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Dr. Micahel Jacob

MGR featuring Dr. Michael Yacob – Venous Disease

Emmanuel Fagbola, MSc Candidate (Translational Medicine)

Last week we had the pleasure of hearing from Dr. Michael Yacob during our Medical Grand Rounds on venous disease, where he elucidated a myriad of venous irregularities that prevent the body’s veins from providing adequate blood flow back to the heart. Tenacious, progressive, and frequently underestimated, venous disease affects a significant portion of the population1-3 and has large socioeconomic, physical, and psychological implications4, 5.

 

To kick off the lecture, Dr. Yacob pointed out that veins and arteries are mirror images of each other, with the point of difference being the saphenous veins in the legs and the cephalic and basilic veins in the arms acting as vital backup systems for venous blood flow. Highlighting the necessity of this complex system, he introduced the concept of deep vein thrombosis (DVT), which is when a clot develops in the deep veins causing overreliance on blood flow through the superficial venous system. Furthermore, these cases have absolute contraindications to superficial vein surgical interventions as superficial system damage will completely compromise limb venous outflow leading to limb loss6. Interestingly, peripherally inserted central catheter (PICC) lines were highlighted as a risk factor for upper extremity DVTs as ~10% of PICCs lead to upper extremity DVTs.

 

Analogous to PICCs, patients with peripheral lines commonly develop superficial venous thrombosis (SVT)7 but rarely develop superficial suppurative venous thrombosis (SSVT). Although both diagnoses involve clots that compromise superficial venous return, SSVT consists of an additional infection component. The standard of care consists of line removal, cold compress, and Tylenol. Moreover, concerns arise when SVT affects the primary superficial system or propagates to the deep venous system8. Consequently, an ultrasound is conducted to confirm diagnosis and anticoagulation is considered if a DVT is suspected9. Lastly, ascending lymphangitis, a bacteria-induced inflammation of the lymphatic vessels from SSVT, was presented as an example where surgical intervention can occur.

 

Dr. Yacob then discussed the most common venous disease which is varicose veins. Veins are constantly working against gravity; therefore, muscle contraction squeezes the deep and superficial venous systems to assist blood propagation back to the heart. Venous insufficiency can result from the dilation of venous walls preventing valve components from making contact and causing leakage10. Chronic DVTs can cause varicose veins via saphenous vein dilation resulting in bi-directional blood flow11. Additionally, venous ulcers can occur when stagnant blood exits the venules and move into the skin, causing inflammation-induced breakdown11. Venixxa is a drug that inhibits chronic dermal inflammation and helps with ulcer-related symptoms; however, the side effects and inability to reverse disease take away from its widespread use as an effective therapeutic. Primary varicose veins result from inherent weakness in superficial veins. Common risk factors such as old age, obesity, and constant standing result in 23% of the population suffering from this disease with >75% being women11. Varicose vein prophylaxis includes regular use of compression socks.

 

The gold standard for effectively diagnosing these venous diseases is ultrasound 12. This diagnostic tool describes the anatomical findings of the superficial, deep, and perforator venous systems. It functions well in elucidating the venous system's hemodynamic activity, a vital aspect of venous insufficiency diagnosis. Finally, ultrasound can provide relevant timelines which includes differentiating acute from chronic thrombosis.

 

Finally, Dr. Yacob discussed one of the most severe forms of venous disease which is an acute iliofemoral DVT. This is different from a traditional DVT as it involves clot-mediated occlusion of the common femoral and iliac veins, resulting in complete obstruction of venous outflow as both backup and main pathways converge at this location13. Furthermore, limb-threatening ischemia from venous outflow obstruction is clinically diagnosed as phlegmasia cerulea dolens. Management of this disease involves emergency thrombolytics. Conversely, non-limb threatening iliofemoral DVT is controversial; however, evidence suggests that thrombolytics help avoid post-thrombotic syndrome.

 

After Rounds, the TMED801 class had the opportunity to discuss venous disease and career pathways with Dr. Yacob. We first delved into surgical treatment of varicose veins in the form of vein stripping and ablation. We discussed how the latter measure is more effective, safer, and conducive to quicker recovery; however, this procedure is not well covered in Canada, forcing many patients to choose the former option. Next, we discussed how vascular surgery is portrayed as a cosmetic surgical intervention in the press resulting in limited service coverage and lack of awareness of venous disease prevalence and severity. Finally, Dr. Yacob outlined his training, including an undergraduate education at the University of Ottawa, medical education in Ireland, and vascular surgery residency back in Ottawa. He also talked about his additional certifications and interests and how they benefit his current practice. In the end, Dr. Yacob encouraged TMED students that having a graduate degree is a great asset to future medical students and practitioners.

 

As translational medicine graduate students at Queen’s University, our research focuses on patients and their diseases through lenses like epidemiology, basic sciences, and artificial intelligence. With the limited translation of leading risk factors of venous disease to the public, inequitable access to optimal venous surgical interventions, and the shift toward valuing research experience as an asset to learners and professionals, it is clear that translational research and implementation is crucial to improving patient outcomes in the field of vascular surgery.

 

On behalf of the TMED 801 class, I would like to extend a big thank you to Dr. Yacob for his time, honest insights, and tireless contribution to patient care in the field of vascular surgery.

 

References

 

1.         Rabe E, Guex JJ, Puskas A, Scuderi A, Fernandez Quesada F, Coordinators VCP. Epidemiology of chronic venous disorders in geographically diverse populations: Results from the vein consult program. Int Angiol. 2012;31:105-115

2.         Rabe E, Régnier C, Goron F, Salmat G, Pannier F. The prevalence, disease characteristics and treatment of chronic venous disease: An international web-based survey. Journal of Comparative Effectiveness Research. 2020;9:1205-1218

3.         Zolotukhin IA, Seliverstov EI, Shevtsov YN, Avakiants IP, Nikishkov AS, Tatarintsev AM, et al. Prevalence and risk factors for chronic venous disease in the general russian population. European Journal of Vascular and Endovascular Surgery. 2017;54:752-758

4.         Nicolaides AN, Labropoulos N. Burden and suffering in chronic venous disease. Advances in Therapy. 2019;36:1-4

5.         Davies AH. The seriousness of chronic venous disease: A review of real-world evidence. Advances in Therapy. 2019;36:5-12

6.         Yeager RA, Moneta GL, Edwards JM, Taylor LM, McConnell DB, Porter JM. Deep vein thrombosis associated with lower extremity amputation. Journal of Vascular Surgery. 1995;22:612-615

7.         Evans NS, Ratchford EV. Catheter-related venous thrombosis. Vascular Medicine. 2018;23:411-413

8.         Scott G, Mahdi AJ, Alikhan R. Superficial vein thrombosis: A current approach to management. British Journal of Haematology. 2015;168:639-645

9.         Cavezzi A. Medicine and phlebolymphology: Time to change? Journal of Clinical Medicine. 2020;9:4091

10.       Hyder ON, Soukas PA. Chronic venous insufficiency: Novel management strategies for an under-diagnosed disease process. R I Med J (2013). 2017;100:37-39

11.       Piazza G. Varicose veins. Circulation. 2014;130:582-587

12.       Garcia R, Labropoulos N. Duplex ultrasound for the diagnosis of acute and chronic venous diseases. Surgical Clinics of North America. 2018;98:201-218

13.       Vedantham S, Thorpe PE, Cardella JF, Grassi CJ, Patel NH, Ferral H, et al. Quality improvement guidelines for the treatment of lower extremity deep vein thrombosis with use of endovascular thrombus removal. Journal of Vascular and Interventional Radiology. 2009;20:S227-S239

 

 

Comments

Name
Kiera Liblik

Tue, 11/09/2021 - 09:59

Hello Emmanuel,
Thank you for an excellent summary and discussion of MGR with Dr. Yacob. You highlighted the lack of awareness of the etiology and treatment of venous disease, partially due to a reputation for varicose vein treatment being 'cosmetic'. Interestingly, a critical analysis on internet patient resources for varicose vein information found that there was significant variability in the quality of information presented as well as the readability/accessibility of information.(1) Although clinicians can provide recommended resources, it is inevitable that patients search their condition on the internet and are exposed to a variety of resources. Do you think that there is a way we can mitigate the negative effects of this overwhelming amount of varied information?
Cheers,
Kiera
(1) Yan, Q., Field, A. R., Jensen, K. J., Goei, C., Jiang, Z., & Davies, M. G. (2021). Critical analysis of the quality of internet resources for patients with varicose veins. Journal of Vascular Surgery: Venous and Lymphatic Disorders, 9(4), 1017-1024.

Name
Kiera Liblik

Hello Kiera,

Thank you so much for your insightful question. I completely agree that the medical information that patients access on the internet has a varying degree of veracity and can detriment the patient’s role in supporting their health and wellness. Readability is another significant concern, as correct information presented to an audience in a manner that is not understandable will result in an incorrect understanding of the material. Thus, I think it can be argued that complex yet correct information and inaccurate information can potentially mislead patients without the guidance of a medical professional.

In short, optimizing knowledge translational may be an effective way to mitigate the adverse effects of this overwhelming information on patients. First, many patients with diseases and conditions tend to have a yearning to learn more about them1. The internet can be a great resource to support this education; however, evidence-based literature from peer-reviewed sources can be difficult for the average individual to comprehend fully. In response, the Journal of Research Involvement and Engagement requires a “Plain English Summary” for all submissions along with an abstract. This plain English summary essentially functions as a lay abstract summarizing the articles using language suitable for both patients and the general public to understand. I believe changes like this can support the public’s ability to engage in scientific literature and potentially limit the reliance on other forms of information available on the internet.

Further, I believe a change where more peer-reviewed journals mandated sections like the plain English summary would positively affect inaccurate sources of medical information on the internet. With more accessible and understandable literature, I could imagine that the editors of non-peer-reviewed sources of information would have the tools to translate information more accurately. Ultimately, a seemingly simple implementation like this can address the issues of low readability of literature and inaccurate information on the web that misleads patients.

The Journal of Research Involvement and Engagement’s submission instructions can be found here: https://researchinvolvement.biomedcentral.com/submission-guidelines/pre…
Reference

1. Benham-Hutchins M, Staggers N, Mackert M, Johnson AH, Debronkart D. “I want to know everything”: A qualitative study of perspectives from patients with chronic diseases on sharing health information during hospitalization. BMC Health Services Research. 2017;17

Name
Emmanuel Fagbola

Name
Kyla Tozer

Tue, 11/09/2021 - 12:07

It was an absolute pleasure having Dr. Yacob discuss his expertise on endovascular surgery. Dr. Yacob is very passionate about his field and communicates what he does clearly. Emmanuel, you did great job outlining they key takeaways and clearly communicating how complex this field is. At this point we have had a few speakers discuss cardiovascular and respiratory sciences; it was interesting to see this all come together ending with the surgical aspect of disease.

During our question-and-answer period we discussed research and medicine. Particularly, how your personal research will impact your applications for residency. In your opinion, Emmanuel, would it be advantageous to approach your research broadly, or get extremely focused, such as endovascular surgery?

Name
Kyla Tozer

That's a great thought-provoking question, Kyla! Thank you to Emmanuel for the great summary, and to Dr. Yacob for the insightful talk. I was also intrigued by Dr. Yacob's comments on the applicability of graduate level research while applying for residency in medicine. Dr. Yacob suggested that many programs look for candidates with a master's in epidemiology or in public health, something general. I'm wondering about the utility of a master's degree that helps build a strong skillset in data analytics, modelling or other general research skills, where the thought process can be transferrable across different medical areas. For example, Dr. Yacob discussed that graduate level experience in Artificial Intelligence (AI) can be spun many different ways while applying to residency, whereas specific subject matter experience can be a strong factor on a residency application for the relevant clinical areas. I think it's also important to consider the skills that we're developing through this program can be highly impactful outside of a career as a physician, and we are learning how to bring positive value regardless of our career choices in healthcare. I'm curious to know what skills our classmates are learning that they will carry with them in their future careers.

Name
Katie Lindale

Hey Kyla,

Thank you for the compliments! In my experience, your question is quite relevant to the graduate students in Translational Medicine at Queen's.

To start, I believe residency programs across the country are looking to train physicians who will excel in training and positively impact patients throughout their careers. Moreover, Dr. Yacob mentioned that research experience is becoming more critical in the assessment of residency applications.

Looking at past MGR discussions and small group chats that I have had with many students in our class over the past couple of months, the connection of seemingly unrelated body systems and their associated medical specialties has been a common theme. Notably, earlier in September, Dr. Boyd's MGR on the connection between neurology and nephrology stood out to me.

With that in mind, students sometimes worry about the research project they select and its related field of study. There seems to be a conception that if one's research discipline does not align with the field of medicine they want to go into, it can be an ineffective demonstration of an applicant's fit into that residency program.

Looking at this conception and the intertwining fields of medicine that are gaining prominence in today's healthcare, I feel that one's research can apply to almost any medical discipline that is seemingly unrelated. Therefore, a strong residency application can be created if an applicant can demonstrate a problem that calls for the intersection of two fields to benefit today's patient population. Going back, I stated earlier that residency programs are looking to train physicians that can serve the patient population profoundly. As such, if an individual's seemingly unrelated research experience and medical specialty interest can help patients, it should be a strong demonstration of their fit into that residency program.

On the other hand, I believe having research that directly aligns with the residency program one is applying to is a much more straightforward but equal demonstration of passion, potential contribution, and fit for that field of medicine.

Name
Emmanuel Fagbola

Name
Alyssa Burrows

Tue, 11/09/2021 - 14:16

Hi Emmanuel,

Thank you for the great summary of Dr. Yacob’s presentation. One topic that caught my attention in this lecture was the risk of deep vein thrombosis (DVT) following peripherally inserted central catheters (PICC). The use of PICCs has increased over the past 35 years and its use has extended beyond the hospital to ambulatory care, skilled nursing facilities and homecare. PICC lines allow for easier administration of medication, nutrients, and blood draws. PICC use is preferred to central venous catheters (CVCs) because of fewer insertion complications and less insertion time1. However as you mentioned there is a risk of DVTs with PICC insertion. Evan et al., found that decreasing the diameter of the PICC (fewer lumen) significantly reduced the amount of DVTs observed1. Bhargava et al., also confirmed this findings in an ICU patient population.2 A history of venous thromboembolism or having undergone surgery while the PICC was inside were risk factors for PICC-DVT. Aspirin and stain pharmacotherapy showed a non-significant reduction for PICC DVTs.3 Overall, reduction in PICC size and pharmacotherapy may decrease DVT risks associated with PICC lines. Open to hearing others thoughts on mechanistic causes of DVTs due to PICC lines or other strategies to reducing the risks.
-Alyssa

1. Evans RS, Sharp JH, Linford LH, et al. Reduction of Peripherally Inserted Central Catheter-Associated DVT. Chest. 2013;143(3):627-633. doi:10.1378/chest.12-0923
2. Bhargava M, Broccard S, Bai Y, Wu B, Dincer E, Broccard A. Risk factors for peripherally inserted central catheter line–related deep venous thrombosis in critically ill intensive care unit patients. SAGE Open Medicine. 2020;8:2050312120929238. doi:10.1177/2050312120929238
3. Chopra V, Fallouh N, McGuirk H, et al. Patterns, risk factors and treatment associated with PICC-DVT in hospitalized adults: A nested case–control study. Thrombosis Research. 2015;135(5):829-834. doi:10.1016/j.thromres.2015.02.012

Name
Alyssa Burrows

Hi Alyssa,

In addition to what you’ve shared, I came across a study that found an association between PICC and DVT with increased concentrations of D-dimers, which are degradation products of cross-linked fibrin as an assessment of coagulation activation (1). Another study found that proper insertion technique of the catheter may actually reduce rates of DVT (2).

Researchers also recently found the Caprini thrombosis risk model to be an independent predictor of the development of PICC-related VT in cancer patients (3). Predictive tools coupled with dynamic monitoring, especially in vulnerable populations, may be beneficial for patients.

Lubnaa

(1) https://thrombosisjournal.biomedcentral.com/articles/10.1186/s12959-021…
(2) https://journals.sagepub.com/doi/full/10.1177/1129729819852203
(3) https://www.sciencedirect.com/science/article/pii/S2213333X20307319

Name
Lubnaa Hossenbaccus

Name
Nolan Breault

Tue, 11/09/2021 - 14:52

Hi Emmanuel,

Great summary of a topic that I think doesn't get as much press as it should. When we think about cardiovascular conditions, the structures that come to mind are most often the arteries (like with hypertension) or the heart itself. Veins (in the words of Dr. Yacob) aren't as "sexy", but they make up an entire side of the coin that is our circulatory system.

By virtue of Dr. Yacob's scope of practice, we learned a lot about surgical techniques for both benign and life-threatening disorders of the veinous system. Something that I found to be good food for thought, after we talked about stripping of the greater saphenous vein, is how novel surgical techniques come into clinical practice. Dr. Yacob identified that pigs exist as the primary preclinical model for new surgical tools, owing to their anatomical and physiological similarities to humans (1). These features align with the modern 3R (replacement, reduction, and refinement) framework in biomedical research, allowing a smoother transition from animal studies to a patient-based practice. While I could find little publicized work on the topic of how gold standard surgical practices evolve, I came across an interview with Dr. Sunit Das, a practicing neurosurgeon at St. Michael's Hospital and Assistant Professor at the University of Toronto. He remarked that there's always a balance between patient safety and outcomes (pertaining to mid-operative risks and post-operative effectiveness) when innovating (2). This presents an ethical dilemma that becomes more or less difficult to negotiate based on the related ailment. When existing techniques are not curative or result in a second occurrence of the disease, the search for new procedures is easily justified versus a situation where the gold standard has good outcomes.

Beyond traditional, physical approaches to surgical innovation (such as the high-end diagnostic imaging device Dr. Yacob showed us), machine learning and the many styles of algorithms involved in artificial intelligence (AI) are also making waves in both the diagnostic landscape as well as guiding procedural work. AI-based surgical research is combining both hardware and software, producing autonomous surgical devices that are beginning to match the outcomes of specialist physicians (3).

As such, like the development pipeline that exists for pharmaceuticals, there are many angles and hurdles to consider when implementing new surgical practices. Looking forward to hearing others' thoughts on this!

Cheers,

Nolan

References
1. Swindle, M. M., et al. (2011) Swine as Models in Biomedical Research and Toxicology Testing. Veterinary Pathology 49:344-356.
2. Caroline, B. (2019) How Physicians in Canada Invent New Surgeries. The Varsity. [online] https://thevarsity.ca/2019/08/11/how-physicians-in-canada-invent-new-su… (Accessed Noavember 9th, 2021)
3. Panesar, S. (2019) Artificial Intelligence and the Future of Surgical Robots. Annals of Surgery 270: 223-226.

Name
Nolan Breault

Hey Nolan,

Thank you for your comments. They built on prominent topics discussed in Dr. Yacob’s talk that I was unable to include in my summary.

I agree with your comments. Once again, they bring the concept of translational medicine into play and showcase that optimizing the translation of multiple forms of research to effective and evidence-based medical advancement can benefit patients.

In terms of innovations, I also agree that they include many caveats akin to the ones you have mentioned. Over the next couple of decades, it would be interesting to see if we can optimize the bench-to-bedside pipeline and increase the rate of innovation. Conversely, will innovation potentially slow down as medicine continues to move forward? Will completely new problems arise calling for a new field of research to support the understanding of new medical anomalies? I feel that only time will tell.

Name
Emmanuel Fagbola

Name
Trinity Vey

Wed, 11/10/2021 - 10:41

Hi Emmanuel,

Thank you for an excellent facilitated discussion last week and well-written summary of Dr. Yacob’s talk.

What really stood out to me from the presentation and subsequent discussion was the idea that varicose vein treatment is often viewed as “cosmetic” in the lay press and even at the level of government policy. What is less well understood is that most people seeking varicose vein treatment experience symptoms including swelling, pain, fatigue, and pruritus, that can impact quality of life (1). As we learnt, chronic venous insufficiency can eventually progress to leg edema, ulcers, and severe leg pain (1). As you can imagine, this can lead to lost work productivity, and other costs on the healthcare system (1).

As you mentioned in your summary, vein ablation is more effective, safer, and allows quicker recovery time than the traditional stripping procedure, however it is much more expensive for patients. It seems unequitable that in Canada, someone can pay for a private operation that will afford them weeks less of recovery time and potentially better outcomes. Those unable to afford the vein ablation may then need to miss weeks of work due to the vein stripping recovery time. I’m wondering if you think there’s anything that could be done to increase the likelihood that the vein ablation cost could be more widely covered in the coming years? Perhaps further empirical evidence about the efficacy of this procedure or awareness about how it is not a “cosmetic” surgery would increase incentive for coverage. As you mentioned, old age is a risk factor for varicose veins, so the burden of this condition will likely only increase in the coming years.

Best,

Trinity

Reference:
1. Mallick R, Raju A, Campbell C, et al. Treatment Patterns and Outcomes in Patients with Varicose Veins. Am Health Drug Benefits. 2016;9(8):455-465.

Name
Trinity Vey

Hi Trinity,

Thank you for your insights on the issue of the cosmetic nature of varicose veins procedures. I appreciate the link you made to our aging population and ever-increasing healthcare costs. I believe Dr. Yacob mentioned that part of the reason the government does not cover another procedure involving glueing of the veins (VenaSeal), is due to the cost. The glue used in the procedure (cyanoacrylate) is very expensive. For VenaSeal to be more widely covered in the future, I believe it may require fiscal conversations between the government and cyanoacrylate manufacturers. Since this glue is commonly used in other procedures, perhaps incentives such as the government buying a percentage of production could persuade drug companies to lower their prices. The ideal solution is that market competition will result in a cheaper, generic version of cyanoacrylate in the near future.

You also mentioned empirical evidence about the efficacy of vein ablation. I think I similar obstacle arises with VenaSeal, as both techniques are relatively new. In the case of the latter, "superglue" treatment for varicose veins has not been around long enough to have shown it keeps veins closed for medium to extended periods of time. Hopefully with continued translational research in this field, both procedures will show promising results long-term to support funding.

Cheers,
Bethany

Name
Bethany Wilken

Name
James King

Fri, 11/12/2021 - 12:11

In reply to by Bethany Wilken (not verified)

Hi Bethany and Trinity,
I wanted to chime into the conversation and add some more details on the efficacy of VenaSeal treatment. Bethany, I totally agree that the VenaSeal treatment requires mid- and long-term study before it will be clear that it is truly superior to the stripping procedure. As Dr. Yacob mentioned, the stripping procedure ensures that the vein is absent, preventing future issues. Thus, I believe it will be a difficult journey to make VenaSeal a treatment that our healthcare system covers.
With that said, a large multi-center post-market study in Singapore showed that the procedure had 100% technical success, with 100% occlusion rate at 2 weeks greater saphenous vein (GSV) or small saphenous vein (SSV) occlusion (1). At 3 months, the occlusion rate was 99.3% and 100% for GSV and SSV, respectively (1). The same study also found that closure of refluxing superficial veins at 6 and 12 months was 99.3% and 97.9% respectively (2). To me, this slight decline in closure rate within only the first year certainly makes me wonder what the 5-, 10- and 20-year closure rates might be.
Regarding the safety of VenaSeal it certainly seems to be incredibly safe. A 2020 meta-analysis compared VenaSeal to other superficial venous therapies which included endovenous laser ablation, radiofrequency ablation, mechanochemical ablation, sclerotherapy, and surgery (3). This analysis found that VenaSeal led to the greatest reductions of postoperative pain scores (3). VenaSeal also had the lowest incidence of adverse events, with surgery being 1.6 times worse (3).
I certainly hope that this therapy will continue to be successful in the long-term for patients seeking relief from their venous ailments.
Best,
James

1. Tang et al., 2021. Early results of an Asian prospective multicenter VenaSeal real-world postmarket evaluation to investigate the efficacy and safety of cyanoacrylate endovenous ablation for varicose veins. Journal of Vascular Surgery: Venous and Lymphatic Disorders.
2. Tang et al., 2021. One-year outcome using cyanoacrylate glue to ablate truncal vein incompetence: A Singapore VenaSeal real-world post-market evaluation study (ASVS). Phlebology: The Journal of Venous Disease.
3. Kolluri et al., 2020. Network meta-analysis to compare VenaSeal with other superficial venous therapies for chronic venous insufficiency. Journal of Vascular Surgery: Venous and Lymphatic Disorders.

Name
James King

Name
Dilakshan Srikanthan

Wed, 11/10/2021 - 15:05

Hi Emmanuel,
Thank you so much for facilitating our discussion with Dr. Yacob and for this wonderful summary of our Grand Rounds and discussion. One of the things that stuck out to me in your post is your mention of the socioeconomic implications of venous diseases. Previously, it has been demonstrated that socioeconomic status (SES) affects the risk of cardiovascular diseases such as myocardial infarction and stroke (1) . A few studies have also found associations between SES indicators and venous thromboembolism including deep vein thrombosis and pulmonary embolism. Some of these risk factors include stress, low income, low educational status, low occupational class, single status and neighborhood deprivation, all of which are associated with increased venous thromboembolism risk (2-5). Given your training in biochemistry, I was wondering if you can think of any plausible mechanisms by which these factors can possibly increase the risk of venous thromboembolisms or if there have been any studies that have postulated/demonstrated some mechanisms? Love to hear your thoughts.

Best,
Dilakshan.
1) de Mestral C, Stringhini S. Socioeconomic status and cardiovascular disease: an update. Curr Cardiol Rep. 2017; 19(11): 115.
2) Rosengren A, Freden M, Hansson PO, Wilhelmsen L, Wedel H, Eriksson H. Psychosocial factors and venous thromboembolism: a long-term follow-up study of Swedish men. J Thromb Haemost. 2008; 6(4): 558- 564.
3) Isma N, Merlo J, Ohlsson H, Svensson PJ, Lindblad B, Gottsater A. Socioeconomic factors and concomitant diseases are related to the risk for venous thromboembolism during long time follow-up. J Thromb Thrombolysis. 2013; 36(1): 58- 64.
4) Holst AG, Jensen G, Prescott E. Risk factors for venous thromboembolism: results from the Copenhagen City Heart Study. Circulation. 2010; 121(17): 1896- 1903.
5) Zoller B, Li X, Sundquist J, Sundquist K. Socioeconomic and occupational risk factors for venous thromboembolism in Sweden: a nationwide epidemiological study. Thromb Res. 2012; 129(5): 577- 582.

Name
Dilakshan Srikanthan

Hello Dilakshan,

Thank you for both your compliments and inquiry.

Stress seems to be a significant risk factor when looking at potential biochemical mechanisms that can contribute to an individual’s risk of developing venous diseases. It is well known that low socioeconomic status (SES) is associated with increased stress levels (1). Stress can have many negative implications on the function of the brain, immune system, cardiovascular system, endocrine system, and gastrointestinal system (2). The main physiological pathway that seems most relevant to these effects is the body’s sympathetic nervous system response.

Stress induces the activation of the sympathetic nervous system (SNS). The SNS then has many effects on the body’s function to respond to stress. Notably, heart rate increases, blood vessels constrict, blood pressure increases, and hormones like epinephrine, norepinephrine, and cortisol are released from the adrenal glands. I believe that vasoconstriction and increased blood pressure can increase an individual’s risk for venous disease (3).

References
1. Baum A, Garofalo JP, Yali AM. Socioeconomic status and chronic stress: Does stress account for ses effects on health? Annals of the New York Academy of Sciences. 1999;896:131-144
2. Yaribeygi H, Panahi Y, Sahraei H, Johnston TP, Sahebkar A. The impact of stress on body function: A review. EXCLI J. 2017;16:1057-1072
3. Mansilha A, Sousa J. Pathophysiological mechanisms of chronic venous disease and implications for venoactive drug therapy. International Journal of Molecular Sciences. 2018;19:1669

Name
Emmanuel Fagbola

Name
Georgia

Wed, 11/10/2021 - 22:25

Thank you, Emmanuel, for your excellent summary of last week's discussion! We are so lucky to learn from the cutting-edge technology at KHSC. I found that Dr. Yacob's mention of the new CT scanner and other technologies stuck with me most. Dr. Yacob mentioned that the learning curve for new, highly advanced technologies in the operating room can be steep, and many experienced surgeons are cautious to introduce patients to the risk of the learning process as opposed to sticking with the tools they know. Those who have been practicing for decades may understandably be apprehensive when expected to learn from tools like virtual reality. As well, surgical innovations such as robotic surgery involve less hands-on experience for the resident than traditional open surgeries, which require a great amount of cooperation between the resident and surgeon (1, 2). As a result, very few people are trained and skilled enough in operating new machines. However, new technology is what drives medicine forward, and likely is worth embracing in many cases. How do you propose we combat the learning curve to better train surgeons, new and old, in cutting-edge technologies?

References
1. Wang, V. L., Pieper, H., Gupta, A., Chen, X., Syed, H., & Meara, M. (2021). Expectations versus reality: Trainee participation on the robotic console in academic surgery. Surgical Endoscopy, 35(8), 4805-4810. doi:http://dx.doi.org/10.1007/s00464-020-07874-0
2. Beane, M. (2021). Robotic surgery: Young doctors struggle to learn, practice in the shadows. Retrieved 11 November 2021, from https://www.statnews.com/2018/01/10/robotic-surgery-doctors-practice/

Name
Georgia

Name
Samantha Ables

Thu, 11/11/2021 - 21:22

In reply to by Georgia Kersche (not verified)

Hi Emmanuel and Georgia,

Thank you for an engaging summary of last week’s grand rounds! How to better help surgeons decrease the learning curve for robotic surgery is an interesting question. A recent paper found that experienced surgeons learning to perform robotic gastrectomy required ~25 cases to become proficient in overcoming complications and an additional ~23 cases to become masters. The authors stated that the learning curve associated with robotic surgery has a considerable effect on surgical outcomes (1). There are some suggestions about how to decrease the learning curve and help patient outcomes for the first few robotic surgery cases. Physicians may benefit from observation, assisting in robotic surgeries, then practicing in simulations with assistance from an experienced physician (2). Mentorship from a surgeon experienced in robotic surgery and a formal skill-development curriculum improve the learning curve in robotic surgery (3). Beyond these suggestions, many of which are likely used already, I wonder what could be used to further decrease the learning curve for new technologies?

Best,

Samantha

References

1. Kim, Min Seo, et al. Comprehensive Learning Curve of Robotic Surgery, Annals of Surgery: May 2021 - Volume 273 - Issue 5 - p 949-956 https://journals.lww.com/annalsofsurgery/Abstract/2021/05000/Comprehens…
2. Nagpal K, Malik ND, Rana N, Madhok H, and Sharma S. Learning Curve in Robotics in ENT and Head and Neck Surgery. July 4, 2020. American Journal of Otolaryngology and Head and Neck Surgery, 3(5) http://www.remedypublications.com/open-access/learning-curve-in-robotic…
3. Rice MK, Hodges JC, Bellon J, et al. Association of Mentorship and a Formal Robotic Proficiency Skills Curriculum With Subsequent Generations’ Learning Curve and Safety for Robotic Pancreaticoduodenectomy. JAMA Surg. 2020;155(7):607–615. https://jamanetwork.com/journals/jamasurgery/fullarticle/2765983

Name
Samantha Ables

Name
Emmanuel Fagbola

Fri, 11/12/2021 - 02:30

In reply to by Georgia Kersche (not verified)

Hey Georgia,

Thank you so much for your question!

I feel that being well versed in these more novel surgical techniques is something that many surgeons have access to in the form of fellowships. After learners complete medical school and residency, they have the opportunity to gain more skills by seeking out fellowship programs that span 1-3 years. Things like robotic surgery would be within training in a fellowship in minimally invasive surgery (MIS). However, as time goes on, I feel that the advanced training offered in fellowships like these will creep into residency training. In turn, I believe that this will support a more widespread comfortability of the many cutting-edge technologies that surgeons can access and promote surgical advancement.

Name
Emmanuel Fagbola

Name
Cassie Brand

Thu, 11/11/2021 - 17:13

Thank you for your summary Emmanuel! One thing that stuck out to me during Dr. Yacob's presentation was that he is not very fond of using Venixxa in patients with venous disease, his reasoning being that patients would need to remain on this therapy for the duration of their lives to keep benefiting from it. Venixxa is an over the counter drug which primarily reduces the inflammatory symptoms associated with venous disease. While I agree that it is not optimal to have patients on non-critical therapeutics indefinitely, many patients are extremely satisfied with the relief and improvement of their quality of life they experience. Perhaps Venixxa is better suited to be used transiently while patients are awaiting vascular surgery to permanently relieve their symptoms. I was also wondering if there are dangers associated with using Venixxa; could long term use mask symptoms that may indicate a worsening and more serious venous disease that requires a physicians attention?

Cassie

Name
Cassie Brand

Name
RE: Venixxa

Fri, 11/12/2021 - 09:46

In reply to by Cassie Brand (not verified)

Dear Cassie,
Thank you for your comment! Interestingly, a large-scale trial is being piloted to investigated the long-term effects of Venixxa on patients with post-thrombotic syndrome (the most frequent complication of DVT). (1) The authors cite that compression stockings are more burdensome than therapeutics and not very effective in up to 1/3 of patients. (1) In that case, if a medication like Venixxa can actually replace the need for compression stockings with limited side effects, perhaps the recommendations will change?
Cheers,
Kiera
1. Galanaud JP, Abdulrehman J, Lazo-Langner A, et al. MUFFIN-PTS trial, Micronized Purified Flavonoid Fraction for the Treatment of Post-Thrombotic Syndrome: protocol of a randomised controlled trial. BMJ Open. 2021;11(9):e049557. Published 2021 Sep 13. doi:10.1136/bmjopen-2021-049557

Name
RE: Venixxa

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