anaemia

What to do for anaemic patient prepared for fempop bypass in few days?

09/18/2015
The outcome is significantly different (poor) for anaemic patient:

A META-ANALYSIS (BJS 2015) showed the following: (DOI: 10.1002/bjs.9861)

  • Anaemia was associated with increased mortality (OR 2·90, 2·30 to 3·68; I2 = 97 per cent; P < 0·001), acute kidney injury (OR 3·75, 2·95 to 4·76; I2 = 60 per cent; P < 0·001) and infection (OR 1·93, 1·17 to 3·18; I2 = 99 per cent; P = 0·01). 
  • Among cardiac surgical patients, anaemia was associated with stroke (OR 1·28, 1·06 to 1·55; I2 = 0 per cent; P = 0·009) but not myocardial infarction (OR 1·11, 0·68 to 1·82; I2 = 13 per cent; P = 0·67). 
  • Anaemia was associated with an increased incidence of red cell transfusion (OR 5·04, 4·12 to 6·17; I2 = 96 per cent; P < 0·001). Similar findings were observed in the cardiac and non-cardiac subgroups.


THEREFORE, the following recommendations applies to anaemic patients undergoing an operation: (DOI: 10.1002/bjs.9898) 

  • Both anaemia and blood transfusion are independently associated with adverse outcomes. 
  • Functional iron deficiency (iron restriction due to increased levels of hepcidin) is the most common cause of preoperative anaemia, and should be treated with intravenous iron. 
  • Intraoperative blood loss can be reduced with antifibrinolytic drugs such as tranexamic acid, and cell salvage should be used. 
  • A restrictive transfusion practice should be the standard of care after surgery.
femoral artery aneurysm

Femoral aneurysm – to treat or not to treat

09/18/2015
ref:

2014 Feb;59(2):343-9. doi: 10.1016/j.jvs.2013.08.090.

The current management of isolated degenerative femoral artery aneurysms is too aggressive for their natural history.

http://www.ncbi.nlm.nih.gov/pubmed/24461859

This series is large enough to provide an excellent natural history analysis of the femoral artery aneurysm.

Abstract

BACKGROUND:

Previous studies have combined anastomotic, catheter-induced, and atherosclerotic isolated femoral artery aneurysms (FAAs) to achieve adequate numbers for analysis and have recommended repair of asymptomatic FAAs with diameters ≥2.5 cm and all symptomatic FAAs. This study evaluated the contemporary management of isolated FAAs.

METHODS:

Patients with FAAs were evaluated using a standardized, prospectively maintained database by a research consortium.

RESULTS:

From 2002 to 2012, 236 FAAs were identified in 182 patients (mean age, 72 years; male-to-female ratio, 16:1) at eight institutions. The mean nonoperative mean diameter was 2.8 ± 0.7 cm, and the operative diameter was 3.3 ± 1.5 cm. FAA location was the common femoral artery in 191, superficial femoral artery (SFA) in 34, and profunda femoris artery in 11. Synchronous aneurysms (mean, 1.7 per patient) occurred in the aorta (n = 113), in the iliac (n = 109), popliteal (n = 86), and hypogastric (n = 56) arteries, and in the contralateral common femoral artery (n = 34), SFA (n = 9), and profunda femoris artery (n = 2). Of the aneurysms repaired, 66% were asymptomatic; other indications for repair were claudication (18%), local pain (8%), nerve compression (3%), rupture (2%), acute thrombosis (1%), and rest pain (0.5%). Acute aneurysm-related complications (rupture, thrombosis, embolus) were associated (P < .05) with FAA diameter >4 cm and intraluminal thrombus, but not location. Mean diameter of asymptomatic aneurysms that developed acute complications was 5.7 ± 1.3 cm for rupture, 4 ± 1.1 cm for thrombosis, and 3.5 cm for embolus. Repair was by interposition or bypass graft in 177 FAAs and by endovascular repair in three SFA aneurysms. Two perioperative deaths, of myocardial infarction and multisystem organ failure, occurred at 30 days. Operative complications included wound infection (6%), seroma (3%), and bleeding (2%). No amputations occurred through 5 years in the operative or nonoperative groups. Survival in operated-on patients was 99% (n = 138) at 3 months, 92% at 1 year, and 81% (n = 20) at 5 years.

CONCLUSIONS:

This largest study of isolated FAAs demonstrates that (1) acute complications did not occur in FAAs ≤3.5 cm, repair criteria of asymptomatic FAAs should be changed to >3.5 cm, and chronic intraluminal thrombus should reduce the threshold for repair, and that (2) current indications for symptomatic FAA repair result in low morbidity and should remain unchanged.
Copyright © 2014. Published by Mosby, Inc.

Direct oral anticoagulation

Direct oral anticoagulants (DOA) – compares favourably to warfarin

08/31/2015

Ref. circulation 2015 

http://www.ncbi.nlm.nih.gov/m/pubmed/25995317/
This is very useful article on the newest addition to well known meds:

Efficacy and Harms of Direct Oral Anticoagulants in the Elderly for Stroke Prevention in Atrial Fibrillation and Secondary Prevention of Venous Thromboembolism: Systematic Review and Meta-Analysis.

Sharma M, et al. Circulation. 2015.

Abstract

BACKGROUND: Evidence regarding the use of direct oral anticoagulants (DOACs) in the elderly, particularly bleeding risks, is unclear despite the presence of greater comorbidities, polypharmacy, and altered pharmacokinetics in this age group.

METHODS AND RESULTS: We performed a systematic review and meta-analysis of randomized trials of DOACs (dabigatran, apixaban, rivaroxaban, and edoxaban) for efficacy and bleeding outcomes in comparison with vitamin K antagonists (VKA) in elderly participants (aged ≥75 years) treated for acute venous thromboembolism or stroke prevention in atrial fibrillation. Nineteen studies were eligible for inclusion, but only 11 reported data specifically for elderly participants. The efficacy in managing thrombotic risks for each DOAC was similar or superior to VKA in elderly patients. A nonsignificantly higher risk of major bleeding than with VKA was observed with dabigatran 150 mg (odds ratio, 1.18; 95% confidence interval, 0.97-1.44) but not with the 110-mg dose. Significantly higher gastrointestinal bleeding risks with dabigatran 150 mg (1.78, 1.35-2.35) and dabigatran 110 mg (1.40, 1.04-1.90) and lower intracranial bleeding risks than VKA for dabigatran 150 mg (0.43, 0.26-0.72) and dabigatran 110 mg (0.36, 0.22-0.61) were also observed. A significantly lower major bleeding risk in comparison with VKA was observed for apixaban (0.63, 0.51-0.77), edoxaban 60 mg (0.81, 0.67-0.98), and 30 mg (0.46, 0.38-0.57), whereas rivaroxaban showed similar risks.

CONCLUSIONS: DOACs demonstrated at least equal efficacy to VKA in managing thrombotic risks in the elderly, but bleeding patterns were distinct. In particular, dabigatran was associated with a higher risk of gastrointestinal bleeding than VKA. Insufficient published data for apixaban, edoxaban, and rivaroxaban indicate that further work is needed to clarify the bleeding risks of these DOACs in the elderly.

SYSTEMATIC REVIEW REGISTRATION: http://www.crd.york.ac.uk/PROSPERO. Unique identifier: PROSPERO CRD42014007171/.

© 2015 American Heart Association, Inc.

familial AAA;

Should you ‘mark’ your AAA patient as ‘FAMILIAL’

08/18/2015
Sources: EJVES Aug 2015

Many definitions exist, the easiest is when at least one first-degree relative (parent, sibling, offspring) is diagnosed with an aortic aneurysm. Based upon family history review, the proportion of patients with AAA with familial AAA is around 13% (range 6–36%).2 Ultrasound screening of the relatives of those with AAAs suggests a prevalence of 17% (range 9–29%) in men and 4% (range 0–11%) in women.

Clinical phenotypes – Studies suggest that patients with familial AAA are significantly more likely to be female, younger, have fewer cardiovascular risk factors (e.g., hypertension and diabetes mellitus), and possibly have a lower carotid intima-media thickness. Studies also show a high rate of thoracic aortic aneurysms and an increased rate of bilateral iliac aneurysms in patients with familial AAA. Relatives of patients with familial AAA also appear to have increased aortic diameters. 

In any case, additional environmental effects, such as smoking, hypertension and hypercholester- olemia could enhance the risk of aneurysm formation and therefore explain the variability in expression of the disease. 

Most accepted genetic aortic aneurysm syndromes are caused by defects in genes involved in the transforming growth factor-b pathway,8 and are associated with syn- dromes like Marfan disease and LoeyseDietz syndrome. 

Until now, family studies have detected a linkage with the 19q13 and 4q31 regions in the genome but without identifying specific genes in these regions. A genome- wide single nucleotide polymorphism with AAA include DAB2IP, LRP1, LDLR, ANRIl, and SORT1.10 Having one of these alleles results in an additional `20% risk for devel- oping AAA; however, the causal relationship of these poly- morphisms still needs to be elucidated.

ACTION PLAN – 

The present American College of Cardiology/American Heart Association guidelines recom- mend ultrasound screening for male relatives aged 60 years or older, while the European Society for Vascular Surgery guidelines recommend ultrasound screening of both male and female relatives aged >50 years who have a family history of AAA. 
It is not known whether endovascular aneurysm repair (EVAR) or open repair (OR) is the optimal treatment for patients with familial AAA. Only very limited data are available; however, as patients with familial AAA tend to be younger, they may benefit from OR, which carries a lower secondary intervention risk with time.  





Uncategorized

Dealing with complex systems – NHS as an example

07/26/2015
TEDx talk by Yves Morieux 

  • To deal with complexity, to enhance the nervous system, we have created what we call the smart simplicity approach based on simple rules. 
  • Simple rule number one: Understand what others do. What is their real work? We need to go beyond the boxes, the job descriptions, beyond the surface of the container, to understand the real content. Me, designer, if I put a wire here, I know that it will mean that we will have to remove the engine to access the lights. 
  • Second, you need to reenforce integrators.Integrators are not middle offices, they are managers, existing managers that you reinforce so that they have power and interest to make others cooperate. How can you reinforce your managers as integrators?By removing layers. When there are too many layers people are too far from the action, therefore they need KPIs, metrics, they need poor proxies for reality. They don’t understand reality and they add the complicatedness of metrics, KPIs. By removing rules — the bigger we are, the more we need integrators,therefore the less rules we must have, to give discretionary power to managers. And we do the opposite — the bigger we are, the more rules we create. And we end up with the Encyclopedia Britannica of rules.You need to increase the quanitity of power so that you can empower everybody to use their judgment, their intelligence. You must give more cards to people so that they have the critical mass of cards to take the risk to cooperate, to move out of insulation. Otherwise, they will withdraw. They will disengage. These rules, they come from game theory and organizational sociology. You can increase the shadow of the future. Create feedback loops that expose people to the consequences of their actions. This is what the automotive company did when they saw that Mr. Repairability had no impact. They said to the design engineers: Now, in three years, when the new car is launched on the market, you will move to the after sales network, and become in charge of the warranty budget, and if the warranty budget explodes, it will explode in your face. (Laughter) Much more powerful than 0.8 percent variable compensation. 
  • You need also to increase reciprocity, by removing the buffers that make us self-sufficient. When you remove these buffers, you hold me by the nose, I hold you by the ear. We will cooperate. Remove the second TV. There are many second TVs at work that don’t create value, they just provide dysfunctional self-sufficiency. 
  • You need to reward those who cooperate and blame those who don’t cooperate. The CEO of The Lego Group, Jorgen Vig Knudstorp, has a great way to use it. He says, blame is not for failure, it is for failing to help or ask for help. It changes everything. Suddenly it becomes in my interest to be transparent on my real weaknesses, my real forecast, because I know I will not be blamed if I fail, but if I fail to help or ask for help. When you do this, it has a lot of implications on organizational design. You stop drawing boxes, dotted lines, full lines; you look at their interplay. It has a lot of implications on financial policies that we use. On human resource management practices. When you do that, you can manage complexity, the new complexity of business, without getting complicated. You create more value with lower cost. You simultaneously improve performance and satisfaction at work because you have removed the common root cause that hinders both. Complicatedness: This is your battle, business leaders. The real battle is not against competitors. This is rubbish, very abstract. When do we meet competitors to fight them? The real battle is against ourselves, against our bureaucracy, our complicatedness. Only you can fight, can do it.Thank you. (Applause)
Popliteal aneurysm

Popliteal artery aneurysm – endovascular approach

06/17/2015

Red: viabhan results becoming very close to open surgery; patency wise only (leave alone infection, zero a, and overall function. 

Results are found here: http://www.goremedical.com/resources/dam/assets/AP1730EU2_PAA_TrackRecord.FNL.mr.pdf
Secondary patency is 91% in first two years (vs almost 100% in open in best practice centres); then both matches afterwards.
So I would now support endovascular approaches even in fairly youngish (65 yr old) patients. 
lymphoedema

Lymphoedema – a challanging situation

05/28/2015
I have seen three lymphoedema patients today consecutively (and rather randomly booked) in clinic. It is a pretty challanging case that so far has no proper cure for. 
 My advice consists currently of the following components (ref. uptodate May 2015) – 
 1- The term complete decongestive therapy (CDT, also called complex decongestive therapy, complex decongestive physiotherapy, or decongestive lymphatic therapy) refers to an empirically derived, multicomponent technique that is designed to reduce the degree of lymphedema and to maintain the health of the skin and supporting structures [14,21,28]. 
 2- CDT generally consists of a two-phase treatment program that can be used in both adults and children [14,21,28]. Success is dependent in part upon the availability of physicians, nurses, and physical therapists that are trained in these techniques. 
 ●The first phase (treatment phase) includes meticulous skin and nail care to prevent infection, therapeutic exercise, a massage-like technique called manual lymph drainage (MLD), and limb compression using repetitively applied, multilayered padding materials and short-stretch bandages. The patients receive daily therapy five days per week, with circumference and volume measurements weekly to see if improvement is continuing or the patient has plateaued [21]. The usual duration of the first stage is two to four weeks. 
 ●The second phase (maintenance phase) is intended to conserve and optimize the benefit attained in the first phase. It consists of compression garments worn during waking hours and, if necessary, self-compression bandaging at night, skin care, continued exercises, and, as necessary, self-MLD. Limb circumference and volume measurements should be monitored every six months or sooner if necessary [21]. 
3- Efficacy of CDT has been suggested in observational studies, which demonstrated a reduction in limb volume with improved pain, cosmesis, and/or function [35-39]. In these studies, the reduction in limb volume ranged from 33 to 68 percent. However, patient compliance is required for long-term success. In one study, at least 90 percent of the lymphedema reduction was maintained in compliant patients at an average follow-up of nine months, while noncompliant patients lost approximately one-third of the initial benefit [35]. The benefit of CDT was shown in a small phase III trial in which 53 patients with lymphedema after breast cancer treatment were randomly assigned to CDT (lymph drainage, multilayer compression bandaging, elevation, remedial exercise, and skin care) versus standard physiotherapy (bandages, elevation, head-neck and shoulder exercises, and skin care) [40]. The group receiving CDT had a significantly greater improvement in edema as measured by circumferential and volumetric measurements.
bmj smoking

smoking .. best ever study

05/25/2015
Taken from BMJ – how to read a paper.

The world’s most famous cohort study, which won its two original authors a knighthood, was undertaken by Sir Austin Bradford Hill, Sir Richard Doll, and, latterly, Richard Peto. They followed up 40 000 British doctors divided into four cohorts (non-smokers, and light, moderate, and heavy smokers) using both all cause mortality (any death) and cause specific mortality (death from a particular disease) as outcome measures. Publication of their 10 year interim results in 1964, which showed a substantial excess in both lung cancer mortality and all cause mortality in smokers, with a “dose-response” relation (the more you smoke, the worse your chances of getting lung cancer), went a long way to showing that the link between smoking and ill health was causal rather than coincidental.31 The 20 year and 40 year results of this momentous study (which achieved an impressive 94% follow up of those recruited in 1951 and not known to have died) illustrate both the perils of smoking and the strength of evidence that can be obtained from a properly conducted cohort study.32 33

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