Transcutaneous oxygen recovery and toe pulse reappearance time in the assessment of peripheral vascular disease.

The accuracy of measurements of transcutaneous oxygen tension (Ptco2) in the diagnosis of peripheral vascular disease (PVD) may be significantly increased by stressing limb circulation with the use of temporary ischemia. The purpose of this study was to compare the transcutaneous oxygen recovery half-time (TORT) and the toe pulse reappearance time (PRT/2) in a series of patients with symptomatic PVD before and after vascular reconstruction. The TORT was defined as the time required to recover half of the decrease in the limb/chest Ptco2 ratio caused by temporary limb ischemia, and is conceptually comparable to the toe PRT/2, the time required to recover half of the control toe pulse amplitude. Measurement of TORT was found to be more feasible (100% vs 58%) and to have a greater diagnostic yield (100% vs 92%) than that of the toe PRT/2. When measured on the dorsum of the foot, TORT values were found to correlate well with the severity of symptoms of PVD; toe PRT/2 values did not correlate with severity of symptoms. Patients who underwent successful vascular reconstruction had significant improvement in their calf and foot TORT values after surgery (p less than .005 and .0005, respectively); postoperative values were similar to those obtained in normal subjects. Toe PRT/2 values usually improved postoperatively, but in many patients postoperative values overlapped with values that were considered abnormal. There was no overlap of TORT values in normal subjects with those in patients with symptomatic PVD. The measurement of TORT may be clinically useful for screening patients with suspected PVD and for assessing quantitatively the results of conservative and surgical therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Noninvasive evaluation of peripheral vascular disease using transcutaneous oxygen tension.

Transcutaneous oxygen tension (PtcO2) was used for noninvasive determination of blood supply in 25 patients evaluated for peripheral arterial disease. PtcO2 values were compared with segmental Doppler pressure, pulse volume recording, pulse reappearance time, and angiography in patients being evaluated for wound healing problems, amputations, and peripheral bypass procedures. PtcO2 was measured using a heated (45 degrees C) Clark polarographic electrode to quantitate the oxygen which diffuses from the dermal capillaries to the skin surface. Control PtcO2 values recorded over the chest or shoulder taken while patients were breathing room air were 78 +/- 8 mm Hg. PtcO2 values greater than 50 mm Hg predicted success for levels of amputation and for wound healing without reconstructive procedures; values of 40 mm Hg or less were associated with continued wound problems and complication after amputation. Increased PtcO2 values after vascular reconstruction of the legs predicted improved clinical status on follow-up examinations up to 6 months. PtcO2 predicted the extent of vascular disease as well as the other noninvasive tests and angiography. We conclude that (1) PtcO2 tension is a simple, accurate, noninvasive method to determine the appropriate level of amputation, wound healing potential, and effectiveness of bypass procedures, and (2) PtcO2 values correlate well with angiography and noninvasive evaluations.

A comparative study of scattered radiation levels from 80-kVp and 240-kVp x rays in the surgical intensive care unit.

The levels of scattered radiation from 80-kVp and 240-kVp mobile x-ray units were measured in the surgical intensive care unit (ICU). The intensity of scatter of the 240-kVp x rays does not decrease with distance as rapidly as with the 80-kVp beam. In an ICU with four beds, the weekly radiation exposure at the nurses' station approximated 0.05 mR (0.13 X 10(-7) C/kg) for the 80-kVp beam and 0.2 mR (0.52 X 10(-7) C/kg) for the 240-kVp beam. Thus, the annual exposure from either unit would be well below the Maximum Permissible Exposure for nonoccupational workers.

Mobile 240 kVp phototimed chest radiography.

Chest radiographs obtained with mobile equipment for 240 kVp phototimed technique and conventional technique were compared in 161 patients. Features of interest were visualization of air space, interstitium, mediastinum, pleura and vessels, tracheobronchial tree, catheters and tubes. The 240 kVp system demonstrated consistently good visualization of central air passages, hilar contours, and pulmonary detail. It was superior to the conventional portable in eliminating respiratory motion, defining lung infiltrates, and localizing the endotracheal tube relation to the carina. The 240 kVp system had noticeable deficiencies in depicting calcifications, bone detail, and fat planes. These deficiencies were not of clinical significance. Although the equipment was compact, easily maneuverable, and simple to operate, the cassette holder was somewhat heavy--a detrimental but manageable factor. Another shortcoming was poor visualization of homogeneously opacified catheters within the mediastinum, although catheters with a dense radiopaque stripe alleviated this problem.

Ultrasonic visualization of the non-opacified gallbladder: response of the normal and obstructed canine gallbladder to C8CCK.

In vitro studies of a simulated gallbladder show that B-scan ultrasonography is as reliable as radiography in measuring changes in volume of the organ. The width or planimetric area of the sonogram correlates with the change in balloon volume and with similar radiographic measurements. In vivo measurements of the normal canine gallbladder stimulated by a carefully prescribed infusion of C8CCK in the dose range of 2.2 to 5.5 ng/kg/min over an 8 to 10 minute interval, showed a clearly defined decrease in gallbladder width. In ligation and division of the common bile duct no change in gallbladder size was demonstrated. We conclude that sonography alone can be used to measure a change in gallbladder size to better differentiate complete obstruction of the common bile duct from medical causes in the jaundiced patient.

Fine needle cholangiography in the diagnosis of persistent jaundice. A case report.

The fine needle technic utilizes a sleeveless, thin, flexible needle for transhepatic cholangiography. This needle can enter small or normal bile ducts in a high percentage of patients. The value of fine needle cholangiography is illustrated in a patient with a stenosis of the common hepatic duct and a left hepatodochalduodenal fistula which eluded diagnosis by all other methods. The use of this technic is described as an alternative procedure to endoscopic retrograde cholangiography when the latter is technically impossible or as an adjunct to intraoperative extrahepatic cholangiography.

Tuberculous enteritis.

Tuberculous enteritis occurs in about 2 percent of patients with pulmonary tuberculosis. Although it is uncommon in the United States, tuberculous enteritis should be considered in any patient with active pulmonary tuberculosis and abdominal complaints. Eight cases of T. enteritis have been treated at Harbor General Hospital in the last 25 years. Associated pulmonary disease was shown radiologically to be present in seven of eight patients. Findings on contrast studies of the gastrointestinal tract showed disease in six of six patients examined. In five patients, surgical operation was required for diagnosis or complications. Resection of diseased bowel with primary anastomosis was done in five patients. Although medical therapy is the mainstay in the treatment of both pulmonary and intestinal tuberculosis, one staged resection of diseased bowel with primary anastomosis is the procedure of choice for complications such as obstruction, hemorrhage or perforation.

Chiba percutaneous transhepatic cholangiography. A valuable method for visualizing the nondilated biliary tract.

Percutaneous transhepatic cholangiography with the Chiba needle has had remarkable results in cannulating small bile ducts. We have roentgenographically visualized a nondilated biliary system in the first five out of seven cases attempted. Including our series, there have been 71 successful Chiba studies in 107 nondilated or presumed normal biliary tracts with only one questionable major complication. The technique is simple to learn, particularly in comparison with endoscopic retrograde cholangiography. Since the incidence of complications is low, surgical standby should seldom be necessary. The value of the Chiba percutaneous transhepatic cholangiogram is described via four unusual case reports.

The value of preoperative saphenous venography for graft evaluation in femoral arterial occlusive disease.

We reviewed the results of preoperative bilateral ascending phlebography in 23 patients who had femoral arterial occlusive disease; seven of the 40 successful saphenous venograms showed significant abnormalities. Varicosities, congenital duplications, superficial or deep thrombophlebitis and saphenous vein length were clearly identifiable. Correlation of the radiographic sphenous diameter with the operative measurement was poor. Nevertheless, four of the 21 patients were spared unnecessary surgery because we had determined by preoperative venography a better vein for autograft than the ipsilateral saphenous vein.

Correlation of the ultrasonic appearance of the portal vein with abdominal arteriography.

The ultrasonic appearance and location of the portal vein is documented by correlation with abdominal arteriography. Five patients were studied by both methods. Various characteristic appearances of the portal vein are presented. The importance of localization of the portal vein during an ultrasonic pancreatic examination is discussed.

Thigh emphysema and hip pain secondary to gastrointestinal perforation.

A patient presenting with thigh emphysema and hip pain may suggest intra-abdominal pathology. Three new and 19 previously reported cases of thigh emphysema secondary to bowel disease are reviewed. The thigh and hip manifestations can obscure the primary intra-abdominal process either due to the obvious emphysema or to the obtunded abdominal signs secondary to associated neuropathy. Only one of 22 patients with thigh emphysema secondary to bowel perforation had gas gangrene. Early diagnosis of this clinical association is essential since eight of the 11 deaths occurred within a few days after admission. Right-sided thigh emphysema suggests appendicitis, whereas left-sided emphysema is more likely to be secondary to left colonic diverticulitis or carcinoma.

Value of gallbladder B-scan ultrasonography.

The gallbladder B-scans of 20 patients who had subsequent surgery were separated into three categories based upon certain sonographic criteria. Our data, in this limited series, revealed gallbladder pathology in each patient who had any one or combination of the following scan characteristics: (1) internal echos, (2) irregular wall, or (3) absence of recognizable gallbladder sonolucency. The category which demonstrated a normal sonographic gallbladder, namely a smooth wall and no internal echos, contained a number of false negatives which proved to have either small stone cholelithiasis or extraphepatic ductal obstruction. Within the described limitations, the B-scan can be a valuable test in confirming the significance of a radiographically nonvisualized gallbladder or in detecting a biliary tract lesion in a patient with a disease entity that precludes radiographic visualization by conventional techniques.

Tuberculous enteritis. Review of a protean disease.

Prior to the advent of antituberculosis drugs, at least 70% of patients with far advanced pulmonary tuberculosis had tuberculous enteritis. Despite the effectiveness of drug therapy, overt cases of tuberculous enteritis occur in the United States and particularly among immigrants from endemic areas. Clinicians often forget to consider this entity. The patient may have no or minimal abdominal complaints. Vague abdominal distress, anorexia and weight loss can be overlooked because of the extensive pulmonary exudative or cavitary disease. Even after an enteric lesion is identified, often it is mistaken for other entities, particularly neoplasm or Crohn's disease. Obviously, the diagnosis is difficult but certain radiological criteria can be indicative of the disease. This report demonstrates the protean manifestations of this entity, the complications which occur despite drug therapy and the need for continued awareness of its existence.