he diseased aorta in Takayasu’s arteritis features areas of ectasia and stenosis; the aorta is left with very little elastic tissue due to diffuse fibrosis of the intima, media, and externa. Stent-supported endovascular aortoplasty and surgical revascularization are associated with higher complication and recurrence rates, even with regular immunomodulation follow-up. Unlike atheromatous disease, the inflexible artery is vulnerable to dissection, and is as “brittle as glass” during balloon angioplasty. Therefore, some authors suggest self-expanding stent or stent-graft supported angioplasty for this condition, with high-pressure dilation,to overcome fibrosis caused by panarteritis. However, the incidence of dissection in this situation appears to be under-reported.
takayasu arteritis is inflammatory disorder of medium sized arteries of unknown etiology, prevent in young female. lead to life threatening complication and long lasting morbidity. early diagnosis and treatment prevent complication and improve quality of life
he diseased aorta in Takayasu’s arteritis features areas of ectasia and stenosis; the aorta is left with very little elastic tissue due to diffuse fibrosis of the intima, media, and externa. Stent-supported endovascular aortoplasty and surgical revascularization are associated with higher complication and recurrence rates, even with regular immunomodulation follow-up. Unlike atheromatous disease, the inflexible artery is vulnerable to dissection, and is as “brittle as glass” during balloon angioplasty. Therefore, some authors suggest self-expanding stent or stent-graft supported angioplasty for this condition, with high-pressure dilation,to overcome fibrosis caused by panarteritis. However, the incidence of dissection in this situation appears to be under-reported.
takayasu arteritis is inflammatory disorder of medium sized arteries of unknown etiology, prevent in young female. lead to life threatening complication and long lasting morbidity. early diagnosis and treatment prevent complication and improve quality of life
Radiological evaluation of takayasu arteritis Dr. muhammad Bin Zulfiqar Servi...Dr. Muhammad Bin Zulfiqar
Radiological evaluation of takayasu arteritis Dr. muhammad Bin Zulfiqar Services Institute of Medical Sciences Services Hospital Lahore
In this presentation we will discuss the role of imaging in TA.
Takayasu arteritis (TA) is a rare nonspecific inflammatory disease of unknown cause, predominantly affecting
the aorta and its main branches, coronary arteries, and pulmonary arteries of young females. It induces a variety
of nonspecific inflammatory symptoms and ischemic symptoms due to stenotic lesions. Further progression
of TA causes destruction of the arterial wall media, leading to aortic regurgitation and aneurysms or
rupture of the involved arteries. Although serological tests specific for TA are not available, new better biomarkers
are emerging such as pentraxin3 and matrix metalloproteinases. Recent advances in imaging modalities
including magnetic resonance angiography, computed tomography (CT), sonography, and fluorodeoxy
glucose positron emission tomography/CT (FDG-PET/CT) allow earlier and accurate diagnosis of TA. Duration
between onset of the disease and diagnosis has become much shorter during the last decade. Medical treatment
for TA is also changing. In addition to the traditional glucocorticoids and immunosuppressants, many
new biological agents are being applied to patients with TA refractory to conventional treatment with favorable
results. As for treatment for vascular complications, efficacy of endovascular treatment is still a matter of
controversy because of the high rate of restenosis at an early stage after the procedure. Based on these advances,
the prognosis and quality of life of TA patients have improved to a great deal. However, there are
many issues that remain to be solved in the management of TA.
Different types of vasculitis have characteristic patterns of blood vessel involvement.However vasculitis is a systemic illness.The symptoms of vasculitis depend on the particular blood vessels that are involved by the inflammatory process
Diagnosis, management, workup in a case of Takayasu's arteritis. Definition, synonyms, history, epidimiology, pathophysiology, etiology of Takayasu's arteritis.
Radiological evaluation of takayasu arteritis Dr. muhammad Bin Zulfiqar Servi...Dr. Muhammad Bin Zulfiqar
Radiological evaluation of takayasu arteritis Dr. muhammad Bin Zulfiqar Services Institute of Medical Sciences Services Hospital Lahore
In this presentation we will discuss the role of imaging in TA.
Takayasu arteritis (TA) is a rare nonspecific inflammatory disease of unknown cause, predominantly affecting
the aorta and its main branches, coronary arteries, and pulmonary arteries of young females. It induces a variety
of nonspecific inflammatory symptoms and ischemic symptoms due to stenotic lesions. Further progression
of TA causes destruction of the arterial wall media, leading to aortic regurgitation and aneurysms or
rupture of the involved arteries. Although serological tests specific for TA are not available, new better biomarkers
are emerging such as pentraxin3 and matrix metalloproteinases. Recent advances in imaging modalities
including magnetic resonance angiography, computed tomography (CT), sonography, and fluorodeoxy
glucose positron emission tomography/CT (FDG-PET/CT) allow earlier and accurate diagnosis of TA. Duration
between onset of the disease and diagnosis has become much shorter during the last decade. Medical treatment
for TA is also changing. In addition to the traditional glucocorticoids and immunosuppressants, many
new biological agents are being applied to patients with TA refractory to conventional treatment with favorable
results. As for treatment for vascular complications, efficacy of endovascular treatment is still a matter of
controversy because of the high rate of restenosis at an early stage after the procedure. Based on these advances,
the prognosis and quality of life of TA patients have improved to a great deal. However, there are
many issues that remain to be solved in the management of TA.
Different types of vasculitis have characteristic patterns of blood vessel involvement.However vasculitis is a systemic illness.The symptoms of vasculitis depend on the particular blood vessels that are involved by the inflammatory process
Diagnosis, management, workup in a case of Takayasu's arteritis. Definition, synonyms, history, epidimiology, pathophysiology, etiology of Takayasu's arteritis.
VASCULITIS INTRODUCTION.
TYPES OF VASCULITIS
DIAGNOSING CRIERIA
TREATMENT AND GUIDELINES
DRUGS USED IN BURGER'S DISEASE
A CASE ON VASCULITIS
APPROACH OF TREATMENT
PATIENT COUNSELLING FOR THE PARTICULAR PATIENT
IMAGES OF A COMPLEX CASE OF MULTIPLE ANEURYSMAL DISEASE IN A 58 YEAR OLD MAN
IMMAGINI DI UN CASO COMPLESSO DI MALATTIA POLINEURISMATICA
(Chirurgia Vascolare-ULSS 15 Alta Padovana)
(Vascular Surgery -ULSS 15 Alta Padovana)
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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2. In 1830, Rokushu Yamamoto described a peculiar condition of a 45 year old in his private practice
record. Yamamoto found that there were no palpable pulses on the patient’s upper limbs and carotid.
3. In 1908, for the first time the Japanese ophthalmologist Mikito Takayasu (a)
reported the case of a 21-year old woman with a peculiar optic fundus abnormality,
characterised by arteriovenous anastomosis around the papilla (b).
4. In 1958, a symposium was organised on this subject. Dr. P. K.Sen,
while chairing a session in the 4th Asian Pacific Congress of
Cardiology, called it non specific aorto arteritis (NSAA) rather than
Takayasus disease .
5. • Takayasu arteritis (TA) is a chronic, granulomatous, large-vessel
panarteritis with preferential involvement of the aorta, its major
branch arteries and the pulmonary artery.
• It is an idiopathic inflammatory disease of the large elastic arteries
occurring in the young and result in the occlusion or ectatic changes in
vessels.
7. Epidemiology
• Worldwide incidence: 2.6 cases per million per year.
• More frequent in Asian countries - Japan, Korea, China, India, Thailand, Singapore and Turkey.
• Japanese patients with Takayasu arteritis - higher incidence of aortic arch involvement.
• In contrast, series from India report higher incidences of abdominal involvement.
Age:
• Predominantly a disease of young females: 2nd or 3rd decades.
• Mean age:
• European study - 41yrs
• Japan - 29yrs
• India – 24yrs
Sex:
• F>M (~80% women)
• India – F : M = 1.6 : 1
8. Pathophysiology
• Predilection for the aorta and its branches.
• Advanced lesions demonstrate a panarteritis with intimal proliferation, fibrosis,
scarring and vascularisation of media.
• Lesions :- stenotic, occlusive, or aneurysmal.
• Vascular changes ->Complications :-
• Hypertension - renal artery stenosis, stenosis of the suprarenal aorta;
• Aortic insufficiency due to aortic valve involvement;
• Pulmonary hypertension
• Aortic or arterial aneurysm.
11. Etiology
• Exact etiology is unknown.
• Underlying pathologic process is inflammatory.
• Several etiologic factors having been proposed:
• Spirochetes
• Mycobacterium tuberculosis
• Streptococcal organisms
• Circulating antibodies due to an autoimmune process.
• Genetic factors may play a role in the pathogenesis.
• Raised ESR, leucocytosis, arthralgia and high titers of anti-aorta antibodies.
• Rheumatic: A study showed some patients had raised ASO titre.
Female predilection: Urinary estrogens elevated.
Estradiol and progesterone (but not testosterones), enhance leucocyte adhesion to endothelial cells in the
presence of TNF.
12. • (a) Active phase of TA in descending thoracic aorta showing a granulomatous
inflammation at the medio-adventitial junction of aorta destroying the structure of an
intercostal artery; (b) chronic phase of TA in descending thoracic aorta showing media
(M) at the outer third with clusters of mononuclear cells. Note marked fibrosis of the
adventitia (A) (Hematoxylin and Eosin, ×250). (c) The cells are lymphocytes, and few
plasma cells and histiocytes (Hematoxylin and Eosin, ×250)
13. • Scanned images of the ascending aorta, arch, left subclavian artery, descending thoracic
aorta (elastic van Gieson), and abdominal aorta (Hematoxylin and Eosin, and elastic van
Gieson) in a diffuse pattern of TA. All segments show marked adventitial fibrosis, the
major cause of wall thickening. Lymph nodes (arrows) are seen around abdominal aorta
14. (a) Multi-focal aortic disease with skip areas showing a large aneurysm in the abdominal aorta. The wall of
the aneurysm when studied histologically also showed the presence of chronic dissection as seen in (b)
(Hematoxylin and Eosin, ×100) and (c) (Elastic van Gieson, ×100). Arrow points to the intimal flap. The wall
is represented only by thickened intima (I) and adventitia (A)
15. Major
histocompatibility
(MHC) class I–
related chain A
(MICA)
Natural
killer and
T-cells
Release of
Proinflammatory
cytokines
Matrix
metalloproteinases
(MMPs)
Inflammatory
response
Antigen Stimulates aortic tissue
Expression of heatshock protein-65
16.
17. Clinical
Presentation
• ~10% of patients are asymptomatic, with the disease detected based on
abnormal vascular findings on examination.
Constitutional symptoms:
Headache (50%-70%)
Malaise (35%-65%)
Arthralgias (28%-75%)
Fever (9%-35%)
Weight loss (10%-18%)
18. Cardiac and vascular features:
Bruit, with the most common location being the carotid artery (80%)
Blood pressure difference of extremities (45%-69%)
Claudication (38%-81%)
Carotodynia or vessel tenderness (13%-32%)
Hypertension (28%-53%; 58% with renal artery stenosis in one series)
Aortic regurgitation (20%-24%)
Raynaud’s syndrome (15%)
Pericarditis (< 8%)
Congestive heartfailure (< 7%)
Myocardial infarction (<3%)
20. On
ExaminationParticular attention to peripheral pulses.
Blood pressure in all 4 extremities.
Ophthalmologic examination.
The most discriminatory finding is a systolic blood pressure difference (>10
mm Hg) between arms.
Hypertension due to renal artery involvement (and sometimes leading to
hypertensive encephalopathy) (~50% ofpatients).
21. Carotidynia may bepresent.
Aortic regurgitation is a common finding.
Absent or diminished pulses are the clinical hallmark of Takayasu
arteritis.
Pulses can be normal in many patients.
Upper limbs are affected more often than lower limbs.
When pulselessness occurs, patient monitoring can be difficult or impossible
calf blood pressures must be obtained.
22. Ophthalmologic examination:
Retinal ischemia,
Retinal hemorrhages,
Cotton-wool exudates,
Venous dilatation and beading,
Microaneurysms of peripheral retina,
Optic atrophy,
Vitreous hemorrhage, and
Classic, wreathlike peripapillary arteriovenous anastomoses (extremely rare).
23. Dermatologic findings: resembling erythema nodosum or ulcerating nodular
lesions may beseen.
Other significant findings include the following:
Vascular bruits – carotid, abdominal, subclavian and femoral arteries
Amaurosis fugax
Focal neurologic deficits consistent with cerebral infarction or TIA
Eclampsia
SAH, probably secondary to hypertension
Myocardial infarction, DCM
Pedal edema due to renal failure secondary to renal artery stenosis and
glomerulonephritis
24. Differential
DiagnosisTakayasu arteritis is rare and difficult to diagnose.
Initially, symptoms arevague.
Disease may have progressed considerably on presentation and diagnosis.
Aortic Coarctation
Atherosclerosis
Buerger Disease (Thromboangiitis Obliterans)
Giant CellArteritis
Sarcoidosis
Systemic Lupus Erythematosus
Wegener Granulomatosis
25. Approach & Work
UP
Laboratory tests
Nonspecific.
ESR may be high (>50 mm/h) in early disease but normal later.
TLC: normal orslightly elevated.
Amoderate, normochromic anaemia may be present in individuals with active
disease.
Raised levels of soluble vascular cell adhesion molecule-1 (VCAM-1).
Hypoalbuminemia is common.
Urinalysis may be consistent with nephrotic syndrome.
26. Imaging studies
CT scanning and MRI:
patterns of stenosis or aneurysms of the arteries.
Angiography:
standard for diagnosis and evaluation of the extent of disease.
Studies show that noninvasive imaging modalities - MRI, USG and 18F-FDG-
PET allow diagnosis of Takayasu arteritis earlier in the disease than standard
angiography and provide a means for monitoring disease activity.
Angiography is used to evaluate only the appearance of the lumen and cannot be
used to differentiate between active and inactive lesions.
27.
28. Diagnostic Criteria
Ishikawa criteria (1986)
Obligatory: Age <40yrs; at the time of diagnosis, at onset of characteristic
symptoms &signs of 1month duration.
Major: 2 major
Lesions in the left and right midsubclavian artery.
The most severe stenosis or occlusion present in the mid portion of the
artery from a 1cm point proximal to the left and right, respectively, of the
vertebral artery orifices to a 3-cm distal point to the orifice as determined
by angiography.
29. Minor: 9 minor
High ESR
Commoncarotid artery tenderness
Hypertension
Aortic regurgitation or annuloaortic ectasia
Lesions of the pulmonary artery
Left mid common carotid artery
Distal brachiocephalic trunk
Thoracic aorta
Abdominal aorta
Diagnosis:
Obligatory criteria + 2 Major criteria or 1Major and ≥ 2 Minor criteria or
≥4 Minor criteria.
Sensitivity of 60.4% and specificity of 95%.
30. Modified Ishikawa's Criteria for Takayasu's Arteritis
(Modified According to Sharma et al.), 1996
The proposed modifications include:
(a) removal of the obligatory criteria of age less than 40 years;
(b) inclusion of characteristic signs and symptoms as a major criteria;
(c) removal of age in defininghypertension;
(d) deletion of the absence of aorto-iliac lesion, in defining abdominal aortic
lesion; and
(e) an addition of coronary artery lesion in absence of risk factors.
31. Three majorcriteria:
1. Left mid-subclavian artery lesion
2. Right mid-subclavian arterylesion
3. Characteristic signs and symptoms of at least 1month duration
claudication,
pulselessness or pulse differences in limbs,
unobtainable or significant blood pressure difference (> 10 mmHg systolic
blood pressure difference in limb),
fever,
neck pain,
transient amaurosis,
blurred vision,
syncope,
dyspnea or
palpitations.
32. Ten minor criteria:
1.High ESR (>20 mm/h)
2. Carotid artery tenderness
3. Hypertension
4. Aortic regurgitation or annuloaortic ectasia
5. Pulmonary artery lesion
6. Left mid common carotid lesion
7. Distal brachiocephalic trunk lesion
8. Descending thoracic aorta lesion
9. Abdominal aorta lesion
10. Coronary artery lesion
Diagnosis: (a) two major or (b) one major and two minor criteria or (c) four
minor criteria.
Sensitivity of 92.5% and specificity of 95%.
33. Criteria Definition
1.Age at disease
onset in year
Development of symptoms or findings related to Takayasu
arteritis at age <40 years.
2. Claudication of
extremities
Development and worsening of fatigue and discomfort in
muscles of one or more extremity while in use, especially
the upperextremities.
3. Decreased
brachial arterypulse
Decreased pulsation of one or both brachial arteries.
4. BPdifference
>10mmHg
Difference of >10mmHg insystolic blood pressure
between arms.
5. Bruit over
subclavian arteriesor
aorta
Bruit audible on auscultation over one or both subclavian
arteries or abdominal aorta.
6. Arteriogram
abnormality
Arteriographic narrowing or occlusion of the entire aorta,
its primary branches, or large arteries in the proximal
upper or lower extremities, not due arteriosclerosis, fibro-
muscular dysplasia, or similar causes: changes usually
focal or segmental.
1990 Criteria of American College of Rheumatology (ACR) for the
Classification of Takayasu Arteritis
34. Diagnosis:
3 of these 6 criteria. (Sensitivity 77.4%, specificity 95%)
>3 criteria yields a sensitivity of 90.5% and a specificity of 97.8%.
35. Takayasu arteritis can be divided into the following 6 types based on
angiographic involvement:
46. Corticosteroids
Mainstay of therapyfor active disease.
Some patients may require additional cytotoxic agents to achieve remission and
taper of chronic corticosteroid treatment.
Oral corticosteroids - 1mg/kg daily or divided twice daily and tapered over
weeks to months as symptoms subside.
IL-6 receptor inhibitor
Humanized monoclonal antibody tocilizumab.
IL-6 as a major component in the proinflammatory process of large-vessel
vasculitis.
Remission using tocilizumab as monotherapy. Then shifting to methotrexate
for maintenance therapy.
Medical Management
47. B-cell depletion
Rituximab, a chimeric IgG1 antibody that binds to CD20 expressed on the
surface of B cells, has shown to improve clinical signs and symptoms.
Cytotoxic agents
Used for patients whose disease is steroid resistant or relapsing.
Continued for at least 1year after remission and are then tapered to
discontinuation.
Methotrexate (0.3 mg/kg/week), azathioprine (1-2 mg/kg/day), and
cyclophosphamide (1-2mg/kg/day).
Cyclophosphamide should be reserved for patients with the most severe and
refractory disease states.
48. Anti-tumor necrosis factor agents
Used in relapsingdisease.
Initial dose of etanercept was 25 mg twice weekly (7 patients);
infliximab (11patients [3 were switched from etanercept to infliximab]) was
given at 3 mg/kg initially and at 2 weeks, 6 weeks, and then every 8 weeks
thereafter.
In 9 of the 14 responders, an increase in the anti-TNF dosage was required to
sustain remission.
53. Cardiovascular procedures
Bypass graft surgery: best long-term patency rate.
Percutaneous balloon angioplasty: good outcomes for short lesions.
Angioplasty and stenting: for recurrent stenosis.
Conventional stents: high failure rates.
Other procedures include aneurysm clipping and revascularization.
PTCA is followed by restenosis at the angioplasty site within 1-2 years in a
substantial number ofpatients.
54. Bypass graftsurgery
Critical thoracic aortic arch arterial stenosis, upper and lower extremity
ischemia, cerebrovascular accidents, and renal artery stenosis.
Anastomotic stenosis or graft occlusion is a potential complication of surgery.
Usually, the graft is a saphenous vein graft.
Examples:
Bypass of renal artery stenosis for renal salvage;
Bypass of innominate or carotid artery;
Bypass between subclavian-axillary and common carotid arteries;
Extraintracranial bypass operations generally are performed for stenosis of
the internal carotid or middle cerebral arteries.
55. Cardiovascular risk factors
STRICT CONTROL of dyslipidemia, hypertension, and lifestyle factors that
increase the risk of cardiovascular disease. These complications are the major
cause of death in Takayasu arteritis.
Aggressive therapy forhypertension.
Low-dose aspirin may have a therapeutic effect in large vessel vasculitis.
Antiplatelet agents and heparin may prove useful in preventing stroke.
Warfarin also has been used.
The literature reports a case of improvement in renal and systemic function
with low-dose intravenous (IV) heparin therapy (10,000 U/d) followed by oral
anticoagulant and antiplatelet agents.
56.
57.
58.
59.
60.
61.
62. Step 1: Exposure of both femoral arteries and the ascending aorta
Step 2: Creation of pre-peritoneal tunnel
Step 3: Placing the graft
Step 4: Ascending aorta to graft anastomosis and
femoral artery to graft anastomosis
Surgical technique for Ascending Aorta- Bifemoral Bypass Grafting
Surgical technique involves:
63.
64.
65. Results of Ascending Aorta-Bifemoral Bypass Grafting
• Of the 56 patients undergoing this procedure (31 for bifurcation block and 25 for middle aortic syndrome) there were three
deaths all due to renal failure, in one it appeared in the immediate post operative period and in two during the early follow
up.
• In the remaining patients there was marked improvement in limb ischemia, signs of claudication were relived, ischemic
ulcers healed, hypertension was better controlled and peripheral pulses returned.
• Long term results of this form of palliation too were gratifying.
• All patients were maintained on anticoagulation and fared well except one patient who discontinued anticoagulants after 3
years and presented with a blocked graft.
• Although the 10 year survival was only 48%, death in these patients was predominantly due to progression of the disease
that resulted into end organ dysfunction.
• A solitary incidence of graft block was salvaged by replacement of the blocked graft limb and embolectomy
66. Advantages of ascending aorta bifemoral graft:
• In aortoarteritis, diffuse involvement of aorta is common as is hypertension, lower limb ischemia, impotence and renal
involvement.
• While attempting an abdominal aorta bi-femoral or thoracic aorta-bi-femoral bypass the graft it is often placed proximally
on a diseased aortic segment.
• Ascending aorta-bifemoral bypass graft avoids this problem.
• It avoids a laparotomy and avoids adhesion specially in re do surgery.
• In reoperation, change of limb of graft is easy as one has to work in superficial planes.
• The technique is simple and is superior to axillo bifemoral graft as an emergency procedure as better blood flow through
the graft is ensured.
• While performing ascending aorta to bifemoral grafting, the surgeon avoids the planes of intense periarterial
inflammation, adhesion, arterial inflammation, and calcification around the diseased aortic segments, thereby making the
procedure very safe.
76. Prognosi
s
Substantial morbidity and mortality.
Approximately 20% of patients have a monophasic and self-limited disease.
ANational Institutes of Health (NIH) study of 60 patients with Takayasu
arteritis:
20% of patients had a monophasic illness, self-limiting illness and
therefore did not require immunosuppressive treatment.
Remaining 80% of patients, who did not have a monophasic illness and
who experienced 1exacerbation, immunosuppressive therapy resulted in
remission in 60%.
Of these, one half experienced relapse after immunosuppressive therapy
was stopped.
77. Complications
Stroke
Intracranial haemorrhage
Seizures
Graft stenosis and/orocclusion
Ischemia
Organ failure
Complications of hypertension
Foetal injury
Valvular heart disease
Retinopathy
Renovascular hypertension
Long-term use of corticosteroids: infection, adrenal suppression, cataracts,
hyperglycemia, hypertension (which complicates blood pressure control),
osteoporosis, and asepticnecrosis.
78. Morbidity and mortality
Overall 10-year survival rate is approximately 90%.
Rate is reduced in the presence of major complications.
5- and 10-year survival rates are approximately 69% and 36%, respectively, in
patients with 2 or more complications.
5- and 10-year survival rates associated with 1or fewer complications are 100%
and 96%, respectively.
Disease remission is the only factor that positively influences physical and mental
quality of life.
Editor's Notes
Potential role of pathogenic or commensal microbes in the pathogenesis of Takayasu arteritis. (A) Gut microbiota. A normal gut microbiota contributes to the development and education of the immune system, which is essential for the maintenance of physiologic homeostasis. Conversely, in the presence of dysbiosis, the number and function of regulatory T-cells are impaired and hyperactive cytotoxic T cells may grow without control, consequently the immune equilibrium is lost. The growing of pathogenic bacteria in the gut, likely harboring antigens that resemble antigens expressed by aortic or vascular tissues of the host, may promote the sensitization of the immune cells to the host own antigens, via molecular mimicry leading to autoimmunity. (B) Vascular microbiota. The colonization of pathogenic bacteria in aortic tissues may promote a local immune reaction against pathogen proteins and recruited immune cells may cross-react with antigens expressed in normal tissues leading to autoimmunity.