Are there predictors for the outcome of a PGE1 treatment in peripheral arterial disease with critical limb ischaemia?

BACKGROUND: In a multivariate retrospective analysis was conducted to examine whether and to what extent PGE1 is therapeutically effective and whether there are predictors of response. PATIENTS AND METHODS: The examination included 767 patients (448 women, 319 men) of a mean age of 71.2 years and with peripheral arterial disease (PAD) having existed for 44.7 months on the average. They suffered from critical limb ischaemia (Fontaine's stages III/IV) and showed average tcpO2 values at the instep of 2 mmHg (0 to 15) and average systolic malleolar artery pressures of 18 mmHg (0 to 35 mmHg). Between 1989 and 2001, the patients had received treatments in hospital with i.v. PGE1 doses (2x20 microg or 1x60 microg/day) for an average of 34.2 days (mean of responder- and non-responder group). Patients were called responders when pain had markedly decreased or disappeared, necroses had been reduced or healed completely, and vascular reconstruction, PTA or amputations were not necessary. RESULTS: The clinical analysis showed 82.4% of the patients to be responders and 17.6% to be non-responders. It was demonstrated that the outcome of the therapy was not dependent on the supine or sitting tcpO2, the malleolar artery pressure, the patient's age or sex, the duration of PAD, the number or kind of concomitant diseases, the patient's general condition, the localization and number of vascular occlusions, the kind of prior therapy, or the number of previous amputations, although differences in some of the parameters, while clinically irrelevant, were found to be statistically significant. They are not predictors of the outcome of a PGE, therapy. CONCLUSIONS: Even in extremely bad haemodynamic situations at the beginning of a therapy (malleolar artery pressures from 0 to 35 mmHg, tcpO2 0 to 15 mmHg, multilevel occlusive disease, multiple previous operations and concomitant diseases), PGE, therapies of more than 20 days - on the average 35.6 days (mean of responder group) - duration allow clinically relevant positive results to be achieved.

[DRG-based cost analysis of inpatient conservative treatment of stage III/IV peripheral arterial occlusive disease]. / DRG-basierte Kostenanalyse zur stationären konservativen Behandlung der PAVK Stadium III/IV.

UNLABELLED: DRG-based cost analysis of inpatient conservative treatment of PAD stage III/IV BACKGROUND: In a prospective study carried out by the German Society of Angiology and the DRG Competence Center, Munich, the question was investigated whether the costs of conservative treatment of patients with PAOD stage III/IV (DRG F65) are adequately represented within the current G-DRG system. METHODS UND PATIENTS: Between September 1 and December 16, 2002, a total of 704 patients with DRG F65 (peripheral vascular diseases) were evaluated at 8 angiologic centers in Germany. Apart from the length of hospital stay, the total costs (cost equivalents) were calculated using a method developed by the DRG Research Group at the University of Münster. Moreover, the study population was compared with a German calculation sample for the DRGs F65A/B, as published by InEK. RESULTS: As it turned out, conservatively treated patients with PAOD stage III or IV (DRGs F65A/B) cause significantly (p < 0.001) higher costs and have significantly (p < 0.001) greater lengths of hospital stay than patients who were also assigned to DRG F65 because of other vascular diseases. At the same time it became clear that angiologic centers treat twice as many patients with critical limb ischemia in comparison with the German average. The reimbursement hitherto estimated by InEK covers not even half the cost actually produced by conservative treatment of PAD stage III/IV. CONCLUSION: To ensure a performance-related reimbursement, a new basis DRG for patients with PAD stage III/IV has to be created, as has ben proposed by the German Society of Angiology. Otherwise, adequate conservative therapy in accordance with existing guidelines, of patients who cannot be treated surgically or interventionally will not be possible any more in the future.

Vital capillary microscopic findings in the nailfold of patients with diabetes mellitus.

BACKGROUND: Preliminary investigation done in 100 healthy adults and 20 healthy children had shown that the interpretation of significance of changes in capillary morphology need to be corrected, since capillary changes previously considered to be pathological are also to be found in large numbers in healthy subjects. Against this background, the question has now been investigated whether the capillary microscopic findings in diabetics deviates from those found in normals, and whether the duration of the diabetes, its treatment, its sequelae, or concomitant diseases have any influence on the capillary microscopic appearance. PATIENTS AND METHODS: In 100 patients aged between 44 and 88 years with type 2 diabetes vital capillary microscopy was carried out on all ten fingers in the usual manner. The evaluation of the video recordings was done only when all the examinations had been completed--by two examiners blinded to the clinical data. RESULTS: It was shown that 66% of the patients demonstrated pathological capillary microscopic findings. These findings included pathologically increased apical and non-apical dilatations (32%), haemorrhagic extravasations (20%) and branchings (45%). No differences were found between the therapy groups (insulin--oral medication) nor was any relationship between the appearance of capillary changes and the duration of diabetes observed. Diabetics with concomitant diabetic sequelae (polyneuropathy), demonstrated no differences in capillary morphology as compared with diabetics with no such sequelae. CONCLUSION: Diabetics are found to have an increased incidence of pathological capillary morphology taking the form of increased apical dilatations, branchings and haemorrhagic extravasations. Neither the treatment, nor the duration of the illness, nor diabetic sequelae appeared to have any influence on the capillary microscopic changes.

[What is the value of determining walking distance in peripheral arterial occlusive disease on the treadmill and in daily life? Prospective correlation study]. / Was bedeuten Gehstreckenbestimmungen bei peripherer arterieller Verschlusskrankheit auf dem Laufband und im Alltag? Prospektive Korrelationsuntersuchung.

AIM: To investigate the question whether and how walking distances measured under standardized conditions on the treadmill and on the level correlate with the patients walking ability under everyday conditions. PATIENTS AND METHOD: In 49 patients (33 men, 16 women, age 34 to 84 years) with Fontaine Stage II peripheral arterial occlusive disease the pain-free and absolute walking distance on the treadmill were measured under standardized conditions, as also the walking distance on the level at freely selected speed. RESULT: It was found that the pain-free walking distance under everyday conditions was about 2 to 3 times longer than that measured under standardized conditions on the treadmill.

The Incidence of Occult Malignant Diseases in Patients With Deep Venous Thrombosis of the Pelvis and Lower Limb

In 318 patients (155 men, 163 women) with an average age of 58.8 years (range 16-97 years), a retrospective study was carried out to determine the incidence of occult malignancies in patients with deep venous thrombosis affecting the pelvis and lower limb, confirmed by phlebography or duplex ultrasonography. It was found that, overall, 7.5% of all patients had occult malignant diseases, the most common being bronchial carcinoma (16%), colonic and renal carcinomas (12% each), and prostatic and pancreatic carcinoma (8% each). Of the patients with occult malignancy, 88% were older than 55 years. This fact shows that acute phlebothromboses may be a paraneoplastic early syndrome more often than was previously thought, and that patients older than 50 should always be screened for the presence of a tumor.

[Heparin-induced thrombocytopenia with unfractionated heparin. A prospective study of inpatient treatment of internal medicine patients]. / Heparin-induzierte Thrombozytopenien unter nichtfraktioniertem Heparin. Eine prospektive Studie bei stationär behandelten internistischen Patienten.

AIM: To investigate the influence of unfractionated heparin on heparin-induced thrombocytopenia (HIT) type II. PATIENTS AND METHOD: In 162 patients with internal diseases treated therapeutically of prophylactically with unfractionated heparin (heparin sodium, heparin calcium), we carried out a prospective study to determine the incidence of HIT type I and II. 55.6% of the patients were female (n = 90) with an average age of 76.5 years (range: 25 to 96 years) and 44.4% male (n = 72) with an average age of 67.5 years (range: 17 to 93 years). A platelet count was taken regularly before the start of heparin treatment, on the first day of treatment and then every second day from day 5 to 20. Whenever HIT II was suspected, an HIPA test was performed. RESULT: Type I HIT occurred in 10%, type II in 3% of the cases. Two of the 5 patients with type II developed severe thrombotic complications. CONCLUSION: In view of the high incidence of HIT, regular platelet counts should always be carried out in patients receiving heparin treatment.

Is the capillary microscopic determination of the visible capillary length a diagnostic criterion in thromboangiitis obliterans?

BACKGROUND: The diagnosis of thromboangiitis obliterans may be difficult to establish in the everyday clinical setting. PATIENTS AND METHODS: In 16 patients with thromboangiitis obliterans vital capillary microscopy was carried out on the nailfold on all ten digits. The longest visible capillary length was noted. As controls we employed 86 healthy subjects. RESULTS: The measurement of the respective longest visible capillary on the nailfold revealed a visible capillary length of more than 0.6 mm in 38% of all patients with thromboangiitis obliterans (n = 16), such capillary lengths were not to be found among healthy subjects (n = 86). CONCLUSIONS: Vital capillary microscopic determination of the visible capillary length is a simple-to-perform, non-invasive examination, which can help to establish the diagnosis.

Capillary microscopy of the nailfold in healthy subjects.

In a total of 100 healthy subjects (36 males, 64 females) aged between 5 and 58 years, capillary microscopy of the nailfold was performed in all the fingers of both hands. The aim of this study was to determine whether capillary abnormalities, hitherto regarded as pathological, were to be found, and if so, to establish their frequency and nature. Capillary branchings - on average 4-5/person - were seen in 78% of the subjects investigated, and proved to be most common in digits IV and V of both hands. Of the subjects investigated, 94% showed meandering, 64% tortuous loops, 25% hemorrhagic extravasations, and 19% apical dilatations of the capillaries. Only a single case of a giant loop was seen. Neither avascular fields, stasis nor reversion of blood flow were seen. Maricq's venule index was increased in 3 subjects. These findings clearly indicate that the significance of deviating capillary patterns need to be reconsidered, for branchings or hemorrhagic extravasations can certainly be found in healthy subjects.

[Leiomyosarcoma in the area of the pelvic vein]. / Leiomyosarkom im Bereich der Beckenvene.

A 37-year-old patient presented with relapsing edema of the left leg lasting for 3 months. The radiological investigations indicated a thrombotic occlusion of the pelvic veins. Surgery revealed a neoplastic growth within the common femoral vein. Histology corresponded to a leiomyosarcoma of the venous wall with intraluminal growth and no indication for penetration of the wall and invasion of the surrounding tissue. In a second operation the tumor-bearing parts of the profound and superficial femoral vein and the external iliac vein were removed. A postoperative infection with involvement of the superficial femoral artery necessitated resection of the artery and replacement by a bypass. Three months after the intervention the patients fares well. The swelling tendency of the left leg is minimal. A local recurrence of the tumor could not be detected so far. Chemotherapy was refused by the patient.