Distal pulse palpation: is it reliable?

Validation of a New Ankle Brachial Index Measurement System Using Pulse Wave Velocity

Peripheral artery disease (PAD) is a common circulatory disorder characterized by the accumulation of fats, cholesterol, and other substances in the arteries that restrict blood flow to the extremities, especially the legs. The ankle brachial index (ABI) is a highly reliable and valid non-invasive test for diagnosing PAD. However, the traditional method has limitations. These include the time required, the need for Doppler equipment, the training of clinical staff, and patient discomfort. PWV refers to the speed at which an arterial pressure wave propagates along the arteries, and this speed is conditioned by arterial elasticity and stiffness. To address these limitations, we have developed a system that uses electrocardiogram (ECG) and photoplethysmography (PPG) signals to calculate pulse wave velocity (PWV). We propose determining the ABI based on this calculation. Validation was performed on 22 diabetic patients, and the results demonstrate the accuracy of the system, maintaining a margin of ±0.1 compared with the traditional method. This confirms the correlation between PWV and ABI and positions this technique as a promising alternative to overcome some of the limitations of the conventional method.

Validation of the Ischaemia Severity Scale (ISS) Based on Non-Invasive Vascular Assessments (SEWSS) for Predicting Outcomes of Diabetic Foot Attack

Assessment of ischaemia severity includes a variety of measures, such as pedal pulse palpation, the ankle/brachial index (ABI), and the toe/brachial index (TBI), but there is a lack of consensus regarding which ischaemia scale is the most effective for determining outcome prognosis. The purpose of this study is to validate the application of the ischaemia severity scale (ISS) in the effective prediction of wound healing, amputations, and mortality for diabetic foot wounds (DFW). This prospective study included 235 consecutive patients graded according to the Saint Elian Wound Score System (SEWSS). The ISS is part of this system, with patients being scored as non-ischaemic (0) or having mild (1), moderate (2), or severe (3) ischaemia. Age, diabetes duration in years, and ulcer size were found to be associated with a longer mean ischaemia of increasing severity. A trend of reduction in the pulse palpation rates (70.4%, 50%, 8.5% to 0%; p < 0.01), ABI (1.1 ± 0.1, 0.86 ± 0.3, 0.68 ± 0.2, 0.47 ± 0.2, p < 0.01), TBI average values (0.90 ± 0.35, 0.62 ± 0.52, 0.50 ± 0.33, 0.10 ± 0.42, p < 0.01), wound healing success (88.7%, 57.7%, 40.7%, 12.9%; p < 0.01), and delay in weeks (Kaplan−Meier: log-rank 44.2, p < 0.01) was observed with increasing values of the ISS (0, 1, 2, and 3). The odds ratio for adverse outcomes increased for each additional level of ischaemia severity. Thus, we demonstrate that the ISS is useful in effectively predicting adverse outcomes for DFW.

Simulator-Based Metrics for Quantifying Vascular Palpation Skill for Cannulation

Palpation is essential for accurate diagnosis and treatment in many clinical examinations and procedures. Specifically, vascular palpation is used to diagnose cardiovascular health issues and identify anatomical landmarks in the peripheral vascular system. However, little attention has been given to quantifying what comprises skilled vascular palpation; therefore, this study aims to objectively quantify the differences between high performer (HP), mid performer (MP), and low performer (LP) behavior towards understanding vascular palpation skills. Eleven HPs, twenty-five MPs, and ten LPs completed sixteen trials on our simulator under various conditions. There were four fistulas, two skin thicknesses, and two motor vibration intensities. Finger force and location data were recorded for each trial on the simulator. We examined three types of palpation metrics: time, force, and location. All three types of metrics demonstrated statistically significant differences between HP and LP palpation behavior. Therefore, these metrics could be used for structured and standardized palpation skills training in the future, potentially improving patient outcomes.

Hap-pulse: A Wearable Vibrotactile Glove for Medical Pulse Wave Rendering

Pulse palpation is an important procedure that allows a physician to rapidly assess the status of a patient's cardiovascular system. This paper explores the possibility of using vibrotactile stimuli to render fine temporal profiles of pulse pressure waves. A lightweight wearable vibrotactile glove, called Hap-pulse, is designed to render fine pulse waves through vibrotactile stimuli on users' fingertips. To preserve the fine features of original pulse waves, models are fitted from real pulse wave data (photoplethysmogram (PPG) pulse waveform database), using fourth-order polynomial functions. A square wave envelope mapping algorithm is proposed to produce vibration amplitudes of Linear Resonance Actuators (LRAs), which aims to render the detailed waveform of systolic and diastolic blood pressure states. Evaluation results suggest that Hap-pulse can render pulse waves with an average correlation coefficient 97.84%. To validate the distinguishability and fidelity of Hap-pulse's palpation rendering, a user study consisting of traditional Chinese medicine doctors and unskilled students is conducted. The correct recognition rate of identifying four typical pulse waves is 87.08% (doctors), 57.50% (untrained students) and 79.59% (trained students). These results indicate a novel application of rendering subtle pulse wave signals with vibrotactile gloves, which illustrates the potential of simulating patient palpation training in virtual or remote medical diagnosis.

[Diabetic foot syndrome-Part 1 : Definition, pathophysiology, diagnostics and classification]

There are ca. 8 million persons with diabetes mellitus living in Germany. A late sequelae of diabetes is the diabetic foot syndrome (DFS), the prevalence of which is greatly increasing. It comprises all alterations of the foot as a result of diabetic polyneuropathy as well as microvascular and macrovascular (peripheral arterial occlusive disease, PAOD) alterations. Many of the ca. 250,000 newly diagnosed diabetic foot ulcers per year become chronic wounds. Despite intensive efforts for prevention, early diagnosis and adequate wound care, ca. 13,000 persons with diabetes undergo major limb amputation in Germany every year. With consistent treatment in interdisciplinary centers and by exhausting all possible methods of wound treatment, pressure relief as well as arterial revascularization, the major amputation rate in patients with diabetic foot problems can be reduced by 80%. With a suitable strategy of prevention, the recurrence rate of foot ulcers would be reduced.

An analysis of radial pulse strength to recorded blood pressure in the Department of Defense Trauma Registry

Introduction

Hemorrhage is the leading cause of potentially preventable death on the battlefield. The tactical combat casualty care guidelines recommend the use of the radial pulse strength to guide the administration of blood products or intravenous fluids when equipment for blood pressure monitoring is not available. Data supporting this measurement tool are limited. We sought to validate this method in a deployed trauma population.

Materials and Methods

This is a secondary analysis of a previously published dataset from the Department of Defense Trauma Registry. In this subanalysis, we focused on emergency department radial pulse strength documented in conjunction with systolic blood pressure readings.

Results

Our predefined search codes captured 28,222 Department of Defense Trauma Registry casualties. Of those, 22,192 casualties had at least 1 radial pulse strength documented, with a total of 27,366 documented measurements total among the 22,192. The median age of casualties was 25 years, most were male (96.8%), U.S. military made up the largest proportion (44.2%), most were injured by explosive (55.8%), and most were in Afghanistan (67.0%) with a median injury severity score of 9. Mean systolic blood pressures were significantly different based on radial pulse strength: strong (129.6), weak (107.5), and absent (85.1). However, when using a binary threshold of 80 mmHg, there were 615 documented instances of hypotension. Within that 615, 55.6% had a strong radial pulse, 29.3% had a weak radial pulse, and 15.1% had an absent radial pulse (P &lt; .001).

Conclusions

Although mean systolic blood pressure was associated with radial pulse quality, when using a binary measurement of hypotension (systolic &lt; 80 mmHg) characterization of the radial pulse was not a reliable indicator of hypotension. Better methods for casualty monitoring must be employed to avoid missing opportunities for intervention.

Accurate Noninvasive Arterial Assessment of the Wounded Lower Limb: A Clinical Challenge for Wound Practitioners

Arterial investigations are an essential part of lower extremity wound assessment. The results of these investigations assist the wound clinician to determine the etiology of the wound, predict healing capacity, and inform further management. There are a number of noninvasive testing methods available to practitioners, all with varying levels of reliability and accuracy. Clinical wound assessment guidelines give varied recommendations when it comes to lower limb vascular assessment in the presence of a wound. This leaves clinicians with little guidance on how to choose the most appropriate test, and uncertainty remains about which tests provide the most accurate information in different patient-specific contexts. Conditions such as advanced age, diabetes, and renal disease are known to affect the accuracy of some commonly used lower limb arterial assessment methods, and alternate testing methods should be considered in these cases. This seminal review discusses the reliability and accuracy of lower limb vascular assessment methods used to guide lower limb arterial assessment in the presence of wounds.

Aortic Bifurcation Saddle Thrombus

Acute aortic pathology demands a high index of suspicion and frequent reevaluations during emergency department (ED) stay for proper diagnosis. This high index of suspicion is crucial to avoid missing the potentially devastating aortic diagnosis. Here, we present a 59-year-old male who presented with chest pain and was ultimately diagnosed with a rare aortic bifurcation saddle thrombus causing acute aortic occlusion. This diagnosis, although rare, highlights a more common point that all patients should be reevaluated for an acute aorta, especially when diagnostic clues are present. The diagnosis was found only because of a thorough reevaluation. Missing the diagnosis would have resulted in death or lifetime dependence on hemodialysis.

The peripheral atherosclerotic profile in patients with type 1 diabetes warrants a thorough vascular assessment of asymptomatic patients

AIMS

Epidemiological data on subclinical atherosclerotic disease in type 1 diabetes mellitus (DM1) are scarce. We aimed to estimate the subclinical atherosclerosis profile of asymptomatic patients with DM1 and an abnormal ankle-brachial index (ABI).

MATERIAL AND METHODS

In a cross-sectional design (ClinicalTrials.gov Identifier: NCT02910271), we estimated ABI in 289 consecutive asymptomatic patients with DM1. An abnormal ABI led to measurements of toe-brachial index (TBI) and peripheral doppler ultrasound (DUS) to diagnose peripheral artery disease (PAD) and/or atherosclerotic carotid plaques (ACP).

RESULTS

A reduced (≤0.9) or increased (>1.2) ABI was detected in 17 (6%) and 75 (26%) patients, respectively. PAD was confirmed by TBI and DUS in 9 (53%) patients with a reduced ABI and 28 (37%) patients with an increased ABI, resulting in a 12.8% (9.4-17.2) prevalence of asymptomatic PAD. Fourteen patients with an abnormal ABI also exhibited ACP [4.8% (2.9-7.9)], with 64% of these patients showing bilateral disease. Artery stenosis was mild or moderate in 21% and 29% of patients, respectively. Thus, 46 [16% (12-21)] patients showed asymptomatic PAD, ACP, or both. According to our data, we would have to explore three asymptomatic patients with DM1 and normal pulses to unmask one case of PAD, and seven asymptomatic patients showing abnormal ABI values to detect one carotid disease.

CONCLUSIONS

Peripheral artery disease is often undiagnosed in asymptomatic patients with DM1. However, its presence may change medical management in a substantial percentage of cases, highlighting the potential benefit of a thorough vascular assessment on these patients.

Physical examination to screen for peripheral artery disease in a defined Primary Care population: A diagnostic accuracy study

INTRODUCTION

Peripheral arterial disease (PAD) is an underdiagnosed prevalent disease which implies high cardiovascular risk. Professionals usually depend on physical examination to screen for PAD.

OBJECTIVE

To assess the diagnostic accuracy of physical examination to screen for PAD in a rural Primary Care population and to evaluate the nurse-physician level of agreement in pedal pulse palpation.

METHODS

Diagnostic accuracy study in which two experienced professionals (physician-nurse) prospectively performed pedal pulse palpation (grading as absent, reduced, normal, or bounding), femoral bruit auscultation and calf circumference (index tests) comparing with Doppler ABI (reference test, positive cut-off: 0.9 ≥ ABI ≥ 1.4) in 158 consecutive subjects.

INCLUSION CRITERIA

presence of diabetes, dyslipidaemia, hypertension, smoking habit (current or former), or age ≥ 65.

RESULTS

Of 315 legs included, PAD was confirmed in 38 (12.1%) legs. Absent dorsalis pedis (DP) and posterior tibial (PT) pulses were found in 37 (11.7%) and 67 (21.3%) legs, respectively. Regarding nurse evaluation, when a positive test was set if DP or PT were absent (more sensitive cut-off), sensitivity was = 86.8 (95% CI: 74.8-98.9), specificity = 82.7 (95% CI: 78.0-87.3), likelihood ratio+ = 5.01 (95% CI: 3.77-6.67), likelihood ratio- = 0.16 (95% CI: 0.07-0.36), and diagnostic odds ratio (dOR) = 31.5 (95% CI: 11.7-84.8). Age, diabetes, and calcification (ABI ≥ 1.4) influenced the rate of a false negative finding in pedal palpation. Physician-nurse weighted kappa coefficient was = 0.649 (95% CI: 0.599-0.699). The presence of a femoral bruit auscultation had a dOR = 3.8 (95% CI: 1.1-13.1), and a calf circumference <34.55 cm had a dOR = 3.2 (95% CI: 1.6-6.4).

CONCLUSIONS AND RELEVANCE

In a mainly asymptomatic Primary Care population, pedal pulse palpation was by far the best diagnostic test, with good diagnostic accuracy and inter-rater agreement. In view of a high sensitivity and capacity to rule out the disease, pedal pulse palpation could be performed as a screening test for PAD and individuals at high cardiovascular risk.

Lower extremity arterial disease in patients with diabetes: a contemporary narrative review

Lower-extremity arterial disease (LEAD) is a major endemic disease with an alarming increased prevalence worldwide. It is a common and severe condition with excess risk of major cardiovascular events and death. It also leads to a high rate of lower-limb adverse events and non-traumatic amputation. The American Diabetes Association recommends a widespread medical history and clinical examination to screen for LEAD. The ankle brachial index (ABI) is the first non-invasive tool recommended to diagnose LEAD although its variable performance in patients with diabetes. The performance of ABI is particularly affected by the presence of peripheral neuropathy, medial arterial calcification, and incompressible arteries. There is no strong evidence today to support an alternative test for LEAD diagnosis in these conditions. The management of LEAD requires a strict control of cardiovascular risk factors including diabetes, hypertension, and dyslipidaemia. The benefit of intensive versus standard glucose control on the risk of LEAD has not been clearly established. Antihypertensive, lipid-lowering, and antiplatelet agents are obviously worthfull to reduce major cardiovascular adverse events, but few randomised controlled trials (RCTs) have evaluated the benefits of these treatments in terms of LEAD and its related adverse events. Smoking cessation, physical activity, supervised walking rehabilitation and healthy diet are also crucial in LEAD management. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in LEAD management. The revascularization strategy should take into account several factors including anatomical localizations of lesions, medical history of each patients and operator experience. Further studies, especially RCTs, are needed to evaluate the interest of different therapeutic strategies on the occurrence and progression of LEAD and its related adverse events in patients with diabetes.

Effectiveness of a multicenter training programme to teach point-of-care vascular ultrasound for the detection of peripheral arterial disease in people with diabetes

Background

The primary aim of this study was to evaluate the effectiveness of a training programme to teach a focused bedside ultrasound scan (PAD-scan; Podiatry Ankle Duplex Scan) for the detection of arterial disease in people with diabetes.

Methods

Five podiatrists and one diabetologist across two hospitals were enrolled in a structured training programme consisting of a training course (1-day), supervised scanning (5-weeks), independent scanning (3-weeks) and a final evaluation of performance (1-day).

Time, technical skills (Duplex Ultrasound Objective Structured Assessment of Technical Skills tool (DUOSATS); minimum score = 6, maximum score = 26) and accuracy (level of agreement with vascular scientist PAD-scan assessment) were assessed for every supervised scan and again for the final evaluation of performance.

Results

A total of 90 PAD-scans in 65 patients were performed during the supervised phase. Participants demonstrated significant improvements in median time (19 min(IQR 13.9–25.5) vs 9.3 min (IQR 7.3–10.5);p = 0.028) and DUOSATS scores (17.5 (IQR 16.8–21) vs 25 (IQR 24–25.3); p = 0.027). At the final evaluation, participants completed scans in 5.4 min (IQR 5.3–5.9), achieved full DUOSAT scores and perfect agreement with the vascular scientist.

Conclusion

A structured training programme, integrated into diabetic foot clinics, was effective in teaching the PAD-scan

Electronic supplementary material

The online version of this article (10.1186/s13047-018-0283-0) contains supplementary material, which is available to authorized users.

Interobserver reliability of the ankle-brachial index, toe-brachial index and distal pulse palpation in patients with diabetes

OBJECTIVE

We conducted a prospective pilot study in patients with diabetes to analyse the interobserver reliability of the ankle-brachial index, toe-brachial index and distal pulse palpation depending on the training of the professional involved.

MATERIALS AND METHODS

The ankle-brachial index, toe-brachial index and distal pulses were assessed by three clinicians with different levels of experience on the same day. Measurements were supervised and recorded by a fourth clinician.

RESULTS

Twenty-one patients (42 ft) were included in this study. We observed moderate agreement between clinicians in the palpation of posterior tibial arteries (K = 0.45, p < 0.001) and low agreement in dorsalis pedis arteries (K = 0.33, p < 0.001). The measurement of ankle-brachial index had moderate agreement between clinicians in patients with medial arterial calcification (K = 0.43, p < 0.001) and low agreement in patients with normal ankle-brachial index (K = 0.4, p < 0.001). The measurement of toe-brachial index had moderate agreement between clinicians in patients with a normal toe-brachial index (K = 0.4, p < 0.001) and in patients with medial arterial calcification (K = 0.60, p < 0.001).

CONCLUSION

Palpation of distal pulses, ankle-brachial index and toe-brachial index determination in patients with diabetes are not highly reproducible and reliable between clinicians with different levels of experience under routine conditions.

Management of peripheral arterial disease in diabetes: a national survey of podiatry practice in the United Kingdom

Background

We aimed to investigate podiatry practice in diagnosing peripheral arterial disease (PAD) in diabetes, decision making once PAD is suspected and limitations of referral pathways.

Methods

A survey, comprising 26 questions was distributed to podiatrists across the UK via mailing lists of collaborating organizations including the College of Podiatry (UK). Response rates were estimated based on NHS workforce data. Analysis of responses from the open-ended questions was performed using inductive content analysis.

Results

Data from 283 respondents were analyzed. Response rate for all NHS podiatrists across the UK was estimated to be 6%. For the detection of arterial disease only 18.8% (n = 49/260) of participants reported using a full combination of history, pulse palpation, Doppler and ABPI assessment. Self-reported confidence in detecting arterial disease was highest amongst podiatrists who felt they had received adequate training compared to podiatrists who felt they had not (median 85 (IQR 75-90) vs 67 (50-77), respectively; p < 0.001) as well as those who see > 20 diabetic patients per week compared to those who see < 20 (median 80 (IQR 70-90) vs 72 (60-82.8), respectively; p < 0.001). Over one third of respondents (35.8%, n = 93/260) were aware of missed cases of PAD in the past year and 17.5% (n = 38/217) believed that this resulted in an amputation in some cases.The survey highlighted a lack of clarity amongst podiatrists regarding referral guidelines. Additionally, 69% (n = 169/242) reported that their patients had to wait longer than 2-weeks for specialist vascular assessment and 67.6% (n = 54/80) reported similar waits for a Duplex Ultrasound scan. There was a statistically significant variation in DUS waiting time across the UK (X² (10, N = 80) = 21.59, p = 0.017). Inability to make a direct referral to vascular services and long delays were reported as major limitations of the referral pathway.

Conclusion

We have identified important targets for further investigation and quality improvement.

Hysteresis Compensation in a Tactile Device for Arterial Pulse Reproduction

This paper describes a system for training healthcare practitioners in the identification of different arterial pulses. The driving system uses a linear solenoid in an open loop force control. Due to the large hysteresis it exhibited, a form of compensation was implemented, based on the classic Preisach model of hysteresis. Implementation of said model resulted in a significant reduction of force tracking error, demonstrating the feasibility of the chosen approach for the intended application.

Detection of spontaneous pulse using the acceleration signals acquired from CPR feedback sensor in a porcine model of cardiac arrest

Background

Reliable detection of return of spontaneous circulation with minimal interruptions of chest compressions is part of high-quality cardiopulmonary resuscitation (CPR) and routinely done by checking pulsation of carotid arteries. However, manual palpation was time-consuming and unreliable even if performed by expert clinicians. Therefore, automated accurate pulse detection with minimal interruptions of chest compression is highly desirable during cardiac arrest especially in out-of-hospital settings.

Objective

To investigate whether the acceleration (ACC) signals acquired from accelerometer-based CPR feedback sensor can be used to distinguish perfusing rhythm (PR) from pulseless electrical activity (PEA) in a porcine model of cardiac arrest.

Methods

Cardiac arrest was induced in 49 male adult pigs. ECG, arterial blood pressure (ABP) and ACC waveforms were simultaneously recorded during CPR. 3-second segments containing compression-free signals during chest compression pauses were extracted and only those segments with organized rhythm were used for analysis. PR was defined as systolic arterial pressure >60 mmHg and pulse pressure >10 mmHg, while PEA was defined as an organized rhythm that does not meet the above criteria for PR. Peak correlation coefficient (CCp) of the cross-correlation function between pre-processed ECG and ACC, was used to discriminate PR and PEA.

Results

63 PR and 153 PEA were identified from the total of 1025 extracted segments. CCp was significantly higher for PR as compared to PEA (0.440±0.176 vs. 0.067±0.042, p<0.01) and highly correlated with ABP (r = 0.848, p<0.001). The area under the receiver operating characteristic curve, sensitivity, specificity and accuracy were 0.965, 93.6%, 97.5% and 96.7% for the ACC-based automatic spontaneous pulse detection.

Conclusions

In this animal model, the ACC signals acquired from an accelerometer-based CPR feedback sensor can be used to detect the presence of spontaneous pulse with high accuracy.

Towards an algorithm for automatic accelerometer-based pulse presence detection during cardiopulmonary resuscitation

Manual palpation is still the gold standard for assessment of pulse presence during cardiopulmonary resuscitation (CPR) for professional rescuers. However, this method is unreliable, time-consuming and subjective. Therefore, reliable, quick and objectified assessment of pulse presence in cardiac arrest situations to assist professional rescuers is still an unmet need. Accelerometers may present a promising sensor modality as pulse palpation technology for which pulse detection at the carotid artery has been demonstrated to be feasible. This study extends previous work by presenting an algorithm for automatic, accelerometer-based pulse presence detection at the carotid site during CPR. We show that accelerometers might be helpful in automated detection of pulse presence during CPR.

Absence of Peripheral Pulses and Risk of Major Vascular Outcomes in Patients With Type 2 Diabetes

OBJECTIVE

The burden of vascular diseases remains substantial in patients with type 2 diabetes, requiring identification of further risk markers. We tested the absence of dorsalis pedis and posterior tibial pulses as predictors of major macrovascular and microvascular events, death, and cognitive decline in this population.

RESEARCH DESIGN AND METHODS

Data were derived from 11,120 patients with type 2 diabetes in the Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified-Release Controlled Evaluation (ADVANCE) study. Absent peripheral pulses at baseline were defined as absence of at least one dorsalis pedis or posterior tibial pulse.

RESULTS

Absent compared with present peripheral pulses (n = 2,218) were associated with increased 5-year risks for major macrovascular events (hazard ratio 1.47 [95% CI 1.28-1.69], P < 0.0001), myocardial infarction (1.45 [1.13-1.87], P = 0.003), stroke (1.57 [1.23-2.00], P = 0.0003), cardiovascular death (1.61 [1.33-1.95], P < 0.0001), heart failure (1.49 [1.21-1.84], P = 0.0002), all-cause mortality (1.48 [1.29-1.71], P < 0.0001), major microvascular events (1.17 [1.00-1.36], P = 0.04), nephropathy (1.24 [1.00-1.54], P = 0.04), end-stage renal disease or renal death (2.04 [1.12-3.70], P = 0.02), and peripheral neuropathy (1.13 [1.05-1.21], P = 0.0008) after multiple adjustment. Participants with absent dorsalis pedis or posterior tibial pulses had comparable hazard ratios. Risks increased proportionally with the number of absent peripheral pulses, with the highest risks observed in patients with three or four absent pulses. Every additional absent pulse increases the risk of all outcomes.

CONCLUSIONS

Absent dorsalis pedis and/or posterior tibial pulses are independent predictors of major vascular outcomes in patients with type 2 diabetes. These simple clinical indicators should be used to improve risk stratification and treatment of these patients.

Acute Paraplegia as a Presentation of Aortic Saddle Embolism

Background. Acute onset paraplegia has a myriad of causes most often of a nonvascular origin. Vascular etiologies are infrequent causes and most often associated with postsurgical complications. Objective. To describe the occurrence and possible mechanism for aortic saddle embolism as a rare cause of acute paraplegia. Case Report. Described is a case of a 46-year-old female who presented with the sudden onset of nontraumatic low back pain with rapidly progressive paraplegia which was subsequently determined to be of vascular origin.

Improving clinical examination in acute tibial fractures by enhancing visual cues: the case for always 'cutting back' a tibial back-slab and marking the dorsalis pedis pulse

Look, feel, move is a simple and widely taught sequence to be followed when undertaking a clinical examination in orthopaedics (Maher et al., 1994; McRae, 1999; Solomon et al., 2010). The splinting of an acute tibial fracture with a posterior back-slab is also common practice; with the most commonly taught design involving covering the dorsum of the foot with bandaging (Charnley, 1950; Maher et al., 1994; McRae, 1989). We investigated the effect of the visual cues provided by exposing the dorsum of the foot and marking the dorsalis pedis pulse. We used a clinical simulation in which we compared the quality of the recorded clinical examination undertaken by 30 nurses. The nurses were randomly assigned to assess a patient with either a traditional back-slab or one in which the dorsal bandaging had been cut back and the dorsalis pedis pulse marked. We found that the quality of the recorded clinical examination was significantly better in the cut-back group. Previous studies have shown that the cut-back would not alter the effectiveness of the back-slab as a splint (Zagorski et al., 1993). We conclude that all tibial back-slabs should have the bandaging on the dorsum of the foot cut back and the location of the dorsalis pedis pulse marked. This simple adaptation will improve the subsequent clinical examinations undertaken and recorded without reducing the back-slab's effectiveness as a splint.

Pulse detection with a single accelerometer placed at the carotid artery: Performance in a real-life diagnostic test during acute hypotension

Pulse detection via palpation is a basic and essential procedure in daily medical practice. We have been investigating the performance of a single accelerometer placed above the carotid artery, which is one of the recommended locations for manual palpation. A low-cost sensor attached by an adhesive measures accelerations due to carotid dilatations and whole body vibrations. A real-time demonstrator has been developed to classify 10 second- windows in "Pulse", "Motion" and "No Pulse" and to infer pulse rate. Data were obtained during a scheduled head-up tilt table test (HUTT). Our results show for a subgroup of 10 patients with acute hypotension a wide spread of "good" signal coverage ranging from as low as 37% up to 100%. Key factors compromising the performance in HUTT are motion artifacts, arrhythmias, sensor placement and sensor-skin coupling. In conclusion, pulse detection with a single accelerometer is sufficiently accurate, if good signal coverage can be achieved.

Noninvasive Arterial Testing in Patients With Diabetes: A Guide for Foot and Ankle Surgeons

BACKGROUND

This study was designed to compare the findings of noninvasive arterial testing in patients with and without diabetic foot pathology.

METHODS

The ABI (ankle brachial index), TBI (toe brachial index), and great toe pressures were measured in 207 patients. PAD (peripheral artery disease) was defined as an ABI < 0.91 on either extremity or a TBI < 0.7.

RESULTS

PAD was identified in 103 of the 207 patients (49.8%), 80 patients with diabetic foot pathology and 23 patients with nondiabetic foot pathology. Although patients with diabetic foot pathology were 1.4 times more likely to have PAD compared to patients without diabetic pathology, this increased risk was not statistically significant (OR 1.41 [95% CI 0.75-2.64], P = .28). Patients with PAD and diabetic foot pathology were 4.9 times more likely to have ischemia (toe pressure < 60 mm Hg) than patients with PAD and nondiabetic foot pathology (OR 4.93 [95% CI 1.35-17.94], P < .05). Patients on dialysis had a 7.3 times increased likelihood of having PAD compared to patients not on dialysis (OR 7.3 [95% CI 1.6-33.6], P < .01). Patients with absent pedal pulses were 4.9 more likely to have PAD than patients with normal pulses (OR 4.9 [95% CI 2.6-9.4], P < .0001). PAD was identified in 97 of 188 patients (51.6%) with peripheral neuropathy compared to 6 of 19 patients (31.5%) without peripheral neuropathy (OR 2.31 [95% CI 0.84-6.33], P = .10).

CONCLUSIONS

Combining the ABI with TBI improved the ability to diagnose PAD in diabetic patients because the ABI has high specificity (low false positives) and the TBI has high sensitivity (low false negatives). The TBI was more reliable in patients with noncompressible arteries, medial artery calcinosis and/or neuropathy. Due to the relative incompressibility of calcified distal arteries in patients with DM, the ABI may be within normal limits in patients with PAD. This false negative result may lead surgeons to assume that normal perfusion is present.

Diagnosis and assessment of peripheral arterial disease in the diabetic foot

Approximately half of all patients with a diabetic foot ulcer have co-existing peripheral arterial disease. Identifying peripheral arterial disease among patients with foot ulceration is important, given its association with failure to heal, amputation, cardiovascular events and increased risk of premature mortality. Infection, oedema and neuropathy, often present with ulceration, may adversely affect the performance of diagnostic tests that are reliable in patients without diabetes. Early recognition and expert assessment of peripheral arterial disease allows measures to be taken to reduce the risk of amputation and cardiovascular events, while determining the need for revascularization to promote ulcer healing. When peripheral arterial disease is diagnosed, the extent of perfusion deficit should be measured. Patients with a severe perfusion deficit, likely to affect ulcer healing, will require further imaging to define the anatomy of disease and indicate whether a revascularization procedure is appropriate.

Temporal changes in the prevalence and associates of foot ulceration in type 2 diabetes: the Fremantle Diabetes Study

AIMS

To assess temporal changes in foot ulceration and its risk factors in community-based people with type 2 diabetes.

METHODS

Baseline data from the longitudinal observational Fremantle Diabetes Study collected from 1993 to 1996 (Phase I) and 2008 to 2011 (Phase II) were analyzed. Generalized linear modeling was used to examine changes in foot ulcer prevalence and its associates between phases. Multiple logistic regression was used to determine associates of prevalent foot ulceration in individual and pooled phases.

RESULTS

There were 16 foot ulcers among 1296 patients in Phase I (1.2%) and 23 in 1509 Phase II patients (1.5%; P=0.86 after age, sex and race/ethnicity adjustment). Glycemic and non-glycemic cardiovascular risk factors were better in Phase II, but diabetes duration was longer, peripheral sensory neuropathy (PSN) was more prevalent and more patients were Aboriginal (P<0.001) than in Phase I. In multivariable analysis of both phases and pooled data, diabetes duration and peripheral sensory neuropathy (PSN) were independent associates of foot ulceration (P≤0.026). Prior hospitalization for ulcer, intermittent claudication, any absent pedal pulse and Aboriginality were also significant in the pooled model (P≤0.009).

CONCLUSIONS

Strong associations between foot ulcer and diabetes duration, PSN, symptomatic and clinically-detectable peripheral vascular disease were observed. Aboriginality also proved an independent risk factor. Since all these risk factors apart from intermittent claudication and impalpable foot pulses were more prevalent in Phase II, improved community- and hospital-based foot care between phases are likely to have attenuated the risk of foot ulcers in Phase II patients.

The dorsal pedis artery as a new distal landmark for extramedullary tibial alignment in total knee arthroplasty

PURPOSE

It is better to use multiple anatomical landmarks to reduce errors in component alignment in total knee arthroplasty. Therefore, it is worthwhile to find a new landmark that can be used as an addition to conventional ones. Herein, we assessed the dorsal pedis artery as a new distal landmark for extramedullary tibial alignment.

METHODS

Fifty-two ankles in patients undergoing total knee arthroplasty and 10 ankles in normal controls were included. Color Doppler ultrasonography was used to locate the dorsal pedis artery at the level of the ankle joint. Conventional landmarks, including the tibialis anterior tendon, the extensor hallucis longus tendon, the extensor digitorum longus tendon, and the malleolar centre, were also located on ultrasound images. The distances between the ankle centre and each landmark were measured and compared.

RESULTS

The dorsal pedis artery was absent in 2 patients and impalpable but visible with ultrasonography in other 2 patients. The dorsal pedis artery was located anatomically closest to the ankle centre in patients (0.4 ± 3.4 mm lateral). Statistical analysis showed that the dorsal pedis artery, the extensor hallucis longus tendon, and the malleolar centre were located significantly closer to the ankle centre comparing with the extensor digitorum longus tendon and the tibialis anterior tendon in both patients and controls (p < 0.001).

CONCLUSIONS

As long as the dorsal pedis artery exists, it can be used as an addition to the conventional landmarks in total knee arthroplasty. Using this new landmark will help reduce errors in coronal plane alignment of tibial component.

LEVEL OF EVIDENCE

II.

Pulse waveform analysis as a bridge between pulse examination in Chinese medicine and cardiology

Pulse examination was probably the earliest attempt to distinguish between health and illnesses. Starting at the pre-Hippocratic era, Chinese medicine practitioners developed techniques for pulse examination and defined pulse images based on their perceptions of pulse waveforms at the radial artery. Pulse images were described using basic variables (frequency, rhythm, wideness, length, deepness, and qualities) developed under philosophical trends such as Taoism and Confucianism. Recent advances in biomedical instrumentation applied to cardiology opened possibilities to research on pulse examination based on ancient Chinese medical theories: the pulse wave analysis. Although strongly influenced by philosophy, some characteristics used to describe a pulse image are interpretable as parameters obtained by pulse waveform analysis such as pulse wave velocity and augmentation index. Those clinical parameters reflect concepts unique to Chinese medicine - such as yinyang - while are based on wave reflection and resonance theories of fluids mechanics. Major limitations for integration of Chinese and Western pulse examination are related to quantitative description of pulse images and pattern differentiation based on pulse examination. Recent evidence suggests that wave reflection and resonance phenomena may bridge Chinese medicine and cardiology to provide a more evidence-based medical practice.

The role of pulse oximetry in chiropractic practice: a rationale for its use

OBJECTIVE

Pulse oximetry is used regularly to assess oxygen saturation levels. The objective of this commentary is to discuss a rationale for using pulse oximetry in chiropractic practice.

DISCUSSION

Pulse oximetry may offer doctors of chiropractic a way to monitor patients' oxygen saturation levels. Quantification of saturation values with heart rate may give clinical aid to the management of chiropractic patients. Markedly reduced saturation levels may necessitate medical referral, whereas mildly reduced levels could lead to changes in chiropractic management.

CONCLUSIONS

Pulse oximetry has the potential to be an integral part of chiropractic practice.

Validation and comparison of currently available stratification systems for patients with diabetes by risk of foot ulcer development

AIMS/HYPOTHESIS

There are five systems to stratify the risk for the development of a diabetic foot ulcer (DFU). This study aimed to prospectively validate all of them in the same cohort of participants to allow their direct comparison.

METHODS

A retrospective cohort study was conducted on all patients with diabetes but without an active DFU attending our podiatry section (n=364) from January 2008 to December 2010. Participants' characteristics and all variables composing the stratification systems were assessed at baseline. Follow-up was performed for 1 year or until DFU occurred.

RESULTS

Participants had a mean age of 64 years; 99.7% had type 2 diabetes and 48.6% were male. Median follow-up was 12 months (1-12) during which 33 subjects (9.1%) developed a DFU. Age, diabetes duration, foot deformity, peripheral vascular disease, diabetic peripheral neuropathy, previous DFU, and previous lower extremity amputation were associated with DFU occurrence. All systems presented greater DFU occurrence frequency as the risk group was higher (χ(2), P<0.001) and showed good diagnostic accuracy values, especially negative predictive value (≥ 95%) and area under the receiver operating curve (≥ 0.73). The lowest performance concerned positive predictive value (≤ 29.5%).

CONCLUSIONS/INTERPRETATION

All the currently available stratification systems show high accuracy to detect which patients will develop a DFU with no significant differences among them. Therefore, for diabetic foot screening and resource allocation, it would be desirable to have a single unified system, combining the available systems, prospectively validated in a multicenter context and testing the inclusion of novel predictive variables' pertinence.

Interrater and intrarater reliability of photoplethysmography for measuring toe blood pressure and toe-brachial index in people with diabetes mellitus

BACKGROUND

A reliable tool to measure arterial flow to the feet in people with diabetes is required given that they are particularly prone to peripheral arterial disease. Traditionally, the ankle brachial index (ABI) has been used to measure arterial circulation, but its application is limited due to calcification of larger arteries. More recently, toe pressure and the toe brachial index (TBI) has been suggested as superior to ABI measurements because they assess smaller digital arteries less prone to arterial calcification. However, reliability studies for the clinical use of photoplethysmography (PPG) in people with diabetes are lacking.

METHODS

Sixty people with diabetes mellitus (35 males and 25 females, mean age 59.6 yrs) consented to take part in the study. The majority (92%) had type 2 diabetes and 8% had type 1 diabetes. Forty-three percent were diagnosed as having peripheral neuropathy when tested using a biothesiometer and 15% were current smokers (10 - 40/day). A podiatrist and a diabetes educator measured toe and brachial blood pressure independently and in a random order using PPG. These measurements were repeated again seven days later, and subsequently analysed with intraclass correlation coefficients (ICC), 95% confidence intervals (CI) and standard error of measurement (SEM).

RESULTS

The intrarater reliability of measuring toe pressures was excellent (ICC3,1 =0.78-0.79, SEM 8 mmHg) and interrater reliability was also excellent (ICC2,2 = 0.93, SEM 4 mmHg). The intrarater reliability for measuring brachial pressures was generally poor (ICC3,1 = 0.40 - 0.42, SEM 19 mmHg) and interrater reliability was fair-good (ICC2,2. 0.65, SEM 14 mmHg). The TBI intrarater reliability was fair-good (ICC3,1 = 0.51-0.72, SEM 0.08), whilst the interrater reliability of TBI was excellent (ICC2,2 = 0.85, SEM 0.07).

CONCLUSIONS

Based on these results, interrater and intrarater reliability of PPG is excellent for measuring toe blood pressure, good for TBI and only fair for brachial pressures in people with diabetes mellitus.

Vascular Laboratory for Critical Limb Ischaemia

This is a narrative review on vascular assessment for critical limb ischaemia in the past and present combining Finnish and Japanese experience.

Diagnostics and treatment of the diabetic foot

Every 30 s, a lower limb is amputated due to diabetes. Of all amputations in diabetic patients 85% are preceded by a foot ulcer which subsequently deteriorates to a severe infection or gangrene. There is a complexity of factors related to healing of foot ulcers including strategies for treatment of decreased perfusion, oedema, pain, infection, metabolic disturbances, malnutrition, non-weight bearing, wound treatment, foot surgery, and management of intercurrent disease. Patients with diabetic foot ulcer and decreased perfusion do often not have rest pain or claudication and as a consequence non-invasive vascular testing is recommended for early recognition of ulcers in need of revascularisation to achieve healing. A diabetic foot infection is a potentially limb-threatening condition. Infection is diagnosed by the presence or increased rate of signs inflammation. Often these signs are less marked than expected. Imaging studies can diagnose or better define deep, soft tissue purulent collections and are frequently needed to detect pathological findings in bone. The initial antimicrobial treatment as well as duration of treatment is empiric. There is a substantial delay in wound healing in diabetic foot ulcer which has been related to various abnormalities. Several new treatments related to these abnormalities have been explored in wound healing with various successes. An essential part of the strategy to achieve healing is an effective offloading. Many interventions with advanced wound management have failed due to not recognizing the need for effective offloading. A multidisciplinary approach to wounds and foot ulcer has been successfully implemented in different centres with a substantial decrease in amputation rate.

Chapter V: Diabetic foot

Ulcerated diabetic foot is a complex problem. Ischaemia, neuropathy and infection are the three pathological components that lead to diabetic foot complications, and they frequently occur together as an aetiologic triad. Neuropathy and ischaemia are the initiating factors, most often together as neuroischaemia, whereas infection is mostly a consequence. The role of peripheral arterial disease in diabetic foot has long been underestimated as typical ischaemic symptoms are less frequent in diabetics with ischaemia than in non-diabetics. Furthermore, the healing of a neuroischaemic ulcer is hampered by microvascular dysfunction. Therefore, the threshold for revascularising neuroischaemic ulcers should be lower than that for purely ischaemic ulcers. Previous guidelines have largely ignored these specific demands related to ulcerated neuroischaemic diabetic feet. Any diabetic foot ulcer should always be considered to have vascular impairment unless otherwise proven. Early referral, non-invasive vascular testing, imaging and intervention are crucial to improve diabetic foot ulcer healing and to prevent amputation. Timing is essential, as the window of opportunity to heal the ulcer and save the leg is easily missed. This chapter underlines the paucity of data on the best way to diagnose and treat these diabetic patients. Most of the studies dealing with neuroischaemic diabetic feet are not comparable in terms of patient populations, interventions or outcome. Therefore, there is an urgent need for a paradigm shift in diabetic foot care; that is, a new approach and classification of diabetics with vascular impairment in regard to clinical practice and research. A multidisciplinary approach needs to implemented systematically with a vascular surgeon as an integrated member. New strategies must be developed and implemented for diabetic foot patients with vascular impairment, to improve healing, to speed up healing rate and to avoid amputation, irrespective of the intervention technology chosen. Focused studies on the value of predictive tests, new treatment modalities as well as selective and targeted strategies are needed. As specific data on ulcerated neuroischaemic diabetic feet are scarce, recommendations are often of low grade.

The ulcerated leg: when to revascularize

The role of peripheral arterial disease in ulcerated diabetic feet has long been underestimated. Progressive claudication, rest pain and the extent of irreversible tissue loss have frequently been indications for revascularization for neuroischaemic ulcers in diabetic patients. These typical ischaemic symptoms are warning signs that are less frequent in diabetic individuals with ischaemia than those without diabetes. Consequently, 30-50% of individuals with diabetes and foot ulcers already have gangrene at admission and are therefore often considered unsuitable for revascularization. Furthermore, the healing of a neuroischaemic ulcer is worsened by microvascular dysfunction, causing arteriovenous shunting, capillary ischaemia, leakage and venous pooling. Therefore, the threshold of revascularizing neuroischaemic ulcers should be lower than that of purely ischaemic ulcers. Comorbidity, ulcer characteristics and infection affect the decision as to when to intervene, as do the severity and extent of occlusive arterial lesions. The window of opportunity for vascular intervention in the neuroischaemic diabetic foot should not be missed, and the need for early vascular intervention as an integrated part of a strategy to achieve healing should be emphasized. Noninvasive vascular testing should be performed on all individuals with an ulcerated diabetic foot. The arterial tree should be imaged if noninvasive tests indicate ischaemia or when mild or questionable ischaemia is diagnosed and conservative treatment does not promote ulcer healing in 6 weeks. Revascularization should be performed whenever feasible to repair distal perfusion to achieve ulcer healing.

Lumbar spinal stenosis associated with peripheral arterial disease: a prospective multicenter observational study

BACKGROUND

Intermittent claudication is a common symptom of both lumbar spinal stenosis (LSS) and peripheral arterial disease (PAD) in middle-aged and elderly people. However, the prevalence and clinical characteristics of LSS with PAD (LSSPAD) have not been investigated in a multicenter study. The aim of this study was to investigate the prevalence and clinical characteristics of LSS associated with PAD.

METHODS

570 patients diagnosed with LSS using a clinical diagnostic support tool and MRI at 64 facilities were enrolled. We evaluated each patient's medical history, physical findings, ankle brachial index, Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) score, and the Short Form 36 (SF-36) score. Statistical analyses were performed to compare LSSPAD patients and LSS patients without PAD using the t test, Mann-Whitney's U test, and multivariate recurrence analysis. p values of <0.05 were considered statistically significant.

RESULTS

The LSSPAD group comprised 38 patients (6.7 %); 20 (3.5 %) had pre-diagnosised PAD while 18 (3.2 %) had undetected PAD. The clinical characteristics of these patients were advanced age, diabetes, and a history of ischemic heart disease and cerebrovascular disorder. 570 patients enrolled, and 448 (78.6 %) of those patients were followed up at three months after enrollment. Pain in buttocks and legs improved less in the LSSPAD group than in the LSS group (p < 0.05). Improvements in the "general health" score in SF-36 were lower in the LSSPAD group than in the LSS group (p < 0.05).

CONCLUSIONS

Advanced age, diabetes, and a history of cerebrovascular disorder and ischemic heart disease were associated with LSSPAD. Because LSSPAD patients show less improvement in QOL than patients with LSS but without PAD do, clinicians should consider the coexistence of PAD in LSS patients.

Decision making in the dysvascular lower extremity

Given the aging population, the number of patients at risk for peripheral arterial disease and critical limb ischemia will increase in the upcoming decade. Using a focused history and physical examination, along with a combination of noninvasive physiologic testing and noninvasive and invasive imaging modalities, one can accurately assess the location and physiologic effect of peripheral arterial disease. This assessment then allows the selection of the most appropriate treatment option for each patient. Treatment options may include exercise and risk-factor modification, amputation, and endovascular or surgical revascularization or a combination of both.

Comparison of the Automated Oscillometric Method With the Gold Standard Doppler Ultrasound Method to Access the Ankle-Brachial Pressure Index

Objective: Despite its screening interest, the ankle-brachial pressure index (ABPI) remains uncommon in general practice, because it needs training and specific devices as Doppler. Easier methods such as the use of automated oscillometric devices may facilitate the peripheral arterial diseases (PADs) screening. We wanted to assess the reliability of the automated oscillometric measurement of the ABPI, compared with the gold standard Doppler ultrasound measurement. Patients and Method: In 287 patients aged 65 years or older without diagnosed PAD, we performed ABPI measurements with oscillometric and Doppler devices. Reproducibility was assessed by the intraclass correlation coefficient of agreement (R) and the Bland and Altman method. Results: The intermethod reliability was bad (R = .346, 95% CI = (0.268-0.420)), with a large confidence interval of the individual differences between the 2 methods: 95% CI = (—0.183-0.346). Conclusion: Automatic oscillometric devices cannot be recommended as reliable methods for ABPI measurement.

[Evidence-based recommendations on primary diagnostics of peripheral arterial occlusive disease in geriatric patients]

The prevalence of peripheral arterial occlusive disease (PAOD) is high in elderly patients and its clinical manifestation is often atypical. Comorbidity and morbidity as a consequence of PAOD are significant. Therefore, standardized primary diagnostics are required among geriatric patients. Drawn from a search of the literature, evidence-based recommendations are provided. Pulse palpation and the evaluation of a patient's medical history are obligatory components of primary diagnostics, even in the absence of typical symptoms. In the case of pathological and ambiguous findings, measuring Doppler ankle pressures is suggested as the next diagnostic step. Further measures depend on the following factors: the presence of lesions on the leg with disturbed blood flow, predominantly in the foot and lower leg areas, degree of PAOD-related ailments, and, finally, intended surgery of the affected leg for other medical reasons.