Quality of life in patients with intermittent claudication

Objective:As intermittent claudication (IC) infrequently progresses to limb loss many clinicians adopt a conservative approach to treatment. Recently percutaneous transluminal angioplasty (PTA) has been applied to patients with IC. If this were to become the first line treatment for IC it would have major implications in terms of hospital facilities as well as cost. A measure is required, therefore, to decide on rationing of limited financial resources. “Quality of life” may be more influential in determining demand on services since objective medical criteria cannot give an insight into the patients feelings of well being.Design:We applied the Nottingham Health Profile, by post, to a group of claudicants and age/sex matched controls. 70% responded from both groups. Claudicants who had recently received intervention were excluded, as were controls complaining of any leg pains on walking.Results:The results showed that claudicants have greater perceived problems in the areas of energy, pain, emotional reactions, sleep, and physical mobility compared to controls (p < 0.05; Mann-Whitney Test). This was reflected by a significantly greater positive response rate to problems with activities of daily living (0.05 > p > 0.02; Chi-square Test) in the claudicant group.Conclusion:Because of the cost and resource implications of introducing measures such as PTA to the treatment of vast numbers of patients with IC, we suggest that trials are needed to compare various treatments using quality of life measurements in addition to traditional efficacy/safety parameters

Predictive haemodynamics in a one-dimensional human carotid artery bifurcation. Part 1: application to stent design

A diagnostic technique is proposed to identify patients with carotid stenosis who could most benefit from angioplasty followed by stent implantation. This methodology involves performing a parametric study to investigate the haemodynamic behavior due to alterations in the stenosis shapes in the internal carotid artery (ICA). A pulsatile 1-D Navier-Stokes solver incorporating fluid-wall interactions for a Newtonian fluid which predicts pressure and flow in the human carotid artery bifurcation is used for the numerical simulations. In order to assess the performance of each individual geometry, we introduce pressure variation factor as a metric to directly compare the global effect of variations in the geometry. It is shown that the probability of an overall catastrophic effect is higher when the stenosis is present in the upstream segment of the ICA. Furthermore, maximum pressure is used to quantify the local effects of geometry changes. The location of the peak and extent of stenosis are found not to influence maximum pressure. We also show how these metrics respond after stent deployment into the stenosed part of the ICA. In particular, it is found that localized pressure peaks do not depend on the length of a stent. Finally, we demonstrate how these metrics may be applied to cost-effectively predict the benefit of stenting

A Case of Pseudo-xanthoma Elasticum Presenting with Ischaemic Claudication

AbstractA 37-year-old man presented with symptoms of intermittent claudication. Investigations revealed atypical calf vessel disease but no obvious aetiology. Ten years later he re-presented with worsening symptoms. CT angiography confirmed the atypical pattern of lower limb arterial disease but also noted calcification of the renal parenchyma, myocardium and scrotum. A diagnosis of pseudo-xanthoma elasticum was confirmed by skin biopsy. Pseudo-xanthoma elasticum is a rare condition that presents infrequently to vascular surgeons. Early recognition should prompt aggressive risk factor management to slow accelerated atherosclerosis. Clinicians should be aware of the clinical features of this condition to allow early diagnosis

The effect of epidural anaesthesia on peripheral resistance and graft flow following femorodistal reconstruction

Objective:To determine the extent to which epidural anaesthesia influences peripheral resistance and graft blood flow following femorocrural reconstruction.Design:Prospective, controlled study measuring blood flow, arterial pressure and peripheral resistance in femorocrural bypass grafts for 20 min following onset of epidural anaesthesia with 15ml of 0.25% bupivacaine.Patients:Twenty patients undergoing femorocrural reconstruction for critical lower-limb ischaemia with in situ long saphenous vein, under general anaesthesia. Ten patients had epidural cannulae inserted preoperatively and injected with bupivacaine after completion of the graft.Results:Peripheral resistance fell in all 10 patients receiving epidural anaesthesia from a mean (range) of 1.07 PRU (0.32–2.2) to 0.49 PRU (0.19–0.72), compared to control values of 0.95 PRU (0.39–2.0) to 0.91 PRU (0.41–1.51; P < 0.01, Wilcoxon). There was a tendency for blood pressure to fall in the study patients (not significant) but graft blood flow still increased from 98 ml min−1 (41–221) to 160 ml min−1 (101–250), compared to flow in the control patients of 101 ml min−1 (45–176) at baseline to 104 ml min−1 (56–168; p < 0.01) at 20 min.Conclusions:Epidural anaesthesia significantly decreases peripheral resistance and increases graft blood flow in femorocrural grafts and would appear, therefore, to be of benefit for patients undergoing femorodistal reconstruction

Thromboxane and neutrophil changes following intermittent claudication suggest ischaemia-reperfusion injury

Objectives:It has been postulated that ischaemia-reperfusion occurs in intermittent claudication resulting in neutrophil activation and release of soluble mediators, increasing systemic vascular permeability and enhancing atherogenesis.Methods:We measured neutrophil deformability, plasma thromboxane levels, and urinary microalbumin excretion in 30 male claudicants, and 10 age- and sex-matched controls, before and after exercise to maximum walking distance. Blood was taken from an antecubital vein.ResultsThere was an increase in urinary microalbumin excretion after exercise in claudicants. Statistically significant increases in the median and 90th percentile transit times (markers of neutrophil deformability) for isolated neutrophils from blood drawn 5 min after exercise in the claudicants were observed with no change in control subjects. Plasma thromboxane concentrations in claudicants increased within 10 min post-exercise. Plasma concentrations in controls were significantly lower throughout the study period. In the claudicant group, a positive correlation between the percentage change in the median transit time for neutrophils, and the percentage change in plasma thromboxane at 60 min post-exercise was found.Conclusions:The results lend further support to the concept of ischaemia-reperfusion events in patients with intermittent claudication, leading to a systemic increase in vascular permeability as a result of endothelial injury or dysfunction (a crucial step in atherogenesis), associated with thromboxane production and neutrophil activation. We suggest that the above changes may contribute to the increased mortality seen in such patients

Large avian frugivores in the Philippines show linear responses to improvements in forest quality

Large avian frugivores are important in ecosystem function, but are seriously threatened across the tropics. To conserve them we must understand their habitat needs and the effects of improved forest management on individual species and the community as a whole. We recorded the presence/absence of 18 parrot, pigeon and hornbill species along nearly 500 km of transects at 24 sites in Luzon, Philippines, and used logistic GLMMs to identify bird-habitat associations based on topographical, forest structure and floristic data taken at 1227 habitat plots. We then searched for more complex relationships and thresholds in species responses along forest quality/restoration gradients using GAMMs. Frugivore species richness was highest in forest with large-girthed trees, although some small-scale agricultural disturbance was tolerated or even favoured. Importantly, richness was highest in forests on flat ground, areas which are usually the first to be converted to agriculture. Individual species were positively associated with large trees but responses to floristic gradients were more variable. Very few species had complex relationships with forest quality; for the great majority, the probability of occurrence increased linearly along the forest quality/restoration gradient. While the precise benefits in terms of seed dispersal, and costs of management, at different points along the quality/restoration gradient are likely to be themselves complex, avian frugivores benefit proportionately from step improvements right along the gradient. Thus, any actions to improve forest quality on Luzon, from reforesting the most degraded lands to preventing degradation of relatively healthy forests, are likely to benefit frugivores