A Systematic Review of the Uptake and Adherence Rates to Supervised Exercise Programs in Patients with Intermittent Claudication

Background Intermittent claudication (IC) is a common and debilitating symptom of peripheral arterial disease and is associated with a significant reduction in a sufferer's quality of life. Guidelines recommend a supervised exercise program (SEP) as the primary treatment option; however, anecdotally there is a low participation rate for exercise in this group of patients. We undertook a systematic review of the uptake and adherence rates to SEPs for individuals with IC. Methods The MEDLINE, Embase, and PubMed databases were searched up to January 2015 for terms related to supervised exercise in peripheral arterial disease. The review had 3 aims: first, to establish the rates of uptake to SEPs, second, the rates of adherence to programs, and finally to determine the reasons reported for poor uptake and adherence. Separate inclusion and/or exclusion criteria were applied in selecting reports for each aim of the review. Results Only 23 of the 53 potentially eligible articles for uptake analysis identified on literature searches reported any details of screened patients (n = 7,517) with only 24.2% of patients subsequently recruited to SEPs. Forty-five percent of screen failures had no reason for exclusion reported. Sixty-seven articles with 4,012 patients were included for analysis of SEP adherence. Overall, 75.1% of patients reportedly completed an SEP; however, only one article defined a minimal attendance required for SEP completion. Overall, 54.1% of incomplete adherence was due to patient withdrawal and no reason for incomplete adherence was reported for 16% of cases. Conclusions Reporting of SEP trials was poor with regard to the numbers of subjects screened and reasons for exclusions. Only approximately 1 in 3 screened IC patients was suitable for and willing to undertake SEP. Levels of adherence to SEPs and definitions of satisfactory adherence were also lacking in most the current literature. Current clinical guidelines based on this evidence base may not be applicable to most IC patients and changes to SEPs may be needed to encourage and/or retain participants

A systematic review and meta-analysis of systemic intraoperative anticoagulation during arteriovenous access formation for dialysis

Purpose: Surgical arteriovenous fistula (AVF) or graft (AVG) is preferred to a central venous catheter for dialysis access. Surgical access may suffer thrombosis early after placement and systemic anticoagulation during surgical access formation may increase patency rates but would be expected to increase bleeding-related complications. A systematic review and meta-analysis of randomised controlled trials was conducted to examine the impact of systemic anticoagulation on access surgery perioperative bleeding and patency rates. Methods: We included randomised controlled trials testing systemic anticoagulation during access formation versus a control group without systemic anticoagulation reporting bleeding complications and access patency. Medline, Embase, CENTRAL and CINAHL were searched up to March 2015. Risk of bias was assessed using the Cochrane risk of bias tool and the Jadad score. Meta-analysis was performed using Cochrane Revman ® software. Results: Searches identified 445 reports of which four randomised studies involving 411 participants were included. Three studies pertained to AVF only and one included both AVF and AVG. Systemic anticoagulation led to increased bleeding events in all access [four trials; risk ratio (RR) 7.18; confidence interval (CI), 2.41 to 21.38; p < 0.001]. Patency was not improved for all access (four trials; RR, 0.64; CI, 0.37 to 1.09; p = 0.10) but was improved when AVF analysed alone (three trials; RR, 0.57; CI, 0.33 to 0.97; p = 0.04). Conclusions: The use of intraoperative systemic anticoagulation during access formation is associated with a highly significant increased risk of bleeding-related complications. A significant improvement in AVF patency was seen, though not when AVF and AVG were analysed together

Extracorporeal shockwave therapy for the treatment of lower limb intermittent claudication: Study protocol for a randomised controlled trial (the SHOCKWAVE 1 trial)

© 2017 The Author(s). Background: Peripheral arterial disease (PAD) has a population prevalence of 4.6% with intermittent claudication (IC) presenting as one of the earliest and most common symptoms. PAD has detrimental effects on patients' walking ability in terms of maximum walking distance (MWD) and pain-free walking distance (PFWD). Research has suggested extracorporeal shockwave therapy (ESWT) may induce angiogenesis in treated tissue; therefore, our objective is to assess the tolerability and efficacy of ESWT as a novel treatment of intermittent claudication. Methods/design: Patients with unilateral claudication will be randomised to receive either ESWT (PiezoWave 2 shockwave system) or sham treatment to the calf muscle bulk three times per week for 3 weeks. All patients are blinded to treatment group, and all assessments will be performed by a masked assessor. Treatment tolerability using a visual analogue scale, ankle-brachial pressure index, MWD, PFWD and safety will all be formally assessed as outcome measures at baseline and at 4, 8 and 12 weeks follow-up. Discussion: This trial will be the first of its kind in terms of methodology in relation to ESWT for intermittent claudication. A double-masked randomised controlled trial will provide useful information about the potential for the use of ESWT as a non-invasive treatment option and the need for further robust research. Trial registration: ClinicalTrials.gov, NCT02652078. Registered on 17 October 2014

Extreme Relativistic Electron Fluxes in GPS Orbit: Analysis of NS41 BDD‐IIR Data

Relativistic electrons in the Earth's outer radiation belt are a significant space weather hazard. Satellites in GPS-type orbits pass through the heart of the outer radiation belt where they may be exposed to large fluxes of relativistic electrons. In this study we conduct an extreme value analysis of the daily average relativistic electron flux in Global Positioning System orbit as a function of energy and L using data from the US NS41 satellite from 10 December 2000 to 25 July 2020. The 1 in 10 year flux at L = 4.5, in the heart of the outer radiation belt, decreases with increasing energy ranging from 8.2 × 106 cm−2s−1sr−1 MeV−1 at E = 0.6 MeV to 33 cm−2s−1sr−1 MeV−1 at E = 8.0 MeV. The 1 in 100 year is a factor of 1.1–1.7 larger than the corresponding 1 in 10 year event. The 1 in 10 year flux at L = 6.5, on field lines which map to the vicinity of geostationary orbit, decrease with increasing energy ranging from 6.2 × 105 cm−2s−1sr−1 MeV−1 at E = 0.6 MeV to 0.48 cm−2s−1sr−1 MeV−1 at E = 8.0 MeV. Here, the 1 in 100 year event is a factor of 1.1–13 times larger than the corresponding 1 in 10 year event, with the value of the factor increasing with increasing energy. Our analysis suggests that the fluxes of relativistic electrons with energies in the range 0.6 ≤ E ≤ 2.0 MeV in the region 4.25 ≤ L ≤ 4.75 have an upper bound. In contrast, further out and at higher energies the fluxes of relativistic electrons are largely unbounded

The proton and electron radiation belts at geosynchronous orbit: Statistics and behavior during high‐speed stream‐driven storms

The outer proton radiation belt (OPRB) and outer electron radiation belt (OERB) at geosynchronous orbit are investigated using a reanalysis of the LANL CPA (Charged Particle Analyzer) 8‐satellite 2‐solar cycle energetic particle data set from 1976 to 1995. Statistics of the OPRB and the OERB are calculated, including local time and solar cycle trends. The number density of the OPRB is about 10 times higher than the OERB, but the 1 MeV proton flux is about 1000 times less than the 1 MeV electron flux because the proton energy spectrum is softer than the electron spectrum. Using a collection of 94 high‐speed stream‐driven storms in 1976–1995, the storm time evolutions of the OPRB and OERB are studied via superposed epoch analysis. The evolution of the OERB shows the familiar sequence (1) prestorm decay of density and flux, (2) early‐storm dropout of density and flux, (3) sudden recovery of density, and (4) steady storm time heating to high fluxes. The evolution of the OPRB shows a sudden enhancement of density and flux early in the storm. The absence of a proton dropout when there is an electron dropout is noted. The sudden recovery of the density of the OERB and the sudden density enhancement of the OPRB are both associated with the occurrence of a substorm during the early stage of the storm when the superdense plasma sheet produces a “strong stretching phase” of the storm. These storm time substorms are seen to inject electrons to 1 MeV and protons to beyond 1 MeV into geosynchronous orbit, directly producing a suddenly enhanced radiation belt population.Key PointsDuring high‐speed stream‐driven storms, the electron and proton radiation belts are directly enhanced by a single substormThe enhancing substorm occurs during the “strong stretching” phase of the storm caused by the superdense plasma sheetProton and electron injection to 1 MeV is seen for these strong stretching phase substormsPeer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/133567/1/jgra52702.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/133567/2/jgra52702_am.pd

A density-temperature description of the outer electron radiation belt during geomagnetic storms

Bi-Maxwellian fits are made to energetic-electron flux measurements from seven satellites in geosynchronous orbit, yielding a number density (n) and temperature (T) description of the outer electron radiation belt. For 54.5 spacecraft years of measurements the median value of n is 3.7 × 10−4 cm−3, and the median value of T is 148 keV. General statistical properties of n, T, and the 1.1–1.5 MeV flux F are investigated, including local-time and solar-cycle dependencies. Using superposed-epoch analysis where the zero epoch is convection onset, the evolution of the outer electron radiation belt through high-speed-stream-driven storms is investigated. The number-density decay during the calm before the storm, relativistic-electron dropouts and recoveries, and the heating of the outer electron radiation belt during storms are analyzed. Using four different “triggers” (sudden storm commencement (SSC), southward interplanetary magnetic field (IMF) portions of coronal mass ejection (CME) sheaths, southward-IMF portions of magnetic clouds, and minimum Dst) a selection of CME-driven storms are analyzed with superposed-epoch techniques. For CME-driven storms, only a very modest density decay prior to storm onset is found. In addition, the compression of the outer electron radiation belt at the time of SSC is analyzed, the number-density increase and temperature decrease during storm main phase are characterized, and the increase in density and temperature during storm recovery phase is determined. During the different phases of storms, changes in the flux are sometimes in response to changes in the temperature, sometimes to changes in the number density, and sometimes to changes in both. Differences are found between the density-temperature and flux descriptions, and it is concluded that more information is available using the density-temperature description

Entropy mapping of the outer electron radiation belt between the magnetotail and geosynchronous orbit

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/94614/1/jgra21264.pd

Phase-Space Density Analysis of the AE-8 Traped Electron and the AP-8 Trapped Proton Model Environments

The AE-8 trapped electron and the AP-8 trapped proton models are used to examine the L-shell variation of phase-space densities for sets of transverse (or 1st) invariants, {mu}, and geometrical invariants, K (related to the first two adiabatic invariants). The motivation for this study is twofold: first, to discover the functional dependence of the phase-space density upon the invariants; and, second, to explore the global structure of the radiation belts within this context. Variation due to particle rest mass is considered as well. The overall goal of this work is to provide a framework for analyzing energetic particle data collected by instruments on Global Positioning System (GPS) spacecraft that fly through the most intense region of the radiation belt. For all considered values of {mu} and K, and for 3.5 R{sub E} &lt; L &lt; 6.5 R{sub E}, the AE-8 electron phase-space density increases with increasing L; this trend--the expected one for a population diffusing inward from an external source--continues to L = 7.5 R{sub E} for both small and large values of K but reverses slightly for intermediate values of K. The AP-8 proton phase-space density exhibits {mu}-dependent local minima around L = 5 R{sub E}. Both AE-8 and AP-8 exhibit critical or cutoff values for the invariants beyond which the flux and therefore the phase-space density vanish. For both electrons and protons, these cutoff values vary systematically with magnetic moment and L-shell and are smaller than those estimated for the atmospheric loss cone. For large magnetic moments, for both electrons and protons, the K-dependence of the phase-space density is exponential, with maxima at the magnetic equator (K = 0) and vanishing beyond a cutoff value, K{sub c}. Such features suggest that momentum-dependent trapping boundaries, perhaps drift-type loss cones, serve as boundary conditions for trapped electrons as well as trapped protons