Circulating levels of cytokines (IL-6 and IL-1beta) in patients with intermittent claudication, at rest, after maximal exercise treadmill test and during restore phase. Could they be progression markers of the disease?

AIM

Inflammation is considered to be one of the main mechanisms for the development and progression of peripheral arterial disease (PAD). Many studies have demonstrated that maximal exercise enhances the acute inflammatory response in claudicant patients, but no one has assessed the duration of this acute inflammatory activation. The aim of this study was to assess of the inflammatory pattern in claudicants and of the inflammatory response after maximal exercise and during the recovery from calf pain.

METHODS

Eleven patients with moderate claudication (MC) (age: 60.5+/-5.8 years; body mass index [BMI]: 27.5+/-4.6; absolute claudication distance [ACD]: 165.4+/-38), 10 patients with severe claudication (SC) (age: 60.3+/-5 years; BMI: 27+/-4.5; ACD: 91+/-11.3) and 8 healthy subjects (age: 59.4+/-6.8; BMI: 28.7+/-4.16) underwent to maximal treadmill test (speed 2.5 km/h, slope 15%). At rest, just after stop of the exercise (appearance of calf pain in patients, and 6 min of treadmill in controls) the circulating levels of interleukin (IL)-1beta and IL-6 have been measured.

STATISTICAL ANALYSIS

variance of mean values, Bonferroni t-test, split plot variance model, variance of d stop-before and stop-recovery have been utilized. P<0.05 has been considered the significant cut-off of the differences.

RESULTS

The maximal exercise excited significant (P<0.01) inflammatory activation in all patients: MC (rest IL-1beta: 1.55, 3.3 at stop; rest IL-6: 5.97, 8.38 at the stop); SC (rest IL-1beta: 2.97, 5.72 at stop; rest IL-6: 6.98, 9.99 at the stop). During recovery, MC showed a reduction of the inflammatory activation, whilst SC showed further increase (IL-1beta: 7.55; IL-6: 11.94).

CONCLUSION

The study confirms the higher inflammatory activation in claudicants and its enhancement after maximal exercise. During recovery, we found two kinds of response: type 1 (controls and MC), in which inflammation subsides, and type 2 (SC) characterized by further inflammatory increase. This trend is not univocal: 3 MC showed a type 2 response and 2 SC showed a type 1. In conclusion, inflammatory activation may depend not only on the degree of endothelial damage, but also on the individual inflammatory attitude, better assessed after maximal exercise than baseline values. This individual inflammatory responsiveness, considering the role of the rest measurement of markers of inflammation recently discussed, could be a useful marker for aggressive PAD.

Effects of elastic stocking on quality of life of patients with chronic venous insufficiency. An Italian pilot study on Triveneto Region

AIM

Even though compression therapy is the most recommended treatment for chronic venous insufficiency (CVI) in the national and international guidelines, its application, at least in Italy, is lower than the estimated need from the prevalence of CVI in the epidemiological studies. Since we believe that the measurement of the impact of compression therapy on quality of life (QoL) could improve the compliance for this precious treatment, we carried out this study on 50 patients with CVI.

METHODS

Fifty patients (23 CEAP C2 and 27 C(3-4-5), selected within a larger study on QoL in CVI), received a prescription for compression therapy. Before treatment and 4 months afterwards, the patients received the instrument for QoL assessment (MOS SF-36; CIVIQ-2; Euro-QoL 5D and a visual analogue scale). The score scales have been adjusted to poorest QoL as 0 and best QoL as 100.

RESULTS

Baseline QoL of patients in class C2 did not show significant difference with the healthy Italian Population, except for the physical role item. The patients in class C(3-4-5) showed significant reduction of QoL. After 4 months all the items of the utilized instrument showed significant improvement (from P<0.01 to P<0.04 for SF-36; from P<0.099 to P<0.006 for other instruments) in all CEAP classes.

CONCLUSIONS

The study unquestionably shows that the compression therapy improves the QoL of patients with CVI, and should be included in the CVI treatment covered by the Public National Health Insurance. Finally, the QoL measurement could be utilized as the scientific method to assess the effectiveness and efficacy of different therapeutic devices.

Quality of life in chronic venous insufficiency. An Italian pilot study of the Triveneto Region

AIM

Chronic venous insufficiency (CVI) is a chronic disease, whose disability has not been appreciated clearly, and several treatment costs are not covered by Public Health Service, probably because its any social impact is not well known. The aim of the study was to assess the impact of CVI on quality of life (QoL), and to compare the sensitivity of more diffused instruments for QoL assessment.

METHODS

One hundred and four patients with CVI received the Italian version of four QoL assessment instruments (MOS SF-36; CIVIQ-2; Euro-QoL 5D and a visual analogical scale). The poorest QoL was adjusted as 0, the best as 100. After filling the questionnaires, patients underwent a clinical and instrumental examination to assess the diagnosis according to the CEAP classification.

RESULTS

The QoL is progressively impaired from CEAP class C1 to class C5-6. The SF-36 showed a normal QoL in patients of CEAP class C1 and C2. Class C3 showed a significant (P<0.0018) reduction of QoL (physical role and bodily pain), and the decline was more significant (P<0.0001) in class C4, involving all physical items and several mental ones. Class C5-6 showed very low scores of physical and social functioning, general health and vitality. Physical and emotional scores were better than C4 patients.

CONCLUSIONS

QoL is progressively impaired in CVI, involving primarily the physical items and the emotional role, with worsening of mental items only in advanced stages. This early involvement of physical items underlines how CVI is not an esthetic problem, but, a disease. Its impact on the lifestyle and QoL is similar to that of other chronic diseases (diabetes, cancer, chronic pulmonary disease), reaching in the class C5-6 the poorest level, similar to heart failure.

[Evaluation of cutaneous necrosis risk in peripheral arterial diseases]

BACKGROUND

In the last years the surgical and pharmacological treatment of critical limb ischaemia has been significantly modified, increasing the reduction of amputation and/or the increase of limbs recovery. However, neither survival nor incidence of amputations changed. This, probably has been related to an inadequate therapy after revascularization procedures or to an increase of complications. The assessment of cutaneous necrosis risk and of the recovery possibility of the ischemic limb can positively influence the therapeutic strategy, in these patients. The aim of this paper is to identify the reference parameters that can represent objectively the limit for cutaneous ischemic suffering, improving the physiological knowledges of critical limb ischemia.

METHODS

In the first phase of our study 56 patients, in different stages of peripheral arterial disease have been, submitted to microcirculatory assessment measuring the pattern of TcPO2 and TcPCO2 in correlation with walking performance expressed as ACD at treadmill test (2.5 Km/h gradient 12.5%). The second phase assesses the clinical outcome after three months of 12 among 19 patients with critical limb ischemia, measuring the changes of TcPO2 and TcPCO2 with postural test and after infusion with prostanoids of two weeks.

RESULTS

A reduction of the TcPO2 and an increase of the acidosis from stable to invalidant claudication have been observed, with a progressive loss of direct correlation between ACD and TcPO2, and an increase of the inverse correlation of the ACD with TcPCO2. In the CLI we found a very low TcPO2 levels with a TcPCO2 levels ( about 120 mmHg) with no correlation of ACD with TcPO2 and TcPCO2. The good clinical outcome was related to an increase of the TcPO2 and to a reduction of the TcPCO2 after postural stimulation and after therapy. In the patients with a bad response to the postural test, a possibility of recovery was observed only in those with a positive answer to therapeutic treatment.

CONCLUSIONS

The invalidant claudication phase can be considered a point of physiopathological change from relative to absolute ischemia that is clinically equivalent to early sign of ischemia. The identification of recoverable patients seems to be related to postural test and pharmacological treatment with an increased values. Viceversa, it is still difficult to identify as non-responders, those patients with a bad postural test, or with a little improvement after pharmacological treatment, as those with an indication to primary amputation. More observations, evaluation data will contribute to a better definition of a negative trend.