Ambulatory Outcome Research Articles

P.20.3 Targeting fibrosis and inflammation in Duchenne Muscular Dystrophy

Duchenne Muscular Dystrophy is the most frequent genetic muscle disease worldwide affecting ∼1:5000 male births. It is caused by a defective <i>DMD</i> gene, which leads to reduced and defective dystrophin protein expression. The constant breakdown of fibres leads to focal necrosis, myophagocytosis and a considerable influx of inflammatory cells into the muscle tissue, which is followed by increasing endomysial fibrosis. Both, inflammation and fibrosis as well as a putative relation are not yet understood immunologically. Fibrosis directly correlates with adverse outcome and early loss of ambulation. We have studied how inflammation is linked to fibrosis in DMD, with an emphasis on the communication between fibroblasts, macrophages and the immune response, especially Th2-immunity, at different time points of disease and identified target molecules involved in this process. Classically activated M1 macrophages exhibit a pro-inflammatory phenotype, while alternatively activated (M2) macrophages are profibrotic and are therefore thought to exhibit a ‘repair phenotype' but may be deleterious at certain stages of the disease in DMD. We have analysed muscle biopsies derived from patients suffering from DMD, which were obtained at different time-points after onset of disease. The immune response was studied on the protein and on the mRNA levels. Depending on the time-point and disease activity, the immune response showed a Th1-M1 or Th2-M2 phenotype respectively. Increasing fibrosis was associated with an M2 polarized immune milieu. The results of this study may provide a basis for the development of a specifically targeted and putatively time-dependent immune intervention in DMD patients, based on the immune profile of their muscle biopsy specimen, which can be systematically and individually assessed. This approach may provide a useful additional therapeutic intervention in addition to modern gene-therapeutic approaches.

Application of a modified surgical safety checklist: User beware!

Use of the Surgical Safety Checklist (SSC) has blossomed since a landmark publication showed improved morbidity and mortality with its implementation. Parallel to increasing use of the SSC is a growing body of research investigating the effect of the SSC on the safety of care delivered. Nevertheless, at least one study shows an inconsistent degree of effect on outcomes. Others have investigated the impact of modifications of the SSC tailored to different clinical settings, as Morgan et al. show in their study, ‘‘Surgical safety checklist: implementation in an ambulatory surgical facility’’, in this issue of the Journal. The purpose of this study was ‘‘to add ambulatory carespecific items to the checklist, to assess adherence to safety checklist items, and to examine the impact of the SSC on safety attitudes and important patient outcomes’’ – all in an ambulatory surgical centre. On first thought, this is a logical concept, given that more and more procedures are being carried out on an ambulatory basis. What distinguishes this study from others that have investigated the impact of a SSC on various outcomes is the ambulatory scope and application of a modified SSC to this unique clinical environment. The primary outcome of the study consisted of two end points obtained through telephone interviews with patients on postoperative day one: (1) severity of pain (assessed on a scale of 1-10) and (2) incidence of postdischarge nausea/vomiting (PDNV). Secondary outcomes included the ‘‘incidence of perioperative antibiotic timing, use of regional anesthesia/ analgesia, length of stay, and the number of hospital admissions’’. Despite engaging a multidisciplinary team (consisting of nurses, surgeons, and anesthesiologists) to identify ambulatory-specific factors for inclusion on a modified SSC, clinically relevant differences in the primary and secondary outcomes were not achieved. Why did this occur? The authors identify several possible reasons for lack of effect with their well-intentioned ambulatory SSC: too many additions creating an unwieldy tool, issues with perceived importance of the new items by perioperative staff using the modified SSC, and low rates of overall checklist completion. Though many possible explanations exist, one must ultimately question if the SSC — with its recognized effect on mortality — can be expected to influence ambulatory outcomes like pain scores and PDNV. In their recent review of how and why checklists work, Weiser and Berry detail two main types of checklists. ‘‘Read-do’’ checklists are also known as ‘‘call-doresponse’’ or ‘‘verbal action and confirmation’’. These checklists are used by one person to identify ‘‘items to consider or tasks to accomplish’’, much like a grocery list or a ‘‘cook book’’. ‘‘Challenge-confirm’’ — also known as ‘‘verbal challenge and response’’ — checklists are generally more formalized and are used by two or more individuals, for example, a flight captain and co-pilot completing pre-takeoff checks. With this type of checklist, the reader of the checklist ‘‘challenges’’ another team member to ‘‘confirm’’ completion of each task in a communication format that is scripted to minimize confusion and maximize efficiency. Many checklists in industry and healthcare are a combination of ‘‘read-do’’ and ‘‘challenge-confirm’’, but use of a checklist (like the SSC) should be much more than simply ‘‘double checking’’, which has been described as the use of ‘‘one fallible person (to) monitor the work of another imperfect C. L. Pysyk, MD (&) Department of Anesthesiology, General Campus, The Ottawa Hospital, 501 Smyth Rd., Critical Care Wing 1401, Ottawa, ON K1H 8L6, Canada e-mail: cpysyk@toh.on.ca

Systematic Review of Patient-Centered Outcomes Following Lower Extremity Flap Reconstruction in Comorbid Patients

Lower extremity soft tissue defects pose a challenging problem to patients with comorbidities. Reconstruction with tissue transfer offers an effective alternative to amputation in this population. Although abundant with data on success and complication rates, the literature has not focused on assessing patient-centered outcomes of these reconstructive procedures. A systematic review was performed by searching an electronic database for relevant studies. The full text of relevant articles was retrieved and the reference lists of those articles reviewed. Single case reports or articles reporting data on wounds sustained from trauma were excluded. In total, 318 articles were identified. After applying inclusion and exclusion criteria, 50 articles reporting data on 1,079 flaps remained for inclusion in this review. Ambulation outcomes were reported by 35 articles with a weighted mean rate of postoperative ambulation of 77.4%. Postoperative time to ambulation ranged from an average of 9 months to 22 months. Quality of life and patient satisfaction outcomes were infrequently and inconsistently reported in the literature. There is a dearth of patient-centered outcomes for lower extremity flap reconstruction currently in the literature. A standardized method to assessing patient-centered outcomes should be employed to better understand the effectiveness of these procedures.Level of Evidence III Therapeutic.

P158 Cough Sound Intensity: The Development of a Novel Measure of Cough Severity

Introduction and ObjectivesCough sound analysis is currently used for the assessment of cough frequency; it is not known if it could be used to assess cough intensity. We investigated the...

Associations between cerebrospinal fluid biomarkers and long-term neurologic outcome in dogs with acute intervertebral disk herniation

To examine associations between CSF biomarkers, initial neurologic dysfunction, and long-term ambulatory outcome in dogs with acute intervertebral disk herniation (IVDH). Prospective clinical study. 54 dogs with acute thoracolumbar IVDH and 16 clinically normal dogs. For each dog, variables, including CSF myelin basic protein (MBP), lactate, calcium, glucose, and total protein concentrations; nucleated cell count; and creatine kinase (CK) and aspartate aminotransferase activities, were measured. For dogs with thoracolumbar IVDH, initial neurologic function was characterized by use of a modified Frankel score (MFS; determined on a scale of 0 to 5, where 0 represented paraplegia with no deep nociception and 5 represented paraspinal hyperesthesia only). Long-term follow-up was assessed. Among dogs with thoracolumbar IVDH, those with CSF CK activity ≤ 38 U/L had a 35-fold increase in the odds of long-term ambulation, compared with the odds in dogs with CSF CK activity > 38 U/L, adjusting for neurologic functioning at the evaluation. The CSF lactate, calcium, and glucose concentrations and aspartate aminotransferase activity were not predictive of long-term ambulatory outcome. Data analysis revealed that long-term functional recovery was > 98% for affected dogs, regardless of their initial MFS, when CSF CK activity was ≤ 38 U/L and MBP concentration was ≤ 3 ng/mL. In dogs with acute thoracolumbar IVDH, CSF CK activity and MBP concentration appeared to be prognostic indicators and, along with initial MFS, can be used to predict long-term ambulatory outcome.

A clinical prediction rule for ambulation outcomes after traumatic spinal cord injury: a longitudinal cohort study

A clinical prediction rule for ambulation outcomes after traumatic spinal cord injury: a longitudinal cohort study

Energy consumption during prosthetic walking and physical fitness in older hip disarticulation amputees

The objective of this study is to investigate energy consumption during prosthetic walking and physical fitness in older hip disarticulation (HD) subjects and to examine the ambulatory outcome in a community setting. The subjects were seven unilateral HD amputees with an average age of 67.7 +/- 3.9 yr. Energy consumption was measured during prosthetic walking at each individual's comfortable walking speed (CWS) by means of a portable telemetric system. An incremental exercise test was performed to evaluate fitness. The average CWS for the subjects was 30.5 +/- 9.6 m/min. The average oxygen consumption rate at each CWS was 18.3 +/- 2.4 mL/kg/min, and the average oxygen cost was 0.639 +/- 0.165 mL/kg/m. The maximum oxygen uptake during exercise as a proportion of predicted maximum oxygen uptake (%VO2max) for the subjects was 57.2 +/- 11.1. Five subjects continued prosthetic walking on return to their communities. Two subjects abandoned prosthetic walking. The %VO2max for the five who continued prosthetic walking after discharge ranged from 55.8 to 72.0. The subjects who abandoned prosthetic walking had lower %VO2max of 43.3 and 44.2. Energy consumption during prosthetic walking at CWS seemed not to be excessive. Older HD amputees in good physical condition were able to successfully walk with a prosthesis in a community setting. A lower level of fitness appears to make community walking prohibitive.

Impact of Canine-Assisted Ambulation on Hospitalized Chronic Heart Failure Patients' Ambulation Outcomes and Satisfaction

Chronic heart failure (HF) is a prevalent and costly disease process. Early ambulation has been shown to have a positive impact on patient outcomes and length of stay. Animal-assisted therapy is a novel modality that has shown to be a safe and effective adjunct to a number of traditional treatment plans. This study sought to synergistically combine ambulation and animal-assisted therapy by using canine-assisted ambulation (CAA) to improve the ambulation outcomes of HF patients. Sixty-nine hospitalized patients with a primary diagnosis of HF were approached to ambulate with a restorative aide. After recording their initial response, they were given the opportunity to participate in CAA (walking with a therapy dog). Initial ambulation refusal rate was compared with a historical population of 537 HF patients. Distance ambulated was recorded using a pedometer and compared with a randomly selected, 64-patient sample from the historical HF patient population, stratified by day of hospital stay. Patient satisfaction was assessed through a 5-item Likert scale survey. The 537-patient historical HF population had an ambulation refusal rate of 28%. When offered the chance to participate in CAA, only 7.2% of the study population refused ambulation (P = .0002). Of the 69-patient study sample, 13 initially refused ambulation then agreed when offered CAA (P = .0009). Distance ambulated increased from 120.2 steps in a randomly selected, stratified historical sample to 235.07 in the CAA study sample (P < .0001). Patients unanimously agreed that they enjoyed CAA and would like to participate in CAA again. Canine-assisted ambulation is a safe and effective adjunct to an early ambulation program for HF patients. Canine-assisted ambulation may decrease hospital length of stay and thereby decrease the costs of HF care. Additional research involving CAA's application to other disease processes in various settings is warranted.

Intrathecal Baclofen Therapy Slows Progressive Disability in Multiple System Atrophy

Evaluate the benefit of intrathecal baclofen (ITB) therapy on function, quality of life, and progression in patients with multiple system atrophy (MSA). We report on three MSA patients at different stages treated with ITB therapy. MSA patients were staged using Watanabe et al. ADL milestones for disease progression and by scales for tone (modified Ashworth scale) ambulation (Hauser ambulation index) and disability (expanded disability status scale) All three patients had an improvement in the modified Ashworth scale and none had progression in their disability or ambulatory outcomes and did not progress as predicted by Watanabe et al. Our results suggest that ITB can maintain (or improve function) and maintain quality of life in patients with MSA. ITB is currently not indicated for patients with MSA but should be studied further for the quality of life benefits and delay in disease progression it potentially provides.

Traumatic Spinal Cord Injury: Predicting Ambulation Outcomes

Traumatic spinal cord injury is infrequent, affecting 10.4 to 83.0 people per million worldwide, but strains the healthcare system and has serious

A clinical prediction rule for ambulation outcomes after traumatic spinal cord injury: a longitudinal cohort study

Traumatic spinal cord injury is a serious disorder in which early prediction of ambulation is important to counsel patients and to plan rehabilitation. We developed a reliable, validated prediction rule to assess a patient's chances of walking independently after such injury. We undertook a longitudinal cohort study of adult patients with traumatic spinal cord injury, with early (within the first 15 days after injury) and late (1-year follow-up) clinical examinations, who were admitted to one of 19 European centres between July, 2001, and June, 2008. A clinical prediction rule based on age and neurological variables was derived from the international standards for neurological classification of spinal cord injury with a multivariate logistic regression model. Primary outcome measure 1 year after injury was independent indoor walking based on the Spinal Cord Independence Measure. Model performances were quantified with respect to discrimination (area under receiver-operating-characteristics curve [AUC]). Temporal validation was done in a second group of patients from July, 2008, to December, 2009. Of 1442 patients with spinal cord injury, 492 had available outcome measures. A combination of age (<65 vs ≥65 years), motor scores of the quadriceps femoris (L3), gastrocsoleus (S1) muscles, and light touch sensation of dermatomes L3 and S1 showed excellent discrimination in distinguishing independent walkers from dependent walkers and non-walkers (AUC 0·956, 95% CI 0·936-0·976, p<0·0001). Temporal validation in 99 patients confirmed excellent discriminating ability of the prediction rule (AUC 0·967, 0·939-0·995, p<0·0001). Our prediction rule, including age and four neurological tests, can give an early prognosis of an individual's ability to walk after traumatic spinal cord injury, which can be used to set rehabilitation goals and might improve the ability to stratify patients in interventional trials. Internationale Stiftung für Forschung in Paraplegie.

Postoperative Survival and Ambulatory Outcome in Metastatic Spinal Tumors : Prognostic Factor Analysis

The purposes of this study are to estimate postoperative survival and ambulatory outcome and to identify prognostic factors thereafter of metastatic spinal tumors in a single institute. We reviewed the medical records of 182 patients who underwent surgery for a metastatic spinal tumor from January 1987 to January 2009 retrospectively. Twelve potential prognostic factors (age, gender, primary tumor, extent and location of spinal metastases, interval between primary tumor diagnosis and metastatic spinal cord compression, preoperative treatment, surgical approach and extent, preoperative Eastern Cooperative Oncology Group (ECOG) performance status, Nurick score, Tokuhashi and Tomita score) were investigated. The median survival of the entire patients was 8 months. Of the 182 patients, 80 (44%) died within 6 months after surgery, 113 (62%) died within 1 year after surgery, 138 (76%) died within 2 years after surgery. Postoperatively 47 (26%) patients had improvement in ambulatory function, 126 (69%) had no change, and 9 (5%) had deterioration. On multivariate analysis, better ambulatory outcome was associated with being ambulatory before surgery (p=0.026) and lower preoperative ECOG score (p=0.016). Survival rate was affected by preoperative ECOG performance status (p<0.001) and Tomita score (p<0.001). Survival after metastatic spinal tumor surgery was dependent on preoperative ECOG performance status and Tomita score. The ambulatory functional outcomes after surgery were dependent on preoperative ambulatory status and preoperative ECOG performance status. Thus, prompt decompressive surgery may be warranted to improve patient's survival and gait, before general condition and ambulatory function of patient become worse.

A clinical prediction rule for ambulation outcomes after traumatic spinal cord injury: a longitudinal cohort study

A clinical prediction rule for ambulation outcomes after traumatic spinal cord injury: a longitudinal cohort study

Cerebrospinal Fluid Myelin Basic Protein as a Prognostic Biomarker in Dogs with Thoracolumbar Intervertebral Disk Herniation

Release of myelin basic protein (MBP) into the cerebrospinal fluid (CSF) is associated with active demyelination and correlates with outcome in various neurological diseases. To describe associations among CSF MBP concentration, initial neurological dysfunction, and long-term ambulatory outcome in dogs with acute thoracolumbar intervertebral disk herniation (IVDH). Fifty seven [corrected] dogs with acute thoracolumbar IVDH and 16 clinically normal dogs. Prospective case series clinical study. Signalment, initial neurological dysfunction as determined by a modified Frankel score (MFS), and ambulatory outcome at >3-month follow-up were recorded. Cisternal CSF MBP concentration was determined by an ELISA. Associations were estimated between CSF MBP concentration and various clinical parameters. Dogs with thoracolumbar IVDH that did not ambulate at follow-up had a higher CSF MBP concentration (median, 3.56 ng/mL; range, 0.59-51.2 ng/mL) compared with control dogs (median, 2.22 ng/mL; range, 0-3.82 ng/mL) (P=.032). A CSF MBP concentration of >or=3 ng/mL had a sensitivity of 78% and specificity of 76% to predict an unsuccessful outcome based on receiver-operating characteristics curve analysis (area under the curve=0.688, P=.079). Affected dogs with a CSF MBP concentration>or=3 ng/mL had 0.09 times the odds of ambulation at follow-up compared with affected dogs with CSF MBP concentration<3 ng/mL when adjusted for initial MFS (95% confidence interval 0.01-0.66, P=.018). These results would suggest that CSF MBP concentration may be useful as an independent prognostic indicator in dogs with thoracolumbar IVDH.

Factors influencing ambulation ability after stroke

Objective To explore the factors influencing ambulation after stroke and how to manage them and improve outcomes. Methods Four hundred and eighty-two stroke survivors were involved in this study.Data were collected on their age,sex,education,location of brain lesion,diagnostic stroke subtype and so on.Multiple regression was applied to analyze the data and determine those factors that could predict ambulation outcomes among these stroke patients.Results The multiple regression analysis of 13 factors revealed that NIHSS scores,time from the onset to receiving rehabilitation therapy,balance,depression,and age were predictors of ambulation outcomes.Conclusions Ambulation outcomes can be improved by muhifaceted rehabilitative approaches including early rehabilitation therapy,balance training,and controlling depression. Key words: Stroke; Ambulation ability; Influence factors; Multiple regression analysis

Malignant cord compression: A critical appraisal of prognostic factors predicting functional outcome after surgical treatment.

Objectives:Advanced tumor disease and metastatic spinal cord compression (MSCC) are two entities with a high impact on patients’ quality of life. However, prognostic factors on the outcome after primary decompressive surgery are less well-defined and not yet standardized. The aim of this review was to identify prognostic variables that predict functional or ambulatory outcomes in surgically treated patients with symptomatic MSCC.Materials and Methods:We conducted MEDLINE database searches using relevant keywords in order to identify abstracts referring to prognostic factors on ambulatory outcomes in surgically treated MSCC patients. Details of all selected articles were assembled and the rates of ambulation were stratified.Results:Evidence from five retrospective comparative trials and one observational prospective study summarizes different prognostic factors with a positive or negative influence on postoperative ambulatory status. Ambulatory patients maintaining ambulation status after decompression of the spinal cord constituted 62.1%. The overall rate of MSCC patients losing the ability to ambulate was 7.5% compared to 23.5 % who regained ambulation. Preoperative ambulation status, time to surgery, compression fracture and individual health status seem to be the most relevant prognostic factors for ambulatory outcome.Conclusions:There is a lack of standardized prognostic tools which allow predicting outcome in surgically treated patients. A quantitative score consisting of reliable prognostic tools is essential to predict loss and/or regain of ambulation and requires validation in future prospective clinical trials.

Clinical Algorithm for Improved Prediction of Ambulation and Patient Stratification after Incomplete Spinal Cord Injury

The extent of ambulatory recovery after motor incomplete spinal cord injury (miSCI) differs considerably amongst affected persons. This makes individual outcome prediction difficult and leads to increased within-group variation in clinical trials. The aims of this study on subjects with miSCI were: (1) to rank the strongest single predictors and predictor combinations of later walking capacity; (2) to develop a reliable algorithm for clinical prediction; and (3) to identify subgroups with only limited recovery of walking function. Correlation and logistic regression analyses were performed on a dataset of 90 subjects with tetra- or paraparesis, recruited in a prospective European multicenter study. Eleven measures obtained in the subacute injury period, including clinical examination, tibial somatosensory evoked potentials (tSSEP), and demographic factors, were related to ambulatory outcome (WISCI II, 6minWT) 6 months after injury. The lower extremity motor score (LEMS) alone and in combination was identified as most predictive for later walking capacity in miSCI. Ambulatory outcome of subjects with tetraparesis was correctly predicted for 92% (WISCI II) or 100% (6minWT) of the cases when LEMS was combined with either tSSEP or the ASIA Impairment Scale, respectively. For individuals with paraparesis, prediction was less distinct, mainly due to low prediction rates for individuals with poor walking outcome. A clinical algorithm was generated that allowed for the identification of a subgroup composed of individuals with tetraparesis and poor ambulatory recovery. These data provide evidence that a combination of predictors enables a reliable prediction of walking function and early patient stratification for clinical trials in miSCI.

Magnetic Resonance Imaging in Dogs with Neurologic Impairment Due to Acute Thoracic and Lumbar Intervertebral Disk Herniation

Magnetic resonance imaging (MRI) is a correlate to physical examination in various myelopathies and a predictor of functional outcome. To describe associations among MRI features, neurological dysfunction before MRI, and functional outcome in dogs with disk herniation. One hundred and fifty-nine dogs with acute thoracolumbar disk herniation. Retrospective case series. Signalment, initial neurological function as assessed by a modified Frankel score (MFS), and ambulatory outcome at hospital discharge and >3 months (long-term) follow-up were recorded from medical records and telephone interview of owners. Associations were estimated between these parameters and MRI signal and morphometric data. Dogs with intramedullary T2W hyperintensity had more severe pre-MRI MFS (median 2, range 0-4) and lower ambulatory proportion at long-term follow-up (0.76) than those dogs lacking hyperintensity (median MFS 3, range 0-5; ambulatory proportion, 0.93) (P=.001 and .013, respectively). Each unit of T2W length ratio was associated with a 1.9 times lower odds of long-term ambulation when adjusted for pre-MRI MFS (95% confidence interval 1.0-3.52, P=.05). Dogs with a compressive length ratio >1.31 (which was the median ratio within this population) had more severe pre-MRI MFS (median 3, range 0-5) compared with those with ratios < or =1.31 (median MFS 3, range 0-4; P=.006). MRI features were associated with initial injury severity in dogs with thoracolumbar disk herniation. Based on results of this study, the T2W length ratio and presence of T2W intramedullary hyperintensity appear to be predictive of long-term ambulatory status.

VERTEBRAL COMPRESSION FRACTURES IN PATIENTS PRESENTING WITH METASTATIC EPIDURAL SPINAL CORD COMPRESSION

Metastatic epidural spinal cord compression (MESCC) is a relatively common and debilitating complication of metastatic disease that often results in neurological deficits. Pathological fractures of the vertebral body in patients with MESCC are not uncommon. The goals of this study were to evaluate the effects of compression fractures on long-term neurological function, as well as understand the factors that predict the development of pathological fractures for patients with MESCC. One hundred sixty-two patients undergoing decompressive surgery for MESCC at an academic tertiary care institution from 1995 to 2007 were retrospectively reviewed. Multivariate proportional hazards regression analysis was used to assess the effects of pathological vertebral body fractures on ambulatory outcome, whereas multivariate logistical regression analysis was used to identify factors associated with preoperative compression fractures. Sixty and 102 patients presented with and without pathological vertebral body fractures, respectively, and MESCC. Patients were followed for a mean of 9.7 +/- 2.6 months. The presence of preoperative compression fractures was independently associated with decreased postoperative ambulatory status (odds ratio, 2.106; 95% confidence interval, 1.123-4.355; P = 0.03). This was independent of age, preoperative ambulatory status, preoperative motor deficit, duration of preoperative symptoms, immediate postoperative motor deficit, and lytic tumor appearance. The factors strongly associated with preoperative compression fractures in this study include lack of sensory deficits (P = 0.01), primary breast cancer (P = 0.008), anterior spine metastases (P = 0.005), thoracic spine involvement (P = 0.01), preoperative chemotherapy (P = 0.03), and, possibly, preoperative radiation therapy (P = 0.16). The findings of this study may provide insight into risk stratifying as well as guiding surgical management for patients with MESCC.

Predictors of Change in Walking Distance in Patients with Peripheral Arterial Disease Undergoing Endovascular Intervention

Endovascular treatment of peripheral artery disease is becoming frequent, yet the clinical factors which predict ambulatory outcomes are not known. To identify predictors of change in walking distance in patients who underwent endovascular intervention for their lower extremity peripheral arterial disease (PAD). A total of 134 patients underwent lower extremity peripheral arterial intervention, 52 patients were contacted via phone between 1 and 36 months (a mean of 22 mo) after their initial procedure. The remaining 82 patients were excluded due to the following reasons: death (n = 13), contact information was not available (n = 50), and refusal to participate in the follow-up (n = 19). The patients were 63 +/- 12 years old (mean +/- standard deviation [SD]), 46% were male, 47% were diabetics, 49% had coronary artery disease, of whom 29% had prior revascularization, and 22% had coronary artery bypass grafts (CABG). The disease severity described by Fontaine classification were as follows: 44.2% were in stage II, 15.4% were in stage III, and 40.4% were in stage IV. Walking distance was improved in 21% of patients, worsened in 73% of patients, and unchanged in 6% of patients. Stepwise multiple regression demonstrated that patients who started to walk or exercise (R = 0.372, P < 0.012) and who had a prior history of CABG (R = 0.467, P < 0.006) were the only independent predictors of the change in walking distance at follow-up. Those who started to walk reported worse walking distance at follow-up, while those with a history of CABG reported better walking distance at follow-up. CABG prior to endovascular intervention is predictive of favorable change in walking distance in patients with PAD at follow-up. Therefore, post-CABG patients are good candidates for exercise rehabilitation and risk factor modification.