Effect of parental smoking on children?

CIMT measurement

Parental Smoking Causes Vascular Damage In Young Children - Surrogate markers of vascular disease are hsCRP, carotid artery intima media thickness. Carotid artery intima media thickness measurement is painless and repeatable. So, in one study specifically, they looked at the children's carotid artery intima-media thickness (CIMT) and arterial wall distensibility, using ultrasonography to take the measurements. The evidence was fairly conclusive and showed that children whose mothers smoked during pregnancy had on average carotid arteries showing 15% more stiffness, as well as arterial thickening of 19 microns, (which is about the thickness of a cassette tape) compared with their smoke free peers. Where both mother and father smoked during the pregnancy the stiffness rose to 21% and thickening to 28 microns. So, we should encourage parents to avoid smoking which is not only harmful to them but also to their children. Increased CIMT is also associated with increased coronary artery disease related events. This parameter has been used in the past and it correlated with the postprandial blood sugar levels.

 

Lipodermatosclerosis and chronic venous disease

Patients with chronic venous disease (venous insufficiency) develop changes in the foot, ankle and leg. They develop varying degrees of varicose veins, skin pigmentation, thickening of the skin and subcutaneous tissues and ulceration in the ankle region.  Skin thickening and nodular formation mimics cellulitis in many patients and there is a possibility that many of them may receive antibiotics for control infection and cellulitis. The thickening of the skin and subcutaneous tissues in chronic venous disease usually occurs on the medial side of the leg. Skin pigmentation is common and it is rare to see the induration and thickening on the medial side without skin pigmentation.   It is still not clear which factors will determine the development of the thickness of the tissues ( Lipodermatosclerosis) and the speed at which they develop in a given patient. We have seen this symptom Lipodermatosclerosis in people who are obese and non-obese, who are tall and short. It may not be uncommon to see a obese man with inverted champagne bottle like legs in vascular surgery clinics. The indurated, sclerotic plaques with a “bound-down” appearance (ie, they appear as if tethered—or bound—to the subcutaneous tissue) affecting the skin from below the knee to the ankle is common in our clinics in patients who had chronic venous disease for more than 10 years with or without history of DVT. Usually there is a sharp demarcation between affected and unaffected skin.  It is proposed that venous reflux leads to increased venous pressures which can result in extravasation of interstitial fluid and red blood cells, decreased diffusion of oxygen to the tissues, and eventual tissue and endothelial damage. As the endothelium is damaged, microthrombi formation and infarction ensue, stimulating fibroblasts to form granulation tissue.  Fibroblast might be playing a major role in progression of the fibrotic reaction in the ankle and leg region. The dilated veins are palpable in this scar like tissues and sometimes they may be source of profuse bleed from the ankle region.  When such a bleed occurs one would be concerned about further bleeds from the leg. Sclerotherapy may help to stop the bleed and heal ulcers. But patients would certainly like to get it excised completely and get skin grafting if possible.

Effect of Injuries in patients receiving warfarin

Injuries in patients who are on oral anticoagulants and antiplatelet drugs

In the recent past increasing number of cardiovascular patients (atrial fibrillation, DVT, post interventions) are put on oral anticoagulants and antiplatelet drugs after a life or limb threatening cardiovascular event.  Therapeutic advancements are increasing probably the need for these special classes of drugs in our patients. We are concerned about the risk of bleeding in such patients.  Spontaneous bleeding is one and prolonged and profuse bleeding from trauma is the other which we may have address in some of these patients. We have already noted the increased risk of puncture site complications (bleeding, pseudo-aneurysm) after angiogram or angioplasty in those receiving the triple antiplatelet therapy in the cardiac patients.  The patients are leading active lives and traveling like any person after recovering from cardiovascular events and there is a probability that they may be prone for injuries. 

If a patient who is on oral anticoagulants or antiplatelet drugs sustain injuries there can be more bleeding and some times it can be life threatening. Bleeding in to the closed cavities such as intracranial, intra thoracic and retroperitoneal can continue for longer periods under the influence of the drugs.  Recently DJ Bonville et al from Albany retrospectively reviewed (3,436) the impact of pre-injury warfarin and antiplatelet drugs (456) on the outcomes of trauma patients from 2004 – 2007 at a New York state level-1 trauma center.   Patients on Warfarin were 3.1 times more likely die after adjusting for potential confounders. Aspirin and clopidogrel were not associated with increased mortality. But these drugs were associated with increased risk of Intra cranial hemorrhage (ICH).   But among the ICH patients increased mortality was associated with warfarin. (Surgery 2011;150: 861-8)

In many countries and in India the aging population is going increase in the coming years. In USA people above 65 years are 13% and they are going to become 20%  in 2050. Some of these are going to receive these medications.  Many studies in the past linked the mortality and morbidity of trauma patients to the use of anticoagulants. In one retrospective study Dossett  et al reviewed one million trauma patients admitted in 402 centers. In this group 36,270 patients were taking warfarin.  Among these taking warfarin 9.3% died and only 4.3% died in the group not taking warfarin. (Arch Surg 2011;146:565-70).

Initiation of oral anticoagulation after giving heparin for 5 days in DVT patients is practiced in many hospitals. The tablet warfarin action is monitored by testing the INR frequently and maintained between 2-3. It is difficult for the patients who are not living close to the towns to get the reliable INR tests. The Indian diet may be also interfering with action of the drugs. Anticoagulation clinics are not present in states like Andhra Pradesh in India. There is a need for the development of web sites to guide these patients about the drug interactions and precautions to be taken while taking the medication. It will be very convenient for the patients if is possible to provide the free testing facilities at the pharmacies supplying (selling) the medications. These patients can carry a card which can be flashed in case of emergency such as trauma to help the treating doctors to take necessary precautions and reverse the effects of anticoagulation (warfarin effect). Correction with Fresh frozen plasma, Injection Vitamin K  and Factor VIIa are used for reversing the warfarin effect.

De-branching of aorta during Aortic Aneurysm repair

Even though it was introduced more than 5 decades back open surgical aortic aneurysm repair is still considered to be a major surgery associated with morbidity and mortality. Aneurysms of the aorta are repaired only in few centers in the state Andhrapradesh. Therefore it is not a popular operation and it is also associated with an expenditure which is unpredictable due to the perioperative and postoperative events.  The common man who is generally dependent on the Govt health services. But very few government hospitals are providing the aneurysmsal surgery services through the cardiothoracic surgery departments. The new health care scheme "Aarogyasri" is covering the aortic aneurysm repair but the reimbursement is limited and so, the providers in the hospitals are hesitant to ask their treating doctors to take up such cases. In the past many complex aortic aneurysms engulfing the important branches were considered to be inoperable or associated with high morbidity. But endovascular repair with debranching of the aorta is making it possible to treat these patients with less morbidity and more predictability of outcomes.

There is a loud rethinking in the west that this type of two stage procedures (debranching and endorepair) can save the patients from morbidity and mortality. But the cost of such procedures still continues to be high and in few institutions in India  it is exorbitantly high.  The Aarogyasri scheme is currently not recognizing and covering such therapies. It would be better and helpful to the patients if the health insurances companies enquire about such procedures and approve few hospitals to provide such therapies to benefit the people who are in need of such treatments.