This study extends earlier trials indicating that atherosclerosis risk factors are underdetected and undertreated in peripheral arterial disease (PAD) patients. Recognition and treatment of hyperlipidemia and hypertension in PAD patients is suboptimal. Diabetes appears to be detected more frequently although glycemic control is still suboptimal. The use of antiplatelet therapy is particularly underutilized. Additionally, despite the demonstrated efficacy of regular exercise in PAD patients, almost half of the study sample was sedentary. Approximately one third of the current study sample was overweight and nearly one third was obese by ATP-III guidelines. Only 31% of subjects were taking dietary measures to improve their cardiovascular health, and even fewer were physically active. To rectify suboptimal management of risk factors, there is a need for increased public awareness of PAD, reimbursement and implementation of screening programs and more aggressive treatment. Future studies are needed to examine innovative interventions for identification and management of cardiovascular risk factors in patients with PAD.
Traumatic brain injury (TBI) is a serious public health problem. The impact of TBI on the individual is multifaceted and includes neurocognitive, behavioral, and psychiatric disturbances as well as greater predisposition for dementia. A common but significant problem reported by patients after TBI is sleep disturbance. The purpose of this manuscript is twofold: (1) to describe our experience with implementation of the newly developed sleep hygiene guidelines; and (2) to report our preliminary results of implementation of the sleep hygiene guidelines on TBI patient outcomes.A mixed methods approach was used to assess implementation of sleep hygiene guidelines and to gather preliminary data on outcomes.Although not statistically significant, the average self-reported sleep duration of these TBI patients was slightly higher in 2010 than 2009, with a FIM score that was similar for both time points. In 2009, the mean change in functional independence measure (FIM) score (n = 34) was 1.44. In 2010, the mean change in FIM score (n = 33) was 1.42. In 2009, most patients (n = 13) admitted to the hospital continued to take medications and were discharged with a sleep aid. In 2010, most patients reported a change in their sleep medication prescriptions (on medications at admission and none at discharge) or had continued to take their prescribed sleep medications from admission to discharge (n = 12).Sleep disorders have a major impact on health outcomes in patients with TBI. To optimize rehabilitation and ultimately improve functional outcomes of patients with TBI, implementation of evidence-based clinical guidelines for sleep is imperative. We report our initial experience with implementation of sleep guidelines.
In patients with congestive heart failure (CHF), the poor relationship between systemic exercise performance and cardiac function, together with morphologic and metabolic abnormalities in skeletal muscle, raises the possibility that skeletal muscle function may be impaired and limit systemic exercise performance. We assessed strength and endurance of the knee extensors during static and dynamic exercise in 16 patients with Class I-IV CHF and eight age-matched sedentary controls and related these measurements to systemic exercise performance. To assess skeletal muscle function independent of peripheral blood flow, endurance was repeated under ischemic conditions. Strength was not significantly different in the two groups. Dynamic endurance, quantified as the decline in peak torque during 15 successive isokinetic knee extensions, was significantly reduced in the patients compared to controls during aerobic (peak torque 65 vs. 86% of initial for exercise at 90 deg/s and 60 vs. 85% for exercise at 180 deg/s; P less than 0.002 for both), and during ischemic exercise (56 vs. 76% of initial torque; P less than 0.01). Static endurance, defined as the time required for force during a sustained maximal voluntary contraction to decline to 60% of maximal, was reduced in the patients compared to controls (40 +/- 14 vs. 77 +/- 29 s; P less than 0.02). There were highly significant relationships between systemic exercise performance and skeletal muscle endurance at 90 and 180 deg/s in the patients with CHF (r = 0.90 and 0.66, respectively). These findings indicate that skeletal muscle endurance is impaired in patients with CHF, that this abnormality is in part independent of limb blood flow, and that these changes may be important determinants of systemic exercise performance.
Patients with peripheral arterial disease experience significant functional limitations due to ischemic symptoms (claudication) and are at high risk for cardiovascular disease morbidity and mortality resulting from untreated cardiovascular disease risk factors and aggressive atherosclerosis. Peripheral arterial disease is commonly undiagnosed and cardiovascular disease risk factors are frequently untreated in this population. The increased risk associated with peripheral arterial disease necessitates greater emphasis on detection and management, not only to improve survival but to improve functional capacity and quality of life. This article briefly describes the detection and medical management with emphasis on lifestyle modification for elders with peripheral arterial disease.
To the practicing clinician, it seems obvious that limb hemodynamics would be the primary determinant of walking distance. However, other determinants, such as skeletal muscle metabolism, may play a role. Accordingly, in the current study, we examined the relationship between measures of limb hemodynamics and walking capacity in patients with peripheral arterial disease (PAD). We measured toe and ankle pressures for calculation of toe-(TBI) and ankle (ABI)-brachial indices; basal and hyperemic calf blood flow (CBF; by plethysmography); and initial (ICT) and absolute (ACT) claudication time using the Skinner-Gardner protocol. As expected, PAD patients had impaired limb hemodynamics with reduced TBI, ABI and a reduction in ABI post-exercise. However, there was no relationship between any of the hemodynamic variables (including ABI, ABI reduction post-exercise, TBI, baseline or maximal CBF) and walking distance as assessed by ICT or ACT. A subset of PAD patients with an ACT >750 s (n =16; ‘long claudicators’) were compared with a subset of PAD patients with an ACT <260 s (n = 16; ‘short claudicators’). The average ACT in the long claudicants was over fivefold greater than the short claudicators. Surprisingly, there were no differences between the two groups in any of the hemo-dynamic variables. There was also no relationship between the initial ABI, TBI, toe pressure, baseline or hyperemic CBF, and the improvement in ACT over the 3-month course of the study. This study found little relationship between hemodynamic variables and functional capacity in PAD. Accordingly, to assess the response to therapeutic interventions, exercise performance and functional status need to be directly measured, and cannot be predicted from hemodynamic measurements.
