Smoking Cessation Strategies in Patients with Peripheral Arterial Disease: An Evidence-based Approach

Editor's Choice - Effect of Physical Activity and Tobacco Use on Mortality and Morbidity in Patients with Peripheral Arterial Disease After Revascularisation: A Korean Nationwide Population Based Cohort Study

OBJECTIVE

To investigate the effects of physical activity (PA) and tobacco use on adverse clinical outcomes after revascularisation for peripheral arterial disease (PAD) in the Western Pacific region, where PAD cases and tobacco use are among the highest in the world.

METHODS

This was a retrospective cohort study using the Korean National Health Insurance Service (NHIS) database and included patients who had received revascularisation for PAD between 2010 and 2015. They were categorised as active or inactive based on the number of days per week they engaged in PA and as current or non-tobacco users (self report). The primary outcome was all cause mortality. Secondary outcomes included major adverse outcome (a composite of all cause mortality, myocardial infarction, and stroke) and major adverse limb event (MALE, a composite of amputation and recurrent revascularisation).

RESULTS

The relatively healthy cohort comprised 8 324 patients (mean age 64.7 years; 76.9% male) following revascularisation for PAD. Among them, 32.7% were inactive and 26.4% were tobacco users. Active patients had better outcomes than inactive patients (all cause mortality adjusted hazard ratio [adjHR] 0.766; 95% CI 0.685 - 0.855, major adverse outcome adjHR 0.795; 95% CI 0.719 - 0.878, MALE adjHR 0.858; 95% CI 0.773 - 0.953). Tobacco users had poorer outcomes than non-users (all cause mortality adjHR 1.279; 95% CI 1.124 - 1.456, major adverse outcome adjHR 1.263; 95% CI 1.124 - 1.418, MALE adjHR 1.291; 95% CI 1.143 - 1.458).

CONCLUSION

Even after receiving revascularisation for PAD, a sizable proportion of patients were physically inactive and used tobacco, leading to adverse clinical outcomes such as death, cardiovascular morbidity, and amputation in Korea. These modifiable risk factors should be addressed systematically, and a comprehensive approach including supervised exercise programmes and tobacco cessation is needed in patients with PAD.

Avicenna and clinical experiences in Canon of Medicine

Avicenna used his medical knowledge and experience of scientists from different nations to create a new style in medicine. For this reason, his textbook, Canon of Medicine, has been considered a medical reference in all universities worldwide for centuries. In this article, some valuable and interesting diagnostic and therapeutic clinical experiences mentioned in the Canon of Medicine are described in five sections. This research was conducted to review Avicenna’s specific clinical observations and interventions in PubMed, Google Scholar, and Scopus databases using the keywords “Avicenna” and “Canon of Medicine”. In this article, we presented several examples of diagnostic and therapeutic clinical experiences mentioned in the Canon of Medicine in 5 areas, including semiology, therapeutic strategy, urology, neurology, obstetrics, and gynecology. Canon of Medicine, as a complete medical series containing the medical experiences from different nations and Iranian medical scientists, has influenced the world’s medical knowledge for several centuries. Some of Avicenna’s clinical and experimental views can be useful from both a historical point of view and new research.

Lipid Optimization in Lower Extremity Peripheral Arterial Disease

AIMS

This review aims to explore the current guidance and issues surrounding lipid optimisation of patients with peripheral arterial disease (PAD).

METHODS

A narrative review of the global PAD guidance, specifically focusing on low density lipoprotein cholesterol (LDL-C) reduction methods including; 'treating to target', 'fire and forget' and LDL-C percentage reduction. Advanced literature searches were carried out in Pubmed and Google Scholar databases comparing most recent PAD lipid guidance.

RESULTS

PAD lipid guidance could be improved internationally to help clinicians implement the best lipid-reduction strategies for their patients and challenge the arbitrary 1.4 mmol/L LDL-C target in line with novel proprotein convertase subtilisin/kexin type 9 inhibitors trials. By educating primary and secondary care staff on the benefits of maximal lipid-reduction therapies, we can reduce major adverse cardiovascular events and major adverse limb events. Championing PAD community clinics may lead to earlier prevention. Research comparing lipid-reduction strategies in practice is needed to improve outcomes internationally, and ongoing practice audited to understand the extent of under-prescribing in PAD.

CONCLUSIONS

This review highlights the current PAD lipid-reduction treatments and the clarity issues of global guidance. Further research is needed to tackle ongoing mortality and morbidity rates in PAD patients against their better off cardiovascular disease (CVD) peers. MESH KEY TERMS: "Cholesterol", "Hydroxymethylglutaryl-CoA Reductase Inhibitors", "Ezetimibe", "Evolocumab", "Alirocumab", "Peripheral Arterial Disease", "Vascular Disease", "Atherosclerosis", "Secondary Prevention", "Lipoprotein, LDL".

Active smoking is associated with higher rates of incomplete wound healing after endovascular treatment of critical limb ischemia

The association between active smoking and wound healing in critical limb ischemia (CLI) is unknown. Our objective was to examine in a retrospective cohort study whether active smoking is associated with higher incomplete wound healing rates in patients with CLI undergoing endovascular interventions. Smoking status was assessed at the time of the intervention, comparing active to no active smoking, and also during follow-up visits at 6 and 9 months. Cox regression analysis was conducted to compare the incomplete wound healing rates of the two groups during follow-up. A total of 264 patients (active smokers: n = 41) were included. Active smoking was associated with higher rates of incomplete wound healing in the 6-month univariate Cox regression analysis (hazard ratio (HR) for incomplete wound healing: 4.54; 95% CI: 1.41-14.28; p = 0.012). The 6-month Kaplan-Meier (KM) estimates for incomplete wound healing were 91.1% for the active smoking group versus 66% for the non-current smoking group. Active smoking was also associated with higher rates of incomplete wound healing in the 9-month univariable (HR for incomplete wound healing: 2.32; 95% CI: 1.11-4.76; p = 0.026) and multivariable analysis (HR for incomplete wound healing: 9.09; 95% CI: 1.06-100.0; p = 0.044). The 9-month KM estimates for incomplete wound healing were 75% in the active smoking group versus 54% in the non-active smoking group. In conclusion, active smoking status at the time of intervention in patients with CLI is associated with higher rates of incomplete wound healing during both 6- and 9-month follow-up.

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

GUIDELINE SUMMARY

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Global vascular guidelines on the management of chronic limb-threatening ischemia

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Review of the role of cigarette smoking in diabetic foot

Diabetic foot ulceration has been a serious issue over the past decades in Asia, causing economic and social problems. Therefore, it is important to identify and reduce the risk factors of diabetic foot. Cigarette smoking has been reported to be associated with diabetes and its macrovascular complications, but the relationship between smoking and diabetic foot ulcers is still unclear. In the present review, we summarize the effects of cigarette smoking on diabetic foot ulcers with respect to peripheral neuropathy, vascular alterations and wound healing. One underlying mechanism of these impacts might be the smoking-induced oxidative stress inside the cells. At the end of this review, the current mainstream therapies for smoking cessation are also outlined. We believe that it is urgent for all diabetic patients to quit smoking so as to reduce their chances of developing foot ulcers and to improve the prognosis of diabetic foot ulcers.

Extracorporeal shockwave therapy for intermittent claudication: Medium-term outcomes from a double-blind randomised placebo-controlled pilot trial

Objectives Peripheral arterial disease most commonly presents as intermittent claudication (IC). Early evidence has suggested that extracorporeal shockwave therapy is efficacious in the short term for the management of intermittent claudication. The objective of this pilot trial was to evaluate the medium-term efficacy of this treatment. Methods This double-blind randomised placebo-controlled pilot trial randomised patients with unilateral intermittent claudication in a 1:1 fashion to receive extracorporeal shockwave therapy or a sham treatment for three sessions per week over three weeks. Primary outcomes were maximum walking distance and intermittent claudication distance using a fixed-load treadmill test. Secondary outcomes included pre- and post-exertional ankle-brachial pressure indices, safety and quality of life assessed using generic (SF36, EQ-5D-3L) and disease-specific (vascular quality of life) measures. All outcome measures were assessed at 12 months post-treatment. Results Thirty participants were included in the study (extracorporeal shockwave therapy, n = 15; sham, n = 15), with 26 followed up and analysed at 12 months (extracorporeal shockwave therapy, n = 13; sham, n = 13). Intragroup analysis demonstrated significant improvements in maximum walking distance, intermittent claudication distance and post-exertional ankle-brachial pressure indices ( p < 0.05) in the active treatment group, with no improvements in pre-exertional ankle-brachial pressure indices. Significant improvements in quality of life were observed in 3 out of 19 domains assessed in the active group. A re-intervention rate of 26.7% was seen in both groups. Conclusions These findings suggest that extracorporeal shockwave therapy is effective in improving walking distances at 12 months. Although this study provides important pilot data, a larger study is needed to corroborate these findings and to investigate the actions of this treatment.

ISRCTN

NCT02652078.

Gender Differences in Peripheral Vascular Disease

In the past 20 years, peripheral artery disease (PAD) has been increasingly recognized as a significant cause of morbidity and mortality in the United States. PAD has traditionally been identified as a male-dominant disease; however, recent population trends and studies in PAD suggest that women are affected at least as often as men. Women comprise a larger population of the elderly than men, as well as an increasing proportion of patients with PAD. Much of the existing research on PAD has focused on whole populations, and gender-specific data on PAD is sparse. This review focuses on gender-specific differences in presentation, management, and outcomes of PAD intervention that are important considerations for the interventional radiologist.

Lifestyle medicine curriculum for a preventive medicine residency program: implementation and outcomes

BACKGROUND

The vast majority of the healthcare problems burdening our society today are caused by disease-promoting lifestyles (e.g., physical inactivity and unhealthy eating). Physicians report poor training and lack of confidence in counseling patients on lifestyle changes.

OBJECTIVE

To evaluate a new curriculum and rotation in lifestyle medicine for preventive medicine residents.

METHODS

Training included didactics (six sessions/year), distance learning, educational conferences, and newly developed lifestyle medicine rotations at the Institute of Lifestyle Medicine, the Yale-Griffin Prevention Research Center, and the Integrative Medicine Center. We used a number of tools to assess residents' progress including Objective Structured Clinical Examinations (OSCEs), self-assessments, and logs of personal health habits.

RESULTS

A total of 20 residents participated in the lifestyle medicine training between 2010 and 2013. There was a 15% increase in residents' discussions of lifestyle issues with their patients based on their baseline and follow-up surveys. The performance of preventive medicine residents on OSCEs increased each year they were in the program (average OSCE score: PGY1 73%, PGY2 83%, PGY3 87%, and PGY4 91%, p=0.01). Our internal medicine and preliminary residents served as a control, since they did participate in didactics but not in lifestyle medicine rotations. Internal medicine and preliminary residents who completed the same OSCEs had a slightly lower average score (76%) compared with plural for resident, preventive medicine residents (80%). However, this difference did not reach statistical significance (p=0.11).

CONCLUSION

Incorporating the lifestyle medicine curriculum is feasible for preventive medicine training allowing residents to improve their health behavior change discussions with patients as well as their own personal health habits.

Outcomes of endovascular treatment for patients with TASC II D femoropopliteal occlusive disease: a single center study

BACKGROUND

Advances in endovascular technology led to an alternative treatment option for TASC II D (TransAtlantic Inter-Society Consensus II class D) lesions. This study was aimed to evaluate the outcomes of endovascular treatment for TASC II D femoropopliteal lesions.

METHODS

Endovascular intervention with bare nitinol stent implantation was performed on 58 limbs (53 patients) with TASC II D femoropopliteal lesions from January 2011 to March 2013. Kaplan-Meier curves of primary patency, assisted patency and second patency were performed. Predictive factors of re-stenosis/occlusion were evaluated by univariate methods.

RESULTS

Total 53 patients with mean age of 74.2 ± 8.2 (range, 58.0-91.0 years) and mean lesion length of 314.8 ± 64.3 mm (188.2-400.4 mm) were enrolled. The mean follow-up time was 12.2 ± 6.1 months (5-38 months). Revascularization was successfully on 95% lesions by bare nitinol stent implantation. Primary patency rates at 1, 2 and 3 years were 63%, 12% and 12%, respectively. Assisted primary patency rates at 1, 2 and 3 years were 77%, 31% and 31%, respectively. Secondary patency rates at 1, 2 and 3 years were 96%, 63% and 63%. During one-year follow-up, no major amputation was occurred. Univariate analysis revealed that number of run-off vessels was a potential predictor of re-stenosis/occlusion.

CONCLUSION

Endovascular treatment of TASC II D femoropopliteal artery occlusion has a high technical success rate with acceptable one-year patency rate. The long-term outcomes are poor, but endovascular intervention could be a good alternative for patients unsuitable for surgical bypass.

[Management of peripheral vascular disease based on current guidelines. Peripheral artery occlusive disease of the iliac and femoral arteries and carotid artery stenosis]

The article summarizes the recommendations of current European and American guidelines concerning the diagnosis and treatment of peripheral arterial occlusive disease and carotid artery stenosis. In comparison to older recommendations, current guidelines concerning endovascular treatment and concomitant medical therapy have been changed in recent years. With the exception of very complex and long lesions, endovascular methods are seen as the therapy of choice for revascularization of the iliac and femoral arteries. For cardiovascular risk reduction, patients with symptomatic peripheral arterial disease and stenosis of the carotid arteries should receive antiplatelet as well as statin therapy and should not be treated different from patients with coronary artery disease.

Therapeutic angiogenesis in critical limb ischemia

Critical limb ischemia (CLI) is a severe form of peripheral artery disease associated with high morbidity and mortality. The primary therapeutic goals in treating CLI are to reduce the risk of adverse cardiovascular events, relieve ischemic pain, heal ulcers, prevent major amputation, and improve quality of life (QoL) and survival. These goals may be achieved by medical therapy, endovascular intervention, open surgery, or amputation and require a multidisciplinary approach including pain management, wound care, risk factors reduction, and treatment of comorbidities. No-option patients are potential candidates for the novel angiogenic therapies. The application of genetic, molecular, and cellular-based modalities, the so-called therapeutic angiogenesis, in the treatment of arterial obstructive diseases has not shown consistent efficacy. This article summarizes the current status related to the management of patients with CLI and discusses the current findings of the emerging modalities for therapeutic angiogenesis.

Preventive aspects in peripheral artery disease

The prevalence of peripheral artery disease is steadily increasing and is associated with significant morbidity, including a significant percentage of amputations. Peripheral artery disease often goes undiagnosed, making its prevention increasingly important. Patients with peripheral arterial disease are at increased risk of adverse cardiovascular outcomes which makes prevention even more important. Several risk factors have been identified in the pathophysiology of peripheral artery disease which should be modified to decrease risk. Smoking, hyperlipidemia, hypertension, and diabetes are among proven risk factors for the development of peripheral artery disease, thus smoking cessation, lipid control, blood pressure control, and glucose control have been tried and shown to be effective in preventing the morbidity associated with this disease. Pharmacologic agents such as aspirin and clopidogrel alone or in combination have been shown to be effective, though risk of bleeding might be increased with the combination. Anticoagulation use is recommended only for acute embolic cases. Other treatment modalities that have been tried or are under investigation are estrogen replacement, naftidrofuryl, pentoxifylline, hyperbaric oxygen, therapeutic angiogenesis, and advanced glycation inhibitors. The treatment for concomitant vascular diseases does not change in the presence of peripheral artery disease, but aggressive management of risk factors should be undertaken in such cases.

Peripheral artery disease. Part 2: medical and endovascular treatment

The treatment of peripheral artery disease (PAD) focuses on risk factor modification, cardiovascular event reduction, limb viability, and symptom improvement. Hypertension, hyperlipidemia, and diabetes mellitus should all be controlled to recommended target levels, and smoking cessation is vital. Antiplatelet therapies, such as aspirin or clopidogrel, should be administered in all patients unless contraindicated. Whenever possible, patients who present with claudication should be offered a regimen comprised of both medical and exercise therapy, which often results in substantial improvement in symptoms. For patients presenting with more-advanced disease, such as acute limb ischemia, critical limb ischemia, and severely-limiting symptoms of PAD, revascularization is often necessary. As a result of the rapid evolution in endovascular revascularization technology and expertise, many patients with PAD can be treated percutaneously. Therefore, in this Review, we will focus on medical therapy and endovascular revascularization of patients with PAD, with reference to surgical bypass in specific clinical scenarios.

The use of Matriderm and autologous skin grafting in the treatment of diabetic ulcers: a case report

The aim of our case report was to analyse the results obtained with the Matriderm system and autologous skin grafting for the surgical treatment of diabetic ulcers. We recruited one patient with diabetic ulcers admitted at the Department of Plastic and Reconstructive Surgery, University of Rome 'Tor Vergata'. The patient underwent Matriderm system and autologous skin grafting for diabetic ulcer treatment. After just a single treatment, we obtained reduction in ulcer after 15 days from the surgical treatment. We achieved a reduction in pain and exudate secretion of the ulcer. We noticed an almost complete restoration of the missing volume and good quality of skin. Matriderm system and autologous skin grafting is a simple, safe and feasible technique. This method, when compared with other methods of treatment, is simple, cheap, less time consuming and does not require sophisticated laboratory facilities.

Peripheral artery disease: current insight into the disease and its diagnosis and management

Peripheral artery disease (PAD), which comprises atherosclerosis of the abdominal aorta, iliac, and lower-extremity arteries, is underdiagnosed, undertreated, and poorly understood by the medical community. Patients with PAD may experience a multitude of problems, such as claudication, ischemic rest pain, ischemic ulcerations, repeated hospitalizations, revascularizations, and limb loss. This may lead to a poor quality of life and a high rate of depression. From the standpoint of the limb, the prognosis of patients with PAD is favorable in that the claudication remains stable in 70% to 80% of patients over a 10-year period. However, the rate of myocardial infarction, stroke, and cardiovascular death in patients with both symptomatic and asymptomatic PAD is markedly increased. The ankle brachial index is an excellent screening test for the presence of PAD. Imaging studies (duplex ultrasonography, computed tomographic angiography, magnetic resonance angiography, catheter-based angiography) may provide additional anatomic information if revascularization is planned. The goals of therapy are to improve symptoms and thus quality of life and to decrease the cardiovascular event rate (myocardial infarction, stroke, cardiovascular death). The former is accomplished by establishing a supervised exercise program and administering cilostazol or performing a revascularization procedure if medical therapy is ineffective. A comprehensive program of cardiovascular risk modification (discontinuation of tobacco use and control of lipids, blood pressure, and diabetes) will help to prevent the latter.

[The diabetic foot]

In the last 20 years the prevalence of diabetes in Germany has increased by approximately 50%. Associated with this is a distinct rise of diabetes-induced comorbidities and long-term consequences. One of the most frequent consequences is the diabetic foot or the diabetic foot syndrome. This is an ulceration of neuropathic and angiopathic origin, which often reaches a chronic stadium due to a poor healing tendency. Despite the disease management program for diabetes in Germany which mainly concentrates on the prophylaxis and multidisciplinary treatment of chronic diseases, there are approximately 250,000 patients with lesions of the foot caused by diabetes of which approximately 50% have to be amputated within 4 years. To achieve a reduction of the amputation rate identification of the main reasons is necessary. In addition a professional therapy of the vascular disorders and a stage-adjusted wound therapy have to take place in an interdisciplinary collaboration in a centre for wound care. Last but not least this aim can only be achieved by a preventive education of diabetics.

The diabetic foot

Diabetes is reaching epidemic proportions and with it carries the risk of complications. Disease of the foot is among one of the most feared complications of diabetes. The ultimate endpoint of diabetic foot disease is amputation, which is associated with significant morbidity and mortality, besides having immense social, psychological and financial consequences. As the majority of amputations are preceded by foot ulceration, it is crucial to identify those at an increased risk. Diabetic foot ulcers may develop as a result of neuropathy, ischaemia or both and when infection complicates a foot ulcer, the combination can become limb and life threatening. Structural abnormalities such as calluses, bunions, hammer toes, claw toes, flat foot and rocker bottom foot need to be identified and managed.

Smoking: a risk factor for progression of chronic kidney disease and for cardiovascular morbidity and mortality in renal patients--absence of evidence or evidence of absence?

Although it is beyond any doubt that smoking is the number one preventable cause of death in most countries, smoking as an independent progression factor in renal disease has been questioned against the background of evidence-based criteria. This is because information from large, randomized, prospective studies that investigate the effects of smoking on renal function in healthy individuals as well as in patients with primary or secondary renal disease are lacking. Since 2003, a substantial number of clinical and experimental data concerning the adverse renal effects of smoking have been published, including large, prospective, population-based, observational studies. These more recent data together with evidence from experimental studies clearly indicate that smoking is a relevant risk factor, conferring a substantial increase in risk for renal function deterioration. This review summarizes the present knowledge about the renal risks of smoking as well as the increased cardiovascular risk caused by smoking in patients with chronic kidney disease. The conclusion is that smoking is an important renal risk factor, and nephrologists have to invest more efforts to motivate patients to stop smoking.

A modified calculation of ankle-brachial pressure index is far more sensitive in the detection of peripheral arterial disease

BACKGROUND

Ankle-brachial pressure index (ABI) is a simple, inexpensive, and useful tool in the detection of peripheral arterial occlusive disease (PAD). The current guidelines published by the American Heart Association define ABI as the quotient of the higher of the systolic blood pressures (SBPs) of the two ankle arteries of that limb (either the anterior tibial artery or the posterior tibial artery) and the higher of the two brachial SBPs of the upper limbs. We hypothesized that considering the lower of the two ankle arterial SBPs of a side as the numerator and the higher of the brachial SBPs as the denominator would increase its diagnostic yield.

METHODS

The former method of eliciting ABI was termed as high ankle pressure (HAP) and the latter low ankle pressure (LAP). ABI was assessed in 216 subjects and calculated according to the HAP and the LAP method. ABI findings were confirmed by arterial duplex ultrasonography. A significant arterial stenosis was assumed if ABI was <0.9.

RESULTS

LAP had a sensitivity of 0.89 and a specificity of 0.93. The HAP method had a sensitivity of 0.68 and a specificity of 0.99. McNemar's test to compare the results of both methods demonstrated a two-tailed P < .0001, indicating a highly significant difference between both measurement methods.

CONCLUSIONS

LAP is the superior method of calculating ABI to identify PAD. This result is of great interest for epidemiologic studies applying ABI measurements to detect PAD and assessing patients' cardiovascular risk.

Prevalence of patients continuing to smoke after vascular interventions

INTRODUCTION

Smoking is one of the most important risk factors for the development and progression of atherosclerosis. Smoking cessation is an obligatory element in the management of vascular problems and in patients scheduled for vascular interventions. The aim of this study was to assess the prevalence of patients smoking before and after vascular surgical procedures and to evaluate the requirements for inpatient programs for smoking cessation and nicotine replacement therapy.

METHODS

500 patients admitted for vascular interventions were included in this prospective study. Smoking status was evaluated both objectively and subjectively. All patients underwent measurements of exhaled breath carbon monoxide to quantify nicotine dependency and all answered a standardized Fagerström questionnaire both on admission and after surgery to identify current smokers.

RESULTS

Of 500 vascular patients included in the study, only 70 (14 %) never had smoked, 243 (49 %) had given up smoking before admission and 161 (32 %) were current smokers. Of the current smokers, 64 (40 %) did not smoke during hospitalization but 97 (60 %) continued to smoke in hospital. Of these 97 patients, 78 (80 %) were men and 19 women; their mean age was 61 +/- 4 years (range 40-84). Four patients had surgery for infrarenal aortic aneurysm, 40 underwent carotid endarterectomy and 53 had peripheral arterial occlusive disease (PAD). There was no difference between abstinent patients and continuing smokers in previous cigarette consumption or Fagerström score, a predictor for long-term smoking behavior. Patients with carotid artery stenosis were significantly more abstinent while hospitalized (P = 0.006); patients with PAD, however, were more likely to continue smoking as inpatients (P = 0.004). Sixty-five percent of continuing smokers stated that they would stop smoking in hospital if counseling and nicotine replacement therapy were provided. With regard to their predominant location of atherosclerosis, patients with PAD were less willing than those with carotid stenosis to abstain from smoking while hospitalized (53 % vs 88 %, respectively; P < 0.001).

CONCLUSION

A substantial proportion of patients admitted for vascular surgery are smokers. More than half of these continue to smoke in the hospital, an environment where smoking is prohibited by law. Counseling, nicotine replacement therapy and smoking-cessation programs are urgently needed for vascular surgical inpatients.

Adherence to nicotine replacement patch therapy in cardiovascular patients

Nicotine Replacement Therapy (NRT) is the most frequently used pharmacological intervention for smoking cessation. Research on the effect of NRT showed serious nonadherence among users. We investigated adherence to NRT in cardiovascular patients. A number of 174 outpatients (N = 174), who smoked > 5 cigarettes a day, received free patches and intensive instructions from nurses. Questionnaires were sent to patients assessing patient characteristics, adherence to a 7-8 weeks time frame and appliance instructions, side effects/withdrawal symptoms, and reasons for nonadherence. Only 38% of the patients was adherent to the time frame. Appliance instructions were followed in 76-96% of the cases, except for smoking; 50% continued to smoke during NRT. In conclusion, despite considerable attention to appliance instructions, access to free patches and additional behavioral support, adherence to NRT in these patients is rather low.

What Is the Future of Diabetic Wound Care?

With diabetes affecting 5% to 10% of the US population, development of a more effective treatment for chronic diabetic wounds is imperative. Clinically, the current treatment in topical wound management includes debridement, topical antibiotics, and a state-of-the-art topical dressing. State-of-the-art dressings are a multi-layer system that can include a collagen cellulose substrate, neonatal foreskin fibroblasts, growth factor containing cream, and a silicone sheet covering for moisture control. Wound healing time can be up to 20 weeks. The future of diabetic wound healing lies in the development of more effective artificial "smart" matrix skin substitutes. This review article will highlight the need for novel smart matrix therapies. These smart matrices will release a multitude of growth factors, cytokines, and bioactive peptide fragments in a temporally and spatially specific, event-driven manner. This timed and focal release of cytokines, enzymes, and pharmacological agents should promote optimal tissue regeneration and repair of full-thickness wounds. Development of these kinds of therapies will require multidisciplinary translational research teams. This review article outlines how current advances in proteomics and genomics can be incorporated into a multidisciplinary translational research approach for developing novel smart matrix dressings for ulcer treatment. With the recognition that the research approach will require both time and money, the best treatment approach is the prevention of diabetic ulcers through better foot care, education, and glycemic control.

Smoking, periodontal disease and the role of the dental profession

Epidemiological investigations support a firm relationship between smoking and periodontal disease. The likely benefits of smoking cessation programmes are considerable for periodontal disease, cancers and nearly all chronic systemic diseases. The mechanisms by which smoking may influence the development and progression of periodontal disease are as yet unclear, but may include changes in the vasculature, the immune and inflammatory systems, tissue oxygenation and the healing processes. Unfortunately, although dental professionals have more opportunities to encourage smokers to quit (most people visit their dentist more frequently than their doctor), dentists claim that they are not well informed on this subject. The purpose of this review is to describe the evidence for a link between smoking and periodontal disease, the possible pathology induced by smoking on the periodontal tissues and its impact on therapy, and to outline the smoking cessation techniques that are currently available.

Treatment for diabetic foot ulcers

People with diabetes develop foot ulcers because of neuropathy (sensory, motor, and autonomic deficits), ischaemia, or both. The initiating injury may be from acute mechanical or thermal trauma or from repetitively or continuously applied mechanical stress. Patients with clinically significant limb ischaemia should be assessed by a vascular surgeon to determine the need for angioplasty, stenting, or femorodistal bypass. When infection complicates a foot ulcer, the combination can be limb or life-threatening. Infection is defined clinically, but wound cultures reveal the causative pathogens. Tissue specimens are strongly preferred to wound swabs for wound cultures. Antimicrobial therapy should be guided by culture results, and should aim to cure the infection, not to heal the wound. Alleviation of the mechanical load on ulcers (off-loading) should always be a part of treatment. Neuropathic ulcers typically heal in 6 weeks with total contact casting, because it effectively relieves pressure at the ulcer site and enforces patient compliance. The success of other approaches to off-loading similarly depends on the patients' adherence to the effectiveness of pressure relief. Surgery to heal ulcers and prevent recurrence can include tenotomy, tendon lengthening, reconstruction, or removal of bony prominences. However, these procedures may result in secondary ulceration and other complications. Ulcer recurrence rates are high, but appropriate education for patients, the provision of posthealing footwear, and regular foot care can reduce rates of re-ulceration.

Systemic antiatherosclerotic treatment for the peripheral arterial occlusive disease patient

Symptomatic and asymptomatic peripheral arterial occlusive disease (PAD) is indicative of widespread atherosclerosis. The major threat is from cardiovascular ischaemic events; thus, an important therapeutic goal is to modify atherosclerotic risk factors. Data from several large drug trials indicate that patients with PAD may gain as much, if not more, benefit from aggressive secondary prevention than those with other manifestations of atherothrombosis. In fact, the level of care for patients with PAD is lower as compared with those with ischaemic heart disease, although PAD is defined to be a coronary artery risk equivalent. This paper reviews observational data and generalisation from trials in patients with other manifestations of cardiovascular disease that support the importance of treating key risk factors such as smoking, diabetes, hypertension and hyperlipidaemia in PAD patients.

CJ, Presti C, Silva ESD, De Luccia N. Doença arterial obstrutiva periférica: que atenção temos dispensado à abordagem clínica dos pacientes?

OBJETIVO: Avaliar como pacientes com doença arterial obstrutiva periférica têm sido tratados, em nosso meio, com relação aos fatores de risco e comorbidades. MÉTODO: Questionário sobre pesquisa e tratamento da dislipidemia, diabetes, exercício, uso de anti-plaquetários, tabagismo e hipertensão arterial no paciente com doença arterial obstrutiva periférica foi aplicado entre os médicos presentes na reunião mensal de março de 2004 da Sociedade Brasileira de Angiologia e Cirurgia Vascular - Regional São Paulo. RESULTADOS: Dos 102 questionários distribuídos, 75 foram respondidos (taxa de resposta de 73,5%). Entre os consultados, 82% pesquisam rotineiramente perfil lipídico e 20% visam alvo de LDL-colesterol abaixo de 100 mg/dl; 94% realizam pesquisa para diabetes melito; 97% recomendam exercício; 79% prescrevem aspirina; 97% aconselham que os pacientes parem de fumar e 60% se restringem ao aconselhamento isoladamente; 18% não realizam a medida da pressão arterial durante a consulta e 19% visam alvo pressórico de 130 x 80 mmHg. Considerando todas as avaliações em conjunto - intervenção no estilo de vida, no sentido de parar de fumar, orientação de exercícios, uso de anti-plaquetários, realização de pesquisa para diabetes melito, controle rigoroso da pressão arterial e lípides - observou-se que 7% dos entrevistados seguem todas essas recomendações como uma rotina estabelecida. CONCLUSÃO: O presente estudo demonstrou que, em nosso meio, a pesquisa e o tratamento dos fatores de risco e comorbidades nos pacientes com doença arterial obstrutiva periférica estão sendo sub-realizados.

Medical management of peripheral arterial disease

Whether symptomatic or not, peripheral arterial disease (PAD), atherosclerosis in the arteries of the lower extremities, is a common disorder in the general population. The prevalence increases with age and under the influence of vascular risk factors. The most classic symptomatic expression of PAD is intermittent claudication. However, the majority of patients with PAD is asymptomatic or has leg symptoms other than classic intermittent claudication. Both symptomatic and asymptomatic subjects with PAD have increased mortality rates, mainly due to cardiovascular and cerebrovascular expressions of atherosclerotic disease. This review focuses on the current available medical therapies for PAD, including risk-factor modification and antiplatelet therapies, as well as strategies for symptomatic relief in both patients with intermittent claudication and patients with critical limb ischemia. In general, risk factor modification and antiplatelet therapy is essential in all patients with PAD to prevent systemic atherosclerotic complications. Furthermore, for symptomatic relief exercise therapy is the main intervention while pharmacological treatment should be only complementary. In patients with critical limb ischemia, when revascularization therapy is not possible, an attempt should be made to avoid amputation with conservative treatment using analgesics, vasodilators and/or anticoagulants. In case of an acute onset of critical limb ischemia, thrombolysis is indicated.

Obstetricians, gynecologists and the anti-smoking campaign: a national survey

OBJECTIVE

To asses the role Jordanian obstetricians and gynecologists play as tobacco cessation counsellors through examining their smoking status, opinions on health risks, factors that influence tobacco use and their perceived barriers to providing effective counselling.

STUDY DESIGN

The setting is a tertiary referral university hospital. A pre-tested postal questionnaire survey was mailed to all 462 licensed obstetricians and gynecologists in Jordan. Descriptive statistics were generated and statistical significance was determined by the chi2-test.

RESULTS

Of 392 respondents, 37.9% were smokers. Most associated smoking with low birth weight and sudden infant death syndrome. Fewer associated smoking with infertility, ectopic pregnancy, placenta praevia, abruptio placentae and cancer of the uterine cervix. Friends, stress, parents' attitude, genetic predisposition, income and education were implicated factors for smoking. Current smokers were more likely to permit smoking in their practices. Non-smokers were most inclined to record their patients' tobacco habits. Only 54.3% provided cessation counselling. Lack of time and inadequate training were perceived barriers.

CONCLUSIONS

A high proportion of obstetricians and gynecologists are smokers. A training program is needed to equip health workers with the skills necessary for the implementation of a successful anti-smoking campaign.

Assessment of smoking status in patients with peripheral arterial disease

OBJECTIVE

To assess the utility of a novel rapid urinary cotinine assay to detect and quantify the level of smoking in patients with peripheral arterial disease.

METHODS

This was a cross-sectional study in a vascular surgical outpatient department of a large teaching hospital. Participants were 100 consecutive subjects presenting to a hospital outpatient clinic with a diagnosis of intermittent claudication confirmed by a positive Edinburgh claudication questionnaire and an ankle-brachial pressure index of less than 0.9. Main outcome measures were patient-offered smoking history, exhaled breath carbon monoxide levels, urinary cotinine levels as measured by a novel rapid assay, and laboratory-measured creatinine-adjusted urinary cotinine levels. Results Fifty-five subjects declared that they were current smokers, 40 declared that they were ex-smokers, and 5 declared that they were never-smokers. Of the 40 ex-smokers, 6 subjects (15%) had urinary cotinine levels greater than 500 ng/mL (regular smokers), and a further 2 (5%) had urinary cotinine levels between 100 and 500 ng/mL (light, irregular, or passive smokers). The rapid urinary cotinine assay had a sensitivity and specificity of 100% and 98%, respectively, in its ability to detect active smoking, and the degree of smoking correlated well with laboratory creatinine-corrected urinary cotinine levels (Spearman coefficient, 0.805; P < .001). By contrast, exhaled carbon monoxide had a sensitivity and specificity of 95% and 89%, respectively, and although it correlated well with urinary cotinine (Spearman coefficient, 0.782; P < .001), it was found on linear regression analysis to be unreliable in differentiating light smokers from nonsmokers.

CONCLUSIONS

Patient-offered smoking history is unreliable because there is no correlation between the patient-reported number of cigarettes smoked per day and urinary cotinine levels. The novel rapid assay for urinary cotinine described here is superior to exhaled carbon monoxide measurement in detecting the level of smoking exposure among patients with intermittent claudication, and its results correlate well with laboratory-measured cotinine.

Life-style Modification in Peripheral Arterial Disease

OBJECTIVE

To review the published evidence supporting the use of life-style modification in peripheral arterial disease (PAD).

DESIGN

A systematic search of the medical literature was performed for relevant studies.

MATERIALS

The publications obtained were then searched for randomised clinical trials which reported end-points of mortality or major cardiovascular event rates with various life-style modifications.

RESULTS

Only one randomised controlled trial was found reporting relevant end-points. Other trials were of other end-points such as walking distance or biochemical markers.

CONCLUSIONS

There is a lack of randomised controlled data proving the benefit of life-style modification in improving mortality and reducing cardiovascular events in patients with PAD. Despite this there is sufficient evidence to recommend some life-style modification as part of the overall approach to risk reduction in these patients. There is compelling evidence to support smoking cessation, increased exercise and improved diet.

Peripheral arterial disease: prognostic significance and prevention of atherothrombotic complications

The prevalence of peripheral arterial disease (PAD) in people aged over 55 years is 10%-25% and increases with age; 70%-80% of affected individuals are asymptomatic; only a minority ever require revascularisation or amputation. Patients with PAD alone have the same relative risk of death from cardiovascular causes as those with coronary or cerebrovascular disease, and are four times more likely to die within 10 years than patients without the disease. The ankle-brachial pressure index (ABPI) is a simple, non-invasive bedside tool for diagnosing PAD - an ABPI less than 0.9 is considered diagnostic of PAD. About half of patients with PAD (defined by an abnormal ABPI) have symptomatic coronary or cerebral vascular disease. The ABPI is an independent predictor of coronary and cerebrovascular morbidity and mortality. Patients with PAD require medical management to prevent future coronary and cerebral vascular events. There are currently insufficient data to recommend routine population screening for asymptomatic PAD using the ABPI.