Few UK vascular centres offer a fully NICE-compliant supervised exercise programme: a national audit.

INTRODUCTION: To determine the current (pre-COVID-19) provision of supervised exercise training (SET) for patients with peripheral arterial disease (PAD) in UK Vascular Centres. METHODS: Hospital Trusts delivering vascular care to patients with PAD were identified from the National Vascular Registry and asked to complete an online questionnaire on their provisions for SET. If a centre offered SET, they were asked questions to determine whether the programme was compliant with NICE guidelines and the difficulties they faced delivering the service. If centres did not offer SET, they were asked what obstacles prevented them implement SET. RESULTS: Of the 78 UK vascular centres, 59 (76%) responded and were included in the audit. Of these, 27 (46%) were able to offer SET but only 21 (36%) could offer it to all their patients with PAD. Only four (6.8%) offered SET that was fully compliant with current NICE guidelines. Reasons identified included insufficient funding, lack of resource and poor patient compliance. CONCLUSIONS: The benefits of SET are well established yet the availability of the service in the UK is poor. The reasons for this are readily identified but have not yet been overcome. Research on novel methods of delivering supervised exercise that mitigates existing barriers, such as home exercise with remote monitoring, should be prioritised to facilitate optimal management for our patients with PAD.

A qualitative study exploring individuals' experiences living with dysvascular lower limb amputation.

PURPOSE: The majority of lower extremity amputations (LEAs) are the result of diabetes or peripheral vascular disease. There is a paucity of literature on individuals' experiences living with dysvascular LEAs in the community, particularly in Canada. The purpose of this study was to explore the perceptions and experiences of community-dwelling adults living with dysvascular LEA. METHODS: Semi-structured qualitative interviews were conducted with individuals with a dysvascular LEA recruited from three rehabilitation hospitals. Participants were included if they were English-speaking adults at least three months post-amputation and no longer receiving inpatient rehabilitation. Sampling was purposive to ensure variation by gender, level of amputation, and geographic location. Data were analyzed using an inductive content-analysis approach. RESULTS: Thirty-five interviews were completed with individuals with dysvascular LEA. Study participants portrayed LEA as having an impact on many aspects of their lives, resulting in changes in their mobility, social activities and roles, and psychological wellbeing. Three main factors shaped individuals' experiences with dysvascular LEA including social support, accessibility, and socioeconomic factors. CONCLUSION: Our findings highlight the impacts of dysvascular LEA in peoples' lives. Future research is warranted to explore how community-based interventions and strategies can address the ongoing needs of individuals with dysvascular LEA.Implications for rehabilitationOur findings highlight the long-term impacts of dysvascular lower extremity amputations, which resulted in changes in mobility, social activities and roles, and psychological wellbeing.Participants identified issues in access to community services and resources, including rehabilitation.Mechanisms to identify people at risk for social isolation need to be developed and implemented in rehabilitation centers.Access to ongoing rehabilitation services in the community are needed to optimize mobility outcomes and address ongoing psychological needs.

The effect of a home exercise intervention on persons with lower limb amputations: a randomized controlled trial.

OBJECTIVE: To establish if a home-based exercise and education programme is more effective than usual treatment in improving function, mobility and quality of life in people with lower limb amputation due to peripheral vascular disease. METHOD: A blocked randomized single-blinded controlled trial (RCT) with 154 participants (54 female; mean age 58) compared a home-based exercise and education programme (n = 77) with usual care (control) (n = 77). Participants were measured at baseline, immediately post intervention at three months, and after a further three months without any intervention. The outcome measures were the Barthel Index, Participation Scale, EuroQuol 5D, Modified Locomotor Capability Index and Timed Up and Go Test. Changes over time were established using generalized estimating equations and analysis of covariance, (P < 0.05). RESULTS: The Participation Scale (18.73 ± 14.91 against 26.67 ± 19.14; P = 0.011), the EuroQuol5D visual analogue scale (69.10 ± 20.31 against 55.37 ± 27.67; P = 0.003), EuroQuol5D utility index (0.672 ± 0.300 against 0.532 ± 0.358; P = 0.25) and the Modified Capability Index (21.03 ± 15.79 against 15.91 ± 13.67; P = 0.034) improved in the intervention group compared with the control group at three months. At six months, there was no difference between the groups in any of the measures except for the EuroQuol5D visual analogue scale (74.52 ± 16.14 against 66.34 ± 22.91; P = 0.033). Although there were no differences between the Timed Up and Go test at 3 (35.39 ± 32.48 against 45.08 ± 41.52; P = 0.192) and six months (28.22 ± 20.96 against 36.08 ± 36.19; P = 0.189) between the groups the intervention group was more mobile. CONCLUSION: This intervention improved function, mobility and quality of life in persons following lower limb amputation in the first three months post amputation.

Conocimiento del cardiólogo sobre el fisioterapeuta y retos al remitir pacientes con enfermedad arterial periférica en Puerto Rico / Cardiologist's knowledge of the physiotherapy and the challenges of referring patients with peripheral arterial disease in Puerto Rico

Objetivos: Esta investigación buscaba explorar el conocimiento que tiene el cardiólogo sobre el papel del fisioterapeuta en el manejo de pacientes con enfermedad arterial periférica (EAP), conocer los niveles de adherencia del médico a las guías de manejo y tratamiento de pacientes con EAP, determinar los retos que enfrenta para remitir pacientes con EAP al fisioterapeuta e identificar estrategias potenciales para promover el mismo. Métodos: La investigación fue realizada mediante un enfoque cuantitativo, utilizando un diseño transversal exploratorio, no experimental. Para abordar los objetivos planteados se construyó y validó un cuestionario, el cual fue administrado a 25 médicos con especialidad en cardiología (68%), cardiología intervencionista (14%) o cirugía vascular (18%). Los datos fueron analizados descriptivamente. Resultados: El conocimiento del médico cardiólogo sobre el papel del fisioterapeuta tanto en aspectos generales, como en la prevención y manejo de pacientes con EAP, fue de un 70%. El 62% de los médicos solo remiten hasta un 10% de sus pacientes con EAP a fisioterapia. Entre las barreras principales para remitir a estos pacientes se encuentra la poca cobertura por parte de las aseguradoras médicas y el alto costo de los servicios de rehabilitación. Conclusión: Educar a los cardiólogos sobre el alcance de la fisioterapia puede llevar a que se reconozca su efectividad. Las barreras encontradas pueden llegar a predisponer al paciente a futuras complicaciones. Aunque hay un desconocimiento sobre el fisioterapeuta, existe la disposición del médico a que se le eduque con el fin de utilizar todas las herramientas disponibles para el bienestar del paciente

Objectives: This study aims to determine the knowledge of the cardiologist of the physiotherapist (PT) role in the management of patients with peripheral arterial disease (PAD). It also set out to determine the levels of adherence of physicians to the clinical management and treatment guidelines of patients with PAD, as well as to determine the challenges the cardiologist faces when referring patients with PAD to the PT, and to identify potential strategies to promote it. Methods: This was a quantitative study, conducted using an exploratory cross-sectional, non-experimental design. To address the proposed objectives, a questionnaire was constructed and validated, which was administered to 25 physicians specialised in cardiology (68%), interventional cardiology (14%), or vascular surgery (18%). A descriptive analysis was performed on the data. Results: The level of physician's knowledge about the role of PT in general and in the prevention and management of patients with PAD was 70%, and 62% of physicians only refer up to 10% of their patients with PAD to the PT. Among the main barriers to referring these patients is the low coverage by health insurance providers, and the high cost of rehabilitation services. Conclusion: Educating cardiologists about the scope of physiotherapy can lead to recognition of its effectiveness. The barriers encountered may predispose the patient to future complications. Although there is a lack of knowledge about the PT, there is a physician's willingness to be educated in order to use all available tools for the patient's well-being

Implementation of a supervised exercise therapy programme.

INTRODUCTION: Guidelines for peripheral vascular disease state that supervised exercise therapy (SET) programmes improve walking distance and quality of life in patients with intermittent claudication. This paper outlines the steps needed to implement a successful SET programme and discusses some of the challenges. METHODS: Edinburgh Leisure was approached to coordinate an exercise programme aimed at rehabilitation, run by level 4 members of the Register of Exercise Professionals. It is estimated to be cost effective at 500 referrals compared with physiotherapy referral. Success is measured by walking distance, reduction of symptoms and weight loss. Edinburgh Leisure also measures success with feedback and membership numbers at its health centres. RESULTS: Between 4 March 2014 and 25 January 2016, 155 patients were referred to the SET programme with a median age of 68 years (range: 39-95 years) and a male-to-female ratio of 1.2:1. Of these, 117 patients attended and 29 have completed the programme. The mean walking distance increased from 298.5m (range: 150-385m) to 360m (range: 195-482m), an improvement of 20%. Increasing class numbers and venues, and introducing evening classes to make the programme accessible to more patients has addressed initial patient engagement issues. CONCLUSIONS: Collaboration with motivated local authorities can help implement a successful healthcare intervention. Early analysis is necessary to improve the system and engage as many patients as possible. The SET programme discussed has shown similar results to those of previous studies but is available at no personal cost to regional patients with intermittent claudication.

A prospective study of short-term functional outcome after dysvascular major lower limb amputation.

This study investigates functional status on Day 21 after dysvascular major lower limb amputation compared with one month pre-amputation and evaluates factors potentially influencing outcome. METHODS: A prospective cohort study design was used. Data were collected via in-person interviews using structured instruments and covered functional level (Barthel index 100) one month pre-amputation and on Day 21. Out of a consecutive sample of patients having major lower limb amputation (tibia, knee or femoral) (n = 105), 51 participated on Day 21 follow-up. Clinical, demographic, body function and environmental data were analysed as factors potentially influencing outcome. RESULTS: From pre-amputation to Day 21, participants' functional level decreased significantly in all ten activities of daily living activities as measured by the Barthel Index. Almost 60% of participants were independent in bed-chair transfer on Day 21. Being independent in transfer on Day 21 was positively associated with younger age and attending physiotherapy after discharge. CONCLUSIONS: The findings indicate that short-term functional outcome is modifiable by quality of the postoperative care provided and thus highlights the need for increased focus on postoperative care to maintain basic function as well as establish and provide everyday rehabilitation in the general population of patients who have dysvascular lower limb amputations.

Complicações cardíacas em cirurgia vascular / Cardiac complications in vascular surgery

CONTEXTO: Aproximadamente 60% dos pacientes portadores de doença arterial oclusiva crônica periférica têm doença coronariana grave, sendo que a principal causa de morte no pós-operatório de cirurgia vascular de grande porte é o infarto agudo do miocárdio. OBJETIVOS: Determinar a prevalência da doença coronariana em pacientes submetidos a cirurgia vascular eletiva de grande porte e sua relação com as complicações cardiológicas pós-operatórias. MÉTODOS: Foram analisados 200 pacientes submetidos a cirurgia vascular arterial eletiva: doença obstrutiva carotídea, aortoilíaca e femoropoplítea distal e doença aneurismática de aorta abdominal e de artérias ilíacas. Os pacientes constituíram três grupos: grupo I, sem doença coronariana; grupo II, com doença coronariana assintomática; e grupo III, com doença coronariana sintomática. As complicações cardiológicas consideradas foram infarto agudo do miocárdio fatal e não fatal, insuficiência cardíaca congestiva, choque cardiogênico, fibrilação atrial aguda e outras arritmias. RESULTADOS: Complicações cardíacas ocorreram em 11 pacientes (5,5%): três infartos agudos do miocárdio não fatais (1,5%) sempre em pacientes do grupo III. A complicação cardíaca mais frequente foi arritmia (exceto fibrilação atrial) ocorrida em cinco (2,5%) pacientes, sendo três do grupo II. A mortalidade precoce foi de nove pacientes (4,5%). Apenas uma morte foi decorrente de problema cardíaco: choque cardiogênico em paciente do grupo III. CONCLUSÕES: A doença coronariana não foi preditora de óbito nos pacientes submetidos a cirurgia vascular periférica de grande porte. A sobrevida dos pacientes com ou sem doença coronariana não mostrou diferenças estatísticas.

BACKGROUND: Approximately 60% of patients with chronic occlusive peripheral arterial disease have severe coronary disease and the principal cause of death during the postoperative period after major vascular surgery is acute myocardial infarction. OBJECTIVES: To determine the prevalence of coronary disease among patients scheduled for elective major vascular surgery and its relationship with postoperative cardiological complications. METHODS: A total of 200 patients who underwent elective vascular arterial surgery for obstructive carotid disease, aortoiliac and distal femoropopliteal disease and aneurysmal disease of the abdominal aorta and iliac arteries were analyzed. These patients were allocated to three groups: group I, free from coronary disease; group II, asymptomatic coronary disease; and group III, symptomatic coronary disease. The cardiological complications analyzed were fatal and nonfatal acute myocardial infarction, congestive heart failure, cardiogenic shock, acute atrial fibrillation and other arrhythmias. RESULTS: Cardiac complications occurred in 11 patients (5.5%): three nonfatal acute myocardial infarctions (1.5%), all in patients from group III. The most common cardiac complication was arrhythmia (excluding atrial fibrillation) in five (2.5%) patients, three from group II. Early mortality was nine patients (4.5%). Just one death was caused by a cardiac problem: cardiogenic shock in a patient from group III. CONCLUSIONS: Coronary disease was not predictive of death among patients who underwent major peripheral vascular surgery. There were no statistical differences in survival between patients with or without coronary disease.

Functional Outcomes After the Prosthetic Training Phase of Rehabilitation After Dysvascular Lower Extremity Amputation.

OBJECTIVE: To describe physical function outcomes and modes of physical therapy intervention for a cohort of patients with dysvascular lower extremity amputation (LEA) during the prosthetic training phase of rehabilitation. DESIGN: A retrospective cohort study. SETTING: Physical rehabilitation clinics at a Veterans Affairs medical center and a university hospital. PATIENTS: Forty-two patients (38 men, 4 women, age 60.2 ± 8.4 years) who completed outpatient physical therapy rehabilitation with prosthetic training after dysvascular LEA. METHODS: All patients underwent a prosthetic training phase of rehabilitation, with standardized outcome measures performed at initiation and discharge. MAIN OUTCOME MEASURES: Performance-based physical function measures included Two-Minute Walk (2 MW), Timed-Up and Go (TUG), and 5-meter gait speed. Self-report physical function measures included the Prosthesis Evaluation Questionnaire-Mobility Section (PEQ-MS) and the Patient-Specific Functional Scale. Rehabilitation dose was tracked as total number of clinic visits, rehabilitation duration, and specific intervention modes. RESULTS: There were significant improvements between initial and discharge values (mean ± SD) for the Two-Minute Walk (67.5 ± 29.9 m and 103.3 ± 45.8 m, respectively, P < .001), gait speed (0.58 ± 0.27 m/s and 0.88 ± 0.39 m/s, respectively, P < .001), TUG (34.8 ± 21.3 seconds and 18.6 ± 13.9 seconds, respectively, P < .001), PEQ-MS (2.2 ± 0.9 and 2.8 ± 0.8, respectively, P < .001), and Patient-Specific Functional Scale (3.2 ± 2.0 and 5.9 ± 2.3, respectively, P < .001). Performance-based (TUG) and self-report (PEQ-MS) changes in functional mobility from initial exam to discharge had low or no correlations with rehabilitation dose measures. The number of clinic visits was 12.7 ± 13.1 and rehabilitation duration was 13.7 ± 16.8 weeks. CONCLUSIONS: Significant improvements in performance-based and self-report measures of physical function occurred during the prosthetic training phase of physical rehabilitation after dysvascular major LEA. Despite improvements in function, gait speed, and TUG outcomes remained below clinically important thresholds, indicating patients were limited in community ambulation and at risk for falls. Lack of moderate or greater correlation between rehabilitation dose and outcome measures may indicate the need for more specific rehabilitation dose measures.

Effect of physical activity assessment on prognostication for peripheral artery disease and mortality.

OBJECTIVE: To examine whether a simple question about the performance of regular vigorous activity is associated with peripheral artery disease (PAD) and mortality. METHODS: A total of 1288 individuals undergoing nonemergency coronary angiography were assessed for participation in regular vigorous activity by questionnaire. Data on demographic characteristics, ankle-brachial indexes, and cardiovascular outcomes were prospectively collected. RESULTS: Compared with those who denied participation in regular vigorous activity, those who reported participation were less likely to have PAD (odds ratio, 0.58; 95% CI, 0.39-0.86), had higher ankle-brachial indexes, had better Walking Impairment Questionnaire scores (P<.001), and experienced reduced all-cause mortality rates (hazard ratio, 0.48; 95% CI, 0.31-0.74). When added to the Framingham Risk Score, the response improved the net reclassification index for all-cause (32.6%) and cardiovascular (32.0%) mortality. CONCLUSION: Among at-risk individuals, regular vigorous activity is associated with decreased PAD and all-cause mortality. Simple and readily available, a single yes/no query about participation in regular vigorous exercise could be used to improve risk stratification.

Mid- to long-term factors influencing functional status of people affected by lower-limb amputation associated with hemiparesis due to stroke.

PURPOSE: In people with lower-limb amputation and hemiparesis, prognostic factors of rehabilitation outcomes were investigated at hospital discharge. This study aims to identify which factors influence functional outcomes at mid- to long-term follow-up. METHODS: Follow-up observational study on forty-four people (68 ± 9 years old) with unilateral amputation for vascular disease, temporally preceding or following hemiparesis due to stroke (26 patients prior amputation; 18 patients prior stroke), was performed. Barthel Index (BI) and Locomotor Capabilities Index (LCI) scores were recorded at discharge from the rehabilitation hospital and 3.4 years later. Use of the prosthesis was also recorded. RESULTS: At the follow-up, BI and LCI scores had significantly decreased (10 and 13%, respectively). Contralaterality of the impairment was the main prognostic factor for reduced functional status (p = 0.025) and prosthesis abandonment (p = 0.028, OR = 4.4), especially for women (OR = 8). Severity of hemiparesis affected the BI score (p < 0.01) and level of amputation the LCI score (p < 0.01). CONCLUSIONS: At the light of the observed decrement of functional status after discharge, particular attention should be paid to the patients more exposed to the risk of worsening and/or prosthesis abandon, such as women with contralateral impairment. The results of this study may assist rehabilitation teams in performing a more specific and effective long-term rehabilitative interventions.

Exercise training and peripheral arterial disease.

Peripheral arterial disease (PAD) is a common vascular disease that reduces blood flow capacity to the legs of patients. PAD leads to exercise intolerance that can progress in severity to greatly limit mobility, and in advanced cases leads to frank ischemia with pain at rest. It is estimated that 12 to 15 million people in the United States are diagnosed with PAD, with a much larger population that is undiagnosed. The presence of PAD predicts a 50% to 1500% increase in morbidity and mortality, depending on severity. Treatment of patients with PAD is limited to modification of cardiovascular disease risk factors, pharmacological intervention, surgery, and exercise therapy. Extended exercise programs that involve walking approximately five times per week, at a significant intensity that requires frequent rest periods, are most significant. Preclinical studies and virtually all clinical trials demonstrate the benefits of exercise therapy, including improved walking tolerance, modified inflammatory/hemostatic markers, enhanced vasoresponsiveness, adaptations within the limb (angiogenesis, arteriogenesis, and mitochondrial synthesis) that enhance oxygen delivery and metabolic responses, potentially delayed progression of the disease, enhanced quality of life indices, and extended longevity. A synthesis is provided as to how these adaptations can develop in the context of our current state of knowledge and events known to be orchestrated by exercise. The benefits are so compelling that exercise prescription should be an essential option presented to patients with PAD in the absence of contraindications. Obviously, selecting for a lifestyle pattern that includes enhanced physical activity prior to the advance of PAD limitations is the most desirable and beneficial.

Tratamiento rehabilitador en la CADASIL: a propósito de un caso / Rehabilitation treatment in CADASIL disease. A case report

La arteriopatía autosómica dominante con infartos subcorticales y leucoencefalopatía (CADASIL) es una angiopatía con herencia autosómica dominante por mutación en el gen NOTCH3 del cromosoma 19. La enfermedad produce migraña con aura, alteraciones psiquiátricas, episodios isquémicos y déficit cognitivos. Su evolución es progresiva y escalonada. Su diagnóstico requiere confirmación detectando la mutación genética característica y/o cambios anatomopatológicos en la piel. El caso que se presenta es un varón de 63 años con cuadros neurológicos episódicos de hemiparesia izquierda y síndrome seudobulbar, con secuelas progresivas. En febrero de 2004 se le diagnosticó CADASIL con mutación G428A (Gys171Tyr) en el exón 4 del gen NOTCH3. Se pautó tratamiento de rehabilitación durante 3 meses utilizando técnicas de fisioterapia y terapia ocupacional. Al año el resultado del tratamiento ha sido satisfactorio. El curso progresivamente incapacitante y la ausencia de tratamiento etiológico hace fundamental un programa adecuado y multidisciplinario de rehabilitación(AU)

CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) is a dominant autosomal hereditary angiopathy produced by the mutation of NOCTH 3 gene in chromosome number 19. The symptoms of the disease include migraine with aurea, psychiatric problems, ischemic episodes and cognitive deficits. The typical course of CADASIL is slowly progressive. The diagnosis must be genetically confirmed through the detection of its characteristic mutations and/or some cutaneous pathological changes. We present the case of a 63-year-old man who suffered from episodic neurological deficits, left hemiparesis, pseudobulbar syndrome, and progressive sequelae. In February 2004, the diagnosis of CADASIL was reached, due to mutation G428A (Gys171Tyr) in exon number 4 of NOTCH 3 gene. Treatment was performed with physical and occupational therapy for 3 months. At one year of follow-up, the result was satisfactory. Due to the disabling and progressive outcome of the disease, and to the lack of etiological treatment, physical and occupational therapy are paramount to minimize its functional impact and sequelae(AU)

Determinants of postacute care discharge destination after dysvascular lower limb amputation.

OBJECTIVE: To examine the factors affecting postacute care discharge decisions among persons undergoing major lower limb amputations as a result of dysvascular causes. DESIGN: A population-based, multicenter prospective study. SETTING: Eighteen participating hospitals in Baltimore, Maryland, and Milwaukee, Wisconsin, served as the referral base for this study. PATIENTS: The study population consisted of patients aged 21 years or older who underwent a major (foot or higher level) lower limb amputation as a result of dysvascular causes. METHODS: Patients were identified and recruited during their acute hospital admission at one of the participating hospitals. Data were drawn from (1) acute care medical chart reviews; (2) surveys administered shortly after patients underwent amputation, while they were receiving acute care, that assessed their function the month before amputation and other demographic and social information; and (3) a 6-month follow-up telephone interview. MAIN OUTCOME MEASURES: The outcome of interest was the postacute discharge setting in which the initial rehabilitation services, if any, were delivered to the patient during the reference period of 6 months after index amputation surgery. Discharge to alternative postacute settings--inpatient rehabilitation facility (IRF), skilled nursing facility (SNF, reference category), and home--were contrasted with use of t- and χ(2) test statistics. A 3-category, multinominal logit model was used to examine the independent effects of sociodemographic, geographic, health, and amputation-related characteristics on the likelihood of discharge to alternative settings. RESULTS: A total of 348 patients consented to participate in the study, with an overall participation rate of 87.1%. One hundred ninety-two patients (55.2%) were discharged to an IRF, 73 (21%) were discharged to an SNF, and 83 (23.8%) were discharged directly home. The mean age of the sample was 63.7 years; the majority (59.2%) were men, and more than one quarter African Americans. More than half of those reporting were poor (income <$15,000/year). On average, patients had 5 co-morbidities, and nearly half had an amputation at the below-knee level. Discharge to an IRF (versus an SNF) was more likely in patients who were married, had greater cognitive functioning, had unilateral below-knee amputations, had Medicaid coverage, and were living in Milwaukee, Wisconsin. Patients were less likely to be discharged home (versus to an SNF) if they were older, unmarried, had a previous history of nursing home residence, and had more perioperative complications. Discharge destination was not affected by gender or race. CONCLUSION: Postacute care decisions largely appear to be made on the basis of medical and family support factors. The findings of this research provide a necessary first step in the challenging task of assessing and quantitatively modeling the long-term functional outcomes of persons who receive postacute care in alternative settings by allowing more optimal case mix adjustment for factors that simultaneously influence rehabilitation setting and outcomes.

Resistance training improves vasoreactivity in end-stage heart failure patients on inotropic support.

PURPOSE: Peripheral vascular abnormalities contribute to compromised functional status in heart failure (HF) patients. The purpose of the present study was to test whether the intervention of moderate-intensity, resistance training could improve peripheral vascular responsiveness, that is, flow-mediated dilation (FMD) in HF. METHODS: Baseline brachial artery FMD analysis (2 minutes of cuff occlusion and 5 minutes of reperfusion) was measured in HF patients on intravenous inotropic support (n = 9) awaiting cardiac transplantation. Unilateral, upper-body resistance exercises (moderate intensity, combination of isometric and isotonic exercises at 60%-80% of maximum) were performed 3 d/wk for 4 weeks. Follow-up FMD analysis was conducted after training. Central hemodynamics were defined via right-side-heart catheterization. RESULTS: At baseline prior to training, HF patients elicited a significant hyperemic response 10 seconds following cuff occlusion (mean increase in blood flow: 194 ± 44 mL/min, P < .05). Despite this significant hyperemic response, HF patients demonstrated a mild, but paradoxical vasoconstriction of nearly 3% at 1-minute after cuff release. Four weeks of resistance training corrected the paradoxical vasoconstriction observed at baseline and resulted in vasodilatation (a positive increase in brachial artery diameter of 0.04 ± 0.04 mm, at 1 minute after cuff release; P < .05). Conversely, in a subset of 3 HF patients, studies in the untrained contralateral arm revealed no change in the FMD response. CONCLUSION: Moderate-intensity upper-body resistance training improved brachial artery FMD in end-stage HF patients on inotropic support. The reversal of the paradoxical vasoconstrictive response to reactive hyperemia following 4 weeks of training may be secondary to local improvements in vascular endothelial function rather than a quantitative change in the reactive hyperemic stimulus.

Atenção integral ao portador de pé diabético / Comprehensive care to patients with diabetic foot

São apresentadas, nessa separata, as principais orientações sobre a atenção às complicações do pé diabético. A neuropatia, com suas diversas apresentações que acometem os membros inferiores dos diabéticos, as lesões da doença arterial obstrutiva periférica (DAOP), as múltiplas apresentações da infecção do pé diabético, e, principalmente, os cuidados preventivos que possam impedir o estabelecimento ou a evolução dessas complicações são tratados de forma sistemática e simplificada, visando a atenção integral desses doentes. Especial cuidado é dado às orientações diferenciadas para os diversos níveis de atenção nos serviços públicos de saúde, porta de entrada virtual de 80% dos infelizes portadores dessa complicação. São aqui apresentados modelos de atenção e sugeridos protocolos que podem contribuir para a efetiva redução do número de amputações, internações e óbitos de diabéticos com complicações nos membros inferiores.

Ergometric performance during exercise training in men with intermittent claudication.

OBJECTIVE: To determine and describe changes in weekly work, power, exercise times, and recovery times during an exercise training intervention in men with peripheral arterial disease (PAD) and intermittent calf claudication. DESIGN: Tracking of weekly exercise training parameters involved repeated measures over time in one group of participants. Other outcomes of this pilot study used a one-group, pretest-posttest design. SETTING: Tertiary-care medical center. PARTICIPANTS: Fifteen male veterans (mean age, 69 years) with Fontaine stage IIa PAD and classic intermittent calf claudication. MAIN OUTCOME MEASUREMENTS: Participants completed graded treadmill exercise tests before and after intervention from which maximal walking power was calculated. Work, power, and exercise and recovery times for each exercise training session were computed and averaged for each week. INTERVENTION: The intervention consisted of an intensive 3-month exercise training program involving walking and calf muscle exercises: 3 sessions per week at the clinic (treadmill walking and calf ergometry) and 2 sessions per week at home (free walking and standing heel raises). RESULTS: After training, participants increased treadmill maximal walking power from 220 to 414 W (by 87%). Treadmill and calf exercise work, power, and exercise time per session increased linearly during 13 weeks of training, whereas recovery time per session of treadmill exercise decreased. During the same period, treadmill and calf exercise training power outputs increased by averages of 227% and 92%, respectively. CONCLUSION: Calculation of work and power during exercise training can be used to track progress quantitatively at short intervals. Weekly linear increases in training work and power per exercise session suggest that optimal intervention duration may be longer than 3 months for men with PAD and intermittent calf claudication.

[Physical activity and peripheral arterial obstructive disease]. / Exercice physique et artériopathie oblitérante des membres inférieurs.

Intermittent claudication (IC) is the most common clinical manifestation of atherosclerotic peripheral arterial disease. Exercise training plays a major role in treating patients with IC. Regular exercise increases functional walking capacity, reduces cardiovascular mortality and improves quality of life. This seems to be achieved by: favorable effect on cardiovascular risk factors, anti-inflammatory effect, increased collateral blood flux, improved rheology profile, endothelial function, fibrinolysis, and muscular metabolism. However, exact mechanisms underlying beneficial effect of exercise remain largely unknown. Exercise modalities will be discussed in this article.

Farmacologia de drogas vasoativas / Pharmacology of vasoactive drugs

As doenças vasculares periféricas (DVPS) caracterizam-se como um problema de circulação nas veias, artérias e sistema linfático. O tratamento primordial para as DVPS é a mudança de hábitos de vida, alimentação e prática de atividade física. A terapia farmacológica inclui a utilização de drogas vasoativas, as quais são utilizadas nas arteriopatias e nas doenças veno-linfáticas. O objetivo deste estudo foi pesquisar em literatura científica sobre a utilização e farmacologia das drogas vasoativas, enfatizando a eficácia da administração e ação local dessas drogas.

Peripheral vascular diseases (PVDS) are characterized as a circulation problem in the veins, arteries, and lymphatic system. The main therapy consists of changes in lifestyle such as diet and physical activity. The pharmacological therapy includes the use of vasoactive drugs, which are used in arteriopathies and venolymphatic disorders. The goal of this study was to research the scientific literature on the use and pharmacology of vasoactive drugs, emphasizing the efficacy of their local actions and administration.

[A new method for prosthetisation of vascular patients with lower limb amputation: initial experiences with osseointegration technique]. / Alsóvégtag-amputált érbetegek új protetizációs lehetôsége: kezdeti tapasztalataink az osseointegrációs technikával.

INTRODUCTION/AIMS: Prostheses use for lower limb amputees is difficult, while the socket is hard, the prosthesis is heavy. Drawbacks of conventional prosthesis are mainly associated with the socket, therefore osseointegration technique is a promising solution, since it doesn't require a socket. Our aim was to introduce this technique in Hungary and extend indication for vascular patients. METHODS: The method includes two operative and one rehabilitation phases: during first operation a titanium screw is fixed into the femoral bone marrow cavity, this connects to an abutment, which also penetrates the skin, making a direct connection between the femur and the prosthesis during the second intervention. During rehabilitation the patient makes loading exercises and learns to walk with new prosthesis. RESULTS: This method was launched in Hungary in 2005. Two female amputees were operated on initially, their second surgery was performed in 2006 (when titanium screw was applied in the male patients, as well). Incorporation of titanium screw was exquisite, and rehabilitation was successful. One of our male patients died eight months after his first operation due to myocardial infarction. CONCLUSION: Based on our experiences, the osseointegration technique facilitates rehabilitation of vascular patients for prostheses use. Adequate follow-up and stable vascular diseases are not contraindications, although further clinical trials are needed to determine its indication.