Results of amputation for gangrene in diabetic and non-diabetic patients. Selection of amputation level using photoelectric measurements of skin-perfusion pressure.

Evaluation was done of 235 patients who had had 273 primary amputations for gangrene. Measurements of local skin-perfusion pressure or systolic blood pressure were made in 222 limbs (188 patients). For the other fifty-one limbs, for which no measurements of pressure were available, the surgeon elected to perform an above-the-knee amputation in nine of seventeen diabetic limbs and a below-the-knee amputation in eight. An above-the-knee amputation was selected by the surgeon for thirty-two of thirty-four non-diabetic limbs and a below-the-knee amputation, for two for which no measurements of pressure were available. Local skin-perfusion pressure was measured distal to the knee before amputation, using a standardized photoelectric technique in 203 limbs and systolic blood-pressure measurements in nineteen. Skin-perfusion pressure was also measured above the knee in seventy-six of the 222 limbs in which a pressure was determined below the knee. These measurements were made available to the surgeon for use as an adjuvant guide to clinical assessment in selecting the appropriate level of amputation. Seventy-four patients (ninety-two amputations) had diabetes and 114 patients (130 amputations) did not. The limbs of the diabetic patients had a significantly higher skin-perfusion pressure at the below-the-knee level (p less than 0.001) than did those of the non-diabetic patients. The ratios of below-the-knee to above-the-knee amputations for the diabetic and non-diabetic patients were 3.8 to one and 1.3 to one (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Long posterior flap versus equal sagittal flaps in below-knee amputation for ischaemia.

We analysed the complication rate in 140 below-knee amputations in relation to surgical technique and the presence of diabetes. In all cases, the skin perfusion pressure was measured below the knee before operation to provide an objective evaluation of the microcirculation. In diabetic patients we found a significantly higher complication rate after using a long posterior flap than after equal sagittal flaps. No such difference could be demonstrated in non-diabetic patients. We suggest that the higher incidence of atherosclerotic lesions in the three major arteries below the knee in diabetic patients may account for the difference. We recommend the use of the sagittal technique for below-knee amputation in diabetic patients.

Interobserver variation in interpretation of electrocardiographic signs of atrial infarction.

The electrocardiogram (ECG) is the only means of diagnosing atrial infarction antemortem. Certain ECG changes (PR-segment displacements) have been taken earlier as signs of atrial infarction. The purpose of this study was to assess the interobserver variation on suggested ECG signs of atrial infarction in patients admitted with acute myocardial infarction. The ECGs from 290 patients were evaluated by three physicians with respect to the occurrence of each of the following seven criteria suggestive of atrial infarction: (1) PR-segment elevation > 0.5 mm in lead I; (2) PR-segment depressions > 0.5 mm in leads II and III; (3) PR-segment depressions > 1.2 mm in leads I, II, and III; (4) PR-segment depressions > 0.5 mm in leads V1 and V2; (5) PR-segment elevations > 0.5 mm in leads V5 and V6; (6) PR-segment depressions > 1.5 mm in precordial leads; and (7) abnormal P waves. Kappa values ranged from 0.00-0.86. Of the seven criteria tested only criteria 2, 4, and 7 could be detected in a reasonable number of patients. The interobserver variations of these criteria were considerable, although the strength of agreement could be designated as fair to moderate.

[The accuracy and reproducibility of clinical examination of adenoma of the thyroid--corrected for randomness with iota and kappa]. / Rigtighed og reproducerbarhed ved klinisk undersøgelse for adenomer i glandula thyreoidea--korrigeret for tilfaeldighed med "iota" og "kappa".

The aim of this study was to evaluate the reliability (accuracy and observer variability) of the clinical examination of the thyroid gland for adenomatous changes. All patients (n = 105) admitted for scintigraphic examination of the thyroid gland were examined by three observers and the thyroid scintigraphy was performed. The study population consisted of the patients (n = 84), where the result of the scintigraphic examination could be classified as either "normal" (n = 24), "solitary adenoma" (n = 32) or "nodular goitre" (n = 28), with scintigraphy used as golden standard. The accuracy was evaluated using each observer's sensitivity, specificity and total agreement with the golden standard for each diagnosis and the observer variability by the overall agreement between each pair of observers. After random agreement was eliminated by calculation of iota and kappa, the results showed a fair reliability of the clinical diagnoses "normal" and "solitary adenoma" (iota between 0.20 and 0.62; kappa between 0.33 and 0.46), but poor reliability for "nodular goitre", (iota between 0.00 and 0.50, kappa between 0.00 og 0.46). Calculation of the newly introduced iota is discussed in the appendix.

[The clinical relevance and reproducibility of pedal pulse palpation]. / Klinisk relevans og reproducerbarhed af pulspalpation på foden.

The object of the present investigation was to investigate the diagnostic information which can be obtained by pedal pulse palpation. This is done by relating the findings on pulse palpation to the measured distal systolic blood pressure and comparison of these results with those of previous examinations where the connection between the distal systolic blood pressure and the prognosis is illustrated. In addition, the reliability of pulse palpation was assessed by an inter-observer investigation. Fifty four patients (average age 66 years) suspected of occlusive arterial disease participated in the investigation. Three observers undertook pulse palpation on the foot in a randomized sequence. The pulse in a foot was defined as the pulse in the dorsalis pedis artery and/or the pulse in the posterior tibialis artery. After this, the distal systolic blood pressure was measured in the patients with the strain gauge technique. Considerable inter-observer agreement was found (kappa-values between 0.66 and 0.76). Provided an observer found the pulse present, severe occlusive arterial disease could be excluded (ankle index less than 50%, toe pressure less than or equal to 30 mmHg). Absence of pulse in a foot provides a high probability for an ankle index less than or equal to 90% and thus a high probability for presence of occlusive arterial disease, but the extent of this cannot, however, be described.

[The post-thrombotic syndrome. Description and comparison of diagnostic methods: clinical examination, venous return time, phlebography and ultrasonography]. / Det posttrombotiske syndrom. Beskrivelse og sammenligning af diagnostiske undersøgelsesmetoder: Klinisk undersøgelse, venøs returtid, flebografi og ultralyd.

Thirty-one patients with deep vein thrombosis (DVT) confirmed by phlebography 5-11 years previously were examined for the post-thrombotic syndrome (PTS). Where all of the patients were concerned, the examination included crossing-off of their symptoms of PTS on a special chart and clinical examination carried out by four doctors independently of one another, for 29 patients also determination of the venous return time by strain gauge pletysmography and for 29 patients also secondary phlebography (SF) and B-method ultrasonic scanning (UL). The degree of severity of PTS was determined by means of a scoring value which was calculated on the bases of four observers assessment of the clinical symptoms and findings. Significant differences were found for the clinical scores for legs with and without previous DVT, which shows that the method is of value despite a not inconsiderable interobserver variation. In the form employed here, pletysmography was found unsuitable for quantitating of PTS. In 60% of the patients, agreement was present between the clinical assessment, SF and UL. The necessity of agreement both as regards the diagnostic clinical criteria and as a measure for the degree of severity of PTS is emphasized. UL is recommended as a screening investigation for changes after DVT. Phlebography is only considered to be indicated in cases where detailed knowledge of the anatomical conditions is desired e.g. prior to venous surgery.

A model for prediction of failure in amputation of the lower limb.

A logistic regression analysis of eighteen variables in eighty-three lower limb amputations was performed in order to predict stump failure. Five variables were identified as having a significant effect on the logistic model: Age had an inverse relation to failure rate (p less than 0.005). This effect was mediated through a subgroup of 23 patients who had had a vascular operation (p less than 0.02), as this group had a higher failure rate and were younger than those without previous vascular surgery. Furthermore, the surgical experience (p less than 0.005) was of major importance for stump failure. Experienced surgeons had a failure rate of 2% while less experienced had a rate of 29% (p less than 0.001). In addition, it was confirmed that the higher the skin perfusion pressure (p less than 0.05) and the amputation level, (p less than 0.05) the better the healing. A model including "skin perfusion pressure," "previous vascular surgery," "amputation level" and "surgical experience" had a good predictive capability with a misclassification rate of 0.08-0.11. Therefore it is suggested that a logistic model including these variables could be a helpful tool to predict the risk of stump failure.

Selection of lower limb amputation level not aided by transcutaneous pO2 measurements.

The transcutaneous oxygen pressure measurements were evaluated as supplementary ones for predicting stump healing in 58 below-the-knee and 16 above-the-knee amputations; the lower level was selected if the skin perfusion pressure was greater than 30 mm Hg below the knee. The failure rates in below-the-knee and above-the-knee amputations were 17 and 25 percent, respectively, and unrelated to the transcutaneous oxygen pressure measured at the amputation level. We conclude that no further information is acquired by measuring transcutaneous oxygen pressure.

The influence of epidermal thickness on transcutaneous oxygen pressure measurements in normal persons.

Transcutaneous oxygen pressure measurements (TcPO2) were performed in ten healthy men (age 30.6 years, range 28-35) in six regions: anterolaterally 10 cm below and above the knee on both legs, 5 cm laterally to umbilicus and on the inside of the left humerus, which was subsequently biopsied for measurements of epidermal thickness from the basal lamina to the uppermost layer of stratum granulosum. Transcutaneous oxygen pressure was on average 70 mmHg (range 42-88 mmHg), and that of epidermal thickness 70 microns (range 43-120 microns). Epidermis was thinnest on the inside of the humerus (mean +/- SD) 61.3 mu +/- 11.0 and about 25% thicker (NS) in the regions above and below the knees. The relationship between TcPO2 (y) and epidermal thickness (x) could be described by the regression equation y = alpha i - 0.26x where the intercept alpha i differed between subjects, the mean value being 88 mmHg (range 77-103). The common regression coefficient of -0.26 was significantly different from zero (p less than 0.01, r2 = 0.49). Although the oxygen gradient across the total epidermis can not be estimated from skin biopsies, correction for the thickness of the living part of the skin may prove beneficial when TcPO2 measurements are used as an indicator of wound healing. The results suggests that the change of oxygen tension across the living part of epidermis is 0.26 mmHg/micron at various skin locations in different subjects.

Clinical relevance of pedal pulse palpation in patients suspected of peripheral arterial insufficiency.

Previous studies in patients with peripheral arterial disease (PAD) have shown that the prognosis is relatively good when the distal systolic ankle index (ankle systolic pressure/arm systolic pressure) is above 50% and the distal toe systolic pressure is above 40 mmHg. In 132 patients suspected of PAD in the legs we investigated the relationship between the presence of pedal pulse and the distal systolic pressure in order to discover what diagnostic and prognostic information could be found from pulse palpation alone. The prospective study consisted of three consecutive series (A, 51 patients; B, 42 patients; and C, 39 patients); three of the authors palpated the arteries of the patients' feet: one author in each series. The palpatory findings were related to the distal systolic pressures. When pedal pulses were present we found: (a) ankle indices above 50%; and (b) toe systolic pressures above 40 mmHg. These minimal pressure values were reproducible in the three series. Furthermore, patients lacking palpable pulses in both feet had ankle indices below 90%. We conclude: (a) if pulses are palpable on both feet of a patient the prognosis for progression is relatively good regarding the patient's PAD; (b) if pedal pulse is palpable an arteriosclerotic ulcer on the foot will heal; and (c) patients lacking palpable pulses in both feet actually suffer from PAD.

Vasospastic angina assessed by hyperventilation-thallium-201 myocardial scintigraphy.

The response to prolonged hyperventilation (HVT) was evaluated by electrocardiography (HVT-ECG) and thallium-201 myocardial scintigraphy (HVT-Tl-Sc) in 40 patients suspected of vasospastic angina. Both tests showed ischaemic changes in 16 patients and no changes in 20 patients. Two patients had abnormal HVT-ECG and normal HVT-Tl-Sc, and the reverse combination was found in two patients. Prolonged HVT was performed in 14 patients during coronary angiography (CAG). Nine developed transient total or subtotal occlusion in one of the major coronary arteries, all of whom had ischaemic HVT-ECG and eight had abnormal HVT-Tl-Sc. In the five patients without spasm at CAG four had normal HVT-ECG and all five normal HVT-Tl-Sc. Our data suggest that HVT-ECG and HVT-Tl-Sc have essentially the same sensitivity and specificity in detecting vasospastic angina.

Altered plasma concentrations of glutamate, alanine and citrate in the early phase of acute myocardial infarction in man.

Plasma levels of glutamate, alanine, free fatty acids (FFA), citrate, glucose, insulin, lactate, creatine kinase and aspartate aminotransferase were determined frequently during the first 2-48 h after onset of chest pain in 10 patients who developed acute myocardial infarction (AMI) and in 8 who did not (non-AMI). An initial decrease in plasma glutamate and increase in alanine was found in AMI compared to non-AMI patients. The AMI group showed early, moderate rises of plasma FFA and citrate concentrations, positively related to the initial ST-segment elevation and to the enzymatic estimated infarct size. The AMI patients were continuously hyperglycaemic, but their relative insulin response i.e. plasma glucose/insulin ratio was identical to that of non-AMI patients. Lactate values did not differ between the two groups. Via participation in the malate-aspartate shuttle and by shunting pyruvate to alanine instead of lactate, glutamate is of importance for maintaining myocardial glucose utilization. Our finding of initial low plasma glutamate concentrations after onset of myocardial infarction suggests insufficient glutamate supply to the ischaemic myocardium. On basis of this and animal experiments, an external supply of glutamate might be a 'metabolic' treatment of AMI, alternative or additional to glucose-insulin-potassium infusion in order to promote myocardial glucose oxidation.

Increased myocardial contractility in short-term type 1 diabetic patients: an echocardiographic study.

Cardiac function was investigated by echocardiography in 24 short-term Type 1 diabetic patients with a mean diabetes duration of 7 years (range 4-14 years) during conditions of ordinary metabolic control. Compared to 24 age and sex matched normal control subjects, measurements of myocardial contractility as left ventricular fractional shortening and mean circumferential shortening velocity were increased by 12% and 20% respectively. Another 8 Type 1 diabetic patients were examined during conditions of poor (hyperglycaemia and ketosis) and good metabolic control. Following improved glycaemic control, left ventricular fractional shortening and mean circumferential shortening velocity decreased by 16% and 24% respectively. Our findings show that short-term Type 1 diabetes is associated with increased myocardial contractility. Furthermore, this condition is related to the state of metabolic control.

Exercise capacity and cardiac function in type 1 diabetic patients treated with continuous subcutaneous insulin infusion. A controlled study.

In order to investigate the effect of improved glycaemic control on exercise capacity and cardiac function, bicycle exercise and echocardiography at rest and after exercise was performed in 24 short-term type 1 diabetic patients, randomized to conventional insulin therapy (CIT) or to continuous subcutaneous insulin infusion (CSII). After 6 months significant improvement in glycaemic control was seen in the CSII group showing a decrease in mean blood glucose and haemoglobin A1c (HbA1c), while no change was observed in the CIT group. Exercise capacity increased by 24% (p less than 0.01) in the CSII group and decreased by 16% (NS) in the CIT group. In the CSII group fractional shortening of the left ventricle during rest decreased by 14% (p less than 0.02), while an increase of 2% (NS) was seen in the CIT group. Further, changes of left ventricular fractional shortening during rest were inversely correlated to changes in exercise capacity. After exercise, fractional shortening of the left ventricle and rate-pressure product was unchanged in the two groups. In conclusion this study shows a beneficial effect of improved glycaemic control induced by CSII on exercise capacity possibly by reducing resting state demands to the cardiovascular system.