The many faces of diabetes. Is there a need for re-classification? A narrative review.

The alarming rise in the worldwide prevalence of obesity and associated type 2 diabetes mellitus (T2DM) have reached epidemic portions. Diabetes in its many forms and T2DM have different physiological backgrounds and are difficult to classify. Bariatric surgery (BS) is considered the most effective treatment for obesity in terms of weight loss and comorbidity resolution, improves diabetes, and has been proven superior to medical management for the treatment of diabetes. The term metabolic surgery (MS) describes bariatric surgical procedures used primarily to treat T2DM and related metabolic conditions. MS is the most effective means of obtaining substantial and durable weight loss in individuals with obesity. Originally, BS was used as an alternative weight-loss therapy for patients with severe obesity, but clinical data revealed its metabolic benefits in patients with T2DM. MS is more effective than lifestyle or medical management in achieving glycaemic control, sustained weight loss, and reducing diabetes comorbidities. New guidelines for T2DM expand the use of MS to patients with a lower body mass index.Evidence has shown that endocrine changes resulting from BS translate into metabolic benefits that improve the comorbid conditions associated with obesity, such as hypertension, dyslipidemia, and T2DM. Other changes include bacterial flora rearrangement, bile acids secretion, and adipose tissue effect.This review aims to examine the physiological mechanisms in diabetes, risks for complications, the effects of bariatric and metabolic surgery and will shed light on whether diabetes should be reclassified.

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.

A Comparison of Quality of Life in Elderly Patients with Intermittent Claudication and Chronic Limb-Threatening Ischemia.

BACKGROUND: Intermittent claudication (IC) and chronic limb-threatening ischemia (CLTI) are both associated with a decreased health status and possibly quality of life (QOL). A better understanding of the differences in QOL between patients with IC and CLTI could be of additional value in shared decision-making. The aim of this study was to compare the QOL at baseline between patients with IC and patients with CLTI. METHODS: The study population was based on 2 study cohorts, 1 cohort consisted of patients with IC (ELECT registry) and the other cohort of patients with CLTI (KOP-study). Patients with an age of ≥70 years were included. QOL at baseline was measured by the WHOQOL-BREF questionnaire. Nonresponders were excluded from data analyses. Student's t-tests and analysis of covariance (ANCOVA) analyses were used to compare QOL between the 2 groups. Outcomes of the ANCOVA analyses were expressed as estimated marginal means. RESULTS: In total, 308 patients were included, 115 patients with IC and 193 patients with CLTI. Patients with CLTI were older (median age 80 years vs. 75 years, P < 0.001) and had more comorbidities. Patients with IC had a statistically significant higher QOL regarding physical health (mean 13.7 [standard deviation (SD) 2.3] vs. 10.8 [SD 2.8], P < 0.001), psychological health (mean 15.3 [SD 2.1] vs. 14.1 [SD 2.4], P < 0.001), environment (mean 16.3 [SD 2.4] vs. 15.5 [SD 2.0], P < 0.002), and the overall domain (mean 3.5 [SD 0.7] vs. 3.1 [SD 0.9], P < 0.001). After correcting for the confounding effect of age and sex, patients with IC still had a statistically significant higher QOL in the physical, psychological, environment, and overall domain. CONCLUSIONS: Patients with IC had a significantly higher QOL in the physical, psychological, environment, and overall domains of the WHOQOL-BREF questionnaire compared with patients with CLTI. This underlines the importance of strategies that reduce disease progression as disease progression is associated with a decrease in QOL.

Radiation exposure in an endovascular aortic aneurysm repair program after introduction of a hybrid operating theater.

BACKGROUND: A hybrid operating theater (HOT) enables optimal image quality, improved ergonomics, and excellent sterility for complex endovascular and hybrid procedures. We hypothesize that the commissioning of a new HOT involves a learning curve. It is unclear how steep the learning curve of these advanced HOTs is. The main purpose of this research was to evaluate radiation exposure parameters in a new HOT for a team of vascular surgeons experienced with infrarenal endovascular aneurysm repair (EVAR) procedures in a conventional operating room with a mobile C-arm. In addition, a comparison of the dose-area product (DAP) achieved in this study and in the literature was made. METHODS: Before commissioning of the HOT, four vascular surgeons completed a comprehensive HOT training program. From the commissioning of the HOT, clinical and procedural data for all consecutive acute and elective patients treated with EVAR were retrospectively collected for a period of 18 months (January 2016-June 2017). A literature review was conducted of the dose-area product in EVAR procedures performed with a dedicated fixed system or mobile C-arm to analyze how this study performed compared with the literature. RESULTS: In the 18-month study period, 77 patients were treated with EVAR (59 electively and 18 acutely), from whom the data were obtained. There was no significant change in radiation exposure parameters over time. From the commissioning of the HOT, EVAR procedures were performed with radiation exposure parameters similar to those of studies found in experienced vascular centers using fixed systems. CONCLUSIONS: Concerning radiation exposure parameters, the commissioning of a new HOT was not accompanied by a learning curve. Radiation exposure parameters achieved in this study were similar to those of studies from experienced and dedicated vascular centers.

Protocol for a prospective, longitudinal cohort study on the effect of arterial disease level on the outcomes of supervised exercise in intermittent claudication: the ELECT Registry.

INTRODUCTION: Despite guideline recommendations advocating conservative management before invasive treatment in intermittent claudication, early revascularisation remains widespread in patients with favourable anatomy. The aim of the Effect of Disease Level on Outcomes of Supervised Exercise in Intermittent Claudication Registry is to determine the effect of the location of stenosis on the outcomes of supervised exercise in patients with intermittent claudication due to peripheral arterial disease. METHODS AND ANALYSIS: This multicentre prospective cohort study aims to enrol 320 patients in 10 vascular centres across the Netherlands. All patients diagnosed with intermittent claudication (peripheral arterial disease: Fontaine II/Rutherford 1-3), who are considered candidates for supervised exercise therapy by their own physicians are appropriate to participate. Participants will receive standard care, meaning supervised exercise therapy first, with endovascular or open revascularisation in case of insufficient effect (at the discretion of patient and vascular surgeon). For the primary objectives, patients are grouped according to anatomical characteristics of disease (aortoiliac, femoropopliteal or multilevel disease) as apparent on the preferred imaging modality in the participating centre (either duplex, CT angiography or magnetic resonance angiography). Changes in walking performance (treadmill tests, 6 min walk test) and quality of life (QoL; Vascular QoL Questionnaire-6, WHO QoL Questionnaire-Bref) will be compared between groups, after multivariate adjustment for possible confounders. Freedom from revascularisation and major adverse cardiovascular disease events, and attainment of the treatment goal between anatomical groups will be compared using Kaplan-Meier survival curves. ETHICS AND DISSEMINATION: This study has been exempted from formal medical ethical approval by the Medical Research Ethics Committees United 'MEC-U' (W17.071). Results are intended for publication in peer-reviewed journals and for presentation to stakeholders nationally and internationally. TRIAL REGISTRATION NUMBER: NTR7332; Pre-results.

Limited Adherence to Peripheral Arterial Disease Guidelines and Suboptimal Ankle Brachial Index Reliability in Dutch Primary Care.

OBJECTIVE/BACKGROUND: The Dutch College of General Practitioners' guideline on peripheral arterial disease (PAD) provides clear recommendations on the management of PAD. An ankle brachial index (ABI) measurement, prescription of antiplatelet drugs and statins, and supervised exercise therapy (SET) for intermittent claudication (IC) are advised. The aims of this study were to determine the adherence of general practitioners (GPs) to their own guideline on PAD and to evaluate the reliability of primary care ABI measurements. METHODS: This was a cross-sectional study. All patients suspected of having symptomatic PAD who were referred by GPs to a large hospital in 2015 were evaluated regarding three of the guideline criteria: (i) ABI measurement; (ii) prescription of secondary prevention; (iii) initiation of SET. ABI values obtained in primary care and the hospital's vascular laboratory were compared using correlation coefficients and regression analysis. An abnormal ABI was defined as a value <.9 (normal ABI ≥.9). RESULTS: Of 308 potential patients with new onset PAD, 58% (n = 178) had undergone ABI measurement prior to referral. A modest correlation between ABI values obtained in primary care and the vascular laboratory was found (r = .63, p < .001). Furthermore, a moderate reliability was calculated (intraclass correlation coefficient 0.60, 95% confidence interval 0.49-0.69, p < .001). Of the new patients with an abnormal ABI, 59% used antiplatelet drugs and 55% used statins. A referral for SET was initiated by a GP in 10% of new PAD patients with IC symptoms. CONCLUSIONS: Adherence by Dutch GPs to their own society's PAD guideline has room for improvement. The reliability of ABI measurements is suboptimal, whereas rates of prescription of secondary prevention and initiation of SET as primary treatment for IC need upgrading.

Preoperative exercise therapy in surgical care: a scoping review.

OBJECTIVES: Several systematic reviews have focused on the role of preoperative exercise therapy (PET) in various fields of surgical care. Aims of the present scoping review are to summarize research findings and to identify gaps in existing literature. METHODS: Two authors independently conducted a comprehensive literature search on systematic reviews regarding PET. The risk of bias was assessed using "the methodology checklist for systematic reviews and meta-analyses of the Scottish Intercollegiate Guidelines Network (SIGN)." Findings of the included systematic reviews were summarized according to type of surgery and type of PET. RESULTS: Twenty-one reviews on PET with a low risk of bias were included. Seven reviews investigated PET in multiple surgical fields and 14 in just a single surgical field. PET was studied before cardiac surgery (n = 9), orthopedic surgery (n = 8), abdominal surgery (n = 8), thoracic surgery (n = 8), vascular surgery (n = 3), and urologic surgery (n = 1). CONCLUSION: Overall, it seems that PET exerts beneficial effects on physical fitness and postoperative outcome measures. Gaps in current literature are the heterogeneity in selected patient populations and outcome measures as well as lack of guidelines on the specific PET regimes. Therefore, there is increasing need for multicenter randomized trials with specifically designed PET programs and a carefully selected patient population to strengthen current evidence.

Symptomatic abdominal aortic aneurysm repair: to wait or not to wait.

BACKGROUND: In patients with a symptomatic abdominal aortic aneurysm (sAAA), acute intervention theoretically reduces rupture risk prior to surgery whereas delayed intervention provides surgery under optimised conditions. In the present study we evaluated differences in 30-day mortality in patients with a sAAA operated within 12 hours compared to patients who received treatment after 12 hours and who were optimized for surgery. METHODS: All patients with a sAAA who were treated within one week after presentation were included in the analyses. The 30-day mortality rates of patients operated within 12 hours were compared to those operated after 12 hours, adjusted for type of operation and for all potential confounders. RESULTS: Of the 89 included patients, 37 patients received surgery within 12 hours. In patients treated within 12 hours, 30-day mortality rate was 6 (16.2%) compared to 3 (5.8%) in patients treated after 12 hours (odds ratio 0.316; CI 0.074-1.358). When adjusted for type of operation and other confounders, odds ratios were 0.305 (CI 0.066-1.405) and 0.270 (CI 0.015-4.836), respectively. CONCLUSIONS: In a substantial amount of patients with an alleged symptomatic AAA, delayed surgery with patient optimisation might be justified. However, specific criteria in order to select patients that might benefit from delayed surgery need further investigation.

Preoperative exercise therapy for elective major abdominal surgery: a systematic review.

OBJECTIVES: The impact of postoperative complications after Major Abdominal Surgery (MAS) is substantial, especially when socio-economical aspects are taken into account. This systematic review focuses on the effects of preoperative exercise therapy (PEXT) on physical fitness prior to MAS, length of hospital admission and postoperative complications in patients eligible for MAS, and on what is known about the most effective kind of exercise regime. METHODS: A systematic search identified randomised controlled trials on exercise therapy and pulmonary physiotherapy prior to MAS. The methodological quality of the included studies was rated using the 'Delphi List For Quality Assessment of Randomised Clinical Trials'. The level of agreement between the two reviewers was estimated with Cohen's kappa. RESULTS: A total of 6 studies were included, whose methodological quality ranged from moderate to good. Cohen's kappa was 0.90. Three studies reported on improving physical fitness prior to MAS with the aid of PEXT. Two studies reported on the effect of training on postoperative complications, showing contradictory results. Three studies focused on the effect of preoperative chest physiotherapy on postoperative lung function parameters after MAS. While the effects seem positive, the optimal training regime is still unclear. CONCLUSION: Preoperative exercise therapy might be effective in improving the physical fitness of patients prior to major abdominal surgery, and preoperative chest physiotherapy seems effective in reducing pulmonary complications. However consensus on training method is lacking. Future research should focus on the method and effect of PEXT before high-risk surgical procedures.

Treatment of temporal artery pseudoaneurysms.

PURPOSE: To give an overview of the etiology and diagnostic process of superficial temporal artery pseudoaneurysms and to evaluate different treatment modalities. BASIC METHODS: PubMed was used for searching multiple databases for relevant clinical studies. PRINCIPAL FINDINGS: A total of 62 studies were included, harboring 82 patients. Surgical excision is the most frequently described treatment, but less invasive treatment modalities as coiling and thrombin injections are gaining popularity. Surgical treatment was successful in all cases (67/67). Endovascular treatment was successful in 69% (9/13); the five cases treated with thrombin injection were all successful. Complementary, a description of our experience with thrombin injection is given. CONCLUSIONS: Limited evidence of minimal invasive treatment for superficial temporal artery pseudoaneurysm is available. Based on this review combined with our limited experience, we suggest thrombin injections to be considered as the future primary treatment modality. In the case of unsuccessful exclusion of the aneurysm, surgical excision can be performed.

Supervised exercise therapy versus non-supervised exercise therapy for intermittent claudication.

BACKGROUND: Although supervised exercise therapy is considered to be of significant benefit for people with leg pain (peripheral arterial disease (PAD)), implementing supervised exercise programs (SETs) in daily practice has limitations. This is an update of a review first published in 2006. OBJECTIVES: The main objective of this review was to provide an accurate overview of studies evaluating the effects of supervised versus non-supervised exercise therapy on maximal walking time or distance on a treadmill for people with intermittent claudication. SEARCH METHODS: For this update, the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched September 2012) and CENTRAL (2012, Issue 9). In addition, we handsearched the reference lists of relevant articles for additional trials. No restriction was applied to language of publication. SELECTION CRITERIA: Randomized clinical trials comparing supervised exercise programs with non-supervised exercise programs (defined as walking advice or a structural home-based exercise program) for people with intermittent claudication. Studies with control groups, which did not receive exercise or walking advice or received usual care (maintained normal physical activity), were excluded. DATA COLLECTION AND ANALYSIS: Two review authors (HJPF and BLWB) independently selected trials and extracted data. Three review authors (HJPF, BLWB, and GJL) assessed trial quality, and this was confirmed by two other review authors (MHP and JAWT). For all continuous outcomes, we extracted the number of participants, the mean differences, and the standard deviation. The 36-Item Short Form Health Survey (SF-36) outcomes were extracted to assess quality of life. Effect sizes were calculated as the difference in treatment normalized with the standard deviation (standardized mean difference) using a fixed-effect model. MAIN RESULTS: A total of 14 studies involving a total of 1002 male and female participants with PAD were included in this review. Follow-up ranged from six weeks to 12 months. In general, supervised exercise regimens consisted of three exercise sessions per week. All trials used a treadmill walking test as one of the outcome measures. The overall quality of the included trials was moderate to good, although some trials were small with respect to the number of participants, ranging from 20 to 304.Supervised exercise therapy (SET) showed statistically significant improvement in maximal treadmill walking distance compared with non-supervised exercise therapy regimens, with an overall effect size of 0.69 (95% confidence interval (CI) 0.51 to 0.86) and 0.48 (95% CI 0.32 to 0.64) at three and six months, respectively. This translates to an increase in walking distance of approximately 180 meters that favored the supervised group. SET was still beneficial for maximal and pain-free walking distances at 12 months, but it did not have a significant effect on quality of life parameters. AUTHORS' CONCLUSIONS: SET has statistically significant benefit on treadmill walking distance (maximal and pain-free) compared with non-supervised regimens. However, the clinical relevance of this has not been demonstrated definitively; additional studies are required that focus on quality of life or other disease-specific functional outcomes, such as walking behavior, patient satisfaction, costs, and long-term follow-up. Professionals in the vascular field should make SET available for all patients with intermittent claudication.

[A chance finding in a woman with abdominal pain]. / Een toevalsbevinding bij een vrouw met buikpijn.

A 73-year-old woman was presented to the emergency department with severe abdominal pain. A CT-scan of the abdomen showed coprostasis and a visceral abdominal aneurysm of the splenic artery. Subsequently, the aneurysm was treated with endovascular coiling.

Applicability of the ankle-brachial-index measurement as screening device for high cardiovascular risk: an observational study.

BACKGROUND: Screening with ankle-brachial index (ABI) measurement could be clinically relevant to avoid cardiovascular events in subjects with asymptomatic atherosclerosis. To assess the practical impact of guidelines regarding the use of ABI as a screening tool in general practice, the corresponding number needed to screen, including the required time investment, and the feasibility of ABI performance, was assessed. METHODS: An observational study was performed in the setting of 955 general practices in the Netherlands. Overall, 13,038 subjects of ≥55 years presenting with symptoms of intermittent claudication and/or presenting with ≥ one vascular risk factor were included. Several guidelines recommend the ABI as an additional measurement in selected populations for risk assessment for cardiovascular morbidity. RESULTS: Screening of the overall population of ≥50 years results in ≈ 862 subjects per general practice who should be screened, resulting in a time-requirement of approximately 6 weeks of full time work. Using an existing clinical prediction model, 247 patients per general practice should be screened for PAD by ABI measurement. CONCLUSION: Screening the entire population of ≥50 years will in our opinion not be feasible in general practice. A more rationale and efficient approach might be screening of subsets of the population of ≥55 years based on a clinical prediction model.

Supervised exercise therapy for intermittent claudication: current status and future perspectives.

Intermittent claudication (IC) has a high prevalence in the older population and is closely associated with cardiovascular and cerebrovascular disease. High mortality rates are reported due to ongoing atherosclerotic disease. Because of these serious health risks, treatment of IC should address reduction of cardiovascular events (and related morbidity/mortality) and improvement of the poor health-related quality of life (QoL) and functional capacity. In several randomized clinical trials and systematic reviews, supervised exercise therapy (SET) is compared with non-supervised exercise, usual care, placebo, walking advice or vascular interventions. The current evidence supports SET as the primary treatment for IC. SET improves maximum walking distance and health-related QoL with a marginal risk of co-morbidity or mortality. This is also illustrated in contemporary international guidelines. Community-based SET appears to be at least as efficacious as programs provided in a clinical setting. In the Netherlands, a national integrated care network (ClaudicatioNet) providing specialized care for patients with IC is currently being implemented. Besides providing a standardized form of SET, the specialized physical therapists stimulate medication compliance and perform lifestyle coaching. Future research should focus on the influence of co-morbidities on prognosis and effect of SET outcome and the potential beneficial effects of SET combined with a vascular intervention.

Endovascular aneurysm repair is superior to open surgery for ruptured abdominal aortic aneurysms in EVAR-suitable patients.

OBJECTIVE: Efficacy results of endovascular repair (rEVAR) for ruptured abdominal aortic aneurysm (rAAA) compared with open surgery are based on several observational studies containing selection bias. The present study compared rEVAR with open surgery in EVAR-suitable patients with an rAAA who all underwent the same preoperative imaging protocol. METHODS: Our policy is to perform a computed tomography angiography on all patients with a suspected rAAA. rEVAR was performed when the rEVAR-vascular surgeon was on call and the patient was suitable for EVAR. Afterwards, two experienced independent blinded experts assessed all computed tomography angiography (CTA) scans on EVAR-suitability. Only EVAR-suitable patients were included in the main analyses. Outcome parameters included mortality (intraoperative, 30-day, and 6-month), complications, reinterventions, and length of hospital stay. RESULTS: From April 2002 until March 2008, 132 consecutive patients with suspected rAAAs were presented. Preoperative CTA confirmed rAAA in 104 patients, of whom 25 underwent rEVAR, and 79 underwent open surgery. In retrospect, the 25 rEVAR patients and 33 patients in the open group were judged EVAR-suitable by the experts. At baseline, there was an equal distribution of physiologic and anatomic characteristics as well as comorbidity. In EVAR-suitable patients, the intraoperative, 30-day, and 6-month mortality was 4.0% (1 of 25), 20.0% (5 of 25), and 28.0% (7 of 25) after rEVAR compared with 6.1% (2 of 33; P >.99), 45.5% (15 of 33; P = .04), and 54.5% (18 of 33; P = .04) after open surgery, respectively. Median length of hospital stay was 9.5 days (interquartile range, 5.0-20.5) after rEVAR and 17.0 days (interquartile range, 9.5-28.0) after open surgery (P = .03). CONCLUSIONS: In EVAR-suitable patients, an absolute perioperative mortality reduction of 25.5% of rEVAR over open surgery was found, which was still present at 6 months of follow-up. These data suggest that rEVAR is a superior treatment option for EVAR-suitable patients with an rAAA compared with an open surgery.

Functional claudication distance: a reliable and valid measurement to assess functional limitation in patients with intermittent claudication.

BACKGROUND: Disease severity and functional impairment in patients with intermittent claudication is usually quantified by the measurement of pain-free walking distance (intermittent claudication distance, ICD) and maximal walking distance (absolute claudication distance, ACD). However, the distance at which a patient would prefer to stop because of claudication pain seems a definition that is more correspondent with the actual daily life walking distance. We conducted a study in which the distance a patient prefers to stop was defined as the functional claudication distance (FCD), and estimated the reliability and validity of this measurement. METHODS: In this clinical validity study we included patients with intermittent claudication, following a supervised exercise therapy program. The first study part consisted of two standardised treadmill tests. During each test ICD, FCD and ACD were determined. Primary endpoint was the reliability as represented by the calculated intra-class correlation coefficients. In the second study part patients performed a standardised treadmill test and filled out the Rand-36 questionnaire. Spearman's rho was calculated to assess validity. RESULTS: The intra-class correlation coefficients of ICD, FCD and ACD were 0.940, 0.959, and 0.975 respectively. FCD correlated significantly with five out of nine domains, namely physical function (rho = 0.571), physical role (rho = 0.532), vitality (rho = 0.416), pain (rho = 0.416) and health change (rho = 0.414). CONCLUSION: FCD is a reliable and valid measurement for determining functional capacity in trained patients with intermittent claudication. Furthermore it seems that FCD better reflects the actual functional impairment. In future studies, FCD could be used alongside ICD and ACD.

Supervised exercise therapy for intermittent claudication in a community-based setting is as effective as clinic-based.

OBJECTIVE: This cohort study was conducted to determine the effect on walking distances of supervised exercise therapy provided in a community-based setting. METHODS: The study included all consecutive patients presenting at the vascular outpatient clinic with intermittent claudication, diagnosed by a resting ankle brachial index<0.9, who had no previous peripheral vascular intervention for peripheral arterial disease, no major amputation, and sufficient command of the Dutch language. The exclusion criterion was the inability to walk the baseline treadmill test for a minimum of 10 m. The intervention was a supervised exercise therapy in a community-based setting. A progressive treadmill test at baseline and at 1, 3, and 6 months of follow-up measured initial claudication distance and absolute claudication distance. Changes were calculated using the mean percentages of change. RESULTS: From January through October 2005, 93 consecutive patients with claudication were eligible. Overall, 37 patients discontinued the supervised exercise therapy program. Eleven stopped because of intercurrent diseases, whereas for 10, supervised exercise therapy did not lead to adequate improvement and they underwent a vascular intervention. Three patients quit the program, stating that they were satisfied with the regained walking distance and did not require further supervised exercise therapy. Ten patients were not motivated sufficiently to continue the program, and in three patients, a lack of adequate insurance coverage was the reason for dropping out. Data for 56 patients were used and showed a mean percentage increase in initial claudication distance of 187% after 3 months and 240% after 6 months. The mean percentage of the absolute claudication distance increased 142% after 3 months and 191% after 6 months. CONCLUSION: Supervised exercise therapy in a community-based setting is a promising approach to providing conservative treatment for patients with intermittent claudication.

A clinical prediction model for the presence of peripheral arterial disease--the benefit of screening individuals before initiation of measurement of the ankle-brachial index: an observational study.

Measurement of the ankle-brachial index (ABI) can provide important information about the presence of subclinical atherosclerosis. Performing the ABI in the overall population is not feasible, but it can be used in a selected population. A simple prediction rule could be of much use to estimate the risk of an abnormal ABI. This was designed as an observational study in the setting of 955 general practices in The Netherlands. A total of 7454 patients aged > or = 55 years presenting with at least one vascular risk factor (smoking, hypertension, diabetes, and hypercholesterolemia) and no complaints of intermittent claudication were included. Patients were selected by the general practitioner during visiting hours and from medical records. Main outcome measures included the prevalence of PAD, defined as an ABI below 0.9, which was related to vascular risk factors using regression analyses on which the PREVALENT clinical prediction model was developed. The overall prevalence of PAD was 18.4%. Since the treatment of individuals with a history of coronary heart disease and cerebrovascular disease will not be influenced by the finding of asymptomatic PAD, these individuals were not taken into account for the development of the clinical prediction model. Analyses showed a significantly increased risk for PAD with increasing age, smoking, and hypertension. The clinical prediction model giving risk factor points per factor (age: 1 point per 5 years starting at 55 years; ever smoked: 2 points; currently smoking: 7 points; and hypertension: 3 points), showed a proportional increase of the PAD prevalence with each increasing risk profile (range: 7.0-40.6%). In conclusion, based on the PREVALENT clinical prediction model, the general practitioner is able to identify a high-risk population in which measurement of ABI is useful.

Symptomatic peripheral arterial disease: the value of a validated questionnaire and a clinical decision rule.

BACKGROUND: If a validated questionnaire, when applied to patients reporting with symptoms of intermittent claudication, could adequately discriminate between those with and without peripheral arterial disease, GPs could avoid the diagnostic measurement of the ankle brachial index. AIM: To investigate the Edinburgh Claudication Questionnaire (ECQ) in general practice and to develop a clinical decision rule based on risk factors to enable GPs to easily assess the likelihood of peripheral arterial disease. DESIGN OF STUDY: An observational study. SETTING: General practice in The Netherlands. METHOD: This observational study included patients of > or =55 years visiting their GP for symptoms suggestive of intermittent claudication or with one risk factor. The ECQ and the ankle brachial index were performed. The prevalence of peripheral arterial disease, defined as an ankle brachial index <0.9, was related to risk factors using logistic regression analyses, on which a clinical decision rule was developed and related to the presence of peripheral arterial disease. RESULTS: Of the 4790 included patients visiting their GP with symptoms suggestive of intermittent claudication, 4527 were eligible for analyses. The prevalence of peripheral arterial disease in this group was 48.3%. The sensitivity of the ECQ was only 56.2%. The prevalence of peripheral arterial disease in a clinical decision rule that included age, male sex, smoking, hypertension, hypercholesterolemia, and a positive ECQ, increased from 14% in the lowest to 76% in the highest category. CONCLUSION: This study indicates that the ECQ alone has an inadequate diagnostic value in detecting patients with peripheral arterial disease. The ankle brachial index should be performed to diagnose peripheral arterial disease in patients with complaints suggestive of intermittent claudication, although our clinical decision rule could help to differentiate between extremely high and lower prevalence of peripheral arterial disease.

Smoking and the patency of lower extremity bypass grafts: a meta-analysis.

OBJECTIVE: Smoking is the major risk factor associated with the development and progression of peripheral arterial disease (PAD). To establish the best estimate of the effect of smoking, smoking cessation, and the dose-response relationship on the patency of lower extremity bypass grafts, we performed a systematic review. METHODS: A search of medical articles and reviews relating to the influence of smoking on the patency of arterial reconstructive grafts in patients with PAD was made. Studies considered for inclusion were those that evaluated the influence of smoking on the primary, secondary, or cumulative patency rates of arterial reconstructive surgery in the lower extremities in patients with PAD. Primary data were used to calculate summary estimates with standard meta-analysis techniques. RESULTS: The 29 eligible studies included 4 randomized clinical trials, 12 prospective studies, and 13 retrospective studies. The effect of smoking on graft patency in the randomized clinical trials and other prospective studies had a 3.09-fold (2.34 to 4.08; P < .00001) increase in graft failure. A comparison of patency rates among all studies that used autogenous or polyester grafts showed no difference. A clear dose-response relationship was present, with a decreased patency in heavy smokers compared with moderate smokers. Smoking cessation restores patency rates toward the never smokers group. CONCLUSION: Continued smoking after lower limb bypass surgery results in a threefold increased risk of graft failure. Smoking cessation, even if instigated after the operation, restored graft patency towards the patency of never smokers. These results indicate that adequate smoking cessation strategies in patients eligible for lower limb bypass surgery are of utmost importance.