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1.
Lower extremity peripheral artery disease: a basic approach.
Chan, KA, Junia, A
British journal of hospital medicine (London, England : 2005). 2020;(3):1-9
Abstract
Peripheral artery disease of the lower limbs is a chronically progressive disorder characterised by the presence of occlusive lesions in the medium and large arteries that result in symptoms secondary to insufficient blood flow to the lower extremities. It is both a manifestation of systemic atherosclerosis and a marker of increased cardiovascular morbidity and mortality. Because of its highly heterogenous clinical picture, a detailed history and physical assessment, a high degree of suspicion for peripheral artery disease and the use of the ankle-brachial pressure index is essential to identify patients with peripheral artery disease. This will allow early administration of basic pharmacotherapy and lifestyle changes to reduce cardiovascular events, minimise claudication symptoms and enable optimal revascularisation to prevent loss of limb function.
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2.
Microvascular Disease Increases Amputation in Patients With Peripheral Artery Disease.
Behroozian, A, Beckman, JA
Arteriosclerosis, thrombosis, and vascular biology. 2020;(3):534-540
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Abstract
It is estimated that >2 million patients are living with an amputation in the United States. Peripheral artery disease (PAD) and diabetes mellitus account for the majority of nontraumatic amputations. The standard measurement to diagnose PAD is the ankle-brachial index, which integrates all occlusive disease in the limb to create a summary value of limb artery occlusive disease. Despite its accuracy, ankle-brachial index fails to well predict limb outcomes. There is an emerging body of literature that implicates microvascular disease (MVD; ie, retinopathy, nephropathy, neuropathy) as a systemic phenomenon where diagnosis of MVD in one capillary bed implicates microvascular dysfunction systemically. MVD independently associates with lower limb outcomes, regardless of diabetic or PAD status. The presence of PAD and concomitant MVD phenotype reveal a synergistic, rather than simply additive, effect. The higher risk of amputation in patients with MVD, PAD, and concomitant MVD and PAD should prompt aggressive foot surveillance and diagnosis of both conditions to maintain ambulation and prevent amputation in older patients.
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3.
[Lower extremity peripheral artery disease : local and systemic complications].
Calanca, L, Alatri, A, Lanzi, S, Deglise, S, Mazzolai, L
Revue medicale suisse. 2019;(674):2247-2250
Abstract
Lower extremity peripheral artery disease can lead to local complications but also to complications in other vascular areas, stressing the systemic impact of the atheromatous disease. The current concepts of MALE (Major Adverse Limb Events) and MACE (Major Adverse Cardiac Events) encompass these risks. The systemic vascular complications, as well as the ones at lower extremities, are associated with significant morbidity and mortality. An optimal therapeutic management and healthy lifestyle, such as regular exercise, are crucial to limit the risk of unfavorable progression of the arterial disease. A close collaboration between the general practitioner and the angiologist is a key to adequate initial management and follow-up of the patients.
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New advances in MRI diagnosis of degenerative osteoarthropathy of the peripheral joints.
Bruno, F, Arrigoni, F, Palumbo, P, Natella, R, Maggialetti, N, Reginelli, A, Splendiani, A, Di Cesare, E, Brunese, L, Guglielmi, G, et al
La Radiologia medica. 2019;(11):1121-1127
Abstract
Degenerative osteoarthropathy is one of the leading causes of the pain and disability from musculoskeletal disease in the adult population. Magnetic resonance imaging (MRI) allows optimal visualization of all tissues involved in degenerative osteoarthritis disease process, mainly the articular cartilage. In addition to qualitative and semiquantitative morphologic assessment, several MRI-based advanced techniques have been developed to allow characterization and quantification of the biochemical cartilage composition. These include quantitative analysis and several compositional techniques (T1 and T2 relaxometry measurements and mapping, sodium imaging, delayed gadolinium-enhanced MRI of cartilage dGEMRIC, glycosaminoglycan-specific chemical exchange saturation transfer gagCEST, diffusion-weighted imaging DWI and diffusion tensor imaging DTI). These compositional MRI techniques may have the potential to serve as quantitative, reproducible, noninvasive and objective endpoints for OA assessment, particularly in diagnosis of early and pre-radiographic stages of the disease and in monitoring disease progression and treatment effects over time.
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5.
Lower extremity artery disease in patients with type 2 diabetes.
Buso, G, Aboyans, V, Mazzolai, L
European journal of preventive cardiology. 2019;(2_suppl):114-124
Abstract
Among all peripheral arterial diseases, lower extremity arterial disease is a serious condition in subjects with type 2 diabetes mellitus, associated with important disability, cardiovascular risk, and socio-economic burden. Patients with both conditions generally display poorer prognosis of affected limbs compared with non-diabetic subjects, leading to increased rates of adverse limb events including amputations. Nonetheless, awareness on lower extremity arterial disease remains somehow suboptimal in the diabetic population, partly related to an atypical clinical presentation in several cases. A regular and appropriate screening for lower extremity arterial disease in patients suffering from type 2 diabetes mellitus is therefore recommended. Affected subjects should receive optimal medical treatment including careful management of the different cardiovascular risk factors through a healthy lifestyle, a regular and structured physical activity, the administration of lipid-lowering, antidiabetic drugs, and (when indicated) antihypertensive and antithrombotic drugs. This review aims to outline current evidence about lower extremity arterial disease in patients with type 2 diabetes mellitus, in order to elucidate its epidemiology, pathophysiology, screening and diagnosis, and management options.
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6.
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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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.
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9.
The influence of patients' nutritional status on the prevalence, course and treatment outcomes of lower limb ischemia: an overview of current evidence.
Spychalska-Zwolińska, M, Zwoliński, T, Anaszewicz, M, Budzyński, J
International angiology : a journal of the International Union of Angiology. 2018;(2):100-111
Abstract
INTRODUCTION The association of lower limb ischemia (LLI) with disturbances in nutritional status, in respect to over- or undernutrition, is still uncertain. The aim of this study was to present the current state of knowledge on this issue. EVIDENCE ACQUISITION Systematic review of papers published between 2006 and 2018. EVIDENCE SYNTHESIS The literature shows inconclusive evidence regarding the impact of nutritional status on the risk, course, prognosis and outcomes of conservative and invasive treatment of LLI. The majority of publications available demonstrate greater LLI prevalence in overweight and obese patients, a worse prognosis both in malnourished and severely obese patients, poorer outcomes of invasive treatment in underweight patients, and better results for endovascular and surgical treatment in patients with overweight and class I obesity, although without such a relationship for conservative therapy. Possible explanations linking nutritional status and LLI seem to be: the endocrine, paracrine, and autocrine activity of adipose tissue, a decrease in physical activity, and the effect of diet-dependent comorbidities, e.g. diabetes mellitus, hypertension and dyslipidemia. CONCLUSIONS There is a growing body of evidence concerning an association between LLI and patients' nutritional status. A so-called "obesity paradox" or "BMI paradox" seems to exist among patients with LLI and mainly concerns outcomes of endovascular and surgical treatment. However, further studies are needed to evaluate the clinical importance of body composition, the distribution and endocrine activity of adipose tissue, and the effect of weight reduction and/or nutritional support in the LLI patient group.
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Prevention of exertional lower body musculoskeletal injury in tactical populations: protocol for a systematic review and planned meta-analysis of prospective studies from 1955 to 2018.
Flanagan, SD, Sinnott, AM, Krajewski, KT, Johnson, CD, Eagle, SR, LaGoy, AD, Beckner, ME, Beethe, AZ, Turner, R, Lovalekar, M, et al
Systematic reviews. 2018;(1):73
Abstract
BACKGROUND Exertional lower body musculoskeletal injuries (ELBI) cost billions of dollars and compromise the readiness and job performance of military service and public safety workers (i.e., tactical populations). The prevalence and burden of such injuries underscores the importance of prevention efforts during activities necessary to sustain core occupational competencies. Attempts to synthesize prevention techniques specific to tactical populations have provided limited insight on the comparative efficacy of interventions that do not modify physical training practices. There is also a need to assess the influence of sex, exposure, injury classification scheme, and study design. Thus, the primary purpose of the systematic review and planned meta-analysis detailed in this protocol is to evaluate the comparative efficacy of ELBI prevention strategies in tactical populations. METHODS A systematic search strategy will be implemented in MEDLINE, EMBASE, Cochrane, and CINAHL. A multi-tiered process will be used to capture randomized controlled trials and prospective cohort studies that directly assess the prevention of ELBI in tactical population(s). Extracted data will be used to compare prevention strategies and assess the influence of heterogeneity related to occupation, sex, exposure, injury characteristics, and study quality. In addition, individual risk of bias, meta-bias, and the quality of the body of evidence will be rigorously tested. DISCUSSION This systematic review and planned meta-analysis will comprehensively evaluate ELBI mitigation strategies in tactical populations, elucidate factors that influence responses to treatment, and assess the overall quality of the body of research. Results of this work will guide the prioritization of ELBI prevention strategies and direct future research efforts, with direct relevance to tactical, health and rehabilitation science, and human performance optimization stakeholders. SYSTEMATIC REVIEW REGISTRATION The systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 3 Jan 2018 (registration number CRD42018081799 ).