[Ciprofloxacin and pivampicillin in acute epididymitis in men above the age of 40 years]

Ciprofloxacin 500 mg orally twice daily was compared to pivampicillin 700 mg orally twice daily for 10 days in 172 men (41-85 years) with acute epididymitis. Failure of treatment occurred in 48 patients, in 15/76 (19.7%) receiving ciprofloxacin versus in 33/82 (40.2%) receiving pivampicillin (p = 0.006). Ciprofloxacin 500 mg orally twice daily is more effective than pivampicillin 700 mg orally twice daily and has fewer adverse events.

A double-blind, randomized, controlled multicentre study to compare the efficacy of ciprofloxacin with pivampicillin as oral therapy for epididymitis in men over 40 years of age

OBJECTIVE

To compare the efficacy and safety of ciprofloxacin 500 mg orally twice daily with pivampicillin 700 mg orally twice daily for 10 days in men with acute epididymitis and over 40 years of age.

PATIENTS AND METHODS

The study comprised 172 men who entered a prospective, controlled, randomized, double-blind, trial of pivampicillin and ciprofloxacin. The median (range) age of the 158 patients eligible for the efficacy analysis was 58 (41-85) years; 41% had previously had a urinary tract infection and 27% had previously had epididymitis. Only one patient had a urethral catheter and 38% were sexually active. About half of the patients were admitted to hospital.

RESULTS

No bacteria could be cultured from samples in 53% of the patients; Escherichia coli could be cultured from 35% and the remaining isolates were the expected urinary pathogens. None of the patients had Gonococci and only one in each group had Chlamydia. Mycoplasma hominis was detected in three patients only and M. genitalium was detected in three, while Ureaplasma was detected in 24 (15%). The treatment failed in 48 patients; in 15 of 76 (20%) receiving ciprofloxacin and in 33 of 82 (40%) receiving pivampicillin. This corresponds to a reduction in the risk of failure of 20.5% (95% confidence limits 6.6-40.2%, P=0. 006). The principal cause of failure was an unsatisfactory clinical response requiring changed antibiotic treatment in 27 patients; adverse events were responsible for failure in 14. The in vitro resistance of cultured bacteria was low in both groups, at approximately 4%. Adverse events, mainly gastro-intestinal, occurred in 17 of 83 (21%) patients starting on ciprofloxacin and in 33 of 89 (37%) receiving pivampicillin (P=0.04).

CONCLUSION

For epididymitis in men over the age of 40 years ciprofloxacin 500 mg orally twice daily is more effective than pivampicillin 700 mg orally twice daily. Furthermore, ciprofloxacin has a lower incidence of adverse events.

Long-term results of the Stamey Bladder-neck suspension procedure and of the Burch colposuspension

This retrospective study compares the long-term results of the Stamey bladder-neck suspension and the Burch colposuspension following operation for urinary incontinence in women. A total of 182 women underwent operation for urinary incontinence: 83 by Stamey bladder-neck suspension and 99 by Burch colposuspension. The case records were perused and questionnaires were sent to the 169 women who were still alive: 129 women had no previous operation for urinary incontinence. At follow-up in this group a median of 7 years after the operation, 32% were completely continent and 39% had improved after the Stamey method, as against 33% and 29%, respectively, after Burch (p > 0.05). The Stamey operation was associated with a lower complication rate (12%) and a lower rate of re-operation (16%) than the Burch operation (23% and 22%, respectively) (p > 0.05). Previous incontinence surgery and mixed type of incontinence was associated with poor outcome in the Stamey group.

[Amputation and arterial reconstruction in peripheral occlusive arterial diseases in Denmark 1977-1993]

Information was retrieved from the national patient register (Landspatientregisteret), that contains information on all admissions to Danish hospitals 1977-1993. The number of admissions during which a diagnosis of occlusive arterial disease (OAD) of the lower extremities was made and an amputation performed increased from 1290 in 1977 to a maximum of 1609 in 1983 (p < 0.001). From 1987 on the number decreased almost 30% to 1111 in 1993 (p < 0.001). During the period the number of admissions during which arterial reconstruction for OAD were performed increased steadily from 963 in 1977 to 2637 in 1993 (p < 0.001). The result may indicate that vascular surgery is effective on a national scale in preventing amputations for OAD.

Prognosis after nephrectomy for renal cell carcinoma

During the period 1977-1988 177 males and 81 females (age 28-87 years) had nephrectomy performed for renal cell carcinoma. The most frequent symptoms were flank pain (54%) and hematuria (53%). Few patients (6%) had the classical triad of symptoms. Overall survival at 2 and 5 years were 0.55 and 0.41. Renal cell carcinoma specific survival were 0.59 and 0.49. Univariate analyses showed that increasing T stage, positive N or M stage, increasing stage according to Robson, hypersedimentation, anaemia and perioperative blood transfusion had a significant detrimental influence on survival. Multivariate analysis showed that simple Robson stage gave a simpler and equally good description as did the TNM stage. In the Cox multiple regression analysis Robson stage and ESR were the only statistically significant variables.

Perioperative blood transfusion does not affect survival after operation for renal cell cancer

We retrospectively studied the effect of perioperative blood transfusion in 208 transfused and 50 nontransfused patients operated on during a 12-year period for renal cell cancer. The 5-year renal cell cancer specific survival rate was 0.46 in the transfused patients versus 0.62 in the nontransfused patients. However, when differences in risk factors were accounted for by Cox regression analysis, perioperative blood transfusion was not a significant risk factor. The study does not support the hypothesis that blood transfusion promotes death after operation for renal cell cancer.

Incidence of diagnosis, operation and death from abdominal aortic aneurysms in Danish hospitals: results from a nation-wide survey, 1977-1990

OBJECTIVE

To study the incidence of various hospital manifestations of abdominal aortic aneurysms.

DESIGN

Retrospective review of a database covering all admissions to Danish hospitals.

SUBJECTS

All patients admitted to Danish hospitals during the period 1977 to 1990.

MAIN OUTCOME MEASURES

Number, and age and sex specific incidence rates of hospital admission for, operation for, or death from abdominal aortic aneurysm.

RESULTS

The number of admissions during which an abdominal aortic aneurysm was diagnosed increased fourfold from 362 in 1977 to 1317 in 1990, and the number of admissions, during which an abdominal aortic aneurysm was operated on, increased by a factor of nearly five from 66 to 307. A quarter of the operations were done for ruptured aneurysm. The number of deaths in hospital increased from 119 in 1978 to about 200 towards the end of the period, but during the last three years it decreased from 236 to 177.

CONCLUSION

Although the study records abdominal aortic aneurysm in hospital only, the data may indicate that the incidence is increasing. The reduction in mortality towards the end of the period may indicate that vascular surgery even on a national scale is effective in reducing mortality from aortic aneurysm.

Changes in the number of lower limb amputations during a period of increasing vascular surgical activity. Results of a nation-wide study, Denmark, 1977-1990

OBJECTIVE

To find out if the number of lower limb amputations for peripheral occlusive arterial disease increased during the period of increased vascular surgical activity 1977-1990.

DESIGN

Retrospective review of a database covering all admissions to Danish hospitals.

SUBJECTS

All patients admitted to Danish hospitals with peripheral occlusive disease during the period 1977-1990.

MAIN OUTCOME MEASURES

Numbers, and age and sex specific incidence rates for admission, arterial reconstruction and amputation.

RESULTS

The number of admissions during which arterial reconstruction for OAD was done increased from 963 in 1977 to 2311 in 1990 (p < 0.001). The number of admissions during which a diagnosis of OAD was made and an amputation done increased from 1290 in 1977 to a maximum of 1609 in 1983 (p < 0.001). The number remained nearly constant in the mid-1980s but decreased during last part of the period to 1181 in 1990 (p < 0.001).

CONCLUSION

The reduction in the number of amputations may indicate that vascular surgery even on a national scale is effective in preventing amputations for OAD.

Peri-operative blood transfusion in relation to tumour recurrence and death after surgery for prostatic cancer

Several reports have suggested that peri-operative blood transfusion promotes tumour recurrence and death after surgery for cancer. We have studied the effect of transfusion in 156 patients operated on for prostatic cancer. A retrospective review was made of the clinical, histopathological and transfusion data in their hospital records. Sixty patients received blood transfusions and 96 did not. The 5-year prostatic cancer specific survival rate was 0.56 in the transfused patients and 0.69 in the non-transfused group. The transfused patients had a higher prevalence of risk factors than did the non-transfused. When the differences in risk factors were accounted for by Cox regression analysis, peri-operative blood transfusion reduced the prostatic cancer death intensity by 36%. The study does not support the hypothesis that blood transfusion promotes recurrence following surgery for prostatic cancer.

Perioperative blood transfusion does not promote recurrence and death after mastectomy for breast cancer. The Danish Breast Cancer Cooperative Group

Several reports suggest that perioperative blood transfusion promotes recurrence and death after cancer surgery. We studied the effect of transfusion in 1599 patients who had mastectomy for carcinoma of the breast. In 228 transfused patients the disease recurred in 110 (48 per cent), compared with 647 (47 per cent) of 1371 non-transfused patients (P = 0.85). The 5-year recurrence-free survival rate was 0.54 in the transfused patients and 0.60 in the non-transfused group (P = 0.44). The transfused patients had a higher prevalence of risk factors than the non-transfused patients. Cox's multiple regression analysis confirmed that perioperative blood transfusion was of no importance. The study does not support the hypothesis that perioperative blood transfusion promotes recurrence after operation for breast cancer.

Perioperative blood transfusion and recurrence and death after resection for cancer of the colon and rectum

Several reports have claimed that perioperative blood transfusion promotes recurrence and death after cancer surgery. We studied the effect of transfusion in 315 patients who had radical resection for carcinoma of the colon and rectum. The disease recurred in 113 (42%) of 268 transfused patients, versus in 15 (32%) in 47 non-transfused patients (P = 0.2). Of the transfused patients 102 (38%) died of colon cancer, versus 13 patients (28%) in the non-transfused group (P = 0.2). The 5-year recurrence-free survival rate was 0.59 in the transfused patients and 0.72 in the non-transfused group (P = 0.10). When differences in confounding background variables were accounted for by Cox multiple regression analysis, the significance of transfusion was even less. The study does not support the hypothesis that perioperative blood transfusion promotes recurrence after operation for colorectal cancer.

[Can chlorophyll reduce fecal odor in colostomy patients?]

The effect of 75 mg chlorophyll tablets thrice daily was studied in 28 colostomy patients. The investigation was carried out as a randomized, double-blind, cross-over study. The effect of chlorophyll did not differ from that of a placebo in the patients' subjective assessment of the unpleasant odour.

Effect of electrode temperature on orthostatic changes in forefoot transcutaneous oxygen tension (tc-PO2)

The influence of increasing the temperature of the transcutaneous oxygen tension (tc-PO2) electrode from 37 to 45 degrees C on the orthostatic changes in tc-PO2 was studied in six normal subjects. The tc-PO2 electrode was mounted on the forefoot. The blood pressure of the forefoot was changed by elevating and lowering the forefoot in relation to heart level. At all electrode temperatures tc-PO2 decreased about 35% when the forefoot was elevated. At electrode temperatures between 41 and 45 degrees C tc-PO2 increased about 20% when the electrode was lowered below heart level. This indicates a passive vascular bed in the heated tissue under the electrode. However, at 37 degrees C tc-PO2 decreased about 40% when the forefoot was lowered. This indicates that the local vasoconstrictor response to increased venous transmural pressure is preserved when the tissue under the electrode is heated to 37 degrees C only. The study suggest that tc-PO2 monitoring at 37 degrees C may be used for continuous, non-invasive monitoring of the local vasoconstrictor response, and thus of arteriolar contractility and intact sympathetic innervation.

Effect of perioperative blood transfusion on recurrence and death after mastectomy for breast cancer

A recent report suggested that perioperative blood transfusion doubles the recurrence rate of breast cancer after mastectomy. In the present retrospective study the effect of transfusion on cancer recurrence and death after mastectomy was investigated in 96 women, 27 with and 69 without blood transfusion. The overall survival rates, the breast-cancer-specific survival and the recurrence-free survival rates were similar in the two groups. The study thus does not support the hypothesis that perioperative blood transfusion promotes recurrence of breast cancer.

Four years' results of a prospective, randomized clinical trial comparing polytetrafluoroethylene and modified human umbilical vein for below-knee femoropopliteal bypass

Polytetrafluoroethylene (PTFE) (Gore-Tex) and human umbilical vein (Biograft) arterial grafts were compared for below-knee femoropopliteal bypass grafting in a prospective randomized clinical trial. One hundred five patients (105 limbs) entered the trial. Seventy-six percent suffered from rest pain, ulceration, or gangrene. The median postoperative ankle-arm blood pressure index was 0.36. Twenty-three limbs had three patent tibial arteries, 46 limbs had two tibial arteries, 31 limbs had one patent artery, and five limbs had isolated popliteal segments. Thirty-four percent were repeat operations. Fifty-five patients were allocated to receive PTFE grafts and 50 to receive human umbilical vein grafts. The two groups were comparable as to preoperative risk factors and operative and postoperative treatment. During the first 4 years (maximum 1609 days) 40 PTFE grafts and 24 umbilical veins occluded. At 1 year the PTFE patency rate was 53% and at 4 years was 22%. For umbilical vein the corresponding figures were 74% and 42% (p = 0.005, Gehan test). During follow-up the incidence of PTFE failure was on the average 2.1 times higher than that of umbilical vein failure (95% confidence limits 1.2 to 3.4).

Local regulation of subcutaneous blood flow and capillary filtration in limbs with occlusive arterial disease. Studies before and after arterial reconstruction

The aim of the study was to examine the local blood flow regulation and the capillary filtration rate in patients with occlusive arterial disease before and after arterial reconstructive surgery. Fourty-seven normal subjects and 99 patients were studied. Subcutaneous blood flow was measured on the forefoot by the local 133Xenon method. Forefoot arterial blood pressure was measured indirectly by cuff and strain-gauge technique. Capillary filtration rate was measured by strain-gauge plethysmography on the forefoot. The arterial and venous pressures of the forefoot were changed by elevating or lowering the foot in relation to heart level. In normal limbs autoregulation was demonstrated during elevation of the limb when blood flow remained almost constant despite the reduction in arterial and perfusion pressures. The local vasoconstrictor response to increased venous transmural pressure was demonstrated when the limb was lowered and blood flow decreased about 30% despite a constant perfusion pressure. In limbs with occlusive arterial disease both local blood flow regulation mechanisms became progressively more abnormal the severe the symptoms and the lower the distal blood pressure. Estimations of the changes in local vascular resistance suggested that the abnormalities in blood flow regulation in all but the severest cases are the result of changes in local perfusion pressure rather than the result of inability of the arteriolar smooth muscle to dilate and constrict in response to changes in arterial and venous pressures. After arterial reconstruction the two mechanisms generally normalized within about a week. However, disturbances occurred in some cases in the early postoperative period, possibly as the result of postoperative pain and stress. Postreconstructive hyperaemia developed in most limbs despite the early normalization of local blood flow regulation. Compared with normal limbs, the forefoot capillary filtration rate was reduced in limbs with occlusive arterial disease. In the early postoperative period the filtration rate remained reduced, but it increased to normal values within three months. Postreconstructive oedema developed independently of the normalization of blood flow regulation, and almost exclusively after femoro-distal by-pass surgery. The study supports the hypothesis that the postreconstructive oedema is a lymphoedema due to surgical trauma, rather than the result of microvascular derangement.

Local regulation of subcutaneous forefoot blood flow during orthostatic changes in normal subjects, in sympathetically denervated patients and in patients with occlusive arterial disease

Local blood flow regulation was studied on the forefoot by the 133-Xenon wash-out method. In 21 normal limbs blood flow decreased 36% when the foot was lowered 40 cm below heart (local vasoconstrictor response). During elevation blood flow was constant to 20 cm, and flow decreased only 10% at further elevation to 40 cm, corresponding to a drop in vascular resistance of 15% (autoregulation of blood flow). In six sympathetically denervated limbs blood flow decreased only 6%, significantly less than in the normal limbs. Autoregulation of blood flow was preserved in these limbs. In 22 limbs with intermittent claudication blood flow decreased only 19%, significantly less than in the normal limbs. However, taking into account the additional increase in arterial pressure that occurs, when a limb with arterial occlusion is lowered there was no significant difference (p = 0.26) in the increase in vascular resistance between the two groups. During elevation vascular resistance decreased significantly in the claudicants indicating preservation of autoregulation. In limbs with rest pain blood flow increased 28% during lowering, and when the additional increase in arterial blood pressure was accounted for, a significant increase in vascular resistance of 21% was noted. During elevation blood flow decreased significantly, and the estimated vascular resistance in this group did not decrease significantly. The study suggests that the increase in blood flow and the relief of ischaemic rest pain induced by lowering are due to an additional increase in arterial pressure rather than due to dilatation of arterioles.

Normalization of local blood flow regulation in the ischemic forefoot after arterial reconstruction

Two local blood flow regulating mechanisms were studied before and after arterial reconstruction in 30 limbs suffering from occlusive arterial disease. Changes in forefoot blood flow were measured from the washout of a subcutaneous 133xenon depot. Arterial and venous pressures were changed by passive lowering and elevation of the foot. In 14 limbs suffering from severe ischemia, the local vasoconstrictor response to increased venous pressure was abolished as blood flow increased 37% when the limbs were lowered 40 cm. Autoregulation of blood flow was abolished also as flow decreased 51% when the limbs were elevated 20 cm. The estimated vascular resistance was constant during lowering and elevation, indicating paralysis of the arterioles. The vasoconstrictor response had returned at the tenth postoperative day as blood flow decreased 32% during lowering. Autoregulation had also returned as blood flow remained almost constant during elevation to 40 cm. In 16 limbs with less severe ischemia, vasoconstrictor response as well as autoregulation was preserved before operation, and no disturbances occurred after operation. Despite the early normalization of local blood flow regulation, postoperative hyperemia developed in most limbs. Post-reconstruction edema developed after all but one of the 13 femorodistal bypass operations and after only one of the 17 aortoiliac reconstructions. This suggests that post-reconstruction hyperemia and post-reconstruction edema are not caused by arteriolar insufficiency.

Direct determination of the tissue-to-blood partition coefficient for Xenon in human subcutaneous adipose tissue

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

Forefoot capillary filtration rate measured during lowering in normal subjects and in patients with occlusive arterial disease before and after arterial reconstruction

Capillary filtration rate (CFR) was measured by a mercury-in-silastic strain-gauge around the forefoot when the forefoot was lowered 40 cm below heart level. In seven normal limbs, CFR was 0.061 (0.049-0.086) ml (100 g min)-1 against 0.049 (0.016-0.071) ml (100 g min)-1 in 24 limbs with occlusive arterial disease (P = 0.01). About 8 days after arterial reconstruction CFR decreased to 0.039 (0.018-0.071) ml (100 g min)-1, but before 3 months after reconstruction CFR increased to normal values 0.061 (0.037-0.071) ml (100 g min)-1. The explanation offered for the reduced CFR before and immediately after arterial reconstruction is temporary thrombosis in the smallest distributing arteries and in the arterioles resulting in heterogeneous flow distribution and decreased fluid filtration in poorly perfused segments of the capillary bed. The results speak against increased capillary filtration as the aetiology of the post-reconstructive oedema.

Effect of chronic sympathetic denervation upon the transcapillary filtration rate induced by venous stasis

The effect of venous pressure elevation upon capillary filtration rate in the limb was studied in 6 chronically sympathectomized patients. Five healthy subjects served as controls. Volume changes of the forearm or calf were recorded by a strain-gauge plethysmograph. Relative blood flow in subcutaneous and muscle tissue during venous stasis was measured by the local 133Xe washout technique. In the denervated limbs there was a linear relationship between net capillary filtration rate and venous pressure elevation. In the controls a non-linear relationship was seen as venous pressure elevation of 40 mmHg only caused an increase in net filtration rate of about 66% of that expected from a linear relationship. In the denervated limbs of blood flow in muscle and subcutaneous tissue remained constant during venous pressure elevation of more than 30 mmHg whereas in the non-denervated limbs blood flow decreased by about 50% in both tissues. The results suggest that a local sympathetic veno-arteriolar (axon) reflex plays a dominant role for the reduced increase in net capillary filtration during large increases in venous pressure. The local axon reflex may therefore act as an edema protecting factor.

A randomized clinical trial of PTFE versus human umbilical vein for femoropopliteal bypass surgery. Preliminary results

PTFE (Goretex) and modified human umbilical vein (Biograft) vascular grafts were compared in femorodistal popliteal artery bypass surgery in a randomized clinical multicentre trial. During 18 months 104 patients (104 limbs) entered the trial. Twenty-five patients suffered from claudication, 54 suffered rest pain and 25 patients had ulceration or gangrene. The median preoperative ankle-arm blood pressure index was 0 . 34. Twenty-three limbs had 3 patent tibial arteries, 45 limbs had 2 tibial arteries, 31 limbs had 1 tibial artery while 5 limbs had an isolated popliteal segment. Thirty-six of the operations were redo-operations. Fifty-four patients were allocated to PTFE and 50 to umbilical vein. During follow-up (maximum 650 days) 24 PTFE grafts occluded against 12 umbilical veins. The 1-year patency rate was 40 per cent in the PTFE group against 75 per cent in the umbilical vein group (P = 0 . 014, Gehans test). During the first year the PTFE failure rate was on average 3 . 1 times higher than that of the umbilical vein.

Changes after arterial reconstruction in the forefoot local vasoconstrictor response to increased venous transmural pressure

Local blood flow regulation on the forefoot was studied by the 133Xe wash-out technique in twenty-seven patients before and after arterial reconstruction for occlusive arterial disease. In thirteen limbs with severe symptoms the local vasoconstrictor response to increased venous pressure was absent preoperatively, as blood flow in the foot increased in median by 47% when the foot was lowered 40 cm below the heart. Three months postoperatively the vasoconstrictor response had returned as blood flow decreased 28% during lowering. Fourteen limbs with milder symptoms had a vasoconstrictor response before operation. In nine limbs of this group treated with aortoiliac reconstruction the vasoconstrictor response was absent at the early postoperative examination, but the response returned till the late examination. It is concluded that the local vasoconstrictor response is normalized after arterial reconstruction. Disturbances may, however, occur in the postoperative period, possibly due to operative stress.

Mechanism of ergotamine-induced decrease of peripheral systolic blood pressure in man

We have previously reported a consistent decrease of peripheral-central systolic blood pressure (SBP) gradients after ergotamine. SBP was measured with cuffs and it is unknown whether measured values reflect changes of intra-arterial SBP or increase of vessel wall tone beneath the cuffs. We hence studied the effect of ergotamine tartrate 0.5 mg intravenously on finger-arm systolic gradients after the following procedures: Infiltration around finger arteries with papaverine (n = 2) and dihydralazine (n = 3), occlusion of blood supply to a finger by an inflated cuff before and 2 hours after ergotamine (n = 6). A normal reduction in finger-arm systolic gradients was seen. The ergotamine-induced decrease of peripheral SBP must therefore be due to a fall in peripheral intra-arterial SBP i.e. to contraction of arteries proximal to the digital arteries. Intra-arterial injection of 10 micrograms ergotamine tartrate caused similar decrease in finger-arm systolic gradients as intravenous administration of 0.5 mg (n = 1) indicating a peripheral site of action.

The influence of changes in arterial blood pressure on transcutaneous oxygen tension (tcPO2) in the newborn

The possible artefacts in transcutaneous oxygen tension (tcPO2) induced by fluctuations in arterial blood pressure were investigated in ten newborn babies. We mounted one tcPO2 electrode on the foot and another on the chest, and the local arterial blood pressure under the foot electrode was reduced 0.6-2.0 kPa (9-15 mmHg) by elevating the foot 11-19 cm above the heart level. In five mature newborns the tcPO2 of the foot decreased significantly (p = 0.015) during elevation by a mean valve of 0.029 kPa (0.22 mmHg) per mmHg decrease in mean arterial blood pressure. In five premature newborns the artefact was insignificant (p = 0.62). We conclude therefore that, in contrast to adults, the artefacts induced by minor fluctuations in arterial blood pressure in newborns are hardly of clinical importance.

Local regulation of blood flow and the occurrence of edema after arterial reconstruction of the lower limbs

The relation between edema after arterial reconstruction of the lower limbs and various potential etiologic factors, including disturbances in local blood flow regulating mechanisms, was investigated in 22 patients with occlusive arterial disease. The occurrence of edema was unrelated to the severity of symptoms as well as to the perioperative changes in distal arterial blood pressure. Postreconstructive edema developed independently of postreconstructive hyperemia and of disturbances in the local vasoconstrictor response to increased venous pressure. The decisive factor for development of edema was the extensive dissection in the thigh and in the popliteal region required for femoropopliteal bypass surgery. Edema developed after nine of nine femoropopliteal bypass operations, and only after one of 12 reconstructions in the aorto-iliac or in the profound femoral segments (p = 0.001). It is concluded that the postreconstructive edema is a lymphedema due to surgical trauma, rather than the result of microvascular derangement.

Local regulation of subcutaneous blood flow in normal subjects and in migraine patients before and after single-dose ergotamine tartrate

Local blood flow regulation of the foot was studied in 15 normal subjects and in nine migraine patients. Changes in arterial and venous pressures were induced by lowering and elevation of the limb. Changes in blood flow were estimated from the changes in the wash-out rate of a subcutaneous 133-Xenon depot. The local vasoconstrictor response to increased venous pressure elicited during lowering was identical in the normal subjects and in the migraine patients. During elevation, however, an abnormality in the autoregulation of blood flow could be demonstrated, as a decrease in blood flow during elevation to +40 cm was more pronounced in the patients than in the normal subjects (P = 0.04). About 3 h after 0.5 mg ergotamine tartrate/70 kg body weight i.v. the local regulation of blood flow had markedly changed in normal subjects as well as in migraine patients. During elevation to +20 and to +40 cm, blood flow increased significantly (P = 0.01 and P = 0.02). In two subjects the isotope depot was infiltrated with lidocaine and the ergotamine-induced increase in blood flow during elevation was blocked. The results may indicate that the veno-receptor of the veno-arteriolar reflex underlying the local vasoconstrictor response is a tension receptor, which due to the veno-constrictor effect of ergotamine is triggered even at heart level.

Pre-operative exercise testing in patients suspected of arteriosclerotic heart disease: methods, risks and reproducibility

In order to estimate the value of haemodynamic parameters in assessing impaired left ventricular function the reproducibility of haemodynamic measurements were investigated at rest and during supine exercise on a bicycle ergometer in fifty-one patients suspected of arteriosclerotic heart disease by means of a Swan-Ganz pulmonary artery thermodilution catheter and a radial artery catheter. Furthermore the minimal significant (P less than 0.05) change from rest to exercise was determined. In conclusion we found that haemodynamic measurements during exercise testing estimate left ventricular function in a safe and reproducible manner. A rise in pulmonary capillary wedge pressure (PCWP) of only 0.9 kPa during exercise was significant, whereas changes in stroke volume index (SVI) were considered significant only when exceeding 9 ml/m2.

The effect of single dose ergotamine tartrate on peripheral arteries in migraine patients: methodological aspects and time effect curve

Ergotamine tartrate (0.5 mg/70 kg) was given intravenously to 17 migraine patients. Arm, finger, ankle and big toe systolic blood pressures were measured with strain gauge technique for up to 4 hours and again after 22 hours. Systolic arm blood pressure increased transiently (duration less than 3 hours). Peripheral systolic blood pressures decreased in all patients (for toes a few to 55 mmHg) and at 22 hours well sustained decreases were still found. Further 10 migraine patients received 2-4 mg ergotamine tartrate as suppositories and peripheral systolic blood pressures were measured for 3 days. A decrease in peripheral systolic blood pressure was found after 24 hours but had disappeared after 48 hours. Contrary to common belief the present study investigating the effect of ergotamine directly on arteries has shown a long duration of its vasoconstrictory effect. Thus the effect of a single dose of ergotamine on the arteries should be followed for days.

Evaluation of patients with only marginally abnormal arm-ankle blood pressure gradients suspected of arterial obliterative disease

Two groups of patients with only marginally abnormal systolic blood pressure gradients from arm to ankle were studied. Group A consisted of 24 patients, who had arteriography performed for unilateral symptoms. In the non-symptomatic limbs a significant correlation was found between the severity of obliterations and the arm to ankle blood pressure gradients, which in all cases was less than 35 mmHg. In Group B consisting of 55 patients suspected of arterial obliterative disease the arm to ankle pressure gradient was measured at rest and after 2 min. of leg exercise. The diagnostic correctness of the two procedures were analysed by the direct method for evaluation of diagnostic tests using the clinical diagnosis as final diagnostic criterion. The maximal diagnostic correctness was 85 % for the gradient at rest using values between 20 and 25 mmHg as criterion for arterial obliterative disease. It equaled the maximal diagnostic correctness of 87 % of the gradient after exercise using values between 45 and 55 mmHg as criterion.

Correlation of transcutaneous oxygen tension to blood flow in heated skin

Blood flow regulation in the foot under a heated (43 degrees C) transcutaneous oxygen tension (tcPo2) electrode was studied in six young subjects. Blood flow under the electrode was estimated from the electrical power consumption of the thermostatistically-controlled heating element in the electrode. Changes in arterial and venous pressures, and thereby in perfusion and transmural pressure and blood flow were induced by elevation and lowering of the foot and by venous stasis. tcPo2 was significantly and positively correlated to the blood flow under the electrode, and blood flow neither showed autoregulation nor vasoconstrictor response as judged from the power consumption. In contrast the blood flow in normal unheated skin measured simultaneously by the 133-Xenon technique showed autoregulation as well as vasoconstrictor response. It is concluded that tcPo2 is a parameter determined by many variables, of which the arterial blood pressure is of particular clinical importance.

Diagnostic correctness of distal blood pressure measurements in patients with arterial insufficiency

The value of distal blood pressure measurement by strain gauge technique in arterial insufficiency was analysed by means of the so-called direct method for evaluation of diagnostic tests, and by the calculation of the diagnostic specificity (predictive value of a positive test), the diagnostic sensitivity (predictive value of a negative test), and the diagnostic correctness (the proportion of patients correctly classified by the test). A blood pressure gradient greater than or equal to 20 mmHg from arm to ankle had a high diagnostic correctness as a screening procedure for arterial insufficiency among forty out-patients. Likewise, in sixty-seven patients admitted for arterial reconstruction a toe blood pressure < 30 mmHg had a high diagnostic correctness in deciding whether constant pain was in fact ischaemic rest pain. In contrast, distal blood pressure measurement was of no value as an indicator of the walking distance of claudicants or in locating the arterial obliterations. It is proposed, that similar evaluations are performed on other tests for arterial insufficiency.

Effect of arterial and venous pressures on transcutaneous oxygen tension

The effect of changes in arterial and venous pressures on transcutaneous oxygen tension (tcPO2) were studied in ten young subjects. The tcPo2 electrode was mounted on the foot, and changes in blood pressures were induced by elevating and lowering the foot and by inflating a cuff around the thigh. tcPo2 decreased gradually during elevation at a rate of 1% per mmHg reduction in arterial pressure. tcPo2 increased during dependency and venous stasis, at a rate of 0.5% per mmHg increase in venous pressure. We propose that tcPo2 is a function of the blood flow under the electrode, and that normal blood flow regulation is abolished in the heated tissue under the electrode.