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This paper describes a currently on-going multicenter, randomized controlled trial designed to assess the efficacy of calf neuromuscular electrical stimulation (NMES) on changes in maximal walking distance in people with lower extremity peripheral artery disease (PAD), compared with a non-intervention control-group. This study (NCT03795103) encompasses five participating centers in France. PAD participants with a predominant claudication at the calf level and a maximal treadmill walking distance ≤300 m are randomized into one of the two groups: NMES group or Control group. The NMES program consists of a 12-week program of electrical stimulations at the calf-muscle level. The primary outcome of the study is the change in maximal treadmill walking distance at 12 weeks. Main secondary outcomes include changes in the pain-free treadmill walking distance; 6 min total walking distance; global positioning system (GPS)-measured outdoor walking capacity; daily physical activity level by accelerometry; self-reported walking impairment; self-reported quality of life; ankle-brachial index; and skin microvascular function, both at the forearm and calf levels. Recruitment started in September 2019 and data collection is expected to end in November 2022. [ABSTRACT FROM AUTHOR]

Background and purpose: Ischaemic stroke has been described in association with COVID‐19. Several pathophysiological mechanisms have been suggested, i.e. prothrombotic state, cardiac injury etc. It was sought to assess the potential association between ischaemic stroke associated with SARS‐CoV‐2 infection and underlying atherosclerotic lesions. Methods: A retrospective analysis of stroke related to large vessel occlusion was conducted amongst patients with SARS‐CoV‐2 infection and underlying mild atherosclerotic disease, between 19 March and 19 April 2020 in six different stroke centers in the Île‐de France area, France. Results: The median age was 52 years, median body mass index was 29.5 kg/m2. All patients displayed previous vascular risk factors such as high blood pressure, diabetes, dyslipidemia or body mass index > 25. The delay between the first respiratory symptoms of COVID‐19 and stroke was 11.5 days. At baseline, all had tandem occlusions, i.e. intracerebral and extracerebral thrombus assessed with computed tomography or magnetic resonance imaging. Cases displayed a large thrombus in the cervical carotid artery with underlying mild non‐stenosing atheroma, after an etiological workup based on angio‐computed tomography or magnetic resonance imaging and/or cervical echography. Conclusion: Our study should alert clinicians to scrutinize any new onset of ischaemic stroke during COVID‐19 infection, mainly in patients with vascular risk factors or underlying atherosclerotic lesions. [ABSTRACT FROM AUTHOR]

The traumatic knee dislocation (KD) is a complex condition resulting in injury to >1 ligament or ligament complexes about the knee, termed multiligament knee injuries. Typically, KDs result in injury to both cruciate ligaments with variable injury to collateral ligament complexes. Very rarely, KD may occur with single cruciate injuries combined with collateral involvement but it is important to understand that not all multiligament knee injuries are KDs. Patients can present in a wide spectrum of severity; from frank dislocation of the tibiofemoral joint to a spontaneously reduced KD, either with or without neurovascular injury. The initial evaluation of these injuries should include a thorough patient history and physical examination, with particularly close attention to vascular status which has the most immediate treatment implications. Multiple classification systems have been developed for KDs, with the anatomic classification having the most practical application. [ABSTRACT FROM AUTHOR]

Keywords: ankle-brachial index (ABI); peripheral artery disease (PAD); toe-brachial index (TBI); vascular physiological testing The number of residents who had performed more than 20 measurements was higher for resting ABI than for PEABI and TBI (84%, 5%, and 37%, respectively; I p i < 0.001 and I p i = 0.006, respectively) and significantly higher for TBI that PEABI (37% vs 5%; I p i = 0.04). Ankle-brachial index (ABI), peripheral artery disease (PAD), toe-brachial index (TBI), vascular physiological testing. [Extracted from the article]

Objective: To assess the ability of a silver lipidocolloid contact layer to promote the healing process of venous leg ulcers (VLUs) presenting inflammatory signs, suggesting a heavy bacteria colonisation, and then delayed healing, in comparison with the same wound dressing not impregnated with silver salts. Method: This was an open-labelled, randomised, controlled trial. VLU presenting at least 3 out of 5 clinical signs suggesting heavy bacterial colonisation were recruited. Patients were treated with contact-layer silver-dressing (CLS; Urgotul Silver [URGO Laboratories]) or contact-layer dressing (CL; Urgotul [URGO Laboratories]) for 4 weeks, then all treated ulcers were treated with CL for 4 additional weeks. Wound evaluation and area measurements were conducted weekly, during the first 4 weeks, and then at weeks 6 and 8. Main efficacy criterion was absolute wound area decrease (AD) at week 4 and week 8. Results: Patients (n=102) were randomised and treated. Ulcers were present for nearly 11 months on average; 65% were recurrent and mean area was 20.0 ± 17.8cm2. Almost 80% of the treated VLU were stagnating/aggravating with their previous treatment. By week 4, mean surface area decreased by 6.5 ± 13.4cm2 (median: 4.2cm2) and 1.3 ± 9.0cm2 (median: 1.1cm2) in CLS and CL groups, respectively (p=0.023). At week 8, median decrease was 5.9cm2 vs 0.8cm2 (p=0.002), with a wound percentage decrease of 48% and 5.6% (p=0.036). Median closure rate was 0.145cm2/day vs 0.044cm2/day (p=0.009) at week 4 and remained higher in the CLS group up to week 8, even after switching to CL dressing in these patients (p=0.001). Odds ratio (multinomial logistic regression) of the chance to reach a &sge;40% wound area reduction was 2.7 (95%CI: 1.1;6.7, p=0.038) for silver-treated ulcers. Dressing tolerance was good in both groups. Conclusion: A 4-week treatment with silver-releasing lipidocolloid contact layer promotes a sustained increase of closure rate of venous leg ulcers presenting inflammatory signs, suggesting a high bacterial load. Declaration of interest: This study was funded by a grant from URGO Laboratories. Dr Meaume and Dr Lazareth have served as paid speakers for URGO Laboratories. Dr Sauvadet and Dr Bohbot are employees of URGO Laboratories. [ABSTRACT FROM AUTHOR]

Objective: To determine the utility of ankle-brachial index (ABI) in screening for unrecognized peripheral arterial disease (PAD). Although PAD is a consistent predictor of cardiovascular morbidity and mortality, it is often under-diagnosed and under-treated. Methods: In this prospective, observational, real-life, epidemiologic study (ELLIPSE) the prevalence of PAD (ABI < 0.9) was calculated in 2146 asymptomatic patients ≥55 years of age who were at high cardiovascular risk and who were hospitalized in departments of cardiology, diabetology, geriatrics, internal medicine, or neurology in metropolitan France. Univariate and multivariate analyses were performed to identify PAD risk factors. The discriminatory power of the model was evaluated by calculating the area under the curve (AUC) of the receiver operating characteristic curve. Results: The ABI was <0.9 in 41.1% of patients. In the multivariate analysis, absence of ≥1 pulse (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.81 to 2.63; P < .0001), arterial bruit (OR, 1.92; 95%CI, 1.34 to 2.75; P < .0004), previous non-Q-wave myocardial infarction (OR, 1.50; 95%CI, 1.08 to 2.08; P = .02), regular smoking (OR, 1.49; 95%CI, 1.22 to 1.80; P < .0001), age ≥81 years (OR, 1.45; 95%CI, 1.15 to 1.82; P = .001), creatinine clearance <60 mL/min (OR, 1.33; 95%CI, 1.08 to 1.63; P = .008), and treated hypertension (OR, 1.28; 95%CI, 1.03 to 1.59; P = .03) were significantly associated with PAD. Although risk increased with the number of variables, the model, based on clinical symptoms and on medical history parameters, was not discriminatory (AUC = 0.66). On average, physicians took 15 minutes to perform the ABI test. Conclusions : The high prevalence of asymptomatic PAD in this patient population suggests that ABI should systematically be performed in high-risk hospitalized patients to ensure that appropriate secondary prevention programs are initiated. [Copyright &y& Elsevier]

A letter to the editor is presented which is concerned with vitamin D supplementation in geriatric patients.

Objective: Ankle brachial index (ABI) is widely used for the diagnosis of lower extremity artery disease (LEAD). The purpose of this prospective study was to validate the diagnostic ability and reproducibility of a four cuff automated oscillometric device vs. the Doppler method., Methods: Patients with suspected LEAD or asymptomatic individuals at risk because of the presence two or more cardiovascular risk factors were enrolled. For each patient, Doppler and oscillometric ABI measurements were repeated by two observers to address intra- and interobserver reproducibility., Results: In total, 118 patients were evaluated. The prevalence of Doppler ABI (Dop-ABI) ≤ 0.90 was 45.8%. Taking the Dop-ABI as the reference, the sensitivity, specificity, accuracy, positive and negative predictive values of oscillometric ABI (Osc-ABI) during the first measurement by the first observer were 89.1%, 94.4%, 94.1%, 91.8%, and 92.4%, respectively. The concordance for diagnosing ABI ≤0.90 between methods was excellent (kappa coefficients ranging from 0.80 to 0.88 with different observers). Intra-observer reproducibility assessed by intraclass correlation coefficient (ICC) between methods were 0.94 for observer 1 and 0.96 for observer 2. The intra-observer reproducibility using the same method was also excellent (ICC 0.94, 95% confidence interval [CI] 0.91-0.95) for Dop-ABI and 0.95 (95% CI 0.93-0.97) for Osc-ABI). The ICC for interobserver reproducibility using the same method was 0.95 (95% CI 0.92-0.96) for Dop-ABI and 0.96 (95% CI 0.94-0.97) for Osc-ABI., Conclusion: This study validates the excellent diagnostic performances of a four cuff oscillometric device specifically designed for screening for LEAD. The simple measurement method could therefore be advocated in primary care where fast, easy, and reliable methods are suitable., (Copyright © 2020 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Background: The resting ankle-brachial index (ABI) is a clinical test to diagnose peripheral artery disease. The Wyatt's score has been proposed to assess the students' performance on ABI measurement on a healthy volunteer (HV). No study has shown that this score is sensitive to different teaching methods. In this randomized controlled trial, we wanted to determine whether didactic learning alone or didactic learning combined with experiential learning improves proficiency in the ABI procedure assessed by the Wyatt's score., Methods: Medical students (n = 30) received a didactic learning, including (1) a presentation of the ABI guidelines and (2) a video demonstration. Each student was then randomized into 2 groups ("the no experiential learning group" and "the experiential learning group"). An initial evaluation was performed after the didactic learning and then the final evaluation at the end of the intervention. A student was considered to be proficient when he performed a correct ABI procedure on an HV. The correct procedure corresponds to the following: (1) correctly answered Wyatt's score and (2) a difference in the ABI measurement between a professor in vascular medicine and a student was ≤0.15., Results: No student was proficient at the initial evaluation. At the final evaluation, there was a significant difference between the number of proficient students for the Wyatt's score depending on their learning group [didactic alone (1/10) or didactic + experiential training (15/20)] and also for the ABI procedure [didactic alone (0/10) or didactic + experiential training (16/20)]. At 6 months, among the 12 students who passed the final evaluation, 4 students passed both the Wyatt's score and the ABI measurement., Conclusions: Our study demonstrates that the Wyatt's score was sensitive to an educational intervention and no improvement was found in the case of "no experiential learning." The Wyatt's score could be used to evaluate the student on ABI measurement after an educational intervention., Trial Registration: A randomized controlled trial was conducted in the Vascular Medicine Department of Rennes University Hospital (France). This was approved by the ethics review board of our institution (no. 16.150)., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background:: The prevalence of exercise-induced ischemia in the asymptomatic limb of patients with unilateral claudication based on history and treadmill evaluation, and with unilateral ipsilateral peripheral artery disease (i.e ankle-to-brachial systolic pressure index <0.90) is unknown., Methods:: We detected exercise-induced ischemia in the asymptomatic limb of patients with apparently unilateral claudication. Among 6059 exercise-oximetry tests performed in 3407 nondiabetic and 961 diabetic patients. We estimated the intensity of ischemia in the both limb (buttocks and calves) using the lowest minimum value of the decrease from rest of oxygen pressure (DROP; limb changes minus chest changes from rest), with significant ischemia defined as DROP lower than -15 mmHg., Results:: We found 152 tests performed in 142 nondiabetic patients and 40 tests performed in 38 diabetic patients. The asymptomatic limb showed significant ischemia in 46.7% and 37.5% of the tests. Strictly unilateral exercise-induced claudication with apparently unilateral peripheral artery disease was rare (<4% of all tests). However, among these highly selected tests, significant ischemia was found in the asymptomatic limb in more than one-third of cases., Conclusion:: The asymptomatic limb of patients with peripheral artery disease should not be considered a normal limb.

Objective: In patients with claudication, an ankle brachial index (ABI) under 0.90 is considered to be abnormal and a sufficient argument for the arterial origin of exercise induced pain. Exercise transcutaneous oxygen pressure (Ex-tcpO2) can provide evidence of exercise induced regional blood flow impairment (RBFI) and confirm the arterial origin of walking induced pain. The frequency with which calf Ex-tcpO2 remains apparently normal in patients with claudication and abnormal ABI is unknown. Causes of these discrepant results have yet to be analysed., Methods: A retrospective analysis of 4575 Ex-tcpO2 tests performed on 3,281 patients was conducted. The focus was on patients with a history of calf claudication and ABI under 0.90. Duplicate or non-standard tests were excluded, as were patients with no pain or those able to walk more than 15 minutes (on a treadmill). Searches were conducted for possible explanations of normal calf Ex-tcpO2 in the selected patients., Results: Cardiorespiratory limitation was identified in 50 patients and isolated non-calf ischemia in 36 of the 106 patients selected. There was no obvious explanation during Ex-tcpO2, but clinical improvement after non-vascular treatment or total absence of improvement after a technically successful revascularisation was noted in 12 patients. Four patients were lost on follow up. Four patients improved after revascularisation, which suggests that the Ex-tcpO2 result was false negative., Conclusions: Ex-tcpO2 is negative in more than 20% of tests performed in patients with an ABI under 0.90 and a history of calf claudication. In most cases, when excluding re-tests and non-limiting or non-calf claudication on the treadmill, non-calf ischemia or a non-vascular limitation occurring during the test were observed. This observation supports both the value of treadmill testing in patients with calf claudication assumed to be of arterial origin (ABI<0.90) and the use of Ex-tcpO2 to detect non-calf ischemia., (Copyright © 2015 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

Background: Ankle-brachial index (ABI) at rest is the main clinical tool to diagnose the presence of lower extremity peripheral artery disease (PAD). The method for ABI procedure (i.e., measurement, calculation and interpretation) is standardised and guidelines were published in 2012. This study sought to: i) assess knowledge about the three major steps of the ABI procedure (i.e., measurement, calculation and interpretation) among residents from different medical schools, ii) compare the ABI knowledge of experienced residents (i.e., who have already performed ABI procedure more than 20 times) with the knowledge of inexperienced residents, and iii) describe the most common errors by residents., Methods: Residents from six medical schools were invited to complete a questionnaire about the ABI procedure., Results: Sixty-eight residents completed the questionnaire. None of them knew how to perform the entire ABI procedure. Overall, 22%, 13% and 41% of residents correctly answered questions about ABI measurement, ABI calculation and ABI interpretation, respectively. Score comparisons underlined the fact that experienced residents (n = 26) answered ABI measurement questions to a significantly better level and had a significantly higher total score than inexperienced residents (n = 42) (P = 0.0485 and P = 0.0332, respectively). Errors were similar for most of the residents., Conclusions: Our study confirms that experienced residents have significantly better ABI procedure knowledge than inexperienced residents. However, none of them are able to perform the entire ABI procedure without any mistake with regard to current guidelines. It is important that training be given to residents in medical schools in order to improve their ABI procedure knowledge.

Background: Supervised exercise programs increase physical performance in patients with peripheral artery disease (PAD). However, there are a limited number of programs, and to date they have failed to provide evidence of long-term adherence to exercise or any meaningful effect on Quality of Life (QoL). We created a program of therapeutic education and a personalized program of reconditioning exercise for patients with PAD., Methods: Patients with an ankle-brachial index (ABI) below 0.9 in at least one limb, and an absolute claudication distance (ACD) ≤500 meters, were included in the study. Quality of Life (QoL) as measured by SF-36, cardiovascular risk factors and functional parameters were evaluated at 0, 3, 6 and 12 months., Results: Forty-six patients completed the program. Cardiovascular risks were controlled and stabilized over time. SF-36 scores improved significantly and remained stable. Initial and absolute claudication distance (ICD and ACD) as well as other functional parameters improved significantly (6 months: +138 m or +203% ICD and +139 m or +84% ACD). Ten patients (22%) did not show improvement in ICD or ACD within the first 3 months, but their SF-36 score did increase at subsequent visits. Interestingly, these patients had a significantly lower ACD at baseline., Conclusions: This study measured beneficial effects of an educational therapeutic program for patients with PAD. The results demonstrate a significant improvement in functional and QoL parameters during the first 3 months of coaching, and long-term persistence of the results even when patients were no longer coached., (© The European Society of Cardiology 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: After an acute coronary syndrome (ACS), optimal medical therapy (OMT) has been shown to be effective in reducing subsequent cardiovascular (CV) events. However, even in populations that reach recommended secondary prevention goals, there is a subset of patients that experience subsequent CV events., Aim: To identify biological or clinical predictors of residual risk of CV events in post-ACS patients receiving OMT., Patients and Methods: A total of 990 post-ACS patients benefited from OMT (optimized treatment during the acute and chronic post-ACS phase, along with a therapeutic and dietary education programme). Traditional CV risk factors and atheroma disease markers (intima-media thickness measurement, carotid atheroma, peripheral arterial disease (PAD) measured by ankle brachial index, and the number of coronary arteries with a >50% stenosis) were evaluated at 3 months post ACS. Cardiovascular events were recorded at follow up., Results: At 20-month follow up, >80% of the patients reached the recommended secondary prevention goals. In this population, diabetes was the only CV risk factor significantly associated with CV events in multivariate analysis including traditional risk factors (HR 1.61, p = 0.017). In multivariate analyses including CV risk factors and atheroma disease markers, only PAD remained significantly associated with CV events (HR 1.83, p = 0.04). The number of vascular beds involved was associated with poorer prognosis (HR for disease in 3-vascular-beds 3.85, p = 0.001, using disease in 1-vascular-bed as a reference group)., Conclusion: In post-ACS patients with OMT, atheroma burden is a powerful prognostic marker of recurrent CV events, while diabetes remains the only independent marker of CV events among traditional CV risk factors.

Objective: Increase in arterial inflow to the lower limbs is important to obtain functional improvement in peripheral artery disease (PAD) patients with claudication. The aim of this study was to assess the effect of electrical stimulation of calf muscles on arterial inflow and tissue oxygen content in PAD in the area of stimulation., Methods: Fifteen adult patients [mean (standard deviation) age, 62 (12 ) years; height, 165 (8)cm; weight, 76 (13) kg; lowest ankle-brachial index 0.66 (0.19)] with stable arterial claudication were recruited. All patients performed a treadmill test (3.2 km/h, 10% slope) associated with a transcutaneous oximetry test expressed as decrease from rest of oxygen pressure (DROP) index values (calf changes minus chest changes from rest) with a maximum walking distance (median [25th/75th percentiles]) of 295 [133-881] m. The DROP index on the symptomatic side was -25 [-18/-34] mm Hg. On another day the patients underwent electrical stimulation in the seated position on the leg that was the most symptomatic on the treadmill. After resting values were recorded, the gastrocnemius was stimulated for 20minutes at increasing contraction rates at 5-minute steps of 60, 75, 86, and 100bpm on the most symptomatic side. Arterial blood inflow with duplex Doppler ultrasound scanning of the femoral artery, DROP transcutaneous oxygen pressure value, and oxygen concentration (O2Hb) from the near-infrared spectroscopic signal of the calf were recorded on both sides. Patients were instructed to report eventual contraction-induced pain in the stimulated calf. Results are given as mean (standard deviation) or median [25th/75th percentiles] according to distribution, and the level of statistical significance was set at P < .05 on two-tailed tests., Results: Lower limb inflow (mL/min) was 64 [48/86] vs 63 [57/81] (P> .05) before stimulation, 123 [75/156] vs 57 [44/92] (P < .01) at 60bpm, 127 [91/207] vs 49 [43/68] (P < .01) at 75bpm, 140 [84/200] vs 57 [45/71] (P < .01) at 86bpm, and 154 [86/185] vs 55 [46/94] (P < .01) at 100bpm on the stimulated vs nonstimulated limb, respectively. No apparent decrease or significant leg difference was observed in DROP index or O2Hb values. None of the patients reported contraction-induced pain in the leg., Conclusions: Electrical stimulation of calf muscle with the Veinoplus device results in a significant increase of arterial inflow without measurable muscle ischemia or pain. Potential use of this device as an adjuvant treatment to improve walking capacity in PAD patients remains to be evaluated., (Copyright © 2013 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Purpose: The ankle brachial pressure index (ABPI) makes it possible to diagnose peripheral artery disease (PAD) and identify patients with a vascular risk. Recently, the Haute Autorité de santé (HAS) issued guidelines. We wanted to determine the interest and impact of these guidelines when applied to patients hospitalised in an internal medicine department., Methods: We systematically measured the ABPI in two internal medicine departments. We compared the results obtained with the screening criteria and the good practices recommended by the HAS., Results: The screening criteria recommended by the HAS were already applied in 91% of our 97 patients. PAD was found in 37.1% of patients. In 83% of cases, the diagnosis was unknown (p = 0.02). The PAD was symptomatic in 83% of the known PAD cases, and 3.3% in newly-diagnosed cases (p < 0.001)). The sensitivity of the HAS screening criteria applied to our population was 100% but almost patients justifies ABPI screening. The specificity was 11.5%, the positive predictive value 40% and the negative predictive value 100%. The optimal treatment recommended was implemented in only 50% of patients with known arteriopathy and in 10% of newly-diagnose PAD (p = 0.04)., Conclusion: PAD prevalence is high in internal medicine department and systematic measurement of ABPI is effective. Determining patients to screen with the HAS criteria has a poor impact in our patients. The optimal treatment is still extremely under-prescribed even in patients with known PAD., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Aims: The deleterious nature of peripheral arterial disease (PAD) is compounded by a status of underdiagnosed and undertreated disease. We evaluated the prevalence and predictive factors of PAD in high-risk patients using the ankle-brachial index (ABI)., Methods: The ABI was measured by general practitioners in France (May 2005-February 2006) in 5679 adults aged 55 years or older and considered at high risk. The primary outcome was prevalence of PAD (ABI strictly below 0.90)., Results: In all, 21.3% patients had signs or symptoms suggestive of PAD, 42.1% had previous history of atherothrombotic disease and 36.6% had two or more cardiovascular risk factors. Prevalence of PAD was 27.8% overall, ranging from 10.4% in patients with cardiovascular risk factors only to approximately 38% in each other subgroup. Prevalence differed depending on the localization of atherothrombotic events: it was 57.1-75.0% in patients with past history of symptomatic PAD; 24.6-31.1% in those who had experienced cerebrovascular and/or coronary events. Regarding the classical cardiovascular risk factors, PAD was more frequent when smoking and hypercholesterolemia history were reported. PAD prevalence was also higher in patients with history of abdominal aortic aneurysm, renal hypertension or atherothrombotic event. Intermittent claudication, lack of one pulse in the lower limbs, smoking, diabetes and renovascular hypertension were the main factors predictive of low ABI., Conclusions: Given the elevated prevalence of PAD in high-risk patients and easiness of diagnosis using ABI in primary care, undoubtedly better awareness would help preserve individual cardiovascular health and achieve public health goals.