Objectives This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To conduct a component network meta‐analysis (CNMA) comparing different SEP combinations to identify the most clinically effective exercise prescription for people with IC. To conduct an economic evaluation comparing different SEP combinations for people with IC to identify which are cost‐effective.

Background: Half of people with chronic limb-threatening ischaemia (CLTI) have frailty. This study aimed to describe the associations of frailty with cognition, disability and quality of life (QoL) among CLTI patients over 1 year following surgical or endovascular procedures. Methods: A single-centre prospective cohort study was undertaken. Patients undergoing a procedure for CLTI between May 2019 and May 2021 were eligible (minimum age >65 initially; >50 from November 2019). Participants underwent preoperative assessments for frailty, physical and cognitive function, disability, mood, disease-specific QoL (Vascular QoL questionnaire (VascuQoL)) and generic health-related QoL (EuroQoL EQ-5D-5L). Follow-up was at 3 months (clinic or telephone) and 12 months (telephone). Baseline frailty was assessed using both the Edmonton frail scale (EFS) and the clinical frailty scale (CFS). Frailty during follow-up was re-assessed at 3 and 12 months using the CFS as it can be performed via telephone. Associations of baseline frailty with disability, QoL and mood scores during follow-up were investigated using repeated measures mixed models. Results: Ninety-nine patients completed the baseline assessments. Forty-five (45%) were classified as frail by the EFS. Frailty was associated with a higher prevalence of cognitive impairment based on the Montreal cognitive assessment (52% vs 17%; p<0.001). Eighty-seven patients were eligible for follow-up. Baseline frailty (EFS) was associated with worse QoL scores at all timepoints (VascuQoL p=0.001; EQ-5D-5L p<0.001). Both those with and without frailty at baseline (EFS) had modest improvement in QoL scores at 12 months (VascuQoL p<0.001; EQ-5D-5L p=0.001). Barthel index (disability) scores were lower for those with frailty at baseline (EFS) (p<0.001) and decreased slightly over 12 months for both groups (p=0.007). Five patients (12%) transitioned from frailty to non-frailty at 12 months based on the CFS. However, 10 patients (23%) transitioned from non-frailty to frailty. Conclusions: CLTI patients with frailty have worse QoL and greater disability both pre- and post-intervention. However, they demonstrate similar QoL benefit to those without frailty at 1 year following intervention. Baseline frailty assessment is important to inform prognostic discussions, expectations and shared decision making in CLTI.

How important is it for trainees to have access to open surgical training opportunities?

Getting It Right First Time (GIRFT) is a national programme of improvement to identify and reduce unwarranted variation and non-evidence-based practice in healthcare. It aims to improve patient care, increase productivity and reduce costs. Professor Tim Briggs, an orthopaedic surgeon, began the programme with a pilot review visiting every orthopaedic surgery department in England. He used publicly available data to illuminate variation, and worked with the clinicians and management to develop improvements. The impressive initial report in 2015 led to NHS Improvement investing £60m to expand the programme to 40 medical and surgical specialties. The follow-up report detailed savings of £696m to the NHS. GIRFT differs from previous programmes of improvement through its peer led, supportive approach to promoting change with early engagement of both clinicians and management. Common themes run through the ten specialty reports published to date: variation in procurement and litigation costs, huge variations in patient treatment options and poor data quality. Successfully applied in orthopaedic surgery, it has been taken on enthusiastically by other specialties. Whether it can deliver its objective of £1.4bn savings while improving patient outcomes is yet to be seen, but its approach is changing the culture of the NHS.

BackgroundCascade genetic and imaging screening for relatives of people with non-syndromic thoracic aortic diseases (NS-TAD) is recommended by guidelines. However, the availability and uptake of cascade screening is low. The aim of this study was to use applied health research methods to identify barriers to screening, and strategies to overcome these.MethodsA cohort study using routinely collected health data evaluated barriers to imaging, genetic testing, and treatment for people with NS-TAD. Delphi consensus exercises and workshops evaluated the screening process and patient experience. Focus groups considered strategies to overcome individual and institutional barriers to uptake. A consensus exercise evaluated the evidence to support cascade screening.ResultsA cohort study of 33,793 patients with a TAD diagnosis between 2013 and 2018 demonstrated barriers to treatment and imaging surveillance in females, non-whites, and people from-low socioeconomic backgrounds. A survey of aortic dissection survivors and relatives in England reported that 33/70 (47%) of aortic dissection survivors who responded had undergone genetic testing, including 10/22 (45%) with a positive family history of TAD. In first- and second-degree relatives 66/150 (44%) and 32/155 (21%) of respondents were offered imaging or cascade genetic testing respectively. Only 19/70 (27%) probands and 20/155 (13%) relatives who responded reported that they were involved in shared decisions about their care. Barriers to the uptake of cascade screening included limited awareness of the disease and genetic aetiology, poor health literacy, concerns about cost-effectiveness of screening with low detection rates, requirements for life-long surveillance, and the management of uncertain test results. The consensus exercise demonstrated that the certainty of the evidence to guide cascade screening was Low or Very Low.ConclusionsBarriers to the implementation of cascade screening in people at high-risk for TAD occur at multiple levels suggesting that a complex intervention is required to improve equity of access.

Introduction: The aim of this study was to investigate the concept of an 8-week personalised activity plan, using short periods of physical activity to break up sitting time in people with Intermittent Claudication (IC), to improve walking ability, and reduce time spent sitting.Methods: The study was designed as a single centre, single arm, before and after study and is registered with clinicaltrials.gov (NCT04572737). The co-primary outcomes are time spent sitting and walking ability measured via the walking impairment questionnaire. Normally distributed data was analysed using paired samples T-tests; non-normally distributed data was analysed using related-samples Wilcoxon signed rank tests.Results: There was a significant improvement in both co-primary outcomes: walking ability and time spent sitting, as well as the following secondary outcomes: total bouts and time spent in prolonged sitting, time spent standing and stepping, anxiety, depression, and activity levels reported on the vascular quality of life questionnaire.Conclusion: An 8-week personalised activity plan to break up sitting time shows promise as a treatment for people with IC, improving walking ability and reducing time spent sitting. This study supports the use of large randomised controlled trials to further develop this treatment in people with IC.

Aim: To quantify differences in device-measured physical activity (PA) behaviours, and physical function (PF), in people with type 2 diabetes mellitus (T2DM) with and without peripheral artery disease (PAD). Materials and methods: Participants from the Chronotype of Patients with T2DM and Effect on Glycaemic Control cross-sectional study wore accelerometers on their non-dominant wrist for up to 8-days to quantify: volume and intensity distribution of PA, time spent inactive, time in light PA, moderate-to-vigorous PA in at least 1-minute bouts (MVPA1min), and the average intensity achieved during the most active continuous 2, 5, 10, 30, and 60minute periods of the 24-h day. PF was assessed using the short physical performance battery (SPPB), the Duke Activity Status Index (DASI), sit-to-stand repetitions in 60 s (STS-60); hand-grip strength was also assessed. Differences between subjects with and without PAD were estimated using regressions adjusted for possible confounders. Results: 736 participants with T2DM (without diabetic foot ulcers) were included in the analysis, 689 had no PAD. People with T2DM and PAD undertake less PA (MVPA1min: -9.2 min [95 % CI: -15.3 to -3.0; p = 0.004]) (light intensity PA: -18.7 min [-36.4 to -1.0; p = 0.039]), spend more time inactive (49.2 min [12.1 to 86.2; p = 0.009]), and have reduced PF (SPPB score: -1.6 [-2.5 to -0.8; p = 0.001]) (DASI score: -14.8 [-19.8 to -9.8; p = 0.001]) (STS-60 repetitions: -7.1 [-10.5 to -3.8; p = 0.001]) compared to people without; some differences in PA were attenuated by confounders. Reduced intensity of activity for the most active continuous 2-30 min in the 24-h day, and reduced PF, persisted after accounting for confounders. There were no significant differences in hand-grip strength. Conclusions: Findings from this cross-sectional study suggest that, the presence of PAD in T2DM may have been associated with lower PA levels and PF.

Background: Objective physical performance-based outcome measures (PerBOMs) are essential tools for the holistic management of people who have had an amputation due to vascular disease. These people are often non-ambulatory, however it is currently unclear which PerBOMs are high quality and appropriate for those who are either ambulatory or non-ambulatory.Research question: Which PerBOMs have appropriate clinimetric properties to be recommended for those who have had amputations due to vascular disease ('vascular amputee')?Data sources: MEDLINE, CINAHL, EMBASE, EMCARE, the Cochrane Library, Cochrane Central Register of Con-trolled Trials (CENTRAL) and Scopus databases were searched for the terms: "physical performance" or "func-tion", "clinimetric properties", "reliability", "validity", "amputee" and "peripheral vascular disease" or "diabetes".Review methods: A systematic review of PerBOMs for vascular amputees was performed following COnsen-sus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology and PRISMA guidelines. The quality of studies and individual PerBOMs was assessed using COSMIN risk of bias and good measurement properties. Overall PerBOM quality was evaluated with a modified GRADE rating. Key clinimetric properties evaluated were reliability, validity, predictive validity and responsiveness.Results: A total of 15,259 records were screened. Forty-eight studies (2650 participants) were included: 7 exclusively included vascular amputees only, 35 investigated validity, 20 studied predictive validity, 23 investigated reliability or internal consistency and 7 assessed responsiveness. Meta-analysis was neither pos-sible nor appropriate for this systematic review in accordance with COSMIN guidelines, due to heterogeneity of the data. Thirty-four different PerBOMs were identified of which only 4 are suitable for non-ambulatory vascular amputees. The Amputee Mobility Predictor no Prosthesis (AMPnoPro) and Transfemoral Fitting Predictor (TFP) predict prosthesis use only. PerBOMs available for assessing physical performance are the One -Leg Balance Test (OLBT) and Basic Amputee Mobility Score (BAMS).Conclusion: At present, few PerBOMs can be recommended for vascular amputees. Only 4 are available for non-ambulatory individuals: AMPnoPro, TFP, OLBT and BAMS.& COPY; 2023 The Authors. Published by Elsevier Masson SAS.This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

Abstract Introduction This study aimed to describe the associations of frailty with cognition, disability, and quality of life (QoL) among individuals with chronic limb-threatening ischaemia (CLTI) over one-year following intervention. Methods Single-centre prospective cohort study. Patients aged ≥65 with CLTI and a planned intervention between May 2019 and May 2021 were eligible for inclusion. Patients underwent frailty, cognitive function, disability and QoL assessments before their procedure. Delirium screening was performed at 24- and 72-hours post-operatively. Frailty, disability and QoL assessments were repeated at three- and 12-months. Results Ninety-nine patients completed baseline assessments, of whom 45 (45%) were classified as frail by the Edmonton frail scale. Frailty was strongly associated with higher prevalence of cognitive impairment (52% vs 17%; p<.001). Eighty-seven patients underwent a procedure. Ten (11%) developed POD, of whom 8 had frailty (p=.003). Cognitive impairment (OR 8.52; 95%CI 1.12, 64.67; p=.038) was independently associated with POD. Frailty was associated with worse vascular quality of life questionnaire (VascuQoL) (p=.001) and EQ-5D-5L scores (p<.001) at all timepoints, however both those with and without frailty had modest improvement in VascuQoL and EQ-5D-5L scores at 12-months (p=.001). Barthel index (disability) scores were lower for those with frailty (p<.001) and decreased slightly over 12-months for both groups (p=.007). Five patients (12%) transitioned from frailty to non-frailty at 12-months (clinical frailty scale), however 10 patients (23%) transitioned from non-frailty to frailty. Conclusion CLTI patients with frailty have worse cognition, QoL and disability. Overall, individuals with CLTI demonstrate progression in frailty and disability at one-year post-intervention.

The paper by Scali et al1 Scali S. Wanhainen A. Neal D. Debus S. Mani K. Behrendt C.-A. et al. Conflicting European and North American society abdominal aortic aneurysm (AAA) volume guidelines differentially discriminate peri-operative mortality after elective open AAA repair. Eur J Vasc Endovasc Surg. 2023; 66: 756-764 Scopus (2) Google Scholar highlights the differences in society recommendations regarding the recommended volume threshold for abdominal aortic aneurysm (AAA) repair. The European Society for Vascular Surgery (ESVS) recommends a minimum of 20, but optimally 30, all aortic aneurysm procedures per year, while the US Society for Vascular Surgery (SVS) refers only to a volume of ≥10 open aneurysm repairs. Based on an analysis of the SVS Vascular Quality Initiative (VQI) dataset of > 8 000 aortic repairs, the authors conclude that the SVS endorsed AAA threshold was superior to the current composite ESVS volume guideline in differentiating centre performance. Conflicting European and North American Society Abdominal Aortic Aneurysm (AAA) Volume Guidelines Differentially Discriminate Peri-operative Mortality After Elective Open AAA Repair European Journal of Vascular and Endovascular SurgeryVol. 66Issue 6PreviewThe European Society for Vascular Surgery (ESVS) guidelines endorse a minimum abdominal aortic aneurysm (AAA) repair volume of 20 open (OAR) and or endovascular (EVAR) AAA repair procedures per year as a proxy for high quality care. In contrast, the Society for Vascular Surgery (SVS) espouses 10 exclusively OARs per year. Given the differences in these volume standards and definitions, debate persists regarding surgeon credentialing and healthcare resource allocation. This analysis aimed to determine which society endorsed volume benchmark better discriminates OAR mortality. Full-Text PDF

The last decade has witnessed a number of changes in the delivery of vascular services nationwide. Vascular surgery attained speciality status in 2012, and is well recognised as an urgent and emergent speciality delivering time-dependent care for patients with aortic aneurysms, carotid surgery for stroke prevention and lower limb revascularisation for critical limb-threatening ischaemia. The National Vascular Registry (NVR), established in 2013, provides effective monitoring and reports on outcomes whilst also delivering a robust programme of quality improvement.1 The National Abdominal Aortic Aneurysm Screening Programme was fully implemented in 2014,2 and this coincided with a move towards centralisation of vascular services to a network model of care with elective and emergency arterial surgery concentrated in arterial hubs. In 2013, NHS England took full responsibility for all specialised commissioning which included all arterial surgery. Over the years, major vascular policy decisions make reference to the Vascular Clinical Reference Group (CRG), yet few clinicians are aware of who these groups are, who they are accountable to and how they are involved in organising, reconfiguring, delivering and monitoring of vascular services in England.

Abstract Aims: Major lower extremity amputations (MLEAs) are understood to be well recorded in secondary care in England in the Hospital Episode Statistics (HES) database. It is unclear how well MLEAs are recorded in primary care databases. Background: This study compared MLEA event case ascertainment in Clinical Practice Research Datalink (CPRD) to that in HES. Methods: MLEA events were ascertained in CPRD and in HES linkage between 1 January 2010 and 31 December 2019. The number of MLEA events and the number of patients with at least one MLEA in each database were recorded and compared. Individual events were matched between the databases using varying date-matching windows. Reasons for differences in case ascertainment were explored. Findings: In total 23 262 patients had at least one MLEA record, 8716 (37.5%) had an MLEA record in HES only, 5393 (23.2%) in CPRD only and 9153 (39.4%) in both. Out of a total of 75 221 events, 13 071 (62.4%) were recorded in HES only and 44 151 (81.3%) in CPRD only. 7874 (37.6%) of HES events were recorded in CPRD and 10 125 (18.6%) of CPRD events were recorded in HES when using the maximum date matching window of 28 days plus the time between admission and procedure. The main reasons for differences in case ascertainment included, re-recordings and miscoding in CPRD. Compared to HES, MLEAs are poorly recorded in CPRD predominantly due to re-recordings of events and miscoding procedures. CPRD data cannot solely be relied upon to ascertain cases of MLEA; however, HES linkage to CPRD may be useful to obtain medical history of diagnoses, medication and diagnostic tests.

Dear Editor, Primary Healthcare undergoes constant and continuous evolution through review and update of guidance, policy and processes. Primary Healthcare Professionals (PHP) need to update their knowledge and skills regularly. Continuing professional development (CPD) enables the renewal of knowledge and skills in healthcare settings. While how PHPs experience and perceive updating knowledge has been reported pre-covid-19 [1], the pandemic required innovative and rapid adaptions to learning and development which may have changed PHP’s educational requirements. For educators, it is important to recognise current PHP educational preferences when developing educational resources and methods of delivery. The educational hiatus imposed by COVID-19 allowed review of the current CPD provision. It was recognised that education for the 21 century PHP must embrace the enduring competencies of professionalism, service provision and personal accountability and include new competencies e.g. remote consulting. CPD must address the workforce and health challenge needs [2], with consideration to PHP well-being priorities in the post-COVID era [3]. A group of academic GPs and vascular surgeons conducted a large-scale survey of 856 PHPs, including 50 individual follow-up interviews, across England during 2021. This spanned a time that much CPD provision had transitioned and PHPs were evaluating the shape of future CPD. The study allowed an understanding of how PHPs currently view and approach their learning. Amidst the changes in working practices required by the pandemic, PHPs demonstrated a commitment to CPD. A main driver for learning was a perceived lack of knowledge or skills, often within a patient contact. Learning purely interesting subjects was highly ranked. PHPs continued to learn and often accelerated their attainment of competencies required for the modern practitioner. A pragmatic approach was taken, valuing learning that was important for individual job roles especially if there is a practical element. There was a strong appetite to maintain accessibility to learning balanced to address their wellbeing needs. Moving forward, PHPs have considered what they value from CPD, how they wish to engage with it and identified different methods of building a community. PHPs value interaction with other PHPs such as virtual networking rooms and would have preferred not to use artificial intelligence or mobile-app-based learning. As much CPD had converted to virtual, this had demonstrated feasibility of such methods. PHPs want education to be delivered with consideration to convenience of time and minimal or no travel unless there are significant networking opportunities. As busy practitioners with long hours, often with family commitments, educational opportunities were chosen to fit life-requirements, rather than vice-versa. Webinars, e-learning and remote group teaching via online platforms were ranked equally as high as weekday practice-level, group and multiple-practice teaching. A hybrid of virtual and in-person CPD with choices for either is now sought by PHPs e.g. virtual conferences and recorded CPD accessible at a later time. PHPs sought CPD recognition and preferred education free of charge. PHPs had no preference for who delivered the education, however it was clear that the educator must focus and apply knowledge and skills to primary care rather than secondary or tertiary care.

BACKGROUND:The aim was to determine the comparative benefits of structured high-pain exercise, structured low-pain exercise, and usual-care control, to identify which has the largest effect on walking ability in people with intermittent claudication (IC). METHODS:A network meta-analysis was undertaken to assess two outcomes: pain-free walking ability (PFWA) and maximal walking ability (MWA). Nine electronic databases were searched. Trials were included if they were: RCTS; involved adults with IC; had at least two of the following arms-structured low-pain exercise, structured high--pain exercise or usual-care control; and a maximal or pain-free treadmill walking outcome. RESULTS:Some 14 trials were included; results were pooled using the standardized mean difference (MD). Structured low-pain exercise had a significant large positive effect on MWA (MD 2.23, 95 percent c.i. 1.11 to 3.35) and PFWA (MD 2.26, 1.26 to 3.26) compared with usual-care control. Structured high-pain exercise had a significant large positive effect on MWA (MD 0.95, 0.20 to 1.70) and a moderate positive effect on PFWA (0.77, 0.01 to 1.53) compared with usual-care control. In an analysis of structured low- versus high pain exercise, there was a large positive effect in favour of low-pain exercise on MWA (MD 1.28, -0.07 to 2.62) and PFWA (1.50, 0.24 to 2.75); however, this was significant only for PFWA. CONCLUSION:There is strong evidence in support of use of structured high-pain exercise, and some evidence in support of structured low-pain exercise, to improve walking ability in people with IC compared with usual-care control (unstructured exercise advice).

Keywords: Amputation; Vascular; Outcome measures Purpose: Patients who have undergone an amputation due to Peripheral Arterial Disease (PAD) and/or diabetes (vascular amputees) often have multiple comorbidities, including decreased physical function due to persistent deconditioning as their PAD progresses into Chronic Limb Threatening Ischemia(CLTI), with symptoms of severe pain at rest or night, ulceration and tissue loss, succeeding major lower limb amputation. Vascular amputees commonly have a poor baseline pre-amputation, more likely to be frailer than their non-vascular amputee counterparts, often do not wear a prosthesis for functional use and many abandon their prosthetic limb within 1 year of prescription. Using objective physical Performance Based Outcome Measures (PerBOM) is essential for monitoring patient progression, proving clinical effectiveness, evidencing good clinical practice and aids the prediction of functional prosthesis users. At present PerBOMs used with vascular amputees vary widely, with little known which are the highest quality with adequate clinimetric measurement properties. This systematic review aims to identify and evaluate the clinimetric measurement properties of PerBOMs used with vascular amputees prior to, during or following an intervention. Methods: Following COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology for conducting systematic reviews for measurement properties for outcome measures and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Registration with International Prospective Register of Systematic Reviews (PROSPERO) (registration number: CRD42019160388). COSMIN risk of bias checklist, good measurement properties and modified GRADE (Grading of Recommendations, Assessment, Development and Evaluations) assessment was completed for each paper for individual PerBOMs for all clinimetric properties including construct validity, predictive validity, responsiveness, reliability and internal consistency. Results: 11702 results were screened, 48 studies included in this systematic review. 35 studies investigated validity, 20 studies investigated predictive validity, 23 studies investigated reliability or internal consistency and seven papers investigated responsiveness (sensitivity and specificity). Of 48 studies, 7 only included vascular amputees, whilst only 2 studies reported vascular amputees results separately. The remaining 39 studies all included a mixed cohort of patients. Thirty-four PerBOMs were identified and evaluated. Only four of these PerBOMs can be used with a non-ambulatory vascular amputee; Amputee Mobility Predictor no Prosthesis(AMPnoPro), Basic Amputee Mobility Score (BAMS), One Leg Balance Test(OLBT) and Transfemoral Fitting Predictor(TFP). AMPnoPro and TFP are for predicting prosthetic use only, exhibiting OLBT and BAMS as the only PerBOMs available for use with non-ambulatory vascular amputees. OLBT and BAMS have clear floor and ceiling effects, where the BAMS has a large ceiling effect and the OLBT inappropriate to use with bilateral amputees. Conclusion(s): Despite a large number of PerBOMs identified within the literature, only four PerBOMs are available for use with the largest population of major amputee patients, vascular amputees. Moreover, there are clear issues with appropriateness and quality of these PerBOMs. Impact: This systematic review will highlight the highest quality PerBOMs based on clinimetric measurement properties to enable clinicians to make decisions on which are appropriate for use with vascular amputee patients. Additionally, this list of PerBOMs has been utilized to develop a scoping survey of UK clinical practice exploring which of PerBOMs are being used in clinical practice. Funding acknowledgements: My PhD has been funded through the George Davies Charitable Fund Trust and I am employed at the University of Leicester as a Research Physiotherapist.

Introduction The Vascular Society of Great Britain and Ireland (VSGBI) Peripheral Arterial Disease Quality Improvement Framework (PAD QIF) stipulates targets for managing patients with chronic limb-threatening ischaemia (CLTI); however, it is unknown whether these are achievable. This survey aims to evaluate contemporary practice for managing CLTI in the UK. Methods A questionnaire was developed in conjunction with the VSGBI to survey the management of CLTI and canvass opinions on the PAD QIF. The survey was distributed to all consultant members of the VSGBI and through a targeted social media campaign. Results Forty-seven consultant vascular surgeons based at 36 arterial centres across the UK responded (response rate from arterial centres = 46%). Only 14.3% of centres provided outpatient consultation within the target of seven days from referral, with only one centre providing revascularisation within the target of seven days from consultation. For inpatient management, 31.6% provided surgical and 23.8% endovascular revascularisation within the target of three days from assessment. While 60% of participants believe the PAD QIF's 5-day 'admitted care' pathway is achievable, only 28.6% thought the 14-day 'non-admitted care' pathway was feasible. Challenges to meeting these targets include the availability of theatre space and angiography lists, and availability of outpatient appointments for patient assessment. Conclusions The opinion of UK vascular surgeons indicates that achieving the targets of the PAD QIF represents a major challenge based upon current services. Adapting existing services with a greater focus on providing an 'urgent' model of care may help to potentially overcome these challenges.

Objective Estimate the prevalence/incidence/number of major lower extremity amputations (MLEAs) in the UK; identify sources of routinely collected electronic health data used; assess time trends and regional variation; and identify reasons for variation in reported incidence/prevalence of MLEA. Design Systematic review and narrative synthesis. Data sources Medline, Embase, EMcare, CINAHL, The Cochrane Library, AMED, Scopus and grey literature sources searched from 1 January 2009 to 1 August 2021. Eligibility criteria for selecting studies Reports that provided population-based statistics, used routinely collected electronic health data, gave a measure of MLEA in adults in the general population or those with diabetes in the UK or constituent countries were included. Data extraction and synthesis Data extraction and quality assessment using the Joanna Briggs Institute Critical Appraisal Instruments were performed by two reviewers independently. Due to considerable differences in study populations and methodology, data pooling was not possible; data were tabulated and narratively synthesised, and study differences were discussed. Results Twenty-seven reports were included. Incidence proportion for the general population ranged from 8.2 to 51.1 per 100 000 and from 70 to 291 per 100 000 for the population with diabetes. Evidence for trends over time was mixed, but there was no evidence of increasing incidence. Reports consistently found regional variation in England with incidence higher in the north. No studies reported prevalence. Differences in database use, MLEA definition, calculation methods and multiple procedure inclusion which, together with identified inaccuracies, may account for the variation in incidence. Conclusions UK incidence and trends in MLEA remain unclear; estimates vary widely due to differences in methodology and inaccuracies. Reasons for regional variation also remain unexplained and prevalence uninvestigated. International consensus on the definition of MLEA and medical code list is needed. Future research should recommend standards for the reporting of such outcomes and investigate further the potential to use primary care data in MLEA epidemiology. Systematic review registration PROSPERO CRD42020165592.

Introduction: Guidance for exercise and pain in intermittent claudication recommends structured exercise programs at moderate-maximum pain, which may overlook the benefit of structured low-pain exercise on walking ability. We undertook a network meta-analysis to determine the comparative benefits of structured high-pain exercise and low-pain exercise, and usual-care control, to identify which has the largest effect on walking ability in people with intermittent claudication. Methods and Results: We searched nine electronic databases; additional trials (RCTs) were identified by hand-searching bibliographies from included studies, relevant reviews and meta-analyses. RCTs were included if: they involved adults with intermittent claudication; included at least two of following arms structured low-pain exercise, structured-high pain exercise or a usual-care control; they had a maximal or pain free treadmill walking outcome. This search resulted in the inclusion of 14 studies (n = 657), reporting the comparison of 9 high-pain arms, 4 low-pain arms, and 13 usual-care arms for maximal walking ability (MWA); and 7 high-pain arms, 4 low-pain arms and 11 usual-care arms for pain free walking ability (PFWA). Results were pooled using SMD. Structured low-pain exercise had a large positive effect on MWA (SMD: 2.23; 95% CI: 1.11 to 3.35) and a large positive effect on PFWA (2.26;1.26 to 3.26) when compared to usual-care control; structured high-pain exercise had a large positive effect on MWA (SMD: 0.95; 95% CI: 0.20 to 1.70) and a moderate positive effect on PFWA (0.77; 0.01 to 1.53) when compared to usual-care control; and structured low-pain exercise, compared to structured high-pain exercise showed a large positive effect in favour of low-pain exercise on MWA (SMD: 1.28, 95% CI: -0.07 to 2.62) and PFWA (1.50; 0.24 to2.75). Conclusions: Our findings support the provision of structured high- and low-pain exercise to improve walking ability in people with intermittent claudication over usual-care alone, with low-pain exercise appearing to have a larger effect. Large head-to-head RCTs are required to confirm the efficacy and safety of different structured exercise programmes prescribed using pain on walking ability in people with intermittent claudication.