Symptomatic peripheral arterial disease: the value of a validated questionnaire and a clinical decision rule

BACKGROUND: If a validated questionnaire, when applied to patients reporting with symptoms of intermittent claudication, could adequately discriminate between those with and without peripheral arterial disease, GPs could avoid the diagnostic measurement of the ankle brachial index. AIM: To investigate the Edinburgh Claudication Questionnaire (ECQ) in general practice and to develop a clinical decision rule based on risk factors to enable GPs to easily assess the likelihood of peripheral arterial disease. DESIGN OF STUDY: An observational study. SETTING: General practice in The Netherlands. METHOD: This observational study included patients of > or =55 years visiting their GP for symptoms suggestive of intermittent claudication or with one risk factor. The ECQ and the ankle brachial index were performed. The prevalence of peripheral arterial disease, defined as an ankle brachial index <0.9, was related to risk factors using logistic regression analyses, on which a clinical decision rule was developed and related to the presence of peripheral arterial disease. RESULTS: Of the 4790 included patients visiting their GP with symptoms suggestive of intermittent claudication, 4527 were eligible for analyses. The prevalence of peripheral arterial disease in this group was 48.3%. The sensitivity of the ECQ was only 56.2%. The prevalence of peripheral arterial disease in a clinical decision rule that included age, male sex, smoking, hypertension, hypercholesterolemia, and a positive ECQ, increased from 14% in the lowest to 76% in the highest category. CONCLUSION: This study indicates that the ECQ alone has an inadequate diagnostic value in detecting patients with peripheral arterial disease. The ankle brachial index should be performed to diagnose peripheral arterial disease in patients with complaints suggestive of intermittent claudication, although our clinical decision rule could help to differentiate between extremely high and lower prevalence of peripheral arterial disease.     

Perspectives of Dutch Physiotherapists on Self-Management Support: A Q-Methodology Study

Self-management support programs are reported to have positive effects on the health and care of people with physical disabilities. It is unclear how physiotherapists (PTs) view self-management support. A cross-sectional study with mixed-methods design using Q-methodology was conducted to determine the perspectives of Dutch PTs on self-management support. PTs (n = 39) rank-ordered 37 validated statements about self-management support from “most disagree (?3)” to “most agree (+3).” Differences in perspectives on self-management support were explored in a by-person centroid factor analysis on the basis of the explained variance (R²). After having sorted the statements, PTs explained their ranking of ?3 and +3 statements in semi-structured interviews. All PTs recognized self-management support as intrinsic part of physiotherapy practice. Nevertheless, four particular perspectives could be identified: (1) the “externally driven educator” (R² = 14%), (2) “internally driven educator” (R² = 9%), (3) “client-centered coach” (R² = 13%), and (4) “client-initiated coach” perspective (R² = 15%). Each perspective reflects particular goals and perceptions of self-management support. Differences were identified with respect to the PTs’ role perception (educating or coaching), drive (external or internal), and collaboration with the patient (as partner or not). The identified perspectives can be used in the physiotherapy education curriculum to create awareness about the various ways of practicing self-management support and the skills needed to be able to tailor support to patient needs and to switch between perspectives.     

Unilateral Reversible Posterior Leukoencephalopathy Syndrome after Coiling of an Aneurysm

Background

Reversible posterior leukoencephalopathy syndrome (RPLS) is radiologically characterized by symmetrical subcortical areas of vasogenic edema that are preferentially parieto-occipital, and it typically resolves after appropriate treatment.

Case Report

We present a patient with strikingly unilateral RPLS that developed 21 days after coiling of an anterior communicating artery aneurysm and several days of triple-H therapy. Cortical and subcortical vasogenic edema and enhancement developed only in the left hemisphere, with a pattern suggesting RPLS. After 7 months the lesions had nearly completely resolved.

Conclusions

The pathophysiological mechanism underlying RPLS is still not well understood, which makes it difficult to explain the unilateral appearance in this case. Since the imaging findings may be confused with other conditions such as ischemia, recognition of RPLS after coiling is necessary in order to avoid inadequate treatment.     

Thrombolytic therapy in patients with acute brain infarction: favorable preliminary results in Maastricht

OBJECTIVE: To assess the feasibility of acute thrombolysis for ischaemic stroke in clinical practice. DESIGN: Prospective. METHOD: On July 1st, 1998 thrombolytic therapy for ischaemic stroke was introduced in the University Hospital Maastricht, the Netherlands. All patients admitted with ischaemic stroke were prospectively registered during the first year. Of all patients with ischaemic stroke, it was determined how many were potentially eligible for thrombolysis within 3 hours of stroke symptom onset, and how many of these patients were actually treated with thrombolysis. Furthermore, the reasons for exclusion from thrombolytic therapy were assessed. Several baseline and clinical patient characteristics were noted. RESULTS: During the first year 18 ischaemic stroke patients were treated with thrombolysis within 3 hours of stroke onset. These 18 patients constituted 7% of all 256 ischaemic stroke patients and 18% of the potentially eligible patients who arrived in the hospital within 3 hours. More than 40% of the ischaemic stroke patients were not eligible for thrombolysis due to late arrival in the hospital. There were no major complications in the 18 treated patients: 3 patients developed an asymptomatic haemorrhagic transformation of the infarct. CONCLUSION: Acute thrombolysis for ischaemic stroke within 3 hours from stroke onset is feasible, and can under specific conditions be applied in clinical practice. Only 7% of all ischaemic stroke patients underwent thrombolysis. This percentage of patients could be increased by an earlier presentation of patients to the hospital.     

A molecular informatics view on best practice in multi-parameter compound optimization

The difference between biologically active molecules and drugs is that the latter balance an array of related and unrelated properties required for administration to patients. Inevitability, during optimization, some of these multiple factors will conflict. Although informatics has a crucial role in addressing the challenges of modern compound optimization, it is arguably still undervalued and underutilized. We present here some of the basic requirements of multi-parameter drug design, the crucial role of informatics and examples of favorable practice. The most crucial of these best practices are the need for informaticians to align their technologies and insights directly to discovery projects and for all scientists in drug discovery to become more proficient in the use of in silico methods.     

Magnetic resonance imaging of progressive hydrosyringomyelia in two patients with meningomyelocele.

Two patients who postoperatively developed extensive multiseptated hydrosyringomyelia following surgical repair of a lumbal meningomyelocele are reported. Since MRI has been available, an increasing number of reports showed that MRI is useful in the diagnosis of hydrosyringomyelia. Hydrosyringomyelia can be considered as a dysraphic lesion. Etiology and pathogenesis of hydrosyringomyelia are still not fully understood. Probably arachnoidal adhesions and cord tethering in both patients may be potential factors in producing cystic degeneration of the underlying structure secondary to ischemia.     

Characterization of human skin equivalents developed at body's core and surface temperatures

Human skin equivalents (HSEs) are in vitro developed three‐dimensional models resembling native human skin (NHS) to a high extent. However, the epidermal lipid biosynthesis, barrier lipid composition, and organization are altered, leading to an elevated diffusion rate of therapeutic molecules. The altered lipid barrier formation in HSEs may be induced by standardized culture conditions, including a culture temperature of 37°C, which is dissimilar to skin surface temperature. Therefore, we aim to determine the influence of culture temperature during the generation of full thickness models (FTMs) on epidermal morphogenesis and lipid barrier formation. For this purpose, FTMs were developed at conventional core temperature (37°C) or lower temperatures (35°C and 33°C) and evaluated over a time period of 4 weeks. The stratum corneum (SC) lipid composition was analysed using advanced liquid chromatography coupled to mass spectrometry analysis. Our results show that SC layers accumulated at a similar rate irrespective of culture temperature. At reduced culture temperature, an increased epidermal thickness, a disorganization of the lower epidermal cell layers, a delayed early differentiation, and an enlargement of granular cells were detected. Interestingly, melanogenesis was reduced at lower temperature. The ceramide subclass profile, chain length distribution, and level of unsaturated ceramides were similar in FTMs generated at 37°C and 35°C but changed when generated at 33°C, reducing the resemblance to NHS. Herein, we report that culture temperature affects epidermal morphogenesis substantially and to a lesser extent the lipid barrier formation, highlighting the importance of optimized external parameters during reconstruction of skin.