The assessment of lower extremity peripheral artery disease impact on body mass center disorders.

BACKGROUND: Lower extremity peripheral artery disease is a problem of contemporary medicine and along with the ischemic heart disease it is considered to be a civilization disease. The risk of the disease increases significantly within a group of people reaching the age of 55 years and is closely related to co-occurring hazardous factors, such as diabetes, hyperlipidemia, hypertension or tobacco smoking. The first symptom reported by patients is intermittent claudication. Such symptoms may indicate that lower extremity peripheral artery disease does have an impact on posture disorders and motor skills. METHODS: The study covered four stages. The first stage involved medical interviews to obtain information regarding anthropometry, age, motor organ surgery, concomitant diseases and the lifestyle. In the following stage the value of the ankle brachial index for both lower limbs were calculated. In case of symptomatic patients, additionally, the location of artery stenosis/aortoiliac section, was verified. The third stage involved using a dynamometric platform for determination of the body mass center position for both studied groups. In the fourth stage a treadmill walk test was used to assess the participants for intermittent claudication. FINDINGS: Based on the obtained results, an attempt was taken to observe the relationship between the clinical characteristics of the disease and the body mass center position deviations. INTERPRETATION: The attempt was undertaken to assess whether the measurement of body mass center position might be a diagnostic parameter to evaluate the patient's condition and thus an indication for taking a decision for surgical treatment or rehabilitation.

Unmet medical needs in intermittent Claudication with diabetes and coronary artery disease-A "real-world" analysis on 21 197 PAD patients.

BACKGROUND: Peripheral artery disease (PAD) is frequently co-prevalent with coronary artery disease (CAD) and diabetes (DM). The study aims to define the burden of CAD and/ or DM in PAD patients at moderate stages and further to evaluate its impact on therapy and outcome. METHODS: Study is based on health insurance claims data of the BARMER reflecting an unselected "real-world" scenario. Retrospective analyses were based on 21 197 patients hospitalized for PAD Rutherford 1-3 between 1 January 2009 to 31 December 2011, including a 4-year follow-up (median 775 days). RESULTS: In PAD patients, CAD is prevalent in 25.3% (n = 5355), DM in 23.5% (n = 4976), and both CAD and DM in 8.2% (n = 1741). Overall, in-hospital mortality was 0.4%, being increased if CAD was present (CAD alone: OR 1.849; 95%-CI 1.066-3.208; DM alone: OR 1.028; 95%-CI 0.520-2.033; CAD and DM: OR 3.115; 95%-CI 1.720-5.641). Both, CAD and DM increased long-term mortality (CAD alone: HR 1.234; 95%-CI 1.106-1.376; DM alone: HR 1.260; 95%-CI 1.125-1.412; CAD and DM: HR 1.76; 95%-CI 1.552-1.995). DM further increased long-term amputation risk (DM alone: HR 2.238; 95%-CI 1.849-2.710; DM and CAD: HR 2.199; 95%-CI 1.732-2.792), whereas CAD (alone) did not. CONCLUSIONS: In a greater perspective, the data identify also mild to modest stage PAD patients at particular risk for adverse outcomes in presence of CAD and/or DM. CAD and DM both are related with a highly increased risk of long-term mortality even in intermittent claudication, and DM independently increased amputation risk.

Gender differences in the prevalence and management of metabolic syndrome and its components in patients with peripheral artery disease.

We compared the prevalence and management of metabolic syndrome (MetS) and its components in men and women with peripheral artery disease (PAD). A total of 70 men and 70 women with PAD were evaluated for presence of MetS. There was no significant gender difference in presence of MetS (P = .399) and the number of MetS components (P = .411). Among PAD patients with each MetS component, there was no significant gender difference in the use (P = .617) and number (P = .716) of blood pressure medications, the use (P = .593) and number (P = .591) of lipid-lowering medications, and the number (P = .155) of diabetic medications. Significantly more women were treated with diabetic medications compared with men (85 vs 57%, P = .026). The prevalence and management of MetS and its components was similar between men and women with PAD, except that more women were treated for diabetes. Patients with PAD having MetS did not receive optimal medical management.

Computerized dynamic posturography in the objective assessment of balance in patients with intermittent claudication.

One-third of all elderly patients fall each year and impaired balance has been recognized as a specific risk factor. Intermittent claudication is common among the elderly population, affecting approximately 5% of the population over the age of 50. The aim of this proof-of-concept study was to assess the prevalence of impaired balance among elderly claudicants and to assess each patient's insight into their own risk of falling. A total of 58 claudicants (45 men), median age of 70 (interquartile range = 65-73) years, underwent objective balance assessment by using computerized dynamic posturography. As compared with 195 (5%) historic controls, 24 (41%) of the claudicants demonstrated abnormal balance when the Sensory Organization Test (SOT) was used. Vestibular dysfunction occurred in 52% of the claudicants. Abnormalities including somatosensory (22%), visual function (17%), and preferential reliance on inaccurate visual cues (17%) occurred less often. Prolonged Motor Control Test latency times were uncommon (n = 13) and were in most cases evenly distributed between those with normal (n = 7) and abnormal (n = 6) composite SOT scores. There was a significant difference in history of falling between claudicants with abnormal and normal SOT scores (p = 0.003), with a higher number of patients with abnormal SOT having experienced falling in the past year. However, no correlation between fear of falling and composite SOT score was found (Spearman rank correlation, r = 0.124; p = 0.381). Impaired balance, particularly secondary to vestibular problems, is very common among claudicants and may predispose to a high incidence of falls. Claudicants with abnormal balance are more likely to have a history of falls but not a fear of falling, thus potentially rendering these patients to be at a greater risk.

An assessment of peripheral vascular disease in patients with diabetic foot ulcer.

BACKGROUND: Peripheral vascular disease (PVD) is a chronic limb ischaemia caused by atherosclerosis of the peripheral arteries. Diabetes mellitus is a risk factor for this disease. The most common symptom of PVD is muscle pain in the lower limbs on exercise. In diabetes, pain perception may be blunted by the presence of peripheral neuropathy. Therefore, a patient with diabetes and PVD is more likely to present with an ischaemic ulcer or gangrene than a patient without diabetes. The use of ankle-brachial-pressure index (ABI) in the clinic and bedside provide a measure of blood flow to the ankle. This could help early detection, initiate early therapy and may thus reduce the risk of critical limb ischaemia and limb loss. OBJECTIVE: The purpose of this study is to evaluate the occurrence of peripheral vascular disease using ankle-brachial index in diabetic patients with and without foot ulcers and the risk factors associated with diabetic foot ulcer (DFU). METHOD: This prospective study involved all type 2 DM patients with foot ulcer (DFU population) and those without foot ulcers (non-DFU population) seen in our hospital. Their demographic, clinical and laboratory parameters were noted and documented. Measurement of ABI was done using a portable hand held Doppler and ankle pressures<0.9 is suggestive of PVD. RESULTS: A total of 74 patients were recruited. Males were 42 (56.8%) and females were 32 (43.2%). The mean age of the patients was 62.89±10.66 years and the duration of diabetes was 7.61±7.57 years. Forty-six (62.2%) presented with foot ulcer while 28 (37.8%) were without foot ulcer. Patients with PVD represented by ABI<0.9 was DFU 31(76.4%) while in non-DFU it was 10 (13.4%). Multivariant analysis of variables associated with DFU in those with ABI<0.9 showed correlation with tobacco use r=.235, p=0.044; duration of diabetes r=-.427; p=0.001; and systolic blood pressure r=-.301; p=0.009. DISCUSSION: The occurrence of PVD determined by the absence of >2 pulses by palpation alone and using ABI was 25.7% and 55.4% respectively. This suggests that assessment by palpation is subjective while the use of Doppler is quantitative and more reliable. DFU patients with PVD showed a significant correlation with tobacco use, duration of diabetes and systolic blood pressure but not with dyslipidaemia. CONCLUSION: This study shows that these patients had risk factors for PVD. The use of hand held Doppler will aid early diagnosis of critical limb at risk of loss and help to prevent and reduce the high rate of limb loss in our patients.

Assessment of biochemical markers in patients with pain of vascular origin.

The aim of this study was to analyse blood plasma biochemical parameters in patients with pain of vascular origin. Blood samples were taken from 62 patients (38-86 years of age) with critical limb ischaemia, claudication or lower limb embolism, and from a control group. The samples were taken at the time of hospital admission, 1 h after surgery, 24 h after surgery, and before discharge. Pain intensity was assessed as mild, moderate or intense. The following biochemical parameters were measured: C reactive protein, total protein, albumin, total cholesterol, HDL and LDL cholesterol, glucose, triglycerides, reduced glutathione, malondialdehyde (MDA), and total antioxidative capacity. In the control subjects, MDA increased postoperatively, whereas albumin, total protein, HDL and total cholesterol decreased. In patients with claudication triglycerides and LDL cholesterol also decreased postoperatively. In patients with critical limb ischaemia, reduced glutathione and antioxidative capacity decreased postoperatively and MDA increased. Except in patients with embolism, MDA and C reactive protein increased following surgery. Patients with critical limb ischaemia and embolism reported the worst preoperative pain. In patients with ischaemia, intense pain persisted during the whole postoperative period while in patients with embolism pain continuously decreased. At different time intervals, pain intensity was related to different biochemical markers. We suggest that the described blood plasma changes might play an important role in pain assessment and pain management.

Completing the audit cycle: comparison of cardiac risk factor management in patients with intermittent claudication in two time periods.

AIM: The first line treatment of patients with intermittent claudication (IC) is to prolong life via cardiac risk factor management. We aimed to compare current standards of secondary prevention with those in a previously published audit. METHODS: Risk factor data was prospectively collated on 304 consecutive new referrals attending the claudication clinic over a 1-year period (2004/2005) and compared to the 104 patients assessed in 2000. RESULTS: In 2004/5 30%, (n=91) of patients did not have a diagnosis of IC confirmed (p<0.01). The use of antiplatelet therapy remained static at 73%. Statin therapy increased in 2004/5 (62% versus 38%, p<0.01) but blood pressure control remained poor with 65% failing to achieve the target levels. Smoking cessation therapy continues to be offered to a minority of patients and 17% of patients have previously undiagnosed diabetes in 2004/2005 (p-value 0.353). The number of patients who have been advised to increase physical activity significantly has fallen from 15% to 2% in the 2004/5 (p<0.01). CONCLUSIONS: Difficulties exist in diagnosing intermittent claudication in primary care and cardiac risk factor management continues to be sub-optimally managed.

Comparação entre o resultado do tratamento clínico de pacientes com claudicação intermitente por obstrução femoropoplítea bilateral versus obstrução aórtica / Comparison between the outcome assessment of the clinical treatment in patients with intermitent claudication due to bilateral femoropopliteal obstruction versus aortic obstruction

Objetivo: A claudicação intermitente é uma das manifestações iniciais da doença arterial obstrutiva periférica. Embora a maioria dos pacientes apresente melhora dos sintomas quando submetidos ao tratamento clínico, alguns não melhoram e podem até apresentar piora. O objetivo deste estudo é verificar se existe diferença no resultado do tratamento clínico de acordo com a localização da obstrução arterial. Métodos: Estudamos 212 pacientes portadores de claudicação intermitente por doença arterial obstrutiva periférica, que foram submetidos a tratamento clínico adequadamente realizado. Dividimos os pacientes em dois grupos: grupo AO (obstrução da aorta) e grupo FP (obstrução femoropoplítea bilateral)...

Prognostic value of noninvasive cardiac tests in the assessment of patients with peripheral vascular disease.

Two hundred thirty-six patients with peripheral vascular disease were prospectively studied to assess whether noninvasive cardiac investigations could predict prognosis better than simple clinical assessment. Clinical history, examination and resting electrocardiography were considered in all patients; exercise electrocardiography, Holter monitoring, radionuclide ventriculography and dipyridamole thallium imaging were performed in a subgroup of 168 patients. Follow-up for 6 to 30 months revealed major cardiac events in 21 patients. Cox survival analysis showed that clinical evidence of prior coronary artery disease was the best variable from clinical assessment that predicted cardiac events, with no other clinical variable adding to the statistical model. When variables from noninvasive cardiac assessment were added to the model, which included clinical evidence of coronary artery disease, dipyridamole thallium heart:lung ratio and left ventricular ejection fraction added significantly and incrementally to the prediction of cardiac events. Results of exercise electrocardiography or Holter monitoring did not add significantly. It is concluded that high lung uptake of thallium during dipyridamole stress, and impaired left ventricular ejection fraction help to identify patients with peripheral vascular disease who are at high cardiac risk, and should therefore be used for selecting subsequent cardiovascular medical, surgical and anesthetic management.

Significance of Buerger's test in the assessment of lower limb ischaemia.

In claudicants with arteriosclerosis obliterans admitted for vascular surgery, Buerger's test was compared with other indicators of lower limb ischaemia. Rest pain, gangrene, trophic changes, and chronic erythromelia were significantly commoner and more distal pulses were absent in Buerger positive limbs. Doppler and transcutaneous oxygen pressures and indices were significantly lower in Buerger positive legs. Significantly more occlusions were noted on arteriography in arteries distal to the adductor hiatus in the Buerger positive group. Buerger's test is a useful adjunct to routine peripheral vascular assessment and, if positive, suggests more severe ischaemia with distal limb artery involvement.

Pentoxifylline efficacy in the treatment of intermittent claudication: multicenter controlled double-blind trial with objective assessment of chronic occlusive arterial disease patients.

The efficacy, safety, and tolerance of pentoxifylline (Trental, Hoechst-Roussel Pharmaceuticals, Inc.) in the treatment of intermittent claudication associated with chronic occlusive arterial disease (COAD) were evaluated in a double-blind, placebo-controlled, parallel-group, multicenter clinical trial involving a total of 128 outpatients. The response to treatment was ascertained at regular intervals during the trial by measuring the distance walked prior to the onset of claudication when patients were subjected to a standardized treadmill test. Pentoxifylline given orally in doses up to 1200 mg/day was significantly more effective than placebo in increasing both the initial and absolute claudication distances in patients with COAD. Reduction of lower limb paresthesias also suggested greater clinical improvement in the pentoxifylline treated patients. These results support the hypothesis that pentoxifylline reduces blood viscosity by improving red cell flexibility, and thereby enhances blood flow in patients with COAD. White the precise mode of therapeutic action requires clarification, pentoxifylline was well tolerated with minimal unwanted effects.

Assessment of reconstructive procedures for femoropopliteal artery occlusive disease.

A total of 117 consecutive reconstructive procedures for femoropopliteal arterial occlusive disease in 105 extremities of 101 patients have been reviewed. The types of procedures included 10 homografts, 28 Dacron and Teflon prosthetic grafts, 16 thromboendarterectomies and 63 vein bypass grafts. There were three postoperative deaths.The results of autogenous vein bypass grafts, as indicated by an early success rate of 90% and late patency rate of 76%, are superior to those obtained by other methods of reconstruction in the institution where this study was made.Early failure of these grafts in most instances relates to technical errors which can be reduced by meticulous surgical technique, operative angiography and close postoperative follow-up with early correction.Some of the late failures can be attributed to stenosis of the graft rather than to the progressive nature of the arteriosclerotic disease. Repeated followup examinations of the extremity at regular intervals and early angiography in the patients with return of symptoms may allow correction of the graft defect and salvage of the extremity.