1. RHEUMATOLOGY BREAKFAST MEETING 17 March 2015

7. William Harvey (1578 -1657) Published Exercitatio Anatomica de Motu Cordis et Sanguinis in Animalibus in 1628 (Anatomical Exercise on the Motion of the Heart and Blood in Animals).

8. CASE 1 Red Blood Cell in a Capillary http://www.allposters.co.uk/-sp/Red-Blood-Cell-in-a-Capillary-SEM-X9000-Posters_i8995133_.htm http://www.allposters.co.uk/-sp/Red-Blood-Cell-in-a-Capillary-SEM-X9000-Posters_i8995133_.htm

9. PRESENTATION IN TIER 2. 24-year-old female. 2-year history of bilateral lower limb pain. Aggravated by 10 mins of brisk walking & relieved by rest. No vascular/neurological symptoms. Onset - after hill walking. Otherwise in good health. No significant PMH/FH/DH. Physical examination unremarkable.

10. CLINICAL IMPRESSION. Possible chronic exertional lower limb pain. PLAN. Refer for orthopaedic review.

11. (Rajasekaran et al, 2012)

12. Pressure studies performed (antero-lateral compartments of both lower legs).

13. Diagnosis of chronic compartment syndrome confirmed. Listed for fasciectomy of the anterior and lateral compartments.

14. Pressure within the compartment increases during exercise. Pain after a specific time, distance or intensity (eases with rest). Associated symptoms: muscle weakness, paraesthesia. Examination may be normal at rest.

15. PATHOPHYSIOLOGY? Increased muscle bulk. Thickened fascia with decreased compartment compliance. Stiff connective tissue (diabetic patients). Reduced microcirculatory capacity. Vascular congestion (resulting from decreased venous return).

16. A NUMBER OF DIFFERENTIAL DIAGNOSES… Medial tibial stress syndrome (‘shin splints’). Tibia or fibula stress # or bone tumour. Tendinopathy. DVT. Lumbar radiculopathy. Peripheral nerve entrapment (peroneal, saphenous, sural). Neurogenic claudication. Vascular claudication. Popliteal artery entrapment.

17. INTRACOMPARTMENTAL PRESSURE (ICP) TESTING. Currently, no validated ICP testing protocol exists (position, depth and angle of needle/catheter insertion, and ankle/knee position). Most commonly cited protocol is the one described by Pedowitz et al (1990)*. *Chronic exertional compartment syndrome is suggested if the patient meets one or more of these criteria.

19. CASE 2 Human blood with red blood cells, T cells (orange) and platelets (green) http://www.nigms.nih.gov/education/life-magnified/Pages/1b4_kunkel-human-blood.aspx http://www.nigms.nih.gov/education/life-magnified/Pages/1b4_kunkel-human-blood.aspx

20. PRESENTATION IN TIER 2. 52-year-old male. C/o 7-year h/o pain in the low back, with bilateral buttock and calf pain. Walking distance: 75-100 yards. Leg symptoms eased by sitting/lumbar spine flexion. Heavy smoker, mixed hyperlipidaemia (simvastatin), peptic ulcer, hiatus hernia.

21. PHYSICAL EXAMINATION FINDINGS. Good ROM in lumbar spine. SLR 60 0 bilaterally and no neurological deficit. All lower extremity joints normal on examination. Lower limb pulses hard to find (at rest). [No blood pressure cuff in clinic].

22. IMPRESSION. ? Lower limb peripheral arterial disease +/- spinal stenosis. PLAN. Discuss with GP. Request MR lumbar spine.

23. Discuss with GP refer for vascular opinion. No evidence of spinal stenosis on MR scan.

24. Referred for non-invasive vascular assessment. GP advised to commence clopidogrel. CT angiogram + cardiopulmonary exercise testing + dobutamine stress echocardiogram.

25. Findings: occluded infra-renal aorta and severe occlusive disease in both the common and external iliac arteries. Listed for aortobifemoral graft. http ://www.vascular.surgery.ucsf.edu/conditions--procedures/aortofemoral-bypass-surgery.aspx

26. Aortobifemoral bypass surgery. Extensive procedure. Accurate assessment of aorta and iliac vessels is essential (CT or MR angiography). ? Cardiologist involvement in pre-operative assessment (most of these patients have coronary artery disease).

27. Statement 1. People who have symptoms of, or who are at risk of developing, peripheral arterial disease (PAD) are offered a clinical assessment and ankle brachial pressure index (ABPI) measurement. Statement 2. People with PAD are offered an assessment for cardiovascular comorbidities and modifiable risk factors. Statement 3. People with intermittent claudication are offered a supervised exercise programme. Statement 4. People with PAD being considered for revascularisation who need further imaging after a duplex ultrasound are offered magnetic resonance angiography (MRA). Statement 5People with intermittent claudication are offered angioplasty only when imaging has confirmed it is appropriate, after advice on the benefits of modifying risk factors has been given and after a supervised exercise programme has not improved symptoms. NICE QUALITY STANDARD 52 (2014)

28. ANKLE BRACHIAL PRESSURE INDEX (ABPI). Accepted as a measure of significant peripheral vascular disease. Systolic pressure at the ankle divided by the systolic pressure at the arm.

29. DIAGNOSTIC CRITERIA FOR PERIPHERAL VASCULAR DISEASE. 0.91–1.3 Normal 0.7–0.9 Mild disease 0.41–0.69 Moderate disease ≤ 0.4Severe disease (critical ischaemia)

30. Limitations of ABPI. ABPI > 1.3 indicates poor compressibility of the arteries and suggests the presence of medial arterial calcification (common in diabetes). High-grade aortoiliac disease can present with normal ABPI at rest due to the presence of a rich collateral network.

31. ‘The evidence supports the theory that low ABPI and the presence of peripheral vascular disease predict cardiovascular morbidity and mortality to a similar level as currently accepted risk factors’. ‘If ABPI was performed by general practitioners and practice nurses it would allow timely recognition, diagnosis and treatment of peripheral vascular disease, and ensure appropriate referral’. Bhasin and Scott (2007)

32. NICE CLINICAL GUIDELINE 147. Lower limb peripheral arterial disease: diagnosis and management (2012): https://www.nice.org.uk/guidance/cg147/resources/guid ance-lower-limb-peripheral-arterial-disease-diagnosis-and- management-pdf https://www.nice.org.uk/guidance/cg147/resources/guid ance-lower-limb-peripheral-arterial-disease-diagnosis-and- management-pdf

34. Bibliography Migliacci, R., et al. (2008). "Ankle–brachial index measured by palpation for the diagnosis of peripheral arterial disease." Family Practice 25 (4): 228-232. Roberts, A. and A. Franklyn-Miller (2012). "The validity of the diagnostic criteria used in chronic exertional compartment syndrome: a systematic review." Scand J Med Sci Sports 22 (5): 585- 595. Rajasekaran, S., et al. (2012). "Exertional Leg Pain in the Athlete." PM&R 4 (12): 985-1000. Bhasin, N. and Scott, D. (2007). “Ankle Brachial Pressure Index: identifying cardiovascular risk and improving diagnostic accuracy.” JRSM 100 : 4-5.