Disease understanding in patients with intermittent claudication: A qualitative study.

The aim of our qualitative study was to investigate the understanding of patients with intermittent claudication (IC) regarding the etiology and atherosclerotic nature of their disease. Patients were recruited from participants of the SUPER study, a randomized trial comparing angioplasty and supervised exercise therapy for alleviation of IC owing to an iliac artery obstruction. Patients were submitted to explorative, semistructured, in-depth interviews that were fully transcribed, coded, and categorized. We interviewed 19 patients. The majority of respondents (79%) recognized smoking as a major risk factor contributing to the etiology of IC. However, nearly one-half (47%) underestimated the effects of unhealthy dietary and exercise patterns. In contrast, a substantial number of respondents (42%) overestimated the contribution of genetics to the etiology of their disease. Most respondents (79%) were unaware of the fact that IC implies systemic atherosclerosis.This study shows that the patients' interpretation of the etiology and nature of IC was mostly incorrect. Therefore, we suggest that health care providers enhance counseling about etiologic factors and the systemic nature of IC to optimize outcomes of lifestyle adjustments.

Introducing the Concept of the Minimally Important Difference to Determine a Clinically Relevant Change on Patient-Reported Outcome Measures in Patients with Intermittent Claudication.

PURPOSE: The minimally important difference (MID) represents the smallest change in score on patient-reported outcome measures that is relevant to patients. The aim of this study was to introduce the MID for the Vascular Quality of Life Questionnaire (VascuQol) and the walking impairment questionnaire (WIQ) for patients with intermittent claudication (IC). METHODS: In this multicenter study, we recruited 294 patients with IC between July and October 2012. Patients completed the VascuQol, with scores ranging from 1 to 7 (worst to best), and the WIQ, with scores ranging from 0 to 1 (worst to best) at first visit and after 4 months follow-up. In addition, patients answered an anchor-question rating their health status compared to baseline, as being improved, unchanged, or deteriorated. The MID for improvement and deterioration was calculated by an anchor-based approach, and determined with the upper and lower limits of the 95 % confidence interval of the mean change of the group who had not changed according to the anchor-question. RESULTS: For the MID analyses of the VascuQol and WIQ, 163 and 134 patients were included, respectively. The MID values for the VascuQol (mean baseline score 4.25) were 0.87 for improvement and 0.23 for deterioration. For the WIQ (mean baseline score 0.39), we found MID values of 0.11 and -0.03 for improvement and deterioration, respectively. CONCLUSION: In this study, we calculated the MID for the VascuQol and the WIQ. Applying these MID facilitates better interpretation of treatment outcomes and can help to set treatment goals for individual care.

Outcomes of infrainguinal revascularizations with endovascular first strategy in critical limb ischemia.

PURPOSE: This study was designed to study the outcome of infrainguinal revascularization in patients with critical limb ischemia (CLI) in an institution with a preference towards endovascular intervention first in patients with poor condition, unfavourable anatomy for surgery, no venous material for bypass, and old age. METHODS: A prospective, observational cohort study was conducted between May 2007 and May 2010 in patients presenting with CLI. At baseline, the optimal treatment was selected, i.e., endovascular or surgical treatment. In case of uncertainty about the preferred treatment, a multidisciplinary team (MDT) was consulted. Primary endpoints were quality of life and functional status 6 and 12 months after initial intervention, assessed by the VascuQol and AMC Linear Disability Score questionnaires, respectively. RESULTS: In total, 113 patients were included; 86 had an endovascular intervention and 27 had surgery. During follow-up, 41 % underwent an additional ipsilateral revascularisation procedure. For the total population, and endovascular and surgery subgroups, the VascuQol sum scores improved after 6 and 12 months (p < 0.01 for all outcomes) compared with baseline. The functional status improved (p = 0.043) after 12 months compared with baseline for the total population. Functional status of the surgery subgroup improved significantly after 6 (p = 0.031) and 12 (p = 0.044) months, but not that of the endovascular subgroup. CONCLUSIONS: Overall, the strategy of performing endovascular treatment first in patients with poor condition, unfavourable anatomy for surgery, no venous material for bypass, and old age has comparable or even slightly better results compared with the BASIL trial and other cohort studies. All vascular groups should discuss whether their treatment strategy should be directed at treating CLI patients preferably endovascular first and consider implementing an MDT to optimize patient outcomes.

Appendico-cutaneous fistula 20 years after groin hernia repair with a polypropylene plug.

The formation of an appendico-cutaneous fistula is rare. Few case reports have been published; most describe the formation of a fistula after appendicitis. Here we describe the case of a 79-year-old woman presenting with an appendico-cutaneous fistula after groin hernia repair. She was referred to our outpatient department with a painful mass in the right groin. An ultrasound showed a fluid containing mass. Incision and drainage was performed. After 9 weeks she was referred again with a persisting open wound. Fistulogram and CT scan showed a fistuleous tract involving the appendix. Wound culture showed Escherichia coli. Diagnostic laparoscopy showed an appendix stuck to the ventral wall of the abdomen without any sign of previous infection. After an appendectomy, pathological investigation revealed an appendix sana. After operation, the fistula persisted due to a polypropylene plug from the previous groin hernia correction. The (infected) plug was removed and the fistula healed.

Pregnancy in chronic kidney disease: need for a common language.

INTRODUCTION: Chronic kidney disease (CKD) is a growing health care problem, affecting 3% of women of childbearing age. AIM: This study attempted to systematically review the literature for 2000-2009 on pregnancy in CKD, as a guide for counseling. METHODS: Data sources included a Medline search for 2000-2009, employing MESH and free terms on pregnancy and CKD, limited to humans and English-language publications. Only studies observing at least 25 pregnancies were considered. The bibliographic search, abstract screening and data extraction were performed in duplicate. Out of over 3,000 references and 276 full texts, 23 studies fulfilled the selection criteria; 3 were added from references. RESULTS: The 26 studies reported on over 2,000 pregnancies. Five main categories were identified: CKD (399 pregnancies, excluding 2 population studies), lupus nephropathy (431 pregnancies), diabetic nephropathy (386 pregnancies), hematuria (310 pregnancies), kidney donors (586 pregnancies) and other. Definitions of diseases, outcomes and stratifications were nonhomogeneous, thus impairing meta-analytic pooling and quantification of the risks. Within these limits, 3 major qualitative determinants of outcome were confirmed as relevant in all subsets: CKD stage, hypertension and proteinuria. Their combination may multiply the interrelated major risks (for the mother: preeclampsia, renal function impairment and proteinuria; for the offspring: small babies, prematurity, death). Specifically, mothers with lupus nephritis have a relevant risk of death (1.15%), and share with diabetic nephropathy, the risk for perinatal death (up to 23% in lupus, 10% in diabetes). Malformations were not increased, except for urinary tract malformation in reflux nephropathy. CONCLUSIONS: There is a strong need to unify definitions and stratifications to allow quantitative evidence-based counseling for pregnant patients with CKD.

Pregnancy and chronic kidney disease: a challenge in all CKD stages.

BACKGROUND AND OBJECTIVES: Chronic kidney disease (CKD) is a challenge for pregnancy. Its recent classification underlines the importance of its early phases. This study's aim was to evaluate outcomes of pregnancy according to CKD stage versus low-risk pregnancies followed in the same center. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: The prospective analysis was conducted from January 2000 to May 2009 with the start of observation at referral and end of observation 1 month after delivery. Ninety-one singleton deliveries were studied; 267 "low-risk" singleton pregnancies served as controls. Because of the lack of hard end points (death, start of dialysis), surrogate end points were analyzed (cesarean section, prematurity, neonatal intensive care). RESULTS: CKD outcome was worse than physiologic pregnancies: preterm delivery (44% versus 5%); cesarean section (44% versus 25%); and need for neonatal intensive care (26% versus 1%). The differences were highly significant in stage 1 CKD (61 cases) versus controls (CKD stage 1: cesarean sections = 57%, preterm delivery = 33%, intensive care = 18%). In CKD, proteinuria and hypertension were correlated with outcomes [proteinuria dichotomized at 1 g/24 h at referral: need for intensive care, relative risk (RR) = 4.16 (1.05 to 16.46); hypertension: preterm delivery, RR = 7.24 (2.30 to 22.79); cesarean section, RR = 5.70 (1.69 to 19.24)]. Statistical significance across stages was reached for preterm delivery [RR = 3.32 (1.09 to 10.13)]. CONCLUSIONS: CKD is a challenge for pregnancy from early stages. Strict follow-up is needed for CKD patients, even when there is normal renal function.

Pregnancy in dialysis patients: is the evidence strong enough to lead us to change our counseling policy?

BACKGROUND AND OBJECTIVES: Although successful pregnancy is rare, results attained with higher dialysis efficiency and the spread of dialysis to different cultural and religious settings are changing the panorama. In this study, we systematically review the recent literature (2000 through 2008) on pregnancy in dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Medline on OVID was searched in November 2008, with MESH and free terms on pregnancy and chronic kidney disease or dialysis; limits were human subjects and English-language articles. Case reports were excluded to minimize publication bias. The final selection and extraction of data were performed in duplicate. RESULTS: From 2840 references, 241 full-text articles were retrieved; eight fulfilled the selection criteria, and two were added from reference lists. In the 10 studies (nine of 10 monocentric), 90 pregnancies were observed in 78 patients (range of cases five to 15). The studies were heterogeneous for definition of outcomes, duration (2 to 16 yr), period (1988 through 1998 to 2000 through 2006), age (25 to 35 yr), and support and dialysis therapy. Daily dialysis was frequently used; type of treatment, membranes, and flows varied widely. Hypertension and anemia were frequent concerns for the mothers. Intrauterine deaths, hydramnios, and small-for-gestational-age or preterm infants were frequent. The possibility of a healthy offspring ranged from 50 to 100% (overall 76.25%). CONCLUSIONS: Evidence on pregnancy in dialysis is heterogeneous; however, the growing number of reports worldwide and the improving results suggest that we should reconsider our counseling policy, which only rarely includes pregnancy in dialysis patients.