Simulated wound assessment using digital planimetry versus three-dimensional cameras: implications for clinical assessment.

BACKGROUND: Clinical management of wounds can benefit from objective measures of response to treatment. Wound surface area and volume are objective measures of wound healing. Using a synthetic wound model, we compare the accuracy and reproducibility of 2 commercially available 3-dimensional (3D) cameras against planimetry and water displacement. METHODS: Twelve ulcers of various sizes and colors were reproduced in modeling clay and cured. Five naive observers used digital planimetry, water displacement, Eykona camera (Fuel 3D, UK), and Silhouette camera (ARANZ, New Zealand) to measure the wounds. RESULTS: When compared with traditional planimetry, wound surface area measurement with Eykona and Silhouette tended to underestimate wounds by 1.7% and 3.7%, respectively. Spearman correlation coefficients were 0.94 (Eykona) and 0.92 (Silhouette). Intraclass correlations for planimetry and the 2 cameras were all 1. Eykona and Silhouette tended to underestimate wound volumes when compared with water displacement by 58% and 23%, respectively. Spearman correlation coefficients were 0.92 (Eykona) and 0.72 (Silhouette). Intraclass correlations for water displacement and the two cameras were all 1. DISCUSSION: Serial accurate objective area measurements are feasible as part of ongoing clinical assessment of wounds. 3D cameras are reliable but have not shown superior accuracy to manual planimetry, and financial concerns and IT integration may limit general clinical usage. Volume measurements of wounds are practicable as part of clinical care

A multi-centre randomised controlled trial comparing radiofrequency and mechanical occlusion chemically assisted ablation of varicose veins - final results of the Venefit versus Clarivein for varicose veins trial

BACKGROUND: Endovenous thermal ablation has revolutionised varicose vein treatment. New non-thermal techniques such as mechanical occlusion chemically assisted endovenous ablation (MOCA) allow treatment of entire trunks with single anaesthetic injections. Previous non-randomised work has shown reduced pain post-operatively with MOCA. This study presents a multi-centre randomised controlled trial assessing the difference in pain during truncal ablation using MOCA and radiofrequency endovenous ablation (RFA) with six months' follow-up. METHODS: Patients undergoing local anaesthetic endovenous ablation for primary varicose veins were randomised to either MOCA or RFA. Pain scores using Visual Analogue Scale and number scale (0-10) during truncal ablation were recorded. Adjunctive procedures were completed subsequently. Pain after phlebectomy was not assessed. Patients were reviewed at one and six months with clinical scores, quality of life scores and duplex ultrasound assessment of the treated leg. RESULTS: A total of 170 patients were recruited over a 21-month period from 240 screened. Patients in the MOCA group experienced significantly less maximum pain during the procedure by Visual Analogue Scale (MOCA median 15 mm (interquartile range 7-36 mm) versus RFA 34 mm (interquartile range 16-53 mm), p = 0.003) and number scale (MOCA median 3 (interquartile range 1-5) versus RFA 4 mm (interquartile range 3-6.5), p = 0.002). 'Average' pain scores were also significantly less in the MOCA group; 74% underwent simultaneous phlebectomy. Occlusion rates, clinical severity scores, disease specific and generic quality of life scores were similar between groups at one and six months. There were two deep vein thromboses, one in each group. CONCLUSION: Pain secondary to truncal ablation is less painful with MOCA than RFA with similar short-term technical, quality of life and safety outcomes

Prospective observational cohort study of the association between antiplatelet therapy, bleeding and thrombosis in patients with coronary stents undergoing noncardiac surgery

Background: The perioperative management of antiplatelet therapy in noncardiac surgery patients who have undergone previous percutaneous coronary intervention (PCI) remains a dilemma. Continuing dual antiplatelet therapy (DAPT) may carry a risk of bleeding, while stopping antiplatelet therapy may increase the risk of perioperative major adverse cardiovascular events (MACE). Methods: Occurrence of Bleeding and Thrombosis during Antiplatelet Therapy In Non-Cardiac Surgery (OBTAIN) was an international prospective multicentre cohort study of perioperative antiplatelet treatment, MACE, and serious bleeding in noncardiac surgery. The incidences of MACE and bleeding were compared in patients receiving DAPT, monotherapy, and no antiplatelet therapy before surgery. Unadjusted risk ratios were calculated taking monotherapy as the baseline. The adjusted risks of bleeding and MACE were compared in patients receiving monotherapy and DAPT using propensity score matching. Results: A total of 917 patients were recruited and 847 were eligible for inclusion. Ninety-six patients received no antiplatelet therapy, 526 received monotherapy with aspirin, and 225 received DAPT. Thirty-two patients suffered MACE and 22 had bleeding. The unadjusted risk ratio for MACE in patients receiving DAPT compared with monotherapy was 1.9 (0.93–3.88), P=0.08. There was no difference in MACE between no antiplatelet treatment and monotherapy 1.03 (0.31–3.46), P=0.96. Bleeding was more frequent with DAPT 6.55 (2.3–17.96) P=0.0002. In a propensity matched analysis of 177 patients who received DAPT and 177 monotherapy patients, the risk ratio for MACE with DAPT was 1.83 (0.69–4.85), P=0.32. The risk of bleeding was significantly greater in the DAPT group 4.00 (1.15–13.93), P=0.031. Conclusions: OBTAIN showed an increased risk of bleeding with DAPT and found no evidence for protective effects of DAPT from perioperative MACE in patients who have undergone previous PCI

Safety of carotid intervention following thrombolysis in acute ischaemic stroke

ObjectivesThrombolysis is effective in improving clinical outcome in the treatment of acute ischaemic stroke. However, thrombolysis results in low recanalisation rates, particularly in the event of carotid occlusion. Carotid intervention is indicated in stroke resulting from significant carotid atherosclerosis, but intervention soon after thrombolysis may be associated with increased risks. This study aims to assess the safety of carotid intervention post-thrombolysis for acute ischaemic stroke.DesignSystematic review.Materials and methodsMEDLINE and EMBASE were searched on 29 May 2014. Inclusion criteria were (i) intra-arterial or intravenous thrombolysis for acute ischaemic stroke; (ii) carotid intervention within 14 days of thrombolysis; and (iii) derivable primary outcome. The primary outcome was 30-day stroke or death. A meta-analysis of incidence was completed for the 30-day stroke or death rates using Freeman–Tukey arcsine transformations and assuming random effects. Point estimates with confidence intervals (CIs) were generated and heterogeneity was assessed. The strength of recommendations and quality of underlying evidence were assessed using the American College of Chest Physicians (ACCP) grading system.ResultsNine included publications recorded 114 carotid endarterectomy (CEA) and four angioplasty interventions. The point estimate of 30-day stroke or death for CEA was 4.93% (95% CI 1.83–9.44), representing four of 114. The strength of recommendation and quality of underlying evidence for CEA as per the ACCP grading system was determined as 1C. There were no cases of stroke or death in patients undergoing angioplasty post-thrombolysis (0/4).ConclusionsEarly CEA post-thrombolysis appears safe, with stroke or death rates similar to that of the operation without thrombolysis. However, the wide CI obtained highlights the uncertainty of this result. Further, we emphasise that this recommendation is supported by low-quality evidence. Additional data are required to confirm the safety of surgery and early endovascular therapy post-thrombolysis

Comparison of microbubble presence in the right heart during mechanochemical and radiofrequency ablation for varicose veins

Objective Mechanochemical ablation is a novel technique for ablation of varicose veins utilising a rotating catheter and liquid sclerosant. Mechanochemical ablation and radiofrequency ablation have no reported neurological side-effect but the rotating mechanism of mechanochemical ablation may produce microbubbles. Air emboli have been implicated as a cause of cerebrovascular events during ultrasound-guided foam sclerotherapy and microbubbles in the heart during ultrasound-guided foam sclerotherapy have been demonstrated. This study investigated the presence of microbubbles in the right heart during varicose vein ablation by mechanochemical abaltion and radiofrequency abaltion. Methods Patients undergoing great saphenous vein ablation by mechanochemical abaltion or radiofrequency ablation were recruited. During the ablative procedure, the presence of microbubbles was assessed using transthoracic echocardiogram. Offline blinded image quantification was performed using International Consensus Criteria grading guidelines. Results From 32 recruited patients, 28 data sets were analysed. Eleven underwent mechanochemical abaltion and 17 underwent radiofrequency abaltion. There were no neurological complications. In total, 39% (11/28) of patients had grade 1 or 2 microbubbles detected. Thirty-six percent (4/11) of mechanochemical abaltion patients and 29% (5/17) of radiofrequency ablation patients had microbubbles with no significant difference between the groups (p=0.8065). Conclusion A comparable prevalence of microbubbles between mechanochemical abaltion and radiofrequency ablation both of which are lower than that previously reported for ultrasound-guided foam sclerotherapy suggests that mechanochemical abaltion may not confer the same risk of neurological events as ultrasound-guided foam sclerotherapy for treatment of varicose veins

A temporal and spatial analysis approach to automated segmentation of microbubble signals in contrast-enhanced ultrasound images: application to quantification of active vascular density in human lower limbs

Contrast-enhanced ultrasound (CEUS) using microbubble contrast agents has shown great promise in visualising and quantifying active vascular density. Most existing approaches for vascular density quantification using CEUS are calculated based on image intensity and are susceptible to confounding factors and imaging artefact. Poor reproducibility is a key challenge to clinical translation. In this study, a new automated temporal and spatial signal analysis approach is developed for reproducible microbubble segmentation and quantification of contrast enhancement in human lower limbs. The approach is evaluated in vitro on phantoms and in vivo in lower limbs of healthy volunteers before and after physical exercise. In this approach, vascular density is quantified based on the relative areas microbubbles occupy instead of their image intensity. Temporal features of the CEUS image sequences are used to identify pixels that contain microbubble signals. A microbubble track density (MTD) measure, the ratio of the segmented microbubble area to the whole tissue area, is calculated as a surrogate for active capillary density. In vitro results reveal a good correlation (r(2) = 0.89) between the calculated MTD measure and the known bubble concentration. For in vivo results, a significant increase (129% in average) in the MTD measure is found in lower limbs of healthy volunteers after exercise, with excellent repeatability over a series of days (intra-class correlation coefficient = 0.96). This compares to the existing state-of-the-art approach of destruction and replenishment analysis on the same patients (intra-class correlation coefficient ≤0.78). The proposed new approach shows great potential as an accurate and highly reproducible clinical tool for quantification of active vascular density

Target balloon-assisted antegrade and retrograde use of re-entry catheters in complex chronic total occlusions

Purpose, Retrograde recanalizations have gained increasing recognition in complex arterial occlusive disease. Re-entry devices are a well described adjunct for antegrade recanalizations. We present our experience with target balloon-assisted antegrade and retrograde recanalizations using re-entry devices in challenging chronic total occlusions. MATERIALS AND METHODS: We report data from a retrospective multicenter registry. Eligibility criteria included either antegrade or retrograde use of the OutbackTM or GoBackTM re-entry catheter in combination with a balloon as a target to accomplish wire passage, when conventional antegrade and retrograde recanalization attempts had been unsuccessful. Procedural outcomes included technical success (defined as wire passage though the occlusion and delivery of adjunctive therapy with <30% residual stenosis at final angiogram), safety (periprocedural complications, e.g., bleeding, vessel injury, or occlusion of the artery at the re-entry site, and distal embolizations), and clinical outcome (amputation-free survival and freedom from target lesion revascularization after 12-months follow-up). RESULTS: Thirty-six consecutive patients underwent target balloon-assisted recanalization attempts. Fourteen (39 %) patients had a history of open vascular surgery in the index limb. Fifteen patients were claudications (Rutherford Class 2 or 3, 21 presented with chronic limb threatening limb ischemia (Rutherford Class 4 to 6). The locations of the occlusive lesions were as follows: iliac arteries in 3 cases, femoropopliteal artery in 39 cases, and in below-the-knee arteries in 12 cases. In 15 cases, recanalization was attempted in multilevel occlusions. Retrograde access was attempted in 1 case in the common femoral artery, in the femoropopliteal segment in 10 cases, in below-the-knee arteries in 23 cases, and finally in 2 patients via the brachial artery. In 10 cases, the re-entry devices were inserted via the retrograde access site. Technical success was achieved in 34 (94 %) patients. There were 3 periprocedural complications, none directly related to the target balloon-assisted re-entry maneuver. Amputation-free survival was 87.8 % and freedom from clinically driven target lesion revascularization was 86.6 % after 12-months follow-up. CONCLUSION: Target balloon-assisted use of re-entry devices in chronic total occlusions provides an effective and safe endovascular adjunct, when conventional antegrade and retrograde recanalization attempts have failed

Deep vein thrombosis exhibits characteristic serum and vein wall metabolic phenotypes in the inferior vena cava ligation mouse model

Deep vein thrombosis (DVT) is a major health problem, responsible for significant morbidity and mortality, and imposes a heavy economic burden to healthcare systems (1). Although most events resolve without complication through spontaneous lysis and recanalization, DVT can be complicated with life-threatening pulmonary embolism (2), while approximately one third of DVT patients develop post-thrombotic syndrome with swelling, pain, skin changes and/or venous ulceration (3).Treatment with anticoagulation prevents further thrombus extension, protects from pulmonary embolism and reduces the risk of chronic lower limb complications. Importantly, unnecessary treatment can result in bleeding. Therefore, accurate and reliable DVT diagnosis is essential. Currently, diagnosis relies on subjective clinical examination and ultrasound imaging (4). A number of biological markers have been investigated with variable results. D-dimer, the most widely used biomarker, is sensitive but lacks specificity (5, 6). Ongoing research efforts target the utility of alternative blood diagnostic biomarkers able to accurately diagnose DVT, guide length and type of treatment, and potentially identify patients who may benefit from more aggressive therapies than standard anticoagulation. New molecular technologies and methods have entered the scientific arena, offering the opportunity to revisit this important clinical need. Metabolic profiling has emerged as a new approach to investigate complex metabolic disease and enable precision medicine. Metabolomics is the comprehensive and systematic identification of the small molecules present in differential abundance in biofluids and are affected by various factors such as diet, lifestyle, genetics, disease, environmental factors and medications. Metabolic profiling approaches to characterizing the metabolome can be either targeted or untargeted. In targeted approaches specific metabolites, representative of suspected biological pathways, are analysed in each sample. Non-targeted analysis simultaneously screens multiple small molecules for alterations in their levels within biofluids. This latter approach can identify novel, unrecognised metabolites and pathways, elucidating the pathophysiology of the disease, and highlighting potential biomarkers, biomarker signatures and/or therapeutic targets. Omics studies, specifically the non-targeted approaches have allowed us to go from hypothesis led to hypothesis generating studies. Metabolomics employs high-throughput analytical platforms (both nuclear magnetic resonance [NMR] spectroscopy and ultra-performance liquid chromatography-mass spectrometry [UPLC-MS]) coupled with statistical modelling to identify metabolites, which are differentially present in the context of health and disease. This provides a platform to screen for candidate biomarkers for DVT diagnosis (7). NMR is a non-destructive, robust and quantitative method that provides information on molecular structure, but lacks sensitivity. MS is more sensitive, but requires pre-separation with a chromatographic method and ionisation of the sample. The combination of NMR and MS provides complimentary and accurate information on metabolites. Metabolomics has been shown to have utility in vascular disease and metabolic changes have previously been identified, at tissue level, between varicose and non-varicose vein, carotid and femoral atherosclerosis, and stable and unstable carotid plaques (8, 9). Recently, NMR spectrometry was used to identify metabolic changes of DVT in animals of different ages (10). This study aims to elucidate the DVT-specific metabolite profile in a murine experimental model