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1.
Lower extremity arterial disease in patients with diabetes: a contemporary narrative review.
Nativel, M, Potier, L, Alexandre, L, Baillet-Blanco, L, Ducasse, E, Velho, G, Marre, M, Roussel, R, Rigalleau, V, Mohammedi, K
Cardiovascular diabetology. 2018;(1):138
Abstract
Lower-extremity arterial disease (LEAD) is a major endemic disease with an alarming increased prevalence worldwide. It is a common and severe condition with excess risk of major cardiovascular events and death. It also leads to a high rate of lower-limb adverse events and non-traumatic amputation. The American Diabetes Association recommends a widespread medical history and clinical examination to screen for LEAD. The ankle brachial index (ABI) is the first non-invasive tool recommended to diagnose LEAD although its variable performance in patients with diabetes. The performance of ABI is particularly affected by the presence of peripheral neuropathy, medial arterial calcification, and incompressible arteries. There is no strong evidence today to support an alternative test for LEAD diagnosis in these conditions. The management of LEAD requires a strict control of cardiovascular risk factors including diabetes, hypertension, and dyslipidaemia. The benefit of intensive versus standard glucose control on the risk of LEAD has not been clearly established. Antihypertensive, lipid-lowering, and antiplatelet agents are obviously worthfull to reduce major cardiovascular adverse events, but few randomised controlled trials (RCTs) have evaluated the benefits of these treatments in terms of LEAD and its related adverse events. Smoking cessation, physical activity, supervised walking rehabilitation and healthy diet are also crucial in LEAD management. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in LEAD management. The revascularization strategy should take into account several factors including anatomical localizations of lesions, medical history of each patients and operator experience. Further studies, especially RCTs, are needed to evaluate the interest of different therapeutic strategies on the occurrence and progression of LEAD and its related adverse events in patients with diabetes.
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2.
Genetic polymorphisms in the FVII gene is associated with lower extremity deep venous thrombosis: A case-control study.
Liu, JW, Chen, DQ
Journal of cellular biochemistry. 2018;(8):6715-6722
Abstract
This study aims to explore the associations between FVII gene polymorphisms (R353Q, 5'F7, and -402G/A) and lower extremity deep venous thrombosis (LEDVT) in a Chinese Han population. LEDVT patients (153) and healthy people (174) were, respectively, as case and control groups and evaluated related biochemical indicators. Gene polymorphisms of R353Q, 5'F7, and -402G/A of FVII, serum FVII level, antithrombin activity, plasma fibrinogen content, and plasma D-dimer (D-D) level were determined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP), ELISA, chromogenic substrate assay, coagulating assay, and Immunoturbidimetry assay, respectively. Compared with the control group, the case group had a higher level of body mass index (BMI), glucose, and fibrinogen, and lower level of total cholesterol (TC). Notable differences were found in GG genotype, G and A alleles, as well as distribution of recessive model of -402G/A. The serum FVII level of GG genotype was higher than that of GA and AA genotypes. FIB and D-D had a higher level had a lower level in GG genotype when compared with GA and AA genotypes. Smoking, drinking, serum FVII level, and -402G/A-GG were the independent risk factors for LEDVT. This study demonstrates that -402G/A of FVII may be a risk factor for LEDVT patients in a Chinese Han population.
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3.
Risk factors analysis of thromboembolectomy for acute thromboembolic lower extremity ischemia in native arteries.
Piffaretti, G, Angrisano, A, Franchin, M, Ferrario, M, Rivolta, N, Bacuzzi, A, Castelli, P, Tozzi, M
The Journal of cardiovascular surgery. 2018;(6):810-816
Abstract
BACKGROUND Aim of this study is to report the results of thromboembolectomy (ThEmb) for acute thromboembolic lower limb ischemia (ATLI) in native arteries and to create a predictive score for amputation-free survival (AFS) at 30 days. METHODS It is a single center, retrospective analysis of a four years period. All patients had ThEmb: adjunctive procedures included femoral and/or popliteal endarterectomy in 30 (18.3%) cases, PTA-stent in 24 (14.6%), and femoral endarterectomy plus PTA-stent in 12 (7.3%). Fasciotomies were performed in 6 (3.6%) patients. Predictors of AFS identified on univariate screen (inclusion threshold, P<.20) were included in a multivariable model. The resulting significant predictors were assigned an integer score to stratify patients into risk groups. RESULTS Authors analyzed 164 limbs in 164 patients. Mean age was 80±10 years (range, 40-99). In-hospital mortality was 9.8% (N.=16); AFS at 30 days was 84.7% (N.=139). The anatomic level (iliac vs. femoropopliteal vs. infrapopliteal) of the occlusion did not affect AFS (P=.326). Multivariable analysis identified six significant predictors of AFS at 30 days: age >85 (P=0.050), chronic obstructive pulmonary disease (P=0.008), chronic renal insufficiency (P=0.019), late (>6 hours) onset (P=0.004), the presence of major neurologic deficit (P=0.023), and an increased (>800IU/L) level of creatine phosphokinase (P=0.001). An integer score generated two risk groups (low-risk 0-2 [70.1% of cohort], and high-risk ≥3 [29.9% of cohort]): stratification of the patients according to risk category yielded significantly different AFS at 30 days (low-risk 5.2% vs. high-risk 38.8%, P<0.0001). CONCLUSIONS Among patients selected to undergo ThEmb for ATLI in native arteries, this risk score identified a group of patients with a 40% chance of death or major amputation at 30 days. The score can help to optimize the operative strategy, but further prospective validation is needed.
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Effects of supervised exercise training on lower-limb cutaneous microvascular reactivity in adults with venous ulcers.
Tew, GA, Gumber, A, McIntosh, E, Kesterton, S, King, B, Michaels, JA, Klonizakis, M
European journal of applied physiology. 2018;(2):321-329
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Abstract
PURPOSE To investigate the effects of a 12-week supervised exercise programme on lower-limb cutaneous microvascular reactivity in adults with venous leg ulceration. METHODS Thirty-eight adults with unilateral venous ulceration who were being treated with lower-limb compression therapy (58% male; mean age 65 years; median ulcer size 5 cm2) were randomly allocated to exercise or control groups. Exercise participants (n = 18) were invited to attend thrice weekly sessions of lower-limb aerobic and resistance exercise for 12 weeks. Cutaneous microvascular reactivity was assessed in the gaiter region of ulcerated and non-ulcerated legs at baseline and 3 months using laser Doppler fluxmetry coupled with iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP). Cutaneous vascular conductance (CVC) was calculated as laser Doppler flux (AU)/mean arterial pressure (mmHg). RESULTS Thirty-seven participants completed follow-up assessments. Median session attendance was 36 (range 2-36). Analyses of covariance revealed greater peak CVC responses to ACh in the exercise group at 3 months in both the ulcerated (adjusted difference = 0.944 AU/mmHg; 95% CI 0.504-1.384) and non-ulcerated (adjusted difference = 0.596 AU/mmHg; 95% CI 0.028-1.164) legs. Peak CVC responses to SNP were also greater in the exercise group at 3 months in the ulcerated leg (adjusted difference = 0.882 AU/mmHg; 95% CI 0.274-1.491), but not the non-ulcerated leg (adjusted difference = 0.392 AU/mmHg; 95% CI - 0.377 to 1.161). CONCLUSION Supervised exercise training improves lower-limb cutaneous microvascular reactivity in adults with venous leg ulceration.
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SGLT2 inhibitors for diabetes are linked to increased risk of lower limb amputation.
Kmietowicz, Z
BMJ (Clinical research ed.). 2018;:k4828
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Acute effects of walking and combined exercise on oxidative stress and vascular function in peripheral artery disease.
Lima, AHRA, Correia, MA, Soares, AHG, Farah, BQ, Forjaz, CLM, Silva, AS, Brasileiro-Santos, MS, Santos, AC, Ritti-Dias, RM
Clinical physiology and functional imaging. 2018;(1):69-75
Abstract
The aim of this study was to compare the effects of a single session of walking and combined exercise on oxidative stress and vascular function in peripheral arterial disease patients. Thirteen patients with peripheral arterial disease underwent two experimental sessions in random order: walking (ten sets of 2-min walking at the speed corresponding to the onset of claudication pain with 2-min interval between sets) and combined exercise (1 × 10 reps in eight resistance exercises plus five-two-minute sets of walking). Before and after the exercise, vascular function (blood flow, leg vascular resistance and blood-flow postreactive hyperaemia) and oxidative stress (malondialdehyde and plasma nitrite levels) were obtained. Blood flow increased similarly after both sessions, whilst leg vascular resistance decreased similarly after both sessions. Plasma nitrite increased only after the combined exercise. Malondialdehyde decreased after both sessions, and the decrease was greater after combined exercise. As a conclusion, a single session of combined exercise improves blood flow and leg vascular resistance similarly to walking session; however, combined exercise promoted better effects on oxidative stress.
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Diabetic polyneuropathy is a risk factor for decline of lower extremity strength in patients with type 2 diabetes.
Nomura, T, Ishiguro, T, Ohira, M, Ikeda, Y
Journal of diabetes investigation. 2018;(1):186-192
Abstract
AIMS/INTRODUCTION The present study elucidated the effect of diabetic polyneuropathy (DPN) on lower extremity strength in a wide age range of type 2 diabetes patients. MATERIALS AND METHODS Participants (n = 1,442) were divided into three age groups (30-49 years, 50-69 years and 70-87 years), and comparisons were made separately for each sex. Lower extremity strength was measured in terms of knee extension force (KEF) with a hand-held dynamometer. KEF was compared according to the presence or absence of DPN. Furthermore, the effect of DPN on KEF with other diabetic complications (diabetic retinopathy and diabetic nephropathy), diabetes status (diabetes duration and glycated hemoglobin) and habitual behavior (regular exercise, smoking and drinking behaviors) as explanatory variables was analyzed using multiple regression analysis in several models. RESULTS The frequency of DPN differed among age groups, ranging from 14.3 to 49.6%, and increasing with age. There was no significant difference in KEF between patients aged 30-49 years with and without DPN. However, among both men and women aged 50-69 years and 70-87 years, patients with DPN showed significantly diminished KEF (11.0-12.9% and 11.9-16.6%, respectively) compared with those without DPN (P < 0.01-0.001). In women aged 50-69 years and 70-87 years, and in men aged 50-69 years, DPN was a significant explanatory variable for KEF in all multiple regression analysis models. CONCLUSION DPN might reinforce a KEF decline in middle-aged and elderly type 2 diabetes patients.
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The relationship between gene polymorphism of MTRR A66G and lower extremity deep venous thrombosis.
Xu, J, Zhou, W
Hematology (Amsterdam, Netherlands). 2018;(10):828-832
Abstract
OBJECTIVE To investigate the relationship between gene polymorphism of MTRR A66G and lower extremity deep venous thrombosis (DVT). METHODS Two hundred and two patients with DVT as experimental group and 240 normal adults (control group) were enrolled in this study and white blood cells were collected, respectively. Polymorphism of the 66 loci in MTRR gene was detected by polymerase chain reaction-sequence-specific primers (PCR-SSP) in two groups. The frequency of genotype and allele distribution of each group was compared. RESULTS The frequency of AA, AG and GG genotypes in 66 sites of MTRR gene were 26.76%, 4 3.66% and 29.58% in DVT group and 43.57%, 44.28% and 12.14% in control group, respectively. There was no significant difference in the distribution frequency between two groups (χ = 3.2, P > .5). CONCLUSIONS The gene polymorphism of MTRR A66G may not be an independent genetic risk factor in DVT in China.
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Threshold of Energy Deficit and Lower-Body Performance Declines in Military Personnel: A Meta-Regression.
Murphy, NE, Carrigan, CT, Philip Karl, J, Pasiakos, SM, Margolis, LM
Sports medicine (Auckland, N.Z.). 2018;(9):2169-2178
Abstract
BACKGROUND Negative energy balance (EB) is common during military operations, diminishing body mass and physical performance. However, the magnitude of negative EB where performance would still be maintained is not well defined. OBJECTIVE Our objective was to explore relationships between EB and physical performance during military operations and define an acceptable negative EB threshold where performance may be maintained. METHODS A systematic search was performed for studies that measured EB and physical performance during military training. A total of 632 articles and technical reports were screened. Lower-body power and strength were the most common performance tests across investigations and were used as physical performance outcomes. Data were extracted from nine eligible studies containing 15 independent subgroups. Meta-regression assessed changes in performance in relation to study duration (days), average daily EB, and total EB (daily EB × duration). RESULTS Changes in physical performance were not associated with average daily EB or training duration. Total EB was associated with changes in lower-body power (r2 = 0.764, P < 0.001) and strength (r2 = 0.836, P < 0.001) independently and combined (r2 = 0.454, P = 0.002). Predictive equations generated from the meta-regression indicated that, for a zero to small (2%) decline in performance, total EB should be limited to - 5686 to - 19,109 kcal, for an entire operation, whereas total EB of - 39,243 to - 59,377 kcal will result in moderate (7%) to large (10%) declines in performance. CONCLUSION These data demonstrated that greater total negative EB is associated with declines in lower-body performance during military operations.
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Analgesics Administered for Pain During Hospitalization Following Lower Extremity Fracture: A Review of the Literature.
Griffioen, MA, OʼBrien, G
Journal of trauma nursing : the official journal of the Society of Trauma Nurses. 2018;(6):360-365
Abstract
Effective treatment of acute pain during hospitalization following lower extremity fracture is critical to improve short-term patient outcomes including wound healing, stress response, hospital length of stay, and cost as well as minimizing long-term negative patient outcomes such as delayed return to work, disability, and chronic pain. As many patients report moderate to severe pain during hospitalization, identifying the analgesics that most effectively reduces pain is a priority to improve patient outcomes. The purpose of this review was to examine published studies describing patient response to analgesics administered orally (PO) or intravenously (IV) in the immediate hospitalization following lower extremity fracture. PubMed was queried for articles published through May 2017 that included information on type of study, population, fracture site, pain measurement tool, analgesic, and result. Of 514 articles found, eight met the inclusion criteria. Analgesics administered PO or IV were fentanyl, hydromorphone, morphine, remifentanil, diclofenac, ibuprofen, ketorolac, and etoricoxib. Five of the studies focused on comparisons between one or more analgesics and three studies compared an IV analgesic to a regional anesthetic agent. Two studies compared different nonsteroidal anti-inflammatory drugs (NSAIDs). Bupivacaine, lignocaine, and levobupivacaine administered as regional nerve blocks were superior to controlling pain compared with IV fentanyl and IV hydromorphone. IV morphine provided faster and better pain relief compared with IV ibuprofen. Based on the limited data available, regional nerve blocks provided superior pain relief compared with opioids, and opioids provided superior pain relief compared with NSAIDs. Different NSAIDs provided similar pain relief.