Robert J. Hinchliffe, MD, MRCS, Clinical Lecturer in Vascular Surgery, St George’s Regional Vascular Institute, St George’s Hospital and St George’s University of London, London, UK.
William Jeffcoate, FRCP, Professor, Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, Nottingham University Hospitals, City Hospital Campus, Nottingham, UK.

Individuals with ulceration of the foot should be identified and referred urgently to a specialist. Unfortunately there is little formal health care education in diabetic foot ulceration and often no specialist referral pathway. We discuss the common modes of presentation of patients with diabetes and foot ulcer. The clinical implications of a range of symptoms and signs will be explained, including the most common diagnostic pitfalls in everyday primary care practice.
Key words: diabetes, peripheral vascular disease, ulcer, vascular surgery, peripheral arterial disease, diabetic foot.

Ernane D. Reis, MD, Assistant Professor, Department of Surgery, Mount Sinai School of Medicine, New York, NY.
Osvaldo J. Yano, MD, Attending Vascular & Endovascular Surgeon, Saint Francis Hospital, Roslyn, NY.

Introduction
Peripheral vascular [arterial] disease (PVD) of the lower extremities is a result of generalized atherosclerosis, and has the same risk factors as do stroke and myocardial infarction.¹ PVD is associated with increased mortality even in asymptomatic patients,² and is an important cause of complications and death after successful coronary revascularization.^3,4 Twenty-five percent of patients with limb-threatening ischemia die within one year of diagnosis.² In patients older than 60 years, the prevalence of clinically detectable PVD is approximately 15%, and claudication occurs in up to 5%.² PVD also reduces ambulatory capacity and quality of life and, therefore, represents an enormous human and financial burden to individual patients and society.⁵

During the last decade, management of arterial disease of the lower extremities has undergone remarkable changes. A true medical revolution is ongoing, as a consequence of the successful introduction of new technologies that can be used alone or in conjunction with established surgical and radiological methods.

D'Arcy Little, MD, CCFP
Director of Medical Education,
York Community Services, Toronto, ON

Introduction and Epidemiology:
Peripheral vascular disease (PVD), a common and often disabling condition, usually results from the atherosclerotic occlusion of the arteries in the lower limbs.¹ Symptomatic PVD is rare in men before the age of 50, but prevalence increases dramatically with age. The Edinburgh Artery Study states that the prevalence of symptomatic PVD increases from 2.2% in men aged 50 to 59, to 7.7% in men aged 70 to 74.^2,3 Before the 7th decade, the prevalence in women is approximately half that seen in men, but this difference diminishes after that age.⁴

Definition and Diagnosis of Intermittent Claudication (IC)
Patients who suffer from intermittent claudication (IC) represent a subset of those patients with symptomatic lower extremity atherosclerotic disease. This review will focus on an approach to the investigation and management of this condition in the elderly population. Only 7-9% of patients with diagnosed lower extremity atherosclerosis suffer from intermittent claudication.5 In 1962, the Rose claudication questionnaire was developed as an epidemiologic instrument for the purposes of identifying patients with IC. It also serves as a good working definition of IC.