Embolism from a left ventricular myxoma presenting with acute limb ischaemia.

Acute limb ischaemia (ALI) secondary to cardiac myxoma is uncommon. Embolic myxoma should be considered a differential diagnosis in young patients with ALI who do not have apparent cardiovascular risk factors. A multidisciplinary approach and comprehensive care can improve outcomes and optimise the collaborative treatment of ALI. Early referral to a hospital that can provide specialised treatment for ALI helps prevent significant tissue loss and surgical complications, such as amputation.A man in his 20s presented with bilateral ALI of both lower extremities, and an arterial duplex scan revealed a thrombus occluding all arterial segments of the bilateral lower extremities. An intracardiac mass adherent to the apical and anterior interventricular septum on two-dimensional echocardiography suggested a complex myxoma. The patient was diagnosed with ALI Rutherford category III, and bilateral hip disarticulation was performed. The patient was discharged with an anticoagulant.

Changes in Skin Perfusion Pressure After Hyperbaric Oxygen Therapy Following Revascularization in Patients With Critical Limb Ischemia: A Preliminary Study.

Hyperbaric oxygen (HBO) therapy promotes wound healing in patients with ischemic disease; however, HBO-induced changes in skin peripheral circulation have not been evaluated in clinical practice. Here, we investigated these changes in patients with critical limb ischemia (CLI), with a focus on the angiosome of crural blood vessels with blood flow improved by endovascular therapy (EVT). Six patients with CLI and ulcers who were treated with HBO after EVT (7 limbs; 1 patient had ulcers in the bilateral limbs) and 3 healthy subjects (6 limbs) were enrolled. HBO therapy was performed at 2 atm under 100% oxygen for 90 min per session. Skin perfusion pressure (SPP) was measured in the dorsum and sole of the foot 1 hour before (pre-SPP) and after (post-SPP) HBO therapy. ΔSPP was calculated as post-SPP minus pre-SPP. SPP measurement regions were divided into those that did (direct region) and did not (indirect region) correspond to the vascular angiosome in which angiography findings of the crus were improved after EVT; i.e., when the anterior tibial artery was effectively treated with EVT, the dorsum was the direct region and the sole was the indirect region, and vice versa when the posterior tibial artery was treated. In the direct, indirect, and healthy subject groups, the ΔSPPs were 20.5±8.7 (p=0.002), -6.4±10.9, and -15.1±18.1 (p=0.014), respectively; that of the direct group was significantly greater than that of the other groups. These results suggest that short-term improvement of the peripheral circulation by HBO therapy was significant in patients with successful revascularization.

Identifying Pain and Effects on Quality of Life from Chronic Wounds Secondary to Lower-Extremity Vascular Disease: An Integrative Review.

GENERAL PURPOSE: To provide information to enable better assessment and management of patients with lower extremity vascular disease (LEVD) chronic wound pain. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After completing this continuing education activity, you will be able to: ABSTRACT: A lack of wound pain validation and provider understanding about the effect of pain on quality of life are the biggest barriers to pain management for patients with chronic wound pain. There is also a need for a holistic, validated pain assessment tool for these patients. This is an integrative review of the literature intended to identify gaps in pain identification and (re)assessment for patients with chronic wounds related to lower-extremity vascular disease.

The Role of Qutenza® (Topical Capsaicin 8%) in Treating Neuropathic Pain from Critical Ischemia in Patients with End-Stage Renal Disease: An Observational Cohort Study.

Objective: Current treatment strategies for painful critical ischemia in patients with end-stage renal disease (ESRD) are suboptimal. A drug that is non-renally excreted has minimal systemic absorption and does not require dose adjustment in renal failure is attractive. The aim of this study was to evaluate the safety and efficacy of Qutenza® (topical capsaicin 8%) for chronic neuropathic pain from critical ischemia in patients with ESRD. Design and Setting: A prospective cohort study was conducted in a single-center, university teaching hospital. Patients: Twenty patients with ESRD were treated with Qutenza® for neuropathic pain from critical limb ischemia. Methods: Patients were followed-up at 1, 6 and 12 weeks post-treatment. The primary end point was the difference in visual analog scale (VAS) between baseline and week 12. Secondary end points were Brief Pain Inventory questionnaire (BPI) scores, quality of life assessment (EQ-5D) and patient global impression of change (PGIC). Safety and tolerability data were also collected. The trial was prospectively registered with clinical trials databases (EudraCT: 2012-001586-32; NCT01704313). Results: There was significant reduction in VAS from baseline to week 12 (-20+/-7%; P = 0.02). There was a significant reduction in all seven domains of the BPI. Quality of life also improved at 12 weeks following treatment in two of the EQ-5D domains (mobility and pain). Qutenza® was well tolerated with no significant side effects in this patient cohort, which included 20% diabetics. Conclusions: In this small, observational study Qutenza® treatment has been shown to be effective and well-tolerated to treat neuropathic pain from critical ischemia in patients with ESRD.

Some Non-FDA Approved Uses for Neuromodulation: A Review of the Evidence.

INTRODUCTION: Neuromodulation, including spinal cord stimulation and peripheral nerve field stimulation, has been used with success in treating several painful conditions. The FDA approved the use of neuromodulation for a few indications. We review evidence for neuromodulation in treating some important painful conditions that are not currently FDA approved. METHODS: This review included an online web search for only clinical trials testing the efficacy of neuromodulation in treating coronary artery disease, peripheral vascular disease (PVD), headache, and peripheral field stimulation. RESULTS: Our systematic literature search found 10, 6, and 3 controlled studies relating to coronary artery disease, PVD, and headache, respectively. Our review also included 5 noncontrolled studies relating to peripheral field stimulation, as no controlled studies had been completed. CONCLUSION: This review article shows compelling evidence based on clinical trials that neuromodulation can be of benefit for patients with serious painful conditions that are not currently approved by the FDA.

Diabetic foot ulcers: evaluation and management.

Diabetic foot ulcers (DFUs) are a common complication of diabetes and present a significant health risk to patients, as well as impose a large economic burden. Evaluation for contributory factors that may impact general health or healing, such as hyperglycemia, peripheral artery disease, neuropathy, and nutritional status, is of the utmost importance. Management of DFUs requires involvement of a multidisciplinary team and a standardized approach to patient care. Standard therapy for DFUs includes offloading and debridement. Assessment and control of infection are critical, including determining the severity of the infection, which may drive therapeutic approaches. For recalcitrant ulcers, adjuvant therapies are used to hasten the healing process, and newer therapies are under investigation.

[Surgical management of sub-retinal haemorrhage secondary to polypoidal choroidal vasculopathy]. / Prise en charge chirurgicale des hémorragies sous-rétiniennes secondaires à une vasculopathie polypoïdale.

We report the case of a 34-year-old black woman with acute and severe unilateral loss of sight related to idiopathic polypoidal choroidal vasculopathy responsible for a sub macular haemorrhage (1/10 on the Monoyer scale). The patient underwent a pars plana vitrectomy associated with a sub retinal administration of tissue plasminogen activator (100 µg) and a pneumatic displacement by gas (C2F6) with facedown positioning for 5 days. There were no intraoperative complications and the clot was lysed and totally displaced from the macula. There was no recurrence of the disease and the retinal epithelium detachment decreased progressively. The final visual acuity was 7/10. This case report illustrates the capacity and efficacy of this surgical procedure in the management of sub macular haemorrhage related to polypoidal choroidal vasculopathy. It provides effective displacement of the clot, limiting retinal damage induced by sub macular haemorrhage. Furthermore, it allows early treatment of the polypoidal aneurysm by laser or dynamic phototherapy and increases final visual acuity. Randomised studies are expected to determine the indication for this surgical procedure in the management of polypoidal choroidal vasculopathy and the possible association of laser, dynamic phototherapy, or anti-VEGF treatments.

Serum phosphorus levels and the spectrum of ankle-brachial index in older men: the Osteoporotic Fractures in Men (MrOS) study.

A higher serum phosphorus level is associated with cardiovascular disease (CVD) events among community-living populations. Mechanisms are unknown. The ankle-brachial index (ABI) provides information on both atherosclerosis and arterial stiffness. In this cross-sectional study (2000-2002), the authors evaluated the association of serum phosphorus levels with low (<0.90) and high (> or =1.40 or incompressible) ABI as compared with intermediate ABI in 5,330 older US men, among whom the mean serum phosphorus level was 3.2 mg/dL (standard deviation, 0.4), 6% had a low ABI, and 5% had a high ABI. Each 1-mg/dL increase in serum phosphorus level was associated with a 1.6-fold greater prevalence of low ABI (95% confidence interval (CI): 1.2, 2.1; P < 0.001) and a 1.4-fold greater prevalence of high ABI (95% CI: 1.0, 1.9; P = 0.03) in models adjusted for demographic factors, traditional CVD risk factors, and kidney function. However, the association of phosphorus with high ABI differed by chronic kidney disease (CKD) status (in persons with CKD, prevalence ratio = 2.96, 95% CI: 1.61, 5.45; in persons without CKD, prevalence ratio = 1.14, 95% CI: 0.81, 1.61; interaction P = 0.04). In conclusion, among community-living older men, higher phosphorus levels are associated with low ABI and are also associated with high ABI in persons with CKD. These associations may explain the link between serum phosphorus levels and CVD events.

[Hirudotherapy in the treatment of peripheral cochleovestibular disorders of vascular origin].

Basic therapy of peripheral cochleovestibular disorders of vascular origin consists of the rational combination of medicamentous and non-medicamentous treatments that collectively ensure positive clinical results. The use of hirudotherapy for the management of peripheral cochleovestibular disorders resulted in the substantial decrease of ear noise and the maintenance of the tendency toward further improvement of cochlear and vestibular functions.

Psychosocial factors in chronic pain in the dysvascular and diabetic patient.

Dysvascular and diabetic patients are faced with high rates of chronic pain as a consequence of numerous secondary sequelae, including diabetic neuropathy and limb loss. Researchers and scientists have put forth a tremendous amount of effort to understand the complex nature of pain in this population of individuals, as well as others with chronic pain secondary to illness and injury. The emergent understanding of anatomy and sensory physiology within the past century has fueled an initial focus of understanding pain from a purely neurologic and biochemical perspective. Over the past few decades, the field has moved toward an understanding of pain as a process involving the dynamic interaction of biologic, psychological, behavioral, and social variables. This article provides a brief overview of several psychosocial processes, cognitive, affective, and behavioral, that have emerged as influential to the experience, impact, and treatment of pain.

Homocysteine and peripheral arterial disease: systematic review and meta-analysis.

OBJECTIVE: To evaluate homocysteine (Hcy) levels in patients with peripheral arterial disease (PAD) as compared to unaffected controls, and to review the clinical effects of therapy aimed at lowering homocysteine in PAD patients. METHODS: MEDLINE, EMBASE and Cochrane databases were searched from 1950 to December 2007. We selected observational studies and trials that evaluated Hcy levels in patients with PAD compared to unaffected controls. We also included trials on the effect of Hcy-lowering therapy (folate supplementation) in PAD patients. Continuous outcomes were pooled in a random effects meta-analysis of the weighted mean difference between comparator groups. RESULTS: We retrieved 33 potentially suitable articles from our search. Meta-analysis of 14 relevant studies showed that Hcy was significantly elevated (pooled mean difference +4.31micromoll; 95% C.I. 1.71, 6.31, p<0.0001 with significant heterogeneity) in patients with PAD compared to controls. As all 14 studies consistently demonstrated raised plasma Hcy levels in PAD patients, the significant heterogeneity in this meta-analysis probably arises from differences in the degree of Hcy elevation. The effect of folate supplementation on PAD was tested in eight clinical trials but clinically important end points were inconsistently reported. CONCLUSION: Patients with PAD have significantly higher Hcy levels than unaffected controls. However, we did not find any robust evidence on clinically beneficial effects of folate supplementation in PAD.

[The electroacupuncture in patients recently operated for peripheral arterial disease. A comparative study of the two electrostimulation techniques]. / Electroacupunctura la bolnavii vasculari periferici recent operati. Studiu comparativ a doua tehnici de electrostimulare.

UNLABELLED: Possible hemodynamic effects of electro acupuncture (A), by two electro stimulation techniques, were studied at patients with femuro - popliteal bypass revascularization. MMATERIAL AND METHOD:In a prospective study, we evaluated two EA techniques, by calculating the ankle-brachial index (ABI) and by estimating the pain with Numeric Rating Scale (NRS: 0 - 10). The patients were grouped in lot A (30 patients) and B (50 patients) according with the EA technique used. In both lots were used the same acupuncture points (acupoint): Pc6, P9, St36 and Sp6. These acupoints are adjacent to peripheral nerves median, radial, peroneal and safenous nerve. Needles, after insertion, were kept in place for 30 minutes. The electro stimulation (2 Hz) was only for 2 minutes in the lot A and for 30 minutes in the lot B. RESULTS: The blood pressure data and ABI shows a significant increase of ABI (between 0.033 and 0.052) after EA at 5 minutes in the both lots (p < 0.05). At 30 minutes, ABI is increased in lot B, but in the lot A the ABI is elevated only at the non surgical leg (p < 0.05). The decrease of pain post EA is better in the lot B (NRS: initially 2.48--post EA pain decreased to 1.46 and remained 1.66 at 2 hours; p < 0.001), than lot A. CONCLUSIONS: The electro stimulation of certain acupoints, at the operated peripheral arterial disease patients, interfere with tissular perfusion and increase temporally ABI. The pain is diminished more significantly by the 30 minutes electro stimulating technique.

Analysis of risk factors associated with complications of hyperbaric oxygen therapy.

PURPOSE: The aim of this study was to verify independent risk factors of pressure equalization problems associated with hyperbaric oxygen (HBO(2)) therapy. METHODS: We reviewed a single-institutional study of 1609 patients with 17604 treatments who had HBO(2) therapy in a multiplace chamber, in which the factors examined and their relationship to complications were assessed, using multivariate analyses, to determine the significantly independent risk factors of complications related to HBO(2) therapy. RESULTS: The compression rate was 0.067 atmospheres absolute/min (6.8 kPa/min). Pressure equalization problems of the middle ear, expressed as pain or discomfort, such as cranial sinus pain, and teeth pain were observed in 156 patients (9.7%). Sixty-six of them could not continue HBO(2) therapy because of these problems. Peripheral circulatory disorders with refractory ulcers or nonhealing wounds and the interval between clinical symptoms and the first day of HBO(2) therapy were independent risk factors of pressure equalization problems. Independent risk factors of cessation due to pressure equalization problems were identified as age more than 61 years, female sex, and interval between symptoms and the first day of HBO(2) therapy. CONCLUSION: It is suggested that chamber compression must be performed with particular care when patients have peripheral circulatory disorders and have short interval between clinical symptoms and the first day of HBO(2) therapy.

Impact of cardioselective beta-blockers on mortality in patients with chronic obstructive pulmonary disease and atherosclerosis.

RATIONALE: beta-Blocker use is associated with improved health outcomes in patients with cardiovascular disease. There is a general reluctance to prescribe beta-blockers in patients with chronic obstructive pulmonary disease (COPD) because they may worsen symptoms. OBJECTIVES: We investigated the relationship between cardioselective beta-blockers and mortality in patients with COPD undergoing major vascular surgery. METHODS: We evaluated 3,371 consecutive patients who underwent major vascular surgery at one academic institution between 1990 and 2006. The patients were divided into those with and without COPD on the basis of symptoms and spirometry. The major endpoints were 30-day and long-term mortality after vascular surgery. Patients were defined as receiving low-dose therapy if the dosage was less than 25% of the maximum recommended therapeutic dose; dosages higher than this were defined as intensified dose. MEASUREMENTS AND MAIN RESULTS: There were 1,205 (39%) patients with COPD of whom 462 (37%) received cardioselective beta-blocking agents. beta-Blocker use was associated independently with lower 30-day (odds ratio, 0.37; 95% confidence interval, 0.19-0.72) and long-term mortality in patients with COPD (hazards ratio, 0.73; 95% confidence interval, 0.60-0.88). Intensified dose was associated with both reduced 30-day and long-term mortality in patients with COPD, whereas low dose was not. CONCLUSIONS: Cardioselective beta-blockers were associated with reduced mortality in patients with COPD undergoing vascular surgery. In carefully selected patients with COPD, the use of cardioselective beta-blockers appears to be safe and associated with reduced mortality.

High-dose atorvastatin in peripheral arterial disease (PAD): effect on endothelial function, intima-media-thickness and local progression of PAD. An open randomized controlled pilot trial.

Beneficial effects of aggressive lipid-lowering with high-dose atorvastatin (80 mg/day) have been demonstrated in patients with coronary and cerebrovascular disease. The impact of such a therapy in patients with peripheral arterial disease (PAD) is less known so far. Here we studied the effects of high-dose atorvastatin on brachial artery endothelial function, common carotid intima-media thickness (IMT) and local progression of PAD in these patients. One hundred of 500 patients screened with documented PAD were randomly assigned to receive 80 mg of atorvastatin daily for six months or to continue on conventional medical treatment. Ninety-six percent of patients in the control group were on standard statin treatment. High resolution B-mode ultrasonography was used to study brachial artery flow-mediated dilation (FMD), IMT and ankle-brachial index (ABI) at baseline and at six months. FMD and IMT at baseline and at six months were 4.1 (0.06-8.6) versus 5.0 (0.76 vs. 8.1) %, p = 0.96, and 0.76 (0.66-0.82) versus 0.73 (0.63-0.81) mm, p = 0.41, respectively, in the atorvastatin group, and 2.66 (-1.9-6.9) versus 3.65 (0.0-8.6)%, p = 0.02, and 0.78 (0.71-0.90) versus 0.77 (0.70-0.90) mm, p = 0.48, in the control group. ABI at baseline and at six months was not different in either group. LDL cholesterol was reduced from 2.53 (2.21-3.28) to 1.86 (1.38-2.29) mM (p < 0.0001) in the atorvastatin group, whereas levels remained stable in the control group [2.38 (1.94-3.16) vs. 2.33 (1.82-2.84) mM, p = 0.61]. Major adverse cardiovascular events occurred in 2.1% in the atorvastatin group and 1.9% in the control group (p = 0.61). In conclusion, in this pilot trial aggressive lipid-lowering with 80 mg of atorvastatin daily for six months had no effect on brachial artery FMD in patients with PAD. IMT and ABI were also similar in patients with and without high-dose atorvastatin at six months.

Reaching target lipid levels in patients at high risk of cardiovascular event: the experience of a Canadian tertiary care lipid clinic.

OBJECTIVES: To determine the proportion of high risk patients followed at a tertiary care lipid clinic who met recommended lipid targets and to identify predictors of reaching goal lipid levels. RESEARCH DESIGN AND METHODS: A retrospective cohort study of 502 high risk patients followed between 1983 and 2003. Clinical and demographic data and fasting lipid profiles were extracted from each patient's first two clinic visits as well as the most recent visit. RESULTS: All patients in this study were at high risk of cardiovascular events due to dyslipidemia. At "Visit 1", only 55 (11.0%) of patients were at target TC/HDL-C < 4.0, and 97 (19.3%) of patients met target LDL-C < 2.5 mmol/l. At "Visit 3", 229 (45.8%) patients reached TC/HDL-C target, and 216 (43.2%) patients were at LDL-C target. The mean change in lipid values between Visit 1 and Visit 3 was significant (p = 0.0002) for LDL-C and (p < 0.0001) for TC/HDL-C. The use of statins, niacin, or salmon oil were all significantly associated with reaching TC/HDL-C target and LDL-C target, as well male gender, diabetes mellitus and peripheral vascular disease were also associated with reaching LDL-C target. Increasing age and lower body mass index were associated with reaching goal TC/HDL-C. CONCLUSIONS: The mean absolute changes in lipid values were significant and median lipid levels approached target levels in patients followed at specialized clinic, however the majority of high risk patients are not meeting goal lipid levels.

Epidural spinal cord stimulation in lower limb ischemia.

Epidural spinal cord stimulation (SCS) has been used as a method to improve microcirculatory blood flow, relieve ischemic pain and reduce amputation rate in patients with severe peripheral arterial occlusive disease (PAOD). In this article, the theories attempting to explain the mechanisms of SCS vasoactive action are presented. Our method of patient screening and our surgical technique for SCS implantation are described. In addition, the various published series reporting on the efficacy of SCS in PAOD are critically reviewed. The contemporary reports demonstrate the efficacy of SCS in ischemic pain relief. In the light of these results and our own experience, we conclude with an appraisal of modern techniques for assessing critical limb ischemia.

Fish oil induced increase in walking distance, but not ankle brachial pressure index, in peripheral arterial disease is dependent on both body mass index and inflammatory genotype.

Peripheral arterial disease (PAD) is an atherosclerotic disease. Evidence suggests that atherosclerosis is an inflammatory condition and long chain n-3 fatty acids, found in oily fish and fish oils, have been shown to reduce inflammation. Genetic and lifestyle factors such as body mass index (BMI) also influence inflammation. In this study we have examined the effect of fish oil in patients with claudication secondary to PAD. Fish oil supplementation, providing 1g EPA and 0.7 g DHA per day for 12 weeks, increased walking distance on a treadmill set at 3.2 km/h with a 7% incline. Walking distance to first pain increased from 76.2+/-8.5 m before fish oil to 140.6+/-25.5 m after fish oil (mean+/-SEM, p=0.004) and total distance walked increased from 160.0+/-21.5 m before fish oil to 242.1+/-34.5 m after fish oil (p=0.002). Fish oil supplementation also improved ankle brachial pressure index (ABPI) from 0.599+/-0.017 before fish oil to 0.776+/-0.030 after fish oil (p<0.001). The increase in walking distance was dependent on both BMI and genotype for single nucleotide polymorphisms in the genes encoding the pro-inflammatory cytokines tumour necrosis factor-alpha and interleukin (IL)-1beta and the anti-inflammatory cytokine IL-10 (detected using amplification refractory mutation system polymerase chain reaction). Neither BMI nor any of the genotypes examined affected the ability of fish oil to increase ABPI. The mechanisms by which fish oil affects walking distance and ABPI do not appear to be the same.

Amino acids stimulate leg muscle protein synthesis in peripheral arterial disease.

OBJECTIVE: Older patients with peripheral arterial disease (PAD) and intermittent claudication have impaired walking ability resulting from reduced lower extremity blood flow. Evidence suggests that leg muscle abnormalities may also contribute to walking intolerance in claudicants. In healthy elderly people, leg muscle protein synthesis can be augmented by nutritional supplementation with amino acids; preliminary data suggest that this increases muscle mass, walking ability, and functional status. In this study, we investigated whether amino acid supplementation would improve leg muscle protein synthesis in elderly PAD subjects, given that reduced leg blood flow might restrict the availability of amino acids to muscle. METHODS: Two groups participated in the study: a group of 11 claudicants (mean age, 62 years; mean ankle-brachial index, 0.62; 46% male) and a group of 9 age- and sex-matched healthy controls (mean ankle-brachial index, 1.1). Both groups underwent measurement of leg blood flow by using strain gauge plethysmography, as well as measurement of baseline and amino acid-stimulated protein synthesis in leg muscle. Protein synthesis was quantified from calf muscle biopsy samples by measurement of the fractional synthetic rate (FSR) of protein, by using the incorporation of the stable isotope l-[ring-(2)H(5)]-phenylalanine into muscle protein. Total protein was extracted from muscle samples, and gas chromatography/mass spectroscopy methodology was used to measure incorporation rates. After measurement of basal FSR, all subjects were given an oral drink of 15 g of essential amino acids, and the measurements of FSR were repeated. Data are expressed as mean +/- SD; statistical analysis of differences between the two groups (with and without amino acid supplementation) was performed by using analysis of variance with repeated measures. RESULTS: Calf blood flow was reduced in the PAD subjects compared with controls (1.44 +/- 0.53 mL/min per 100 mg of tissue vs 2.40 +/- 0.57 mL/min per 100 mg of tissue; P = .005; t test). FSR in the basal state was equivalent between the two groups (healthy, 0.060% +/- 0.025% per hour; PAD, 0.061% +/- 0.029% per hour; P = .97). Equivalent increases (P < .05) occurred in both groups in response to oral amino acid supplementation (healthy, 0.087% +/- 0.012% per hour; PAD, 0.104% +/- 0.041% per hour; P > .05; analysis of variance). CONCLUSIONS: Despite reduced leg blood flow, elderly PAD patients synthesize calf muscle protein in the basal state in a fashion similar to that in healthy elderly people. More importantly, administration of exogenous amino acids produces a significant increase in protein synthesis in these patients that is also equivalent to that in healthy elderly people. Our goal is to use these results as the basis for an intervention study to determine whether long-term oral amino acids, by augmenting calf muscle protein synthesis, increase calf muscle mass, walking ability, and functional status in elderly claudicants.