Reprinted article "Exercise training versus angioplasty for stable claudication. Long and medium term results of a prospective, randomised trial".

OBJECTIVES: To compare percutaneous transluminal angioplsty (PTA) against exercise training in the treatment of stable claudication. DESIGN: Prospective, randomised trial. MATERIALS: Fifty-six patients with unilateral, stable, lower limb claudication assessed prior to randomisation, at 3 monthly intervals for 15 months, and at approximately 6 years follow-up. Thirty-seven patients were available for long term review. OUTCOME MEASURES: Ankle/brachial pressure index (ABPI), treadmill claudication and maximum walking distances, percentage fall in ankle systolic pressure after exercise. RESULTS: Significant increases were seen in ABPI in the patients treated with PTA at all assessment to 15 months. However in terms of improved walking performance, the most significant changes in claudication and maximum walking distance were seen in the exercise training group. At long term follow-up, there was no significant difference between the groups. Subgroup analysis by angiographic site of disease showed greater functional improvement in those patients with disease confined to the superficial femoral artery treated by exercise training. The overall prognosis for the whole group of patients was benign, with only two (4%) undergoing amputation. CONCLUSIONS: Exercise training confers a greater improvement in claudication and maximum walking distance than PTA, especially in patients with disease confined to the superficial femoral artery.

Exercise training versus angioplasty for stable claudication. Long and medium term results of a prospective, randomised trial.

OBJECTIVES: To compare percutaneous transluminal angioplasty (PTA) against exercise training in the treatment of stable claudication. DESIGN: Prospective, randomised trial. MATERIALS: Fifty-six patients with unilateral, stable, lower limb claudication assessed prior to randomisation, at 3 monthly intervals for 15 months, and at approximately 6 years follow-up. Thirty-seven patients were available for long term review. OUTCOME MEASURES: Ankle/brachial pressure index (ABPI), treadmill claudication and maximum walking distances, percentage fall in ankle systolic pressure after exercise. RESULTS: Significant increases were seen in ABPI in the patients treated with PTA at all assessment to 15 months. However in terms of improved walking performance, the most significant changes in claudication and maximum walking distance were seen in the exercise training group. At long term follow-up, there was no significant difference between the groups. Subgroup analysis by angiographic site of disease showed greater functional improvement in those patients with disease confined to the superficial femoral artery treated by exercise training. The overall prognosis for the whole group of patients was benign, with only two (4%) undergoing amputation. CONCLUSIONS: Exercise training confers a greater improvement in claudication and maximum walking distance than PTA, especially in patients with disease confined to the superficial femoral artery.

Opportunistic screening for abdominal aortic aneurysm.

OBJECTIVE: To contribute to the current debate on screening for abdominal aortic aneurysm (AAA). SETTING: Radiology department of the John Radcliffe Hospital, Oxford. METHODS: The prevalence of AAA in 317 clinically referred male patients aged 65-74 undergoing abdominal ultrasonography with no clinical suspicion of an AAA was investigated over a period of one year. RESULTS: Over the year 15/317 (5%) patients were found to have an aneurysm (defined as aortic diameter (> or = 30 mm), with eight (3%) patients having an aortic diameter of > or = 40 mm. Six months later appropriate management for the AAA had been started for only four patients. A knowledge assessment questionnaire sent to 245 hospital clinicians and general practitioners showed that 17 (12%) of the 139 respondents would initiate no review of patients found to have an aneurysm of 30-39 mm and two would take no action with aneurysms of 40-49 mm. Thirty two (23%) respondents would seek advice on management for all categories of aneurysm, 14% from the radiologist. CONCLUSIONS: Opportunistic screening for AAA in men undergoing clinically indicated abdominal ultrasonography is easy, productive, without discernible cost, and discloses a prevalence of AAA comparable with that of population screening programmes. Routine opportunistic measurement of aortic diameter during abdominal ultrasonography in the at risk group would allow 12-15% of men aged 65-74 to be screened for AAA within five years without the need for any additional resources.

Colonic preparation with Picolax: patient tolerance and approaches to fluid replacement.

Sodium picosulphate (Picolax) is widely used for bowel preparation prior to colonic investigation or surgery. The most troublesome side effect reported is headache, which has been thought to be due to dehydration. In a prospective randomized study we investigated the incidence of adverse effects in patients given Picolax prior to barium enema examination, and assessed the incidence of adverse effects with different oral fluid regimens. A total of 197 outpatients were allocated to one of five fluid regimens on the day prior to the enema: (a) 4 pints of Dioralyte (glucose and electrolyte solution); (b) 4 pints of half-strength Dioralyte; (c) 4 pints of water; (d) 6 pints of water; and (e) free fluids. In a questionnaire, 36% of patients had no headache (graded 0/5), while 38% had a significant headache (graded 3/5 or greater). Sixteen per cent had significant abdominal pain, 42% had dry mouths, 43% thirst and 34% tiredness or irritability. There was no correlation between headache and fluid regimen. Furthermore, we have found no evidence of dehydration. None of the five fluid regimens was shown to offer any advantage, and we therefore recommend that patients be allowed to drink according to thirst when taking Picolax.

Assessment of the biliary tract by antegrade cholecystography after percutaneous cholecystostomy in patients with acute cholecystitis.

The diagnostic value of formal antegrade cholecystography in a consecutive series of 44 patients with scintigraphically confirmed acute cholecystitis, treated by percutaneous transperitoneal cholecystostomy, has been evaluated. A total of six patients did not have antegrade cholecystography (catheter migration in five patients and gangrenous gallbladder perforation in one). Antegrade cholecystography was performed in the remaining 38: 10 patients with persisting cystic duct obstruction and 28 patients with patent cystic ducts. In the persisting cystic duct obstruction group, antegrade cholecystography confirmed the cause of gallbladder outflow obstruction as impacted calculi in either the gallbladder neck or cystic duct in all patients. In the patent cystic duct group, antegrade cholecystography demonstrated the common ducts well in all but two patients, and common duct calculi in eight of nine patients. Three patients had common duct calculi in non-dilated ducts. Antegrade cholecystography is an easy and safe method of clarifying gallbladder pathology in all patients, and can be used to evaluate the common duct for associated common duct calculi in most patients.

Is percutaneous transluminal angioplasty better than exercise for claudication? Preliminary results from a prospective randomised trial.

Percutaneous transluminal angioplasty (PTA) is a commonly performed procedure for the treatment of intermittent claudication despite the lack of controlled studies. The aim of this study was to compare PTA with supervised exercise therapy for patients with arterial occlusive disease judged suitable for PTA at angiography. Patients were assessed before treatment commenced and at three monthly intervals afterwards. Assessment included measurement of resting ankle brachial pressure indices (ABPI), and claudicating and maximum walking distances on a treadmill up a 10 degrees incline. Twenty patients were randomised to receive PTA and 16 exercise. The groups were similar in age, sex, smoking habits and arteriographic pattern of disease. In the PTA group two patients had angioplasties that were technically unsuccessful and two other patients subsequently required surgery. One patient in the exercise group subsequently had a PTA. After PTA, mean ABPI were significantly improved at 3, 6 and 9 months (P less than 0.01) without a corresponding significant increase in mean maximum walking distances. However in the exercise group despite no increase in mean ABPI, mean maximum walking distances increased progressively, with significant increases at 6, 9 and 12 months (P less than 0.01).

Cystic degeneration of fibrous dysplasia masquerading as sarcoma.

An area of fibrous dysplasia of bone may undergo rapid enlargement which may be due to either cystic degeneration or malignant transformation. These complications may be clinically and radiologically indistinguishable and, unless both are borne in mind, incorrect management may follow. Magnetic resonance imaging was used in one of our cases and was the only imaging modality to demonstrate the true nature of the condition.

Skeletal hyperostosis and extraosseous calcification in patients receiving long-term etretinate (Tigason).

In an ongoing study of patients on long-term etretinate (Tigason) therapy, 13 patients with a congenital or inherited disorder of keratinization and 10 patients with psoriasis were examined to investigate the incidence of, and the factors associated with, skeletal hyperostosis. Skeletal scintigraphy, plain radiographs, haematological and biochemical analyses were performed. Using all criteria, 7 of 13 patients with a congenital or inherited disorder of keratinization showed evidence of hyperostosis. No single investigation was able to detect all these cases; in particular, skeletal scintigraphy was positive in only nine of the 13 patients who showed hyperostosis. Eleven of the 13 patients with hyperostosis gave a history of musculoskeletal symptoms compared with three of the 10 patients without hyperostosis. There was no clear association with total dose or duration of treatment. Serum chemistry and haematological studies were normal. In two patients the 24-h urinary calcium excretion was significantly elevated, an abnormality which has not been described previously. Annual lateral thoracic spine radiographs with additional views of symptomatic areas are recommended for patients on long-term etretinate therapy.

Symptomatic submucosal lipoma of the large bowel.

Symptomatic large bowel lipomata may be of considerable size and usually present in middle age with symptoms of obstruction or bleeding. Although they are rare, their recognition is important so that patients may be spared unnecessary colonic resection for a presumptive malignant diagnosis. Colonoscopic removal may often be feasible. Six cases are reported together with a review of the literature emphasizing the characteristic features.

A relationship between perioperative blood transfusion and recurrence of carcinoma of the sigmoid colon following potentially curative surgery.

Preoperative blood transfusions are used to improve graft survival in renal transplantation. If such an immunomodulating effect occurred in cancer surgery perioperative blood transfusion may be detrimental to patient outcome. A retrospective study of 68 patients undergoing potentially curative surgery for adenocarcinoma of the sigmoid colon, over a 10 year period was performed. Thirty-three patients (49%) had a perioperative blood transfusion of which two-thirds received either one or two units. Transfused patients had a poorer prognosis compared to non-transfused patients (0.28 and 0.53 five year product limit recurrence free fractions respectively; P less than 0.01 on generalised Savege test of entire recurrence free curves). Perioperative transfusion was the most sensitive prognostic indicator of recurrence on Cox proportional hazards regression analysis (relative risk 2.6; P less than 0.01, after adjustment for histological stage). Although a causal relationship is not proven, prospective work is urgently needed.