Chapter IV: Treatment of critical limb ischaemia

Recommendations stated in the TASC II guidelines for the treatment of peripheral arterial disease (PAD) regard a heterogeneous group of patients ranging from claudicants to critical limb ischaemia (CLI) patients. However, specific considerations apply to CLI patients. An important problem regarding the majority of currently available literature that reports on revascularisation strategies for PAD is that it does not focus on CLI patients specifically and studies them as a minor part of the complete cohort. Besides the lack of data on CLI patients, studies use a variety of endpoints, and even similar endpoints are often differentially defined. These considerations result in the fact that most recommendations in this guideline are not of the highest recommendation grade. In the present chapter the treatment of CLI is not based on the TASC II classification of atherosclerotic lesions, since definitions of atherosclerotic lesions are changing along the fast development of endovascular techniques, and inter-individual differences in interpretation of the TASC classification are problematic. Therefore we propose a classification merely based on vascular area of the atherosclerotic disease and the lesion length, which is less complex and eases the interpretation. Lesions and their treatment are discussed from the aorta downwards to the infrapopliteal region. For a subset of lesions, surgical revascularisation is still the gold standard, such as in extensive aorto-iliac lesions, lesions of the common femoral artery and long lesions of the superficial femoral artery (>15 cm), especially when an applicable venous conduit is present, because of higher patency and limb salvage rates, even though the risk of complications is sometimes higher than for endovascular strategies. It is however more and more accepted that an endovascular first strategy is adapted in most iliac, superficial femoral, and in some infrapopliteal lesions. The newer endovascular techniques, i.e. drug-eluting stents and balloons, show promising results especially in infrapopliteal lesions. However, most of these results should still be confirmed in large RCTs focusing on CLI patients. At some point when there is no possibility of an endovascular nor a surgical procedure, some alternative non-reconstructive options have been proposed such as lumbar sympathectomy and spinal cord stimulation. But their effectiveness is limited especially when assessing the results on objective criteria. The additional value of cell-based therapies has still to be proven from large RCTs and should therefore still be confined to a research setting. Altogether this chapter summarises the best available evidence for the treatment of CLI, which is, from multiple perspectives, completely different from claudication. The latter also stresses the importance of well-designed RCTs focusing on CLI patients reporting standardised endpoints, both clinical as well as procedural.

Early detection of subclinical organ dysfunction by microdialysis of the rectus abdominis muscle in a porcine model of critical intra-abdominal hypertension

The aim of this study was to evaluate microdialysis of the rectus abdominis muscle (RAM) for early detection of subclinical organ dysfunction in a porcine model of critical intra-abdominal hypertension (IAH). Microdialysis catheters for analyses of lactate, pyruvate, and glycerol levels were placed in cervical muscles (control), gastric and jejunal wall, liver, kidney, and RAM of 30 anesthetized mechanically ventilated pigs. Catheters for venous lactate and interleukin 6 samples were placed in the jugular, portal, and femoral vein. Intra-abdominal pressure (IAP) was increased to 20 mmHg (IAH20 group, n = 10) and 30 mmHg (IAH30, n = 10) for 6 h by controlled CO2 insufflation, whereas sham animals (n = 10) exhibited a physiological IAP. In contrast to 20 mmHg, an IAH of 30 mmHg induced pathophysiological alterations consistent with an abdominal compartment syndrome. Microdialysis showed significant increase in the lactate/pyruvate ratio in the RAM of the IAH20 group after 6 h. In the IAH30 group, the strongest increase in lactate/pyruvate ratio was detected in the RAM and less pronounced in the liver and gastric wall. Glycerol increased in the RAM only. After 6 h, there was a significant increase in venous interleukin 6 of the IAH30 group compared with baseline. Venous lactate was increased compared with baseline and shams in the femoral vein of the IAH30 group only. Intra-abdominal pressure-induced ischemic metabolic changes are detected more rapidly and pronounced by microdialysis of the RAM when compared with intra-abdominal organs. Thus, the RAM represents an important and easily accessible site for the early detection of subclinical organ dysfunction during critical IAH.

Efficient team actions: Outline of a theory of teams in sport

So far, social psychology in sport has preliminary focused on team cohesion, and many studies and meta analyses tried to demonstrate a relation between cohesiveness of a team and it's performance. How a team really co-operates and how the individual actions are integrated towards a team action is a question that has received relatively little attention in research. This may, at least in part, be due to a lack of a theoretical framework for collective actions, a dearth that has only recently begun to challenge sport psychologists. In this presentation a framework for a comprehensive theory of teams in sport is outlined and its potential to integrate the following presentations is put up for discussion. Based on a model developed by von Cranach, Ochsenbein and Valach (1986), teams are information processing organisms, and team actions need to be investigated on two levels: the individual team member and the group as an entity. Elements to be considered are the task, the social structure, the information processing structure and the execution structure. Obviously, different task require different social structures, communication and co-ordination. From a cognitivist point of view, internal representations (or mental models) guide the behaviour mainly in situations requiring quick reactions and adaptations, were deliberate or contingency planning are difficult. In sport teams, the collective representation contains the elements of the team situation, that is team task and team members, and of the team processes, that is communication and co-operation. Different meta-perspectives may be distinguished and bear a potential to explain the actions of efficient teams. Cranach, M. von, Ochsenbein, G., & Valach, L. (1986).The group as a self-active system: Outline of a theory of group action. European Journal of Social Psychology, 16, 193-229.

Voter Participation in the 1998 Bundestag Elections: A Theoretical Modification and Empirical Application of Downs’ Theory of Voter Participation

This article seeks to contribute to the illumination of the so-called 'paradox of voting' using the German Bundestag elections of 1998 as an empirical case. Downs' model of voter participation will be extended to include elements of the theory of subjective expected utility (SEU). This will allow a theoretical and empirical exploration of the crucial mechanisms of individual voters' decisions to participate, or abstain from voting, in the German general election of 1998. It will be argued that the infinitely low probability of an individual citizen's vote to decide the election outcome will not necessarily reduce the probability of electoral participation. The empirical analysis is largely based on data from the ALLBUS 1998. It confirms the predictions derived from SEU theory. The voters' expected benefits and their subjective expectation to be able to influence government policy by voting are the crucial mechanisms to explain participation. By contrast, the explanatory contribution of perceived information and opportunity costs is low.

IN.PACT Amphirion paclitaxel eluting balloon versus standard percutaneous transluminal angioplasty for infrapopliteal revascularization of critical limb ischemia: rationale and protocol for an ongoing randomized controlled trial

BACKGROUND The effectiveness and durability of endovascular revascularization therapies for chronic critical limb ischemia (CLI) are challenged by the extensive burden of infrapopliteal arterial disease and lesion-related characteristics (e.g., severe calcification, chronic total occlusions), which frequently result in poor clinical outcomes. While infrapopliteal vessel patency directly affects pain relief and wound healing, sustained patency and extravascular care both contribute to the ultimate "patient-centric" outcomes of functional limb preservation, mobility and quality of life (QoL). METHODS/DESIGN IN.PACT DEEP is a 2:1 randomized controlled trial designed to assess the efficacy and safety of infrapopliteal arterial revascularization between the IN.PACT Amphirion™ paclitaxel drug-eluting balloon (IA-DEB) and standard balloon angioplasty (PTA) in patients with Rutherford Class 4-5-6 CLI. DISCUSSION This multicenter trial has enrolled 358 patients at 13 European centers with independent angiographic core lab adjudication of the primary efficacy endpoint of target lesion late luminal loss (LLL) and clinically driven target lesion revascularization (TLR) in major amputation-free surviving patients through 12-months. An independent wound core lab will evaluate all ischemic wounds to assess the extent of healing and time to healing at 1, 6, and 12 months. A QoL questionnaire including a pain scale will assess changes from baseline scores through 12 months. A Clinical Events Committee and Data Safety Monitoring Board will adjudicate the composite primary safety endpoints of all-cause death, major amputation, and clinically driven TLR at 6 months and other trial endpoints and supervise patient safety throughout the study. All patients will be followed for 5 years. A literature review is presented of the current status of endovascular treatment of CLI with drug-eluting balloon and standard PTA. The rationale and design of the IN.PACT DEEP Trial are discussed. IN.PACT DEEP is a milestone, prospective, randomized, robust, independent core lab-adjudicated CLI trial that will evaluate the role of a new infrapopliteal revascularization technology, the IA-DEB, compared to PTA. It will assess the overall impact on infrapopliteal artery patency, limb salvage, wound healing, pain control, QoL, and patient mobility. The 1-year results of the adjudicated co-primary and secondary endpoints will be available in 2014. TRIAL REGISTRATION NCT00941733

Outline of a theory of efficient teams in Sport.

Introduction So far, social psychology in sport has preliminary focused on team cohesion, and many studies and meta-analyses tried to demonstrate a relation between cohesiveness of a team and its performance. How a team really co-operates and how the individual actions are integrated towards a team action is a question that has received relatively little attention in research. This may, at least in part, be due to a lack of a theoretical framework for collective actions, a dearth that has only recently begun to challenge sport psychologists. Objectives In this presentation a framework for a comprehensive theory of teams in sport is outlined and its potential to integrate research in the domain of team performance and, more specifically, the following presentations, is put up for discussion. Method Based on a model developed by von Cranach, Ochsenbein and Valach (1986), teams are considered to be information processing organisms, and team actions need to be investigated on two levels: the individual team member and the group as an entity. Elements to be considered are the task, the social structure, the information processing structure and the execution structure. Obviously, different task require different social structures, communication processes and co-ordination of individual movements. Especially in rapid interactive sports planning and execution of movements based on feedback loops are not possible. Deliberate planning may be a solution mainly for offensive actions, whereas defensive actions have to adjust to the opponent team's actions. Consequently, mental representations must be developed to allow a feed-forward regulation of team member's actions. Results and Conclusions Some preliminary findings based on this conceptual framework as well as further consequences for empirical investigations will be presented. References Cranach, M.v., Ochsenbein, G. & Valach, L. (1986). The group as a self-active system: Outline of a theory of group action. European Journal of Social Psychology, 16, 193-229.

Perception of critical situations involving football fans: dynamics of conflict escalation and de-escalation

Title: The perception of critical situations involving football fans – how conflicts escalate or de-escalate Authors: Brechbühl, A.1, Schumacher, A.1 & Seiler, R.1 1Institute of Sport Science, University of Bern, Switzerland Abstract: Introduction: Fan violence in the context of football matches is a prominent issue in today’s western societies and Switzerland presents no exception. A lot of research has been conducted on reasons for fan violence, mostly with fans of national teams. A prominent model is the Elaborated Social Identity Model (ESIM; Drury & Reicher, 2000): ESIM highlights the importance of interactions between the involved groups and their effect on the development of social identities. Another model is the aggravation mitigation model (AM model; Hylander & Guvå, 2010) which illustrates factors that can contribute towards an escalation or non-escalation of group violence, such as the “categorization” of the opponent group. Despite these models, research about the individual perceptions, and in particular, what factors distinguish between an escalation versus a non-escalation of a potentially violent situation in domestic football, is as yet scarce. This explorative study examines perceptions of critical situations in the domestic football fan context in Switzerland. Methods: An explorative qualitative design was employed to gather data about critical situations (CS) around football matches of two clubs of the Raiffeisen Super League. A CS is defined as a setting in or around the football stadium where violence between football fans and another group could occur. Eight CS were identified and analysed. Fifty-nine narrative interviews with individuals involved in a CS, e.g. fans, police officers or security personnel, were conducted. Interviews were analysed using interpretative phenomenological analysis (IPA). Results: The involved opposing groups expressed group-specific perceptions. Furthermore a strong tendency to negatively stereotype the opponent group was observed. Provocative symbols, such as balaclavas or riot-gear uniforms, were considered as highly relevant for the interpretation of the situation. Successful communication and sufficient distance between opponent groups supported the appeasement of a CS. These findings also underline the importance of knowledge about the local fan culture. This culture serves as basis for the perception of legitimacy, which was assessed to be essential for a de-escalation of a CS by fans. Discussion/Conclusion: This study improves the understanding of fan violence in the domestic football context in Switzerland. Based on the results it is suggested to deploy security or police forces without riot gear but with the goal of seeking dialogue with the fans to increase the likelihood of a peaceful ending in a CS. The findings also support the applicability of the ESIM (Drury & Reicher, 2000) and the AM model (Hylander & Guvå, 2010) in the context of domestic fan violence. Due to possible differences in the local fan cultures in Switzerland, research in this area should be continued. References: Drury, J., & Reicher, S. (2000). Collective action and psychological change: The emergence of new social identities. British Journal of Social Psychology, 39, 579-604. Hylander, I., & Guvå, G. (2010). Misunderstanding of out-group behaviour: Different interpretations of the same crowd events among police officers and demonstrators. Nordic Psychology, 62, 25-47.

Perceptions of critical situations involving football fans: the dynamics of conflict escalation or de-escalation

Fan violence in the context of football matches has drawn the attention of stakeholders and the media. This phenomenon has also attracted the scientific community’s attention, where research mostly focused on reasons for violence escalation. The Elaborated Social Identity Model (ESIM; Drury & Reicher, 2000) for example focuses on group-interactions and social identities, while the Aggravation Mitigation Model (AM model; Hylander & Guvå, 2010) concentrates on factors contributing to an escalation or a non-escalation of group-violence. However individual perceptions of the different persons involved in potential conflicts have not been sufficiently examined. Beside of that research in domestic football or involving ultrafans is scarce. Especially in Switzerland, there is a lack of research concerning the dynamics of the development or non-development of fan violence. This exploratory study included eight critical situations from the season 2012/2013 of the Swiss premier league to gather data about the perceptions of various persons involved (fans, police officers or security) and the dynamics contributing towards escalation or de-escalation. Fifty-nine narrative interviews were conducted and analysed with interpretative phenomenological analysis (Smith, Flowers, & Larkin, 2009). The individuals involved (fans, police and security personnel) showed groupspecific perceptions and a tendency to stereotype the opponent group. Provocative symbols (balaclavas or riot-gear uniforms) were important for the interpretation of the situation. No escalation occurred when successful communication and sufficient distance between the groups was established. Knowledge about the local fan culture is important, because it influences the perception of legitimacy on the side of the fans. This study improves the understanding of fan violence and is congruent with the ESIM and the AM model. It is suggested to deploy police dialogue teams without riot gear. Their task is to establish direct communication with the fans to facilitate a peaceful ending of a critical situation.

Wright’s Version of Critical Realism

N. T. Wright’s research project “Christian Origins and the Question of God” is characterized by its use of the method of critical realism. Now, “critical realism” is a term that has been used in connection with different epistemo-logical positions because the term has been “constantly reinvented.” It is very easy to make up a term when one wants to distinguish oneself from an assumed naïve approach to reality. As has been observed earlier, the use of a distinct term does not necessarily mean the same if used by another author; the context is important. One has to track literal dependencies to evaluate whether continuity with former uses of a term is intended. That is to say, the term “critical realism” has proven to be equivocal, although this has rarely been noticed . This does not mean that taking such a critical realist stance cannot present a decisive advantage over rather unreflective approaches to whatever sort of reality. Nevertheless, philosophically it can probably only be a start. The purpose of this contribution to this compendium will be to analyze the content claims and the status of N. T. Wright’s critical realism in these regards, with a special emphasis on Paul and the Faithfulness of God, of course.