Da un protocollo sperimentale a un modello assistenziale per l’arteriopatia periferica: compliance, outcome riabilitativo e costo-efficacia di un programma originale di sport-terapia

Background Exercise training is an effective, low-cost yet underutilized therapy to improve the functional ability of patients with intermittent claudication. Its diffusion could be favoured by models of intervention that would help ensure functional and cardiovascular improvements, patient compliance and lower costs for the healthcare system. Recently an original model of sport therapy for peripheral arterial disease (PAD) prescribed at hospital and performed at home (Test in-Train out, Ti-To) showed to be more effective than a traditional home based training. Aim of the study The study aims to evaluate compliance, effect on rehabilitative outcomes and cost-effectiveness of the Ti-To model in its application as a health care model during a two- years period. Subjects and Methods 250 (age 70.5±9.2, M=191) out of 289 patients included in the Rehabilitation Program were recruited into the study . Compliance was evaluated by means of a score ranging from 0 to 4 (higher score indicates higher compliance). Rehabilitative outcomes, evaluated upon entry and at discharge, were: Ankle Brachial Index (ABI), Pain Threshold Speed (PTS) and Maximal Speed (Smax) measured by means of an incremental treadmill test, Initial Claudication Distance (ICD) and Absolute Claudication Distance (ACD) measured by means of a constant load treadmill test. Quality of life (QoL) was also evaluated in a sample composed of 90 patients by means of SF 36 questionnaire. Besides a cost effectiveness analysis was performed in order to determine the cost to walk an additional meter for ICD and ACD, the cost to gain 10% of ICD and ACD and to increase of 1 m/min the parameter PTS. The intervention was based on two 10 min-sessions/day of intermittent walking performed at home at an intensity 20%-30% lower than PTS and on serial check-ups at hospital to update the exercise program. The rehabilitative team included one doctor, a nurse and one expert of sport sciences. Results Average compliance score was 3.1±0.9. Functional parameters significantly improved (ABI: 0.60±0.16 a 0.64±0.18, p<0.0001; PTS (Km/h): 2.9±1.2 a 4.0±1.2 p<0.0001; Vmax (Km/h) 3.6±1.2 a 4.3±1.1; ICD (m) 79.2±47.8 a 115.8±53.4, p<0.0001; ACD (m): 125.3±69.6 a 179.9±71.9, p<0.0001). Baseline characteristics of patients who underwent QoL evaluation were not different from the whole population under study. All SF 36 subscales significantly improved (p<0.0001). Most of parameters showed a moderate to large Cohen’s d Effect Size. 1839 visits were performed (7.4±2.0/patient). The average cost of a visit and of a therapy cycle were € 68.93 and €507.20 respectively, with an average cost of €8,14 E to walk one additional meter before stopping and a cost to gain 10% of ICD and ACD and 1m/min of PTS respectively of 65.8 e € 72,2 e €23.56. Conclusion An original rehabilitative model for PAD based on exercise prescribed at hospital and performed at home showed a high compliance, effectiveness on improving functional capacity and QoL and a lower cost-effectiveness ratio compared to the available models of intervention in AOP

Elastic stockings effect on leg volume variability in healthy workers under prolonged gravitational gradient exposure

The aim of this study was to determine the elastic stockings effect on healthy workers (HW) who are exposed to a prolonged hydrostatic pressure overload for professional reasons. The cohort was composed by 20 HW who voluntarily underwent a water plethysmography test before and after eight hour of standing up in an operating room, wearing elastic stockings. After 8 h of gravity exposure, we demonstrated the absence of leg volume increase in case of elastic stockings use. In the morning measurement we found that the lower limb volume was 1967.5 mL±224, while in the evening it was 1962.5 mL±227 (P<0.0828). The decreased volume is significantly correlated with the time that was spent under gravity forces for working purpose wearing elastic stockings (R2=0.99, P<0.0001). Our experiment demonstrates that elastic stockings may effectively counteract the increased leg volume over time in workers who are exposed to prolonged gravitational gradient. Further longitudinal studies are needed to determine if the above effect could correct one of the major risk factors for the development of chronic venous insufficiency

A novel device for non-invasive cerebral perfusion assessment

Currently brain perfusion can be assessed by the means of radio-invasive methods, such as single-photon emission computed tomography and positron emission tomography, or by hightech methods such as magnetic resonance imaging. These methods are known to be very expensive, with long examination time, and finally, cannot be used for assessing brain oxygen distribution in relation to exercise and/or cognition-tests. The near infrared spectroscopy (NIRS) is a non-invasive diagnostic technique. In real time it is capable of measuring tissue oxygenation using portable instrumentation with a relative low cost. We and other groups previously adopted this instrument for investigation of the oxygen consumption in the muscles at rest and during exercise. NIRS can be now used to assess brain perfusion through the intact skull in human subjects by detecting changes in blood hemoglobin concentrations. Changes in perfusion can be related to both arterial and venous problems. This novel equipment features allow for a wide field of innovative applications where portability, wearability, and a small footprint are essential. The present review shows how to use it in relation to exercise protocols of the upper and lower extremities, measured in healthy people and in conditions of arterial and chronic cerebro-spinal venous insufficiency

Histologic and sonographic features of holmium laser in the treatment of chronic venous disease

A new holmium laser (HOL) has been introduced to the market. The device is able to reduce the great saphenous vein (GSV) caliber in a tumescence-free procedure, favoring an effective sclerotherapy of large vessels. Aim of the present investigation is to provide the first in vivo data about the effect of HOL on GSV histology

A specifically designed aquatic exercise protocol to reduce chronic lower limb edema

Objective Despite the fact that muscle pump activation is known to positively impact chronic lower limb edema, objective measurements of standardized exercises for venous-lymphatic rehab are lacking. The aim of this investigation is to determine the effectiveness of an addressed physical activity exploiting the advantages of an aquatic environment.Material and methods Thirty-two lower limbs of 16 patients affected by bilateral chronic leg swelling were included (12 females, 4 males). All the patients underwent a protocol of five sessions of physical exercises specifically conceived inside a pool. Volumetry, subcutaneous thickness, ankle range of motion and symptomatology were assessed as outcome measures.Results One week after the end of the protocol, the average reduction in lower limb volume was 303.1369.72ml (p=0.00002) and 334.38 +/- 62.50ml (p=0.000003) in the right and left legs, respectively. Ankle range of motion and feeling of heaviness significantly improved.Conclusion A specifically designed aquatic protocol is able to positively impact chronic leg swelling offering a first line rehab for this medical condition

Assessment of lower limbs edema in healthy workers who are exposed to long-term gravity

The aim of this study is to establish changes in leg volumes in healthy subjects (HS) after prolonged standing and prolonged lying. The study was carried out on two HS groups: the group A (20 subjects) included physicians and nurses who underwent a water plethysmography test, before and after eight hours of standing still in the operating room. The group B (20 subjects) included volunteers who were assessed before and after 10 h of supine resting. Group A: baseline leg volume was 1857.5 mL±196.9 on the right and 1850 mL±194.7 on the left limb. After eight hours of hydrostatic pressure action the two lower limbs volume was significantly increased to 1945 mL±209.6, and to 1940 mL±216.2, respectively (P<0.0001). The increased volume is significantly correlated with time (R2=0.95, P<0.0001). Group B: baseline leg volume was 1875 mL±175.1 on the right, and 1862.5 mL±166.9 on the left limb. After ten hours of resting supine the volume was 1770 mL±195.6, and to 1757.5 mL±194.2, respectively (P<0.0001). The decreased volume is significantly but inverted correlated with time (R2=−0.98, P<0.0001). This study demonstrates how the hydrostatic pressure is a main determinant for fluid accumulation in the lower extremity. To counteract the gravitational gradient becomes the mandatory prophylactic approach for healthy individuals who are exposed to an increased chronic venous disease risk

Technique for intraoperatory harvesting of adipose derived stem cells: towards cell treatment of recalcitrant ulcers

Successful wound and ulcer repair remains a major biomedical challenge in the 21st Century. Innovative and alternative treatment options have been investigated over the last decade and stem cells application has been suggested as a possible novel therapy for regenerative medicine. In particular, stem cells derived from adipose tissue have been attracting a lot of attention in recent years as an alternative to the use of cells derived from bone marrow. This technical note describes the procedure introduced by Coleman for intraoperatory harvesting of adipose derived-stem-cells and proposes a rationale for using it in difficult wound healing and recalcitrant ulcers

On the consistency of flow rate color Doppler assessment for the internal jugular vein

Color Doppler methodology to assess the vessel blood flow rate is based on the time averaged velocity of the blood measured in the longitudinal plane and the cross sectional area measurement taken either in the longitudinal plane, by assuming circular cross sectional area, or in the transversal plane. The measurement option in longitudinal plane is based on the assumption of circular cross sectional area, while the transversal one needs to evaluate both time-averaged velocity and cross sectional area in the same vessel point. A precise and validated assessment methodology is still lacking. Four healthy volunteers underwent internal jugular vein colour Doppler scanning. The cross sectional area was assessed by means of B-mode imaging in the transversal plane all along the vessel cervical course. During this assessment, cross sectional area, major and minor axis of the vessel were measured and recorded. The distance between the internal jugular vein wall and the skin surface were measured together with the intra-luminal diameter and statistically correlated with the cross sectional area data. The internal jugular vein cross sectional area measured on the transversal plane were significantly different from the cross sectional area calculated using the assumption of circular shape. The intra-luminal distance showed high correlation with the measured cross sectional area. The proper anatomical point in the cross sectional area transversal measurement can be identified by using the internal jugular vein intra-luminal distance as landmark

A seasonal periodicity in relapses of multiple sclerosis? A single-center, population-based, preliminary study conducted in Bologna, Italy

Fabrizio Salvi, Ilaria Bartolomei, Angelo Lorusso, and Elena Barbarossa are with the Department of Neuroscience, Multiple Sclerosis Center, Bellaria Hospital, Bologna, Italy -- Michael H. Smolensky is with the Department of Biomedical Engineering, the University of Texas at Austin, USA -- Ann Maria Malagoni, Paolo Zamboni, and Roberto Manfredini are with the Vascular Diseases Center, University of Ferrara, Italy -- Roberto Manfredini is with the Department of Internal Medicine, Hospital of the Delta, Azienda Unità Sanitaria Locale, Ferrara, Italy and the Department of Clinical and Experimental Medicine, Clinica Medica and Vascular Diseases Center, University of Ferrara, ItalyBackground: Temporal, i.e., 24-hour, weekly, and seasonal patterns in the occurrence of acute cardiovascular and cerebrovascular events are well documented; however, little is known about temporal, especially seasonal, variation in multiple sclerosis (MS) and its relapses. This study investigated, by means of a validated chronobiological method, whether severe relapses of MS, ones requiring medical specialty consultation, display seasonal differences, and whether they are linked with seasonal differences in local meteorological variables. Results: We considered 96 consecutive patients with severe MS relapse (29 men, 67 women, mean age 38.5 ± 8.8 years), referred to the Multiple Sclerosis Center, Bellaria Hospital, Bologna, Italy, between January 1, 2007 and December 31, 2008. Overall, we analyzed 164 relapses (56 in men, 108 in women; 115 in patients aged < 40 years, 49 in patients ≥40 years). Relapses were more frequent in May and June (12.2% each) and the least frequent in September (3.7%). Chronobiological analysis showed a biphasic pattern (major peak in May-June, secondary peak in November-December, p = 0.030). Analysis of monthly mean meteorological data showed a significant seasonal pattern in ambient temperature (peak in July, p < 0.001), relative humidity (peak in January, p < 0.001), and wind speed (peak in June, p = 0.011). Conclusions: In this Italian setting we found a biphasic pattern, peaks in spring and autumn, in severe MS relapses requiring medical consultation by doctors of the MS specialty center apparently unrelated to meteorological variables. Confirmations of the findings on larger multi-center populations residing in different climatic conditions are needed to further explore the potential seasonality of MS relapses and associated environmental triggers.Biomedical [email protected]