Lidocaine patch as noninvasive alternative treatment option in children with anterior cutaneous nerve entrapment syndrome: A retrospective case series.

BACKGROUND: Chronic abdominal pain in children is occasionally caused by anterior cutaneous nerve entrapment syndrome (ACNES). Diagnosing and treating this typical peripheral abdominal wall neuropathy is challenging. Management usually starts with minimally invasive tender point injections. Nevertheless, these injections can be burdensome and might even be refused by children or their parents. However, a surgical neurectomy is far more invasive. Treatment with a Lidocaine 5% medicated patch is successfully used in a variety of peripheral neuropathies. AIMS: This single center retrospective case series aimed to evaluate the effectiveness and tolerability of lidocaine patches in children with ACNES. METHODS: Children aged under 18 diagnosed with ACNES who were treated with a 10 day lidocaine patch treatment between December 2021 and December 2022 were studied. Patient record files were used to collect treatment outcomes including pain reduction based on NRS and complications. RESULTS: Twelve of sixteen children (mean age 13 years; F:M ratio 3:1) diagnosed with ACNES started the lidocaine patch treatment. Two patients achieved a pain free status and remained pain free during a 4 and 7 months follow-up. A third child reported a lasting pain reduction, but discontinued treatment due to a temporary local skin rash. Five additional patients reported pain reduction only during application of the patch. The remaining four children experienced no pain relief. No adverse effects were reported. CONCLUSION: Lidocaine patches provides pain relief in a substantial portion of children with ACNES.

Visceral symptoms in patients with anterior cutaneous nerve entrapment syndrome (ACNES): expression of viscerosomatic reflexes?

PURPOSE: Anterior cutaneous nerve entrapment (ACNES) is characterized by neuropathic pain in a predictable, circumscript abdominal area. The diagnostic delay is long, with half of ACNES-affected individuals reporting nausea, bloating, or loss of appetite mimicking visceral disease. The aim of this study was to describe these phenomena and to determine whether treatment could successfully reverse the visceral symptoms. METHODS: This prospective observational study was conducted between July 2017 and December 2020 at SolviMáx, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Máxima Medical Center, Eindhoven. Adult patients who fulfilled published criteria for ACNES and reported at least one visceral symptom at intake were eligible for the study. A self-developed Visceral Complaints ACNES Score (VICAS) questionnaire that scores several visceral symptoms (minimum 1 point, maximum 9 points) was completed before and after therapy. The success of treatment was defined as at least 50% reduction in pain. RESULTS: Data from 100 selected patients (86 females) aged 39 ± 5 years were available for analysis. Frequently reported symptoms were abdominal bloating (78%), nausea (66%) and altered defecation (50%). Successful treatment significantly reduced the number of visceral symptoms, with a VICAS before of 3 (range 1-8) and after of 1 (range 0-6) (p < 0.001). A low baseline VICAS was associated with successful treatment outcome (OR 0.738, 95% CI 0.546-0.999). CONCLUSION: Patients with ACNES may report a variety of visceral symptoms. Successful treatment substantially reduces these visceral symptoms in selected patients.

Pulsed radiofrequency or surgery for anterior cutaneous nerve entrapment syndrome: Long-term results of a randomized controlled trial.

PURPOSE: Patients with anterior cutaneous nerve entrapment syndrome (ACNES) often require a step-up treatment strategy including abdominal wall injections, pulsed radiofrequency (PRF) or a neurectomy. Long-term success rates of PRF and surgery are largely unknown. The aim of the current study was to report on the long-term efficacy of PRF and neurectomy in ACNES patients who earlier participated in the randomized controlled PULSE trial. METHODS: Patients who completed the PULSE trial were contacted about pain status and additional treatments in the following years. Treatment success was based on numerical rating scale (NRS) following IMMPACT recommendations and Patient Global Impression of Change (PGIC) scores. RESULTS: A total of 44 of the original 60 patients were eligible for analysis (73.3%). Median follow-up was 71.5 months. One patient (4.3%) was still free of pain after a single PRF session, and five additional patients (21.7%) were free of pain by repetitive PRF treatments. By contrast, 13 patients (61.9%) in the neurectomy group were still free of pain without additional treatments. All pain recurrences and therefore primary re-interventions occurred in the first 2 years after the initial treatment. CONCLUSION: Approximately one in five ACNES patients undergoing PRF treatment reports long-term success obviating the need of surgical intervention. Surgery for ACNES is long-term effective in approximately two of three operated patients. Recurrent ACNES beyond 2 years after either intervention is rare.

The Scratch Collapse Test in patients diagnosed with Anterior Cutaneous Nerve Entrapment Syndrome (ACNES): A report of three cases.

INTRODUCTION AND IMPORTANCE: The Scratch Collapse Test (SCT) is currently used as a supportive tool diagnosing peripheral nerve neuropathies including carpal tunnel syndrome or peroneal nerve entrapment. Some patients with chronic abdominal pain suffer from entrapment of terminal branches of intercostal nerves (anterior cutaneous nerve entrapment syndrome, ACNES). ACNES is characterized by a severe disabling pain at a predictable area of the anterior abdomen. Clinical examination shows altered skin sensation and painful pinching at the area of pain. However, these findings may be subjective. CASE PRESENTATION: In three female patients aged 71, 33, and 43 years with suspected ACNES, the SCT was positive when scratching over the skin of the affected nerve-ending at the abdominal wall. The diagnosis ACNES was confirmed with a local abdominal wall infiltration at the tenderpoint in all three patients. In case three, the SCT turned negative after lidocaine infiltration. CLINICAL DISCUSSION: ACNES was hitherto a clinical diagnosis just based on clues in medical history and physical examination. Performing a SCT in patients possibly having ACNES may additionally contribute to the diagnosis. CONCLUSION: The SCT may serve as an additional tool for diagnosing patients with possible ACNES. A positive SCT in patients with ACNES supports the hypothesis that ACNES is indeed a peripheral neuropathy of terminal branches of the lower thoracic intercostal nerves. Controlled research is necessary to confirm the role of a SCT in ACNES.

Systematic Review of Innovative Diagnostic Tests for Chronic Exertional Compartment Syndrome.

The diagnosis chronic exertional compartment syndrome is traditionally linked to elevated intracompartmental pressures, although uncertainty regarding this diagnostic instrument is increasing. The aim of current review was to evaluate literature for alternative diagnostic tests. A search in line with PRISMA criteria was conducted. Studies evaluating diagnostic tests for chronic exertional compartment syndrome other than intracompartmental pressure measurements were included. Bias and quality of studies were evaluated using the Oxford Levels of Evidence and the QUADAS-2 instrument. A total of 28 studies met study criteria (MRI n=8, SPECT n=6, NIRS n=4, MRI and NIRS together n=1, miscellaneous modalities n=9). Promising results were reported for MRI (n=4), NIRS (n=4) and SPECT (n=3). These imaging techniques rely on detecting changes of signal intensity in manually selected regions of interest in the muscle compartments of the leg. Yet, diagnostic tools and protocols were diverse. Moreover, five studies explored alternative modalities serving as an adjunct, rather than replacing pressure measurements. Future research is warranted as clinical and methodological heterogeneity were present and high quality validation studies were absent. Further optimization of specific key criteria based on a patient's history, physical examination and symptom provocation may potentially render intracompartmental pressure measurement redundant.

Short- and long-term results of operative iliac artery release in endurance athletes.

OBJECTIVE: Endurance athletes can develop intermittent claudication due to sports-related flow limitations of the iliac artery (FLIA) caused by arterial kinking. In the present study, we investigated the short- and long-term efficacy of an operative release for iliac artery kinking. METHODS: Between 1996 and 2015, all patients with a diagnosis of FLIA due to iliac artery kinking without substantial arterial stenosis (<15%) or an excessive arterial length (vessel length to straight ratio, <1.25) who had undergone surgery were included. The short-term follow-up protocol consisted of cycling tests, the ankle brachial index with a flexed hip, and Doppler echography examinations to determine the peak systolic velocity before and 6 to 18 months after surgery. Additionally, the short- and long-term efficacy were evaluated using questionnaires. RESULTS: A total of 142 endurance athletes (155 legs; 88.4% male; median age, 26 years; interquartile range [IQR], 22-31 years) were available for analysis. In the short term, the symptoms had decreased in 83.9% of the patients, with an overall 80.3% satisfaction rate. Power during a maximal cycling test had improved from 420 W (IQR, 378-465 W) to 437 W (IQR, 392-485 W; P < .001). The symptom-free workload had increased from 300 W (IQR, 240-340 W) to 400 W (IQR, 330-448 W; P < .001). The postexercise ankle brachial index with a flexed hip had increased from 0.53 (IQR, 0.40-0.61) to 0.57 (IQR, 0.47-0.64; P = .002), and the peak systolic velocity with a flexed hip had decreased from 1.88 m/s (IQR, 1.45-2.50 m/s) to 1.52 m/s (IQR, 1.19-2.07 m/s; P < .001). Postoperative imaging studies revealed some degree kinking in 33.9%, mostly asymptomatic. The long-term results were evaluated after a median of 15.2 years (IQR, 10.9-19.5 years). The athletes had cycled an additional 125.500 km (IQR, 72.00-227.500 km), which was approximately equal to the 131.000 km (IQR, 98.250-220.000 km) cycled before the diagnosis of FLIA. On the long term, 63.9% of the athletes reported persistent reduction of complaints, with an overall 59.1% satisfaction rate. Eight patients had required reintervention, six because of treatment failure and two because of newly developed FLIA. CONCLUSIONS: Operative iliac artery release for sports-related functional kinking in the absence of stenosis or an excessive vessel length was effective for most athletes in the short and long term.

Test-retest reliability of skeletal muscle oxygenation measurement using near-infrared spectroscopy during exercise in patients with sport-related iliac artery flow limitation.

The ankle-brachial index is an accurate tool for detecting claudication in atherosclerotic patients. However, this technique fails to identify subtle flow limitations of the iliac arteries (FLIA) in endurance athletes. Near-infrared spectroscopy (NIRS) is a noninvasive technique that measures skeletal muscle tissue oxygenation status. The aim of the present study is to examine the absolute and relative test-retest reliability of NIRS and evaluate its potential as a diagnostic tool in FLIA. NIRS-derived exercise variables were analyzed during exercise and recovery in FLIA 17 patients and 19 healthy controls. The relative reliability of absolute variables (such as the maximal value) were slight to yet predominantly substantial (intraclass correlation coefficient [ICC], ICC range: 0.06-0.76) with good to excellent absolute reliability (absolute limits of agreement [ALoA], ALoA range: 0.8 ± 10.2 to 0.7 ± 13.1; coefficient of variation [CV], CV range: 5%-11%). Absolute values encompassing signal amplitudes showed moderate to almost perfect relative reliability (ICC range: 0.51-0.89) and poor to good absolute reliability (ALoA range: -1.3 ± 7.0 to -2.5 ± 15.7; CV range: 15%-32%). Kinetic variables showed moderate to almost perfect relative reliability for most recovery kinetics variables (ICC range: 0.54-0.86) with fair to good absolute reliability (ALoA range: 0.4 ± 12.2 to 3.9 ± 37.9; CV range: 18%-27%). Particularly, kinetic variables showed significant differences between patients and healthy subjects. NIRS is found to be a reliable method for examining muscle tissue oxygenation variables. Given the significant differences in especially recovery kinetics between normal subjects and patients, NIRS may contribute to diagnosing FLIA in endurance athletes.

The Effect of Arterial Disease Level on Outcomes of Supervised Exercise Therapy for Intermittent Claudication: A Prospective Cohort Study.

OBJECTIVE: To assess whether level of arterial obstruction determines the effectiveness of SET in patients with IC. BACKGROUND DATA: Guidelines advocate SET before invasive treatment for IC, but early revascularization remains widespread, especially in patients with aortoiliac disease. METHODS: Patients were recruited from 10 Dutch centers between October 2017 and October 2018. Participants received SET first, followed by endovascular or open revascularization in case of insufficient effect. They were grouped according to level of stenosis (aortoiliac, femoropopliteal, multilevel, or rest group with no significant stenosis). Changes from baseline walking performance (maximal and functional walking distance on a treadmill test, 6-minute walk test) and vascular quality of life questionnaire-6 at 3 and 6 months were compared, after multivariate adjustment for possible confounders. Freedom from revascularization was estimated with Kaplan-Meier analysis. RESULTS: Some 267 patients were eligible for analysis (aortoiliac n = 70, 26%; femoropopliteal n = 115, 43%; multilevel n = 69, 26%; rest n = 13, 5%). No between group differences in walking performance or vascular quality of life questionnaire-6 were found. Mean improvement in maximal walking distance after 6 months was 439 m [99% confidence interval (CI) 297-581], 466 m (99% CI 359-574), 353 m (99% CI 210-496), and 403 m (99% CI 58-749), respectively (P = 0.40). Freedom from intervention was 73.9% for aortoiliac disease and 88.6% for femoropopliteal disease (hazard ratio 2.46, 99% CI 0.96 - 6.30, P = 0.013). CONCLUSIONS: Short-term effectiveness of SET for IC is not determined by the location of stenosis. Although aortoiliac disease patients improved walking performance and health-related quality of life similarly compared to other arterial disease level groups, they underwent revascularization more often.

Access flow volume (Qa) and survival in a haemodialysis population: an analysis of 5208 Qa measurements over a 9-year period.

BACKGROUND: The aim of this study was to determine associations between characteristics of arteriovenous access (AVA) flow volume (Qa; mL/min) and 4-year freedom from cardiovascular mortality (CVM) in haemodialysis (HD) patients. METHODS: HD patients who received a primary AVA between January 2010 and December 2017 in one centre were analysed. Initial Qa was defined as the first Qa value obtained in a well-functioning AVA by a two-needle dilution technique. Actual Qa was defined as access flow at a random point in time. Changes in actual Qa were expressed per 3-month period. CVM was assessed according to the European Renal Association-European Dialysis and Transplant Association classification. The optimal cut-off point for initial Qa was identified by a receiver operating characteristics curve. A joint modelling statistical technique determined longitudinal associations between Qa characteristics and 4-year CVM. RESULTS: A total of 5208 Qa measurements (165 patients; 103 male, age 70 ± 12 years, autologous AVA n = 146, graft n = 19) were analysed. During follow-up (December 2010-January 2018, median 36 months), 79 patients (48%) died. An initial Qa <900 mL/min was associated with an increased 4-y CVM risk {hazard ratio [HR] 4.05 [95% confidence interval (CI) 1.94-8.43], P < 0.001}. After 4 years, freedom from CVM was 34% lower in patients with a Qa <900 mL/min (53 ± 7%) versus a Qa ≥900 mL/min (87 ± 4%; P < 0.001). An association between increases in actual Qa per 3-month period and mortality was found [HR 4.48/100 mL/min (95% CI 1.44-13.97), P = 0.010], indicating that patients demonstrating increasing Qa were more likely to die. In contrast, actual Qa per se was not related to survival. CONCLUSIONS: Studying novel AVA Qa characteristics may contribute to understanding excess CVM in HD patients.

Supervised Exercise Therapy is Effective for Patients With Intermittent Claudication Regardless of Psychological Constructs.

OBJECTIVE: According to current guidelines, supervised exercise therapy (SET) is the treatment of choice for intermittent claudication (IC). Little is known about the potential consequences of psychological factors on the effectiveness of treatment. The aim of this study was to determine possible associations between a set of psychological constructs and treatment outcomes, and to investigate whether self efficacy increased after SET. METHODS: This was a substudy of the ELECT Registry, a multicentre Dutch prospective cohort study in patients with IC receiving primary SET. A complete set of validated questionnaires scoring extraversion, neuroticism, conscientiousness, anxiety, depression, self control, optimism, and self efficacy was obtained in 237 patients (median age 69 years, 40% female). Anxiety and depression were dichotomised using established cutoff scores, whereas other scores were analysed as continuous measures. Multiple linear regression analyses determined possible associations between these independent variables and maximum and functional walking distances (MWD and FWD, respectively), Six Minute Walk Test (6MWT), and VascuQol-6 (dependent variables). Self efficacy during 12 months of SET was analysed using a linear mixed model. RESULTS: Neuroticism and anxiety were associated with lower overall VascuQol-6 scores (estimate -1.35 points [standard error (SE) 0.57; p = .018] and -1.98 points [SE 0.87, p = .023], respectively). Optimism and self efficacy demonstrated higher overall 6MWT (5.92 m [SE 2.34; p = .012] and 1.35 m [SE 0.42; p = .001], respectively). Self control was associated with lower overall log MWD (-0.02 [SE 0.01; p = .038] and log FWD (-0.02 [SE 0.01; p = .080), whereas self efficacy had a higher overall log MWD (0.01 [SE 0.003; p = .009]) and log FWD (0.01 [SE 0.003; p = .011]). Depressive patients with IC demonstrated a greater improvement in 6MWT during follow up (17.56 m [SE 8.67; p = .044]), but this small effect was not confirmed in sensitivity analysis. Self efficacy did not increase during follow up (0.12% [SE 0.49; p = .080]). CONCLUSIONS: The beneficial effects of SET occur regardless of the psychological constructs, supporting current guidelines recommending a SET first strategy in each patient with IC.

Vascular Quality of Life Questionnaire-6 Before and After Supervised Exercise Therapy in Patients with Intermittent Claudication.

OBJECTIVE: The Vascular Quality of Life Questionnaire-6 (VascuQoL-6) is a short, disease specific instrument used to determine health related quality of life (HRQoL) in patients with peripheral arterial disease. This study aimed to assess the minimally important difference (MID) and substantial clinical benefit (SCB) of the VascuQoL-6 in Dutch patients with intermittent claudication (IC) receiving supervised exercise therapy (SET). METHODS: Consecutive patients with IC who were recruited from a single centre between January 2016 and December 2016 completed the VascuQoL-6 before initiation and after three months of SET. They subsequently answered an anchor question rating their current health status as much improved, improved, unchanged, deteriorated, or much deteriorated, compared with baseline. The MID for improvement and deterioration and SCB were calculated using anchor based and distribution based methods. RESULTS: A total of 124 patients with IC (58% male, mean age 68 years) completed the study protocol. Baseline VascuQoL-6 scores increased from 16.3 ± 4.4 to 18.7 ± 3.8 after three months of SET (p < .001). MID values ranged from +2.0 to +3.8 points regarding HRQoL improvement and from +0.2 to -2.2 points regarding HRQoL deterioration. The SCB ranged from +3.7 to +5.0 points. Depending on the MID approach, 32% - 41% of patients achieved a clinically meaningful improvement in HRQoL. CONCLUSION: Approximately one in three patients with IC reported a clinically meaningful improvement in HRQoL after three months of SET. The range of MID and SCB values provides caregivers with an idea of how much change in VascuQoL-6 scores is considered relevant or substantial by their patients. Applying cutoff points for MID and SCB may optimise the interpretation of trial results and may help to set a benchmark for success of SET.

Ultrasound-guided abdominal wall infiltration versus freehand technique in anterior cutaneous nerve entrapment syndrome (ACNES): randomized clinical trial.

BACKGROUND: The optimal technique of abdominal wall infiltration for chronic abdominal wall pain due to anterior cutaneous nerve entrapment syndrome (ACNES) is unknown. The aim of this study was to compare pain reduction after an abdominal wall anaesthetic injection by use of an ultrasound-guided technique (US) or given freehand (FH). METHODS: In this multicentre non-blinded randomized trial, adult patients with ACNES were randomized (1:1) to an US or a FH injection technique. Primary outcome was the proportion of injections achieving a minimum of 50 per cent pain reduction on the Numeric Rating Scale (range 0-10) 15-20 min after abdominal wall infiltration ('successful response'). Secondary outcomes were treatment efficacy after 6 weeks and 3 months, and the influence of the subcutaneous tissue thickness on treatment outcome. RESULTS: Between January 2018 and April 2020, 391 injections (US = 192, FH = 199) were administered in 117 randomized patients (US = 55, FH = 62; 76.0 per cent female, mean age 45 years). The proportion of successful responses did not significantly differ immediately after the injection regimen (US 27.1 per cent versus FH 33.2 per cent; P = 0.19) or after 3 months (US 29.4 per cent versus FH 30.5 per cent; P = 0.90). Success was not determined by subcutaneous tissue thickness. CONCLUSION: Pain relief following abdominal wall infiltration by a US or FH technique in ACNES is similar and not influenced by subcutaneous tissue thickness. REGISTRATION NUMBER: Dutch Clinical Trial Register NL8465.

Systolic finger pressures during an Allen test before hemodialysis access construction predict severe postoperative hand ischemia.

OBJECTIVE: The Allen test is a simple bedside method for determining hand perfusion. Earlier studies in patients on hemodialysis (HD) found that an Allen test before access construction did not predict hand ischemia later on. The study aimed to assess whether an Allen test combined with finger plethysmography before access surgery has a potential to predict the onset of severe HD access induced distal ischemia (HAIDI). METHODS: Before the first access construction in patients with chronic kidney disease, systolic finger pressures (Pdig, in millimeters of mercury) were obtained using plethysmography at rest and after serial compression of the radial and ulnar artery. A decrease in Pdig (∂Pdig) was calculated as the difference between Pdig-rest and Pdig-compression. The severity of postoperative HAIDI was graded as suggested by a 2016 consensus meeting. Patients with a severe type of HAIDI (grade 2b-4, intolerable pain, invasive treatment required) were compared with controls not having HAIDI. RESULTS: A total of 105 patients with chronic kidney disease (mean age 70 ± 13 years; 65% males) receiving their first access between January 2009 and December 2018 in one center fulfilled study criteria. Ten patients (10%) developed severe HAIDI at 14 ± 5 months after access construction. Before access creation, all patients with HAIDI demonstrated a radial or ulnar dominant hand perfusion pattern compared with just 57% in controls (P = .010). Compression resulted in an almost two-fold greater ∂Pdig in patients with severe HAIDI (51 ± 8 mm Hg vs 27 ± 3 mm Hg; P = .005). A 40-mm Hg ∂Pdig cut-off value demonstrated optimal tests characteristics (sensitivity of 80%, specificity of 77%, positive predictive value of 27%, negative predictive value of 97%) indicating a 10 times greater risk of developing severe HAIDI. CONCLUSIONS: Finger plethysmography quantifying ∂Pdig during an Allen test before access creation may identify patients who have a substantially increased risk of developing severe hand ischemia after HD access surgery.

Persistent pain relief following a single injection of a local anesthetic for neuropathic abdominal wall and groin pain.

OBJECTIVES: It is our experience that a small portion of patients with neuropathic abdominal wall pain syndromes such as the anterior cutaneous nerve entrapment syndrome (ACNES) have a long term beneficial response following just one single tender point injection (TPI) with a local anesthetic agent. This report focuses on the phenomenon of ongoing pain relief following a single local anesthetic injection in neuropathic abdominal wall and groin pain syndromes. METHODS: This report is an overview based on earlier studies from a center of expertise for neuropathic abdominal wall and groin pain syndromes. All studies on neuropathic abdominal wall and groin pain syndromes reporting on efficacy of a diagnostic TPI using a local anesthetic agent were included. RESULTS: A total of 10 studies including 834 patients fulfilled study criteria. Each of these 10 studies found that approximately 10% (range, 4-25%) of the cases experienced persistent pain relief after a single TPI with lidocaine 1%. CONCLUSIONS: Persistent pain relief after a single TPI using a local anesthetic agent may be observed in approximately one of 10 patients suffering from neuropathic abdominal wall or groin pain syndromes. When a patient is suspected of having a neuropathic abdominal wall or groin pain syndrome, a single TPI using a local anesthetic agent should be administered as long term pain relief may occasionally occur.

Fasciectomy for Recurrent Chronic Exertional Compartment Syndrome of the Anterior Leg.

PURPOSE: This study aimed to determine whether a fasciectomy for recurrent chronic exertional compartment syndrome of the anterior leg (ant-CECS) after a minimally invasive fasciotomy is safe and beneficial. METHODS: Demographics and clinical course of patients undergoing a fasciectomy for ongoing exercise-related leg pain (ERLP) after an earlier minimally invasive fasciotomy for ant-CECS were prospectively obtained using questionnaires. Patient-reported severity and frequency of pain, tightness, weakness, cramping, and paresthesia in rest and during exercise were scored before and after surgery. A successful outcome was defined as a self-reported good or excellent result. RESULTS: Between January 2013 and March 2019, 24 of the 958 patients evaluated for ERLP were included in the study (15 females; median age, 24 yr; range, 14-37 yr). Intracompartmental pressure values before the minimally invasive fasciotomy and before the fasciectomy were not different. Perioperative findings were fibrotic bands, pseudofascias, or complete fusions of fascial edges. Postoperative superficial wound infections requiring oral antibiotics occurred in four legs. After rehabilitation, the total symptom scores during exercise and resting conditions decreased threefold compared with preoperatively (exercise, 55 ± 5 to 17 ± 3, P < 0.001; rest, 30 ± 4 to 10 ± 2, P < 0.001). All cardinal symptoms decreased significantly, but the largest improvements were reported for pain and tightness. At follow-up (median, 12 months; range, 2-65 months), 79% of patients reported a successful outcome, whereas 75% had returned to physical activity. CONCLUSION: An anterior fasciectomy with associated treatment of correlated pathologies can be safe and beneficial in patients with ongoing ERLP who previously underwent a minimally invasive fasciotomy for ant-CECS.

Severe hemodialysis access-induced distal ischemia may be associated with poor survival.

BACKGROUND: Some hemodialysis patients develop hemodialysis access-induced distal ischemia due to insufficient loco-regional perfusion pressure and consequent poor arterial flow. We hypothesized that patients with severe hemodialysis access-induced distal ischemia had worse survival compared with patients with mild or no hemodialysis access-induced distal ischemia. METHODS: This single-center retrospective observational cohort study included three groups of prevalent hemodialysis patients with an upper extremity vascular access between 2006 and 2018. Symptomatic patients had signs and symptoms of hemodialysis access-induced distal ischemia and low digital brachial indices (<60%) and were divided into a mild (Grade I-IIa) and a severe hemodialysis access-induced distal ischemia (IIb-IV) group. The control group consisted of hemodialysis patients without signs of hemodialysis access-induced distal ischemia with digital brachial indices ≥60%. Factors potentially related to 4-year survival were analyzed. RESULTS: Mild hemodialysis access-induced distal ischemia-patients displayed higher digital brachial indices (n = 23, 41%, ±3) compared with severe hemodialysis access-induced distal ischemia-patients (n = 28, 24%, ±4), whereas controls had the highest values (n = 48, 80%, ±2; p < .001). A total of 44 patients (44%) died during follow-up. Digital brachial index (hazards ratio 0.989 [0.979-1.000] p = .046) was related to overall mortality following correction for presence of arterial occlusive disease (hazards ratio 2.28 [1.22-4.29], diabetes (hazards ratio 2.00 [1.07-3.72], and increasing age (hazards ratio 1.03 [1.01-1.06] as was digital pressure (hazards ratio 0.990 [0.983-0.998], p = .011). Overall survival was similar in mild hemodialysis access-induced distal ischemia and controls (2-year, 79% ±5; 4-year, 57% ±6, p = .818). In contrast, 4-year survival was >20% lower in patients with severe hemodialysis access-induced distal ischemia (2-year 62%± 10; 4-year 34% ± 10; p = .026). CONCLUSION: Presence of severe hemodialysis access-induced distal ischemia may be associated with poorer survival in hemodialysis patients. Lower digital brachial index values are associated with higher overall mortality, even following correction for other known risk factors.

Diagnostic accuracy of automated oscillometric determination of the ankle-brachial index in peripheral artery disease.

OBJECTIVE: Peripheral artery disease (PAD) is underdiagnosed in primary care settings, partly because of limited accuracy of the Doppler ankle-brachial index (ABI). This study aimed to assess the diagnostic accuracy of an automated oscillometric ABI device compared with reference standard vascular laboratory Doppler ABI equipment and to examine the influence of oscillometric errors on performance. METHODS: Consecutive patients who were referred to a large general hospital for an ABI measurement were invited to participate. In each patient, the oscillometric analysis was followed by the Doppler analysis. Legs with incompressible ankle arteries were excluded from analysis. ABI values were compared using the Bland-Altman method. Oscillometric errors were defined as the incapacity of the oscillometer to report a value of ABI. A receiver operating characteristic curve was constructed, and the area under the curve was computed. RESULTS: A total of 201 patients participated. The Bland-Altman plot showed a mean difference of 0.05 ± 0.12 (limits of agreement, -0.20 to 0.29), representing a small ABI overestimation after oscillometry. Oscillometric errors occurred more commonly in limbs with PAD than in limbs without PAD (28% and 7%, respectively; P < .001). Considering a 0.9 threshold and after oscillometric error exclusion, the oscillometric ABI showed a 74% sensitivity and a 97% specificity for a diagnosis of PAD. When oscillometric errors were considered as abnormal ABIs, sensitivity increased to 86% and specificity was maintained at 95%. The receiver operating characteristic curve showed an area under the curve of 0.96. The best oscillometric ABI cutoff point was 1.00. Using this threshold and when considering oscillometric errors as abnormal ABIs, sensitivity improved to 94% while maintaining specificity at 92%. CONCLUSIONS: Oscillometric ABI showed good diagnostic accuracy compared with the reference standard. However, the high incidence of oscillometric errors and the challenges to correctly interpret readings may limit the use of the oscillometric method in PAD diagnosis.