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

ObjectiveThis cohort study was conducted to determine the effect on walking distances of supervised exercise therapy provided in a community-based setting.MethodsThe 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.ResultsFrom 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.ConclusionSupervised exercise therapy in a community-based setting is a promising approach to providing conservative treatment for patients with intermittent claudication

Abdominal aortic aneurysm is associated with a variant in low-density lipoprotein receptor-related protein 1

Abdominal aortic aneurysm (AAA) is a common cause of morbidity and mortality and has a significant heritability. We carried out a genome-wide association discovery study of 1866 patients with AAA and 5435 controls and replication of promising signals (lead SNP with a p value &lt; 1 × 10-5) in 2871 additional cases and 32,687 controls and performed further follow-up in 1491 AAA and 11,060 controls. In the discovery study, nine loci demonstrated association with AAA (p &lt; 1 × 10-5). In the replication sample, the lead SNP at one of these loci, rs1466535, located within intron 1 of low-density-lipoprotein receptor-related protein 1 (LRP1) demonstrated significant association (p = 0.0042). We confirmed the association of rs1466535 and AAA in our follow-up study (p = 0.035). In a combined analysis (6228 AAA and 49182 controls), rs1466535 had a consistent effect size and direction in all sample sets (combined p = 4.52 × 10-10, odds ratio 1.15 [1.10-1.21]). No associations were seen for either rs1466535 or the 12q13.3 locus in independent association studies of coronary artery disease, blood pressure, diabetes, or hyperlipidaemia, suggesting that this locus is specific to AAA. Gene-expression studies demonstrated a trend toward increased LRP1 expression for the rs1466535 CC genotype in arterial tissues; there was a significant (p = 0.029) 1.19-fold (1.04-1.36) increase in LRP1 expression in CC homozygotes compared to TT homozygotes in aortic adventitia. Functional studies demonstrated that rs1466535 might alter a SREBP-1 binding site and influence enhancer activity at the locus. In conclusion, this study has identified a biologically plausible genetic variant associated specifically with AAA, and we suggest that this variant has a possible functional role in LRP1 expression.</p

Neurogenic thoracic outlet syndrome caused by infection and scar tissue formation in the clavicle trajectory in a patient without a clavicle

Introduction: We present a patient that suffers from severe neurogenic thoracic outlet syndrome (NTOS) complaints without having a clavicle bone. This exceptional case shows the importance of scar tissue generation as an important cause for neurogenic thoracic outlet syndrome, especially in patients with previous surgery or infection in the thoracic outlet region. Report: The presented patient was a 60-year-old women with typical NTOS complaints. Her complaints started when she was 40 years of age and were progressive over the last two years. Her medical history revealed a complicated right clavicle fracture. At the age of five, the fracture caused a serious infection that was treated with ointments, weekly injections, and antibiotics. At the age of seven, the clavicle was removed. In a multidisciplinary meeting it was concluded that she suffered NTOS, most likely due to prolonged infection in her childhood and extensive scar tissue in the trajectory of the lost clavicle. During surgery a substantial amount of dense fibrotic tissue surrounding the brachial plexus was found and removed, which confirmed the hypothesis of scar tissue related compression with subsequent complaints. The anterior and medial scalene muscles were also removed. The first rib was left in situ. The patient showed significant post-operative improvements measured with the DASH, CBSQ and TOS disability scale. She defines the outcome of surgery by the Derkash classification as ‘Good’. Discussion: This case report shows that compression of the brachial plexus compression can exist because of extensive scar tissue formation due to severe infection, without involvement of a clavicle and no relevant impact of the first rib. The formation of scar tissue in this patient led to disabled nerve gliding and extrinsic compression of the brachial plexus. Therefore, history of infection in the thoracic outlet should be considered as predisposing factor for the development of NTOS complaints

Preoperative exercise therapy for elective major abdominal surgery: A systematic review

AbstractObjectivesThe 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.MethodsA 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.ResultsA 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.ConclusionPreoperative 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

Comparison of midterm results for the Talent and Endurant stent graft

Objective Stent graft evolution is often addressed as a cause for improved outcomes of endovascular aneurysm repair for patients with an abdominal aortic aneurysm. In this study, we directly compared the midterm result of Endurant stent graft with its predecessor, the Talent stent graft (both Medtronic, Santa Rosa, Calif). Methods Patient treated from January 2005 to December 2010 in a single tertiary center in The Netherlands with a Talent or Endurant stent graft were eligible for inclusion. Ruptured abdominal aortic aneurysms or patients with previous aortic surgery were excluded. The primary end point was the Kaplan-Meier estimated freedom from secondary interventions. Secondary end points were perioperative outcomes and indications for secondary interventions. Results In total, 221 patients were included (131 Endurant and 90 Talent). At baseline, the median aortic bifurcation was narrower for the Endurant (30 mm vs 39 mm; P <.001). Median follow-up was 64.1 ± 37.9 months and 59.2 ± 25.3 months for Talent and Endurant, respectively. The estimated freedom from secondary interventions at 30 days, 1 year, 5 years, and 7 years was 94.3%, 89.4%, 72.2%, and 64.1% for Talent and 96.8%, 89.3%, 75.2%, and 69.2% for Endurant (P =.528). The indication for secondary interventions does differ; more patients required an intervention for a proximal neck-related complication (type Ia endoleak or migration) in the Talent group (18.2% vs 4.8%; P =.001), whereas more interventions for iliac limb stenosis were seen in the Endurant group (0.0% vs 4.8%; P =.044). In a binomial regression analysis, suprarenal angulation, infrarenal neck length, and type of stent graft were independent predictors of neck-related complications. Conclusions Evolution from the Talent stent graft into the Endurant has resulted in significant reduction of infrarenal neck-related complications; on the other hand, iliac interventions increased. The overall midterm secondary intervention rate was comparable

Three Year Patency and Recurrence Rates of Revision Using Distal Inflow with a Venous Interposition Graft for High Flow Brachial Artery Based Arteriovenous Fistula

Item does not contain fulltex

Manipulating spatial distance in virtual reality: Effects on treadmill walking performance in patients with intermittent claudication

Research indicates that the manipulation of spatial distance between objects in a previously observed environment may go unnoticed when the categorical information of these objects, such as their order, matches that of memory for the environment. Using a repeated measures design, we investigated whether manipulations of spatial distance in virtual reality (VR) can influence treadmill exercise performance (i.e., walking distance) in patients with intermittent claudication; a cramping pain or discomfort in the legs, which occurs during exercise. Participants (N = 19) carried out four treadmill exercise sessions; one without VR and three with a VR environment to move through while walking. They were instructed to walk until the pain forced them to stop. All VR sessions contained the same environment, but in the second and third session it was ‘stretched’ and ‘compressed’. Walking distance was not influenced by the mere addition of VR. However, both VR manipulations led to greater walking distance than the VR baseline session and participants walked furthest when presented with the stretched environment. The results indicate that the manipulation of spatial distance in VR can be of clinical relevance; a finding that may be applied in the development of future medical applications