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Background: Determination of the optimal amputation level is essential for patients, morbidity and rehabilitation. Various non-invasive procedures have been proposed to determine the optimal level of amputation. There is no consensus on the minimal tcPO2 level that is required to predict the healing of the stump. Therefore we aimed to rank the probability of primary wound healing at the most distal level and to answer the question if there is a lower limit of tcPO2 below which healing cannot occur. Patients and methods: 56 consecutive patients undergoing amputation below the knee for ischaemic gangrene of limbs were prospectively enrolled in the study. 39 were men (18 of whom were diabetics) and 17 women (8 diabetics) whose ages ranged from 45 to 87 years (mean 73 years). The total of 71 amputations was performed on the 56 patients: 39 below-knee with primary healing and, in 16 patients the above-knee reamputation was performed, due to the non-healing wound on the below-knee stump. The level of the amputation (below or above the knee) was in all cases decided solely on clinical grounds. TcPO2 was measured on each patient prior to amputation, on the dorsum of the foot and 10 cm below the knee. Results: The median tcPO2 value on the dorsum of the foot of diseased legs before amputation was 12 mm Hg (range from 0 to 22 mm Hg). At the anticipated level of the amputation of the shank, the median value of tcPO2 was 28 mm Hg (8–56 mm Hg). Patients with primary healing of postoperative wounds had significantly higher values of tcPO2 than patients with failure to heal (37mm Hg; range15–56mm Hg vs.18 mm Hg; range 8–36 mm Hg, p < 0.01). The success rate increased with higher tcPO2 values at the level of amputation. The 15% prevalence of reamputations was obtained for tcPO2 values between 25 and 36 mm Hg (median value 33 mm Hg) and the threshold value of tcPO2 below which the stump failed to heal was 15 mm Hg. Conclusions: Our study showed that tcPO2 is a reliable indicator of local ischemia. The integration of this parameter with other personal clinical criteria may be a valuable help to the surgeon in decision making.

Gužic-Salobir B, Keber I, Seljeflot I, Arnesen H, Vrabic L (University Medical Centre, Ljubljana, Slovenia; Ullevaal University Hospital, Oslo, Norway; and Novo Nordisk A/S, Ljubljana, Slovenia). Combined hormone replacement therapy improves endothelial function in healthy postmenopausal women. J Intern Med 2001; 250: 508–515. Objectives. Large scale epidemiological studies suggest that hormone replacement therapy (HRT) reduces cardiovascular events in postmenopausal women. Improvement in endothelial function may contribute to this protective effect. Design. In a prospective, double blind study, 61 healthy postmenopausal women were randomized to receive either oral continuous combined HRT [oestradiol 2 mg and norethisterone acetate (NETA) 1 mg per day] or placebo. Endothelial function, assessed by flow-mediated vasodilation (FMD) of the brachial artery and expression of soluble endothelial cell adhesion molecules (CAM) were determined before, after 3 and 6 months of therapy. Results. The FMD was significantly improved in women on combined HRT (from 5.97% to 10.94% after 3 months and to 10.58% after 6 months; both P

Acute myocardial infarction (AMI) is more frequent in winter months than in summer months. The aetiologic mechanisms underlying this seasonal pattern are poorly understood. We investigate whether seasonal variation of metabolic and haemostatic coronary risk factors exists, and whether this variation is more pronounced in subjects with coronary artery disease (CAD). In 82 subjects (47 free of clinical signs of CAD and in 35 survivors of AMI), measurements of body mass index (BMI), lipoproteins, glucose, insulin, plasminogen activator inhibitor-1, tissue-type plasminogen activator (t-PA), euglobulin clot lysis time, fibrinogen, and platelet count were performed twice in the cold months (December and March) and twice in the warm months (June and September). Significantly higher BMI (26.8 versus 26.2 kg/m2, P0.01), glucose (5.5 versus 5.1 mmol/l, P0.01), total cholesterol (5.61 versus 5.32 mmol/l, P0.05), low-density lipoprotein cholesterol (3.63 versus 3.34 mmol/l, P0.05), triglycerides (1.79 versus 1.61 mmol/l, P0.01), Lp(a) (270.7 versus 237.5 mg/l, P0.01), fibrinogen level (3.50 versus 2.95 g/l, P0.00001), platelet count (212 x 10(9) versus 173 x 10(9)/l, P0.01) and significantly lower high-density lipoprotein cholesterol level (1.22 versus 1.28 mmol/l, P0.05) were observed in the cold months compared with the warm months. Significant seasonal variation of t-PA activity (1.19 versus 0.87 IU/ml, P = 0.015) and t-PA antigen (8.5 versus 7.3 ng/ml, P = 0.05) was demonstrated only in subjects with CAD. Clustering of peak values of several metabolic and haemostatic coronary risk factors was observed in winter months. This variation might be of aetiopathogenetic importance for the seasonal pattern of acute myocardial infarction.