A Prospective Study of Painful Symptoms,Small-fibre Function and Peripheral Vascular Disease in Chronic Painful Diabetic Neuropathy

Fifty diabetic patients with chronic painful sensorimotor neuropathy were studied prospectively to clarify the natural history of this condition and the roles of small-fibre damage and concomitant peripheral vascular disease (PVD). Initially, 30 patients had no significant PVD (ankle:brachial Doppler ratio > 1.0). Pain was assessed using a visual analogue scale (0–10 cm), and small-fibre function by thermal limen (TL), heat-pain threshold (HPT), and weighted pinprick threshold (PPT). At follow-up, on average 3.6 years later (range 3.0–4.1), 11 patients had died (6 with PVD) and contact had been lost with 6. Pain scores fell in subjects without PVD (n = 24; median (range), from 4.8 (0.5–10.0) to 2.0 (0.0–9.2) cm, p < 0.001) and also in those with PVD (n = 9; from 5.1 (2.0–8.2) to 2.1 (0.0–8.0) cm, p < 0.05). Seven patients (5 without PVD) became pain-free; at presentation, these 7 patients had experienced pain for a shorter period of time. Despite this symptomatic improvement, small-fibre function generally deteriorated in both groups, with significant worsening (p < 0.05) of HPT and PPT in patients without PVD, and in HPT and TL in patients with PVD. Neuropathic pain therefore tends to improve with time and can resolve completely. By contrast, small-fibre function continues to deteriorate, indicating that these peripheral measures do not predict the evolution of painful symptoms. The presence or absence of PVD does not appear to affect the natural history of neuropathic pain or its symptomatology.     

A Comparison of Different Methods of Assessing Free Radical Activity in Type 2 Diabetes and Peripheral Vascular Disease

Increased free radical activity in diabetes mellitus may contribute to the higher prevalence and mortality from macrovascular disease in diabetic patients. To investigate this, levels of plasma antioxidants (superoxide dismutase, caeruloplasmin, plasma, and lysate thiol), diene conjugates, lipid peroxides, and chemiluminescence were measured in diabetic and non-diabetic patients with peripheral vascular disease compared with healthy control subjects. Caeruloplasmin, diene conjugate ratio, and lipid peroxides were significantly increased in patients with vascular disease but there was no difference between diabetic and non-diabetic patients. Conjugated diene ratio correlated with caeruloplasmin (r = 0.40, p < 0.02) and inversely with superoxide dismutase level (r = ?0.36, p < 0.05) but there was no significant correlation between other antioxidants and diene conjugates, lipid peroxides or chemiluminescence. The relationship between different indirect measurements of free radical activity is variable but there appears to be no additive effect of diabetes on the increased free radical activity associated with vascular disease.     

Pulse Pressure as a Risk Factor for Peripheral Vascular Disease in Type 2 Diabetic Patients

This study examined whether pulse pressure (PP) could be an independent predictor and associated with severity of peripheral vascular disease (PVD) in 396 type 2 diabetic patients (143 men and 253 women, aged 64.1 ± 11.2 years). Peripheral vascular disease was diagnosed by an ankle‐brachial index (ABI) < 0.90 and as severe PVD if ABI < 0.80. Association was evaluated before and after adjustment for age, sex, diabetes duration, hypertension, smoking, fasting plasma glucose (FPG), total cholesterol (TC), usage of insulin, and usage of angiotensin‐converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB); and for systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP), respectively. Results showed that PP increased from no (n = 348) to mild (n = 25) and severe (n = 23) PVD (one‐way ANOVA, p < 0.001; multiple comparisons, p < 0.05 for any two groups). The PP increase from no to mild PVD was due to SBP increase; while further increase to severe PVD was due to both DBP drop and an even higher SBP. Adjusted odds ratio (AOR) for PVD for every 1‐mmHg PP increment was 1.035 (1.012–1.058). When PP was categorized as tertiles (<50, 50–59 and ≥60 mmHg), respective AOR for PVD for second and third vs. first tertile was 2.605 (1.008–6.729) and 2.835 (1.123–7.156). Pulse pressure was also predictive for ABI independent of the effects of the confounders and the other parameters of blood pressure. In conclusion, PP was an independent predictor and correlated with severity of PVD in type 2 diabetic patients.     

Skin Capillary Circulation is More Impaired in the Toes of Diabetic Than Non-diabetic Patients with Peripheral Vascular Disease

The aim of the present study was to investigate if diabetes negatively influences the skin microvascular reactivity in the toes of patients with peripheral vascular disease (PVD). Twenty healthy subjects, 20 diabetic, and 20 non-diabetic patients with PVD participated. One foot in each subject was investigated. The patient groups were matched for age, sex, and toe pressure. The capillary blood cell velocity in the nailfold of the great toe was investigated by videophotometric capillaroscopy, and the total skin microcirculation within the same area by laser Doppler fluxmetry. Capillary blood cell velocity and laser Doppler flux were studied during rest, and following a 1 min arterial occlusion at the toe base. The skin microvascular reactivity was impaired in both diabetic and non-diabetic patients. In the diabetic patients the disturbances were mainly seen in the capillaries, and the capillary blood flow was severely reduced during reactive hyperaemia (p<0.01). In contrast, the total skin microcirculation was normal, indicating that sufficient blood reaches the area, but does not come out into the capillaries. The ratio between capillary blood cell velocity and laser Doppler flux, representing the distribution of blood between nutritional and non-nutritional blood compartments, was reduced in the diabetic patients (p<0.05). These findings may contribute to the higher risk for development of chronic foot ulcers in diabetic patients with PVD.     

A Case of Polyarteritis Nodosa Presenting Initially as Peripheral Vascular Disease

Polyarteritis nodosa is a rare necrotizing vasculitis that can be progressive and fatal, and its initial presenting symptom may be leg claudication due to peripheral vascular ischemia. To date, there have been fewer than ten case reports of polyarteritis nodosa presenting as peripheral vascular disease. We report a case of a 38-year-old man initially diagnosed to have premature peripheral vascular disease who presented 1 year later with symptoms consistent with giant cell arteritis and subsequently developed bowel ischemia leading to a fatal outcome. Based on the autopsy and the patient’s clinical course, the final diagnosis was polyarteritis nodosa. This case illustrates the challenges in diagnosing polyarteritis nodosa and the importance of considering vasculitis in young patients presenting with atypical presentations of diseases such as peripheral vascular disease or giant cell arteritis.     

White Blood Cell Count Predicts All-Cause Mortality in Patients with Suspected Peripheral Arterial Disease

Objective

We investigated whether markers of inflammation—white blood cell (WBC) count, C-reactive protein (CRP), and lipoprotein-associated phospholipase A2—are associated with mortality in patients referred for noninvasive lower-extremity arterial evaluation.

Methods

Participants (n = 242, mean age 68 years, 54% men) were followed for a median of 71 months. Ankle-brachial index (ABI), WBC count, plasma CRP, and lipoprotein-associated phospholipase A2 were measured at the start of the study. Factors associated with all-cause mortality were identified using Cox proportional hazards.

Results

During the follow-up period, 56 patients (25%) died. Factors associated with higher mortality were greater age, history of coronary artery disease/cerebrovascular disease, lower ABI, higher serum creatinine, and higher WBC count/plasma CRP. In stepwise multivariable regression analysis, ABI, serum creatinine, WBC count, and CRP were associated significantly with mortality. Patients in the top tertile of WBC count and CRP level had a relative risk of mortality of 3.37 (confidence interval [CI], 1.56-7.27) and 2.12 (CI, 0.97-4.62), respectively. However, only the WBC count contributed incrementally to prediction of mortality. Inferences were similar when analyses were limited to patients with peripheral arterial disease (ABI < 0.9, n = 114).

Conclusion

WBC count, but not plasma CRP level, provides incremental information about the risk of death in patients referred for lower-extremity arterial evaluation and in the subset of these patients with peripheral arterial disease.     

体外反搏在缺血性脑血管病康复中的作用与机制

尽管治疗手段在发展,缺血性脑血管疾病仍是致死和致残的主要原因。体外反搏可增加脑血流灌注,可降低缺血区域的神经细胞损害。国内体外反搏治疗缺血性脑血管疾病的临床研究结果提示该方法有效、安全及不良反应轻微,但由于大多存在研究设计的缺陷,未能提供充足的临床证据。国外有限的研究提示了体外反搏对缺血性脑血管疾病具有良好的治疗效果。体外反搏对脑血管病的治疗机制尚未完全阐明,可能与增加脑部血流灌注,增加侧支循环形成,改善血管内皮功能及促进血管新生和脑重塑有关。体外反搏可能是一种很有潜力的缺血性脑血管疾病的治疗和辅助治疗手段,但期待更多前瞻性、随机对照临床试验的证实。     

Mortality in Peripheral Arterial Disease: A Comparison of Patients Managed by Vascular Specialists and General Practitioners

BACKGROUND Peripheral arterial disease (PAD) is undertreated by general practitioners (GPs). However, the impact of the suboptimal clinical management is unknown. OBJECTIVE To assess the mortality rate of PAD patients in relation to the type of physician who provides their care (GP or vascular specialist). DESIGN Prospective study. SETTING Primary care practice and academic vascular laboratory. PARTICIPANTS GP patients (n = 60) were those of the Peripheral Arteriopathy and Cardiovascular Events study (PACE). Patients managed by specialists (n = 82) were consecutive subjects with established PAD who were referred to our vascular laboratory during the enrolment period of the PACE study. MEASUREMENTS All-cause and cardiovascular mortality. RESULTS After 32 months of follow-up, specialist management was associated with a lower rate of all-cause mortality (RR = 0.04; 95% CI 0.01–0.34; p = .003) and cardiovascular mortality (RR = 0.07; 95% CI 0.01–0.65; p = .020), after adjustment for patients’ characteristics. Specialists were more likely to use antiplatelet agents (93% vs 73%, p < .001), statins (62% vs 25%, p < .001) and beta blockers (28% vs 3%, p < .001). Survival differences between specialists and GPs disappeared once the use of pharmacotherapies was added to the proportional hazard model. The fully adjusted model showed that the use of statins was significantly associated with a reduced risk of all-cause mortality (RR = 0.02; 95% CI 0.01–0.73, p = .034) and cardiovascular mortality (RR = 0.02; 95% CI 0.01–0.71, p = .033). CONCLUSIONS Specialist management of patients with symptomatic PAD resulted in better survival than generalist management. This effect appears to be mainly caused by the more frequent use of effective medicines by specialists.     

Peripheral Neuropathy as a Presenting Feature of Type 2 Diabetes: A Case-Controlled Study

The characteristics and outcome of 68 newly diagnosed Type 2 diabetic patients who presented with clinically evident peripheral neuropathy were compared with matched controls who had no neuropathy at diagnosis. All subjects (34 male) whose median age was 68 (range 47–89) yr were identified from a computerized diabetes register and presented in 1982–1990. The groups were compared at diagnosis for haemoglobin A₁, body mass index, blood pressure, smoking, and alcohol consumption, and for co-existent coronary and peripheral vascular disease. Mortality and morbidity were recorded to March 1991. Significantly more patients with neuropathy had co-existent peripheral vascular disease: 24(35%) compared to 6(9%) controls (p = 0.0021). Twenty (30%) of those with neuropathy and no controls had retinopathy at diagnosis, which was sight-threatening in 10. Seven (10%) with neuropathy but no controls presented with foot ulcers, one requiring limited amputation. Two more patients with neuropathy and one control subsequently developed foot ulcers resulting in one or more amputation in each group. Twenty-one (31%) of those with neuropathy and 14 (21%) controls died (p = 0.2109). In conclusion more diabetic patients with clinically evident peripheral neuropathy at diagnosis have peripheral vascular disease than matched patients without neuropathy. It is likely that macrovascular disease either exacerbates or causes the neuropathy in this group of patients. They are at high risk of developing foot ulceration and high priority should be given to foot care in planning their management.     

Self-Reported Peripheral Arterial Disease Predicts Future Vascular Events in a Community-Based Cohort

Background  Lower extremity peripheral arterial disease (PAD) is highly prevalent and strongly associated with cardiovascular morbidity and mortality. The ankle-brachial index used to screen for PAD is not routinely performed in primary care settings. Objective  To determine if self-reported PAD is an independent predictor of combined vascular events (myocardial infarction, ischemic stroke, and vascular death). Design  Ongoing population-based prospective cohort (the Northern Manhattan Study). Subjects enrolled between July 1993 and June 2001 with a mean follow-up time of 7.1 years. Patients  Subjects (n = 2,977), aged 40 years or older and free of prior stroke or myocardial infarction, were classified as having self-reported PAD if they answered affirmatively to one of two questions regarding exercise-induced leg pain or a prior diagnosis of PAD. Main Outcome Measures  Combined vascular outcome defined as incident myocardial infarction, incident ischemic stroke, or vascular death. Results  The mean age of the cohort was 68.9 ± 10.4 years; 64% were women; 54% Hispanic, 25% African-American, 21% Caucasian; 15% reported having PAD. After a mean follow-up of 7.1 years, self-reported PAD was significantly predictive of combined events (n = 484) in the univariate model (HR 1.5, 95% CI, 1.2–1.9) and after adjustment for traditional cardiovascular risk factors (HR 1.3, 95% CI, 1.0–1.7). Conclusion  Self-reported PAD is an independent risk factor for future vascular events in this predominantly non-white cohort. The addition of two simple PAD questions to the routine medical history in general medicine settings could identify high-risk patients who would benefit from further vascular evaluation and risk factor modification.     

Peripheral Arterial Disease in Patients with Atrial Fibrillation: The AFFIRM Study

BackgroundPeripheral arterial disease has been linked with worse outcomes in patients with atrial fibrillation. The aim of this study is to assess the impact of peripheral arterial disease on mortality and stroke in a cohort of patients with atrial fibrillation.MethodsThis was an ancillary analysis of the Atrial Fibrillation Follow-up Investigation of Rhythm Management (AFFIRM) trial. A comparison of baseline characteristics was made between patients with atrial fibrillation with and without diagnosed peripheral arterial disease. Multivariate cox regression analysis was performed to compare the risk of stroke, death, and cardiovascular death among the two groups.ResultsThe prevalence of peripheral arterial disease in the whole cohort of 4060 patients with atrial fibrillation was 6.7%. Patients with peripheral arterial disease tended to be older; had higher prevalence of diabetes mellitus, hypertension, and smoking; and were more likely to have a history of coronary artery disease, heart failure, cardiac surgery or cardiac intervention, and stroke or transient ischemic attack (all P < .05). After multivariate adjustment, peripheral arterial disease was significantly associated with overall higher mortality (hazard ratio 1.34, 95% confidence interval 1.06-1.70, P = .016) in patients with atrial fibrillation, but the rates of ischemic stroke were similar in the two groups (3.9% vs 3.5%, P = 0.874).Subgroup analysis confined to the patients with non-anticoagulated atrial fibrillation showed that peripheral arterial disease was an independent predictor of ischemic stroke (hazard ratio 3.37, 95% confidence interval 1.25-9.09, P < .016).ConclusionPeripheral arterial disease predicts higher mortality in atrial fibrillation, and was an independent predictor of ischemic stroke in patients with non-anticoagulated atrial fibrillation. Proactive surveillance and optimization of medical management in this group of patients is warranted, given the high risks associated with peripheral arterial disease where atrial fibrillation is also present.     

Approach to Peripheral Neuropathy for the Primary Care Clinician

Peripheral neuropathy is commonly encountered in the primary care setting and is associated with significant morbidity, including neuropathic pain, falls, and disability. The clinical presentation of neuropathy is diverse, with possible symptoms including weakness, sensory abnormalities, and autonomic dysfunction. Accordingly, the primary care clinician must be comfortable using the neurologic examination—including the assessment of motor function, multiple sensory modalities, and deep tendon reflexes—to recognize and characterize neuropathy. Although the causes of peripheral neuropathy are numerous and diverse, careful review of the medical and family history coupled with limited, select laboratory testing can often efficiently lead to an etiologic diagnosis. This review offers an approach for evaluating suspected neuropathy in the primary care setting. It will describe the most common causes, suggest an evidence-based workup to aid in diagnosis, and highlight recent evidence that allows for selection of symptomatic treatment of patients with neuropathy.     

姜黄素在脑血管疾病防治中的应用

临床和动物实验表明姜黄素具有抗氧化、降血脂、抗炎、抗凝、抑制血管生成、抗肿瘤等药理作用.通过综述姜黄素的药理作用,进一步探讨其在脑血管病的防治中的降低脑危险因素、脑保护等作用.