Systematic review of endovascular intervention and surgery for common femoral artery atherosclerotic disease.

BACKGROUND: Endovascular intervention has emerged as a potential alternative to open surgery in treating common femoral artery (CFA) atherosclerotic disease. The aim of this systematic review was to assess the safety and efficacy of both techniques. METHODS: Thirteen electronic databases from 1980 to 3 January 2018 were searched. Study quality was assessed using the National Institute for Health and Care Excellence Interventional Procedure Programme quality assessment tool. Safety and efficacy outcome measures were analysed. RESULTS: Thirty-one studies reporting 813 endovascular procedures and 3835 endarterectomies were included. Only two small RCTs have been reported. The methodological quality of available studies was generally low and follow-up short. Safety endpoint assessment revealed a similar risk of wound haematoma for endovascular intervention and endarterectomy (5·5 (95 per cent c.i. 0·2 to 17·2) versus 3·9 (1·7 to 6·9) per cent respectively), a lower risk of wound infection with endovascular procedures (0 versus 5·9 (3·4 to 9·0) per cent) and a lower risk of wound lymph leakage (0 versus 5·7 (3·3 to 8·6) per cent). Efficacy endpoint assessment at 1 year identified that endovascular intervention had a lower primary patency rate than endarterectomy (78·8 (73·3 to 83·8) versus 96·0 (92·2 to 98·6) per cent respectively), a higher revascularization rate (16·0 (6·1 to 29·4) versus 5·8 (1·0 to 14·2) per cent) and a similar amputation rate (2·7 (1·2 to 4·8) versus 1·9 (0·7 to 3·8) per cent). CONCLUSION: Endovascular intervention of CFA disease appears to reduce the risk of wound complications but is associated with a lower patency rate and increased rates of subsequent revascularization procedures. Standardization of the endovascular technique and quantification of the proportions of patients suitable for either technique are required.

Coronary subclavian steal syndrome-is there a need for routine assessment for subclavian artery stenosis following coronary bypass surgery?

Subclavian artery stenosis (SAS) resulting in coronary subclavian steal syndrome (CSSS) is a common but under recognized pathology following coronary artery bypass surgery (CABG). Patients with SAS may be asymptomatic due to the sub-clinical diversion of blood flow from the myocardium and retrograde blood flow during catheter angiography in the left internal mammary artery (LIMA) may be the first suggestion of CSSS. The management of SAS, causing CSSS, may rarely require acute assessment and intervention. However, full anatomical assessment of the stenosis morphology may be limited on fluoroscopy. Correction of SAS may be essential to achieve effective reperfusion therapy.

Biliary and portal vein strictures following treatment of Hodgkin's lymphoma.

Treatment of abdominal lymphoma can be associated with bowel stricture or perforation. Rarely, the common bile duct or portal vein can be involved. This is the first case of stricture formation of both the portal vein and common bile duct in a patient following successful treatment of lymphoma. The development of extensive hilar varices rendered surgical management high risk. A staged approach to treatment was used. First, a percutaneous portal vein stent was placed, resulting in resolution of the hilar varices. This was followed by a surgical hepaticojejunostomy, performed without complication. Gastrointestinal complications are rare following treatment of lymphoma but may affect a variety of sites. The safe and effective treatment of this case highlights the benefit of a multidisciplinary approach to complex medical and surgical problems.

Short-term effects of screening for cardiovascular risk in the deaf community: a pilot study.

There is limited information on the risk of cardiovascular disease amongst the Deaf community. Given that the access of Deaf people to mainstream health promotion is likely to be hindered by language barriers, we were interested to assess the short-term impact of cardiovascular health promotion within this group. Using a pilot study we investigated changes in cardiovascular risk factors amongst Deaf people identified to be at high cardiovascular risk, who received standard health promotion by a medical team specializing in cardiovascular health promotion. The short-term impact of cardiovascular health promotion in this group did not reduce estimates of cardiovascular risk. The reasons for this are likely to relate to the design and delivery of health promotion to Deaf people, which deserves further study.

Omega-3 polyunsaturated acids and cardiovascular disease: notable ethnic differences or unfulfilled promise?

The consumption of long chain omega-3 polyunsaturated acids (PUFA) is considered to protect against cardiovascular disease and promote longevity following a heart attack. Historically, research in this area was fuelled by compelling reports of the cardiovascular benefits of omega-3 PUFA in select populations and cultures. More recent studies, in wider populations, suggest discordant findings: differences that are difficult to reconcile as the mechanism of action of omega-3 PUFA are poorly understood. As such, the use of this 'natural treatment' for cardiovascular disease is increasingly controversial, and potentially one of unfulfilled promise. To what extent does ethnicity influence the impact that omega-3 PUFA have on cardiovascular disease and its associated complications? We were interested to review the benefits of omega-3 PUFA in the management of cardiovascular risk amongst diverse ethnic groups. Using a systematic review of literature relating to omega-3 PUFA and cardiovascular disease, we found ethnicity to be a factor that accounts for inconsistency between studies. Some of the effects of omega-3 PUFA are limited to cultures with a very high omega-3 intake, and in turn, ethnicity moderates the efficiency with which PUFA are derived from the diet. Moreover, omega-3 PUFA are an important health care intervention in the current climate of globalization, where supplementation is likely to give protection to cultural groups undergoing dietary transition. Future epidemiological research into the efficacy of omega-3 PUFA in cardiovascular disease should consider the influence of ethnicity.

Triglycerides and small dense low density lipoprotein in the discrimination of coronary heart disease risk in South Asian populations.

INTRODUCTION: Coronary heart disease (CHD) is exceptionally prevalent amongst globally dispersed migrant groups originating from the Indian subcontinent, but the contribution of dyslipidaemia to their increased risk remains poorly defined. METHODS: Fasting lipids and lipoproteins, apolipoproteins (Apo), low density lipoprotein (LDL) diameter and oxidised LDL were measured amongst rural Indians in India (n=294) and their migrant contemporaries in the UK (n=242). The performance of qualitative and quantitative measures of lipid metabolism were compared in the discrimination of WHO defined metabolic risk and raised Framingham CHD risk scores (>15%) using Receiver Operating Characteristic (ROC) curves. RESULTS: LDL diameter was correlated with triglycerides (R(2)=0.12, P<0.001) and with high density lipoprotein (HDL) cholesterol levels (R(2)=0.15, P<0.001) in both groups. Migrants had less small dense LDL (95% CI: 12.5-14.2%) vs. rural Indians (15.7-17.2, P<0.05). On ROC analysis, triglycerides were the only consistent discriminators of metabolic and CHD risk scores (all P< or =0.001). Apo B was also a strong indicator of raised CHD risk scores. Irrespective of site, individuals with raised triglycerides also had higher total cholesterol and Apo B, denser LDL, lower HDL and more oxidised LDL (all P< or =0.01). DISCUSSION: Fasting triglycerides reflect both qualitative and quantitative aspects of lipid metabolism, and are a comprehensive discriminator of CHD risk in this South Asian population.

Audit of the use of IVC filters in the UK: experience from three centres over 12 years.

AIM: To audit the use of inferior vena cava (IVC) filter insertions at three UK centres over 12 years to assess whether trends in filter use in the UK mirrored those seen elsewhere. MATERIALS AND METHODS: Radiology department databases were interrogated for IVC filter insertions and removals between 1994 and 2006. Reports for these interventions, along with prior and subsequent imaging reports, were analysed. Follow-up data were obtained when available. RESULTS: Five hundred and sixteen filters were placed with a significant year-on-year trend towards increasing use. Fifty-seven percent of filters placed were for absolute indications and 37% for relative indications. The filters were used for prophylaxis in 6% of patients in the absence of proven pulmonary embolism (PE) or deep vein thrombosis (DVT). A retrievable filter was used in 74% of cases with retrieval attempted in 40% of these and no evidence of an increasing rate of retrieval over time. A significant complication related to insertion or retrieval was encountered in 0.4 and 1% of procedures, respectively. Mean 24 h and 30 day mortalities were 1 and 8%, respectively. There was an absence of organized follow-up at all three centres. CONCLUSION: IVC filter use in the UK is increasing. The use of retrievable filters has not resulted in increased filter retrieval. Filter insertion and retrieval is associated with a low risk of significant complication, but lack of systematic follow-up limits conclusions regarding safety and efficacy.

Development of electronic software for the management of trauma patients on the orthopaedic unit.

INTRODUCTION: Continuity of patient care is an essential prerequisite for the successful running of a trauma surgery service. This is becoming increasingly difficult because of the new working arrangements of junior doctors. Handover is now central to ensure continuity of care following shift change over. The purpose of this study was to compare the quality of information handed over using the traditional ad hoc method of a handover sheet versus a web-based electronic software programme. It was hoped that through improved quality of handover the new system would have a positive impact on clinical care, risk and time management. METHODS: Data was prospectively collected and analyzed using the SPSS 14 statistical package. The handover data of 350 patients using a paper-based system was compared to the data of 357 cases using the web-based system. Key data included basic demographic data, responsible surgeon, location of patient, injury site including site, whether fractures were open or closed, concomitant injuries and the treatment plan. A survey was conducted amongst health care providers to assess the impact of the new software. RESULTS: With the introduction of the electronic handover system, patients with missing demographic data reduced from 35.1% to 0.8% (p<0.0001) and missing patient location from 18.6% to 3.6% (p<0.0001). Missing consultant information and missing diagnosis dropped from 12.9% to 2.0% (p<0.0001) and from 11.7% to 0.8% (p<0.0001), respectively. The missing information regarding side and anatomical site of the injury was reduced from 31.4% to 0.8% (p<0.0001) and from 13.7% to 1.1% (p<0.0001), respectively. In 96.6% of paper ad hoc handovers it was not stated whether the injury was 'closed' or 'open', whereas in the electronic group this information was evident in all 357 patients (p<0.0001). A treatment plan was included only in 52.3% of paper handovers compared to 94.7% (p<0.0001) of electronic handovers. A survey revealed 96% of members of the trauma team felt an improvement of handover since the introduction of the software, and 94% of members were satisfied with the software. CONCLUSIONS: The findings of our study show that the use of web-based electronic software is effective in facilitating and improving the quality of information passed during handover. Structured software also aids in improving work flow amongst the trauma team. We argue that an improvement in the quality of handover is an improvement in clinical practice.

Circulating biomarkers of angiogenesis as indicators of left ventricular systolic dysfunction amongst patients with coronary artery disease.

BACKGROUND: Patients with coronary artery disease (CAD) and left ventricular systolic dysfunction (LVSD) are often asymptomatic. Angiogenesis is implicated in the physiology of vascular repair and cardiac remodelling, and is one of many pathophysiological processes implicated in heart failure. We hypothesized that plasma indices associated with angiogenesis [angiogenin, vascular endothelial growth factor (VEGF), and angiopoietin (Ang)-1 and Ang-2] would be abnormal in CAD patients with LVSD, being correlated with EF and wall motion abnormalities (wall motion score) independently of underlying CAD (coronary atheroma score). We also evaluated the specificity of angiogenic 'biomarkers' in their detection of LVSD [ejection fraction (EF) <40%] amongst CAD patients. METHODS: Using a cross sectional approach, we measured angiogenin, VEGF, Ang-1 and Ang-2 by ELISA in 194 CAD patients (aged 34-81 years) undergoing elective coronary angiography. RESULTS: Levels of angiogenin were inversely related with EF (r = -0.17, P = 0.02) and positively with coronary atheroma scores (r = 0.15, P = 0.04, but not independently of EF). Other angiogenic markers were unrelated to objective measures of LVSD but VEGF (P = 0.008) and Ang-2 (P = 0.015) were lower amongst those patients with heart failure. Angiogenin levels were related to wall motion scores (r = 0.16, P = 0.024). CONCLUSION: Heart failure has a modest impact on biomarkers of angiogenesis, in patients with CAD. Further research is warranted into the diagnostic and prognostic utility of biomarkers of angiogenesis, in this common cardiac condition.

Effects of coronary artery disease and percutaneous intervention on the cardiac metabolism of nonesterified fatty acids and insulin: Implications of diabetes mellitus.

BACKGROUND: Nonesterified fatty acids (NEFA) and insulin have been implicated in the pathogenesis of diabetes mellitus (Type 2 diabetes) and coronary artery disease (CAD). We hypothesized that intracardiac levels of insulin and NEFA within the aortic root, coronary sinus and systemic venous levels would be different in patients with coronary atherosclerosis and/or diabetes. We also studied the metabolic cardiac response following percutaneous coronary intervention (PCI). METHODS: A total of 67 subjects (42 males; mean age 60 +/- 11 years) were recruited, of which three groups were identified: Group I - those with no CAD or Type 2 diabetes (n = 17); Group II - those with CAD but no Type 2 diabetes (n = 40); and Group III - patients with Type 2 diabetes and CAD (n = 10). Of the whole cohort, 34 patients (51%) proceeded to PCI. NEFA and insulin levels were analysed using enzymatic colorimetric and a monoclonal immuno-autoanalyser techniques, respectively. Subsequently, fractional extraction (FFE) of both variables was calculated. RESULTS: Nonesterified fatty acids and insulin concentrations were lower in the aortic root versus coronary sinus (both P < 0.05). FFE of NEFA was 2x higher in Group I (P < 0.01) with a sevenfold reduction in insulin FFE in Group III. Following PCI, systemic NEFA levels increased significantly (P < 0.05) with no significant change seen within the coronary sinus (P = NS), whilst a reduction in insulin concentrations at all three sites was observed (all P < 0.01). No significant difference in FFE of NEFA was seen after PCI when comparing Groups II and III. There was a drop in insulin extraction in Group II (nondiabetic subjects, from 12% to -4%, P = 0.04), compared with an increase seen in Group III (Type 2 diabetes patients, from -4% to 3%, P = 0.03). CONCLUSION: There is an intracardiac gradient of NEFA and insulin in Groups I-III. Cardiac NEFA metabolism was higher in those with mild CAD compared with those with obstructive CAD whereas intracardiac insulin extraction was lower in Group III (diabetic) patients. PCI was associated with a systemic rise in NEFA, with a reduction in insulin levels and cardiac utilization, but these effects were blunted in diabetic patients.

Validated LC Method for the Estimation of Voriconazole in Bulk and Formulation.

Reversed phase high performance liquid chromatographic method was developed and validated for the estimation of voriconazole in bulk and formulation using prominence diode array detector. Selected mobile phase was a combination of water:acetonitrile (35:65 % v/v) and wavelength selected was 256 nm. Retention time of voriconazole was 3.95 min. Linearity of the method was found to be 0.1 to 2 mug/ml, with the regression coefficient of 0.999. This method was validated according to ICH guidelines. Quantification was done by calculating area of the peak and the detection limit and quantitation limit ware 0.026 mug/ml and 0.1 mug/ml, respectively. There was no significant difference in the intra day and inter day analysis of voriconazole determined for three different concentrations using this method. Present method can be applied for the determination of voriconazole in quality control of formulation without interference of the excipients.

Circulating serum adiponectin levels in patients with coronary artery disease: relationship to atherosclerotic burden and cardiac function.

BACKGROUND: Abnormal adipocyte function is implicated in both the pathophysiology of coronary heart disease (CHD) and cardiac function, where adiponectin provides a putative link. However, the utility of adiponectin as a discriminator of CHD severity is unclear and may be confounded by cardiac function. We hypothesized that plasma adiponectin would relate to indices of coronary artery disease severity (coronary atheroma scores, CAS), ejection fraction (EF) and regional wall motion abnormalities (RWMA) therein. METHOD: We measured adiponectin using a cross-sectional approach, we measured plasma adiponectin enzyme-linked immunosorbent assay in 204 consecutive patients (aged 34-81 years) undergoing elective coronary angiography. RESULTS: Levels of adiponectin decreased in an ordinal fashion across tertiles of increasing CAS (P = 0.047), but were nonsignificantly correlated to absolute values of CAS (P = 0.06). Adiponectin levels were unrelated to left ventricular dysfunction related measures of RWMA or EF. On multivariate analysis, (including factors relating to CHD risk, history and medication) adiponectin levels were independently inversely associated with triglycerides (P = 0.001), CAS tertiles (P = 0.01) and positively with age (P < 0.001). CONCLUSION: Levels of adiponectin decreased with coronary artery disease severity, without impact from systolic dysfunction, but levels may be moderated through established CHD risk factors such as smoking and triglycerides. Further work is warranted as to the clinical prognostic utility of this marker amongst CHD patients.

Human adipose tissue-derived mesenchymal stem cells combined with hematopoietic stem cell transplantation synthesize insulin.

BACKGROUND: Type 1 diabetes mellitus (DM) is an autoimmune disorder with disturbed glucose/insulin metabolism, which has no medical treatment other than life-long insulin therapy, despite which 30% of subjects develop organ failure. Herein we have reported the use of human adipose-tissue-derived, insulin-making mesenchymal stem cells (h-AD-MSC) transfused with unfractionated cultured bone marrow (CBM) in 5 insulinopenic DM patients. PATIENTS AND METHODS: Five (M:F, 2:3) insulinopenic DM patients of 0.6 to 10 years' duration, ages 14 to 28 years under treatment insulin (Human with 14-70 U/d) showed postprandial blood sugars between 156 to 470 mg%, glycosylated hemoglobin 6.8% to 9.9% and c-peptide levels of 0.02 to 0.2 ng/mL. They underwent intraportal administration of xenogeneic-free h-AD-MSC (mean dose = 1.5 mL; cell counts, 2.1 x 10(3)/muL). The CD45-/90+/73(+) cells (29.8/16.8%) showed c-peptide levels of 3.08 ng/mL, insulin level of 1578 micro IU/mL. The aliquot was supplemented with CBM (mean dose 94 mL with cell counts: 18.7 x 10(3)/microL) containing CD45-/34+ elements of 0.93%. The Institutional Review Board approved the study protocol and consent forms. RESULTS: All patients were successfully infused CBM plus h-AD-MSC without any untoward effects and showed 30% to 50% decreased insulin requirements with 4- to 26-fold increased serum c-peptide levels, with a mean follow-up of 2.9 months. CONCLUSION: This report describes safe and effective treatment of insulinopenic diabetics using insulin-producing h-AD-MSC plus CBM without xenogeneic materials.