Multimodal Supervised Exercise Training Is Effective in Improving Long Term Walking Performance in Patients with Symptomatic Lower Extremity Peripheral Artery Disease

This study aimed to evaluate the effect of a multimodal supervised exercise training (SET) program on walking performance for 12 months in patients with symptomatic lower extremity peripheral artery disease (PAD). Consecutive patients with Fontaine stage II PAD participating in the SET program of our hospital were retrospectively investigated. Walking performance, assessed using a treadmill with measures of the pain-free and maximal walking distance (PFWD, MWD, respectively), and 6 min walking distance (6MWD), were tested before and following SET, as well as at 6 and 12 months after SET completion. Ninety-three symptomatic patients with PAD (65.0 ± 1.1 y) were included in the study. Following SET, the walking performance significantly improved (PFWD: +145%, p ≤ 0.001; MWD: +97%, p ≤ 0.001; 6MWD: +15%, p ≤ 0.001). At 6 months, PFWD (+257%, p ≤ 0.001), MWD (+132%, p ≤ 0.001), and 6MWD (+11%, p ≤ 0.001) remained significantly improved compared with the pre-SET condition. At 12 months, PFWD (+272%, p ≤ 0.001), MWD (+130%, p ≤ 0.001), and 6MWD (+11%, p ≤ 0.001) remained significantly improved compared with the pre-training condition. The walking performance remained significantly improved in both women and men for up to 12 months (p ≤ 0.001). Multimodal SET is effective at improving walking performance in symptomatic patients with PAD, with improvements lasting up to 12 months.

[Advances in the treatment of complex venous malformation: endovenous laser]

Congenital venous malformations (VMs) are the most common vascular abnormalities. Their treatment can be complex, depending on their size and surrounding tissues involvement. To date, sclerotherapy is considered the gold standard for the treatment of VMs. This technique, which aims to destroy the endothelium and thus cause fibrosis and retraction of the vascular lesion, is less effective in voluminous VMs. Endovenous thermal ablation is a widely validated treatment in the management of venous insufficiency, showing better efficacy than sclerotherapy in terms of trans-parietal vessel destruction. This approach has therefore also been described in the treatment of VMs. This technique has been introduced for the treatment of complex VMs at the Centre for Malformations and Rare Vascular Diseases of the CHUV.

Ultrasound-guided percutaneous endovenous laser treatment combined with sclerotherapy for the treatment of large intramuscular venous malformations

BACKGROUND

Among vascular anomalies, congenital venous malformations (VMs) are the most common lesions. Treatment of VMs is sometimes difficult or cumbersome, depending on their size and tissue involvement. Surgery may lead to invasive and mutilating excisions, often allowing only partial removal, with an increased risk of recurrence. Sclerotherapy is a mainstream technique, resulting in endothelium destruction, fibrosis and subsequent shrinkage of the vascular lesion, also with a risk of recurrence. However, this technique may not be efficient in cases of large and infiltrating VMs. Endovenous thermal ablation has been found to be more effective than sclerotherapy for transmural vascular destruction and has therefore been employed in the treatment of VMs.

METHODS

In this study we described a combined technique for the treatment of large intramuscular VMs in seven consecutive patients, associating endovenous laser ablation with sclerotherapy. The aim was to assess feasibility and safety of the procedure.

RESULTS

We reported a high immediate technical success, clinical and radiological improvement, with no complications.

CONCLUSIONS

The preliminary results presented herein show, that combining EVLA and sclerotherapy for the treatment of voluminous persistent intramuscular VM is safe and technically feasible. The combination of a wide direct intimal thermal damage with chemical sclerotherapy is the force of this approach. The small number of cases and the medium term follow up represent though a limitation.

[Pelvic congestion syndrome]

Pelvic congestion syndrome is an underdiagnosed disease, defined as chronic pelvic pain lasting more than 6 months, associated with pelvic varicose veins in premenopausal women. Diagnose is based on imagery after exclusion of other causes of pelvic pains. Echography is first line diagnostic modality. Conservative treatment is often insufficient and pelvic veins embolization is required to improve symptoms.

Multimodal Supervised Exercise Significantly Improves Walking Performances Without Changing Hemodynamic Parameters in Patients With Symptomatic Lower Extremity Peripheral Artery Disease

We evaluated the outcome of multimodal supervised exercise training (SET) on walking performances and different hemodynamic parameters (ankle/toe-brachial index [ABI/TBI], and transcutaneous oxygen pressure [TcPO₂]) in patients with symptomatic lower extremity peripheral artery disease (PAD). Whether hemodynamic parameters predict walking performances at baseline and following SET was also investigated. Fontaine stage II PAD's patients following a 3-month SET were retrospectively included. Hemodynamic parameters and walking performances (pain-free [PFWD], maximal [MWD], and 6-minute [6MWD] walking distance) were measured in each patient. Eighty-five symptomatic PAD patients were included. Following SET, PFWD, MWD, and 6MWD significantly increased (+142%, +94%, +14%; respectively; P ≤ .001). Toe-brachial index significantly increased (MD: 0.04 ± 0.01; P = .02), whereas ABI and TcPO₂ did not change significantly. At baseline, patients with higher TBI and TcPO₂ performed significantly better (PFWD: β = 0.25, P = .01 for TBI; PFWD: β = 0.30, P = .005, and MWD: β = 0.22, P = .04, for TcPO₂). No significant relationship was observed at baseline between ABI and walking performances. Baseline values of hemodynamic parameters did not significantly correlate with changes in walking performances. Multimodal SET significantly improves walking performances. Following SET, no significant changes in ABI and TcPO₂ were observed. Toe-brachial index values significantly improved after SET. However, this increase was very modest and its clinical relevance remains questionable. Although baseline TBI and supine TcPO₂ values predict baseline walking performances, no association was found between baseline hemodynamic parameters and changes in walking performances following SET.

D-dimer levels and risk of recurrence following provoked venous thromboembolism: findings from the RIETE registry

BACKGROUND

Patients with venous thromboembolism (VTE) secondary to transient risk factors may develop VTE recurrences after discontinuing anticoagulation. Identifying at-risk patients could help to guide the duration of therapy.

METHODS

We used the RIETE database to assess the prognostic value of d-dimer testing after discontinuing anticoagulation to identify patients at increased risk for recurrences. Transient risk factors were classified as major (postoperative) or minor (pregnancy, oestrogen use, immobilization or recent travel).

RESULTS

In December 2018, 1655 VTE patients with transient risk factors (major 460, minor 1195) underwent d-dimer measurements after discontinuing anticoagulation. Amongst patients with major risk factors, the recurrence rate was 5.74 (95% CI: 3.19-9.57) events per 100 patient-years in those with raised d-dimer levels and 2.68 (95% CI: 1.45-4.56) in those with normal levels. Amongst patients with minor risk factors, the rates were 7.79 (95% CI: 5.71-10.4) and 3.34 (95% CI: 2.39-4.53), respectively. Patients with major risk factors and raised d-dimer levels (n = 171) had a nonsignificantly higher rate of recurrences (hazard ratio [HR]: 2.14; 95% CI: 0.96-4.79) than those with normal levels. Patients with minor risk factors and raised d-dimer levels (n = 382) had a higher rate of recurrences (HR: 2.34; 95% CI: 1.51-3.63) than those with normal levels. On multivariate analysis, raised d-dimers (HR: 1.74; 95% CI: 1.09-2.77) were associated with an increased risk for recurrences in patients with minor risk factors, not in those with major risk factors.

CONCLUSIONS

Patients with raised d-dimer levels after discontinuing anticoagulant therapy for VTE provoked by a minor transient risk factor were at an increased risk for recurrences.

[Should patients with type 2 diabetes be screened for lower extremity arterial disease?]

Lower extremity arterial disease (LEAD) is a serious and invalidating disease with a relatively high prevalence in the diabetic population. Patients suffering from both conditions have a less favourable prognosis of affected limbs compared to non-diabetic patients, with more frequent adverse limb events such as amputations. Nevertheless, awareness of LEAD remains sub-optimal in the diabetic population. Regular and appropriate screening for this condition is therefore recommended. Affected individuals should receive optimal medical treatment, including intensive management of the various cardiovascular risk factors and strict blood glucose control.

[Intima-media thickness and carotidofemoral plaques for cardiovascular risk stratification]

Cardiovascular (CV) diseases are still one of the most important -killers in developed countries. In the last 40 years, great progresses have been achieved in recognizing and treating these diseases and their underlying risk factors. Risk assessment models using tradi-tional risk factors estimate the probability of a cardiovascular event in most cases and drive preventive treatment. However, these risk assessment models have weaknesses, and it is estimated that about 30 % of cardiovascular events are related to undetected risks. Many surrogate parameters have been investigated and have the potential to better predict CV risk beyond classical risk factors. The aim of this article is to assess the value of measuring the intima-media thickness and the detection of atheroma of the carotid and femoral bifurcation by ultrasound.

[Exercise training therapy in patients with lower extremity peripheral artery disease]

Patients with lower extremity peripheral artery disease (PAD) have decreased functional capacities leading to decreased quality of life and increased cardiovascular morbidity and mortality. Exercise therapy is recommended among first-choice therapeutic options and improves overall physical function and quality of life in symptomatic patients with PAD. Exercise therapy is also effective in patients with PAD following revascularization. Other than walking, different training modalities are safe, feasible and effective to induce clinical benefits for these patients. We present here the role of exercise therapy and its specificities in the management of PAD.

[Best medical treatment of lower extremity arterial disease in 2018]

Lower extremity artery disease is a very common disease, which is frequently associated with consistent disability in terms of both clinical symptoms and functioning. It is also associated with important morbidity and mortality, because of a significant increase in overall cardiovascular risk in affected patients. The establishment of an optimal medical treatment, including a careful management of the different cardiovascular risk factors through a healthy lifestyle, a regular and structured physical activity and the administration (if indicated) of antihypertensive, lipid-lowering, antidiabetic and antithrombotic drugs is a fundamental component in the clinical management of these patients and should always be considered by the clinicians facing the disease.

[Deep vein thrombosis in uncommon localisations]

Venous thromboembolism (VTE) with its two components, deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common disease with an incidence of 0,75‑2,69/1000. Deep vein thrombosis is localized in unusual sites in about 10 %, and rare DVT's have specific symptoms and risk factors. Uncommon DVT's are often related to local factors, inflammation, cancer, hematologic diseases and thrombophilia. Their diagnostic workup is less straightforward than in suspected VTE of lower limbs and PE, and rare DVT's are often unexpected findings of imaging studies. By extrapolating evidence of lower limbs VTE, most rare DVT are treated by anticoagulants, except retinal vein thrombosis. However, evidence for the type and duration of anticoagulation is limited.

[The treatment of venous malformations in adult patients: the role of US-guided sclerotherapy]

Venous malformations are slow flow dysplastic lesions, constituted by a vascular nest without arterial or capillary connections, more or less independent of the normal venous anatomy and circulation. In certain cases a treatment is required for symptom relief or for natural complications management. The percutaneous sclerotherapy under ultrasound guidance is increasingly used as an effective and mini-invasive option, allowing obtaining very good results with minor side effects. Several substances have been used with different efficacy and side effects rate. We review the literature and present some cases.

[Interventional treatment of venous insufficiency]

Interventional treatment of venous insufficiency has been revolutionized by endovascular techniques. Some of these techniques, and particularly thermal ablation (endovenous laser, radiofrequency) are now recommended as first-line therapy in the latest international guidelines. This is because of less post-operative pain, a shorter leave from employment and similar or lower recurrence rate. Endovenous techniques allow safer and more efficient treatment of certain particular conditions : small saphenous vein, ulcers, and recurrent varicose veins. In addition to clinical history and examination, a duplex sonography of deep and superficial veins, performed by an angiologist, is the most important exam in order to determine proper indication and best treatment strategy for each patient.

[Relevance of contrast ultrasound with microbubbles in vascular medecine]

Application of ultrasound contrast media has become a standard in diagnostic imaging in cardiology and in the characterization of focal lesions in multiple organs, especially of the liver. In the past years there was a growing body of evidence for their usefulness in vascular medicine. The development of contrast media, microbubbles with a stabilizing envelope and filled with gaz, small enough to pass through pulmonary capillaries made real-time imaging of organ perfusion possible. Ultrasound contrast media are rapidly eliminated by exhalation and can safely be administered to patients with renal failure. The objective of this review is to describe the basic principles of ultrasound contrast imaging and to inform about vascular applications of contrast ultrasound.

Variability of phyllochron, plastochron and rate of increase in height in photoperiod-sensitive sorghum varieties

BACKGROUND AND AIMS

West African sorghum (Sorghum bicolor) varieties are generally highly photoperiod-sensitive, which is a necessary adaptation to the variable onset date of the rainy season and the variable dates of sowing in the savannah zone. Depending on sowing date, plants can produce from 12 to >40 leaves on the main culm, with height varying from 1 m to more than 5 m. The present study aimed to better understand the complex phenology of these variables.

METHODS

A 2-year series of monthly sowings of three West African sorghum varieties was conducted near Bamako, Mali. Drought stress was avoided by supplemental irrigation. Rate of initiation of primordia at the stem apex was recorded, together with rate of leaf emergence and increase in plant height.

KEY RESULTS

Leaf initiation and appearance rates (plastochron(-1) and phyllochron(-1)) were constant for a given sowing date in cases where less than 20 leaves were produced (generally observed with late sowing dates). In contrast, rates were bilinear for early sowing dates, for which plants produced more than 20 leaves. The secondary rates, which occurred from the 20th leaf onwards, were only half of the initial rate. Plastochron and phyllochron showed large variations among sowing dates, and were correlated with the rate of plant height increase. The initial plastochron and phyllochron were positively correlated with soil temperature and negatively correlated with both day length and day-to-day change of day length prevailing at plant emergence, but these factors explained only half of the variation observed.

CONCLUSIONS

Although they belong to different genetic groups and have different height and photoperiod sensitivity, the three varieties studied exhibited similar response patterns of development rates among phenological phases and seasons, with the local landrace showing the greatest variation due to its longer vegetative phase and longer stem internodes. The possible adaptive advantages in African savannah environments of bilinear development rates and the associated limitation in height increase are discussed.

A simplified conceptual model of carbon/nitrogen functioning for QTL analysis of winter wheat adaptation to nitrogen deficiency

Breeding new varieties adapted to low-input agricultural practices is of particular interest in light of current economical and environmental concerns. Improving nitrogen (N) uptake and N utilization efficiency (NUE) are two ways of producing varieties tolerant to low N input. To offer new possibilities to breeders, it is necessary to acquire more knowledge about these two processes. Knowing C and N metabolisms are linked and knowing N uptake is partly explained by root characteristics, we carried out a QTL analysis for traits associated with N uptake and NUE by using both a conceptual model of C/N plant functioning and a root architecture description. A total of 120 lines were selected according to their genotype among 241 doubled haploids derived from two varieties, one N stress tolerant and the other N stress sensitive. They were grown in hydroponic rhizotrons under N-limited nutritional conditions. Initial conditions varied among genotypes; therefore, total root length on day 1 was used to correct traits. Heritabilities ranged from 13 to 84%. Thirty-two QTL were located: 6 associated with root architecture (on chromosomes 4B, 5A, 5D and 7B), 6 associated with model efficiencies (1B, 2B, 6A, 6B, 7A, 7B and 7D) and 20 associated with state variables (1A, 1B, 2B, 4B, 5A, 5B and 6B). The effects of the dwarfing gene Rht-B1 on root traits are discussed, as well as the features of a conceptual plant functioning model, as a useful tool to assess pertinent traits for QTL detection. It is suggested that further studies that couple QTL with a functioning model and a root architecture description could serve in the search for ideotypes.

Integrated physiological and agronomic modelling of N capture and use within the plant

Today farmers have several constraints to take into account in managing their crops: (i) competitiveness: productivity must be maintained or increased whereas inputs must be decreased, (ii) the environmental consequences of cultural practices: pesticide and fertilizer use must be decreased, and (iii) product quality must be improved and nitrogen nutrition is an important factor in harvest quality. These new constraints sometimes conflict: maximum yield is often obtained with large amounts of N, increasing the risks of N leaching. The determination of rates and dates for nitrogen application must become more precise in this context. Tools are required for the forecasting of crop requirements, the diagnosis of N deficiencies during the crop cycle and breeding of new adapted varieties. Models and diagnosis indicators have been developed to meet these needs, but those relating to nitrogen are often based on empirical relationships. Moreover, the available models and indicators often fail to account for cultivar-specific responses. The improvement of agronomic tools and the breeding of new varieties adapted to new cropping systems should be based on a thorough understanding of the key metabolic processes involved, and the relative contributions of these processes to yield determination in conditions of fluctuating N supply. For both purposes, more information is required about plant and crop N economy. In this paper, the way in which N absorption and use within the plant and crop, plant responses to deficiencies and excesses of nitrogen are taken into account in major agronomic models is described first. The level of sophistication of the modules comprising these models depends on operational objectives. Secondly, the ways in which the most recent molecular plant physiology findings can, and indeed should, be integrated into models at the crop and crop cycle levels are described. The potential value of this approach for improving current agronomic models and diagnostic tools, and for breeding more efficient varieties is also discussed.