[The vascular surgeon's role in interdisciplinary treatment of diabetic foot syndrome]. / Interdisziplinäre Wundzentren in der Behandlung des diabetischen Fusssyndroms. Die Rolle des Gefässchirurgen.

There are more than 6 million diabetes patients in Germany. Due to long-term neuropathic and angiopathic sequelae, the number of patients with "diabetic foot syndrome" has increased dramatically in recent years. Diabetic foot ulcers have become one of the most common pathologies in interdisciplinary wound care centers. Because of its complex pathogenesis, diabetic foot syndrome needs a multidisciplinary therapeutic approach. More than 150,000 diabetics per year develop foot ulcers that often heal slowly and progress into chronic wounds. Despite all efforts at prevention, early diagnosis, and adequate therapy, more than 20,000 diabetics suffer major limb amputation in Germany every year. Applying stringent standards of care in interdisciplinary wound care centers, the amputation rate in patients with diabetic foot syndrome can be reduced to less than 50%. This article describes the complexity of diabetic foot syndrome with respect to pathogenesis, diagnostics, and therapy from a vascular surgeon's point of view. The importance of an interdisciplinary approach is emphasized.

[Is the generally accepted therapeutic benefit of exercise training in patients with peripheral arterial occlusive disease evidence based? Analysis of the Cochrane review]. / Ist der allgemein akzeptierte therapeutische Nutzen des Gehtrainings bei Patienten mit arterieller Verschlusskrankheit evidenzbasiert? Analyse des Cochrane-Reviews.

When assessing the quality of clinical trials in intermittent claudication, on principle the same strict biometric and medical standards need to be applied for studies on the effect of walking exercise as for conservative drug treatment studies. However, as demonstrated by a recent review of the Cochrane Collaboration, this is apparently not always the case. The review included ten randomized controlled studies published between 1966 and 1997 with a total of 258 patients. The exercise regimes varied considerably between studies with regard to mode, intensity, frequency, duration and supervision, just as the treadmill tests employed to measure walking distance and walking time, respectively (primary endpoint). None of these studies used a confirmatory approach, and they all have a number of further methodological flaws when taking current biometric and medical guidelines into account. Also unmentioned in the abstract remains the important fact that, owing to missing data, finally only 53 patients from three studies could be pooled for the actual meta-analysis. All in all, the Cochrane review under discussion here is hardly suitable to scientifically prove the generally accepted efficacy of walking exercise in intermittent claudication. At the same time, it becomes clear that even publications of well-reputed institutions such as the Cochrane Collaboration should always be critically scrutinized. On the other hand, applying modern guidance for investigation under the aspect of evidence based medicine must not lead to a retrospective discrimination of accepted historical scientific data and thereby call into question proven therapeutic strategies.

Cerebrovascular manifestations of Takayasu arteritis in Europe.

OBJECTIVES: Takayasu arteritis is well known as a cause of stroke in Asia but has rarely been described in the Western world. Here we report the clinical and neuroimaging follow-up of a series of patients with Takayasu arteritis from Europe. METHODS: Seventeen consecutive patients who fulfilled the diagnostic criteria for Takayasu arteritis of the American College of Rheumatology were evaluated on follow-up by standardized neurological examination, sonography and MRI. RESULTS: At follow-up almost 20 yr after onset of symptoms, the subclavian artery and the common carotid artery were often affected. In addition, evidence of intracranial pathology was found in seven patients. In contrast to the severe vessel involvement, the neurological state was stable. Two patients had suffered from stroke before the diagnosis was made and therapy was initiated, and one patient had recurrent transient ischaemic attacks. Intermittent dizziness was associated with pathology of the vertebral and basilar arteries. However, clinical symptoms of subclavian steal syndrome were rare. CONCLUSION: This case series shows that the clinical neurological course of Takayasu arteritis on treatment is benign in most cases despite the severe vascular involvement.

[The prevalence of hyperhomocysteinemia in thromboangiitis obliterans. Does homocysteine play a role pathogenetically?]. / Prävalenz der Hyperhomocysteinämie bei der Thrombangiitis obliterans. Spielt Homocystein pathogenetisch eine Rolle?

OBJECTIVE: As hyperhomocysteinaemia is known to be an important risk factor in the early onset of arteriosclerotic occlusive disease and leg-vein thrombosis, we investigated the prevalence of hyperhomocysteinaemia in patients with thromboangiitis obliterans (TAO), a condition predominantly affecting peripheral arteries and veins. PATIENTS AND METHODS: Plasma homocysteine (HC), before and after administration of methionine (0.1 g/kg) as well as serum folic acid, vitamins B6 and B12 were measured in 15 patients with TAO (12 men, 3 women; mean age 33.3 years: group 1), in 15 non-smokers without peripheral vascular disease (group 2) and 15 smokers without peripheral vascular disease (group 3). At the time of the study, of those in group 1 seven were active smokers, seven were ex-smokers and one was a non-smoker. RESULTS: Before methionine administration four patients (27%), none of the healthy non-smokers and one smoker without vascular disease (7%) had increased HC levels (> 13.9 nmol/ml). The difference between groups 1 and 2 was statistically significant (P < 0.05), but not that between groups 1 and 3 and between 2 and 3. 4 hours after methionine increased HC levels (> or = 31 nmol/ml) were measured in nine patients but in none of the healthy controls. The difference between patients and the two control groups without vascular disease was clearly significant (P = 0.0107). There was a difference in folic acid levels between the patients and the smokers without vascular disease: in eight patients (53%) the levels were in the lower third of normal, in six (40%) they were in the middle and in one (7%) in the upper third. Corresponding levels in group 3 were: four (27%), three (20%) and eight (53%). CONCLUSION: Hyperhomocysteinaemia occurs frequently in patients with TAO. It may play an important and nicotine-independent role in its pathogenesis.

[Comparison between argon and excimer laser angioplasty in patients with lesions of the femoral and popliteal arteries: clinical and angiography results after 1 year]. / Vergleich zwischen Argon- und Excimerlaserangioplastie bei Patienten mit Läsionen der A. femoralis und A. poplitea: Klinische und angiographische Ergebnisse nach 1 Jahr.

The aim of this study was to compare acute and long term results of thermic argon laser versus athermic XeCl-excimer laser for recanalization of femoropopliteal lesions in 43 patients with peripheral vascular disease stage IIb to IV according to Fontaine. The argon laser system was applied in 29 lesions (9 stenoses, 20 occlusions up to 31 cm length) and an excimer laser was used in 28 lesions (10 stenoses, 18 occlusions up to 30 cm length). In all cases balloon dilatation followed laser recanalization to achieve a sufficient primary result (< 25% stenosis rate). Primary success was obtained in 86% with both laser systems. After 1 year 62.5 of the recanalized vessels with excimer laser and 56% with argon laser were still patent. Neither acute nor long term results showed significant differences between both laser systems. Compared to the argon laser, the procedure with the excimer laser was of shorter duration which may be advantageous under routine conditions. After one year, combining the results of both systems, the reocclusion rates of stenoses amounted to 22%, the reocclusion rates of short distance occlusions to 35% and that of long occlusions more than 10 cm length to 71%. With regard to the high reocclusion rate after reopening of long occlusions the laser systems seem to be of advantage, compared to balloon angioplasty mainly in critical stenosis and short occlusions which cannot be passed with the guide-wire.

The effects of tertatolol on lipid profile.

Tertatolol is a noncardioselective beta-blocker without intrinsic sympathomimetic activity. In a preliminary 3-month open study, it was shown that T was devoid of any atherogenic effect since HDL-cholesterol (HDL-C) and apoprotein levels did not change for 3 months of therapy. To investigate the long-term effects of tertatolol on the lipid profile and its safety in hypertensive patients with peripheral arterial disease (PAD), a 9-month, randomized, double-blind, parallel group study was carried out in 40 patients. Tertatolol 5 mg once daily was compared with metoprolol 200 mg once daily. If BP was not controlled after 2 months, a vasodilatator agent, dihydralazine, was added at the lowest dose required to control BP (diastolic BP < 90 mm Hg). Lipoprotein fractions and apoproteins were assayed before (M0) and after 2, 6 and 9 months of therapy. At the same occasions, peripheral arterial disease (PAD) was evaluated on exercise tests carried out on a treadmill and on the regional blood flow measured in the ankle arteries by the Doppler technique. Four patients were not eligible for analysis. In the tertatolol group, 1 patient with a normal BP, and 2 patients who dropped out, 1 because of persistent nausea and 1 because of personal reasons. In the metoprolol group, 1 patient refused to take dihydralazine. In the 35 fully documented patients, BP control was achieved in both groups. The mean reductions in supine systolic/diastolic BP were 31.4/14.6 and 34.7/17.1 mm Hg in the tertatolol and metoprolol groups, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Intravascular ultrasound (IVUS) in patients with peripheral arterial occlusive disease (PAOD).

The new method of intravascular ultrasound (IVUS) permits an exact documentation of the pathomorphology of diseased arteries in a two-dimensional cross section image. Exact quantification of the vessel transverse diameters is achiveable. The different ultrasonic properties of fat, connective tissue and calcified tissue allow evaluation of intimal plaque composition. Thrombotic arterial occlusions can be detected. First experiences with IVUS prove, that this method is clearly superior to contrast arteriography and transcutaneous ultrasound, in terms of characterization and quantification of the extent of vessel wall disorders. Distinct structures, such as dissecting membranes or intimal flaps, which may escape arteriographic detection, are clearly visualized by IVUS. False adjustment of the physical parameters of the ultrasonic beam and non coaxial orientation of the ultrasound catheter within the vessel lead to false quantification of the transverse vessel diameters and to over- or underestimation of the echodensity and as a consequence of the intimal plaque composition. Simultaneous imaging of neighbouring arteries, veins or arterial branches allow longitudinal orientation within the vessel. Exact orientation however is only provided by simultaneous fluoroscopy. The present study demonstrates the value of IVUS as a guiding method of transcutaneous interventional procedures. The advantage could be an optimal selection of the recanalizing technique, appropriate to the arterial lesion. The result of interventional therapy can be documented immediately. Furthermore specific injuries of the vessel wall, leading to additional interventions and influencing short and long-term prognosis, can be imaged with high accuracy.

Medical edema protection--clinical benefit in patients with chronic deep vein incompetence. A placebo controlled double blind study.

In a randomized placebo controlled parallel double blind study on 40 patients suffering from venous edema in chronic deep vein incompetence, the edema-reducing effect of horse chestnut seed extract vs. placebo, being the main test variable, was demonstrated by hydroplethysmography to be statistically significant. In addition, measurements of leg volume under aggravated conditions (edema provocation) were conducted, which yielded the same results. Additional measurements of leg circumference tendentially confirm the demonstrated clinical efficacy of verum, as is true for phlebody-namometric measurements (pressure at rest, minimum pressure, replenishment time) as well. By measuring the leg volume before and after edema provocation, it could be shown that the clinical benefit for the patient is present in all everyday situations (in movement as well as on sitting or standing). Treatment with an edema protective agent of the horse chestnut seed extract type is thus a useful adjunct to compression therapy. The tested preparation were well tolerated.

Pharmacokinetics of mezlocillin after intraarterial or intravenous injection in patients with peripheral arterial occlusive disease (PAOD).

In the first part of this study, which was already published in this journal, tissue- and serum concentrations of Mezlocillin were compared one hour after a single dose of 2 g injected either intraarterially or intravenously in patients with ischemic lesions, due to PAOD or moist diabetic gangrene. In nearly all tissues of the minor perfused metatarsus and in the thigh, estimated as being physiologically perfused, there was an impressive trend to higher concentrations after i.a. injection. The concentrations in the thigh were higher than in the metatarsus after both, i.a. or i.v. injection. In this second part, tissue concentrations are compared three to four hours after the end of i.a. or i.v. injection of the same dose. After this interval of time, there is no longer any striking difference between the tissue concentrations after i.a. compared to i.v. injection within the physiologically perfused thigh, the concentrations in the reduced perfused metatarsus still show a convincing tendency to higher values after i.a. injection. It is concluded, that the initial tissue concentration of an antibiotic depends on its concentration within the inflowing blood and on the amount of the blood perfusion. The decline of the tissue concentration time course is more pronounced after i.a. injection. The advantage of higher concentrations after i.a. injection is limited to the initial phase after the injection.

Antidromic activation of sensory afferent fibres in sympathetic nerves of the cat by stimulation of collaterals within the dorsal medulla oblongata.

Action potentials were evoked in the white ramus of the third thoracic segment by electrical stimulation in the dorsal medulla oblongata. The following findings indicate that these potentials are due to antidromic activation of collaterals of afferent fibres in sympathetic nerves rather than to orthodromic synaptic activation of preganglionic sympathetic neurones via bulbospinal sympatho-excitatory pathways: (i) they had short latencies yielding intraspinal conduction velocities of 13-43 m/sec; (ii) they followed short trains of stimuli at frequencies up to 600 Hz; and (iii) they were abolished by cutting the dorsal roots of the same spinal segment.

Tonic descending inhibition of the spinal somato-sympathetic reflex from the lower brain stem.

In chloralose-anaesthetized cats the spinal and supraspinal components of the somato-sympathetic reflex were evoked in the white ramus at T3 and/or L2 by stimulation of intercostal and spinal nerves. A reversible blockade of all ascending and descending spinal pathways was performed by cooling the spinal cord between the second and third cervical segment. Total blockade of conduction was produced at temperatures below 8.5 degrees C (281.5 K). The spinal blockade produced the following reversible effects. (1) Mean arterial pressure fell to 30-50 mm Hg (4.0-6.7 kpa) and the tonic background activity in the white ramus was reduced to 0-24% of control (mean 12.1 +/- 10.0%). (2) The amplitude of the early spinal reflex was increased from 100% to 111-316% (mean 200.9 +/- 49.5%, n = 49) at the thoracic level and to 125-342% (mean 181.4 +/- 74.4%, n = 7) at the lumbar level. The onset latency of the spinal reflex at T3 (range 8-21 msec) was shortened by 0.5-3.0 msec (mean 1.7 +/- 0.9 msec). (3) Supraspinal components were completely abolished. (4) Neither baroreceptor denervation nor midcollicular decerebration altered these effects. (5) The cold block induced increase of the amplitude of the spinal reflex was reduced by the alpha-adrenoceptor agonist clonidine; this effect was reversed by the alpha-adrenoceptor antagonist yohimbine. Selective cooling of the dorsolateral funiculus caused the same effects on the spinal and supraspinal reflexes as cold block of the whole spinal cord. From these findings it is concluded that in the anaesthetized cat the spinal component of the somato-sympathetic reflex is modulated by a descending tonic inhibition. This inhibition acts at both the thoracic and the lumbar level and its origin is in the medulla oblongata. This inhibition is, however, independent of baroreceptor inputs. The pathways descends in the dorsolateral funiculus. It is suggested that noradrenaline or adrenaline might be involved in the transmission of this inhibitory influence.