Mesenteric vascular disease: A population-based cohort study.

OBJECTIVES: Mesenteric vascular disease carries a high risk of mortality and morbidity; however, due to obscure clinical presentation, it can be under-recognized. Currently, epidemiology of mesenteric vascular disease remains poorly defined. The aim of this study is to analyze changes in Scottish mortality rates from mesenteric vascular disease overtime. METHODS: This is a retrospective, longitudinal population-based cohort study using data extracted from death certificates and Scottish Index of Multiple Deprivation. All deaths related to a vascular disorder of the intestines recorded as an underlying cause of death between 1979 and 2014 were identified using International Classification of Disease-9 or International Classification of Disease-10 code groups. Data included demographics and location of death. The residence postcodes were used to classify socio-economic status using the Scottish Index of Multiple Deprivation. RESULTS: From 2,142,921 deaths over 36 years, 14,530 (0.7%) were due to mesenteric vascular disease with a median (interquartile range) age of 77 and a 2:1 female to male gender ratio. The mean ± standard deviation age significantly increased from 72.6 ± 12.1 in 1979 to 76.8 ± 11.1 in 2014 (p < 0.001, R2 = 0.772). Males were consistently younger than females at the time of death. The two lowest Scottish Index of Multiple Deprivation categories accounted for half of the cohort, throughout the study period (p = 0.068). The adjusted death rate per 100,000 population increased from 7.6 in 1979 to 12.1 in 2014. CONCLUSIONS: The reported death rates of mesenteric vascular disease in Scotland between 1979 and 2014 have nearly doubled. Mesenteric vascular disease affects twice as many women as men and is associated with social deprivation. The increased reporting of mesenteric vascular disease is likely due to increased recognition and incidence. These implications should be considered when planning healthcare provision in Scotland.

Exercise therapy in routine management of peripheral arterial disease and intermittent claudication: a scoping review.

BACKGROUND: Little is known about the extent to which routine care management of peripheral arterial disease (PAD) and intermittent claudication (IC) align with best practice recommendations on exercise therapy. We conducted a scoping review to examine the published literature on the availability and workings of exercise therapy in the routine management of patients with PAD and IC, and the attitude and practice of health professionals and patients. METHODS: A systematic search was conducted in February 2018. The Cumulative Index of Nursing and Allied Health Literature, Ovid MEDLINE, Allied and Complementary Medicine Database, ScienceDirect, Web of Science and the Directory of Open Access Repositories were searched. Hand searching of reference lists of identified studies was also performed. Inclusion criteria were based on study aim, and included studies that reported on the perceptions, practices, and workings of routine exercise programs for patients with IC, their availability, access, and perceived barriers. RESULTS: Eight studies met the eligibility criteria and were included in the review. Studies conducted within Europe were included. Findings indicated that vascular surgeons in parts of Europe generally recognize supervised exercise therapy as a best practice treatment for IC, but do not often refer their patients for supervised exercise therapy due to the unavailability of, or lack of access to supervised exercise therapy programs. Available supervised exercise therapy programs do not implement best practice recommendations, and in the majority, patients only undergo one session per week. Some challenges were cited as the cause of the suboptimal program implementation. These included issues related to patients' engagement and adherence as well as resource constraints. CONCLUSION: There is a dearth of published research on exercise therapy in the routine management of PAD and IC. Available data from a few countries within Europe indicated that supervised exercise is underutilized despite health professionals recognizing the benefits. Research is needed to understand how to improve the availability, access, uptake, and adherence to the best exercise recommendations in the routine management of people with PAD and IC.

Efficacy and Feasibility of Pain management and Patient Education for Physical Activity in Intermittent claudication (PrEPAID): protocol for a randomised controlled trial.

BACKGROUND: Physical activity (PA) improves functional capacity and quality of life and provides secondary prevention benefits in individuals with peripheral arterial disease (PAD) and intermittent claudication (IC). However, pain and patient lack of knowledge are key barriers to the uptake of, and adherence to, PA recommendations. This trial will test the efficacy and feasibility of a non-invasive pain management intervention with and without patient education to improve PA in individuals with PAD and IC. METHODS: This is a randomised, controlled assessor-blinded feasibility trial with four parallel groups. Eighty adults with PAD and IC will be randomly assigned 1:1:1:1 to Active TENS (transcutaneous electrical nerve stimulation), Placebo TENS, Active TENS + Patient education or Placebo TENS + Patient education groups. All groups will continue to receive usual care over the intervention period. Participants randomised to Active TENS will receive a TENS device (preset at 120 Hz, 200 µs) and will be instructed to use the device daily at home or elsewhere for 6 weeks with a patient-determined intensity of "strong but comfortable". Placebo TENS group participants will receive the same model of TENS device and instructions for use as those in the active group, except that the stimulation dose will be safely altered to produce non-therapeutic, ineffective stimulation. Participants randomised to patient education will receive a one-off 3-h workshop of structured group education (four to five persons in each group) and three sets of twice-weekly phone calls. Efficacy outcomes will be assessed at baseline, after 6 weeks of intervention and at 3 months follow-up. Absolute claudication distance using the Gardner treadmill protocol will be assessed as the primary outcome. Secondary outcomes will assess initial claudication distance, daily PA and patient-reported outcomes including quality of life, pain self-efficacy, depression, disease perception and walking impairment pain intensity and quality. Feasibility outcomes will assess rates of recruitment, retention and adherence. Focus groups with participants at the end of the trial will explore the acceptability of the interventions. DISCUSSION: This trial will determine the efficacy and feasibility of using a low-cost, CE-marked non-invasive pain management modality delivered with or without a patient-centred education intervention to improve PA in individuals with PAD and IC. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03204825 . Registered on 2 July 2017.

The Influence of Socio-economic Deprivation on Mobility, Participation, and Quality of Life Following Major Lower Extremity Amputation in the West of Scotland.

OBJECTIVE: Lower extremity amputation (LEA) is more common in people from lower socio-economic groups. This study examined this further by investigating the influence of socio-economic status on mobility, participation, and quality of life (QoL) after LEA. METHODS: Prospective data were gathered for all LEAs performed in one year in one Scottish Health Board, commencing March 2014. A postcode derived Scottish Index of Multiple Deprivation (SIMD) was applied by quintile (SIMD 1 = most deprived). Routine data were collected on the cohort of 171 patients; 101 participants consented and received postal questionnaires on QoL (EQ-5D-5L), participation (Reintegration to Normal Living Index [RNLI]), and mobility (Prosthetic Limb User Survey of Mobility), six (n = 67) and 12 months (n = 50) after LEA. RESULTS: The mean ± SD age of the cohort was 66.2 ± 11.4 years; 75% were male and 53% had diabetes. In total, 67% lived in SIMD 1 and 2 and 11.1% in SIMD 5. Sixty per cent had a transtibial amputation. Mortality was 6% at 30 days 17% at six, and 29% at 12 months. Those in SIMD 1 were significantly younger (62.9 years) than those in SIMD 5 (76.3 years). Significantly more participants with a transfemoral amputation (TFA) lived in SIMD 1 (44%) compared with SIMD 5 (11%) (p = .004). Participation was low (RNLI scores: 6 months = 55.7; 12 months = 56.6) and PLUS M scores suggested mobility was poor overall at six (39.1) and 12 months (38.9). Mean QoL was 0.37 at 6 months and 0.33 at 12 months. CONCLUSION: Although this study observed more LEAs in those from low socio-economic areas, it is impossible to conclude whether QoL after LEA is truly influenced by socio-economic status. There was an association between the disproportionately high rate of LEAs in SIMD groups 1 and 2 and the high prevalence of smoking, 61% vs. only 21% of those in the least deprived areas (SIMD 3, 4, and 5) being current smokers.

Peroneal artery entrapment syndrome (PRAES): a rare cause of ischaemic toes.

A 75-year-old man presenting with intermittent discolouration of his left toes was referred to vascular surgery with suspicion of embolic vascular disease. A contrast-enhanced MR angiogram was performed which revealed bilateral dominant peroneal arteries (PRAs). There was evidence of short atherosclerotic stenosis directly at the point where the left PRA passes through the tibiofibular interosseous membrane which we postulate to be the source of the emboli. We present what is believed to be the first reported case of PRA entrapment complicated by distal toe emboli.

Barriers and enablers to walking in individuals with intermittent claudication: A systematic review to conceptualize a relevant and patient-centered program.

BACKGROUND: Walking limitation in patients with peripheral arterial disease (PAD) and intermittent claudication (IC) contributes to poorer disease outcomes. Identifying and examining barriers to walking may be an important step in developing a comprehensive patient-centered self-management intervention to promote walking in this population. AIM: To systematically review the literature regarding barriers and enablers to walking exercise in individuals with IC. METHODS: A systematic review was conducted utilizing integrative review methodology. Five electronic databases and the reference lists of relevant studies were searched. Findings were categorized into personal, walking activity related, and environmental barriers and enablers using a social cognitive framework. RESULTS: Eighteen studies including quantitative (n = 12), qualitative (n = 5), and mixed method (n = 1) designs, and reporting data from a total of 4376 patients with IC, were included in the review. The most frequently reported barriers to engaging in walking were comorbid health concerns, walking induced pain, lack of knowledge (e.g. about the disease pathology and walking recommendations), and poor walking capacity. The most frequently reported enablers were cognitive coping strategies, good support systems, and receiving specific instructions to walk. Findings suggest additionally that wider behavioral and environmental obstacles should be addressed in a patient-centered self-management intervention. CONCLUSIONS: This review has identified multidimensional factors influencing walking in patients with IC. Within the social cognitive framework, these factors fall within patient level factors (e.g. comorbid health concerns), walking related factors (e.g. claudication pain), and environmental factors (e.g. support systems). These factors are worth considering when developing self-management interventions to increase walking in patients with IC. Systematic review registration CRD42018070418.

Changes in the demographics of intravenous drug users with mycotic common femoral artery pseudoaneurysm as a consequence of self-injection does not influence outcome following emergency ligation.

Objectives The reported annual incidence of mycotic pseudoaneurysm of the common femoral artery in intravenous drug users has been estimated at 0.03%. Over the past 5 years in Scotland, the proportion of people receiving specialist attention for heroin use over the age of 40 years has increased from 15 to 22%. Although routinely managed with arterial ligation (without reconstruction), some series have reported rates of major limb amputation of up to 10%. We sought to define whether this management strategy was still acceptable in an older population. Methods Retrospective review of patients presenting to a tertiary vascular service with mycotic pseudoaneurysm of the common femoral artery due to arterial injection by intravenous drug users between October 2010 and March 2016. Variables of interest included patient demographics and requirement for major amputation. Results There were 55 patients identified. The annual incidence of mycotic pseudoaneurysm of the common femoral artery in intravenous drug users was 2.1%. It was more common in men (3:1) and the mean age at presentation was 41 years (standard deviation ± 8 years). Three patients underwent major limb amputation during the index admission for severe limb ischaemia (two transfemoral amputations; one hip-disarticulation). Following discharge two patients were readmitted (134 and 200 days, respectively, following primary ligation) for major limb amputation due to of critical limb ischaemia. Conclusions Despite the increasing age of intravenous drug users presenting with mycotic pseudoaneurysm of the common femoral artery primary ligation of pseudoaneurysm would seem to remain an appropriate therapeutic intervention.

The impact of gender, level of amputation and diabetes on prosthetic fit rates following major lower extremity amputation.

BACKGROUND: Diabetes mellitus is a leading cause of major lower extremity amputation. OBJECTIVE: To examine the influence of gender, level of amputation and diabetes mellitus status on being fit with a prosthetic limb following lower extremity amputation for peripheral arterial disease. STUDY DESIGN: Retrospective analysis of the Scottish Physiotherapy Amputee Research Group dataset. RESULTS: Within the cohort with peripheral arterial disease ( n = 1735), 64% were men ( n = 1112) and 48% ( n = 834) had diabetes mellitus. Those with diabetes mellitus were younger than those without: mean 67.5 and 71.1 years, respectively ( p < 0.001). Trans-tibial amputation:trans-femoral amputation ratio was 2.33 in those with diabetes mellitus, and 0.93 in those without. A total of 41% of those with diabetes mellitus were successfully fit with a prosthetic limb compared to 38% of those without diabetes mellitus. Male gender positively predicted fitting with a prosthetic limb at both trans-tibial amputation ( p = 0.001) and trans-femoral amputation ( p = 0.001) levels. Bilateral amputations and increasing age were negative predictors of fitting with a prosthetic limb ( p < 0.001). Diabetes mellitus negatively predicted fitting with a prosthetic limb at trans-femoral amputation level ( p < 0.001). Mortality was 17% for the cohort, 22% when the amputation was at trans-femoral amputation level. CONCLUSION: Of those with lower extremity amputation as a result of peripheral arterial disease, those with diabetes mellitus were younger, and more had trans-tibial amputation. Although both age and amputation level are good predictors of fitting with a prosthetic limb, successful limb fit rates were no better than those without diabetes mellitus. Clinical relevance This is of clinical relevance to those who are involved in the decision-making process of prosthetic fitting following major amputation for dysvascular and diabetes aetiologies.

MRI using ultrasmall superparamagnetic particles of iron oxide in patients under surveillance for abdominal aortic aneurysms to predict rupture or surgical repair: MRI for abdominal aortic aneurysms to predict rupture or surgery-the MA(3)RS study.

INTRODUCTION: Population screening for abdominal aortic aneurysms (AAA) halves the associated mortality and has led to the establishment of national screening programmes. Prediction of aneurysm growth and rupture is challenging and currently relies on serial diameter measurements with ultrasound. Recently, a novel MRI-based technique using ultrasmall superparamagnetic particles of iron oxide (USPIO) has demonstrated considerable promise as a method of identifying aneurysm inflammation and expansion. METHODS AND ANALYSIS: The MA(3)RS study is a prospective observational multicentre cohort study of 350 patients with AAA in three centres across Scotland. All participants will undergo MRI with USPIO and aneurysm expansion will be measured over 2 years with CT in addition to standard clinical ultrasound surveillance. The relationship between mural USPIO uptake and subsequent clinical outcomes, including expansion, rupture and repair, will be evaluated and used to determine whether the technique augments standard risk prediction markers. To ensure adequate sensitivity to answer the primary question, we need to observe 130 events (composite of rupture or repair) with an estimated event rate of 41% over 2 years of follow-up. The MA(3)RS study is currently recruiting and expects to report in 2017. DISCUSSION: This is the first study to evaluate the use of USPIO-enhanced MRI to provide additional information to aid risk prediction models in patients with AAA. If successful, this study will lay the foundation for a large randomised controlled trial targeted at applying this technique to determine clinical management. TRIAL REGISTRATION NUMBER: Current Controlled Trials: ISRCTN76413758.

Using centrally held data to validate carotid surgery outcome data.

BACKGROUND AND PURPOSE: Outcome audit data for peer group comparison must be transparent, objective, and independently reproducible. Personal data sets are difficult to maintain and often lack complete follow-up. Local coding difficulties make initial retrieval of centrally held data unreliable. However starting with a complete list of interventions, reliable identification of patients who have experienced an adverse postoperative event may be possible using record linkages. METHODS: A surgical database, augmented by a hand-search of all theater registries and personal logbooks, identified 378 carotid endarterectomies performed for stroke prevention in symptomatic patients, in a single hospital between 2002 and 2009. A list of the names, unique patient identifiers, and operation dates was sent to the Information Services Division of National Health Service Scotland. Data were requested pertaining to all deaths and potential diagnoses of stroke after surgery. Every identified case was scrutinized. RESULTS: There were 30 (8%) readmissions or transfers of care identified within 30 days of surgery. From this, 12 strokes were identified with another 2 strokes, occurring without readmission, diagnosed in the outpatient clinic. Only 6 of the postoperative strokes were identified during the index admission. There were 2 early deaths resulting in a combined stroke and death rate of 4.2% (95% confidence intervals, 2.4%-6.9%). CONCLUSIONS: These outcome data are similar to the outcomes of the major carotid surgery trials. Record-linked data retrieval seems to be an appropriate starting point for outcome-based audit. This has the potential to generate robust, transparent data for comparison between individuals and centers for a specific procedure.