Uwe Müller-Bühl

Relevance of claudication pain distance in patients with peripheral arterial occlusive disease

BACKGROUND Determination of both the pain-free and the maximum walking distances is part of a routine program in the angiological examination of patients with PAOD. It is however as yet not clear which of these two parameters is more relevant in determining a patients pathological condition. PATIENTS AND METHODS In 150 patients with stable intermittent claudication, the claudication pain distance (CPD) and the maximum pain distance (MPD) were determined on a treadmill at 3.0 km/h and 12% inclination. The results were compared with the angiographic findings, the Doppler pressure values and the subjective quality of life (PAVK-86-Questionnaire). RESULTS The average pain-free walking distance was 89 +/- 71 m, and the maximum walking distance was 198 +/- 141 m. There was no correlation between both walking distances and the angiographic extent of PAOD. Only the MPD correlated with the ankle systolic Doppler pressure and the ankle/brachial pressure index of the claudicating leg (r = 0.16, p < 0.05 and r = 0.20, p < 0.01). Both the CPD and the MDP had a significant influence on the life quality of the patients (CPD: r = -0.41, p < 0.001; MPD: r = -0.47, p < 0.001). In the multiple regression analysis, beside the body mass index, the MPD was found to be the greatest predictor for the pathologically relevant quality of life dimensions pain, complaints and functional status. CONCLUSIONS The maximum walking distance correlated in a better way than pain-free walking distance with the objective and subjective assessment criteria of PAOD. Therefore, as regards the stage of the disease and the life quality of the patient, this parameter has a greater importance. This fact deserves to receive greater attention in everyday clinical practice and when conducting clinical trials.Background: Determination of both the pain-free and the maximum walking distances is part of a routine program in the angiological examination of patients with PAOD. It is however as yet not clear which of these two parameters is more relevant in determing a patient’s pathological condition. Patients and methods: In 150 patients with stable intermittent claudication, the claudication pain distance (CPD) and the maximum pain distance (MPD) were determined on a treadmill at 3,0 km/h and 12% inclination. The results were compared with the angiographic findings, the Doppler pressure values and the subjective quality of life (PAVK-86-Questionnaire). Results: The average pain-free walking distance was 89 ± 71m, and the maximum walking distance was 198 ± 141 m. There was no correlation between both walking distances and the angiographic extent of PAOD. Only the MPD correlated with the ankle systolic Doppler pressure and the ankle/brachial pressure index of the claudicating leg (r = 0.16, p < 0.05 and r = 0.20, p...

Correlation of hemodynamic and functional variables with the angiographic extent of peripheral arterial occlusive disease

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.

Secondary Pharmacotherapeutic Prevention among German Primary Care Patients with Peripheral Arterial Disease

Background. The aim of the study was to determine the secondary preventive medical supply of patients with peripheral arterial disease (PAD) in German primary care. Methods and Results. A population-based case control study was conducted using electronic medical records of patients extracted from the CONTENT primary care database of Heidelberg, Germany, between April 2007 and March 2010. The prescription rates of cardiovascular medication among symptomatic PAD patients were analysed by means of the ATC classification and compared with those of patients with cardiovascular disease (CVD). 479 cases with PAD and 958 sex- and age-matched control CVD patients were identified. PAD patients showed significantly lower prescription rates for cardiac agents (21.7% versus 37%), β-blockers (50.1% versus. 66.2%), and lipid-lowering agents (50.3% versus 55.9%) compared to CVD patients. In contrast, significantly more prescriptions of antidiabetic agents (28.2% versus 20.3%), particularly insulin and analogues (12.5% versus 8%), and calcium channel blockers (29.2% versus 24.3%) were found in PAD patients. Low-dose aspirin use among both PAD and CVD patients was underestimated, as it is available without a prescription. Conclusions. Optimal pharmacotherapeutical care of patients with PAD requires more intensive cardioprotective medication in primary care settings.

Three year results of endovascular therapy with a new generation nitinol stent for femoro-popliteal artery lesions - a single-center outcome analysis of a subcohort of MISAGO 2 study

BACKGROUND Advances in stent technology have widened the field of indications for stent treatment of femoro-popliteal artery lesions, however the use of stents in bending arterial segments is restricted because some first- and second-generation nitinol stent designs did not respond well to the mechanical forces of femoro-popliteal segments in motion which pose a substantial risk of stent fracture inducing in-stent-stenosis. New generation nitinol stents are supposed to overcome these limitations but long-term results are rare. PATIENTS AND METHODS In forty-five patients (mean age 68 y, range 50 - 85) with peripheral arterial disease (TASC II A-C, Rutherford category 2 - 5) forty-six lesions of the superficial femoral artery (37) or popliteal artery (9) were treated [25 high-grade stenoses, mean length 53 mm (range 30 - 145 mm); 21 chronic total occlusions, mean length 74 mm (range 30 - 180 mm)]. 74 % of lesions were located in the mobile bending arterial segments in the distal femoral or the popliteal segment. Clinical reevaluation performed at discharge, at 6, 12, 24, and 36 months included at least the measurement of ankle-brachial index (ABI) and duplex sonography. RESULTS Procedural success rate was 100 %. At 6, 12, 24, and 36 months, cumulative primary patency rate was 93.5 %, 84.8 %, 80.5 %, and 74.3 % (SE<10); freedom from target lesion revascularization rate was 95.7 %, 89.2 %, 84.9 %, and 79.3 % (SE<10); Rutherford category and ABI improved in all patients and clinical success was maintained in more than 85 % of patients. CONCLUSIONS Sustained technical and clinical success and good clinical long-term results were achieved with Misago™ nitinol stent implantation in femoro-popliteal lesions with moderate risk for in-stent-stenosis, and in the distal femoral and popliteal mobile segment.

Changes in drug therapy following hospital discharge for patients in a general practice: a German incident study

ObjectiveIn primary care, clinically recommended drug medication is often modified after hospitalization. The aim of the study was to examine the frequency and factors associated with GPs changing the hospital drug treatment in a sample of patients discharged from the hospital.MethodsIn a prospective study, the prehospital, hospital and posthospital diagnoses and drug treatment of 130 patients consecutively recruited from 15 general practices were recorded over a period of 12 months. The ICD-10 classification was used to compare the data from hospitals and general practices. GPs who changed the hospital drug treatment were interviewed in a semistructured way concerning their reasons for changing.ResultsThe most frequent diagnoses during and after hospitalization were listed in the ICD-10 chapters ‘Diseases of the cardiovascular system’ (34.3%) and ‘Endocrine, nutritional and metabolic diseases’ (18%). Accordingly, the most frequently prescribed drug medication was related to these chapters (47.5% and 15.9%, respectively). Hospitalization led to a significant increase in the number of drugs per patient [prehospital 5.4; hospital 6.6; posthospital 6.7; (p < 0.001)]. GPs changed the hospital drug recommendations of the discharge letters in 60.7% of the cases. They omitted drugs in 27.6%, replaced prehospital drug medication in 26.3%, changed to other manufacturers in 9.3%, added new drugs in 13.1% and changed the dosage in 4.2% of the cases. Changes in drug medication correlated significantly with the number of drugs and number of diagnoses (p < 0.001). The most frequently mentioned reason for drug changing by GPs was cost savings (30.3%). But more often they changed drug medication for patient-related reasons (42.4%): ‘better individual drug effect’ in 18.5%, ‘no reasonable indication’ in 17.1% and ‘not related to adequate diagnosis’ in 6.8% of the cases.ConclusionAfter hospital discharge, GPs changed more than half of posthospital drug recommendations. Although they believed that economical aspects were the most important reason for their behavior, most drug changes were done for patient-related reasons.

Increased health care utilization by patients with peripheral arterial disease in primary care: data from the CONTENT study

BACKGROUND Due to demography the proportion of elderly patients with peripheral arterial disease (PAD) in primary care settings is continuously growing. The study aimed to compare general practitioner care of patients with PAD with those without PAD. PATIENTS AND METHODS The analyzed data are derived from the general practice morbidity research network CONTENT (CONTinuous morbidity registration Epidemiologic NETwork). A sample of 480 patients with ensured PAD diagnosis was extracted from a total of 89516 steadily registered primary care patients. Matched pair analysis with the propensity score was used statistically to compare the data of each PAD patient with data of three associated control patients. RESULTS During a two-year period, PAD patients had significantly more consultations (20.1 vs. 18.0; p < 0.0001), more referrals to specialists (5.5 vs. 3.5; p < 0.0001) and a higher rate of hospitalization (0.3 vs. 0.1; p < 0.0001) than corresponding controls. The analysis of reasons for doctor-patient encounters showed a significantly higher number of disordered sleep, alcohol abuse, dyspnea and tobacco abuse among PAD patients compared to patients without PAD. The ranking of the most frequent reasons for referral to specialists suggested significantly more diagnoses related to cardiovascular disease in PAD patients. In the PAD cases, 20.4 % of all inpatient treatments were related to complications of the vascular disease, whereas no patient of the control group had to be hospitalized due to vascular disease problems. CONCLUSIONS The CONTENT episode-based registration presents a realistic and detailed picture of health care utilization of PAD patients. They overuse medical services in primary care compared to corresponding unaffected patients. This is associated with deficits in their life-style behavior, increased cardiovascular morbidity and increased inpatient care.

Portsystem nicht optimal plaziert

ZusammenfassungNach einer Darmteilresektion wegen eines Kolonkarzinoms wurde bei dem 80-Jährigen für die anschließende Chemotherapie rechts ein infraklavikulärer Port implantiert. Eine lokale strangförmige Verhärtung über dem Schlüsselbein störte den Mann nicht. Im Routinelabor fiel drei Monate später ein erhöhter D-Dimerwert von 3,8 mg% auf und war Anlass, nach einem thrombotischen Geschehen zu fahnden.

Rote Beine nach dem Städtebummel

ZusammenfassungDie 71-jährige gesunde Frau bemerkte während einer sommerlichen Städtereise durch Italien eine auffällige schmerzlose rötliche Hautverfärbung beider Unterschenkel. Allergische Reaktionen oder Erkrankungen der Haut waren ihr bislang nicht bekannt.

Nicht jede Beule in der Leiste ist eine Hernie

ZusammenfassungEine 69-jährige Frau wurde vor einem Jahr endoskopisch an einem „Schenkelbruch“ der linken Leiste operiert. Nach dem Eingriff besteht immer noch eine schmerzlose Schwellung in der linken Leiste, die sich besonders beim Husten bemerkbar macht.

Psoriasis vulgaris - Therapie klassisch oder modern?

Die Schuppenflechte (Psoriasis) ist eine entzündliche, häufig schubförmig verlaufende Hauterkrankung mit typischen Effloreszenzen. Die Krankheit beginnt meistens im Jugendalter und verläuft in ungefähr 90 Prozent der Fälle chronisch. Der Verlauf der Erkrankung ist dennoch sehr variabel. Sehen wir einerseits rudimentäre Verlaufsformen mit einem geringen Befall der Streckseiten der großen Gelenke, die im Alltag fast nicht bemerkt werden und die betroffenen Patienten auch kaum belasten, so sehenwir andererseits auch schwere und sehr schwere Verlaufsformen, bei denen fast die gesamte Haut befallen ist. Klinisch imPsoriasis vulgaris – Therapie klassisch oder modern? P. Engeser J. Barlet U. Müller-Bühl