Decrease in the Incidence of Buerger's Disease Recurrence in Northern Thailand

Purpose Buerger's disease is a peripheral arterial occlusive disease (PAOD), which occurs mainly in young male smokers. It is common in Asia, the Middle East, and Eastern European countries, but rare in North America and Western European countries. We investigated the changes in the prevalence and recurrence of Buerger's disease at a referral hospital in northern Thailand. Methods We conducted a retrospective study of patients with Buerger's disease admitted to Chiang Mai University Hospital between January 1988 and December 2002. Buerger's disease was diagnosed according to Shionoya's clinical criteria. Results We evaluated 78 patients with Buerger's disease, with a collective total of 108 admissions. Forty-one patients were admitted for initial treatment, and 37 patients had a history of treatment and were admitted for worsening of Buerger's disease. Between 1988 and 1995, 23 patients were admitted with newly diagnosed Buerger's disease, 52 were admitted because of Buerger's disease exacerbation, and 372 were admitted for a PAOD; whereas between 1996 and 2002, the respective numbers were 18, 15, and 632 (2.9 ± 1.9/year vs 2.6 ± 1.3/year, P = 0.25; 6.5 ± 1.1/year vs 2.1 ± 1.1/year, P = 0.001; 54.1 ± 6.7/year vs 81.6 ± 5.2/year, P < 0.0001). Of the 78 patients with Buerger's disease, 76 were men and 2 were women, with a mean age at onset of 34.1 ± 5 years. The predominant symptom on admission was burning pain in the feet and hands in 75%, digital gangrene in 74%, and a digital ulcer in 43.5%. Conclusions The incidence of recurrence of Buerger's disease seems to be decreasing in our institution, whereas the incidence of this disease and its recurrence both seem to be decreasing in Western countries and Japan.     

A hospital-based survey of risk factors for diabetic foot ulceration in northern Thailand

Ulceration of the foot is found more commonly in patients with diabetes mellitus than those without it. Foot ulcers affect the lives of patients in many ways, and though good care can be defined, loss of limb is a common occurrence in this patient group. Therefore, early detection of the foot at risk for foot ulceration is of paramount importance. Many risk factors for this type of ulcer have been previously reported such as neuropathy, deformity of the foot, arterial occlusion, and poor glycemic control. The authors conducted a hospital-based survey in patients attending a hospital diabetic clinic to establish a baseline database and found that the percentages of sensory neuropathy, history of claudication and poor glycemic control were 19.2%, 5.7%, and 79.7%, respectively. This suggests the need to establish good diabetic control and health education for our patient population.     

Temporal Trends in the Risks of Stroke and Death due to Endarterectomy for Symptomatic Carotid Stenosis: An Updated Systematic Review

ObjectivesTo determine whether there is any evidence of a systematic reduction in the operative risk of carotid endarterectomy (CEA) for symptomatic stenosis in recent years.MethodsWe performed a systematic review of all studies published between 2000 and 2008 inclusive that reported the risks of stroke and death for symptomatic carotid stenosis. We compared the reported risks with our previous review of studies published prior to 2001 and between studies that were reported by surgeons alone and studies that included neurologists or stroke physicians as assessors/authors, with particular reference to the proportion of operative strokes to operative deaths.ResultsOf 494 studies, only 53 reported operative risks for patients with symptomatic stenosis separately. In keeping with the findings of our previous review, the pooled operative risk of stroke and death reported in studies published by surgeons alone (3.9%, 95% confidence interval (CI): 3.4–4.3) was significantly lower (p < 0.001) than that reported in studies that involved neurologists (5.6%, 95% CI: 5.1–6.2). The pooled ratio of operative stroke:operative death was 4.0 (range: 3.6–4.5) in studies involving neurologists or stroke physicians and 2.7 (range: 2.1–3.9) in studies involving only surgeons (p = 0.002). We found no evidence of a reduction in published risks of death or stroke and death due to CEA for symptomatic carotid stenosis between 1985 and 2008. Indeed, the 1.4% (range: 1.2–1.6%) pooled operative mortality in studies published during 2001–2008 was significantly higher than that reported in ECST and NASCET (1.0%, 95% CI: 0.9–1.1%). However, the average age of patients having CEA has continued to increase during this period.ConclusionsThere is no evidence of a systematic reduction over the last decade in the published risks due to CEA for symptomatic stenosis. The lower proportion of non-fatal operative strokes in surgeon-only studies suggests that some minor operative strokes have been missed.     

Reducing lower extremity amputations due to diabetes: the application of diabetic-foot protocol in Chiang Mai University Hospital

The aim of this study was to determine whether intensive treatment and education strategies for diabetic patients with ulcers help in preventing leg amputation. From August 2005 to March 2007, a diabetic-foot protocol using a multidisciplinary approach was applied at our hospital. All the subjects were educated regarding diabetic-foot disease and its complications and prevention. This report compares the amputation rate in patients receiving the protocol care from August 2005 to March 2007 with those who had standard care from August 2003 to July 2005. Seventy-three and 110 diabetic-foot ulcer patients received protocol and standard foot care, respectively. The incidence of major amputations in the protocol and standard care groups was 4.1% and 13.6%, respectively (P= .03). Our protocol was associated with improved diabetic-foot care outcomes. It can be used by any hospital to improve outcomes for patients with diabetes.     

A correlation study between ankle brachial pressure index and the severity of coronary artery disease

Previous studies have shown that there was a correlation between low ankle brachial pressure index (ABPI) and the presence of the coronary artery disease (CAD). However, few studies have investigated the correlation between ABPI and the severity of CAD by using a scoring system. The authors aimed to investigate this correlation by using ABPI and CAD diagnosed by coronary angiography (CAG). A total of 213 consecutive patients awaiting CAG in Maharaj Nakorn Chiang Mai Hospital from July 2009 to November 2009 were enrolled in this study. The ABPI was measured before CAG. The severity of CAD was graded on CAG by using SYNTAX scores. The authors found a significantly negative correlation between ABPI and SYNTAX scores (correlation coefficient = -.172, P = .01). The authors concluded that ABPI appeared to correlate negatively with the severity of CAD in the Thai population.     

Mini-laparotomy for repair of infrarenal abdominal aortic aneurysm.

AIM: In this study, we evaluated the surgical results of minimal incision aortic surgery (MIAS) compared with the transabdominal approach (TPA) and the retroperitoneal approach (RPA) to repair non-ruptured infrarenal abdominal aortic aneurysm (AAA). METHODS: Three different surgical techniques were studied prospectively in 72 consecutive patients with non-ruptured infrarenal AAA. These patients were randomized into 3 groups of 24 patients each. Group I comprised of patients who underwent MIAS repair. They were compared with group II patients, who underwent the traditionally long midline TPA, and group III patients, who underwent the left RPA to repair non-ruptured infrarenal AAA. All surgery was performed between January 2000 and December 2004. Demographic characteristics, including age, sex, body weight, aneurysm size, previous abdominal operations and comorbid factors of the three groups studied, were compared using the Fischer's exact test. Parameters including operative time, intraoperative fluid administration, and transfusion requirements were compared using the 2-tailed Student t test. Length of stay in the Intensive Care Unit (ICU), time to resumption of regular dietary feeding, and hospital length of stay were recorded and compared using the Wilcox rank sum test. The incidence of 30 day postoperative complications and mortality were compared between the three groups. All 72 patients who entered this study had informed consent. RESULTS: There was no significant difference between group I (MIAS), group II (TPA), and group III (RPA) with regard to age, sex distribution, aneurysm size, or body weight. There was male sex prevalence in all three groups. Surgical exposure of the common femoral arteries was more commonly required in group III (RPA) than in the other groups. Although the length of incision tended to be longer in group III (RPA) than in group II (TPA) and I (MIAS), there was no significant difference in intraoperative time, or aortic cross-clamped time among the three groups. There was a significant difference in the need for intraoperative fluid, the most being in group II (TPA) and the least in group I (MIAS). There was significantly less blood loss in group I (MIAS), as compared with the other 2 groups, but intraoperative blood transfusion for all groups was not significantly different. ICU stay, return to general dietary feeding, and hospital length of stay for group I (MIAS) and III (RPA) were significantly lower than in group II (TPA), which had a higher incidence of postoperative ileus. CONCLUSIONS: MIAS is as safe as retroperitoneal repair and standard transabdominal repair in the treatment of non-ruptured infrarenal AAA, and also more costefficient than retroperitoneal and standard transabdominal repair.     

Seasonal variation of Buerger's disease in Northern part of Thailand.

OBJECTIVES: Buerger's disease is a common peripheral arterial occlusive disease in Asia, Middle East, and eastern European countries. This study was undertaken to investigate the seasonal variation in admission pattern of with patients Buerger's disease at our institution which is a referral hospital in the Northern Thailand. MATERIAL AND METHODS: Patients with Buerger's disease admitted to Chiang Mai University Hospital between January 1987 and December 2002 were studied retrospectively. Data are reported as mean+/-SD. Statistical significance was analyzed by Chi-square test. RESULTS: Eighty-four patients (82 men and two women) with Buerger's disease were evaluated on 121 admissions. Forty-five were newly diagnosed cases, who were admitted for initial treatment, and 39 were known cases who experienced worsening of the disease. Sixty-three admissions (52%) took place during winter (November to February), 44 admissions (34.6%) during the rainy season (June-October) and only 14 admissions (11.6%) occurred during the summer (March-May). There was a significant difference in the monthly admission rates during the three seasons (p<0.05). CONCLUSION: Admission for Buerger's disease showed a significant seasonal variation, with a peak in the winter followed by the rainy and summer season, respectively. Further research is needed to confirm our findings and evaluate the underlying mechanisms.     

A comparison of socio-behavioral risk factors between HIV-infected and non-infected older adults in Northern Thailand

There is a shift in the demographic profile of people living with HIV toward older age groups. The current study compares alcohol use, smoking, and physical exercise between HIV-infected and non-infected older adults recruited in 12 community hospitals in Chiang Mai Province, Northern Thailand. Participants in the two groups were 50 years and above, matched by age and gender. The sample included 364 participants in each of the groups. Older adults living with HIV were less likely to report drinking alcohol in the past year (AOR, 0.55; CI, 0.34–0.89, P?=?0.015) and more likely to report being currently engaged in physical activities (AOR, 2.58; CI, 1.77–3.76, P?<?0.001). There was no difference between the two groups in terms of “current smoking status”. Older adults living with HIV were healthier than their non-infected counterparts in terms of the socio-behavioral risks.     

Meta‐analysis of small randomized controlled trials in surgery may be unreliable

Background:

Meta‐analysis of randomized controlled trials (RCTs) should provide reliable evidence about the effects of interventions. This may be less reliable when only small trials are available.

Methods:

The sample size was determined for all surgical RCTs included in Cochrane Collaboration systematic reviews. The difficulty in interpreting meta‐analysis of small trials is illustrated using two specific reviews.

Results:

The typical sample size for surgical RCTs was small with a median of only 87 participants. Only 39·8 per cent had adequate prerandomization treatment allocation concealment. In both systematic reviews that were assessed in detail, statistically significant early results from meta‐analysis of several small RCTs did not reliably predict the results of subsequent RCTs.

Conclusion:

Surgical RCTs tend to be small and underpowered. Meta‐analysis of such trials does not necessarily produce reliable results. Copyright © 2010 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.