Search

Study Design: A prospective randomized controlled trial (RCT) in persons with spinal cord injury (SCI) and ongoing pressure injury (PI)., Objectives: The main aim was to perform a cost-utility analysis (CUA) alongside the RCT comparing regular care to regular care with additional videoconference consultations. Secondary aims were to assess costs and greenhouse gas emission related to transportation in the two study groups., Setting: Two spinal cord units in Norway., Methods: Participants were allocated to a regular care group (RCG) and a regular care group with additional videoconference (VCG), in a 1-year follow-up between 2016 and 2018. Costs were prospectively collected, and health-related quality of life (HRQoL) data were collected at baseline and 12 months. The outcome was quality-adjusted life years (QALYs), derived from the EQ-5D-5L questionnaire. Results are reported as incremental cost-effectiveness ratio (ICER), expressed as the cost per additional QALY gained. Transportation related costs and environmental emissions were compared by t-tests., Results: There were 56 participants included, 28 in each group. Of these 27 in the VCG and 26 in the RCG completed. Three participants died. The mean cost per patient was € 8819 in the VCG and € 3607 in the RCG, with 0.1 QALYs gained in the VCG. No significant differences were identified regarding HRQoL or secondary outcomes., Conclusion: The VCG costs € 5212 more for an additional 0.1 QALYs, giving an ICER of € 52,120 per QALY. No significant differences were found regarding transportation-related costs, or emission of greenhouse gases., Trial Registration: www., Clinicaltrials: gov ; NCT02800915, TeleSCIpi. CRISTIN.no. https://app.cristin.no/projects/show.jsf?id=545284 . Sunnaas Rehabilitation hospital's web page, available at https://www.sunnaas.no/fag-og-forskning/fagstoff/sar ., (© 2024. The Author(s).)

This exploratory descriptive study aimed to describe characteristics and management of background pain related to chronic leg ulcers. A total of 121 participants were recruited from two wound care clinics using a consecutive sampling method. Data were obtained through screening interview, clinical examination, and questionnaires. The mean average background pain intensity was 4.5 (SD 2.56) (CI 95% 4.0-5.0). Pain interfered mostly with general activity (mean 4.3), sleep (mean 4.1), and walking ability (mean 4.0) (0-10 NRS). The most frequently reported descriptors of background pain were 'tender', 'stabbing', 'aching', and 'hot-burning'. Most of the participants stated that the pain was intermittent. Less than 60% had analgesics prescribed specifically for ulcer related pain, and the respondents reported that pain management provided a mean pain relief of 45.9% (SD 33.9, range 0-100). The findings indicate that ulcer related background pain is a significant problem that interferes with daily function, and that pain management in wound care is still inadequate., (© 2021 The Authors. International Wound Journal published by Medicalhelplines.com Inc (3M) and John Wiley & Sons Ltd.)

Background: Geographical, financial and travel-related barriers may impact access to necessary health care for people in need of long-term follow-up., Objective: The goal of the research was to perform a nonblinded, randomized, controlled trial on health-related quality of life (HRQoL), healing, interaction, and satisfaction of patients with spinal cord injury (SCI) and PI receiving multidisciplinary videoconference consultations from a wound clinic to the participant's home versus regular outpatient care. The multidisciplinary team consisted of a medical doctor, a wound nurse, and an occupational therapist. In both groups, district nurses attended the consultations at the participant's home., Methods: A total of 56 participants, 28 in each group, were randomized to a videoconference group (VCG) or a regular care group (RCG). Validated questionnaires were used to measure and compare the follow-up effect on HRQoL. Percentage reduction of wound volume was measured at end of the follow-up. A Likert scale was used to measure the satisfaction of the patients and district nurses regarding the interaction between different modalities of care in the 2 groups., Results: The HRQoL did not show significant differences between the 2 groups (P values ranging from .09 to .88) or the rate of PI healing, experienced interaction, and satisfaction in the groups. A total of 67% (37/55) of all PIs healed, 64% (18/28) in the VCG and 70% (19/27) in the RCG. Mean reduction in ulcer volume was 79% in the VCG and 85% in the RCG (P=.32). A Kaplan-Meier plot with a logrank test regarding time to healing did not show any significant difference between the 2 groups., Conclusions: Videoconference-based care seems to be a safe and efficient way to manage PIs in terms of HRQoL, healing, interaction, and satisfaction compared to conventional care for people with SCI. This should be considered when planning for future care. SCI has a huge impact on the individual, the family, and the health care system. There is an urgent need to improve systems of care so that individuals who live far from specialists and require long-term follow-up for conditions such as PI can get optimal treatment., Trial Registration: ClinicalTrials.gov NCT02800915; https://clinicaltrials.gov/ct2/show/NCT02800915 and Current Research Information System in Norway (CRISTIN) 545284; https://app.cristin.no/projects/show.jsf?id=545284., (©Ingebjørg Irgens, Jana Midelfart-Hoff, Rolf Jelnes, Marcalee Alexander, Johan Kvalvik Stanghelle, Magne Thoresen, Tiina Rekand. Originally published in JMIR Formative Research (https://formative.jmir.org), 19.04.2022.)

Study Design: A national, retrospective, cross-sectional study., Objectives: To analyze the prevalence of pressure injury (PI), and characteristics associated with PI development in the hospitalized population of persons with a newly acquired spinal cord injury (SCI) between 2004 and 2014., Setting: All three specialized Spinal Cord Units in Norway., Methods: Demographic data related to prevalence and potential risk factors were retrieved from the electronic medical record (EMR). Statistical analyses were performed, using IBM SPSS Statistics, version 23., Results: We identified 1012 individuals with a new SCI. Mean age at injury was 48 years (SD 19). The period prevalence of PI was 16% (95% CI = 0.14-0.19), and identified PI associations were complete SCI (OR = 0.1), being injured abroad (OR = 2.4), bowel (OR = 13), and bladder (OR = 9.2) dysfunction; comorbidities like diabetes mellitus 1 (OR = 7.9), diagnosed depression (OR = 3.8), ventilator support (OR = 3.0), drug abuse (OR = 3.0), and concurrent traumatic brain injury (OR = 1.7). Individuals in the age group of 15-29 years had higher odds of PI compared with middle-aged individuals (45-59 years)., Conclusion: PI is a serious complication after SCI. The association between depression or comorbidity and PI occurrence should be investigated more thoroughly. We recommend implementation of a simple follow-up program regarding observation and prevention of PI. Increased awareness of factors that could contribute to PI will help to focus on better prevention and early recognition of PI. This will contribute to more optimal rehabilitation.

Background: Incontinence-associated dermatitis (IAD) is a specific type of irritant contact dermatitis with different severity levels. An internationally accepted instrument to assess the severity of IAD in adults, with established diagnostic accuracy, agreement and reliability, is needed to support clinical practice and research., Objectives: To design the Ghent Global IAD Categorization Tool (GLOBIAD) and evaluate its psychometric properties., Methods: The design was based on expert consultation using a three-round Delphi procedure with 34 experts from 13 countries. The instrument was tested using IAD photographs, which reflected different severity levels, in a sample of 823 healthcare professionals from 30 countries. Measures for diagnostic accuracy (sensitivity and specificity), agreement, interrater reliability (multirater Fleiss kappa) and intrarater reliability (Cohen's kappa) were assessed., Results: The GLOBIAD consists of two categories based on the presence of persistent redness (category 1) and skin loss (category 2), both of which are subdivided based on the presence of clinical signs of infection. The agreement for differentiating between category 1 and category 2 was 0·86 [95% confidence interval (CI) 0·86-0·87], with a sensitivity of 90% and a specificity of 84%. The overall agreement was 0·55 (95% CI 0·55-0·56). The Fleiss kappa for differentiating between category 1 and category 2 was 0·65 (95% CI 0·65-0·65). The overall Fleiss kappa was 0·41 (95% CI 0·41-0·41). The Cohen's kappa for differentiating between category 1 and category 2 was 0·76 (95% CI 0·75-0·77). The overall Cohen's kappa was 0·61 (95% CI 0·59-0·62)., Conclusions: The development of the GLOBIAD is a major step towards a better systematic assessment of IAD in clinical practice and research worldwide. However, further validation is needed., (© 2018 British Association of Dermatologists.)

The following article presents a telemedicine system that has been introduced in southern Jutland, Denmark. Using 'low-tech' equipment, such as camera-equipped mobile phones and normal desktop computers with an internet connection, health professionals have been able to communicate and collect data in a clinical database more effectively. This system aims to improve interdisciplinary collaboration, through facilitating the interaction between health professionals and also other parties that are involved in the provision of care, such as administrative staff and local reimbursement authorities.

The aim of the study was to evaluate the use of freeze-dried and dissected small muscle biopsy specimens ("dry") for the determination of human muscle electrolyte content and ouabain binding capacity, compared with an easier method, without this freeze-drying step ("wet"). Freeze-drying and dissection of muscle biopsy specimens reduced the variation in the determination of muscle potassium and magnesium content. The total coefficient of variation was 8.6% in the dry determination of muscle potassium content and 13.5% in the wet determination (P < 0.05). In the determination of muscle magnesium content, the total coefficient of variation was 7.4% in the dry determination and 13.7% when determined wet (P < 0.005). Muscle sodium content had a very large coefficient of variation, independent of the method used. The content of dry solids was too high in biopsies which were incubated in Tris-vanadate buffer (31.9%), compared to biopsies which were not incubated in Tris-vanadate buffer (24.9%, P < 0.001). Hereby, the measured ouabain binding capacity became too high when measured wet. In conclusion, muscle electrolyte content and ouabain binding capacity should be determined after drying and microdissection of the biopsies, because this method confers the least variation and the highest accuracy., (Copyright 1998 Academic Press.)

Biochemical analysis and immunohistochemical techniques support the theory that hyperamylasaemia in lung cancer is due to amylase production in carcinoma cells. The vast majority of amylase-producing carcinomas are adenocarcinomas with amylase isoenzyme similar to the salivary type. This prospective study assesses alpha-amylase expression in resectable lung cancer. Seventy four patients with resectable lung cancer were studied. Amylase activity in tumour tissue was analysed and isoamylase identification performed. Immunohistochemical analysis was performed using a polyclonal rabbit antibody against human salivary amylase. Hyperamylasaemia occurred in 13 out of 70 patients. Increased amylase activity in tumour tissue was found in 10 out of 52 cases, of which only two were associated with hyperamylasaemia. With the exception of one large cell carcinoma and one squamous cell carcinoma, the tumours were adenocarcinomas. Immunohistochemical analysis revealed amylase expression in seven adenocarcinomas and two adenosquamous carcinomas. In conclusion, immunohistochemical amylase expression was restricted to carcinomas with adenomatous differentiation. Biochemical analysis confirmed amylase production in 5 of 7 cases examined, the tissue amylase isoenzymes being of salivary type. However, hyperamylasaemia and a slightly increased amylase activity in tumour tissue may be caused by factors other than amylase-producing carcinoma cells.

Patients with primary hyperparathyroidism have increased bone turnover, but it is less well documented how brief periods of excess parathyroid hormone (PTH) (endogenous or exogenous) affect bone metabolism. In the present double blind study, we examined the effect of either ethylenediaminetetraacetatic acid (EDTA) or placebo on serum levels of PTH and biochemical markers of bone turnover in 15 women and 39 men (aged 41 to 81 years) suffering intermittent claudication due to atherosclerosis. Disodium EDTA was administered as 20 repeated infusions of 3 grams during a period of 5-9 weeks. Serum calcium and serum phosphate decreased following treatment (p < 0.001) and remained unchanged in the placebo group. However, the differences between the groups were insignificant (ANOVA p = 0.13 and p < 0.10, respectively). PTH increased 2 1/2 fold following EDTA treatment (p < 0.001, ANOVA). The change in serum PTH was inversely correlated with the change in serum calcium (r = -0.53, p < 0.01). In the EDTA group, urinary hydroxyproline/creatinine and calcium/creatinine increased after treatment (ANOVA p < 0.001 and p < 0.05, respectively). Serum bone alkaline phosphatase decreased significantly in the EDTA group immediately after treatment (p < 0.001, ANOVA) and returned to baseline level at three months while only an insignificant decrease in serum osteocalcin was seen following treatment. We conclude that EDTA treatment increases endogenous PTH secretion considerably and leads to increased bone resorption. However, no changes in osteoblastic markers indicating increased activation of bone remodeling could be demonstrated. Our findings support that chelation therapy with EDTA is accompanied by bone loss.

Objective: To study whether intravenous disodium-ethylene diamine tetraacetic acid (EDTA) affects blood lipids in patients with intermittent claudication., Design: Double-blind, randomized, placebo-controlled trial., Participants: Twenty-nine patients with intermittent claudication (systolic ankle-brachial blood pressure index < 0.8; pain free walking distance 50-200 m)., Intervention: 3 g EDTA or placebo (isotonic saline) per infusion over a period of 5-9 weeks to a total of 57 g EDTA. Patients received vitamins, minerals and trace-elements daily., Results: 14 patients received EDTA and 15 placebo. There was no statistically significant difference in the plasma concentration of cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol or triglyceride between the 2 groups., Conclusion: Treatment with EDTA does not alter blood lipids in patients with intermittent claudication.

During the period July 1987-April 1988, ninety-one patients with arterial insufficiency in the lower limbs were referred to the Department of Thoracic and Vascular Surgery at Aalborg Hospital. The mean delay between contact with the general practitioner and the vascular surgeon was nine months. Twenty-nine of the patients contacted alternative therapists before referral to the vascular surgeon. Twenty-five of these patients had suffered from intermittent claudication for at least two years and the total cost of treatment was 76,013 Danish crowns (900 Danish crowns or approximately pounds 75 per patient).

A 62-year-old man suffering intermittent claudication had 20 infusions of EDTA in a double blind, placebo controlled trial. No effect on symptoms or systolic ankle/brachial blood pressure index was found. Following the trial, he received 30 further infusions of EDTA in a private clinic. The systolic ankle/brachial index was unchanged throughout the total period as measured in Hillerød Central Hospital. However, the private clinic found a significant increase in the index following EDTA treatment. The reason for this discrepancy could be poor technique in the clinic or it could be due to bias or manipulation. The discrepancy explains the difference between the positive results claimed by the private EDTA clinics and the results of the double blind placebo controlled Danish trial.

Intermittent claudication is a symptom triggered from the musculature during walking. The pathogenesis of the pain is unknown. All patients with peripheral vascular disease must abstain from smoking, perform physical exercise and dietary advice is sometime needed. Reconstructive vascular surgery or percutaneous transluminal angioplasty (PTA) are indicated when the occupational pattern and, in some instances, the recreational activities, are threatened. The results of these treatments are good. For various reasons a number of patients, however, cannot be offered these treatments. These patients must be informed of the importance of physical exercise and discontinuation of smoking. Some of these patients can be offered supplementary medical treatment (e.g. pentoxifylline).

A double-blind, randomized multicentre study was undertaken to evaluate the possible effect of chelation treatment with ethylenediamine-tetraacetic acid (EDTA) in patients with severe intermittent claudication. A total of 153 patients received 20 intravenous infusions of either 3 g Na2EDTA or placebo during a period of 5-9 weeks. Vitamin, mineral and trace element supplements were administered orally. The changes observed in the pain-free and maximal walking distances, measured on a treadmill, were similar in the two groups. During the 3-month (n = 149) and 6-month (n = 123) follow-up period, no long-term therapeutic effect of EDTA could be demonstrated. The ankle-brachial blood pressure index remained unchanged throughout the study period. This study failed to demonstrate any effect of EDTA chelation treatment in intermittent claudication.

Nocturnal fluctuations in subcutaneous blood flow in the lower leg and foot were measured during sleep in Type 1 diabetic patients without autonomic neuropathy. Subcutaneous blood flow was measured, simultaneously, 100 mm above the malleolus on the medial aspect of the right lower leg and at the dorsum of the left foot in 10 diabetic patients, and on the right lower leg only in 10 normal human subjects over 12-20 h. The 133Xe wash-out technique, portable CdTe (Cl) detectors and a portable data storage unit were used. The tracer depots were applied by means of the epicutaneous, atraumatic labelling technique. In diabetic patients, subcutaneous blood flow increased 102 +/- 68% in the lower leg and 111 +/- 98% in the foot at 113 +/- 32 min and 107 +/- 37 min, after going to sleep. The hyperaemic phase lasted 128 +/- 43 min and 150 +/- 42 min, respectively. The hyperaemic response was not different from that in the control subjects (89 +/- 61%). There was no significant correlation between the absolute hyperaemia in the leg and that in the foot. In conclusion, Type 1 diabetic patients without autonomic neuropathy have normal nocturnal hyperaemia during sleep.

In a randomized, double-blind, controlled study, 153 patients with claudication were each given either 20 infusions of Na2EDTA or 20 infusions of saline. Walking distances and ankle/brachial indices were measured before, during, and after treatment. In 30 patients, angiograms and transcutaneous oxygen tensions were obtained before, during, and after treatment. The patients' subjective evaluations of the effect of treatment were also recorded. It is concluded that EDTA chelation therapy has no effect in patients with intermittent claudication in the legs caused by arteriosclerosis.

Primary aorto-enteric fistulas is now being a rare occurrence because of an aggressive approach in terms of surgery of abdominal aortic aneurysms. Three cases is presented in an attempt to elucidate the ethiology, pathogenesis and diagnostic possibilities when dealing with primary aorto-enteric fistulas. The clinical presentation of the patients with primary aorto-enteric fistulas is inconstant, but a hightened index of suspicion should be present when a patient presents with gastrointestinal bleeding of obscure origin, abdominal or back pain and an abdominal mass. Endoscopy and diagnostic imaging may detect a fistula, but a high rate of false negative investigations are produced. The result of diagnostic workup is often laparotomy, which is the safest diagnostic method and may save the patients life.

A method for continuous measurement of subcutaneous adipose tissue blood flow in the forefoot over 24 h (SBF) is described. The method is based on the radioisotope wash-out principle using 133-Xenon (133Xe). A portable semiconductor detector is placed just above a local depot of 37-74 kBq 133Xe in 0.1 ml isotonic saline, injected into the subcutaneous adipose tissue in the forefoot. The detector is connected to a memory unit allowing for storage of data. Because of the short distance, the recorded elimination rate constant must be corrected for combined convection and diffusion of the radioactive indicator. Characteristic 24-h blood flow patterns were unveiled in patients with normal peripheral circulation and in patients having ischaemic nocturnal rest pain. In normal subjects, SBF doubled from day to night. This is ascribed to the local veno-arteriolar sympathetic axon reflex, which induces vasoconstriction when the transmural pressure of the veins exceeds approximately 25 mmHg. In patients having ischaemic rest pains SBF was reduced by 37% on the average from day to night. This was caused by nocturnal hypotension, which is reflected proportionally in the foot. As the resistance vessels most probably are fully dilatated in feet with rest pain, the blood pressure drop during sleep causes the perfusion pressure and, therefore, blood flow to drop below a certain critical limit. There was a pronounced correlation between the reduction systemic mean arterial blood pressure and SBF. The patients complaining of intermittent claudication, but no rest pains, demonstrated a variety of changes in SBF compatible with the continuous spectrum of peripheral arteriosclerotic disease. The reduced blood flow during sleep in patients having ischaemic rest pains give rise to the concept of the development of gangrene during sleep.

During a 4 1/2-years period sigmoideoscopy was performed when patients developed diarrhea and/or unexpected low abdominal pain within the first days following aortic reconstruction. In our investigation rigid sigmoideoscopy, revealed all the cases of major ischemic colitis.

The effect of initial elective arterial reconstructive surgery was evaluated in relation to employment and social status. Ninety patients with intermittent claudication were followed for a period of 3.5 years. The male to female ratio was 1:12. At the time of operation, all the patients were under the age of 60 years and potentially professionally active. The indication for operation in fifty-nine patients was intermittent claudication. For thirty-one patients, the indication for operation was ischaemic rest pain, gangrene or ulcer. Fifty-six patients (74%) returned to active employment following vascular reconstructive surgery. It is concluded that reconstructive vascular surgery is of great importance for rehabilitation and in the success of resumption of active employment.

This study evaluates iliofemoral bypass reconstruction in limb-salvage, graft patency, and appearance of contralateral symptoms. The study included 62 consecutive iliofemoral bypass reconstructions during 1980-82. The indication for surgery was disabling intermittent claudication in 19% of the patients and severe ischaemia in 81%. At follow-up 42 patients were examined, 16 were dead and 4 were lost to follow-up. The primary mortality was 5%. At 3 years postoperatively the survival rate was 78%, ipsilateral limb-salvage 88%, graft patency 83%, and patency of the contralateral iliofemoral segment 92%. During the follow-up period reconstructive vascular surgery on the contralateral aortoiliac segment was performed in only 3 patients. The results of the iliofemoral bypass reconstruction in this study were comparable to the results of aortic bifurcation grafts, and the patency of the contralateral iliofemoral segment was higher than might have been expected. The iliofemoral bypass reconstruction seems to be useful for patients with unilateral affection of the iliofemoral segment, for limb-salvage concerning patients in poor general condition, and for patients who have had a contralateral amputation.

In this study 624 trochanteric and subtrochanteric femoral fractures have been assessed retrospectively with regard to stability of the fracture, reduction, internal fixation, healing and weight bearing. It is seen that stable fractures pose no serious problems. In the group of unstable fractures, varus displacement and perforation by the nail of the head of the femur occurred because of lack of stability of the McLaughlin apparatus. Results of a device with a fixed angle and a sliding screw nail are compared.

Wash-out of 133xenon from a local depot in the subcutaneous adipose tissue in the forefoot was measured continuously during 24 hours on subsequent recordings in 51 feet (normal circulation: 10, intermittent claudication: 22 and ischaemic nocturnal rest pain: 19) with a mean time interval of 26 days (range: 3-90 days). The patients were studied under two different conditions. Firstly, during the day in the erect position, awake (sitting, standing and quiet walking) and secondly, during night hours in the supine position, asleep. The coefficient of variation of nocturnal adipose tissue blood flow was calculated to 10%, and for the ratio of blood flow from day to night to 5%. The method is thus considered apt as a monitor in the treatment of peripheral vascular disease, for example, surgery and medical therapy. As predominant source of error is the formation of oedema.

The systolic pressure observed in 150 patients with peripheral arterial disease has been compared to their symptoms and signs. In patients with claudication the ankle mean pressure was 58 mmHg. In patients with rest pain it was 33 mmHg and in patients with chronic ulcerations it was 20 mmHg. In these 3 groups the mean ankle-foot pressure gradient was low (2-10 mmHg) were detected at the level of the iliaco-femoral and femora-popliteal segments. In the group of diabetic patients an high gradient was observed. Patients with peripheral arterial disease can be divided in four symptomatic groups but the angiographic and physiological patterns of patients with rest pain and ischemic ulcerations are similar and they are the best candidates to reconstructive arterial surgery.

A method is presented which allows for continuous registration of forefoot blood flow over 24 h. Blood flow was estimated by the radioactive Xenon washout method and a portable CdTe detector system was used to measure the tracer disappearance rate. Since the semiconductor detector is placed very close to the tracer depot the washout rates registered are a mixture of rate constants due to tracer removal by blood flow and diffusion of the tracer depot away from the detector. Rate constants only due to diffusion were obtained over 24 h from amputated feet and similarly from normal feet with circulatory arrest in several 20 min periods during 24 h. The rate constants due to blood flow could thus be calculated by subtraction of the appropriate diffusion rate constants from the recorded rate constants. Blood flow in the forefoot during 24 h was measured in 10 experimental subjects with normal peripheral circulation. Blood flow during daytime did not differ between the first and second day. Blood flow during night-time was about twice that during daytime.

The tissue-to-blood partition coefficient for Xenon (lambda Xe) in the subcutaneous tissue in the forefoot was determined by physical and chemical analysis. The difference between patients with normal circulation (n = 10) and serve ischaemia (n = 13) was insignificant; pooled mean: 7.42 +/- 1.57 ml x g-1. The lambda Xe in the forefoot was significantly lower than lambda Xe of the abdominal wall (lambda Xe - abd: 8.67 +/- 1.27 ml x g-1; P = 0.03). The influence of oedema on the local blood flow [in ml x (100 g x min)-1] and on the post-reconstructive hyperaemia (in ml x min-1) is discussed. It is concluded that local blood flow determinations, based on 133Xenon wash-out rates, in individual cases, are not possible. In subcutaneous tissue with low lipid contents, the ratio between the post- and preoperative wash-out rates tend to underestimate the post reconstructive hyperaemia. This is due to the volume increase of the subcutaneous tissue being larger than the decrease of the tissue-to-blood partition coefficient due to the oedema.

In a double-blind cross-over trial an oral thromboxane synthetase inhibitor (TSI) or placebo was given to 15 patients with severe foot ischaemia. After TSI therapy, rest pain remitted in nine out of 14 legs, while remission during placebo was seen in three out of 11 legs (NS). The ankle and toe systolic blood pressures remained constant during both study periods. Nocturnal adipose tissue blood flow in the forefoot was measured by the xenon wash-out method. A significant increase of the nocturnal perfusion rate constant during TSI therapy was found. A slight oedema developed during TSI therapy. This causes a change of the composition of the tissue under study and thus of lambda-xenon. The perfusion rate in the present study thus merely illustrates the latter and not a true increase in blood flow.

Four patients with bilateral arterial insufficiency were treated with i.v. hydroxyethylrutoside for three days (1.5 grs twice a day). All patients experienced relief of symptoms. By continuous registration of subcutaneous nutritional blood flow in the forefoot (by 133Xenon clearance technique) a significant increase in nutritional blood flow of 33% on the average during the second and third hour after medication could be demonstrated. The drug seems to be of use in treating subacute occlusions and thrombosis of arteries in the lower extremity.

Simultaneous measurement during 24 h of mean arterial blood pressure (MABP) and forefoot subcutaneous adipose tissue blood flow (SBF) was undertaken in eight patients (15 feet) with different degrees of arterial insufficiency. The recordings were undertaken with the patients in the supine position only. The MABP decreased by 19 +/- 9% from awake to asleep independently of symptomatology. In two limbs with normal circulation, SBF decreased by 8 +/- 7%. In five limbs with arterial insufficiency but no rest pain SBF decreased by 16 +/- 8%, and in eight limbs with ischaemic nocturnal rest pain, SBF was reduced by 32 +/- 12% during sleep. It is concluded that nocturnal hypotension is the major aethiological factor for the symptom ischaemic nocturnal rest pain.

This retrospective study of 279 embolectomies in 252 patients shows a mortality of 27%, and an amputation rate of 15% within the first month after the embolectomy. The mortality as well as the rate of amputations decreased through the first year. After this period the mortality was comparable to that of a normal population and the rate of amputation was negligible. The mortality rate as well as the number of amputations increased with increasing time-lag of the embolectomy. In addition, the rate of amputation increased with preexisting intermittent claudication. There was no significant difference in amputation rate between limbs with and without palpable pulsations in the groin on admission, but 8 out of 103 limbs without groin pulsations had successful major vascular reconstruction performed after failing embolectomy in contrast to none in the group where pulsations were present. In 28 patients the embolectomy was followed by impairment of renal function and 14 of these died. It is concluded that embolectomy must be performed as early as possible, vascular reconstruction must be considered if the embolectomy fails to revascularize the limb, preventive measures should be taken against renal failure, i.e. the myonephropathic-metabolic syndrome.

We have studied the circulatory changes in the lower extremities after reconstructive vascular surgery in ten patients with intermittent claudication. The following examinations were carried out 3 days before, 3 days, and 28 days after the operation: measurement of ankle systolic blood pressure, calf plethysmography, resting calf muscle blood flow and resting subcutaneous foot blood flow. The vasoconstrictor response (veno-arteriolar reflex) was also assessed. On the night before the operation and on the 28th night after aorto-bifemoral bypass surgery, subcutaneous adipose tissue blood flow in the forefoot was measured during sleep. The ankle systolic blood pressure and the ankle index rose significantly. The former increased from 57 +/- 16.4 mmHg to 93 +/- 24.0 mmHg (mean +/- S.E.M.) and was still elevated on the 28th postoperative day. The total limb blood flow, the muscle blood flow and the blood flow in the subcutaneous tissue of the forefoot during daytime were unchanged. In contrast, the blood flow in the forefoot during sleep increased significantly from 3.5 +/- 1.63 ml x (min x 100 g)-1 to 5.2 +/- 2.14 ml x (min x 100 g)-1 (mean +/- S.E.M.) on the 28th night. The vasoconstrictor response was potentiated, and increased from 27% before the operation to 45% on the third postoperative day. This change was maintained 28 days postoperatively. In conclusion the increase in arterial blood pressure was only reflected in the vasoconstrictor response which had returned to normal by the third postoperative day and nocturnal blood flow in the subcutaneous adipose tissue which did likewise.

131Iodo-antipyrine (131I-AP) is commonly used for blood flow measurements in adipose tissue. These estimations have been based on the assumption of the tissue-to-blood partition coefficient being 1 ml g-1. No exact determination of the tissue-to-blood partition coefficient for 131I-AP in adipose tissue has been carried out. In the present study a partition coefficient of 1.12 +/- 0.06 (mean +/- S.D.) for 131I-AP in adipose tissue has been determined based on the partition coefficient for 131I-AP between lipid-saline (1.24 ml g-1), red blood cells-plasma (0.64 ml g-1), protein-saline (0.19 ml g-1) and plasma-saline (0.84 ml ml-1).

The effects of acebutolol (with intrinsic sympathomimetic activity (ISA] and metoprolol (without ISA) on arm blood pressure, ankle systolic blood pressure, claudication distances (CD) and maximal walking distances (MWD) were compared in patients with essential hypertension and intermittent claudication. Fourteen patients participated in a long-term, open, randomized cross-over study. After randomization the patients received either acebutolol, 200 mg b.i.d., or metoprolol, 100 mg b.i.d. After eight weeks the drugs were shifted and after another eight weeks they were withdrawn. Arm and ankle blood pressure, CD and MWD were determined before randomization and after 4, 8, 12 and 16 weeks, and again 4-6 weeks after withdrawal of the drugs. The arm blood pressure was reduced by 20/13 mmHg after acebutolol and by 22/21 mmHg after metoprolol. In spite of a significant decrease in arm blood pressure there were no significant changes in ankle blood pressure, CD or MWD after the two drugs. After withdrawal of the drugs and after the arm blood pressure had returned to the control value no significant changes were seen in CD, MWD or ankle blood pressure. It is concluded that beta-blockers have no deleterious effect on CD, MWD or ankle blood pressure in patients with hypertension and intermittent claudication. No effect of ISA was demonstrated.

In a series of 38 consecutive patients with advanced peripheral vascular disease (i.e. rest pain) reconstructive vascular surgery was performed with the distal anastomosis below the knee. Ankle/arm pressure index (AAI) was 0.28 (0.11-0.47) preoperatively; accumulated graft patency rate was 0.47 (SD = 0.08) after one year, after three years 0.22 (SD = 0.08). At follow-up (June 83) 34 patients were still alive, 11 patients with patent grafts and an AAI of 0.87 (0.74-1.01). During the study 19 patients required amputation. Seven patients had an occluded graft, but had avoided amputation. Although the prognosis in regard to graft patency is poor, we still suggest that distal vascular surgery should be considered prior to primary amputation.

The fate of 257 consecutive patients (100 women) aged 36-85 years (mean 65) first seen with intermittent claudication in 1977 was analysed after a mean of 6.5 (SD 0.5) years. When first seen none of the patients complained of rest pain or had ulcers or gangrenous lesions on the feet. At follow up 113 of the patients (44%) had died. Causes of death were no different from those in the general population. Mortality was twice that of the general population matched for age and sex. Mortality among the men was twice that among the women. In men under 60 mortality was four times that expected. The rate of clinical progression of the arteriosclerotic disease (that is, rest pain or gangrene) of the worst affected leg was 7.5% in the first year after referral. Thereafter the rate was 2.2% a year. An ankle systolic blood pressure below 70 mm Hg, a toe systolic blood pressure below 40 mm Hg, or an ankle/arm pressure index below 50% were individually significantly associated with progression of the arteriosclerotic disease. These findings show the importance of peripheral blood pressure measurements in the management of patients with intermittent claudication due to arteriosclerotic disease.

Local subcutaneous 133xenon (133Xe) elimination was registered in the human forefoot in 34 patients. The tissue/blood partition coefficient for Xe was estimated individually by simultaneous registration of 133Xe and [131I]antipyrine ([131I]AP) washout from the same local depot. When measured in this way, an average partition coefficient for Xe was found to be 4.3 +/- 1.23 ml g-1. This value is significantly lower than the partition coefficient found in a previous in vitro study in which a Xe partition coefficient of 7.5 +/- 1.57 ml g-1 was found. Thus, if the local blood flow is calculated using the partition coefficient found by the double isotope technique, significantly lower values are obtained than if the in vitro determined coefficient is used. This difference is explained mainly by local dilution when injecting xenon subcutaneously. In short-term studies, utilization of the double isotope technique reduces the coefficient of variation on average flow determinations, thus an improvement in accuracy of local blood flow estimation can be obtained compared to the method in which an average partition coefficient is used. For long-term studies a partition coefficient of 7.5 ml g-1 seems valid.

Adipose tissue blood flow in the forefoot was measured simultaneously with mean systemic arterial blood pressure over 24 hours in 8 patients (15 feet) with different degrees of arterial insufficiency. Mean systemic arterial pressure decreased by 19 +/- 9% during sleep, irrespective of symptomatology. In two limbs, with a normal peripheral circulation, blood flow decreased by 8 +/- 7%. In five limbs with arterial insufficiency, but no rest pain, blood flow decreased by 16 +/- 8% and in eight limbs with ischaemic nocturnal rest pain blood flow was reduced by 32 +/- 12% during sleep. It is concluded that nocturnal hypotension is a major factor in the production of nocturnal ischaemic rest pain.

Twenty-four hour continuous recording of xenon (133Xe) wash-out from the forefoot was performed on patients with normal circulations (n = 10) and on patients with different degrees of arterial insufficiency (n = 36). During day hours the calculated subcutaneous blood flow in the forefoot was on average the same in patients with normal circulations and in patients with different degrees of arterial insufficiency (mean: 2.0 +/- 0.8 ml min-1 100 g-1). During sleep the blood flow nearly doubled in patients with normal circulations; no systematic change was seen in patients with intermittent claudication. In patients with severe ischaemia, i.e. having rest pain, the blood flow decreased by approximately 50%. The changes in local blood flow may be due to changes in local sympathetic tone and to changes in local perfusion pressure.

In a patient who had sustained bullet wounding 9 years previously, acute appendicitis was associated with presence of a bullet in the appendix. The case is described.