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Aims: This study explored the reliability, validity and perceived comfort of a novel thumb pressure measure and calculation of a toe–thumb index to identify their suitability as an adjunct or alternatives to ankle–brachial and toe–brachial indices. Methods and Results: Repeated manual thumb and toe systolic blood pressures were conducted using two raters, over two time points, on 34 healthy participants. Concurrent automated toe, thumb and brachial systolic blood pressures as well as comfort ratings for these measures (using a 10 mm visual analogue scale) were captured once by a research assistant. Automated thumb and brachial measures showed fair correlation (ρ = 0.36, p = 0.03) and a toe–thumb index and toe–brachial index good correlation (ρ = 0.62, p < 0.01). Intraclass correlation coefficients (ICC) identified moderate intra‐rater reliability for manual thumb pressures for Rater 1 and 2 (ICC 0.57, 95% CI [0.14, 0.79] and ICC 0.74, 95% CI [0.49, 0.87], respectively), while inter‐rater reliability was poor (ICC = 0.16, 95% CI [−0.85, 0.47]). Concurrent validity comparing manual and automated measures for thumb pressure was also poor (ICC −0.05, 95% CI [−1.06, 0.72] and ICC 0.42, 95% CI [−0.16, 0.72] Rater 1 and 2 respectively). Thumb measures were significantly more comfortable than brachial measures (5 mm, p < 0.00). Conclusion: Thumb systolic pressures are correlated with brachial systolic pressures, with reasonable intra‐rater reliability, however, correlation is only fair and measurement error wider than clinically acceptable. Furthermore, manual measures are poorly correlated with automated units. Consequently, caution is required in applying these techniques. As thumb measures were perceived as significantly more comfortable than brachial measures and have an advantage where brachial pressures cannot, or should not, be obtained, further evaluation is warranted. [ABSTRACT FROM AUTHOR]

Background and Objectives: The interrelationship between thyroid function and the state of the cardiovascular system has been investigated both in preclinical and human studies. However, it remains unclear whether there is any association between thyroid hormones and features of subclinical cardiovascular dysfunction in euthyroid patients. Material and Methods: This study involved 45 people (females: 57.8%) with no thyroid disease who, during planned hospitalization, underwent thyroid ultrasound, determination of biochemical parameters of thyroid function, and measurement of ankle-brachial index (ABI) and toe-brachial index (TBI). People with signs of acute illness or a deterioration of their health were excluded. Results: Significant correlations were found between free triiodothyronine (FT3) and several parameters of both ABI (R = 0.347; p = 0.019 for the mean ABI taken from right side and left side values) and TBI (R = 0.396; p = 0.007 for the mean TBI taken from right side and left side values), as well as the maximal toe pressure (TP) taken from right side and left side values (R = 0.304; p = 0.045). Thyrotropin (TSH) was shown to be significantly correlated only with the maximal TBI value (taken from right side and left side values) (R = 0.318; p = 0.033), whereas free thyroxin (FT4) was shown to be significantly correlated only with the minimal TBI value (taken from right side and left side values) (R = 0.381; p = 0.01). Thyroid volume (TV) was shown to be correlated with TP (R = 0.4; p = 0.008 for the mean TP taken from right side and left side values) and some parameters of TBI value (R = 0.332; p = 0.028 for the mean TBI taken from right side and left side values), but no significant correlations were found between TVand ABI parameters. Patients with a mean ABI value ≤ 1.0 or a mean TBI value ≤ 0.75 have lower TSH, FT3, FT4, and TV than the rest of the study population, but the difference was statistically significant only for FT3. Conclusions: Even in a population of euthyroid patients with no diagnosed thyroid disease, there are some significant correlations between the volume and function of the thyroid gland and the selected features of subclinical cardiovascular dysfunction such as ABI and TBI. [ABSTRACT FROM AUTHOR]

Background Although ankle‐brachial index (ABI) and photoplethysmography (PPG) have also shown adequate sensitivity in detecting peripheral arterial disease, their diagnostic performance is less reliable in asymptomatic cases or those with high atherosclerotic cardiovascular risks. Methods and Results We evaluated 130 participants using ABI, PPG, and duplex ultrasonography, diagnosing 65 with peripheral arterial disease. From the PPG, we derived 2 parameters: PPG amplitude ratio of the lower‐to‐upper extremities (PPGratio) and the PPG amplitude of the lower extremity (PPGamp). Sensitivity, specificity, accuracy, and the area under receiver operating characteristic (ROC) curve were calculated for PPG parameters and ABI, and their combination of both methods. Univariate and multivariate logistic regression assessed the prognostic potential of these parameters. ROC analysis revealed optimal cutoff values in diagnosing peripheral arterial disease were 0.417 for PPGratio and “58” for PPGamp. Both PPGratio and PPGamp demonstrated significantly higher sensitivities, 78.4% and 75.7%, respectively, compared with 55.9% for ABI

Multilayer compression bandaging (MLB) remains the primary treatment in lymphedema in association with manual lymphatic drainage. However, MLB can be contraindicated in patients with advanced lower extremity artery disease (LEAD). Presently, the prevalence of LEAD in lymphedema patients remains unknown. The goals of this study included i) to estimate the prevalence of LEAD, defined by toe-brachial index (TBI) less than 0.7, and ii) to measure the evolution of TBI after 30 min of MLB. A cross-sectional study was performed during a 3-month period on patients presenting with lower extremity lymphedema. Demographic data, basal TBI (T=0min) and TBI after 30 min of MLB at rest (T=30min) were recorded. Twenty-four patients with a total of 29 lymphedema limbs were included with a mean age of 62 years-old [Inter-quartile range (IQR) = 48 - 68] and 65.5% presenting with primary lymphedema. Non-symptomatic LEAD, defined as TBI < 0.7, was found in 8 lymphedema limbs (27.6%). Advanced age, severe stages, and longer duration of lymphedema were associated with LEAD in univariate analysis. Median TBI increased significantly between T=0min and T=30min of MLB: 0.81 [IQR: 0.68 - 0.93] and 0.96 [IQR: 0.82 - 1.12] respectively (p= 0.004). Distal localization of lymphedema was associated with a decrease in TBI at T=30min in univariate analysis. Subclinical LEAD was found in over a quarter of lymphedema limbs and was more frequent in patients with advanced age, severe stages, and longer duration of lymphedema. Based on these findings, subclinical peripheral artery disease may be widely underestimated in lymphatic pathologies. [ABSTRACT FROM AUTHOR]

Background and Objectives: The interrelationship between thyroid function and the state of the cardiovascular system has been investigated both in preclinical and human studies. However, it remains unclear whether there is any association between thyroid hormones and features of subclinical cardiovascular dysfunction in euthyroid patients. Material and Methods: This study involved 45 people (females: 57.8%) with no thyroid disease who, during planned hospitalization, underwent thyroid ultrasound, determination of biochemical parameters of thyroid function, and measurement of ankle-brachial index (ABI) and toe-brachial index (TBI). People with signs of acute illness or a deterioration of their health were excluded. Results: Significant correlations were found between free triiodothyronine (FT3) and several parameters of both ABI (R = 0.347; p = 0.019 for the mean ABI taken from right side and left side values) and TBI (R = 0.396; p = 0.007 for the mean TBI taken from right side and left side values), as well as the maximal toe pressure (TP) taken from right side and left side values (R = 0.304; p = 0.045). Thyrotropin (TSH) was shown to be significantly correlated only with the maximal TBI value (taken from right side and left side values) (R = 0.318; p = 0.033), whereas free thyroxin (FT4) was shown to be significantly correlated only with the minimal TBI value (taken from right side and left side values) (R = 0.381; p = 0.01). Thyroid volume (TV) was shown to be correlated with TP (R = 0.4; p = 0.008 for the mean TP taken from right side and left side values) and some parameters of TBI value (R = 0.332; p = 0.028 for the mean TBI taken from right side and left side values), but no significant correlations were found between TVand ABI parameters. Patients with a mean ABI value ≤ 1.0 or a mean TBI value ≤ 0.75 have lower TSH, FT3, FT4, and TV than the rest of the study population, but the difference was statistically significant only for FT3. Conclusions: Even in a population of euthyroid patients with no diagnosed thyroid disease, there are some significant correlations between the volume and function of the thyroid gland and the selected features of subclinical cardiovascular dysfunction such as ABI and TBI.

The purpose of the study was to characterize lower extremity peripheral arterial disease (LEPAD) in a series of kidney transplant patients and to assess the impact on adverse outcomes. A retrospective cohort study was conducted including kidney transplant recipient patients who underwent screening for LEPAD. The outcomes evaluated were classified as perioperative and post-transplant, including cardiovascular events, amputation, mortality, and loss of the graft. A total of 141 renal transplant patients screened for LEPAD were identified, with an average follow-up of 3 years. LEPAD occurred in 14.2% (20/141). No differences in cardiovascular risk factors were found between the groups, except for smoking (45% vs. 24%, p < 0.05). In the group with LEPAD, the most compromised anatomical segment was the infrapopliteus, with no iliac involvement found. The Cox proportional hazards model indicated that the variables age, gender, and weight were significant in patients with LEPAD. There were no differences between the groups in terms of graft loss and death. The infrapopliteal segment is the area of greatest stenosis in kidney transplant patients with LEPAD. Together with smoking, they can explain the presence of major amputations in kidney transplant patients; however, they had no impact on graft functionality or death.

Toe–brachial index (TBI) measurement helps to detect peripheral artery disease (PAD) in patients with incompressible ankle arteries due to medial arterial calcification, which is most frequently associated with diabetes. We aimed to evaluate how an automated four-limb blood pressure monitor equipped with TBI measurement could contribute to PAD screening. In 117 patients (mean age 63.2 ± 12.8 years), ankle–brachial index (ABI) measurement was performed using the Doppler-method and the MESI mTablet. TBI was obtained via photoplethysmography (MESI mTablet, SysToe) and a laser Doppler fluxmeter (PeriFlux 5000). Lower limb PAD lesions were evaluated based on vascular imaging. A significant correlation was found between Doppler and MESI ankle–brachial index values (r = 0.672), which was stronger in non-diabetic (r = 0.744) than in diabetic (r = 0.562) patients. At an ABI cut-off of 0.9, Doppler (AUC = 0.888) showed a sensitivity/specificity of 67.1%/97.4%, MESI (AUC 0.891) exhibited a sensitivity/specificity of 57.0%/100%; at a cut-off of 1.0, MESI demonstrated a sensitivity/specificity of 74.7%/94.8%. The TBI values measured using the three devices did not differ significantly (p = 0.33). At a TBI cut-off of 0.7, MESI (AUC = 0.909) revealed a sensitivity/specificity of 92.1%/67.5%. Combining MESI ABI and TBI measurements recognised 92.4% of PAD limbs. Using an ABI cut-off level of 1.0 and sequential TBI measurement increases the sensitivity of the device in detecting PAD. The precise interpretation of the obtained results requires some expertise. [ABSTRACT FROM AUTHOR]

The purpose of the study was to characterize lower extremity peripheral arterial disease (LEPAD) in a series of kidney transplant patients and to assess the impact on adverse outcomes. A retrospective cohort study was conducted including kidney transplant recipient patients who underwent screening for LEPAD. The outcomes evaluated were classified as perioperative and post-transplant, including cardiovascular events, amputation, mortality, and loss of the graft. A total of 141 renal transplant patients screened for LEPAD were identified, with an average follow-up of 3 years. LEPAD occurred in 14.2% (20/141). No differences in cardiovascular risk factors were found between the groups, except for smoking (45% vs. 24%, p < 0.05). In the group with LEPAD, the most compromised anatomical segment was the infrapopliteus, with no iliac involvement found. The Cox proportional hazards model indicated that the variables age, gender, and weight were significant in patients with LEPAD. There were no differences between the groups in terms of graft loss and death. The infrapopliteal segment is the area of greatest stenosis in kidney transplant patients with LEPAD. Together with smoking, they can explain the presence of major amputations in kidney transplant patients; however, they had no impact on graft functionality or death. [ABSTRACT FROM AUTHOR]

Abstract Background Patients with schizophrenia have an increased prevalence of risk factors for peripheral artery disease (PAD) and is expected to have an increased prevalence of PAD. PAD can be detected utilizing toe–brachial index (TBI) which screens for vascular pathology proximal to the toes. Methods Using a cross-sectional design, we defined the subpopulations: (1) Patients diagnosed with schizophrenia less than 2 years before inclusion (SCZ

Background: Diabetes, end stage renal disease (ESRD), and peripheral arterial disease (PAD) are associated with a higher risk of diabetes-related lower limb amputation. Timely identification of PAD with toe systolic blood pressure (TSBP) and toe-brachial pressure index (TBPI) is critical in order to implement foot protection strategies to prevent foot complications in people with ESRD. There is limited evidence describing the effect of haemodialysis on TSBP and TBPI. This study aimed to determine the variability of TSBP and TBPI during haemodialysis in people with ESRD, and to determine whether any observed variability differed between people with and without diabetes. Methods: TSBP and TBPI were taken before dialysis (T1), one hour into dialysis (T2) and in the last 15 min of dialysis (T3) during a single dialysis session. Linear mixed effects models were undertaken to determine the variability in TSBP and TBPI across the three time points and to determine whether this variability differed between people with and without diabetes. Results: Thirty participants were recruited, including 17 (57%) with diabetes and 13 (43%) with no diabetes. A significant overall reduction in TSBP was observed across all participants (P < 0.001). There was a significant reduction in TSBP between T1 and T2 (P < 0.001) and between T1 and T3 (P < 0.001). There was no significant overall change in TBPI over time (P = 0.62). There was no significant overall difference in TSBP between people with diabetes and people with no diabetes (mean difference [95% CI]: -9.28 [-40.20, 21.64], P = 0.54). There was no significant overall difference in TBPI between people with diabetes and people with no diabetes (mean difference [95% CI]: -0.01 [-0.17, 03.16], P = 0.91). Conclusion: TSBP and TBPI are an essential part of vascular assessment of the lower limb. TBPI remained stable and TSBP significantly reduced during dialysis. Given the frequency and duration of dialysis, clinicians taking toe pressures to screen for PAD should be aware of this reduction and consider how this may have an impact on wound healing capacity and the development of foot related complications. [ABSTRACT FROM AUTHOR]

Rationale & objectiveA low ankle-brachial index (ABI) is used to diagnose peripheral artery disease (PAD) but may be normal or elevated in patients with medial arterial calcification and stiff vessels, as is common in chronic kidney disease (CKD). The toe-brachial index (TBI) has been recommended because it is not influenced by medial arterial calcification, but alone the TBI does not capture risk associated with medial arterial calcification. We hypothesized that the difference between ABI and TBI (ABI - TBI) would capture both PAD and medial arterial calcification and thus better identify mortality risk from PAD, particularly in those with CKD.Study designProspective cohort study.Setting & participants471 patients with clinical suspicion for PAD referred for vascular testing.ExposuresABI, TBI, and ABI - TBI.OutcomeAll-cause mortality.Analytical approachCox proportional hazards models evaluating the association of ABI - TBI with mortality over 7 years.ResultsMean age was 68 years, 89% were men, 35% had diabetes, 64% had CKD, and mean estimated glomerular filtration rate was 55 mL/min/1.73 m2. Median ABI was 0.96 (interquartile range [IQR], 0.73-1.08), median TBI was 0.62 (IQR, 0.46-0.81), and median ABI - TBI was 0.23 (IQR, 0.14-0.39). Higher ABI - TBI values were associated with increased risk in mortality only among participants with ABI values ≥ 0.9 (P = 0.03). Among participants with CKD and ABI values ≥ 0.9, participants with ABI - TBI values higher than the median had greater (HR, 1.79; 95% CI, 1.18-2.72) risk for mortality (P = 0.005). This was attenuated after age adjustment (HR, 1.41; 95% CI, 0.91-2.20) but did not change after further adjustment for confounders.LimitationsMainly male cohort derived from a vascular laboratory; lack of limb outcomes and data for albuminuria.ConclusionsA high ABI - TBI value may be associated with higher risk for mortality in persons with CKD and a normal ABI. Age affects this association, and further studies evaluating ABI - TBI in larger populations are required.

IntroductionThe ankle-brachial index (ABI) is the most common test to diagnose peripheral artery disease (PAD). In dialysis patients, the ABI may under-diagnose PAD, due to a high prevalence of concomitant medial arterial calcification (MAC). The toe-brachial index (TBI) is not as susceptible to misclassification by MAC. Taking the ABI and TBI together in the form of their difference, the ABI-TBI, may provide a single measure for assessing both atherosclerosis and calcification. The relationship of these variables in dialysis patients has not been well studied.MethodsWe identified 37 dialysis patients referred for vascular studies between 2009 and 2017 in the San Diego Veterans Administration Medical Center (SDVAMC). The ABI and TBI were performed systematically for each patient, and TBI was performed regardless of ABI or waveform. We examined associations between ABI, TBI, and the difference between them (ABI-TBI) with all-cause mortality and major adverse limb events (MALE), which includes revascularizations and amputations.FindingsThe mean age was 65 years and 30% were African American. All patients were men, reflecting the Veterans Administration population. There were 26 deaths during follow-up and mortality was highest in patients who had low ABI and low TBI and least in those with high ABI and high TBI. Persons with TBI < 0.7 had an increased risk of all-cause mortality. The ABI-TBI, and the ABI itself, were not significantly associated with all-cause mortality although the patterns were similar.DiscussionAlthough ABI may be an important initial risk stratification tool, the TBI may be a more informative predictor of mortality in dialysis patients. Strengths of this study include a high rate of MALE and deaths. The TBI, and the difference between ABI and TBI, should be studied further in a larger cohort of persons with advanced kidney disease.

Background: Patients with schizophrenia have an increased prevalence of risk factors for peripheral artery disease (PAD) and is expected to have an increased prevalence of PAD. PAD can be detected utilizing toe–brachial index (TBI) which screens for vascular pathology proximal to the toes. Methods: Using a cross-sectional design, we defined the subpopulations: (1) Patients diagnosed with schizophrenia less than 2 years before inclusion (SCZ < 2), (2) Psychiatric healthy controls matched to subpopulation 1 on sex, age, and smoking status, and (3) Patients diagnosed with schizophrenia 10 or more years before inclusion (SCZ ≥ 10). TBI was calculated by dividing toe pressures by systolic brachial blood pressure, and PAD was defined by TBI < 0.70. Logistic regression analysis with PAD as outcome and sex, age, smoking status, BMI, skin temperature, diagnosis of schizophrenia, and comorbidities as explanatory variables was conducted. Results: PAD was present in 26.2% of patients diagnosed with SCZ < 2 (17 of 65) and in 18.5% of psychiatric healthy controls (12 of 65) with no statistically significant difference in prevalence rates (p = 0.29). PAD was present in 22.0% of patients diagnosed with SCZ ≥ 10 (31 of 141). In logistic regression, patients diagnosed with SCZ < 2 had an increased odds of PAD with psychiatric healthy controls as reference (Odds ratio = 2.80, 95% confidence interval 1.09–7.23, p = 0.03). The analysis was adjusted for age, sex, smoking status, BMI and comorbidities such as hypertension, diabetes and heart disease. Conclusions: This study did not find statistically significant increased prevalence rates of PAD in patients with schizophrenia even though patients with SCZ were compared to psychiatric healthy controls using TBI. Utilizing logistic regression PAD was associated with schizophrenia diagnosis within the last 2 years, age and skin temperature. As PAD is initially asymptomatic, screening could be relevant in patients with schizophrenia if other risk factors are prevalent. Further large-scale multicenter studies are warranted to investigate schizophrenia as a potential risk factor for PAD. Trial registration: Clinicaltrials.gov identifier NCT02885792. [ABSTRACT FROM AUTHOR]

Background: Consecutive patients admitted to angiology department were evaluated. Measurements of ankle-brachial and toe-brachial index as well as peripheral arteriography were performed in all participants to confirm PAD. In tobacco smokers with PAD spirometry was performed to identified patients with COPD. Clinical information was obtained from the patients on the basis of questionnaires. Patients and methods: Consecutive patients admitted to angiology department were evaluated. Measurements of ankle-brachial and toe-brachial index as well as peripheral arteriography were performed in all participants to confirm PAD. In tobacco smokers with PAD spirometry was performed to identified patients with COPD. Clinical information was obtained from the patients on the basis of questionnaires. Results: Eighty-eight out of 300 consecutive patients were included and assessed. COPD was diagnosed in 33 (37.5%) hospitalized smokers with PAD. COPD has not previously been diagnosed in 28 (84.8%) patients who met the criteria of the disease. Conclusions: There was high prevalence of COPD among tobacco smokers hospitalized in the angiology department. Most of them had never had spirometry performed before. The underdiagnosis rate is relatively high; therefore, all patients with PAD who smoke tobacco should have a spirometry performed, as a screening for COPD.

Objective: Two walking tests including the six-minute walk test (6MWT) and the incremental shuttle walk test (ISWT) are widely used to evaluate functional ability in individuals with disease conditions. However, it remains unclear whether these walking tests effectively manifest clinical impairment in individuals with asymptomatic peripheral artery disease (PAD). We aimed (i) to compare the walking performance of individuals with and without asymptomatic PAD using the 6MWT and ISWT, and (ii) to investigate the correlation between ankle-brachial index and toe-brachial index (ABI-TBI) and the walking distance., Methods: A cross-sectional, crossover, matched pairs design was employed in this study. Asymptomatic PAD was diagnosed using ABI-TBI measurements. Seventy-six participants (38 with asymptomatic PAD and 38 without PAD) were randomly ordered to perform the walking tests. During the 6MWT, participants walked along the 30-meter corridor at their self-selected pace for six minutes, and the six-minute walk distance (6MWD) covered was recorded. In the ISWT, participants walked at a 12 prescribed speed level, and the incremental shuttle walk distance (ISWD) covered was recorded., Results: Result revealed no difference in 6MWD between individuals with asymptomatic PAD and without PAD (mean distance: 501.6 m vs 516.8 m, p = 0.24). Asymptomatic PAD individuals exhibited a significantly shorter ISWD than those without PAD (median distance: 270 m vs 340 m, p = 0.003). No participants reported any leg pain symptoms during the 6MWT and ISWT. A statistically significant positive correlation was observed between the right leg TBI and ISWD in all participants (r = 0.23, p = 0.04)., Conclusions: Individuals with asymptomatic PAD demonstrated poorer walking performance than those without PAD when assessed using ISWT but not the 6MWT. Asymptomatic PAD is also associated with diminished walking performance during the ISWT. Thus, ISWT may show the clinical impairment in this population., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: We investigated whether the toe–brachial index (TBI) is associated with stroke prognosis and evaluated this association in patients with normal ankle–brachial index (ABI). Methods: Acute ischemic stroke patients who underwent TBI measurements were enrolled. Poor functional outcome was defined as modified Rankin Scale score ≥3. Major adverse cardiovascular event (MACE) was defined as stroke recurrence, myocardial infarction, or death. Normal ABI was defined as 0.9 ≤ ABI ≤ 1.4. Results: A total of 1,697 patients were enrolled and followed up for a median 39.7 (interquartile range, 25.7–54.6) months. During the period, 305 patients suffered MACE (18.0%), including 171 (10.1%) stroke recurrences. TBI was associated with hypertension, diabetes, atrial fibrillation, aortic plaque score, ABI, and brachial–ankle pulse wave velocity (all p < 0.05). In multivariable logistic regression, TBI was inversely associated with poor functional outcome in all patients [odds ratio (OR) 0.294, 95% confidence interval (CI) 0.114–0.759], even in patients with normal ABI (OR 0.293, 95% CI 0.095–0.906). In multivariable Cox regression, TBI < 0.6 was associated with stroke recurrence [hazard ratio (HR) 1.651, 95% CI 1.135–2.400], all-cause mortality (HR 2.105, 95% CI 1.343–3.298), and MACE (HR 1.838, 95% CI 1.396–2.419) in all patients. TBI < 0.6 was also associated with stroke recurrence (HR 1.681, 95% CI 1.080–2.618), all-cause mortality (HR 2.075, 95% CI 1.180–3.651), and MACE (HR 1.619, 95% CI 1.149–2.281) in patients with normal ABI. Conclusions: Low TBI is independently associated with poor short- and long-term outcomes in acute ischemic stroke patients despite normal ABI. [ABSTRACT FROM AUTHOR]

Introduction: We investigated whether the toe–brachial index (TBI) is associated with stroke prognosis and evaluated this association in patients with normal ankle–brachial index (ABI).Methods: Acute ischemic stroke patients who underwent TBI measurements were enrolled. Poor functional outcome was defined as modified Rankin Scale score ≥3. Major adverse cardiovascular event (MACE) was defined as stroke recurrence, myocardial infarction, or death. Normal ABI was defined as 0.9 ≤ ABI ≤ 1.4.Results: A total of 1,697 patients were enrolled and followed up for a median 39.7 (interquartile range, 25.7–54.6) months. During the period, 305 patients suffered MACE (18.0%), including 171 (10.1%) stroke recurrences. TBI was associated with hypertension, diabetes, atrial fibrillation, aortic plaque score, ABI, and brachial–ankle pulse wave velocity (all p < 0.05). In multivariable logistic regression, TBI was inversely associated with poor functional outcome in all patients [odds ratio (OR) 0.294, 95% confidence interval (CI) 0.114–0.759], even in patients with normal ABI (OR 0.293, 95% CI 0.095–0.906). In multivariable Cox regression, TBI < 0.6 was associated with stroke recurrence [hazard ratio (HR) 1.651, 95% CI 1.135–2.400], all-cause mortality (HR 2.105, 95% CI 1.343–3.298), and MACE (HR 1.838, 95% CI 1.396–2.419) in all patients. TBI < 0.6 was also associated with stroke recurrence (HR 1.681, 95% CI 1.080–2.618), all-cause mortality (HR 2.075, 95% CI 1.180–3.651), and MACE (HR 1.619, 95% CI 1.149–2.281) in patients with normal ABI.Conclusions: Low TBI is independently associated with poor short- and long-term outcomes in acute ischemic stroke patients despite normal ABI.

Objective: Systemic sclerosis (SSc) is a connective tissue disease characterized by microangiopathy. Peripheral arterial disease, increasingly studied during SSc, is responsible for digital ulcers, associated with a high risk of amputation. The aim of our study was to assess the frequency of lower limb arterial impairment in SSc patients by measuring ankle-brachial index (ABI), toe pressure (TP), and toe-brachial index (TBI). Methods: Systemic sclerosis patients were included prospectively during 1 year in Tenon and Saint-Antoine Hospitals, Paris. Clinical and biological data were recorded. For each patient, ABI, TP, and TBI were measured and an arterial duplex ultrasonography was prescribed in case of abnormal results. Results: Eighty-six patients were included (94% women, median age 62 years). Only 24% of them had no lower limb hemodynamic vascular abnormalities; 44% had an isolated microvascular abnormality (normal ABI and TBI<0.75); 31% had at least a macrovascular injury associated or not with microvascular impairment (abnormal ABI) and 12.6% had a TP<50 mmHg. During follow-up, there was a trend towards association of low TBI with more major adverse event (all-cause mortality, non-fatal stroke, non-fatal myocardial infarction, and lower limb ischemic manifestations) than normal TBI. Conclusion: By measuring ABI and TP, we showed that 76% of SSc patients had hemodynamic arterial lower limb abnormalities related to macro- and/or microvascular impairment and that 28% had vascular stiffness. In SSc patients, ABI is not an accurate tool to detect lower limb arterial disease, likely due to underlying micro- and macrovascular changes. Key Points • The presence of lower limb macro-and/or microvascular involvement was detected in 76% of SSc patients. • In SSc patients, ABI is not an accurate tool to detect lower limb arterial disease, likely due to underlying microvascular changes and frequent arterial stiffness. [ABSTRACT FROM AUTHOR]

Background Toe systolic pressures (TSP) are an essential part of a lower limb wound assessment. They assist wound clinicians ascribe aetiology, and predict wound healing capacity, assisting with triage and ongoing care planning. TSP method The toe cuff should be placed around the base of the hallux securely. The photoplethysmography (PPG) probe should be placed on the distal pulp of the hallux so that the probe is flush with the skin surface, affixed with tape. Wait for a strong cyclical signal from the probe to appear on the Doppler screen. Next, inflate the cuff, taking care not to overinflate. Once a flat line with the PPG signal is obtained on the screen, inflate a further 20mmHg. Then, slowly deflate the cuff at a rate of 2-5mmHg per second. The first regular cyclical waveform on the screen is the point at which the pressure in the artery is greater than the pressure in the cuff, and is considered the TSP. Discussion TSP are a valuable measure to include in wound practice. TSP are an important part of wound staging systems, can predict wound healing capacity and help guide ongoing management. [ABSTRACT FROM AUTHOR]

Abstract Background Podiatric vascular assessment practices in the United Kingdom (UK) are currently unknown. This study aimed to describe the current practices for performing lower limb vascular assessments by podiatrists in the UK, and, to investigate the effect of practitioner characteristics, including education level and practice setting, on the choice of tests used for these assessments. Methods A cross-sectional observational online survey of registered podiatrists in the UK was conducted using SurveyMonkey® between 1st of July and 5th of October 2018. Item content related to: practitioner characteristics, vascular testing methods, barriers to completing vascular assessment, interpretation of vascular assessment techniques, education provision and ongoing management and referral pathways. Descriptive statistics were performed, and multinomial logistic regression analyses were used to determine whether practitioner characteristics could predict the choice of vascular tests used. Results Five hundred and eighty five participants accessed the online survey. After drop-outs and exclusions, 307 participants were included in the analyses. Comprehensive vascular assessments had most commonly been performed once (15.8%) or twice (10.4%) in the past week. The most common indicators for performing vascular assessment were symptoms of suspected claudication (89.3%), suspected rest pain (86.0%) and history of diabetes (85.3%). The most common barrier to performing vascular assessment was time constraints (52.4%). Doppler examination (72.3%) was the most frequently reported assessment type, with ankle-brachial index (31.9%) and toe brachial index (5.9%) less frequently performed. There were variable interpretations of vascular test results. The most common topic for education was smoking cessation (69.5%). Most participants (72.2%) were confident in determining ongoing management, with the majority referring to the patient’s general practitioner (67.6%). Practitioner characteristics did not predict the types of vascular tests performed. Conclusion The majority of vascular assessments currently performed by podiatrists in the UK are inconsistent with UK or international vascular guidelines and recommendations. Despite this, most podiatrists felt confident in diagnosing, referring and managing patients with peripheral arterial disease (PAD), however many felt they needed more education to feel confident to assist patients with PAD to manage their cardiovascular risk factors.

Introduction Patients with schizophrenia have a reduced life expectancy compared to the general population, and cardiovascular diseases contribute to this. Peripheral arterial disease (PAD) is associated with excess all-cause mortality and specifically with cardiovascular morbidity and mortality. The risk factors for PAD, such as diabetes, smoking, hypertension, dyslipidaemia and obesity, are more common among patients with schizophrenia which could contribute to a possibly higher prevalence of PAD among patients with schizophrenia. Objectives To investigate PAD utilizing toe brachial index (TBI) in a population of patients diagnosed with schizophrenia with the purpose of establishing prevalence rates amongst newly diagnosed as well as more chronic patients. Methods A cross-sectional study of patients with schizophrenia (ICD10-diagnosis F20 or F25) with a study population of 57 patients diagnosed with schizophrenia within the last 2 years, psychiatric healthy controls matched by age, sex and smoking status and 142 patients with a schizophrenia diagnosis more than 10 years ago. The primary outcome is TBI in patients with schizophrenia stratified to the two subpopulations. The TBI will be calculated from the arm and toe systolic pressures. The toe pressures were measured using photoplethysmography (SysToe®, Atys Medical). Results No results are available yet. The cohort will be described by age, sex, smoking status, body fat percentage and physical comorbidities. The TBI of the two subpopulations will be compared with psychiatrically healthy controls using paired t-tests if data is normally distributed. If transformation is unsuitable, Wilcoxon test will be carried out instead. Conclusions No results are available yet. Results will be presented at the EPA’s congress 2021. Disclosure No significant relationships.

Objectives: The endovascular treatment (EVT) of patients with critical limb ischemia (CLI) has received considerable interest in recent years and has significantly affected the associated amputation and survival rates. Nonetheless, that this management modality may be influenced by various logistical and regional situations prompted us to design a local registry to evaluate its applicability and efficacy in our community.Methods: The IRANCLI study is a prospective, observational study that has been established as a registry. The therapeutic and follow-up protocols of this study have been approved by a multidisciplinary team. Recruited patients with CLI are followed up after in-hospital therapeutic management, endovascular revascularization, or minor amputations or debridement in cases with ulcers. The follow-up consists of active monitoring to spot patients with a recurrence of CLI signs and symptoms at early stages. Within 3 years, eligible patients are recruited to the study and are followed up for 3 years. Analyses are carried out to evaluate outcomes – comprising major adverse limb events (the primary outcome), amputation-free survival, limb salvage, event-free survival, major adverse cardiovascular and cerebrovascular events, 30 days' postprocedural adverse events, and procedural success. The predictors of procedural failure and long-term follow-up adverse events are assessed. Result and Conclusion: The IRANCLI study evaluates postendovascular revascularization outcomes and the long-term follow-up of patients with CLI. Uncovering the predictors of EVT failure and adverse events during the follow-up may improve the prospect of cases with CLI by streamlining the determination of both the patients who would benefit the most from EVT and those who would need a closer active follow-up.

Abstract Background Asymptomatic peripheral artery disease (PAD) increases the risk of mortality in non-hemodialysis patients. However, the association between asymptomatic PAD and mortality rate remains unclear in patients on hemodialysis. Methods This retrospective cohort study aimed to assess the prognostic significance of asymptomatic PAD in a population of 310 hemodialysis patients. Patients with an ankle–brachial index of 1.40 with a toe–brachial index of

Objective: The aim was to assess the prognostic impact of perfusion assessments including ankle–brachial Index (ABI) and toe–brachial Index (TBI) on survival of patients who present with diabetic foot ulceration and to analyse clinical outcomes when patients are categorised into three levels of limb ischaemia. Method: This was a retrospective cohort analysis of consecutive patients presenting with foot ulceration. Patients continued with their standard of care, after having baseline assessments of limb perfusion. Patients were retrospectively categorised into three groups according to baseline ABI and TBI: Group 1 (n=31) non-ischaemic (TBI≥0.75, ABI≥0.9), Group 2 (n=67) isolated low TBI with foot ischaemia (TBI<0.75, ABI≥0.90) and Group 3 (n=30) foot–leg ischaemia (TBI<0.75, ABI<0.90). Results: A total of 128 patients took part in the study. Low TBI was associated with a significant decrease in patient survival (42±20 versus 51±16 months, p=0.011). There was a progressive and significant decline in mean patient survival time (51±16 versus 44±20 versus 39±22 months, respectively, for ANOVA across the three groups, p=0.04). Patients with isolated low TBI had angioplasty and bypass at a rate similar to that of patients in Group 3 (low ABI and low TBI). The proportion of angioplasties was significantly higher in the isolated low TBI (19.4% (13/67) versus the non-ischaemic 3.2% (1/31), p=0.033). Such revascularisation resulted in ulcer healing within the foot ischaemic group that was similar to the non-ischaemic group (68% versus 60% over 12 months, p=0.454). Conclusion: Regardless of ABI level, measurement of TBI identifies patients with isolated low TBI who require specialised care pathways and revascularisation to achieve ulcer healing that is similar to non-ischaemic patients. [ABSTRACT FROM AUTHOR]

Arterial investigations are an essential part of lower extremity wound assessment. The results of these investigations assist the wound clinician to determine the etiology of the wound, predict healing capacity, and inform further management. There are a number of noninvasive testing methods available to practitioners, all with varying levels of reliability and accuracy. Clinical wound assessment guidelines give varied recommendations when it comes to lower limb vascular assessment in the presence of a wound. This leaves clinicians with little guidance on how to choose the most appropriate test, and uncertainty remains about which tests provide the most accurate information in different patient-specific contexts. Conditions such as advanced age, diabetes, and renal disease are known to affect the accuracy of some commonly used lower limb arterial assessment methods, and alternate testing methods should be considered in these cases. This seminal review discusses the reliability and accuracy of lower limb vascular assessment methods used to guide lower limb arterial assessment in the presence of wounds. [ABSTRACT FROM AUTHOR]

Purpose: To present the 6-month results of the Stromal Cell-Derived Factor-1 Plasmid Treatment for Patients with Peripheral Artery Disease (STOP-PAD) trial. The trial was an attempt to alter the course of chronic limb-threatening ischemia (CLTI) with a biological agent vs placebo after successful arterial revascularization at or below the knee. Materials and Methods: The multicenter, randomized, double-blinded, placebo-controlled, phase 2B STOP-PAD trial (ClinicalTrials.gov identifier NCT02544204) randomized 109 patients (mean age 71 years; 68 men) with Rutherford category 5 or 6 CLTI and evidence of persistent impaired forefoot perfusion following recent successful revascularization to 8- (n=34) or 16-mg (n=36) intramuscular injections of a non-viral DNA plasmid-based treatment vs placebo (n=34). The primary efficacy outcome was the 6-month wound healing score evaluated by an independent wound core laboratory; the primary safety endpoint was major adverse limb events (MALE), a composite of major amputation plus clinically-driven target lesion revascularization at 6 months. Results: Only one-third of the patients had complete wound healing at 6 months in the placebo (31%), 8-mg injection (33%), and 16-mg injection (33%) groups. In addition, the observed increase in the toe-brachial index from baseline to 6 months was statistically significant in each group; however, this did not result in lower rates of MALE at 6 months (24% in the placebo, 29% in the 8-mg injection, and 11% in the 16-mg injection groups). During the 6-month period, 6 patients (6%) died, and 24 patients (23%) had an amputation [only 4 (4%) major]. Conclusion: Combining revascularization and biological therapy failed to improve outcomes in CLTI at 6 months. STOP-PAD has provided insights for future trials to evaluate biological therapy. [ABSTRACT FROM AUTHOR]

The ankle-brachial index (ABI) may underestimate the severity of peripheral arterial disease (PAD) in patients with noncompressible vessels. This study analyzed limitations of the ABI and toe-brachial index (TBI), if done alone, in patients with symptomatic PAD, diagnosed by duplex ultrasound (DUS) examination, particularly in patients with diabetes and chronic kidney disease (CKD). This is a retrospective review of prospectively collected data. All patients underwent resting ABIs, TBI, and/or DUS. An ABIs of 0.90 or less in either leg was considered abnormal, and the term inconclusive ABIs (noncompressibility) was used if the ABI was 1.3 or greater. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy (OA) of ABIs in detecting 50% or greater stenosis of any arterial segment based on DUS were determined. A TBI of less than 0.7 was considered abnormal. We included 2226 ABIs and 1383 DUS examinations: 46% of patients had diabetes, 16% had CKD, and 39% had coronary artery disease. Fifty-three percent of the ABIs were normal, 34% were abnormal, and 13% were inconclusive. For patients with limb-threatening ischemia, 40% had normal ABIs, 40% abnormal ABIs, and 20% were inconclusive. The sensitivity and OA for ABIs in detecting 50% or greater stenosis in the whole series were 57% (95% confidence interval [CI], 53.7-61.2) and 74% (95% CI, 71.9-76.6); for diabetics 51% (95% CI, 46.1-56.3) and 66% (95% CI, 62.3-69.8); nondiabetics 66% (95% CI, 59.9-70.9) and 81% (95% CI, 78.2-83.9). For patients with CKD, the sensitivity and OA for ABIs in detecting 50% or greater stenosis was 43% (95% CI, 34.3-52.7) and 67% (95% CI, 60.2-73.0) versus patients with no CKD 60% (95% CI, 56.3-64.6) and 76% (95% CI, 73.1-78.1). If patients with inconclusive ABIs were excluded, these values were 69% (95% CI, 65.2-72.9) and 80% (95% CI, 77.2-81.9) in the whole series; 67% (95% CI, 61.6-72.7) and 75% (95% CI, 70.5-78.4) for diabetics; and 63% (95% CI, 51.3-73.0) and 78% (95% CI, 70.6-83.9) for patients with CKD. Thirty-three percent of TBIs were normal and 67% were abnormal. The sensitivity and OA for abnormal TBI in detecting 50% or greater stenosis were 85% (95% CI, 78.9-90.0) and 75% (95% CI, 70.1-80.2) in the whole series; 84% (95% CI, 76.0-90.3) and 74% (95% CI, 67.1-80.2) for diabetics; and 77% (95% CI, 61.4-88.2) and 72% (95% CI, 59.9-82.3) for patients with CKD. For those with inconclusive ABIs, these values for TBI were 75% and 69%. Of symptomatic patients with PAD with 50% or greater stenosis on DUS examination, 43% had normal/inconclusive resting ABIs (49% in diabetics and 57% in CKD). TBI may help in patients with inconclusive ABIs. These patients should undergo further imaging to determine proper treatment. [ABSTRACT FROM AUTHOR]

Introduction: Intermittent claudication includes a wide spectrum of peripheral artery disease ranging from asymptomatic with reduced perfusion to lifestyle-limiting atherosclerotic disease. The purpose of this study was to evaluate the management of claudicants with a low toe-brachial index (TBI)., Methods: This study was a retrospective review of consecutive patients that presented in 2015 with claudication and a low TBI (<0.6) monitored over 5 years. The patient demographics, co-morbidities, and vascular-related characteristics (ankle-brachial index, TBI, calcified vessels, and wounds) were collected. The patients were separated into two cohorts: diabetics and non-diabetics. The outcomes included progression to chronic limb threatening ischemia (CLTI), interventions (endovascular or open), minor amputations, major amputations, and mortality., Results: A total of 184 patients with 356 limbs were identified as claudicants with a low TBI, and there were 103 diabetics with 81 non-diabetics. The ABI and TBI were similar between the diabetics and non-diabetics, but the diabetics had a significantly higher number of calcified vessels ( p < .001) and progression to CLTI ( p < .001). The time to revascularization and number of patients that had a revascularization procedure were similar between the two groups, and nearly half of the revascularization procedures were performed within the first 6 months. The major amputation rate trended higher in the diabetic population, and there was a statistically significantly higher rate of minor amputations in the diabetics over the 5 years (Log-rank, p < .001). There was no difference in 5-year survival between diabetics and non-diabetics, and the overall 5-year mortality was 34%., Conclusion: Patients presenting with claudication and low TBI, especially with diabetes, are at a higher risk to develop chronic limb threatening ischemia. Claudicants with a low TBI should have closer follow-up and more aggressive risk factor modification to reduce long-term mortality., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Based on our previous reports, ipsilateral systolic toe pressure (STP) and toe-brachial index (TBI) have a strong association with midterm cardiovascular and overall mortality as well as with amputation-free survival in patients with symptomatic lower extremity peripheral artery disease (PAD). The effect of the often overlooked contralateral lower limb on patient outcome remains unknown. This study aimed to resolve the significance of contralateral STP (CL_STP) and contralateral TBI for long-term overall and cardiovascular mortality. This is a retrospective cohort study of 727 consecutive patients with symptomatic lower extremity PAD. All patients admitted to the Department of Vascular Surgery at Turku University Hospital for digital subtraction angiography between January 2009 and August 2011 and for whom STP measurements were available were recruited and observed for up to 7 years. Dates and causes of death were collected from the national cause of death registry of Statistics Finland. In the study cohort, STP was <30 mm Hg in 67 contralateral limbs and 227 ipsilateral limbs. CL_STP <30 mm Hg resulted in a 60-month estimated freedom from cardiovascular death and overall survival of 39% (standard deviation [SD], 0.57) and 25% (SD, 0.41), respectively, and contralateral TBI <0.25, of 45% (SD, 0.54) and 36% (SD, 0.54), respectively. Cumulative freedom from cardiovascular death and overall survival at 60 months for patients with ipsilateral STP <30 mm Hg varied by CL_STP as follows: CL_STP <30 mm Hg: 41% (SD, 0.58) and 25% (SD, 0.43); CL_STP of 30 to 49 mm Hg: 56% (SD, 0.49) and 44% (SD, 0.49); STP ≥50 mm Hg: 62% (SD, 0.52) and 47% (SD, 0.52), respectively. In Cox regression analysis, low STP or TBI of either extremity was associated with significant (P <.001) risk of death for cardiovascular or any reason. Low STP and TBI of both contralateral and ipsilateral lower extremities are associated with high cardiovascular and overall mortality in symptomatic PAD patients. Bilaterally low STP and TBI are associated with a particularly poor prognosis. [ABSTRACT FROM AUTHOR]

Purpose: To find a relationship of diabetic retinopathy with ankle-brachial (ABI) in patients of type 2 diabetes. Study Design: It was a cross-sectional observational study. Place and Duration of Study: Arif Memorial Teaching hospital and Rashid Latif Medical College from January 2019 to June 2019. Material and Methods: 120 patients were selected by purposive convenient sampling from outpatient department of Arif Memorial Teaching hospital. After clinical history, complete ocular examination was performed. Random blood glucose levels were measured using Glucometer. Ankle-brachial index was calculated by dividing the systolic pressure at ankle by the systolic blood pressure at arm. Statistical analysis was done using SPSS 25. Independent sample t test and chi square tests were used to find out the significance of the results. Results: In this study of 120 diabetic patients, 80 (66.7%) were female and 40 (33.3%) were males. Mean Ankle Branchial Index (ABI) of Males was 0.96 ± 0.11 and for females was 0.97 ± 0.14. Among 120 participants of this study, 73 (60.83%) patients had no signs of diabetic retinopathy, 35 (29.16%) patients had NPDR and 12 (10%) patients had PDR. ABI was not associated with gender and duration of diabetes. However, there was negative and weak linear relationship between BSR and ABI (r = -0.221). This correlation was higher in diabetics of less than 5 year duration (r = -0.286) than in patients of more than 5 years duration of diabetes (r = -0.129). Conclusion: Our study indicates that ABI is not significantly related with diabetic retinopathy. However, there is a weak linear relationship of ABI with high blood sugar levels. [ABSTRACT FROM AUTHOR]

Objective: Renal podocalyxin is a marker for kidney diseases. Previous studies have shown the expression of serum podocalyxin (s-Podxl) in the endothelial cells of blood vessels. We aimed to investigate the association between s-podxl levels and peripheral arterial disease (PAD) in subjects with type 2 diabetes (T2DM).Subjects and Methods: Serum Podxl levels were analyzed in 69 subjects with normal glucose tolerance and PAD (NGT-PAD), 120 subjects with T2DM and PAD (D-PAD) and 36 subjects with T2DM without PAD (D-NPAD).Results: In D-PAD Patients, s-Podxl was significantly higher (17.67 ± 20.7 ng/mL) than in D-NPAD subjects (9.97 ± 5.34 ng/mL; P < 0.001). Subjects with NGT-PAD had significantly higher s-Podxl levels (15.34 ± 18.21 ng/mL), than D-NPAD patients (P < 0.001). Subjects with D-PAD and medial calcific sclerosis (MCS) had significantly higher s-Podxl levels compared to the same group but without MCS (P < 0.02). In D-PAD patients, MCS (P = 0.003) and glycosylated hemoglobin (P < 0.001) were the two variables that had the strongest prediction for s-Podxl as revealed by regression analysis. Multivariate regression showed that an increase of one standard deviation in s-Podxl was associated with an odds ratio of 3.4 (95% confidence interval = 2.2-4.6, P < 0.001) for the prevalence of PAD.Conclusions: This is the first study showing an association between s-Podxl and PAD in patients with T2DM. S-Podxl was higher in D-PAD patients than in D-NPAD subjects. In NGT-PAD patients, s-Podxl was also higher than in D-NPAD patients. In patients with D-PAD, s-Podxl was positively associated with MCS. [ABSTRACT FROM AUTHOR]

Aim To investigate the association of ankle-brachial index (ABI) and toe-brachial index (TBI) with metabolic parameters and the risk factors causing a divergence between ABI and TBI in patients with diabetes. Methods Outpatients who were simultaneously examined for both ABI and TBI were included. Multiple regression analysis was performed to assess the association of ABI and TBI with metabolic parameters. Furthermore, logistic regression analysis was performed to detect the risk factors causing a divergence between ABI and TBI. Results Of the 307 patients that were enrolled, 77 had normal ABI but decreased TBI. ABI was inversely associated with plasma glucose and triglycerides and positively associated with high-density lipoprotein cholesterol. In contrast, TBI was inversely associated with the duration of diabetes, plasma glucose and haemoglobin A1c. Logistic regression analysis showed that smoking history and a history of cardiovascular disease were associated with an increased risk of the divergence between ABI and TBI. Conclusion Our findings suggest that smoking history and a history of cardiovascular disease are important risk factors in patients with diabetes who had normal ABI but decreased TBI. Patients with multiple vascular complications are at a high risk of coexisting peripheral artery disease, even if their ABI is normal. [ABSTRACT FROM AUTHOR]

Abstract Objective To assess the role of ABI and TBI in the detection of ulcer wounds among diabetic patients. Methods A retrospective approach is used to enroll 192 diabetic patients to detect their ulcer wounds using ABI and TBI index. HbA1c and lipid profile were other important variables in determining the efficacy of screening test. Frequency analysis and Pearson Correlation were used to analyze the data through SPSS. Findings The results have shown that 57.1% male and 42.9% female were treated in <0.60 ABI group; 67.4% male and 32.6% female were treated in 0.60–0.90 ABI group; 65.9% male and 34.1% female were treated in 0.90–1.30 ABI group; and 63.8% male and 36.2% female were treated in >1.30 ABI group. The correlation showed insignificant association between ABI and ulcer outcomes, but significant association between TBI and ulcer outcomes at 5% level of significance. Conclusion The study concluded that ABI should be based on standardized normal values to be used as an effective biomarker in screening diabetic foot ulcer patients. [ABSTRACT FROM AUTHOR]

Aims: We investigated associations of carotid intima-media thickness (CIMT) and carotid plaque with ankle-brachial index (ABI) and toe-brachial index (TBI) in Chinese adults.Methods: A cross-sectional analysis was performed in 6688 participants from a well-defined Chinese community. CIMT and carotid plaque was measured with a high-resolution B-mode tomographic ultrasound system. Low ABI was defined as ABI ≤ 0.90. Low TBI was defined as TBI ≤ 0.60. Carotid plaques were classified as normal, homogeneous or heterogeneous according to morphology.Results: After adjusting for age, sex and body mass index, each 0.10 mm CIMT increase was associated with 0.0123 unit decrease in TBI (P = 0.004) and 0.0063 in ABI (P = 0.04) in patients with diabetes. After further adjustments for waist circumference, smoking and drinking habits, hypertension, lipids and hemoglobin A1c, the associations between CIMT and TBI remained significant; while those with ABI were disappeared. Meanwhile, each 0.10 mm increment of CIMT or rank of carotid plaque morphology was associated with a risk of presence of low TBI (CIMT: odds ratio: 1.21, 95% confidence interval: 1.05-1.40; carotid plaque morphology: 1.45, 1.01-2.08) in patients with diabetes after adjustments. However, no associations were found between CIMT or carotid plaque morphology and TBI or ABI in non-diabetic participants.Conclusions: CIMT and carotid plaque morphology were significantly associated with TBI in patients with diabetes. [ABSTRACT FROM AUTHOR]

Highlights • The toe–brachial index (TBI) has prospective value in screening, prognostic, and monitoring contexts. • In order to be effective in these contexts, the TBI must not be susceptible to large sporadic fluctuations. • Across a 6-month timespan, significant ipsilateral and contralateral changes appear to occur spontaneously in the TBIs of many people who have subnormal TBIs. • Some TBI changes might result from deficiencies in measurement procedures. • Researchers and clinicians should be aware that TBIs can be spontaneously fluctuant, and should also abide by recommended procedures when obtaining TBIs. Abstract Objective To be effective in screening, prognostic, and monitoring contexts, the toe–brachial index (TBI) should not be susceptible to large sporadic fluctuations from one time to another. In order to identify whether those fluctuations exist in people who have suboptimal TBIs, the temporal stability of their TBIs was examined in detail across 6 months. Methods TBI readings from SysToe and Omron automated devices were taken from 21 participants at baseline and at 2- and 6-month timepoints subsequently. The primary inclusion criterion was that participants had at least one of three baseline TBIs on either foot ≤0.65 if a standard 25-mm wide occlusion cuff was used, or ≤0.85 if a 15-mm occlusion cuff was used. Results After excluding five participants because of their extremely high TBI fluctuations, TBI stability within the remaining 16 participants was examined. Ipsilateral TBIs changed by ≥0.10 on at least one foot for 11 participants across the initial 2-month timespan (maximum difference 0.26) and for same number of participants across the full 6-month timespan (maximum difference 0.36), with the composition of the 11-person groups differing slightly for the two timespans. Contralateral differences were ≥0.10 for five participants across the 2-month timespan (maximum difference 0.26) and for nine participants across the 6-month timespan (maximum difference 0.42), again with some group overlap. The foot with the higher TBI at baseline remained so across the 6 months. Conclusions For many people with suboptimal TBIs there might be inherent ipsilateral and contralateral inconsistency among TBI readings. This threatens the effectiveness of TBIs for screening, prognostic, and monitoring purposes. In order to maximize the prospects of the TBI as a valuable metric, adherence to standard protocols should be observed and other prospects for the TBI to assess vascular supply to the foot more effectively should be considered. [ABSTRACT FROM AUTHOR]

Objective: We conducted a prospective pilot study in patients with diabetes to analyse the interobserver reliability of the ankle-brachial index, toe-brachial index and distal pulse palpation depending on the training of the professional involved. Materials and Methods: The ankle-brachial index, toe-brachial index and distal pulses were assessed by three clinicians with different levels of experience on the same day. Measurements were supervised and recorded by a fourth clinician. Results: Twenty-one patients (42 ft) were included in this study. We observed moderate agreement between clinicians in the palpation of posterior tibial arteries (K = 0.45, p < 0.001) and low agreement in dorsalis pedis arteries (K = 0.33, p < 0.001). The measurement of ankle-brachial index had moderate agreement between clinicians in patients with medial arterial calcification (K = 0.43, p < 0.001) and low agreement in patients with normal ankle-brachial index (K = 0.4, p < 0.001). The measurement of toe-brachial index had moderate agreement between clinicians in patients with a normal toe-brachial index (K = 0.4, p < 0.001) and in patients with medial arterial calcification (K = 0.60, p < 0.001). Conclusion: Palpation of distal pulses, ankle-brachial index and toe-brachial index determination in patients with diabetes are not highly reproducible and reliable between clinicians with different levels of experience under routine conditions. [ABSTRACT FROM AUTHOR]

Heel ulcerations are a significant burden of care in both hospital and long-term care settings. The presence of peripheral arterial disease as a contributing factor to delayed healing is often not recognized, resulting in prolonged healing and high patient morbidity and mortality. Formal vascular evaluation and intervention is often not performed as these patients can have palpable pedal pulses while having localized ischemia of the heel. As routine noninvasive vascular studies can be affected by medial calcinosis and collateralization and do not specifically assess tissue perfusion to the heel, a false sense of security of adequate perfusion for healing can result. Indocyanine green fluorescence angiography (ICGFA) allows for real-time visualization and objective assessment of site specific tissue perfusion not limited by the factors that can make routine noninvasive vascular studies unreliable or unobtainable. A retrospective medical record review of a subset of patients with chronic heel ulceration from a prospective institutional review board-approved study in which serial ICGFA was performed during their treatment course was performed. ICGFA was able to identify local heel ischemia and expedite vascular intervention. ICGFA should be considered as an additional vascular study in patients presenting with chronic, nonhealing heel ulcerations.Levels Of Evidence: Level IV: Diagnostic, Case series. [ABSTRACT FROM AUTHOR]

Background and aims We assumed that hand-held Doppler ultrasound (DUS) at rest was insufficient to assess the severity of peripheral artery disease (PAD). Toe pressure and transcutaneous tissue oxygen pressure were studied to prove whether these could identify more patients with severe lower limb ischemia; exercise was applied to provoke ischemia. Methods 120 patients with PAD and 30 volunteers without PAD were recruited. DUS, transcutaneous tissue oxygen pressure (tcpO 2 ) and toe pressure measurements were performed at rest and after exercise. The differential power of these examinations for severe limb ischemia (SLI) was determined by receiver-operating curves (ROCs) and pattern recognition by independent multicategory analysis (PRIMA). Results There was an obvious significant difference between the patient and control groups at rest; after exercise; the ratio of severely impaired values (ankle-brachial index – ABI, toe-brachial index – TBI, tcpO 2 measured on index forefoot) increased significantly in the patient group ( p  < 0.05). TBI, tcpO 2 , ABI measured after exercise could differentiate SLI better than the values of these tests at rest ( p  < 0.001). In ROC analysis, the largest area under the curve (AUC) was covered by post- (AUC: 0.860) and pre-exercise TBI (AUC: 0.785), and post-exercise tcpO 2 (AUC: 0.720) ( p  < 0.001). Post-exercise TBI gained the best discriminant score in PRIMA. Conclusions Pre- and post-exercise non-invasive vascular tests could reveal severe limb ischemia. Toe pressure measurement and TBI should become a basic part of the vascular workup. [ABSTRACT FROM AUTHOR]

Although the ankle-brachial index (ABI) has been used as an indicator of peripheral artery disease and vascular supply to the foot for over 50 years, it is now associated with reservations and qualifying empirical evidence to the extent that the provocative step of abandoning it totally might be advisable. In this article, the results of three publications concerning the ABI are initially described in some depth and the results from eight additional publications are then summarized more briefly. Cumulatively, the research indicates that ABIs that seem to be normal, as well as those in the subnormal range, are often inflated by medial arterial calcification and can therefore produce a high proportion of false-negative screening test results for arterial disease as well as a misleadingly high impression of vascular sufficiency to the lower extremity. The toe-brachial index is suggested as being likely to overcome the problems associated with the ABI, and other alternatives to the ABI and TBI are acknowledged. [ABSTRACT FROM AUTHOR]

Objectives This study sought to determine the relationship between change in ankle-brachial index (ABI) and toe-brachial index (TBI) and outcomes following revascularization of critical limb ischemia (CLI). Background An increase in ABI of 0.15 after revascularization for peripheral artery disease with claudication is considered significant. However, the utility of using change in ABI or TBI to predict outcomes in patients with CLI is unproven. Methods This was an observational study of 218 patients with Rutherford class V or VI CLI that underwent endovascular therapy. Receiver-operating characteristic curve analysis determined cutpoints in post-procedure ABI and TBI, as well as change in these values for endpoints of wound healing, major adverse limb events (MALE), and repeat revascularization. Results After multivariable Cox proportional hazards analysis adjusting for age, diabetes, glomerular filtration rate, smoking, Rutherford class, and baseline ABI or TBI, neither static post-procedure ABI nor post-procedure TBI were associated with wound healing (hazard ratio [HR]: 1.21; 95% confidence interval [CI]: 0.77 to 1.89; p = 0.40; HR: 1.49; 95% CI: 0.98 to 2.27; p = 0.065, respectively). However, change in ABI ≥0.23 was independently associated with wound healing (HR: 1.87; 95% CI: 1.12 to 3.15; p = 0.018) and less repeat revascularization (HR: 0.40; 95% CI: 0.19 to 0.84; p = 0.015), but not MALE. Increase in TBI ≥0.21 was independently associated with wound healing (HR: 1.63; 95% CI: 1.02 to 2.59; p = 0.039), and reduced MALE (HR: 0.27; 95% CI: 0.09 to 0.77; p = 0.014), but not repeat revascularization. Conclusions A change in ABI and TBI from pre-procedural values provides prognostic value in determining which patients may have wound healing and reduced MALE. [ABSTRACT FROM AUTHOR]

Introduction To investigate the diagnostic accuracy of an automated toe blood pressure device for detecting peripheral arterial disease in older people. Methods Ninety participants underwent toe and brachial blood pressure measurements and colour duplex ultrasonography of the right lower limb. Peripheral arterial disease was diagnosed if > 50% arterial obstruction was identified in any lower limb vessel using colour duplex ultrasonography. A receiver operating characteristic curve was analysed and the sensitivity and specificity of commonly used toe brachial index and toe blood pressure values were determined. Results The optimum toe brachial index threshold value for diagnosing peripheral arterial disease was 0.72 (sensitivity 76.2%, specificity 75%). The area under the curve was 0.829 (95% CI 0.743 to 0.915, p < 0.0001) suggesting fair diagnostic accuracy. A toe blood pressure of 70 mmHg was found to have excellent specificity (97.92%) for detecting PAD but poor sensitivity (42.86%). Conclusions The accuracy of automated toe blood pressure and TBI measurements was determined to be good when using colour duplex ultrasound as the reference standard for the non-invasive diagnosis of peripheral arterial disease. Results should be interpreted in the context of all clinical signs and symptoms. [ABSTRACT FROM AUTHOR]

Aims/hypothesis: The study aimed to evaluate toe-brachial index (TBI) and ankle-brachial index (ABI) as determinants of incident cardiovascular disease (CVD) and all-cause mortality in people with type 2 diabetes and microalbuminuria. Methods: This was a prospective study including 200 participants. Unadjusted and adjusted (traditional risk factors and additional inclusion of N-terminal pro-brain natriuretic peptide [NT-proBNP] and coronary artery calcification) Cox regression models were performed. C statistics and relative integrated discrimination improvement (rIDI) evaluated risk prediction improvement. Results: Median follow-up was 6.1 years; 40 CVD events and 26 deaths were recorded. Lower TBI was associated with increased risk of CVD (HR per 1 SD decrease: 1.55 [95% CI 1.38, 1.68]) and all-cause mortality (1.41 [1.22, 1.60]) unadjusted and after adjustment for traditional risk factors (CVD 1.50 [1.27, 1.65] and all-cause mortality 1.37 [1.01, 1.60]). Lower ABI was a determinant of CVD (1.49 [1.32, 1.61]) and all-cause mortality (1.37 [1.09, 1.57]) unadjusted and after adjustment for traditional risk factors (CVD 1.44 [1.23, 1.59] and all-cause mortality 1.39 [1.07, 1.60]). After additional adjustment for NT-proBNP and coronary artery calcification, lower TBI remained a determinant of CVD ( p = 0.023). When TBI was added to traditional risk factors, the AUC increased significantly for CVD, by 0.063 (95% CI 0.012, 0.115) from 0.743 ( p = 0.016), but not for all-cause mortality; adding ABI did not improve the AUC significantly. The rIDI for TBI was 46.7% ( p < 0.001) for CVD and 46.0% ( p = 0.002) for all-cause mortality; for ABI, the rIDI was 51.8% ( p = 0.004) for CVD and 53.6% ( p = 0.031) for all-cause mortality. Conclusions/interpretation: Reduced TBI and ABI were associated with increased risk of CVD and all-cause mortality, independent of traditional risk factors in type 2 diabetes, and improved prognostic accuracy. [ABSTRACT FROM AUTHOR]

Intraclass correlation coefficients (ICCs) are frequently employed in health science research, often to assess intrarater and interrater reliability. In many cases, insufficient details are provided about these ICCs and there seem to be misunderstandings about their selection and how they should be interpreted. This paper is intended primarily to provide a clear, accessible description of ICCs, including how they should be selected, interpreted, and reported. Emphasis is given to areas where researchers seem to encounter the greatest conceptual difficulties and to exhibit the greatest misconceptions. Two extended examples are used to support the points being made. Major additional aims of this paper are to raise the awareness of authors, reviewers, and editors concerning the importance of using appropriate ICCs, and to encourage them to ensure that complete and accurate information about ICCs is reported in journal articles. Failure to do so perpetuates a risk that incorrect decisions might be made about matters that are of crucial importance for people's health. [ABSTRACT FROM AUTHOR]

Aims This study aimed to assess whether transcutaneous oxygen tension (TcPO 2 ) was associated with the presence of microvascular complications in type 2 diabetic (T2D) patients and whether TcPO 2 could act as an independent risk factor for predicting the occurrence of microvascular events in these patients. Methods We recruited 436 patients with T2D. Based on the presence of diabetic kidney disease, diabetic retinopathy, and/or diabetic peripheral neuropathy, the patients were divided into groups with and without microvascular complications. The differences between these 2 groups were examined using the chi-square test and the t test. The influencing factors of diabetic microangiopathy were studied using a logistic regression analysis. Results The results showed that sex, diabetes duration, smoking history, TcPO 2 , and HbA1c were independent risk factors for the occurrence of diabetic microvascular events ( P < 0.05). In particular, the risk of developing microvascular complications was 10.16 times higher in patients with low TcPO 2 than that in those with high TcPO 2 (OR = 10.157, 95% CI: 4.602–22.418). Conclusion This study showed that TcPO 2 was significantly negatively associated with the occurrence of microvascular events in type 2 diabetic patients and that TcPO 2 may be an independent risk factor for predicting the occurrence of microvascular complications in these patients. These results suggest that for type 2 diabetes mellitus with clinically reduced TcPO 2 , we should pay close attention to the occurrence of microvascular complications and engage in early prevention. [ABSTRACT FROM AUTHOR]

Objective To explore lite application of noninvasive arteriosclerosis detection method and color ultrasound in diagnosing early arteriosclerosis among patients with type 2 diabetes. Methods One hundred and twenty patients with type 2 diabetes (diabetes group) and homochro-nous 100 healthy controls! control group) were enrolled in our study Angeial color Doppler ultrasound technique was utilized in detecting the intima-media thickness (IMT) of the common carotid arteries while arteriosclerosis detector was applied in measuring the brachial-ankle pulse wave velocity! baPWV) and toe-brachial index (TBI). Analysis and evaluation of risk factors was made based on the measured data. Results The differences of measured baPWV. TBI ami IMT were all statistically significant between the two groups (P <0.05). Multiple linear regression analysis showed that low (high)-density lipoprotein cholesterol, uric acid and systolic blood pressure were risk factors for abnormal IMT; age, systolic blood pressure and blood sugar were risk factors for abnormal baPWV; age, systolic blood pressure and blood sugar were independent risk factors for abnormal TBI while high-density li]H)prolein eholesterol was a protective factor for TBI. Conclusion The severity of early peripheral arteriosclerosis in patients with type 2 diabetes can be predicted with a combined application of noninvasive arteriosclerosis detection indexes and IMT measured by angeial ultrasound technique. It is fit for clinical promotion and application for its convenience, noninvasiveness and good repeatability. [ABSTRACT FROM AUTHOR]

Aims: It is unclear how well non-invasive lower-limb vascular assessments can identify those at risk of foot complications in people with diabetes. We aimed to investigate the relationship between a history of foot complication (ulceration or amputation) and non-invasive vascular assessments in people with diabetes.Methods: Bilateral ankle-brachial index (ABI), toe brachial index (TBI) and continuous wave Doppler (CWD) were performed in 127 adults with diabetes (97% type 2; age 66.08±11.4years; 55% men; diabetes duration 8.8±7.6years; 28% on insulin therapy; 31% with foot complication history. Correlations were performed between known risk factors for, and documented history of, foot complication. Regression analysis was used to determine the effect of TBI on the likelihood of a prior foot complication.Results: By logistic regression, the likelihood of foot complication history was highest in those with TBI <0.6 (OR=7.74, p=0.001); then longer diabetes duration (OR=1.06, p=0.05). HbA1c did not independently predict history of foot complications (OR=1.10, p=0.356).Conclusions: Likelihood of previous foot complication in this population was ~8 times higher when TBI was <0.6. Such clinical risk profiling was not shown by other non-invasive measures. Prioritizing TBI as a measure of lower-limb vascular disease may be useful to prospectively identify those at risk of diabetic foot complications. [ABSTRACT FROM AUTHOR]

The toe–brachial index (TBI) is used as an adjunct to the ankle–brachial index (ABI) for non-invasive lower limb vascular screening. With increasing evidence suggesting limitations of the ABI for diagnosis of vascular complications, particularly in specific populations including diabetes cohorts, the TBI is being used more widely. The aim of this review was to determine the sensitivity and specificity of the TBI for detecting peripheral artery disease (PAD) in populations at risk of this disease. A database search was conducted to identify current work relating to the sensitivity and specificity of toe–brachial indices up to July 2015. Only studies using valid diagnostic imaging as a reference standard were included. The QUADAS-2 tool was used to critically appraise included articles. Seven studies met the inclusion criteria. Sensitivity of the TBI for PAD was reported in all seven studies and ranged from 45% to 100%; specificity was reported by five studies only and ranged from 16% to 100%. In conclusion, this review suggests that the TBI has variable diagnostic accuracy for the presence of PAD in specific populations at risk of developing the disease. There was a notable lack of large-scale diagnostic accuracy studies determining the diagnostic accuracy of the TBI in detecting PAD in different at-risk cohorts. However, standardised normal values need to be established for the TBI to conclusively determine the diagnostic accuracy of this test. [ABSTRACT FROM AUTHOR]