Peripheral vascular Disease

Diabetic patients are high risk for developing peripheral vascular disease. Life style practices such as smoking, obesity, increases the risk. Nurses need to take up the responsibility to educate and create awareness among diabetic patients to improve their knowledge and thus reduce the mortality and morbidity rate caused by peripheral vascular disease. Nurses can play a vital role in motivating the diabetic patients in lifestyle modifications by giving adequate counselling regarding healthy lifestyle practices. Nurses can develop evidence based practise and include video assisted teaching as an integral nursing intervention. Nurses should use video assisted teaching program as a modality to increase the level of knowledge in their clinical area as it is interesting, harmless and highly effective.

Abstract: This illustrated review article gives an evidence-based update on the different modalities used for imaging peripheral vascular disease (duplex ultrasound, computed tomog- raphy angiography, magnetic resonance angiography, and digital subtraction angiography). After discussing the latest technological developments for each modality, their limitations are also highlighted. The evidence is presented for the various modalities’ roles in the imaging of peripheral vascular disease, including problem-solving applications. The strengths and weak- nesses of each modality are therefore critically appraised, including the salient technological, clinical, and fi nancial aspects. This review allows the general and specialist practitioner to make an informed decision on how best to deploy imaging tests in peripheral vascular disease as part of an evidence-based approach. The article concludes with a rational imaging algorithm for the investigation of peripheral vascular disease.

This is to certify that “USEFULNESS OF PULSE OXIMETRY AND ANKLE BRACHIAL INDEX FOR SCREENING ASYMPTOMATIC PERIPHERAL VASCULAR DISEASE IN TYPE 2 DIABETES MELLITUS” is a bonafide work done by Dr. A. S. NATH Post graduate student, Department of General Medicine, Kilpauk Medical College, Chennai- 10, under my guidance and supervision in partial fulfilment of rules and regulations of the Tamil Nadu Dr. M.G.R Medical University, for the award of M.D. Degree Branch I (General Medicine) during the academic period from MAY 2016 To MAY 2019.

A number of concomitant cardiovascular diseases can affect middle-aged to elderly patients with peripheral vascular disease, resulting in polypharmacy in many cases. This has led to the study of the possible interactions of sulodexide with other drugs. No interference was found with the concomitant use of sulodexide and diuretics/antihypertensives, oral hypoglycemic drugs, gastric protectors, bronchodilators and expectorants, tranquilizers and anxiolytics, hepatic protectors, antibiotics/systemic disinfectants, nitroderivatives, insulin, and LMWH. 66–68 To summarize, oral administration of

ischemia (ulceration and rest pain) Notes: A normal or subnormal ABi in a diabetic patient should prompt health care providers to consider the possibility of even worse vascular disease than the value would imply in non-diabetic patients. Additionally a falsely elevated ABi, such as greater than 1.3, which is common in DM patients, is associated with increased cardiovascular event rates. ABI is derived first by determining the systolic blood pressure in both brachial arteries and then in the dorsalis pedis and posterior tibial arteries. it can then be calculated for each lower extremity and interpreted as shown in the table. To determine the ABi score, after measuring the brachial systolic value one must evaluate the systolic values of the lower extremities. Adapted from Clinics in Podiatric Medicine and Surgery; 31(1); Chin JA, Sumpio Be; Diabetes mellitus and peripheral vascular disease: diagnosis and management; 11–26; Copyright © 2014, with permission from elsevier. 1

compromised. This results from multiple contributing factors. Peripheral neuropathy and ischemia from peripheral vascular disease (PVD) are noted to be the major underlying causes. In the presence of these factors, even moderate ischemia can cause ulcers and impair healing. DFU can be categorized as Neuropathic ulcer (NPU) or Neuro-ischemic (NIU) requiring different treatment and with different prognosis. 6,7 Prevalence of

Patients with PAD have a 15-30% 5 year mortality rate and two-to six fold increased risk of death from coronary heart disease. Mortality is highest in those with the most severe PAD. The likelihood of symptomatic progression of PAD appears less than the chance of succumbing to coronary artery disease. Approximately 75-80% of nondiabetic patients who present with mild to moderate claudication remain symptomatically stable. Deterioration is likely to occur in the remainder, with approximately 1-2% developing critical limb ischemia. Approximately 25% of patients with critical limb ischemia survive and undergo amputation within 1 year. The prognosis is worse in patients who continue to smoke cigarettes or who have diabetes mellitus.

Photo plethysmography (PPG), first introduced in the 1930 ′ s to assess the vascular sys- tem, uses an infrared light source and a light receptor to estimate the variation of blood volume [44]. There are two common PPG sensor designs; one in which the toe or finger is placed between a light source and a light receptor, commonly known as PPG (Fig. 1b); in the second configuration, known as quantitative PPG or light reflection rheography (LRR) (Fig. 1c), the light source and receptor are placed beside each other [31]. PPG pro- duces a pulsatile waveform (AC) superimposed on a slowly changing baseline (DC) [45]. The AC component is used to measure changes in the blood volume due to arterial pul- sation, and the DC component changes in total blood volume [31, 45, 46]. The derived arterial pulse wave enables the diagnosis of arterial incompetence [31]. Venous refilling time can also be measured by calculating changes in blood volume between static posi- tioning and post-exercise (usually ten dorsiflexion manoeuvres) [31]. Venous refilling time is the time taken for the PPG curve to return to a stable value for at least 5 s [47]. Table 2 provides a summary of the sensitivity and specificity values calculated from eval- uations of PPG for the diagnosis of PVDs.

closely for persistent infection that may require additional surgical intervention. In patients with adequate arterial circulation, the wound can be closed secondarily after resolution of the infection. All patients with evidence of concomitant arterial occlusive disease are considered for lower extremity revascularization with open bypass surgery or endovascular stenting or angioplasty to optimize wound healing and limb salvage.

Chronic venous disease is a common cause of ulceration around the gaiter area (Nicolaides et al., 2008). Several factors might affect tissue viability and susceptibility to ulceration, but the structural and functional integrity of the microcirculation to maintain blood flow, tissue oxygenation and nutrient delivery might be particularly important (Iabichella et al., 2006). Therefore, microvascular endothelial dysfunction, which persists after varicose-vein surgery (Study 3), might be a contributory factor towards the relatively high incidence of venous ulceration in post-surgical varicose-vein patients (18% over a 5-yr period; Nelzen and Fransson, 2007). In the present study, the pre-training peak responses to ACh in the supine position (mean of whole cohort = 39 PU) were similar to those observed previously for this patient group (mean = 45 PU; Study 3) and lower than those observed for age-matched healthy controls (mean = 63 PU; Study 3), suggesting that the patients had microvascular endothelial dysfunction at baseline. Exercise training appeared to abolish the difference in ACh-responsiveness between the patients in this study and the age-matched healthy controls of Study 3 (62 vs. 63 PU, respectively; P = 0.841), which suggests that this change might be clinically meaningful with respect to risk of venous ulceration. Indeed, the moderate-to-large effect sizes for the ACh data (Cohen's d = 0.63 and 1.37 for the supine and standing positions, respectively) support this interpretation. However, a longer-term study with clinical end-points is needed to clarify this.

Covariates included patient characteristics (age, gender, body mass index [BMI]), lifestyle factors (smoking status and alcohol consumption), comorbidities and drug treatment. Only GP records occurring within the 5-year period before initial diagnosis of gout were used to evaluate comorbidities and drug treatment. Comorbidities were grouped into 17 diagnostic categories (myocardial infarction, congestive heart failure, peripheral vascular disease, cerebrovascular disease, dementia, chronic pulmonary disease, rheumatologic disease, peptic ulcer disease, mild liver disease, moderate or severe liver disease, diabetes mellitus [DM], DM with chronic complications, renal diseases, any malignancy [including leukaemia and lymphoma], metastatic solid tumour and human immunodeficiency virus [HIV] infection) for calculation of the Charlson comorbidity index[52, 53] and other comorbidities (alcohol abuse, anaemia, cardiac arrhythmias, depression, drug abuse, hip fracture, hypertension, hypothyroidism, multiple sclerosis, neurological diseases, psoriasis, psychosis, urolithiasis and valvular heart disease). The definitions of these conditions were also based on physician diagnoses recorded as READ codes. Medications evaluated include aspirin, anticoagulants, anticonvulsants, lipid lowering agents (statin, fibrate and other), antihypertensives

Results: Maximum patients with diabetes were between 60 - 69 years of age. Of the total number of patients 49% were found to be hypertensive, 39% were found to be obese, 16% of the study population were smokers and 50% were found to have hypercholesterolaemia. The prevalence of retinopathy, neuropathy and nephropathy were 37%, 24% and 20% respectively. The prevalence of coronary artery disease, peripheral vascular disease and cerebrovascular disease was found to be 29%, 5% and 10% respectively.

cardiac arrhythmias and conduction disorders, valvular disorders and endocarditis, pericardial disorders, myocarditis, peripheral vascular disease, hypertension, dementia, chronic pulmonary disease, pulmonary circulation disorders, rheumatic arthritis/collagen vascular disease, liver disease, Parkinson’s disease, other extrapyramidal and movement disorders, depression, diabetes, renal failure, cancer (except malignant neoplasm of the skin), obesity, alcohol abuse, drug abuse, osteoporosis and other disorders of bone density and structure, syncope, dizziness and tendency to fall, vision disorders, dyslipidemia, bipolar disorders, schizophrenia, smoking, anxiety disorders, obsessive compulsive disorders, other movement disorders, pain, infectious diseases, delirium, use of insulin, antidiabetic medications, antithrombotic medications, cardiac glycosides, antiarrhythmic medications, other antihypertensive medications, diuretics, vasodilators, β-adrenergic agonists, calcium antagonists, aCE inhibitors, angiotensin ii antagonists, lipid-lowering medications, hormone therapy, glucocorticoids, antiparkinson medications, respiratory medications, nonsteroidal anti-inflammatory medications, antipsychotics, antiepileptic medications, anxiolytics, hypnotics and sedatives, muscle relaxants, number of medications (1–4, 5–8, 9 and more), hospitalized time (≤5%, >5%), Charlson Comorbidity index (≤2, >2), nursing home residence. c reference category remote users of any aD. d reference category remote users of the same aD.

All data were analysed using the ‘Statistical Package for the Social Sciences’ statistical software package. Basic descriptive statistics were used to analyse the population characteristics (age, gender and nationality; see online supplementary file for classification) and four NCDs clusters (cardiovascular diseases (coronary heart disease, stroke and peripheral vascular disease), cancers, COPD and T2DM).

As various factors contribute to the occurrence of depression 5,6,8,10,11,12 and its persistence over time, establishing support for people who have undergone amputation is challenging. In the UK it is customary that people receive introductory counselling at their rehabilitation centre soon after a lower limb amputation. However, the onus is then on them to request counselling again if their needs remain or change. This is problematic given that depression can remain for up to 3 years 11,12 and that older people who have undergone amputation are unlikely to seek counselling 13 . Further, for those with diabetes and/or peripheral vascular disease, depression may already exist before the amputation 14,15 . This may add to the complexity of the factors that lead to it persisting over time. It is important that clinicians are able to understand thecomplexity of physical and psychological wellbeing so that appropriate support can be provided. Depression can be measured with existing tools 16 but these may not capture the persons overall feelings of wellbeing and there is no quantifiable tool to measure this.

Coronary artery disease was defined on basis of changes in 12 lead resting echocardiogram and any documented past event of myocardial infarction, coronary artery bypass grafting or any other invasive procedure to treat the coronary artery disease. Peripheral vascular disease was defined as absent pedal pulses or history of a past event of gangrene, amputation, vascular surgery or ischemic foot ulcer. Stroke was defined as a recorded past event of transient ischemic attack or cerebral vascular accident. Diabetic retinopathy was defined by fundoscopy (direct ophthalmoscopy) performed on dilated pupils by ophthalmologists. Diabetic nephropathy was diagnosed on basis of presence of urinary albumin in range of 30-300mg/day on repeated testing. Peripheral neuropathy was defined by history of pain, tingling numbness.

In comparison with the general population, patients with DM are predisposed to mycotic infections such as mucormycosis, and Candida infection of the mucous membranes, nails and skin folds [23]. Besides the high blood glucose levels and impaired immunity, diabetes related medical conditions may also provide contribution to the development of OM in diabetic patients [24]. For example, peripheral vascular disease results in impaired wound healing and increased risk of infection, and peripheral neuropathy results in decreased ability to detect the presence and the progression of infection [25]. Although conflicting reports [26,27] are available, patients with DM have been reported to prone to dermat- ophyte infections [28,29]. In addition, in two recent large scale studies [9,11], the prevalence of OM has been shown to be significantly higher in diabetic patients than normal individuals and increasing age, male gender, family his- tory of onychomycosis, concurrent intake of immunosup- pressive agents and peripheral vascular disease have been shown as independent risk factors for the development of OM. In contrast, in the present study, we did not find any correlation of increasing age, male gender, and family his- tory of onychomycosis with the development of OM. This difference may be, in part, due to distinct characteristics of our patients (uremia plus DM). As we excluded patients receiving immunosuppressive agents and we did not investigate the presence of peripheral vascular disease in

Soft tissue and foot infections are significantly associated with diabetes. The relative frequency of cellulites is 9 times more in diabetic patients than in non-diabetic subjects. Similarly, patients with osteomyelitis were more who had infections in foot in their report and the relative proportions of hospitalization of patients with osteomyelitis were 12 times more than in non-diabetic subjects [110]. The risk of hospitalization was more than non-diabetic subjects. Significant risk factors that were independent risk factors in a multivariate analysis were infections to bone and duration of ulcer >30 days and peripheral vascular disease [116]. The variable in 112 diabetic foot ulcer were history of previous amputation, peripheral vascular disease and neuropathy but not socioeconomic status as the significant risk factors [117]. Fortunately, upto 50% diabetic individual who had one foot infection episode will have another episode within few years. Thus infection is often the proximate cause leading to amputation in their outcome [37, 55]. India, with a population of more than 1.1 billion, has the dubious distinction of having a larger number of people with diabetes and there were no major difference in the risk factors when compared with developed countries, while the clinical features may vary in developing countries because of the regional factors [118].

The breakdown of Diabetic foot was traditionally considered to result from peripheral vascular disease, peripheral neuropathy and infection. More recently other contributory causes such as psychosocial factors and abnormalities of pressure and loads under the foot is implicated. There is also no compelling evidence that infection is direct cause of ulceration, it is likely that infection becomes established once the skin break occurs and thus a consequence rather than a cause of ulceration. Infections

Methods: We analyzed data from 174 patients selected from the University Hospital of the West Indies diabetes clinic using gender-stratified random sampling. An interviewer- administered questionnaire was used to obtain data on self-reported CVD (coronary heart disease [CHD], cerebrovascular disease, and peripheral vascular disease [PVD]), physical activity, alcohol consumption, and smoking. Trained nurses performed blood pressure and anthropometric measurements. A capillary blood sample was collected to measure glycosylated hemoglobin, and urine was tested for protein and microalbumin. Means and proportions for patient charac- teristics, CVD outcomes, and risk factors were calculated. Logistic regression was used to identify factors independently associated with CVD.