascribed to stent thrombosis, whereas stent thrombosis was involved in 78% of later-occurring deaths.

Conclusions  The 5-year MACE rate was insignificantly different, but the cardiac mortality was higher after DES versus BMS implantation in patients with STEMI. Stent thrombosis was the main cause of late cardiac deaths.

So, in the coming periods, how one can make an informed decision about using the drug eluting stents in clinical practice if these results are taken seriously. The drug eluting stents are expensive and we may say that BMS ( the less expensive) may be getting preference in the developing nations. But does that means there is a possibility that the absorbable drug eluting stents may stand a good chance as they not be associated with the late effects of drug eluting non absorbable stents. 

Long-Term Outcome After Drug-Eluting Versus Bare-Metal Stent Implantation in Patients With ST-Segment Elevation Myocardial Infarction5 Years Follow-Up From the Randomized DEDICATION Trial (Drug Elution and Distal Protection in Acute Myocardial Infarction)

Lene Holmvang, MD; Henning Kelbæk, MD; Anne Kaltoft, MD; Leif Thuesen, MD; Jens Flensted Lassen, MD; Peter Clemmensen, MD; Lene Kløvgaard, RN; Thomas Engstrøm, MD; Hans E. Bøtker, MD; Kari Saunamäki, MD; Lars R. Krusell, MD; Erik Jørgensen, MD; Hans-Henrik Tilsted, MD; Evald H. Christiansen, MD; Jan Ravkilde, MD; Lars Køber, MD; Klaus Fuglsang Kofoed, MD; Christian J. Terkelsen, MD; Steffen Helqvist, MD

J Am Coll Cardiol Intv. 2013;6(6):548-553. doi:10.1016/j.jcin.2012.12.129

Venous thrombosis in Cancer patients - are there any special features!

The risk of venous thrombosis is higher in cancer patients. But we do not know if there are specific features for the venous thrombosis in cancer patients. We believe that the thrombosis is dependent on the circulating procoagulant factors associated with or released by the cancer tissues. Is the proximal deep vein thrombosis  (iliac vein) more common in cancer patients? 

In a study conducted on - For 3263 patients with cancer, the venous thrombosis incidence was: total 31.4% (n=1026), proximal 14.5% (n=472), bilateral 8.5% (n=278) and multiple venous sites 4.6% (n=149). The rate of clinical suspicion of pulmonary embolism was 49.9% (n=1628). For 1026 patients withthrombosis, proximal thrombi were nearly as frequent as distal thrombi, with 17.6% (n=181) iliocaval thrombi. Gastrocnemial, popliteal and femoral veins were almost equally concerned by thrombosis with respective rates of 28.7% (n=278), 27.1% (n=294) and 25.6% (n=263). Superficial veins were concerned in 23.5% (n=241). Partial or floating clots occurred frequently in 4 localizations: common femoral, external iliac, femoral and popliteal veins. J Mal Vasc. 2013 Jun 18. pii: S0398-0499(13)00131-5. doi: 10.1016/j.jmv.2013.05.001. [Epub ahead of print]

This results of this study point out that - Proximal, multiple, partial, mobile thrombi, and such unusual locations as gastrocnemial or superficial thromboses, are potentially indicators for selecting patients that may benefit from a cancer check-up because their venous thrombosis could be due to cancer.

It may not be cost effective to screen all patients for cancer in our clinical practice - in addition to the above factors related to venous thrombosis, we should remember that recurrence of DVT requiring admissions ( 2 or 3 times) in last 6 months should also prompt us to think and investigate for the cryptogenic malignancies. We found this very useful in our clinical practice not to miss the hidden malignancies.  

30th June 2013