bluuebunny/crossref_metadata_2025 huggingface dataset:
Peripheral arterial disease and depressed mood in older men and women
Authors: Arseven Adnan , Guralnik Jack M , O’Brien Erin , Liu Kiang , McDermott Mary McGrae
Published: January 2007

The objective of this study was to determine whether lower extremity peripheral arterial disease (PAD) is associated with depressive symptoms and whether PAD-related disability mediates the association between PAD and depressive symptoms. The study used a cross-sectional design set in an academic medical center. A cohort of men and women aged 55 years and older with ( n = 93) or without ( n = 74) PAD was recruited. PAD subjects were identified from a blood flow laboratory and a general medicine practice. Non-PAD subjects were identified from the same general medicine practice. PAD was diagnosed and quantified using the ankle-brachial index (ABI). Depressive symptoms were assessed by the 15-item short version of the Geriatric Depression Scale (GDS-S; score range 0-15, 0 = no depressive symptoms). The six-minute walk test and the Walking Impairment Questionnaire (WIQ) distance score (score range 0-100, 100 = better walking ability) were measures of walking impairment. PAD subjects had depressive mood (DM) (defined by GDS-S score ≤5) twice as often as controls (24% vs 12%, p = 0.06). After adjustment for age, education, and number of comorbidities, the prevalence of depressive mood among PAD subjects was increased, but this association was not significant (OR = 1.8, 95% CI 0.7-4.4). The WIQ distance score weakened the association between PAD and DM, and higher distance scores were associated with a lower likelihood of DM (OR = 0.98 per one unit of the WIQ, 95% CI 0.96-0.99). Among PAD subjects, severe PAD (ABI >0.5) was not significantly associated with DM (OR = 1.4, 95% CI 0.5-4.1), but a greater 6-min walk distance was associated with a lower likelihood of DM (OR = 0.8 per 100 feet, 95% CI 0.70-0.97). Substituting the WIQ scores for six-min walk distance in the model showed that higher WIQ scores were associated with lower likelihood of DM among PAD subjects (OR = 0.98 per one unit of the WIQ, 95% CI 0.95-1.0), though the association did not achieve statistical significance. In conclusion, these data suggest that PAD may be associated with an increased risk of DM and that this relationship may be related to PAD-associated disability. An evaluation for depression may be appropriate in men and women with PAD. Findings should be evaluated in a larger study cohort.
Proteinuria in a placebo-controlled study of basic fibroblast growth factor for intermittent claudication
Authors: Cooper Leslie T , Hiatt William R , Creager Mark A , Regensteiner Judith G , Casscells Ward , Isner Jeffrey M , Cooke John P , Hirsch Alan T
Published: January 2007

Intermittent claudication is the most common symptom of peripheral arterial disease (PAD), in part due to an inadequate rise in limb blood flow with exercise. Claudication causes a severe impairment in functional capacity and quality of life in over 3 million Americans. Basic fibroblast growth factor (bFGF) stimulates angiogenesis in vivo and improves limb blood flow in several animal models of hindlimb ischemia. However, the relative safety and efficacy of angiogenic molecules in the treatment of claudication has not been fully evaluated in prospective, blinded clinical trials. In this study, a randomized, double-blind, placebo-controlled, phase II trial of recombinant human bFGF for the treatment of intermittent claudication was performed. bFGF was administered weekly by intravenous infusions of 2 μg/kg for 6 sequential weeks (total dose 12 μg/kg). The primary efficacy endpoint was change in peak walking time (PWT) on a graded exercise treadmill protocol. Secondary efficacy endpoints included changes in functional status as measured by validated questionnaires. The study was stopped prematurely after treatment of the first 24 subjects due to proteinuria in five of the 16 subjects who received systemic bFGF, which exceeded 1000 mg/24 h in four of these five subjects. The small sample size limited evaluation of the predefined efficacy endpoints; however, there was no significant difference between the treatment and control groups for any of the measures of efficacy. In conclusion, intravenous administration of bFGF delivered at low doses weekly for 6 weeks was associated with a high rate of severe proteinuria. It is speculated that bFGF-related proteinuria in this study was primarily related to the systemic route of administration and the frequent dosing schedule. Future clinical trials of bFGF protein should carefully monitor renal function and consider alternative dosing schedules and drug administration routes.
Three cases of digital ischemia successfully treated with cilostazol
Authors: Dean Steven M , Satiani Bhagwan
Published: January 2007

Three patients were evaluated for refractory digital ischemia. The first patient presented with chronic, post-traumatic, unremitting, cold, painful, right fourth and fifth fingers. The symptoms had failed to improve despite topical nitroglycerin and a calcium channel blocker. Baseline digital plethysmography documented impaired perfusion within the affected digits. Cilostazol (Pletal®) was added to the medical regimen and at the 8-week follow-up the fourth and fifth fingers were warm with repeat plethysmography displaying normal perfusion. A second patient had CREST syndrome-associated painful bilateral index finger ulcerations that had evolved despite taking a calcium channel blocker. Consequently the patient was started on cilostazol and within 4 weeks the digital ulcerations and pain had resolved. The third patient with traumatic right fifth digital arterial thrombosis was seen for persistent pain and cyanosis in spite of undergoing thrombolysis and subsequent anticoagulation with vasodilator therapy. Digital plethysmography established fixed ischemia within the fifth finger; subsequently, cilostazol was prescribed. Four weeks later the digital pain and cyanosis had essentially resolved. A follow-up plethysmographic waveform documented restored perfusion. Although approved for the treatment of intermittent claudication, cilostazol was successfully utilized in the setting of severe digital ischemia.
Vascular viewpoint
Authors: Anand Sonia S
Published: January 2007

Question: Is anticoagulant treatment for calf vein thrombosis for 6 weeks duration associated with acceptable recurrence and safety outcomes? Is anticoagulant therapy for 3 months duration for proximal deep vein thrombosis (DVT) or pulmonary embolism (PE) associated with acceptable recurrence and safety outcomes?

Population: Men and women with a first episode of symptomatic calf vein thrombosis or proximal DVT confirmed by ultrasound or venography, or PE confirmed by lung scan or angiography. Patients with pregnancy, thrombophilia, severe PE, and cancer were excluded.

Design and methods: After treatment with heparin and oral anticoagulants targeting an INR of 2-3, patients with calf DVT were randomized to 6 weeks ( n = 105) versus 3 months ( n=92) of treatment, and patients with proximal DVT and/or PE were randomized to 3 months ( n = 270) versus 6 months ( n=269) of treatment. The outcome events were recurrences and major, minor, or fatal bleeding complications. The mean follow-up time was 12 months.

Results: A total of 736 patients were enrolled. For calf vein thrombosis the recurrence of DVT or PE after 6 weeks of therapy was 2/105 (2.0%) versus 3/92 (3.4%) with 3 months of therapy, relative risk of 0.58 (95% CI: 0.10-3.36). The rates of major bleeding were 1/105 (1.0%) and 3/92 (3.4%) respectively, relative risk of 0.29 (95% CI: 0.03-2.72). For proximal DVT or PE, the recurrence rate after 3 months of therapy was 21/270 (8.1%) versus 23/269 (8.7%) after 6 months of treatment, relative risk of 0.93 (95% CI: 0.53-1.65). The rates of major bleeding were 5/270 (1.9%) versus 7/269 (2.6%) respectively, relative risk of 0.73 (95% CI: 0.24-2.27).

Conclusion: After isolated calf vein DVT, 6 weeks of oral anticoagulation is sufficient. For proximal DVT or PE, 3 and 6 months of anticoagulant therapy is equivalent. For patients with temporary risk factors who have a low risk of recurrence, 3 months of treatment seems to be sufficient.
Rationale for the use of platelet aggregation inhibitors in PAD patients
Authors: Agnelli Giancarlo
Published: January 2007

Peripheral arterial disease (PAD) is a major risk marker for systemic ischaemic events. The understanding of PAD has moved from PAD as an organ-specific disease to PAD as the lower-limb localization of a multifocal disease, i.e. atherothrombosis. Blood platelet activation and aggregation is a common denominator in atherothrombotic events, and use of antiplatelet agents in patients with PAD can inhibit thrombus formation and reduce the occurrence of myocardial infarction (MI), ischaemic stroke (IS) and vascular death. Many studies have investigated various antiplatelet regimens for preventing acute cardiovascular events in patients with a prior ischaemic event, although many of these studies had a number of limitations. The Antiplatelet Trialists’ Collaboration performed a meta-analysis of 23 stroke trials and found an average odds risk reduction of 25% for a combined endpoint of stroke, MI or vascular death. The concept of atherothrombosis as a multifocal disease was challenged by the Clopidogrel versus Aspirin in Patients at Risk of Ischaemic Events (CAPRIE) trial. This study showed an 8.7% decrease in the relative risk reduction for further atherothrombotic events with clopidogrel over aspirin (p = 0.043) for the overall population, in terms of the combined endpoint of IS, MI or vascular death.
Unfractionated versus low-molecular-weight heparin in the treatment of venous thromboembolism
Authors: Bounameaux Henri
Published: January 2007

Low-molecular-weight heparin (LMWH) fractions are prepared from standard unfractionated heparin (UFH) and are thus similar to UFH in many aspects. The main advantages of this new class of antithrombotic agents as compared with UFH are: (1) an improved bioavail-ability and a prolonged half-life, which alleviate cumbersome laboratory monitoring and may permit one single daily subcutaneous injection; and (2) an improved efficacy-to-safety ratio, with less bleeding despite similar or improved efficacy. For these reasons, LMWH is progressively replacing UFH for preventing postoperative thromboembolism and for treating established deep vein thrombosis and pulmonary embolism. However, the effects of the new compounds need to be evaluated carefully in some other indications (arterial thrombosis, unstable angina, or myocardial infarction - the latter also in conjunction with thrombolytic treatment) before they can generally replace UFH in pharmacotherapy.
Heparin attenuates norepinephrine-induced venoconstriction
Authors: Hawari Feras I , Shykoff Barbara E , Izzo Joseph L
Published: January 2007

Reversal by heparin of norepinephrine-induced constriction of normal hand veins was studied. Venous size was measured using a linear variable differential transformer (LVDT) during infusions of saline, norepinephrine, insulin and norepinephrine, and graded doses of heparin with norepinephrine. Heparin reduced the venoconstrictive effects of norepinephrine (p, 0.01), with the effects beginning at 18.5 nmol/min (0.05 U/min) and reaching a maximum between 185 nmol/min and 1.85 mmol/min (0.5 and 5 U/min). Maximal heparin-induced venorelaxation correlated with the maximal insulin effect within individuals (r = 0.8, p, 0.01) and was unchanged by the addition of insulin. Methylene blue, a non-specific inhibitor of the nitric oxide cGMP cascade, reduced heparin-induced venorelaxation. In conclusion, heparin in either physiologic or pharmacologic concentrations attenuated norepinephrine-induced venoconstriction. A common mechanism of venorelaxation by heparin and insulin is not excluded given the correlation and lack of additivity of maximum effects and their inhibition by methylene blue.
The natural history of asymptomatic moderate internal carotid artery stenosis by duplex ultrasound
Authors: Olin Jeffrey W , Fonseca Carmen , Childs Mary Beth , Piedmonte Marion R , Hertzer Norman R , Young Jess R
Published: January 2007

The purpose of this study was to determine the rate of progression of the degree of carotid stenosis and to determine the risk of continued observation in a group of asymptomatic patients with moderate stenosis of at least one internal carotid artery. Between 1989 and 1994, 2130 patients were found to have 60-79% stenosis of at least one internal carotid artery following a duplex ultrasound examination in the authors' vascular laboratory. Of these, 465 patients (255 men, 210 women) were asymptomatic and had more than one ultrasound examination, and they form the basis of this retrospective review.

The mean ± SD age was 68.8 ± 9.0 years. The mean ± SD number of ultrasound examinations was 3.1 ± 1.4 (range 2-11). The mean ± SD follow-up was 24.4 ± 17.6 months (range 2-79 months). Over the period of follow-up 72 patients (15.5%) progressed to 80-99% stenosis (n=71) or to occlusion (n=1). The estimated percentage of patients who progressed by life table methods were 5 ± 1% at 1 year, 11 ± 2% at 2 years and 20 ± 3% at 3 years. There was no statistically significant difference in the rate of progression in men compared with women. Twenty-one patients had a late ipsilateral TIA or stroke. Five out of 72 patients (6.9%) who progressed had a late ipsilateral TIA compared with nine out of 393 patients (2.3%) who did not progress (estimated risk ratio 16.1, P=0.0001). Four out of 72 patients (5.6%) who progressed had a late ipsilateral stroke compared with three out of 393 patients (0.76%) who did not progress (estimated risk ratio 23.6, p=0.0002). The cumulative ipsilateral stroke rate using life table methods was 0.22% at 1 year, 1% at 2 years and 2.4% at 3 years.

In a large cohort of asymptomatic patients, the frequency of progression of 60-79% internal carotid artery stenosis was 5% at 1 year, 11% at 2 years and 20% at 3 years. Patients who progressed were more likely to have symptoms, but the rate of unheralded stroke was relatively low over a 3-year time period. Surveillance carotid ultrasound examinations should be performed in patients with moderate carotid stenosis. Because of the lack of clear benefit, carotid endarterectomy for asymptomatic 60-79% internal carotid artery stenosis cannot be justified.
Diabetes, advanced glycation endproducts and vascular disease
Authors: Wautier Jean-Luc , Guillausseau Pierre-Jean
Published: January 2007

The high incidence of vascular complications in patients with diabetes mellitus remains incompletely understood. Several metabolic or endocrine abnormalities have been postulated as possible triggers for micro and macroangiopathies. This review article focuses on the consequences of hyperglycemia, leading to the formation of advanced glycation endpro-ducts (AGE), on vascular function. Advanced glycation endproducts are the product of the binding of aldoses onto free amino groups of proteins or lipoproteins, which, after molecular rearrangement, result in a class of molecules of a brown color and specific fluorescence. Different cell membrane proteins have been shown to bind AGE and the best characterized receptor for AGE has been named RAGE. The AGE receptor is present on different cell types including endothelial cells, smooth muscle cells, lymphocytes and monocytes.

Experimental studies have revealed that the binding of AGE to RAGE produces an activation of monocytes and endothelial cells. Activated endothelial cells produce interleukin and express vascular cell adhesion molecule and tissue factor. Advanced glycation endproducts, when infused into animals, induce an increase in vascular permeability. The blockade of RAGE by specific antibodies corrects the hypermeability observed in diabetic animals.

The prevention of AGE formation by aminoguanidine treatment improves the microvascular lesions found in diabetic animals either in the retina or the glomerus. The infusion of recombinant RAGE in diabetic animals corrects hyperpermeability. The colocalization of RAGE and AGE at the microvascular site of the injury suggests that their interaction may play a significant role in the pathogenesis of diabetic vascular lesions.
Lymphedema: classification, diagnosis and therapy
Authors: Szuba Andrzej , Rockson Stanley G
Published: January 2007

This review presents the diagnostic features, the pathophysiology and the available therapies for lymphedema. This disease is often able to be diagnosed by its characteristic cliniccal presentation, yet, in some cases, ancillary tests might be necessary to establish the diagnosis, particularly in the early stages of the disease and in edemas of mixed etiology. These diagnostic modalities are also useful in clinical studies.

Available modalities include isotopic lymphoscintigraphy, indirect and direct lymphography, magnetic resonance imaging, computed tomography and ultrasonography. Lymphedema may be primary or secondary to the presence of other diseases and/or to the consequences of surgery. Primary lymphedema may occur at any phase of life but it most commonly appears at puberty. Secondary lymphedema is encountered more often. The most prevalent worldwide cause of lymphedema is filariasis, which is particularly common in south-east Asia. In the USA, postsurgical lymphedema of the extremity prevails. Complications of chronic limb lymphedema include recurrent cellulitis and lymphangiosarcoma.

Most patients are treated conservatively, by means of various forms of compression therapy, including complex physical therapy, pneumatic pumps and compressive garments. Volume reducing surgery is performed rarely. Lymphatic microsurgery is still in an experimental stage, although a few centers consistently report favorable outcomes.
Neutrophil function in peripheral arterial occlusive disease: the effects of prostaglandin E1
Authors: Weiss Thomas , Eckstein Henning , Weiss Claus , Diehm Curt
Published: January 2007

The role of polymorph nuclear neutrophils (PMN) in limb ischemia and reperfusion has been recognized only in recent years. The present study aimed to investigate the systemic and local (in femoral venous blood) effects of intra-arterially or intravenously applied prostaglandin E1 (PGE1) on systemic and ischemia-induced local changes in neutrophil function. Thirty patients with intermittent claudication were randomly assigned to intra-arterial or intravenous infusion of prostaglandin E1 (10 mgIAor15 mg IV over 30 min). Prior to infusion femoral arterial and venous blood samples were obtained from the predominantly affected leg under resting conditions and immediately after a 3-min period of ischemia induced by suprasystolic thigh compression. After 24 h additional blood samples were obtained at baseline, following infusion of prostaglandin E1, and again after another 3-min period of ischemia following the prostaglandin E1 infusion.

Intra-arterially administered prostaglandin E1 caused an increase in the PMN count by 3.5 ± 2% (p,0.05) and a decrease in free oxygen radical production by 13 ± 8% (p,0.05) measured by whole blood chemiluminescence. Additionally, a trend for lower PMN filterabilities (9 ± 12%, NS) was observed. Intra-arterially infused prostaglandin E1 significantly reduced the ischemia-induced decrease in neutrophil filterability (arterial and venous blood difference after ischemia - control: 22 ± 17% (p,0.05); IA PGE1:8 ± 11% (NS), each compared to baseline). Intravenously administered prostaglandin E1 showed similar systemic effects as the intra-arterial application, but did not affect the ischemia-induced changes in neutrophil filterability. In conclusion, prostaglandin E1 reduces PMN activation in patients with peripheral arterial occlusive disease.
Reflex sympathetic dystrophy: facts and hypotheses
Authors: Kurvers Harrie AJM
Published: January 2007

Reflex sympathetic dystrophy (RSD) syndrome has been recognized clinically for many years. It is most often initiated by trauma to a nerve, neural plexus, or soft tissue. Diagnostic criteria are the presence of regional pain and other sensory changes following a noxious event. The pain is associated with changes in skin colour, skin temperature, abnormal sweating, oedema, and sometimes motor abnormalities. The clinical course is commonly divided into three stages: first (acute or hyperaemic), second (dystrophic or ischaemic), and third (atrophic) stage. The diagnosis is primarily clinical, but roentgenography, scintigraphy, thermography, electromyography and assessment of nerve conduction velocity can help to confirm the diagnosis. Although a wide variety of treatments have been recommended, the only therapies found to be effective in large studies aim at interfering with the activity of the sympathetic nervous system. To this end, efferent sympathetic nerve activity can be interrupted surgically or chemically. Alternatively, adrenoceptor blockers may be used to relieve pain. Numerous theories have been proposed to explain the pathophysiology. Sympathetic dysfunction, which often has been purported to play a pivotal role in RSD, has been suggested to consist of an increased rate of efferent sympathetic nerve impulses towards the involved extremity induced by increased afferent activity. However, the results of several experimental studies suggest that sympathetic dys-function consists of supersensitivity to catecholamines induced by (partial) autonomic denervation. Besides, it has been suggested that excitation of sensory nerve fibres at axonal level causes release of neuropeptides at the peripheral endings of these fibres. These neuropeptides may induce vasodilation, increase vascular permeability, and excite surrounding sensory nerve fibres - a phenomenon referred to as neurogenic inflammation. At the level of the central nervous system, it has been suggested that the increased input from peripheral nociceptors alters the central processing mechanisms.
A multi-modal approach to the management of bypass graft failure
Authors: Greenberg Roy K , Ouriel Kenneth
Published: January 2007

Bypass graft failure is an unsolved problem in the contemporary treatment of peripheral arterial occlusion. Thrombolysis of a failed bypass graft is performed with instillation of plasminogen activators directly into the substance of the thrombus. Thrombolytic techniques can restore the bypass graft to its pre-occlusive state, clearing the inflow and outflow tracts of propagated thrombus and unmasking the causative lesion responsible for graft occlusion. Open surgery, or an endovascular modality, can then be employed to directly address these lesions. Recent randomized trials have demonstrated the safety and efficacy of a thrombolytic treatment strategy when the graft occlusion is acute, that is, when the patient presents within 2 weeks of the event. The appropriate management of the patient with an acutely occluded bypass graft includes thrombolysis, endovascular modalities and open surgery, employed in conjunction, to improve patient outcome over that observed with an immediate operation alone.
The interface of atherosclerosis and thrombosis: basic mechanisms
Authors: Libby Peter
Published: January 2007

Occlusive vascular disease most often results from thrombosis superimposed on atherosclerotic plaque. Disruption of plaque exposes thrombogenic substances within the plaque to blood and may result in thrombotic occlusion of the affected vessel. Mural thrombi may be incorporated into plaque, enhancing the evolution of atherosclerotic lesions. inflammation plays a key role in the formation and complication of atherosclerosis. inflammatory mediators regulate processes that determine the composition of the plaque's fibrous cap, a structure that separates blood from the thrombogenic lipid core. Several inflammatory mediators control the release of metalloproteinases (enzymes that break down cap constituents) from smooth muscle cells, macrophages and other cells within plaque. inflammatory mediators also control the production of connective tissue matrix by cells in the plaque. Factors involved in coagulation, such as thrombin, can regulate non-thrombotic functions of vascular wall cells such as smooth muscle proliferation or cytokine release. The many mechanisms involved in arterial occlusive disease present numerous points at which intervention with pharmacologic agents may prove effective in lowering the risk of acute arterial thrombotic complications.
Atherothrombosis: mechanisms and clinical therapeutic approaches
Authors: Fuster Valentin , Badimon Juan Jose , Chesebro James H
Published: January 2007

Eroded or disrupted atherosclerotic plaques act as a substrate for thrombosis, leading to ischemic coronary artery and cerebrovascular disease. Plaques vary greatly in composition, size, and the degree of stenosis they cause. Plaques can be categorized based on these features, which helps to estimate the likelihood of rupture and subsequent thrombosis. Vascular plaques often begin at regions with low and oscillatory shear forces that cause chronic minimal endothelial damage or dysfunction. Lipoproteins enter the vessel wall, promoting the recruitment of monocytes, which imbibe lipids and become foam cells. Smooth muscle cells invade these early plaques, producing connective tissue fibrils that form a fibrous cap over the lipid center; rupture of this cap is an important cause of thrombosis. Passive plaque disruption occurs when physical forces cause cap rupture; active disruption occurs when the cap is attacked by macrophages and proteolytic enzymes. Tissue factor is one of many factors within plaque that stimulates thrombosis.
Rationale for antiplatelet therapy in patients with atherothrombotic disease
Authors: Dormandy John A
Published: January 2007

The most common cause of morbidity and mortality in developed countries results from atherosclerosis and superimposed thrombosis (atherothrombosis) leading to partial or complete vascular occlusion. Much evidence supports the idea that all atherothrombosis is similar, regardless of which vascular bed it occurs in. Thus, similar therapies may be used for patients with symptomatic cardiac, cerebral, or peripheral vascular disease. The types of agents that have shown efficacy in atherothrombosis include antihypertensives, lipid-lowering agents and antiplatelet agents. The focus of this article is on the antiplatelet agents, of which there are several subcategories, including ADP receptor antagonists, GpIIb/IIIa antagonists, cyclooxygenase inhibitors and prostacyclin analogues. Clinical testing of these agents is ongoing and the efficacy and safety of the various agents are being defined. To date, the ADP receptor antagonist, clopidogrel, appears to provide the best antithrombotic result with the fewest side effects. Further testing may reveal that combinations of the various forms of antiplatelet agents may provide even further improvements on safety and efficacy.
Results of the CAPRIE trial: efficacy and safety of clopidogrel
Authors: Creager Mark A
Published: January 2007

The recent CAPRIE trial (clopidogrel versus aspirin in patients at risk of ischaemic events) compared clopidogrel with aspirin in reducing the risk of vascular events in 19 185 patients with clinical manifestations of atherosclerosis. Participants were randomized to receive daily oral clopidogrel (75 mg) or aspirin (325 mg). Treatment periods ranged from 1 to 3 years. The primary outcome measurement was an aggregate of myocardial infarction, ischemic stroke and vascular death. Event rates of 5.32% and 5.83% were associated with clopidogrel and aspirin therapy, respectively. Clopidogrel therapy resulted in a relative risk reduction of 8.7% (CI 0.3-16.5%) compared with aspirin therapy (p = 0.043). Gastrointestinal hemorrhages occurred in 1.99% of patients treated with clopidogrel and 2.66% of patients treated with aspirin (p, 0.002). There were no significant treatment-based differences in the rates of intracerebral hemorrhages and hemorrhagic deaths or thrombocytopenia. These results indicate that clopidogrel is more effective and safer than aspirin in reducing adverse cardiovascular events in patients with atherosclerosis.
Early development of deep-vein thrombosis following hip fracture surgery: the role of venous wall thickening detected by B-mode ultrasonography
Authors: Cracowski Jean-Luc , Bosson Jean-Luc , Baloul Fatsah , Moirant Cyrille , Hunt Mark , Merloz Philippe , Carpentier Patrick , Franco Alain
Published: January 2007

Deep-vein thrombosis (DVT) remains the most frequent complication following hip surgery. This study was designed in order to evaluate the development of DVT after hip fracture surgery, and to determine if venous wall thickening detected before surgery predisposes patients to postoperative DVT.

Systematic ultrasound examinations were performed on 100 consecutive patients undergoing hip fracture surgery on the day preceding the operation, and then postoperatively on days 2, 5 and 10. A total of 12 proximal, 28 distal deep-vein and four saphenous vein thromboses were detected. Of the DVT, 19 (43%) were detected at day 2. Five out of eight patients with venous wall thickening had a previous history of DVT. Venous wall thickening was positively correlated with proximal DVT development (62.5% versus 8% incidence in the group of patients with and without venous wall thickening respectively; p, 0.001, relative risk = 7.8). This study highlights the high frequency of early major thromboembolic events following hip fracture surgery. It is considered that patients with a previous history of venous thromboembolic disease should undergo B-mode ultrasonographic examination before hip fracture surgery. Patients in whom venous wall thickening is detected should have repeated postoperative ultrasonographic examinations enabling early detection of DVT.
Atherosclerotic aneurysms of the superficial femoral artery: report of two ruptured cases and review of the literature
Authors: Dimakakos Panos B , Tsiligiris Vassilios , Kotsis Thomas , Papadimitriou John D
Published: January 2007

Isolated arteriosclerotic aneurysms of the superficial femoral artery are rare. In citing the literature a total of 30 cases in 28 patients in the last 25 years were found. In addition to the above cases, two aged patients with ruptured aneurysms of the superficial femoral artery are reported; these were managed successfully with partial aneurysmectomy and restoration of the circulation of the extremity with a synthetic graft. The prognosis for this type of aneurysm following surgical therapy is good, despite the advanced age of the patients, and amputation is relatively rare, occurring in only two out of the 30 aneurysms (6.6%) reported. The risk of rupture is 46.6% (14/30) and is greater than that found in peripheral aneurysms. This, in association with the possibility of the creation of thrombosis (5/30; 16.6%) or embolization (1/30; 3.3%), threatens the extremity itself as well as the life of the patient, increasing the risk of complications and even death at a rate of 66.6% (20/30). Timely diagnosis, immediate surgical reconstruction and prompt mobilization, however, can guarantee a good prognosis for these aged patients.
Quantitative and qualitative progression of peripheral arterial disease by non-invasive testing
Authors: Bird Cameron E , Criqui Michael H , Fronek Arnost , Denenberg Julie O , Klauber Melville R , Langer Robert D
Published: January 2007

There is little information on the progression of peripheral arterial disease (PAD) over time. A series of 508 patients with a prior examination for PAD were contacted and brought in for follow-up to evaluate the natural history of PAD. A total of 85 patients were excluded because they had interventions in both limbs prior to their return visit. Progression was assessed in the remaining 423 patients for a total of 755 limbs, both quantitatively and qualitatively using six categories of PAD severity. There was a modest overall categorical progression of disease: 228 limbs (30.2%) displayed categorical progression, while 172 limbs (22.8%) improved over a 4.6-year average follow-up. Through analysis of quantitative change, it was determined that more quantitative progression occurred than was evident from categorical progression. Two of the three non-invasive tests employed, the ankle/brachial index (ABI) and posterior tibial peak forward flow velocity (peak PT), showed statistically significant progression during follow-up: mean ABI change =-0.019, 95% confidence interval (CI) =-0.031 to -0.007; mean peak PT change =-2.32 cm/s, 95% CI =-3.20 to -1.44. The toe/brachial index (TBI) also suggested progression: mean change =-0.013, but the 95% CI included no change. Standard scores (sum of the Z-scores for ABI, peak PT and TBI) were calculated. The standard score progressed approximately 0.34 units (standard deviations), p-value,0.001, over 4.6 years; or about 0.07 standard deviations per year. There were independent and statistically significant (p, 0.05) associations between the rate of PAD progression (standard score change) and age, diabetes, classic (`Rose') intermittent claudication, moderate to severe PAD in the same limb, moderate to severe PAD in the contralateral limb and future therapeutic intervention. There were independent and suggestive associations (0.05, p-value, 0.15) between PAD progression and pain at rest, mild PAD in the same limb, and mild PAD in the contralateral limb. PAD progression was not associated with gender, atypical claudication, or amputation status.

Thus, in this cohort of PAD patients, PAD on average progressed significantly over 4.6 years. This progression was independently related to age, diabetes and several markers of disease severity.
Combination of pressure and velocity parameters in the non-invasive diagnosis of aorto-iliac disease
Authors: Fronek Arnost , Oglevie Steve , Curran Barbara , Fronek Kitty
Published: January 2007

Three different femoral artery flow velocity parameters in combination with segmental pressure measurements were evaluated for their respective diagnostic value in identifying the presence or absence of hemodynamically significant aorto-iliac disease.

A total of 60 patients (119 legs) were examined both non-invasively and with arteriography. Doppler flow velocities were recorded using a 5-MHz CW Doppler velocity metering system. Of the three parameters used (peak velocity, decay time and deceleration), a decay time of 220 ms yielded the most practical discriminant value. The accuracy increases when in addition the upper thigh/arm pressure ratio values are considered.

The results indicate that the combination of femoral artery decay time with the upper thigh/arm pressure index provides a simple and accurate non-invasive screening method to confirm or rule out aorto-iliac disease. This helps to determine whether the patient is a candidate for arteriography and for potential surgical intervention.
Fibroblast growth factor as therapy for critical limb ischemia: a case report
Authors: Cooke John P , Bhatnagar Ritu , Szuba Andrzej , Rockson Stanley G
Published: January 2007

In an attempt to avert impending, primary amputation, an 85-year-old woman with chronic critical leg ischemia was enrolled in an experimental protocol to induce therapeutic angiogenesis. Treatment consisted of six consecutive, weekly intravenous infusions of recombinant basic fibroblast growth factor (bFGF). Angiographic evaluation was performed before and after therapy. The patient's clinical response was monitored through serial measurements of the ankle/brachial index and by repetitive assessment of limb flow by mercury strain-gauge plethysmography.

A beneficial clinical response was detectable by week 4 of therapy, which was characterized by an improved walking distance, relief of ischemic pain, a marked reduction in analgesic consumption, and healing of persistent, unresponsive, painful inflammation of the hallux. The clinical improvement was sustained throughout the remaining weeks of therapy and follow-up evaluation. Plethysmography documented improved blood flow; specifically, the augmentation of digital flow was sustained and correlated with the marked improvement in the patient's clinical status.
Increased carotid artery intimal-medial thickness: risk factor for exercise-induced myocardial ischemia in asymptomatic older individuals
Authors: Nagai Yoji , Metter E Jeffrey , Fleg Jerome L
Published: January 2007

Asymptomatic coronary artery disease (CAD) is prevalent in the general population and has been associated with an increased risk for symptomatic CAD. Although the diagnosis of asymptomatic CAD is currently dependent on exercise testing and coronary angiography, other vascular diagnostic techniques could potentially be of aid in the assessment. Increased intimal-medial thickness (IMT) of the common carotid artery as assessed by B-mode ultrasonography is a purported index of atherosclerosis, and is associated with symptomatic CAD. Based on a recent report, this article will focus on the relationship between IMT and asymptomatic CAD as evidenced by exercise ECG, and in combination with exercise thallium scintigraphy. It was found that exercise-induced ST segment depression was associated with increased IMT independent of age, coronary risk factors and manifest CAD. After adjustment for age, IMT progressively increased from healthy subjects to asymptomatic subjects with positive exercise ECG alone, to those with concordant positive ECG and thallium scintigraphic findings who had IMT virtually identical to that in subjects with manifest CAD. Each 0.1 mm increase in IMT was associated with a 1.91-fold (95% CI 1.46-2.50) increased risk for concordant positive exercise tests or manifest CAD, independent of other coronary risk factors. These findings and the review of the literature suggest the potential utility of carotid ultrasonography in identifying asymptomatic individuals at higher risk for CAD.
Effects of dietary l-arginine on the reactivity of canine coronary arteries
Authors: Ray Edward C , Landis Michael E , Miller Virginia M
Published: January 2007

Experiments were designed to determine the effects of supplemental dietary l-argi-nine on the endothelial and smooth muscle function of canine coronary arteries. One group of dogs was fed the standard laboratory chow while another group was supplemented with 250 mg/kg per day l-arginine. All dogs had undergone bilateral reversed interposition saphenous vein grafting and received 325 mg/day oral aspirin. After 5 weeks of arginine feeding, left circumflex coronary arteries were removed, cut into rings, and suspended for the measurement of isometric force in organ chambers. Concentration-response curves were obtained to l-arginine, UK-14,304 (a2-adrenergic agonist) and A23187 (calcium ionophore) in the absence and presence of NG-monomethyl-l-arginine (l-NMMA) and tetraethylammonium (TEA) alone or in combination.

Serum concentrations of l-arginine increased by about 20% following 2 weeks of arginine feeding and remained elevated throughout the study. In rings with and without endothelium contracted with prostaglandin F2a, l-arginine caused concentration-dependent contractions in rings from control animals but no significant change in tension in rings from arginine-fed animals. Contractions to l-arginine in control animals were reduced by either l-NMMA or TEA. Endothelium-dependent relaxations to the a2-adrenergic agonist were decreased with arginine feeding while relaxations to the calcium ionophore and the endothelium-derived factor nitric oxide were similar among groups. Relaxations to UK-14,304 were reduced by l-NMMA in both groups but by TEA only in rings from control animals.

These results suggest that dietary supplementation with l-arginine modifies reactivity of endothelium and smooth muscle by at least two mechanisms: one associated with activation of potassium channels and the other with receptor-coupled release of nitric oxide.
Clinical utility of lipid and lipoprotein levels during hospitalization for acute myocardial infarction
Authors: Gaziano J Michael , Hennekens Charles H , Satterfield Suzanne , Roy Christopher , Sesso Howard D , Breslow Jan L , Buring Julie E
Published: January 2007

The management of dyslipidemia after myocardial infarction (MI) is an important aspect of post-myocardial infarction care. However, acute changes in the lipid profile immediately following myocardial infarction have resulted in uncertainty regarding the clinical utility of lipid levels assessed during hospitalization for MI. We studied the effect of the timing of plasma lipid assessment among 294 patients who presented with MI to determine whether the differences between the serum lipid values in-hospital when compared with post-discharge values (generally 2-3 months after MI) would have a substantial impact on the decision to initiate lipid-lowering therapy. We found that the mean total and LDL cholesterol levels were significantly lower in-hospital when compared with generally 2-3 months later. However, patients whose lipids were measured within 48 h of presentation did not have significantly different values compared with generally 2-3 months post-discharge. Moreover, despite slightly lower in-hospital levels, 83.7% of patients were above the National Cholesterol Education Program target LDL for secondary prevention and 57.6% met the criteria for drug therapy based on in-hospital assessment. Total and LDL cholesterol levels fall modestly after an acute MI; however, from a clinical perspective, in-hospital levels can be used to guide decisions regarding lipid-lowering therapy which can begin in the immediate post-MI setting. In-hospital levels approximate post-MI levels, particularly if drawn within 48 h of presentation. All patients with acute myocardial infarction should have complete lipid profiles measured prior to discharge.
Correlation of hemodynamic and functional variables with the angiographic extent of peripheral arterial occlusive disease
Authors: Müller-Bühl Uwe , Wiesemann Armin , Oser Barbara , Kirchberger Inge , Strecker Ernst-Peter
Published: January 2007

The aim of the study was to determine whether hemodynamic and functional variables are related to the angiographic extent of lower limb atherosclerosis. In 150 patients with stable intermittent claudication, the Bollinger angiogram score was compared with the resting Doppler pressure values, and the initial claudication distance (ICD) and absolute claudication distance (ACD) with treadmill exercise. The extent of lower limb atherosclerosis correlated significantly with the age of the patients and the duration of the claudication. The angiogram scores of the patients were negatively correlated with the ankle systolic blood pressure (SBP) and the ankle/brachial index (ABI). In a multiple regression analysis, ABI was the most predictive variable for the angiographic severity of disease. ICD, ACD and work on the treadmill failed to correlate with the angiogram summation score. If patients were classified into groups for those with iliac or femoropopliteal disease, a weak correlation between ACD and femoropopliteal angiogram score was found. The comparison between Doppler measurements and treadmill exercise testing showed no significant correlation between SBP/ABI of the more diseased limb and ICD. However, both SBP and ABI did correlate significantly with ACD (r = 0.16, p, 0.05 and r = 0.20, p, 0.01, respectively). In conclusion, SBP and ABI are reliable parameters for indirect assessment of the angiographic extent of lower limb atherosclerosis. In contrast, the walking capacity of claudicant patients is independent of the angiographic severity of the disease.
Clinical applications of brachytherapy for the prevention of restenosis
Authors: Lee David P , Lo Sidney , Forster Kenneth , Yeung Alan C , Oesterle Stephen N
Published: January 2007

Restenosis remains the bane of percutaneous coronary intervention. Local delivery of radiation, brachytherapy, is a promising therapy for the prevention of restenosis. Animal studies have suggested that brachytherapy may be an effective treatment for preventing restenosis. The type of radiation as well as the doses and delivery systems are currently under study; several clinical trials are underway. This paper reviews the biological basis, including animal studies, of intracoronary brachytherapy as well as the current data from clinical trials.
Statins and cerebrovascular disease: plaque attack to prevent brain attack
Authors: Mohler Emile R , Delanty Norman , Rader Daniel J , Raps Eric C
Published: January 2007

Stroke is the third leading cause of death in the USA and in the developed world. The beneficial role of cholesterol reduction in decreasing stroke has been uncertain. However, recent data indicate that statin treatment in patients with a history of myocardial infarction not only reduces the risk of a second myocardial infarction, coronary heart disease, revascularization procedures and death, but also significantly reduces the risk of stroke. However, the mechanism(s) by which statins reduce stroke remain uncertain. Thus, the therapeutic armamentarium for the reduction of stroke in secondary prevention now includes cholesterol reduction with statins.
The trauma patient: critical decision making. When to explore the abdomen. A South African perspective
Authors: Bautz Peter
Published: January 2007

Groote Schuur Hospital Trauma Unit (GSHTU) manages 110 gunshot wounds (GSW) and 400 stabbings per month. Eighty per cent of all laparotomies are for GSW. Knowledge of the various regions of the abdominal cavity is vital in penetrating injuries. Intraperitoneal injuries tend to manifest early, while retroperitoneal injuries are treacherous in that delayed presentations are the norm. The diaphragm position at the time of penetrating injuries determines whether thoraco-abdominal injuries are intrathoracic only, combined diaphragm and abdominal, or diaphragm and abdominal injuries only. Special investigations commonly miss hollow visceral injuries, so careful clinical examination is of greater importance than ultrasound or computerized tomography scanning. Initial conservative management is recommended for the stabbed abdomen, but laparotomy is generally indicated for all abdominal GSW. Polytrauma victims generally do not have significant intra-abdominal injuries unless there is unexplained hypotension, unexplained reduced haemoglobin levels, denervated abdomens and distended abdomens with shock.
Anaesthesia in adverse climates
Authors: Houghton IT
Published: January 2007

While civilization and technological advances provide ever greater control over the environment, so does mankind’s ability to travel in increasing numbers to parts where the climate may be adverse. Indeed, disasters may be man-made, as well as naturally occurring. Thermoregulation is important in cold climates and hypothermia causes profound physiological changes, which affect anaesthesia. Heat loss must be minimized during anaesthesia in the cold and it will almost always be essential to provide some heating for the operating room. The cold may cause difficulties with the vaporization of volatile anaesthetic agents. At altitude, there are the twin problems of cold and reduced atmospheric pressure. Again, these factors will affect both physiological and equipment function adversely. Heat and high humidity also affect both patient physiology and the functioning and life expectancy of anaesthetic equipment in use and storage. Hyperpyrexia is a particular hazard in the unacclimatized and there is an increased requirement for fluid replacement.
Aspects of the knee: meniscal injury and surgery
Authors: Learmonth DJA
Published: January 2007

The meniscus is a vital structure for the proper function of the knee joint. The anatomy and biomechanics of the meniscus are ideally suited for its function. Tears in the meniscus may be traumatic and or degenerative. They may also be associated with other knee ligament or chondral pathology. Clinical symptoms and signs of a meniscal tear are variable and most clinical signs unreliable. The magnetic resonance imaging scan is the most accurate imaging for the diagnosis of meniscal tears. Surgical treatment is aimed at preserving as much meniscus as possible to reduce the risk of later osteoarthritis. Meniscal repair and transplantation/replacement are evolving surgical treatments.