RESUMEN
In order to assess two simple methods of evaluation of claudication, a standard questionnaire and visual analogue scale, a comparison was made between them and the post-exercise pressure index used as a gold standard. Fifty-eight consecutive stable claudicants were recruited to the study, 51/58 having arterial insufficiency according to post-exercise pressure measurements. Both methods appeared to correlate rather poorly with post-exercise pressures. Thus visual analogue scale cannot be used alone to assess walking tolerance but as it offers qualitative information it may be used to supplement pressure measurements in the assessment of incapacity caused by intermittent claudication.
Asunto(s)
Claudicación Intermitente/fisiopatología , Índice de Severidad de la Enfermedad , Adulto , Tobillo/fisiopatología , Brazo/fisiopatología , Presión Sanguínea , Ejercicio Físico/fisiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Dimensión del Dolor , Autoevaluación (Psicología) , Encuestas y CuestionariosRESUMEN
The aim of this study was to evaluate the reliability of distal pulse palpation. The dorsalis pedis and the tibialis posterior arteries of 25 patients with suspected lower limb arterial disease were independently palpated by three vascular surgeons and three medical students in the outpatient clinic and by two vascular nurses and one physician in the vascular laboratory. The palpation findings were compared to the ankle/brachial index (ABI). Palpable and unpalpable pulses were best separated with ABI 0.76 as the cutoff point. The degree of misdiagnosis was unacceptably high, with an underdiagnosis of more than 30%. The agreement was highest (kappa 0. 68, good) among the vascular laboratory personnel in the peaceful vascular laboratory and lowest (kappa 0.38, fair) among the vascular surgeons in the busy outpatient clinic. The poor agreement and the high proportion of misdiagnosis obtained in the outpatient clinic argue against the use of pulse palpation as a single diagnostic method. Palpable pulses with low ABIs clearly state the need for more objective measurements whenever ischemia is suspected. Yet, by carefully palpating both pedal arteries under good, nonhurried conditions the reproducibility and accuracy of pulse palpation can be tolerable.
Asunto(s)
Palpación/métodos , Enfermedades Vasculares Periféricas/diagnóstico , Pulso Arterial/métodos , Adulto , Anciano , Anciano de 80 o más Años , Presión Sanguínea/fisiología , Distribución de Chi-Cuadrado , Errores Diagnósticos , Femenino , Pie/irrigación sanguínea , Humanos , Pierna/irrigación sanguínea , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Enfermedades Vasculares Periféricas/fisiopatología , Reproducibilidad de los Resultados , SístoleRESUMEN
BACKGROUND AND AIMS: Purpose of the study was to find out if reactive hyperemia stress test could serve as an alternative for treadmill exercise test in assessment of mild intermittent claudication (IC). MATERIAL AND METHODS: A total of 22 claudicants with resting ankle brachial index (ABI) ranging from 0.61 to 1.23 were stressed with progressive treadmill exercise test and suprasystolic thigh occlusion test to provoke reactive hyperemia. Immediate pressure measurements were obtained after the test. RESULTS: ABI drop after progressive exercise test was in average 0.29 and after reactive hyperemia 0.16. The pressures indices after these stress tests correlated well (r = 0.82). The tests were equally good in detecting mild arteriosclerotic disease. CONCLUSIONS: In conclusion, although postexercise ABI was able to detect mild atherosclerotic disease as the reason for IC with a better marginal than hyperemia test both methods are useful. In circumstances where the patient is for some reason unable to carry out treadmill test reactive hyperemia test is an alternative for differential diagnosis. This enables vascular surgeons to improve their diagnostics without vascular laboratory.
Asunto(s)
Hiperemia , Claudicación Intermitente/diagnóstico , Arteriosclerosis/diagnóstico , Arteriosclerosis/fisiopatología , Arteria Braquial/fisiopatología , Prueba de Esfuerzo , Humanos , Claudicación Intermitente/fisiopatología , Valor Predictivo de las Pruebas , Flujo Sanguíneo RegionalRESUMEN
To assess reproducibility of the exercise test in intermittent claudication, a prospective, comparative, randomized study was undertaken. Ten patients with stable intermittent claudication of ischaemic origin were exercised on a flat surface (0-Ex), with 12% steady inclination (12-Ex) and with progressively increasing inclination (p-Ex) in a random order during three different sessions. The ankle-brachial index (ABI) at rest and after exercise (rABI, exABI), initial and maximum walking distance (IWD, MWD) and metabolic equivalent (MET) were obtained as the main outcome measures. The results were analysed using intraindividual coefficients of variation (CVs) and standard deviations (SDs). The ABI values of the worst extremity were used in evaluation of results. Reproducibility of the exercise ABI appeared to be good, especially during progressively increasing exercise, the mean CV being 9 +/- 5%. The best mean CV was observed during p-Ex (16% +/- 14%) for maximum walking distance. The mean CV for initial walking distances ranged from 30% to 54%. Treadmill exercise testing to measure walking distances is highly inaccurate and the value of exercise on the flat treadmill should be questioned. Graded exercise appeared to be the most reproducible in this respect. The ABI after exercise, however, was a reliable single parameter when assessing arterial insufficiency causing decreased walking capacity.
Asunto(s)
Prueba de Esfuerzo/métodos , Claudicación Intermitente/diagnóstico , Claudicación Intermitente/fisiopatología , Caminata/fisiología , Anciano , Anciano de 80 o más Años , Análisis de Varianza , Presión Sanguínea/fisiología , Electrocardiografía Ambulatoria , Femenino , Humanos , Masculino , Persona de Mediana Edad , Isquemia Miocárdica/diagnóstico , Isquemia Miocárdica/fisiopatología , Consumo de Oxígeno/fisiología , Estudios Prospectivos , Reproducibilidad de los Resultados , Posición Supina/fisiología , SístoleAsunto(s)
Arteriosclerosis Obliterante/diagnóstico , Claudicación Intermitente/diagnóstico , Isquemia/diagnóstico , Pierna/irrigación sanguínea , Arteriosclerosis Obliterante/fisiopatología , Arteriosclerosis Obliterante/cirugía , Diagnóstico Diferencial , Humanos , Claudicación Intermitente/terapia , Isquemia/terapia , Pierna/cirugíaRESUMEN
The importance of the distinction between acute embolic ischaemia and acute on chronic ischaemia caused by a thrombus superimposed on an arteriosclerotic stenoses has been emphasized during the recent years, as the differentiation should affect the choice of surgical treatment. A retrospective attempt was made to differentiate between acute ischaemia (AI = embolism) and acute on chronic ischaemia (AOCI = thrombosis) of the leg by categorizing the patients according to the clinical characteristics they presented. The material consisted of 194 ischaemic lower limbs of 189 patients who underwent a balloon-catheter thromboembolectomy because of sudden arterial occlusion. The retrospective diagnosis of AI was made in 94 (48%) and AOCI in 69 (36%) cases. The preoperative assessment could not be done in 43 (22%) patients by surgeon working at the emergency room. The retrospective distinction was impossible in 31 (16%) patients. The preoperative diagnosis was in better agreement with the retrospective category when AI, as opposed to AOCI, was the aetiology of occlusion (70% vs 46%). The results of the present study emphasize the difficulties of clinical assessment. These findings suggest a routine angiography as an evaluative tool in the planning of optimal management especially as most of the patients today can be treated simultaneously by thrombolysis.
Asunto(s)
Isquemia/diagnóstico , Pierna/irrigación sanguínea , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Arteriosclerosis/complicaciones , Arteriosclerosis/diagnóstico , Arteriosclerosis/cirugía , Enfermedad Crónica , Diagnóstico Diferencial , Embolectomía , Femenino , Humanos , Isquemia/etiología , Isquemia/cirugía , Pierna/cirugía , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Trombectomía , Tromboembolia/complicaciones , Tromboembolia/diagnóstico , Tromboembolia/cirugíaRESUMEN
The efficacy of thrombolysis was retrospectively studied in patients with acute on chronic ischaemia in the lower extremity. A total number of 68 thrombolytic treatments were given to 65 patients, 58 (85%) because of native arterial occlusions and 10 (15%) because of occluded grafts. Tissue plasminogen activator was the lytic agent used in all patients. In native arteries, thrombolysis alone was successful in 15 (52%) out of 29 legs, whereas 22 (85%) out of 26 thrombolyses followed by angioplasty or surgery were effective. Thrombolysis alone was successful in two and failed in five out of 10 occluded grafts. Patency was achieved by combination with surgery in the other three cases. Twelve-month patency was 34% after thrombolysis alone and 69% (P < 0.05) when combined with surgery or angioplasty. The 30-day mortality rate was 9%. Thrombolysis can be used alone in acute on chronic ischaemia in the lower extremities. The immediate and the long-term results are clearly improved when thrombolysis is combined with angioplasty or reconstructive surgery to treat the underlying cause.
Asunto(s)
Isquemia/terapia , Pierna/irrigación sanguínea , Activadores Plasminogénicos/uso terapéutico , Terapia Trombolítica , Activador de Tejido Plasminógeno/uso terapéutico , Enfermedad Aguda , Adulto , Anciano , Anciano de 80 o más Años , Angioplastia de Balón , Enfermedad Crónica , Femenino , Estudios de Seguimiento , Humanos , Infusiones Intraarteriales , Isquemia/diagnóstico por imagen , Isquemia/etiología , Pierna/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Activadores Plasminogénicos/administración & dosificación , Radiografía , Estudios Retrospectivos , Tromboembolia/complicaciones , Tromboembolia/diagnóstico por imagen , Tromboembolia/terapia , Activador de Tejido Plasminógeno/administración & dosificación , Resultado del TratamientoRESUMEN
OBJECTIVE: To assess the efficacy of arterial surgery in restoring ability to walk and working capacity. DESIGN: Retrospective follow up study. SETTING: Fourth Department of Surgery, Helsinki University Central Hospital. SUBJECTS: 67 middle-aged patients (mean age 53 years) with chronic incapacitating ischaemia of the lower limb. INTERVENTIONS: Arterial reconstruction. MAIN OUTCOME MEASURES: Clinical outcome, vascular laboratory assessments, mortality, morbidity, return to work, and retirement. RESULTS: According to objective vascular laboratory criteria a primary positive effect was achieved in 63/67 (94%). Fourty-eight of the 65 surviving patients (74%) were free of symptoms on treadmill testing three months after the operation. Working capacity was restored in 41/50 of the patients not yet retired (82%). Three years postoperatively 77% of the surviving patients still fared objectively better than before operation. The 10-year survival rate was 67%. Fourteen of the 22 patients who died did so of cardiovascular diseases (64%). Advanced distal ischaemia (indicated by a preoperative ankle-brachial index of 0.5 or less) was associated with increased risk of death. Altogether 251 working years were achieved of the 435 that could have potentially been gained. The most common reason for retirement during follow up was progression of peripheral arterial disease in the lower limbs in 13/41 patients (32%). At the end of the study there were nine patients still working with potentially 73 working years left. CONCLUSION: These results indicate that arterial surgery can restore working capacity in middle aged patients with threatening or temporary invalidity. Long term outcome, especially mortality, is mostly affected by other signs of cardiovascular disease, whereas working capacity is dependent on a wider variety of factors.
Asunto(s)
Isquemia/cirugía , Pierna/irrigación sanguínea , Evaluación de Capacidad de Trabajo , Adulto , Arterias/cirugía , Enfermedad Crónica , Femenino , Estudios de Seguimiento , Humanos , Isquemia/fisiopatología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
The decreasing frequency of elective ulcer surgery and the persisting frequency of emergency surgery for peptic ulcer diseases has often been reported. The reason for the divergent epidemiological behaviour of the two subgroups of surgical candidates is not clear. The present cross-sectional, population-based analysis of patients undergoing peptic ulcer surgery evaluates the mode of preoperative therapy in elective and emergency cases. It also assesses the present frequency of peptic ulcer surgery, ulcer complications, and the immediate results of ulcer surgery in a target population. The evaluation concerned 117 adult patients (F/M ratio 1/1.1, mean age 58.7 +/- 1.8 years) operated on for peptic ulcer disease in Helsinki City between March 1990 and February 1991. The annual frequency of elective surgery was 8.3 and of emergency surgery 20.7 per 10(5) residents in Helsinki. 30% of the patients treated surgically had no preoperative symptoms or antiulcer medication; the others were on on-demand type H2-receptor antagonist therapy. Whereas there was no mortality from the elective surgery the mortality rate for the emergency surgery was 10%, mainly due to cardiopulmonary reasons among elderly, high-risk patients. In conclusion, since our previous report for 1987 for the same target population in Helsinki, the incidence of emergency surgery has additionally increased, while the incidence of elective surgery has continuously decreased.
Asunto(s)
Úlcera Péptica/cirugía , Anciano , Análisis de Varianza , Antiinflamatorios no Esteroideos/uso terapéutico , Distribución de Chi-Cuadrado , Estudios Transversales , Procedimientos Quirúrgicos Electivos , Femenino , Finlandia/epidemiología , Humanos , Masculino , Persona de Mediana Edad , Úlcera Péptica/complicaciones , Úlcera Péptica/mortalidad , Complicaciones Posoperatorias , Factores de RiesgoRESUMEN
To determine the effect of modern drug treatment on the incidence and type of ulcer operations, a retrospective survey was made of ulcer surgery performed on adult Helsinki residents during the years 1972, 1977, 1982 and 1987, with regard to indications and types of surgery. The introduction of H2-receptor blockers in 1979 was followed by a marked reduction in the incidence of elective ulcer surgery. On a population basis, the annual incidence of duodenal ulcer (DU) operations diminished by 50 per cent over the period 1972-1987, and that of operations for gastric ulcer by about two thirds, the falling trend being most marked among male DU patients. Figures for emergency surgical intervention in cases of haemorrhage or perforation remained unchanged during the period, as did the mean age of patients admitted for elective surgery, though the mean age of patients undergoing emergency surgery manifested a rising trend. The number of patients undergoing elective surgery for DU diminished, a trend first and foremost attributable to the fact that proximal selective vagotomy was performed more rarely, while the number of resections increased. The incidence of surgical treatment of pyloric and gastric ulcers remained unchanged during the period.