Dissertations / Theses on the topic 'Peripheral vascular diseases'

Thesis (Ph. D.)--Ohio State University, 2003.
Title from first page of PDF file. Document formatted into pages; contains xiii, 123 p.; also includes graphics (some col.). Includes bibliographical references (p. 114-123). Available online via OhioLINK's ETD Center

The work presented includes over thirty peer reviewed published manuscripts based on studies undertaken during my surgical career. As Principal Investigator, I led the study conception/design/data acquisition/analysis/interpretation and was involved with writing the final drafts of all manuscripts prior to their formal submission to high impact factor peer-reviewed specialist journals. The thesis is divided into subsections reflecting my development and different interests within surgery. The subsections start with my learning basic research principles, moving onto clinical problem solving in general surgical dilemmas, followed by a collection of papers in my subspecialty of vascular surgery. The work culminates with a group of papers focused on aneurysmal disease, specifically, abdominal aortic aneurysms (AAA), the clinical impact of which has had a bearing on the introduction of a National AAA Screening Program in Wales in 2013. I conclude these sections with a collection of papers that reflect my long term commitment to surgical training both at regional level (as Secretary and Deputy Chairman to the Higher Surgical Training Committee and Chairman of the Basic Surgical Training Committee) and national level including my involvement with the Four Royal Colleges of Surgeons for the Intercollegiate Examinations in General Surgery. This examination is undertaken at completion of junior surgical training and used to confirm a doctor's competence for safe independent practice as a consultant. In conclusion, over forty years of academic research during my career as a vascular surgeon has provided unique insight into the pathophysiology, treatment and ultimately prevention of artherosclerotic disease. These findings have improved health policies in Wales and significantly reduced patient morbidity and mortality.

Peripheral vascular diseases such as peripheral artery disease (PAD) and critical limb ischemia (CLI) are growing at an ever-increasing rate in the Western world due to an aging population and the incidence of type II diabetes. A growing economic burden continues because these diseases are common indicators of future heart attack or stroke. Common therapies are generally limited to pharmacologic agents or endovascular therapies which have had mixed results still ending in necrosis or limb loss. Therapeutic angiogenic strategies have become welcome options for patients suffering from PAD due to the restoration of blood flow in the extremities. Capillary sprouting and a return to normoxic tissue states are also demonstrated by the use of angiogenic cytokines in conjunction with bone marrow cell populations. To this point, it has been determined that spatial and temporal controlled release of growth factors from vehicles provides a greater therapeutic and angiogenic effect than growth factors delivered intramuscularly, intravenously, or intraarterialy due to rapid metabolization of the cytokine, and non-targeted release. Furthermore, bone marrow cells have been implicated to enhance angiogenesis in numerous ischemic diseases due to their ability to secrete angiogenic cytokines and their numerous cell fractions present which are implicated to promote mature vessel formation. Use of angiogenic peptides, in conjunction with bone marrow cells, has been hypothesized in EPC mobilization from the periphery and marrow tissues to facilitate neovessel formation. For this purpose, controlled release of angiogenic peptides basic fibroblast growth factor (FGF-2) and granulocyte-colony stimulating factor (G-CSF) was performed using tunable ionic gelatin hydrogels or fibrin scaffolds with ionic albumin microspheres. The proliferation of endothelial cell culture was determined to have an enhanced effect based on altering concentrations of growth factors and method of release: co-delivery versus sequential. Scaffolds with these angiogenic peptides were implanted in young balb/c mice that underwent unilateral hindlimb ischemia by ligation and excision of the femoral artery. Endpoints for hindlimb reperfusion and angiogenesis were determined by Laser Doppler Perfusion Imaging and immunohistochemical staining for capillaries (CD-31) and smooth muscle cells (alpha-SMA). In addition to controlled release of angiogenic peptides, further studies combined the use of a fibrin co-delivery scaffold with FGF-2 and G-CSF with bone marrow stem cell transplantation to enhance vessel formation following CLI. Endpoints also included lipophilic vascular painting to evaluate the extent of angiogenesis and arteriogenesis in an ischemic hindlimb. Tissue engineering strategies utilizing bone marrow cells and angiogenic peptides demonstrate improved hindlimb blood flow compared to BM cells or cytokines alone, as well as enhanced angiogenesis based on immunohistochemical staining and vessel densities.

Peripheral arterial disease (PAD) is an atherosclerotic disease in the peripheral arteries, which reduces blood supply to the lower extremities. Intermittent claudication is the symptom that develops early in PAD patients and is accompanied by the haemodynamic finding of a fall in systolic blood pressure at the ankles following exercise. In PAD patients, exercise performance is not well correlated with haemodynamic measurements and other mechanisms have been suggested to account for the impairment. There have been reports about the impaired mitochondrial metabolism (eg, decreased activities of mitochondrial enzymes) and abnormal mitochondrial structure in the skeletal muscle in PAD patients. It is not known, however, whether mitochondrial ATP production is impaired in the skeletal muscle in PAD. Whether the mitochondrial function is impaired in PAD patients, and whether the impaired mitochondrial function in the muscle contributes to the impaired exercise performance in PAD patients is unknown. The object of this work is to explore the mitochondrial function in the skeletal muscle of PAD patients and its relationship to exercise performance. Impaired exercise performance in PAD patients is evaluated using a treadmill walking performance test, which is closely correlated to patients' daily activity performance. Treadmill walking however, in addition to being influenced by local muscle factors, is influenced by central contributions, such as cardiac output and the central nervous system. As walking is limited by intermittent claudication in PAD patients localized in the legs, it would be valuable to develop a local calf muscle performance test to better understand the underlying pathophysiology in PAD. Such a protocol has not been used previously in experiments involving PAD patients. Hence, the research aim for Study 1 was to establish a calf muscle performance test protocol and to investigate its variability. Fourteen healthy control subjects and eight PAD patients undertook the maximal plantar flexion test once a week for five weeks using a Kin-Com Dynamometer. In the traditional assessment, the total impulse and peak impulse are the variables that were measured as representing the calf muscle performance. Both these variables are significantly lower in PAD patients than in controls. Alternatively, by applying simple mathematical models, the muscle function dimensions of endurance, strength and fatigability can be investigated in a single test. Compared with control subjects the PAD patients had lower muscle endurance, lower muscle strength, higher fatigue index, but no difference were found in magnitude or rate-of-fatigue. The variability of the test was different for different estimated parameters of the models, with the highest variability in muscle fatigability (rate of fatigue, CV=75% in controls) and the lowest variability in muscle strength (CV=16% in controls). The variability of the traditional assessment parameters, which included total impulse and peak impulse, was around 13% in controls and 18- 24% in PAD patients for the five tests. Based on these findings the calf muscle performance test can be applied in PAD patients to investigate different muscle function dimensions. While many of the dimensions were impaired in PAD patients compared with controls, the high variability of some of the parameters have to be considered during its application. Having established a local calf muscle performance test, the aim of Study 2 was to explore the relationship between the calf muscle performance and the traditional treadmill walking performance. Seventeen PAD patients and fourteen control subjects were tested using both the calf muscle performance test described earlier and walking performance test. The walking performance was tested using a graded treadmill protocol. The total walking time was significantly lower in PAD than that in control subjects. No variable of calf muscle performance correlated with walking performance in control subjects. However, in PAD patients, a number of calf muscle performance variables correlated with walking performance. The total impulse and the peak impulse in the best legs (higher ABI) tended to correlate with pain-time. In simple mathematical models, the muscle endurance in the worst legs (lower ABI) correlated positively with pain-walking time, and the muscle fatigue-index in the worst legs correlated negatively with total walking time. In conclusion, in PAD patients, some dimensions of calf muscle performance correlated with walking performance. This suggests that some factors of local calf muscle performance might contribute to the impaired walking performance in PAD patients. The research aim for Study 3 was to investigate a number of calf muscle physiological factors, and to ascertain their relationship with calf muscle and walking performance in PAD patients and control subjects. The physiological factors examined include ankle brachial pressure index (ABI), calf muscle weight, calf blood flow, and skeletal muscle mitochondrial ATP production rate (MAPR) in vitro. The calf muscle weight in PAD patients was significantly lower than that in control subjects. In PAD patients, the calf muscle weight was significantly lower in the worst legs than that in the best legs. The ABI was lower in PAD than in controls and significantly lower in PAD worst legs than in PAD best legs. The leg blood flow (measured by venous-occlusion plethysmography) was lower in PAD than that in controls, but there was no significant difference between PAD best legs and PAD worst legs. The MAPR was measured using different substrate combinations. The MAPR (PM, pyruvate + malate), MAPR (PCM, palmitoyl-carnitine + malate) and MAPR (PPKM, pyruvate + palmi_toyl-carnitine + alpha-ketoglutarate + malate) shows the capacity of mitochondria to produce ATP by oxidising glucose or fatty acids or both of these substrates respectively. The MAPR for the three substrate combinations in PAD patients was no different from controls. The relationship between these physiological measurements and exercise performance differed between PAD and controls. In control subjects, the calf muscle weight, ABI, leg blood flow and MAPR were not significantly correlated with walking performance, but correlated with some variables of local calf muscle performance. In PAD patients, the calf muscle weight, ABI and blood flow did not correlate with walking performance. However, the MAPR (PMkg) was positively correlated with total walking time, and MAPR (PPKMg) was positively correlated with pain-free walking time. In calf muscle performance, in the best legs, the body weight was positively correlated with total impulse and peak impulse; the calf muscle weight was positively correlated with contraction number and peak impulse; and the blood flow correlated with peak impulse. In the worst legs, the calf muscle weight and ABI were not significantly correlated with any variables; the leg blood flow was negatively correlated with contraction number; the mitochondrial protein content correlated with total impulse; the MAPR (PM) tended to correlate with peak impulse. These results suggest the importance of all these local muscle physiological factors in calf muscle performance. However, only MAPR was important in the walking performance in PAD patients. The aim of Study 4 was to further explore the relationship between MAPR and exercise performance in PAD patients after exercise training. The effect of 16 weeks of treadmill exercise training on exercise performance and MAPR was evaluated in five PAD patients. In the treadmill walking performance test, total walking time increases ranged from 100 to 150% in these five patients. The pain-free walking time increased in three patients but did not change in the other two. In the calf muscle performance test, the total impulse and contraction number increased in both legs of four patients and decreased in both legs of one patient, but the magnitude of improvement was less than 5% and the peak impulse did not change in a consistent trend. The changes in body weight, calf muscle weight, and ABI in these five patients were less than 5%. However, the increased blood flow measured by venousocclusion plethysmography in both legs ranged from 100 to 150%. The MAPR by oxidising glucose was significantly higher in trained patients than that in untrained patients, which suggested a possible change in mitochondrial function in response to exercise training. Such change in mitochondrial function may have a potential role in contributing to calf muscle performance and walking performance after exercise training. In summary, for the first time, a local calf muscle performance test has been established to allow better understanding of calf muscle pathophysiology in PAD patients. Using this test, it has been shown that calf muscle performance is significantly impaired in PAD patients compared with control subjects. The impairment is characterised by lower muscle endurance, lower muscle strength and higher fatigability. The impaired local calf muscle performance might contribute to the impaired overall walking performance in PAD patients. The MAPR, especially 5 through oxidising glucose, contributed to walking performance. In this pilot exercise training study, a 20 weeks exercise training program failed to improve the calf muscle performance and walking performance in PAD patients. The higher MAPR in oxidising glucose in trained PAD patients again suggested the importance of muscle glucose oxidation as a contributing factor in the exercise performance in PAD patients.

Thesis (M.D.)--Aberdeen University, 2008.
With: Surgical revascularisation in patients with severe limb ischaemia induces a pro-thrombotic state / P. Collins ... et al. Platelets. 2006: 17(5), 311-317. With: A preliminary study on the effects of exercising to a maximum walking distance on platelet and endothelial function in patients with intermittent claudication / P. Collins ... et. Eur. J. Vasc. Endovasc. Surg. 2006: 31, 266-273. Includes bibliographical references.

peripheral arterial disease (PAD), a limiting factor in the success of percutaneous transluminal angioplasty (PTA) is the development of restenosis secondary to vascular smooth muscle cell (SMC) proliferation. The aim of this study was to determine the effect of combination antiplatelet therapy on the ability of plasma, from patients undergoing PTA, to stimulate SMCs in vitro. We aimed to investigate the effect of combination treatment on levels of circulating adhesion molecules and factors which mediate SMC proliferation in experimental models. We also sought to demonstrate any association between changes in measured markers and the development of restenosis or vascular events. Methods Fifty patients were randomised to receive clopidogrel or placebo, for thirty days, in addition to their daily 75mg aspirin. To measure proliferative capacity, diluted plasma was incubated with 24h-growth-arrested rat vascular SMCs, and Extracellular-regulated-kinase (ERK)1/2 activation was analysed by Western blotting at baseline, 1-hour pre-PTA, and at 1-hour, 24-hours and 30-days post-PTA. Plasma platelet-derived growth factor (PDGF-BB), soluble (s)E-selectin, sICAM-1 (intracellular adhesion molecule-1) and von Willebrand factor (vWF) were measured by ELISA (Enzyme-linked immunosorbent assay), at the same time-points. Platelet activation was measured by flow cytometry of ADP-stimulated platelet fibrinogen binding at baseline and 1-hour post-PTA. Patients’ notes and all investigations were reviewed for 2 years post-PTA to record restenosis or vascular events. Results Samples were available for all 50 patients at baseline, 1-hour pre-PTA and 1-hour post-PTA timepoints. In this cohort ERK1/2 activation was significantly increased post-PTA in both the aspirin/clopidogrel and aspirin/placebo groups. Those who developed a symptomatic restenosis had a significantly higher level of SMC activation at the 1-hour post-PTA time-point. There was a statistically significant decrease in PDGF-BB, and increase in vWF, following loading with clopidogrel. sICAM-1 levels significantly decreased in the aspirin/placebo group following PTA. ADP-stimulated platelet fibrinogen binding was significantly inhibited by clopidogrel therapy post-PTA. Conclusions This is the first study to show in-vitro ERK1/2 activation (a marker of SMC proliferation) increases post-PTA. Patients developing a symptomatic restenosis had a significantly higher level of SMC activation at the 1-hour post-PTA time-point. Clopidogrel therapy had no significant effect on ERK1/2 activation, although it did reduce PDGF-BB in the larger cohort of patients. Further work is required to evaluate potential therapeutic treatments which may reduce peripheral PTA-induced smooth muscle cell activation.

Objectives This thesis aimed to explore psychological factors associated with walking behaviour in patients with Peripheral Arterial Disease, within the framework of Leventhal et al’s (1998) Common-sense Model of Self-regulation of Health and Illness. The objective was to identify psychological factors which could be modified to increase walking behaviour in these patients. Method A series of three studies were conducted to achieve these aims. The first study was an exploratory qualitative study, to explore the illness and treatment beliefs and walking behaviour of patients with intermittent claudication. The second study was a cross-sectional postal questionnaire to a cohort of patients with intermittent claudication, which tested the influence of the psychological factors identified in the qualitative study, in a larger sample. The final study was a randomised controlled trial of a brief psychological intervention designed to modify the illness and walking beliefs of patients with intermittent claudication, in order to increase walking behaviour. Results Beliefs about intermittent claudication, and beliefs about walking were both found to be associated with walking behaviour in the qualitative study. The results from the cross-sectional postal questionnaire confirmed this relationship – taken as a set, illness and walking beliefs accurately predicted adherence to minimum walking levels for 93.4% of the sample. The brief psychological intervention successfully modified illness and treatment beliefs and increased walking behaviour in patients newly diagnosed with intermittent claudication. Conclusion This thesis highlights the importance of illness and walking beliefs to the walking behaviour of patients with intermittent claudication. The thesis has added to the body of knowledge about intermittent claudication, and the findings of this thesis have implications for the treatment of patients with intermittent claudication within the health service. Theoretical and clinical implications of this research are discussed.

Peripheral arterial disease (PAD) is a common manifestation of stenoses and occlusions of the arteries of the lower extremities. Clinically, PAD is an important effect on functional ability, and quality of life because symptomatic patients are typically able to walk less than one to three blocks before rest is required.The double product break point (DPBP), also defined as the oxygen consumption at which the first portion of nonlinear increase in rate pressure product (systolic blood pressure X heart rate) begins has been identified to determine the anaerobic threshold during exercise test. The purpose of this study was to determine whether the DPBP could be detected in patients with PAD during a symptom-limited GXT on the motor-driven treadmill. Six male subjects (68.2 ± 6.5 yrs) with history of diagnosis of PAD participated in this study. Double product (DP) was assessed every 15 seconds during the test via the Kyokko Bussan CM-4001 automated blood pressure unit. The DPBP and VT were determined visually by three blinded observers. The mean values of Peak V02 and maximal heart rate were 19.4 ± 5.8 (ml/kg/min) and 130 ± 13 (bpm), respectively. In 4 of the six exercise tests in the present study, the DPBP and the VT were determined. The mean V02 at the DPBP and the VT were 15.7 ± 2.6 ml/kg/min and 14.2 ± 0.6 ml/kg/min, corresponding to 73 ± 7.2 and 74.5 ± 5.4 % respectively. In 3 of the six exercise tests both of the DPBP and VT were determined. The Mean V02 at the DPBP and VT were 14.6 ± 1.8 and 14.3 ± 0.7, respectively. The difference of the mean VO2 at the VT and DPBP was -.0.33 ml/kg/min.In conclusion, the results of the present study suggest that the DPBP can be identified and used as a useful marker to determine the functional performance in PAD patients. Walking time or distance measurement depends on the patient's perception of the pain. Thus, this study provides an objective way to appraise the functional performance and therapeutic results obtained from the exercise training in PAD patients, and provides a reference for exercise prescription for this population.
School of Physical Education

Background: Anti-platelet therapy reduces vascular complications in patients with peripheral occlusive arterial disease (POAD) with aspirin the most commonly prescribed agent. However, aspirin resistance can be observed in patients who suffer clinical thromboembolic events, or have persistent platelet activity despite regular aspirin treatment. The clinical benefits of clopidogrel or combination aspirin and clopidogrel therapy may be due to superior platelet inhibition or the inhibition of platelets in aspirin resistant patients. Aim: To investigate the effects of aspirin, clopidogrel, and combination therapy on platelet inhibition in patients with POAD, and to test the response of laboratory defined aspirin resistant patients to alternative antiplatelet therapies. Methods: 50 patients were recruited from the vascular outpatient clinic at Royal North Shore hospital, at the consulting rooms of Royal North Shore Hospital vascular surgeons and the associated vascular imaging laboratories. Patients with confirmed symptomatic peripheral vascular disease were randomised to receive either aspirin or clopidogrel for 2 weeks, followed by 2 weeks of combined aspirin and clopidogrel therapy. Patients were then asked to “crossover” to the alternative antiplatelet monotherapy for the final two weeks of the trial. After each 2 week course of antiplatelet therapy, platelet activation was flow cytometrically determined by detecting platelet membrane expression of the activation markers CD62P, PACl, fibrinogen receptor and platelet-leukocyte aggregates. Measurements were performed after the addition of PGE, (for resting activation levels), and after platelet activation by low and high dose (0.5&5uM) ADP. Global platelet function was assessed using the Platelet Function Analyser-100 (PFA-lOO) with the Collagen/Epinephrine and the Collagen/ADP cartridges. Results: By flow cytometry, no significant differences in activation marker expression between aspirin, clopidogrel and combination treated patients were detected in the PGE, treated control groups. There were statistically significant differences in levels of all platelet activation markers expressed between the three antiplatelet therapies (ANOVA, p<0.001), with clopidogrel and combination therapy significantly reducing expression after both low and high dose ADP compared to aspirin (Wilcoxon p<0.05). No significant differences in marker expression were observed between clopidogrel and combination therapies. With the PFA-lOO, 9 of 50 (18%) patients were aspirin resistant by the Coll/Epi cartridge. Six of 9 aspirin resistant patients became sensitive to aspirin after combination antiplatelet therapy. Both PFA-lOO cartridges were insensitive to clopidogrel monotherapy. Statistically significant differences in Coll/ADP closure times were seen between combination therapy and aspirin (Wilcoxon p=0.0102). There was no significant difference in median levels of flow cytometric platelet activation between aspirin resistant and sensitive patients (Mann-Whitney p>0.05). Conclusions: Clopidogrel and combination therapy significantly inhibit platelet activation compared to aspirin in patients with POAD, but no significant difference in platelet inhibition was observed between clopidogrel and combination therapy. A significant proportion of POAD patients were resistant to aspirin by PFA-l 00. The majority of these patients became sensitive to aspirin with combined aspirin and clopidogrel therapy.

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Intermittent claudication (IC) is the main symptom of peripheral arterial occlusive disease (PAOD) and it can severely affect the walking capacity. This study aimed to investigate the effects of a short-course physical exercise program on intermittent claudication of PAOD patients. Twelve out of the 34 recruited subjects were excluded for several reasons. Twenty-two subjects (14 males, mean age 64.4 ± 10.4 years, ankle-brachial index ≤ 0.8) with varied clinical characteristics were included, and all have participated in Programa de Reabilitação de Doenças Vasculares Periféricas do Núcleo de Cardiologia e Medicina do Exercício (NCME) of the CEFID/UDESC. The physical performance was objectively assessed by means of a 6-minute walk test and subjectively assessed by means of the walking impairment questionnaire. The primary walking test was carried out in order to assess the initial and absolute claudication distances, and lasted up to 15 minutes. The final test lasted up to 30 minutes, if necessary. The results showed that 3 out of the 22 participants had no claudication, being able to walk up to one hour without pain. The mean improvement of the initial claudication distance for the 19 remaining participants was 74.15% (67.6 ± 61.4m, p<0.05). Eleven patients (50%) did not report absolute claudication pain during the primary test; 3 patients, with prior absolute claudication pain, completed the final walking test without reporting pain, and the 8 remaining patients, who still reported absolute claudication pain, had a mean improvement of 48.61% (84.3 ± 58.8m, p<0.05) in walking distance. Regarding the distance walked in 6 minutes, the mean improvement of the 22 patients was 17% (41.1 ± 62.5, p<0.05). It was also possible to notice mean improvement (n = 22) of 14.30% (p<0.05) in walking capacity impairment; 17.56% (p<0.05) in walking distance; 4.59% (p=0.258) in walking speed and 5.49% (p=0.468) in stair climbing. In conclusion, a short-course physical exercise program is effective in PAOD and IC patients. Throughout the walking test, the initial and absolute claudication distances and the distance walked in 6 minutes were significantly improved. The walking impairment questionnaire showed considerable improvements related to walking impairment and walking distance, however, concerning walking speed and stair climbing, the improvements were not statistically significant.
A claudicação intermitente (CI) é o principal sintoma da doença arterial obstrutiva periférica (DAOP) e pode comprometer severamente o desempenho de caminhada. O objetivo do estudo foi investigar os efeitos de um programa de exercício físico a curto prazo na claudicação intermitente de pacientes com DAOP. Dos 34 indivíduos selecionados, 12 foram excluídos por diversos motivos. Os 22 incluídos (14 do gênero masculino, média de idade 64,4 + 10,4 anos, índice tornozelo braquial < 0,8), todos participantes do Programa de Reabilitação de Doenças Vasculares Periféricas do Núcleo de Cardiologia e Medicina do Exercício (NCME) do CEFID/UDESC, apresentavam características clínicas heterogêneas. O desempenho físico foi avaliado objetivamente por meio do teste de caminhada de 6 minutos e subjetivamente pelo questionário de dificuldade para caminhar. O teste inicial de caminhada, destinado à avaliação das distâncias de claudicação inicial e absoluta, foi prolongado até 15 minutos e o final, quando necessário, até 30 minutos. Os resultados demonstraram que, dos 22 participantes do estudo, 3 deixaram de sentir a claudicação, caminhando até uma hora no programa de exercícios sem referir dor. Nos 19 pacientes restantes, a melhora média da distância de claudicação inicial foi de 74,15% (67,6 ± 61,4m, p<0,05). Dos 22 pacientes incluídos no estudo, 11 (50%) não apresentaram dor da claudicação absoluta no teste inicial; 3 pacientes, antes com dor da claudicação absoluta, completaram o teste de caminhada final sem essa manifestação e nos restantes (8 pacientes), que ainda apresentavam dor da claudicação absoluta, foi observada melhora média na distância caminhada de 48,61% (84,3 ± 58,8m, p<0,05). Quanto à distância percorrida em 6 minutos, a melhora média dos 22 pacientes foi de 17% (41,1 ± 62,5, p<0,05). Foi ainda constatado melhora média (n = 22) de 14,30% (p<0,05) na dificuldade para caminhar; 17,56% (p<0,05) na distância de caminhada; 4,59% (p = 0,258) na velocidade de caminhada e 5,49% (p = 0,468) na subida de degraus. Conclui-se que um programa de exercício físico a curto prazo é eficiente no tratamento de pacientes com DAOP e CI. Foi possível observar, por meio do teste de caminhada, melhora significativa na distância para claudicação inicial e absoluta e na distância percorrida em 6 minutos. A aplicação do questionário de dificuldade para caminhar demonstrou melhoras significativas relacionadas à dificuldade para caminhar e à distância de caminhada, sendo, entretanto, as melhoras relacionadas à velocidade de caminhada e subida de degraus consideradas estatisticamente não significativas.

INTRODUÇÃO: O termo Síndrome Metabólica denomina um conjunto de fatores de risco cardiovascular associado à resistência à insulina e a um aumento da morbidade e da mortalidade. A síndrome metabólica está relacionada a diversas doenças, especialmente aquelas ligadas à aterosclerose, como a doença arterial periférica. A claudicação intermitente é sintoma característico de um estágio inicial da doença arterial periférica, no qual o conhecimento dos seus fatores predisponentes, entre os quais a síndrome metabólica, torna-se importante para a instituição do tratamento médico adequado, a fim de prevenir ou retardar a progressão da aterosclerose. OBJETIVO: O objetivo deste estudo transversal foi determinar a prevalência da síndrome metabólica em pacientes com claudicação intermitente e sua correlação com a idade, gênero, localização da obstrução arterial e associação com doença arterial coronária sintomática. MÉTODO: Foram estudados 170 pacientes com doença arterial obstrutiva dos membros inferiores de etiologia aterosclerótica cuja única manifestação clínica era dor tipo claudicação intermitente. A idade média foi de 65 anos (33-89 anos). Havia 117 homens (68.8%) com idade média de 65.6 anos (33-84 anos) e 53 mulheres (31.1%) com idade média de 63.7 anos (35-89 anos). RESULTADOS: A síndrome metabólica foi diagnosticada em 98 pacientes (57.6%), 62 homens (63.3%) e 36 mulheres (36.7%). A idade média dos pacientes com síndrome metabólica foi de 63.5 anos, contra 67.0 anos dos pacientes sem síndrome metabólica (P = .027). Considerando os doentes com 65 anos, a síndrome metabólica esteve presente em 46 (48.9%) indivíduos e em 52 (68.4%) pacientes abaixo de 65 anos (P = .011). CONCLUSÕES: A Síndrome Metabólica é uma comorbidade frequente em indivíduos com claudicação intermitente, com prevalência significativamente mais elevada em indivíduos com idade inferior a 65 anos. Não houve associação entre a Síndrome Metabólica e o sexo dos pacientes com claudicação intermitente. Não houve também relação entre a Síndrome metabólica e doença coronariana sintomática na população estudada. A Síndrome Metabólica não afetou nenhum segmento anatômico arterial preferencialmente nos claudicantes
INTRODUCTION: The metabolic syndrome consists in a group of cardiovascular risk factors referring to insulin resistance, associated with increased cardiovascular morbidity and mortality. Metabolic syndrome is correlated to several illnesses, especially those associated with atherosclerosis, like peripheral arterial disease. Intermittent claudication is a symptom of an early stage of peripheral arterial disease, and the precocious diagnosis of metabolic syndrome is important for adequate medical treatment, in order to prevent or delay the progression of atherosclerosis. OBJECTIVES: The aim of this cross-sectional study is to determine the prevalence of the metabolic syndrome in patients with intermittent claudication and its correlation with age, gender, localization of arterial obstruction and association with symptomatic coronary artery disease. METHODS AND RESULTS: There were studied 170 consecutive patients with intermittent claudication, determined by physical examination, which revealed absence or weakness of pulses on the limb or limbs that were limiting deambulation, and an ankle-brachial index 0.9. The mean age was 65 years (33-89 years). There were 117 men (68.8%) with mean age of 65.6 years (33 84 years) and 53 women (31.1%) with mean age of 63.7 years (35 89 years). Metabolic syndrome was diagnosed in 98 patients (57.6%), 62 men (63.3%) and 36 women (36.7%). The mean age of patients with metabolic syndrome was 63.5 years, against 67.0 years of patients without metabolic syndrome (P= .027). Considering patients with 65 years old, the metabolic syndrome was present in 46 (48.9%) individuals and in 52 (68.4%) patients below 65 years old (P= .011). CONCLUSIONS: The metabolic syndrome is frequent among patients with intermittent claudication, with a significant higher prevalence in claudicants < 65 years of age. The metabolic syndrome was not correlated with sex and symptomatic coronary artery disease. The metabolic syndrome did not affect any specific arterial segment in claudicant patients

As alterações vasculares são complicações clínicas secundárias a elevação da pressão arterial que podem comprometer a capacidade funcional e aumentar o risco de mortalidade. Um instrumento utilizado como marcador de doença arterial obstrutiva periférica que vem merecendo amplo interesse clínico e científico é o Índice Tornozelo-Braquial (ITB). Segundo diretrizes para a prática clínica, valores de ITB <=0,9 ou >=1,3 são considerados patológicos e associados a uma alta incidência de morbimortalidade cardiovascular. Este estudo descritivo e de corte transversal teve por objetivo identificar o risco cardiovascular em hipertensos do avental branco por meio da determinação do ITB com uso de esfigmomanômetros oscilométricos automáticos. Foi desenvolvido em um município localizado ao Nordeste do Estado de São Paulo, no período de agosto de 2010 a junho de 2011. Os participantes foram divididos em normotensos, hipertensos e hipertensos do avental branco, classificados de acordo com o diagnóstico médico e resultado da Monitorização Ambulatorial da Pressão Arterial (MAPA). As variáveis investigadas foram: idade, cor da pele, situação familiar conjugal, naturalidade, índice de escolaridade, profissão, peso, estatura, circunferência abdominal, pressão arterial em braços e tornozelos e ITB. O cálculo do ITB foi realizado pela relação da maior pressão arterial sistólica (PAS) da artéria tibial posterior com a maior pressão sistólica das artérias braquiais. As análises descritivas foram realizadas por meio do pacote estatístico StatisticalPackage for the Social Sciences - SPSS, versão 15.0. Utilizou-se análise de variância (ANOVA) para medidas repetidas e teste Tukey para comparações múltiplas das médias. O grau de relação linear nos escores de PAS e ITB foi verificado mediante a utilização do Coeficiente de Correlação de Pearson. Os resultados foram expressos como médias ± erros padrões das médias (EPM), e as diferenças consideradas estatisticamente significantes para p<0,05. Participaram do estudo 135 indivíduos, sendo 37% normotensos, 37% hipertensos e 26% hipertensos do avental branco. Em todos os grupos, a maioria dos participantes é do sexo feminino, de cor branca, vive com o cônjuge, é natural do estado de São Paulo, exerce atividades domésticas e tem ensino fundamental incompleto. Hipertensos do avental branco apresentam risco intermediário na análise de todas as variáveis clínicas estudadas. Apesar de não ter sido encontrada diferença significante na análise dos valores de ITB na comparação dos grupos, alterações compatíveis com doença arterial obstrutiva periférica e calcificação arterial foram observadas somente nos grupos hipertensão e hipertensão do avental branco. A análise do ITB de menor valor mostrou que 10% dos hipertensos e 5,7% dos hipertensos do avental branco apresentaram ITB<=0,9 e 6% dos hipertensos e 11,4% dos hipertensos do avental branco apresentaram ITB>1,3. Há correlação negativa entre os valores de PAS e ITB nos grupos hipertensão e hipertensão do avental branco. Estes achados remetem à premissa de que a hipertensão do avental branco não deve ser compreendida como uma condição benigna, sendo caracterizada por um quadro clínico que pode evoluir para hipertensão arterial estabelecida. A mensuração do ITB merece importância na abordagem clínica dos pacientes, devendo constituir um instrumento de avaliação do risco cardiovascular valorizado pelos profissionais na rotina dos serviços de saúde.
The vascular changes are secondary clinical complications of high blood pressure which can compromise the functional capacity and increase the risk of mortality. The Ankle-Brachial Index (ABI) is an instrument used as a marker of peripheral occlusive arterial disease which has attracted broad scientific and clinical interest. According to guidelines for clinical practice, ABI values <=0.9 or >=1.3 are considered pathological and associated with a high incidence of cardiovascular morbidity and mortality. This descriptive and cross-sectional study aimed at identifying cardiovascular risk in white coat hypertension by determining the ABI through the use of automatic oscillometric sphygmomanometers. The study was performed in a municipality located in the northeastern of the state of São Paulo, from August 2010 to June 2011. Participants were divided into normotensive, hypertensive, and white coat hypertensive subjects, classified according to the medical diagnosis and outcome of Ambulatory Blood Pressure Monitoring (ABPM). The variables investigated were: age, color of skin, marital family situation, nationality, level of education, occupation, weight, height, waist circumference, ankle-brachial blood pressure and ABI. The calculation of ABI was performed by the ratio between the higher systolic blood pressure (SBP) of the posterior tibial artery and the highest systolic brachial artery. Descriptive analyzes were performed using the Statistical Package for Social Sciences Statistical Package - SPSS, version 15.0. The analysis of variance (ANOVA) was used for repeated measures and Tukey test for multiple comparisons of means. The degree of linear relationship in the scores of SBP and ABI was verified by using the Pearson correlation coefficient. The results were expressed as means ± standard errors of the mean (SEM), and the differences were considered statistically significant at p<0.05. The study included 135 subjects, 37% normotensive, 37% hypertensive and 26% white coat hypertensive subjects. In all groups, most participants are female, white, live with the spouse, from the state of São Paulo, housewives and have incomplete elementary education. White coat hypertensive subjects have intermediate risk in the analysis of all clinical variables studied. Although no significant difference was found in the analysis of ABI values in the comparison of groups, changes consistent with peripheral occlusive arterial disease and arterial calcification was observed only in the groups with hypertensive and white coat hypertensive subjects. The analysis of the lower ABI value showed that 10% of hypertensive subjects and 5.7% of white- coat hypertensive subjects had ABI<=0.9 and 6% of hypertensive subjects and 11.4% of white-coat hypertensive subjects had ABI>1.3 . There is a negative correlation between SBP and ABI in the groups of hypertensive and white coat hypertensive subjects. These findings relate to the premise that white coat hypertension should not be understood as a benign condition, being characterized by a clinical condition that can lead to established hypertension. The measurement of ABI deserves importance in clinical management of patients and should be a tool for assessing cardiovascular risk valued by professionals in the routine of health services.

Introdução: Inúmeros estudos estabeleceram correlações entre o índice tornozelo-braço (ITB), um marcador de aterosclerose subclínica, e o prognóstico cardiovascular em diferentes populações. No entanto, poucos estudos avaliaram a correlação entre os valores do ITB e lesões cardiovasculares e renais, exclusivamente, em pacientes com hipertensão arterial e diabetes. Objetivo: Estudar a prevalência de alterações morfofuncionais cardíacas, carotídeas, retinianas e renais de acordo com a presença ou não de valores de ITB alterados (ITB <= 0,9 ou ITB > 1,4) em pacientes hipertensos com diabetes tipo 2. Métodos: Foram incluídos no estudo 99 pacientes hipertensos diabéticos com idade entre 50 e 80 anos. A aferição do ITB foi realizada em todos os pacientes por método validado e estes foram classificados em Grupo 1 (ITB normal, n = 49) ou Grupo 2 (ITB alterado, n =50). Todos os pacientes foram submetidos, em até 06 meses, à realização de ecodopplercardiograma, ultrassonografia de carótidas, retinografia colorida, aferição da taxa de filtração glomerular (TFG) e da albuminúria de 24h. Os pacientes foram analisados para a ocorrência ou não de um desfecho-composto ecocardiográfico que incluiu alterações morfológicas e funcionais cardíacas relevantes para a prática clínica. Os pacientes dos grupos 1 e 2 foram também comparados quanto à prevalência de placas carotídeas com ou sem repercussão hemodinâmica, TFG < 60 ml/mim/m2, albuminúria de 24h > 30mg e presença ou não de retinopatia. Por fim, foram comparadas as frequências médias das seguintes lesões de órgãos-alvo de ambos os grupos, considerando-se valor unitário para a presença de cada uma delas: hipertrofia do ventrículo esquerdo, retinopatia hipertensiva, TFG < 60 ml/min/m2 e estenose da artéria carótida interna > 50% do seu diâmetro. Resultados: A média de idade dos pacientes foi 65,4 ± 7 anos, sendo 61,6% deles do sexo feminino. A presença de níveis elevados de pressão arterial sistólica (153,4 ± 18 versus 170 ± 26 mmHg), de albuminúria de 24h > 30mg (55,3% versus 82,6%) e de TFG < 60 ml/min/m2 (12,8% versus 33,3%) foi significativamente maior (p < 0.05) entre os pacientes do Grupo 2. O desfecho-composto ecocardiográfico foi mais prevalente no grupo 2 (84,0% versus 59,2%; p = 0,006) e a frequência média de lesões de órgãos-alvo também foi maior nos pacientes do grupo 2 (0,36 ± 0,31 versus 0,19 ± 0,19; p = 0,001). Análise por regressão logística binária revelou que o ITB foi uma das variáveis preditoras independentes para o desfecho-composto ecocardiográfico (OR = 3,43; IC 95% = 1,07 - 11,0; p = 0,04). A partir da análise por regressão linear obteve-se um modelo final no qual o ITB foi uma das três variáveis preditoras independentes para a estimativa da frequência média de lesões de órgãos-alvo com coeficiente beta = 13,22 (1,81 - 24,63), ao lado da idade e do infarto prévio. Conclusão: Nossos dados mostram que valores de ITB alterados estão associados à maior prevalência de lesões em órgãos-alvo, principalmente alterações ecocardiográficas, em pacientes com hipertensão arterial e diabetes
Introduction: A lot of studies have established strong correlations between the ankle-brachial index (ABI), a marker of subclinical atherosclerosis and cardiovascular prognosis in different populations. However, few studies have assessed the correlation between the values of the ABI and cardiovascular and renal lesions in patients with hypertension and diabetes. Objective: To study the prevalence of cardiac, carotid, renal and retinal morphological and functional changes according to the presence or not of altered ABI values (ABI <= 0.9 or ABI > 1.4) in hypertensive patients with type 2 diabetes. Methods: It was included 99 diabetic hypertensive patients aged between 50 and 80 years. The measurement of the ABI was performed in all patients by validated method and they were classified in Group 1 (normal ABI, n = 49) or group 2 (altered ABI, n = 50). All patients were submitted, up to 6 months, to Doppler echocardiography, carotid ultrasound, color retinography, assessment of glomerular filtration rate (GFR) and 24h albuminuria. Patients were analyzed for the occurrence or not of a composite echocardiographic outcome which included morphological and functional cardiac alterations relevant to clinical practice. Patients in groups 1 and 2 were compared regarding the prevalence of carotid plaques with or without hemodynamic repercussion, TFG < 60 ml/min/m2, 24h albuminuria > 30 mg and the presence or not of retinopathy. Finally, we compared the prevalence of mean frequency of the following end-organ lesions of both groups, considering unit value for each one: left ventricular hypertrophy, hypertensive retinopathy, TFG < 60 ml/min/m2 and internal carotid artery stenosis > 50%. Results: The mean age of the patients was 65.4 ± 7 years, with 61.6% of them female. The presences of elevated levels of systolic blood pressure (153.4 ± 18 versus 170.0 ± 26 mmHg), of 24h albuminuria > 30 mg (55.3% versus 82.6%) and TFG < 60 ml/min/m2 (12.8% vs. 33.3%) were significantly greater (p < 0.05) among the patients of Group 2. The composite echocardiographic outcome was more prevalent in Group 2 (84.0% versus 59.2%, p = 0.006) and the average frequency of subclinical injury of target organs was also greater in patients of Group 2 (0.36 ± 0.31 versus 0.19 ± 0.19; p = 0.001). Binary logistic regression analysis revealed that the ABI was one of the independent predictors of composite echocardiographic outcome (OR = 3.43; IC 95% = 1.07 - 11.0; p = 0.04). From the linear regression analysis it was obtained a final model in which the ABI was one of three independent predictors for the estimation of the average frequency of end-organ damage with ? coefficient = 13.22 (1.81-24.63), besides age and previous myocardial infarction. Conclusion: Our data demonstrates that changed ABI values are associated with higher prevalence of subclinical end-organ lesions, principally changes in echocardiographic parameters, in patients with hypertension and diabetes

INTRODUÇÃO: O diagnóstico de enfermagem Perfusão Tissular Periférica Ineficaz (PTPI) e suas características definidoras (CD) ainda não foram validados em pacientes com doença arterial obstrutiva periférica dos membros inferiores (DAOMI), por meio de testes que avaliam a capacidade funcional e a função vascular arterial. OBJETIVO: Validar algumas CD de PTPI em pacientes com DAOMI sintomática e verificar sua importância na determinação desse diagnóstico de enfermagem. CASUÍSTICA E MÉTODO: Foram selecionados 65 pacientes com DAOMI (62,2 + 8,1 anos; 56,9% do sexo masculino; índice tornozelo-braquial - ITB = 0,59 + 0,14), nos quais a PTPI foi diagnosticada mediante a presença de claudicação intermitente e ITB < 0,90, e 17 indivíduos--controle (63,4 + 8,7 anos; 41,2% do sexo masculino; ITB = 1,14 + 0,08). Todos os participantes foram submetidos a exame físico, à medida do ITB, à avaliação de sua capacidade funcional e das propriedades funcionais das artérias. O ITB foi calculado para cada membro inferior, dividindo-se a maior pressão arterial do tornozelo pela maior pressão obtida nos braços; para análise considerou-se o pior ITB. Os pacientes com PTPI secundária à DAOMI foram divididos de acordo com o grau de prejuízo da circulação periférica. A capacidade funcional foi determinada por meio do teste de caminhada de seis minutos (TC6), registrando-se as distâncias percorridas, total e livre de dor. As propriedades funcionais das artérias foram avaliadas em termos da rigidez da parede (VOP C-F e VOP C-R), utilizando-se o Complior®, e da reatividade vascular, com a técnica de ultrassom vascular de alta resolução em condições basais, após manobra de hiperemia reativa e após administração sublingual de nitrato. A hiperemia reativa promove vasodilatação dependente do endotélio e é mediada pelo fluxo (DMF); por sua vez, o nitrato é um doador de óxido nítrico e causa vasodilatação independente do endotélio. RESULTADOS: A prevalência da CD pulsos periféricos ausentes ou filiformes foi maior nos pacientes com PTPI do que nos indivíduos-controle (> 70,0% versus 5,3%, respectivamente, p < 0,0001). Ainda, observou-se que pacientes com PTPI percorreram menores distâncias no TC6 (265,1 + 77,4 versus 354,7 + 42,1 m, p < 0,001) e apresentaram maior VOP C-F (12,2 + 4,0 versus 9,6 + 2,2 m/s, p = 0,016), menor DMF (2,7 + 4,2% versus 6,1 + 5,4%, p = 0,014) e menor dilatação pós- -nitrato (14,3 + 8,4% versus 20,6 + 10,0%, p = 0,019). Na análise individual, verificou-se que a presença das CD associou-se à redução das distâncias percorridas no TC6, total e livre de dor, ao aumento da VOP C-F e a menores DMF e dilatação pós-nitrato. Na análise conjunta, pulsos pedioso e/ou tibial posterior ausentes ou filiformes foram preditivos de: (1) menor capacidade funcional, com redução de 61 metros na distância total percorrida e 124 metros na distância livre de dor; (2) maior rigidez da parede arterial, pois aumentou em 18% a média da VOP C-F; e (3) maior prejuízo da reatividade vascular, evidenciada pela redução de 2,6% na DMF. Além disso, a alteração na amplitude de algum pulso periférico ou sopro na artéria femoral esquerda aumentou 1.024 vezes a chance de ocorrência de PTPI. Observou-se que as distâncias, total e livre de dor, percorridas no TC6, a VOP C-F e a dilatação pós-nitrato associaram-se de forma significativa com o maior prejuízo da circulação periférica, verificado pelo ITB, sendo que o aumento de 1m na distância percorrida livre de dor reduziu em 0,8% (IC 95% = 0,985 - 0,998) a chance de prejuízo grave (ou moderado e grave) da circulação periférica. Já o aumento de 1m/s na VOP C-F elevou essa chance em 23,7% (IC 95% = 1,057 - 1,448). CONCLUSÃO: A CD pulsos periféricos ausentes ou filiformes foi a mais relevante para o diagnóstico de enfermagem PTPI, pois apresentou maior prevalência, associou-se à maior limitação funcional e mostrou forte associação com alterações funcionais das artérias.
INTRODUCTION: The nursing diagnosis Ineffective Peripheral Tissue Perfusion (PTPI) and its defining characteristics (CD) have not yet been validated in patients with peripheral arterial obstructive disease (DAOP) in the lower limbs, through tests that evaluate functional capacity and arterial vascular function. OBJECTIVE: To validate some CD of PTPI in patients with symptomatic DAOP and verify the relevance of these characteristics in determining this nursing diagnosis. METHOD: 65 patients with DAOP were selected (62.2 + 8.1 years; 56.9% male; ankle brachial index - ABI = 0.59 + 0.14), in which PTPI was diagnosed considering the presence of intermittent claudication and ABI <0.90, and 17 control subjects (63.4 + 8.7 years; 41.2% male; ABI = 1.14 + 0.08). All participants were submitted to physical assessment, ABI measurement, evaluation of functional capacity and arteries functional properties. ABI was calculated for each leg, dividing the higher pressure of the ankle by the higher pressure of the arms, whereas the worst ABI was considered. Patients with ABI related to DAOP were split according to the impairment of peripheral circulation. Functional capacity was determined through the six-minute walk test (TC6). Total and pain free distances were recorded. Arteries funcional properties were evaluated in terms of arterial stiffness (C-F PWV and C-R PWV) using the Complior®, and in terms of vascular reactivity using high-resolution ultrasound in basal condition and after reactive hyperemia and sublingual administration of nitrate. Reactive hyperemia promotes endotlhelium dependent vasodilation which is flow mediate (DMF); nitrate is a nitric oxide donor and causes endothelium independent vasodilation. RESULTS: The prevalence of the CD absent or weak peripheral pulses was higher among patients with PTPI compared with control subjects (> 70.0% versus 5.3%, respectively, p < 0.001). Patients with PTPI traveled shorter distances in the TC6 (265.1 + 77.4 versus 354.7 + 42.1 m, p < 0.001), presented higher C-F PWV (12.2 + 4.0 versus 9.6 + 2.2 m/s, p = 0.016), lower FMD (2.7 + 4.2% versus 6.1 + 5.4%, p = 0.014) and lower post nitrate dilation (14.3 + 8.4% versus 20.6 + 10.0%, p = 0.019) than the control group. The individual analysis of CD showed that their presence were associated with reduction in the total and pain free walking distances in TC6, increased C-F PWV, and diminished FMD and post nitrate dilation. The absent or weak dorsalis pedis and/or posterior tibial arterial pulses in the cluster analysis predicted: (1) poor functional capacity, reduction of 61 meters in the total walking distance and 124 meters in the pain free walking distance; (2) higher arterial stiffness, because the average of C-F PWV increased 18%; and (3) greater impairment of vascular reactivity, evidenced by a reduction of 2.6% in the FMD. In addition, alteration in the amplitude of some peripheral pulse or bruit in the left femoral artery increased 1024 times the risk of PTPI. Total and pain free walking distances in the TC6, C-F PWV and the post nitrate dilation were significantly associated with greater impairment of peripheral circulation evaluated through ABI. An increase of 1m of pain free travelled distance reduced the risk of severe (or moderate and severe) impairment of peripheral circulation in 0.8% (CI 95% = 0.985 - 0.998), whereas an increase of 1m/s in the C-F PWV increased the risk by 23.7% (CI 95% = 1.057 - 1.448). CONCLUSION: The CD absent or weak peripheral pulses was the most relevant characteristic determining the nursing diagnosis PTPI because it presented the highest prevalence, was associated with reduced functional capacity, and presented a strong association with arteries functional alteration.

Bibliography: leaves 91-98.
Patients with peripheral vascular disease (PVD) suffer from the symptom of intermittent claudication and are walking intolerant. However, it is not clear what contributes to walking intolerance in patients with PVD.

During a surveillance programme all the known diabetics (1150) were identified from a general population of 97,034 representing all patients registered with 10 general practices. A control group of 751 non-diabetic subjects were also drawn from the same general population. A single observer reviewed 1077 (93.6%) of the diabetics and 480 (69%) of the controls. Peripheral vascular disease was detected using doppler ankle/brachial pressure index in 20.6% (95% CI 18.2-23.0) of diabetics and 9.6% (95% CI 7.0-11.2) of controls. There was no significant difference between the prevalence in non-insulin dependent and insulin dependent diabetics after adjusting for age. The prevalence in either type of diabetes was however significantly greater than in controls. Multiple logistic regression analysis revealed that age, cerebrovascular disease, coronary artery disease, mean systolic blood pressure, blood glucose, proteinuria and serum cholesterol were significantly and independently associated with the presence of peripheral vascular disease in diabetics. Body mass index was inversely associated. For controls only age and smoking were found to be significant variables. Neuropathy determined by clinical evaluation and sensory vibration thresholds was found in 16.8% (95% CI 14.6-19.0) of diabetics and 2.9% (95% CI 1.4-4.3) of controls (p