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OBJECTIVES: Chronic Mesenteric Ischaemia (CMI) is an underdiagnosed but severe condition. Access to functional testing is often limited and the diagnosis is usually based primarily on symptoms and imaging. One of the functional tests available is measurement of the Splanchnic Blood Flow (SBF). The purpose of the present investigation was to evaluate if changes in the splanchnic perfusion after revascularisation can be detected by measuring the SBF and hepatic vein oxygenation.MATERIALS AND METHODS: The SBF was measured in ten patients before and after revascularisation of the mesenteric arteries by either percutaneous transluminal angioplasty (n=9) or open revascularisation (n=1). The SBF was measured indirectly using Fick's principle and using the tracer Tc-99m Mebrofenin along with assessment of hepatic blood oxygenation, before and after a standard meal, following catheterisation of a hepatic vein and the femoral artery.RESULTS: Nine of ten patients (90%) achieved a profound increase in SBF after revascularisation (mean increase in postprandial response to meal stimulation from 71±95 mL/min to 531±295 mL/min, P=.001), and an increase in postprandial hepatic vein oxygen saturation (from 52±14% to 59±13%, P=.006). The symptoms of the patients diminished accordingly. One patient had no symptom relief, and no increase in postprandial SBF, but an angiographic result with no significant stenosis post revascularisation.CONCLUSIONS: Revascularisation increased the SBF and hepatic vein oxygen saturation significantly concurrent with symptom relief and according with the angiographic successful result in the vast majority of patients. A satisfying angiographic result post vascular intervention does not rule out CMI. This article is protected by copyright. All rights reserved.

Inland people’s attitude towards municipal amalgamation reform in Norway from 2013 to 2018 has become more positive. However, a majority does not support the ongoing reform, but the changes have been substantial during such a short time period. However, these changes seem not to be a result of new and more positive judgements of the reforms’ results and outcome. By contrast, the majority has been more critical of anticipated consequences of the amalgamation reform into larger municipalities. Instead, we considered the changes as a type of ‘resignation’ towards a reform pressure from the national government and general changes in their environment. More citizens’ assess that positive municipal economic development and more local competence are favourable effects of mergers, and this finding supports this claim. The reform is likely to catch up with their local units anyway, and the citizens’ attitudes are adapting to what they expect will occur in the upcoming years.

Background: Peripheral arterial disease (PAD) in the presence of a normal ankle-brachial index (ABI) can be diagnosed noninvasively by measuring a postexercise ABI or by measuring the toe-brachial index (TBI). Methods: This was a prospective comparative study. Over a period of 30 months, a total of 415 patients who were referred with the suspicion of vascular claudication and resting values of 0.91 ≤ ABI1.10 (P ≤ 0.022 for both), but there were no statistically significant differences found in other ABI intervals (P > 0.200 for all). Conclusions: The magnitude of the TBI reduction correlates with an increased probability of an abnormal postexercise ABI. However, this is due in part to limbs with a low TBI having a lower resting ABI on average than limbs with a normal TBI, which also correlates with the probability of an abnormal exercise test result. This study shows that the TBI and the postexercise ABI are not interchangeable for establishing a PAD diagnosis.

22. juli-kommisjonens rapport ble møtt med noe nær samstemt begeistring i media, fra høringsparter og i det politiske miljøet da den ble lansert i 2012. Rapporten framsto som grundig og ærlig, men etter nærlesing i enkelte politiog fagmiljøer ble det etter hvert avdekket noen klare analytiske svakheter. Kan en rapport være både god og dårlig på en gang, og betyr det noe? Svaret på begge spørsmålene er ja. Vårt utgangspunkt er å skille mellom de emosjonelle og de administrative behovene som oppstår etter en nasjonal katastrofe: terapeutisk sorgbearbeiding versus forvaltningspolitisk læring. Vår påstand er at slik kommer ett dilemma og ett paradoks til syne. Dilemmaet er at hvis en utredning skal fungere terapeutisk, kan den ikke samtidig inneha alle de kvalitetene som kreves av en treffsikker forvaltningspolitisk analyse. Paradokset er at rapportens terapeutiske suksess ga den en forvaltningspolitisk legitimitet dens analytiske kvaliteter ikke gjør den fortjent til. English summary The report of the public investigative commission was extremely well received by media, interest organizations and political bodies when released one year after the terrorist attacks of 22 July 2011. Upon closer reading, however, students of policing and public administration have argued that although meticulous and convincing in its depiction of events, it suffers from serious analytical deficiencies. How to make sense of this? Our point of departure is to distinguish between the emotional and the administrative needs that arise after a national disaster and trauma: Collective therapy versus administrative and political reform. Thus, a dilemma and a paradox emerge. The dilemma is that in order to work therapeutically and contribute to reconciliation, investigations of this kind must renounce analytical clarity somewhat. The paradox is that its therapeutic success conferred an administrative legitimacy on the report that its analytical deficiencies did not merit.

Background: Chronic mesenteric ischaemia (CMI) is a vastly underdiagnosed condition that typically leads to postprandial abdominal pain and weight loss. The aim of the study was to explore the involvement of various mesenteric vessels in total splanchnic blood flow (SBF) and hepatic vein oxygenation. Methods: Single-blinded comparative trial of 476 patients clinically suspected of CMI. Routine investigation included measurement of hepatic vein oxygen saturation, indirect measurement of the total splanchnic blood flow (SBF), using Fick's principle and the tracer [ 99mTc]Mebrofenin, before and after a meal, and digital subtraction angiography. Results: A total of 176 of the 476 patients (36%) had at least one angiographically significant stenosis (lumen reduction ≥70%). In patients with a significant one-vessel disease, the percentage having CMI according to SBF was 10% for a celiac trunk stenosis (n = 60), 50% for a superior mesenteric stenosis (n = 24) and 6% for an inferior mesenteric artery stenosis (n = 34). In patients with a significant two-vessel disease, the percentage with CMI according to SBF response was 92%, 18% and 79%, for no significant stenosis of the celiac trunk (n = 13), superior mesenteric artery (n = 17) and inferior mesenteric artery (n = 19), respectively. Conclusion: Patients with significant one- or two-vessel stenosis involving the superior mesenteric artery have a higher likelihood of CMI according to flow criteria and a greater postprandial decrease in hepatic vein saturation on average than patients with no involvement of the superior mesenteric artery.

BACKGROUND AND AIMS: Classically, peripheral arterial disease (PAD) is diagnosed by a low ankle-brachial index (ABI), but the diagnosis can also be made based on toe-brachial index (TBI) measurements. The objective of this study was to characterize patients with low TBI but normal ABI, and chart potential underestimation of PAD prevalence by solitary use of ABI.METHODS: A total of 3739 consecutive patients with known or suspected PAD referred for ABI and TBI measurements in a four-year period were compared to an age- and gender matched control group (n = 17,340).RESULTS: In the patient cohort, 65.0% had low ABI, 20.5% had low TBI but normal ABI, and 14.5% had normal indices. When comparing the frequencies of comorbidities related to atherosclerotic disease (myocardial infarction, congestive heart failure, cerebrovascular disease, diabetes mellitus, chronic kidney failure), there were no significant differences among patients with low ABI or low TBI with normal ABI in any of the variables (all p > 0.06). Of the patients with low TBI and normal ABI, 18.7% were diagnosed with diabetes mellitus type I or II, and 8.2% with chronic kidney disease.CONCLUSIONS: Patients with low TBI but normal ABI represented 20.5% of patients referred with the suspicion of PAD. Furthermore, patients with low TBI but normal ABI presented similar comorbid characteristics to patients with low ABI, who have a well-described increased risk of cardiovascular morbidity and mortality. The solitary use of ABI underestimated the prevalence of PAD in the population, and PAD screening could potentially be improved by routine application of TBI.

Ventilation/perfusion single-photon emission computed tomography performed using an aerosol of carbon-coated technetium is frequently used for diagnosing pulmonary embolism. Certain patients may suffer from chronic obstructive pulmonary disease (COPD); for such patients, the formation of mucus clots in airways can cause accumulation of the aerosol in the larger airways. This centralized deposition of the aerosol leads to insufficient activity in peripheral lung segments and subsequently results in ventilation images of substandard or even nondiagnostic quality. Continuous positive airway pressure (CPAP) therapy improves airway dynamics and quality of life for COPD patients. We report for the first time the results for two patients for whom initial ventilation scans were of insufficient quality, but diagnostic-quality images were obtained after CPAP therapy.

Objective: In patients with peripheral arterial disease (PAD), measurements of distal blood pressure form the basis of assessing the severity of the disease along with symptoms and objective findings. The reliability and accuracy of a fully automated bedside device (SysToe) vs. strain gauge plethysmography (SGP) in patients with low toe pressures in a bedside setting in an outpatient clinic of vascular surgery were investigated. Methods: This was a prospective, single blinded study carried out in compliance with the Standards of Reporting of Diagnostic Accuracy Studies. A total of 94 outpatients with symptomatic PAD in an outpatient vascular surgery clinic were included and had index measurements performed with the automated bedside device in a bedside setting by observers with no training in routine distal pressure measurements. SGP reference measurements were performed in a vascular laboratory. Results: There was agreement between modalities regarding the diagnostic classification of chronic limb threatening ischaemia (CLTI) in 79/94 (84%) patients. For detection of CLTI, Cohen's kappa was 0.57 with a sensitivity of 94%, specificity of 82%, positive predictive value (PPV) 52%, and negative predictive value (NPV) 98%. On average, the automated bedside device underestimated the pressures, compared with the SGP. The mean difference between SGP and SysToe was 9 ± 16 mmHg for right limbs and 10 ± 16 mmHg for left limbs (p < .001). Conclusion: The automated bedside device showed a high sensitivity and a high NPV for excluding CLTI. However, the low PPV may result in overdiagnosis. The automated bedside device may function as a screening tool identifying patients in need of further diagnostics with more accurate equipment, for example SGP.

This paper analyzes how superintendents, school board members and principals translate what happens when school reforms meet the local levels of implementation in Norway. The underlying theoretical premise is that contemporary reforms mirror two seemingly incompatible reform strategies, respectively, external control and professional commitment. The analysis, based on a review of findings from a Nordic research project, reveal that school boards and superintendents employ elements of both control and professional trust when they interact with school principals, and superintendents mainly act as mediators. Implications for research and practice are discussed.

AIM: To examine the interchangeability of two methods for distal pressure measurement based on photoplethysmography using a truncated or full display of the arterial inflow curve, respectively.METHODS: Toe and ankle pressures were obtained from 69 patients suspected of peripheral arterial disease (PAD). Observer reproducibility of the curve readings was examined by blinded reassessment of the pressure curves in a randomly selected subgroup (60 limbs).RESULTS: There were no significant differences in mean pressures between the two methods (p for all > .455). The limits of agreement for the differences were -15.0-15.4 mmHg for right toe pressures, -16.3-16.2 mmHg for left toe pressures, -14.2-15.7 mmHg for right ankle pressures, and -18.3-17.7 mmHg for left ankle pressures. Correlation analysis revealed intraclass correlation coefficients ≥0.960 for all measuring sites. Cohen's Kappa showed excellent agreement in diagnostic classification, with κ = 0.930 for the diagnosis of PAD and perfect agreement in the diagnosis of critical limb ischemia (κ = 1.000). The analysis of intra-observer variation for curve reading showed limits of agreement of -3.9-4.0 for toe pressures and -7.6-7.7 for ankle pressures for the method involving truncated display and -3.1-3.2 for toe pressures and -6.3-8.6 for ankle pressures for the method involving full display of the signal.CONCLUSION: The present study shows minimal differences in diagnostic classification, as well as in ankle and toe pressures, between the full display and the truncated display of the photoplethysmographic pulse signal. Furthermore, the inter-observer variation was low for both of the photoplethysmographic methods investigated.

Mercury-in-silastic strain gauge pletysmography (SGP) is a well-established technique for blood flow and blood pressure measurements. The aim of this study was to examine (i) the possible influence of clinical clues, e.g. the presence of wounds and color changes during blood pressure measurements, and (ii) intra- and inter-observer variation of curve interpretation for segmental blood pressure measurements.A total of 204 patients with known or suspected peripheral arterial disease (PAD) were included in a diagnostic accuracy trial. Toe and ankle pressures were measured in both limbs, and primary observers analyzed a total of 804 pressure curve sets. The SGP curves were later reanalyzed separately by two observers blinded to clinical clues. Intra- and inter-observer agreement was quantified using Cohen's kappa and reliability was quantified using intra-class correlation coefficients, coefficients of variance, and Bland-Altman analysis.There was an overall agreement regarding patient diagnostic classification (PAD/not PAD) in 202/204 (99.0%) for intra-observer (κ = 0.969, p0.001), and 201/204 (98.5%) for inter-observer readings (κ = 0.953, p0.001). Reliability analysis showed excellent correlation between blinded versus non-blinded and inter-observer readings for determination of absolute segmental pressures (all intraclass correlation coefficients ≥ 0.984). The coefficient of variance for determination of absolute segmental blood pressure ranged from 2.9-3.4% for blinded/non-blinded data and from 3.8-5.0% for inter-observer data.This study shows a low inter-observer variation among experienced laboratory technicians for reading strain gauge curves. The low variation between blinded/non-blinded readings indicates that SGP measurements are minimally biased by clinical clues.

ObjectiveTo assess the accuracy of a fully automated portable device (APD) for diagnosing peripheral arterial disease (PAD) by measuring the toe–brachial index (TBI) and using mercury-in-silastic, strain-gauge plethysmography (SGP) as reference.DesignProspective, randomised, double-blinded diagnostic accuracy study.Materials and methodsA total of 204 consecutive patients with known or suspected PAD were randomly assigned to measurement of TBI by the portable device followed by the SGP technique or the opposite sequence. Finally, ankle–brachial index (ABI) was assessed by SGP.ResultsThe APD showed a sensitivity of 98.8%, a specificity of 61.0%, a positive predictive value of 91.0% and a negative predictive value of 92.6% for detecting PAD compared to a full SGP test comprised of ABI and TBI. According to the SGP test, 35 patients (17.2%) had an ABI > 0.90 but a TBI

The article raises the question of whether there is a relationship between the trust that citizens have in people and the trust they have in various institutions such as public administration and media/press. The data were collected from two major surveys, and the universe is limited to citizens of two Norwegian counties. The analyses show that there is a spillover effect between the trust that citizens have in people and institutions (in general) and the degree of trust citizens have in the various particular institutions. Trust between persons, and between persons and institutions, appears to have a bandwidth-type structure. These aspects or factors can be grouped into personal trust, public institutional trust and media/ press trust. These different factors are correlated with each other.

BACKGROUND Warm ischemia and subsequent reperfusion of the heart can induce a temporary dysfunction known as myocardial stunning. The aim of this study was to investigate the ability of tissue Doppler imaging (TDI) to quantify longitudinal myocardial stunning close to the apex, and perform a comparison with sonomicrometry using a well-established large size porcine model. METHODS In anesthetized pigs, postischemic myocardial stunning was induced by occluding LAD for 15 min followed by 90 min reperfusion (n = 7). Long-axis strain and strain rate was quantified by both TDI and sonomicrometry. RESULTS During reperfusion, peak systolic strain measured by TDI decreased from -11.2% (+/-3.0) at baseline to -4.9% (+/-3.6), -3.4% (+/-2.9), and -4.3% (+/-5.0) at 30, 60, and 90 min, respectively (all P < 0.007). Postsystolic strain increased from -1.3% (+/-1.6) at baseline to -6.4% (+/-4.4), -4.8% (+/-4.0), and -5.2% (+/-2.7) by TDI in the reperfusion phase (all P < 0.048 except at 60 min of reperfusion (P = 0.081)). Postsystolic index increased from 0.10 (+/-0.13) at baseline to 0.56 (+/-0.24), 0.54 (+/-0.30), and 0.64 (+/-0.37) subsequently (all P < 0.012). [Correction added after online publication 30-May-2007: In the preceding sentence, the phrase 'Postsystolic index decreased from 0.10 (+/-0.13)' was changed to 'Postsystolic index increased from 0.10 (+/-0.13).'] Difference-mean and line of identity plots did not disclose any systematic error, but revealed substantial variation, indicating a mismatch between TDI and sonomicrometry. CONCLUSIONS It is feasible to quantify postischemic myocardial stunning by TDI in a large size porcine model using longitudinal postsystolic shortening, and postsystolic index as indicators. TDI and sonomicrometry data reach the same end point, but the two techniques are not interchangeable when investigating myocardial stunning close to apex in reference to longitudinal strain and strain rate.

Transnational bodies such as OECD have had great influence in the national educational debate in Norway since the first PISA study was made public in 2001. A range of social technologies, such as participation in international rank-based tests, national standardized tests and various teacher and student surveys, have been implemented stepwise in order to more tightly monitor the work of schoolteachers. These trends have been institutionalized towards a consistent regulative system by means of two structural elements. The national quality assurance system was established in 2005 to tighten the links between national policies and classroom practice. The semi-independent National Directorate of Education and Training was established and radically up-scaled (in terms of staffing) at the same time, to lead reform initiatives for municipalities and schools and to manage the national quality system. This also put superintendents in a normative and cultural crossfire between the longstanding norms of the teaching profession and traditional policy cultures in education, on one hand, and the reform agendas and the instruments influenced by the OECD, on the other. The results of surveys of superintendents, school board members and school leaders illustrate aspects of the new situation for superintendents in the midst of governance chains and networks. The main inference taken from the data is that superintendents have to operate multiple arenas within and beyond the municipality organization, which puts them in a crossfire of conflicting expectations and demands.

Education is of fundamental value for a society; to raise and foster a new generation of citizens in a global and local multicultural context. It is therefore crucial to identify the competences that are needed for multiple actors in the school governance chain, with the aim of achieving this mission in different contexts over time.

External school inspection and state supervision represent key instruments in many European countries for improving the quality of education. Although some countries, such as England, France, and the Netherlands, have a long tradition of school inspectorates, other countries such as Sweden only recently reintroduced a school inspection system (Johansson O, Holmgren M, Nihlfors E, Moos L, Skedsmo G, Paulsen JM, Risku M, Local Decisions under Central Watch – a new Nordic quality assurance system. In: Moos L (ed) Transnational influences on values and practices in Nordic educational leadership – is there a Nordic model? Springer, Dordrecht, 2013). In Denmark, the relationship between the state and the municipalities is conducted through a public governance contract. For example, subject matter aims that used to be very broad and loose at this level were supplemented with clear aims that were developed into shared aims from 2006 onwards. Moreover, a state supervision system was introduced to standardize the quality assurance procedure. In a similar vein, Norway conducted a national quality assurance system in 2006, paired with national achievement testing systems, to chart and publish the results and a state supervision system. In contrast to Sweden, the local governance level – municipalities – in Denmark and Norway is the target of state supervision; thus, inspection and control are more loosely coupled with schools and principals at the “street level.” In Finland, the National Board of Education conducts national evaluations, and this state agency is also responsible for the national evaluation of learning outcomes. Notably, in this respect, Finland deviates from the international stream of state quality assurance and inspection, not at least linked to the political system’s resistance to ranking schools and municipalities and the external publication of performance indicators.

Objectives To assess the intra- and inter-observer variation in laser Doppler flowmetry curve reading for measurement of toe and ankle pressures. Methods A prospective single blinded diagnostic accuracy study was conducted on 200 patients with known or suspected peripheral arterial disease (PAD), with a total of 760 curve sets produced. The first curve reading for this study was performed by laboratory technologists blinded to clinical clues and previous readings at least 3 months after the primary data sampling. The pressure curves were later reassessed following another period of at least 3 months. Observer agreement in diagnostic classification according to TASC-II criteria was quantified using Cohen's kappa. Reliability was quantified using intra-class correlation coefficients, coefficients of variance, and Bland–Altman analysis. Results The overall agreement in diagnostic classification (PAD/not PAD) was 173/200 (87%) for intra-observer ( κ = .858) and 175/200 (88%) for inter-observer data ( κ = .787). Reliability analysis confirmed excellent correlation for both intra- and inter-observer data (ICC all ≥.931). The coefficients of variance ranged from 2.27% to 6.44% for intra-observer and 2.39% to 8.42% for inter-observer data. Subgroup analysis showed lower observer-variation for reading of toe pressures in patients with diabetes and/or chronic kidney disease than patients not diagnosed with these conditions. Bland–Altman plots showed higher variation in toe pressure readings than ankle pressure readings. Conclusions This study shows substantial intra- and inter-observer agreement in diagnostic classification and reading of absolute pressures when using laboratory technologists as observers. The study emphasises that observer variation for curve reading is an important factor concerning the overall reproducibility of the method. Our data suggest diabetes and chronic kidney disease have an influence on toe pressure reproducibility.

BackgroundPeripheral arterial disease (PAD) can be diagnosed noninvasively by segmental blood pressure measurement and calculating an ankle-brachial index (ABI) or toe-brachial index (TBI). The ABI is known to be unreliable in patients with vascular stiffness and fails to detect the early phase of arteriosclerotic development. The toe vessels are less susceptible to vessel stiffness, which makes the TBI useful. However, the diagnostic limits used in guidelines, clinical settings, and experimental studies vary substantially. This review provides an overview of the evidence supporting the clinical use of the TBI.MethodsA review of the literature identified studies reporting the use of the TBI regarding guideline recommendations, normal populations, correlations to angiographic findings, and prognostic implications.ResultsEight studies conducted in a normal population were identified, of which only one study used imaging techniques to rule out arterial stenosis. A reference value of 0.71 was estimated as the lowest limit of normal based on the weighted average in studies with preheating of the limbs. A further seven studies showed correlations of the TBI with angiographic findings. The TBI had a sensitivity of 90% to 100% and a specificity of 65% to 100% for the detection of vessel stenosis. Few studies investigated the value of the TBI as a prognostic marker for cardiovascular mortality and morbidity, and no firm conclusions could be made. Studies have, however, shown correlation between the TBI and comorbidities such as kidney disease, diabetes, and microvasculature disease.ConclusionsIn contrast to the well-defined and evidence-based limits of the ABI, the diagnostic criteria for a pathologic TBI remain ambiguous. Although several guidelines and reviews of PAD diagnostics recommend a TBI

We examine the reliability of single and repeated blood pressure measurements at ankle, toe, and arm levels for the diagnosis of peripheral arterial disease (PAD) by laser Doppler flowmetry. Segmental pressures were measured in 200 patients with known or suspected PAD. Segmental indices were calculated using (1) one measurement [M-1], two measurements [M-2], or by a predefined reproducibility criterion (RC) as well as (2) by using one brachial blood-pressure (BBP-one) or correspondent to each segmental pressure (BBP-all) as reference. The agreement in diagnosis of PAD by Cohen's Kappa was κ = 0.930 when comparing RC to M-1, and κ = 0.977 when comparing RC to M-2. The same comparison showed excellent relative reliability for segmental indices (all intra-class correlation coefficients (ICC) ≥ 0.980). Diagnostic classification agreement for BBP-all versus BBP-one were κ = 0.831 for RC, κ = 0.804 for M-1, and κ = 0.847 for M-2. The relative reliability analysis showed excellent correlation in segmental indices (all ICC ≥ 0.957). The study shows minimal difference in segmental indices and diagnostic classification when comparing calculations based on the listed strategies. However, the study indicated that it is important to measure BBPs correspondent to each segmental pressure.

Objective Mitral valve replacement with preservation of the entire subvalvular apparatus entails superior postoperative left ventricular function compared with other techniques. However, this option is often not possible because of valve pathology. We hypothesized that preservation of only 4 mitral valve secondary ("strut") chordae would be functionally and geometrically equivalent to total valve preservation in the long-term setting. In a porcine mitral valve replacement model we investigated the long-term effects of 3 surgical techniques on left ventricular function and geometry: (1) total preservation of the native valve, (2) strut chordal preservation, and (3) total excision of the subvalvular apparatus. Methods Forty 60-kg pigs were randomized to 1 of the 3 techniques. Global and regional left ventricular function and dimensions were assessed with cardiovascular magnetic resonance and conductance catheter 90 days after mitral valve replacement. Groups were compared by multivariate analysis of variance. Results There was no overall difference between groups 1 and 2. Group 3 animals had (1) greater base-apex diastolic and systolic lengths, and smaller short-axis diameters, and (2) lower sphericity indices, and greater base-apex and short-axis fractional shortening than groups 1 and 2. Regional analysis showed slimming and elongation to occur primarily in the basal left ventricular segments. Left ventricular contractility and hemodynamic parameters did not differ between groups. Conclusions Strut chordal preservation was equivalent to total valve preservation during mitral valve replacement, whereas total chordal resection caused significant left ventricular slimming with compensatory increases in fractional shortening. Therefore, to preserve left ventricular geometry, special attention must be paid to maintain the valvular–ventricular continuity through the strut chordae during mitral valve replacement. This concept may have important therapeutic implications for chordal-sparing mitral valve replacement.

Today we live in a society with many choices and possibilities which were absent just a few decades ago. Knowledge is seen as temporary, and many paradoxes are experienced in the flow of information surrounding us. A basic insecurity can be seen as a consequence of this development. This paper re-thinks the consequences at the administrational and organisational levels, when mistrust is institutionalised as the natural and rational mindset instead of trust. Another consequence is a desire to reduce actual risk by attempting to control the future with risk assessment and control procedures, instead of accepting the complexity as something that is. An administrative strategy based upon mistrust and focused on control and management of colleagues seems self-perpetuating and contributes to a form of management cynicism that is neither effective nor professionally stimulating or innovative. The benefit of behaving trustingly can override having to tolerate some insecurity and deviation.

ObjectiveTo assess the diagnostic accuracy of laser Doppler flowmetry (LDF) with mercury-in-silastic strain gauge plethysmography (SGP) as a reference test for measuring the toe and ankle pressures in patients with known or suspected peripheral arterial disease (PAD).MethodsThis was a prospective, randomized, blinded diagnostic accuracy study. Toe and ankle pressures were measured using both methods in 200 consecutive patients, who were recruited at our vascular laboratory over a period of 30 working days. Classification of PAD and critical limb ischemia (CLI) was made in accordance with TASC-II criteria.ResultsThe LDF method demonstrated 5.8 mm Hg higher mean toe pressures than the SGP method for the right limb and 7.0 mm Hg for the left limb (both P < .001). There were no significant differences in the mean ankle pressures (both P > .129). The limits of agreement for the differences (SGP − LDF) were −31.7 to 20.2 mm Hg for right toe pressures, −28.0 to 14.0 mm Hg for left toe pressures, −25.5 to 22.8 mm Hg for right ankle pressures, and −26.9 to 24.6 mm Hg for left ankle pressures. A correlation analysis of the absolute pressures using the two methods showed an intraclass correlation coefficient of 0.902 (95% confidence interval [CI], 0.835-0.938) for right toe pressures, 0.919 (95% CI, 0.782-0.960) for the left toe pressures, 0.953 (95% CI, 0.937-0.965) for right ankle pressures, and 0.952 (95% CI, 0.936-0.964) for left ankle pressures. Cohen's Kappa showed an agreement in the diagnostic classification of κ = 0.775 (95% CI, 0.631-0.919) for PAD and κ = 0.780 (95% CI, 0.624-0.936) for CLI.ConclusionsLDF showed a good correlation with SGP over a wide range of toe and ankle pressures, as well as substantial agreement for the diagnostic classification of PAD including CLI.