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The effects of upright positions (sitting and standing) on cerebral haemodynamics early post an ischaemic stroke are not well understood. Neither is their influence on longer term clinical outcomes. Concerns that early upright activity (sitting, standing and walking activities, often termed early mobilisation) may worsen cerebral perfusion within penumbral tissue early post stroke, particularly in people with occlusive disease, guided the development of the research in this thesis. This thesis is comprised of four studies that collectively aimed to shed light on the uncertainty around the effects of head positioning, particularly upright positions, on cerebral haemodynamics and clinical outcomes in acute ischaemic stroke. The first study, a comprehensive systematic review and meta-analysis, highlighted the dearth of studies assessing changes in cerebral haemodynamics in upright sitting and standing in acute ischaemic stroke. Yet getting out of bed, sitting up and walking, are early activity practices that, while part of routine stroke unit care, are not strongly guided by evidence. This review also showed the dearth of head positioning studies that examined occlusive disease as a patient-related factor that may contribute to further reductions in cerebral perfusion during upright activity. This review highlighted important research gaps to be addressed in the subsequent studies. The second study aimed to explore whether occlusive disease contributed to worse clinical outcomes in people with ischaemic stroke treated with very early mobilisation (more frequent out of bed upright activities, started <24h of stroke onset). This post hoc retrospective substudy of the A Very Early Rehabilitation (AVERT) trial showed a greater proportion of participants with occlusive disease having worse 3-month clinical outcomes (modified Rankin Scale, deaths) treated with very early mobilisation compared to usual care. However, no significant associations between occlusive disease, clin

BackgroundIntermittent claudication (IC) is the classic symptomatic form of peripheral arterial disease affecting an estimated 4.5% of the general population aged 40 years and older. Patients with IC experience limitations in their ambulatory function resulting in functional disability and impaired quality of life (QoL). Endovascular revascularisation has been proposed as an effective treatment for patients with IC and is increasingly performed.ObjectivesThe main objective of this systematic review is to summarise the (added) effects of endovascular revascularisation on functional performance and QoL in the management of IC.Search methodsFor this review the Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (February 2017) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1). The CIS also searched trials registries for details of ongoing and unpublished studies.Selection criteriaRandomised controlled trials (RCTs) comparing endovascular revascularisation (conservative therapy consisting of supervised exercise or pharmacotherapy) versus no therapy (except advice to exercise) or versus conservative therapy (i.e. supervised exercise or pharmacotherapy) for IC.Data collection and analysisTwo review authors independently selected studies, extracted data, and assessed the methodological quality of studies. Given large variation in the intensity of treadmill protocols to assess walking distances and use of different instruments to assess QoL, we used standardised mean difference (SMD) as treatment effect for continuous outcome measures to allow standardisation of results and calculated the pooled SMD as treatment effect size in meta-analyses. We interpreted pooled SMDs using rules of thumb (<0.40 = small, 0.40 to 0.70 = moderate, > 0.70 = large effect) according to the Cochrane Handbook for Systematic Reviews of Interventions. We calculated the p

Background Although supervised exercise therapy (SET) provides significant symptomatic benefit for patients with intermittent claudication (IC), it remains an underutilized tool. Widespread implementation of SET is restricted by lack of facilities and funding. Structured home-based exercise therapy (HBET) with an observation component (e.g., exercise logbooks, pedometers) and just walking advice (WA) are alternatives to SET. This is the second update of a review first published in 2006. Objectives The primary objective was to provide an accurate overview of studies evaluating effects of SET programs, HBET programs, and WA on maximal treadmill walking distance or time (MWD/T) for patients with IC. Secondary objectives were to evaluate effects of SET, HBET, and WA on pain-free treadmill walking distance or time (PFWD/T), quality of life, and self-reported functional impairment. Search methods The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register (December 16, 2016) and the Cochrane Central Register of Controlled Trials (2016, Issue 11). We searched the reference lists of relevant studies identified through searches for other potential trials. We applied no restriction on language of publication. Selection criteria We included parallel-group randomized controlled trials comparing SET programs with HBET programs and WA in participants with IC. We excluded studies in which control groups did not receive exercise or walking advice (maintained normal physical activity). We also excluded studies comparing exercise with percutaneous transluminal angioplasty, bypass surgery, or drug therapy. Data collection and analysis Three review authors (DH, HF, and LG) independently selected trials, extracted data, and assessed trials for risk of bias. Two other review authors (MvdHand JT) confirmed the suitability and methodological quality of trials. For all continuous outcomes, we extracted the number of participants, mean outcome, and standa

Background: Although supervised exercise therapy (SET) is generally accepted as an effective noninvasive treatment for intermittent claudication (IC), Dutch vascular surgeons were initially somewhat hesitant as reported by a 2011 questionnaire study. Later on, a nationwide multidisciplinary network for SET was introduced in the Netherlands. The aim of this questionnaire study was to determine possible trends in conceptions among Dutch vascular surgeons regarding the prescription of SET. Methods: In the year of 2015, Dutch vascular surgeons, fellows, and senior residents were asked to complete a 26-item questionnaire including issues that were considered relevant for prescribing SET such as patient selection criteria and comorbidity. Outcome was compared to the 2011 survey. Results: Data of 124 respondents (82% males; mean age 46 years; 64% response rate) were analyzed. SET referral rate of new IC patients was not different over time (2015: 81% vs. 2011: 75%; P = 0.295). However, respondents were more willing to prescribe SET in IC patients with chronic obstructive pulmonary disease (2015: 86% vs. 2011: 69%; P = 0.002). Nevertheless, a smaller portion of respondents found that SET was also indicated for aortoiliac disease (2015: 63% vs. 2011: 76%; P = 0.049). Insufficient health insurance coverage and/or personal financial resources were the most important presumed barriers preventing patients from initiating SET (80% of respondents). Moreover, 94% of respondents judged that SET should be fully reimbursed by all Dutch basic health insurances. Conclusions: The concept of SET for IC is nowadays generally embraced by the vast majority of Dutch vascular surgeons. SET may have gained in popularity in IC patients with cardiopulmonary comorbidity. However, SET remains underutilized for aortoiliac disease. Reimbursement is considered crucial for a successful SET implementation.

BackgroundIntermittent claudication (IC) is the classic symptomatic form of peripheral arterial disease affecting an estimated 4.5% of the general population aged 40 years and older. Patients with IC experience limitations in their ambulatory function resulting in functional disability and impaired quality of life (QoL). Endovascular revascularisation has been proposed as an effective treatment for patients with IC and is increasingly performed.ObjectivesThe main objective of this systematic review is to summarise the (added) effects of endovascular revascularisation on functional performance and QoL in the management of IC.Search methodsFor this review the Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (February 2017) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 1). The CIS also searched trials registries for details of ongoing and unpublished studies.Selection criteriaRandomised controlled trials (RCTs) comparing endovascular revascularisation (conservative therapy consisting of supervised exercise or pharmacotherapy) versus no therapy (except advice to exercise) or versus conservative therapy (i.e. supervised exercise or pharmacotherapy) for IC.Data collection and analysisTwo review authors independently selected studies, extracted data, and assessed the methodological quality of studies. Given large variation in the intensity of treadmill protocols to assess walking distances and use of different instruments to assess QoL, we used standardised mean difference (SMD) as treatment effect for continuous outcome measures to allow standardisation of results and calculated the pooled SMD as treatment effect size in meta-analyses. We interpreted pooled SMDs using rules of thumb (<0.40 = small, 0.40 to 0.70 = moderate, > 0.70 = large effect) according to the Cochrane Handbook for Systematic Reviews of Interventions. We calculated the p

Background: Although supervised exercise therapy (SET) is generally accepted as an effective noninvasive treatment for intermittent claudication (IC), Dutch vascular surgeons were initially somewhat hesitant as reported by a 2011 questionnaire study. Later on, a nationwide multidisciplinary network for SET was introduced in the Netherlands. The aim of this questionnaire study was to determine possible trends in conceptions among Dutch vascular surgeons regarding the prescription of SET. Methods: In the year of 2015, Dutch vascular surgeons, fellows, and senior residents were asked to complete a 26-item questionnaire including issues that were considered relevant for prescribing SET such as patient selection criteria and comorbidity. Outcome was compared to the 2011 survey. Results: Data of 124 respondents (82% males; mean age 46 years; 64% response rate) were analyzed. SET referral rate of new IC patients was not different over time (2015: 81% vs. 2011: 75%; P = 0.295). However, respondents were more willing to prescribe SET in IC patients with chronic obstructive pulmonary disease (2015: 86% vs. 2011: 69%; P = 0.002). Nevertheless, a smaller portion of respondents found that SET was also indicated for aortoiliac disease (2015: 63% vs. 2011: 76%; P = 0.049). Insufficient health insurance coverage and/or personal financial resources were the most important presumed barriers preventing patients from initiating SET (80% of respondents). Moreover, 94% of respondents judged that SET should be fully reimbursed by all Dutch basic health insurances. Conclusions: The concept of SET for IC is nowadays generally embraced by the vast majority of Dutch vascular surgeons. SET may have gained in popularity in IC patients with cardiopulmonary comorbidity. However, SET remains underutilized for aortoiliac disease. Reimbursement is considered crucial for a successful SET implementation.

Background Although supervised exercise therapy (SET) provides significant symptomatic benefit for patients with intermittent claudication (IC), it remains an underutilized tool. Widespread implementation of SET is restricted by lack of facilities and funding. Structured home-based exercise therapy (HBET) with an observation component (e.g., exercise logbooks, pedometers) and just walking advice (WA) are alternatives to SET. This is the second update of a review first published in 2006. Objectives The primary objective was to provide an accurate overview of studies evaluating effects of SET programs, HBET programs, and WA on maximal treadmill walking distance or time (MWD/T) for patients with IC. Secondary objectives were to evaluate effects of SET, HBET, and WA on pain-free treadmill walking distance or time (PFWD/T), quality of life, and self-reported functional impairment. Search methods The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register (December 16, 2016) and the Cochrane Central Register of Controlled Trials (2016, Issue 11). We searched the reference lists of relevant studies identified through searches for other potential trials. We applied no restriction on language of publication. Selection criteria We included parallel-group randomized controlled trials comparing SET programs with HBET programs and WA in participants with IC. We excluded studies in which control groups did not receive exercise or walking advice (maintained normal physical activity). We also excluded studies comparing exercise with percutaneous transluminal angioplasty, bypass surgery, or drug therapy. Data collection and analysis Three review authors (DH, HF, and LG) independently selected trials, extracted data, and assessed trials for risk of bias. Two other review authors (MvdHand JT) confirmed the suitability and methodological quality of trials. For all continuous outcomes, we extracted the number of participants, mean outcome, and standa

Objective/Background: A previous budget impact analysis regarding a supervised exercise therapy (SET) first treatment strategy (stepped care model [SCM]) for Dutch patients with intermittent claudication (IC) showed a low referral rate in 2009, despite solid evidence of the effectiveness of SET programs. Recently, several campaigns have stimulated stakeholders in the field to adopt a SET first strategy in patients with IC. The aim of the present study was to reassess SCM adherence after a 2 year period.Methods: IC related invoices of patients in 2011 were obtained from a large Dutch health insurance company (3.5 million persons). Patients were divided into two groups based on their initial treatment. A SET group had started SET between 12 months before (initiated by general practitioner) and 3 months after (initiated by vascular surgeon) presentation at a vascular surgery outpatient clinic. An intervention (INT) group was treated by revascularisation within 3 months of outpatient presentation. Costs of IC treatment in this 2011 cohort were compared with the earlier 2009 cohort.Results: IC related invoices of 4135 patients were available. In 2011, the initial treatment was SET in 56% (2009: 34%; +22% [p <.001]) and INT in 44% (2009: 66%; -22% [p <.001]) of the IC population. Additional revascularisation was performed in 19% of patients in the SET group (2009: 6%; +13% [p <.001]) and also in 19% of patients in the INT group (2009: 35%; -16% [p <.001]). Later on, 29% of patients in the INT group were referred for SET (2009: 10%; +19% [p <.001]). Average costs of IC treatment per patient in 2011 were 6% lower than in 2009 ((sic)6885 vs. (sic)7300; p = .020).Conclusion: A 22% increase in adherence to SET as a first treatment strategy in Dutch patients with IC was attained between 2009 and 2011. This shift suggests successful SCM implementation resulting in lower costs for the national healthcare system. (C) 2017 European Society for

Intermittent claudication (IC) is a manifestation of peripheral arterial disease. IC has a high prevalence in the older population, is closely associated with other expressions of atherosclerotic disease and often co-exists in multimorbid patients. Treatment of IC should address reduction of cardiovascular risk and improvement of functional capacity and health-related quality of life (QoL). As recommended by contemporary international guidelines, the first-line treatment includes supervised exercise therapy (SET). In several randomized controlled trials and systematic reviews, SET is compared with usual care, placebo, walking advice and endovascular revascularization. The evidence supporting the efficacy of SET programs to alleviate claudication symptoms is robust. SET improves walking distance and health-related QoL and appears to be the most cost-effective treatment for IC. Nevertheless, only few of all newly diagnosed IC patients worldwide receive this safe, efficient and structured treatment. Worldwide implementation of structured SET programs is seriously impeded by outdated arguments favoring an invasive intervention, absence of a network of specialized physical therapists providing standardized SET and lack of awareness and/ or knowledge of the importance of SET by referring physicians. Besides, misguiding financial incentives and lack of reimbursement hamper actual use of SET programs. In the Netherlands, a national integrated care network (ClaudicatioNet) was launched in 2011 to combat treatment shortcomings and stimulate cohesion and collaboration between stakeholders. This care intervention has resulted in optimized quality of care for all patients with IC.

Intermittent claudication (IC) is a manifestation of peripheral arterial disease. IC has a high prevalence in the older population, is closely associated with other expressions of atherosclerotic disease and often co-exists in multimorbid patients. Treatment of IC should address reduction of cardiovascular risk and improvement of functional capacity and health-related quality of life (QoL). As recommended by contemporary international guidelines, the first-line treatment includes supervised exercise therapy (SET). In several randomized controlled trials and systematic reviews, SET is compared with usual care, placebo, walking advice and endovascular revascularization. The evidence supporting the efficacy of SET programs to alleviate claudication symptoms is robust. SET improves walking distance and health-related QoL and appears to be the most cost-effective treatment for IC. Nevertheless, only few of all newly diagnosed IC patients worldwide receive this safe, efficient and structured treatment. Worldwide implementation of structured SET programs is seriously impeded by outdated arguments favoring an invasive intervention, absence of a network of specialized physical therapists providing standardized SET and lack of awareness and/ or knowledge of the importance of SET by referring physicians. Besides, misguiding financial incentives and lack of reimbursement hamper actual use of SET programs. In the Netherlands, a national integrated care network (ClaudicatioNet) was launched in 2011 to combat treatment shortcomings and stimulate cohesion and collaboration between stakeholders. This care intervention has resulted in optimized quality of care for all patients with IC.

Objective/Background: A previous budget impact analysis regarding a supervised exercise therapy (SET) first treatment strategy (stepped care model [SCM]) for Dutch patients with intermittent claudication (IC) showed a low referral rate in 2009, despite solid evidence of the effectiveness of SET programs. Recently, several campaigns have stimulated stakeholders in the field to adopt a SET first strategy in patients with IC. The aim of the present study was to reassess SCM adherence after a 2 year period.Methods: IC related invoices of patients in 2011 were obtained from a large Dutch health insurance company (3.5 million persons). Patients were divided into two groups based on their initial treatment. A SET group had started SET between 12 months before (initiated by general practitioner) and 3 months after (initiated by vascular surgeon) presentation at a vascular surgery outpatient clinic. An intervention (INT) group was treated by revascularisation within 3 months of outpatient presentation. Costs of IC treatment in this 2011 cohort were compared with the earlier 2009 cohort.Results: IC related invoices of 4135 patients were available. In 2011, the initial treatment was SET in 56% (2009: 34%; +22% [p <.001]) and INT in 44% (2009: 66%; -22% [p <.001]) of the IC population. Additional revascularisation was performed in 19% of patients in the SET group (2009: 6%; +13% [p <.001]) and also in 19% of patients in the INT group (2009: 35%; -16% [p <.001]). Later on, 29% of patients in the INT group were referred for SET (2009: 10%; +19% [p <.001]). Average costs of IC treatment per patient in 2011 were 6% lower than in 2009 ((sic)6885 vs. (sic)7300; p = .020).Conclusion: A 22% increase in adherence to SET as a first treatment strategy in Dutch patients with IC was attained between 2009 and 2011. This shift suggests successful SCM implementation resulting in lower costs for the national healthcare system. (C) 2017 European Society for

Aims: The purpose of this study was to evaluate factors that contribute to a patent IRA (infarct - related artery) and the prognostic impact of a patent IRA in patients with ST-elevation myocardial infarction. Methods and results: Using the Swedish angiography and angioplasty registry (SCAAR) we included all patients with STEMI and one-vessel coronary artery disease who underwent primary PCI of the culprit lesion only from May 2005 to December 2007. A patent IRA was found in 1,104 of 3,284 patients. Patients with an occluded IRA had significantly increased 7-day mortality (HR, 3.03, 95% CI 1.68-5.46, P<0.001). The incidence of an occluded IRA increased with higher age, in patients over 80 years of age (OR, 1.23, 95% CI; 0.92-1.64), lower in patients on lipid-lowering drugs (OR, 0.68, 95% CI; 0.54-0.86) and lower in patients pre-treated with heparin (OR 0.71, 95% CI; 0.60-0.83) or GPIIb/IIIa receptor blockade (OR 0.77, 95% CI; 0.61-0.97). Treatment with acetylsalicylic acid or clopidogrel had no effect on IRA patency. Conclusions: IRA patency was associated with a lower 7-day mortality. Older STEM I patients and patients not taking lipid-lowering drugs or pre-treated with heparin or GPIIb/IIIa receptor blockers seem to constitute risk groups for having an occluded IRA.

Objective To examine the safety and efficacy of endovascular management of isolated infrarenal aortic occlusive disease within our centre. Design and methods Retrospective analysis of all patients who underwent endovascular treatment of occlusive disease that is confined to the infrarenal aorta between September 1993 and November 2004. Results Primary aortic stenting was carried out in 16 women and five men using self-expanding (12 patients) and balloon expanding stents to treat both occlusions (six) and stenoses (15). Indications included intermittent claudication (13), critical limb ischaemia (six), and distal embolisation (three). Significant postoperative complications within 30 days were noted in three, including one death. Fifteen patients completed 1-year follow-up with primary patency in 14 and secondary patency in the remaining patient. Clinical improvement was documented in all patients. Conclusion Primary stenting for occlusive disease isolated in the infrarenal aorta is relatively safe in selected patients with encouraging early follow-up results.