Multivariate analysis-based prediction rule for pulmonary embolism.

The diagnosis of pulmonary embolism (PE) is still an unresolved problem. The aim of this prospective observational study was to derive and validate a prediction rule (PEscore) by which PE can be diagnosed by easily obtainable and rapidly available investigations. Included were consecutive patients with a clinical suspicion of PE admitted to a community hospital. Risk factors and clinical and instrumental investigations were registered. PE was diagnosed by angiography, scintigraphy, or autopsy. In 168 patients, PE was either diagnosed (angiography, n = 28; autopsy, n = 18) or excluded (angiography, n = 12; scintigraphy, n = 99; autopsy, n = 11). Based on the results of clinical and instrumental findings, a PEscore was derived by a multiple regression analysis, calculated as: [0.29 x proven leg vein thrombosis (0 = no, 1 = yes)] + [0.25 x ECG right heart strain (0 = no, 1 = yes)] + [0.22 x neck vein distension (0 = no, 1 = yes)] + [0.20 x dyspnoea (0 = no, 1 = yes)] + [0.13 x suspicious chest X-ray (0 = no, 1 = yes)] - [0.17 (constant)]. The PEscore was tested further in 139 subsequent cases. In these patients, the PEscore was 0.65+/-0.17 (diagnosed PE, n = 47) and 0.18+/-0.17 (excluded PE, n = 92), respectively (p = 0.0001). Depending on a given PE-score, the level of probability of PE can be assessed. Calculation of the PEscore can be helpful in clinical decisions when PE is suspected.

[Indirect lymphography--possibilities and limits of roentgen diagnosis of the lymphatic system]. / Indirekte Lymphographie--Möglichkeiten und Grenzen der Röntgendiagnostik des Lymphgefässsystems.

Indirect lymphangiography enables to opacify peripheral lymph-collectors. In case of lymph valve insufficiency and dermal back flow also small skin lymphatics can be visualized. Indirect lymphangiography showed various new lymphatic patterns in different kinds of leg oedema. Specificity of 89% and sensitivity of 97% recommends the method as a good diagnostic tool for diagnosis of lymphoedema in a suspected clinical situation. Indirect lymphangiography is not able to opacify proximal or central lymphcollectors and lymph nodes.

[Artificial edema of the extremity]. / Zum Problem des artefiziellen Extremitätenödems.

Our report describes a 46-year-old woman with self-inflicted oedema of the left leg and the left arm. She induced leg oedema by an elastic bandage tourniquet and arm oedema by holding her arm dependent and immobile. A preexisting disorder of the affected leg (postthrombotic syndrome) and of the affected arm (hypoesthesia subsequent to surgical injury of the plexus brachialis) delayed the diagnostic proceedings. Our case report shows that: Confirmed presence of organic disease does not exclude limb oedema of self-inflicted origin. Oedema resulting from a tourniquet and "hysterical oedema" can be developed by one and the same patient. Effective care of such patients is only possible if dermatologist and psychiatrist work together all the time (liaison psychiatry).

[Compression therapy in post-thrombotic syndrome]. / Kompressionstherapie beim postthrombotischen Syndrom.

The most important aim of compression therapy in postthrombotic legs is prevention of dermatosclerosis and ulcus cruris. For the acute stage of leg swelling and for venous ulceration we prefer compression bandages ("therapy phase"). The effect of compression therapy with bandages depend on the material of the used bandages (short or long-stretch bandages), the stretching the bandages are applied with, the number of layers, the local pads and on well done application of the bandages. After removal of oedema compression therapy should be continued with medical compression stockings ("maintenance phase"). Compression stockings should be fit on carefully and be checked from time to time to guarantee their application by the patient.

[Aztreonam, a new approach in the therapy of gonorrhea]. / Aztreonam, eine neue Möglichkeit in der Gonorrhoe-Therapie.

The isolated gonococcal strains cultured from 99 patients (64 men and 35 women) with uncomplicated genital gonorrhoea were tested with regard to their susceptibility to aztreonam. No resistant strain was found. The bacteriological evaluation of 50 of these strains showed a minimum inhibitory concentration (MIC) of 0.0075 to 3.906 mcg/ml. Four of the tested strains were penicillinase-producing strains of N. gonorrhoeae. 95 patients (95.9%) were cured after administration of a single dose of 1 g aztreonam by intramuscular injection. It was not possible to exclude reinfection of the 4 remaining patients. No side effects were reported.

[Clinical aspects of lymphedema and contrast medium lymphography]. / Klinische Aspekte des Lymphödems und Kontrastmittellymphographie.

Primary lymphedema of the lower extremities is a clinical entity often misdiagnosed, especially in its mild, distal forms. Its characteristics are: swelling, tightness of the skin, and deepening of the skin folds of one foot, mainly in young girls. Proximal forms with involvement of the lower leg and thigh are often congenital. In later years, these manifestations have to be distinguished from secondary lymphedema due to a block in the lymph nodes (e.g. in malignoma), starting with swelling of the proximal regions of the extremities and the genitalia. Indirect lymphography, especially with new contrast media, however, offer new diagnostic possibilities. The best routine method to confirm or exclude lymphedema is isotopic lymphography.

[Diagnostic value and criteria for evaluating indirect lymphography in lymphedema]. / Diagnostische Wertigkeit und Beurteilungskriterien der indirekten Lymphographie beim Lymphödem.

To evaluate the deciding diagnostic criteria of indirect lymphography in lymphoedema of the leg, 91 investigations were reviewed. 72 examinations were from lymphoedematous legs as judged by clinical appearance and isotopic lymphography and 19 from healthy legs. After subepidermal infusion of adequate water soluble contrast media (e.g. Jotrolan) in healthy legs, 17 from 19 cases showed normal ellipsoid dye-deposits with normally structured lymph-collectors. In two cases pathological lymph-collectors were shown (specificity 89%). In the 72 legs with lymphoedema the most prominent pathological features were altered lymph-collectors and/or dermal backflow. Only two cases revealed a normal pattern (Sensitivity 97%). Indirect lymphography therefore may be recommended as a sensitive but less specific diagnostic tool for proving lymphoedema in a suspected clinical situation.

[Conservative treatment of chronic lymphedema]. / Die konservative Therapie des chronischen Lymphödems.

Decongestion of chronic lymphedema can be achieved by supportive bandages without elasticity, manual lymph drainage (especially in cases of secondary lymphedema after treatment of cancer), and remedial exercises performed while wearing bandages. Hygienic skin care is necessary to avoid attacks of recurrent erysipelas. In order to preserve the reduction of the edema once achieved, the patients have to wear elastic sleeves or stockings daily.

Indirect lymphography with iotrolan.

Iotrolan was used in concentrations of 240 and 300 mg I/ml for indirect lymphography in a total of 70 patients, and permitted a diagnostic evaluation of the peripheral lymphatics in all cases. The contrast quality was found to correlate with the concentration used. The concentration of 300 mg I/ml Iotrolan was judged to provide the better contrast density and definition. Side effects were limited to transient local erythema and pain during the infusion in one patient and a protracted reaction resembling serum sickness in another patient (Iotrolan 240 mg I/ml). Because of its excellent tolerance, Iotrolan is particularly suitable after subepidermal infusion for indirect lymphography, during which the local lymph drainage of cutaneous regions of interest can be evaluated.

[Indications-related use of stockings--measuring venous pump function]. / Indikationsgerechte Bestrumpfung--Messung der venösen Pumpfunktion.

In 48 patients (16 healthy persons, 16 patients with venous incompetence and 16 patients with phlebographic proved status after thrombosis) the effect of medical compression stockings of different compression pressure (Sigvaris Thrombo, Sigvaris 503, Sigvaris 504) on venous pumping function was studied by foot volumetry. In patients with varicosis and preexistent reduced pumping function the expelled volume in average ascended from 13.0 to 16.23 (+25%, Sigvaris 503), respectifly to 16.52 (+27%, Sigvaris 504) (p less than 0.05 Wilcox and Wilcoxon test). In patients in status after deep leg vein thrombosis with very reduced pumping function it came to an increase of expelled volume from 8.48 to 11.08 (+31%, Sigvaris 503) and to 12.55 (+48%, Sigvaris 504) (p less than 0.01). The hospital stocking Sigvaris Thrombo did not really improve the venous pumping function. So for the first time the common prescription of medical compression stockings class II in patients with varicosis and in mild cases of chronic venous incompetence and of stockings class III in patients in status after deep leg vein thrombosis is justified by measurement.

Clinical use of indirect lymphography in different forms of leg edema.

Indirect lymphography by subepidermal infusion of newly developed nonionic, dimeric contrast media (e.g., Iotrolan) opacifies peripheral lymphatics of the skin. Using this method we examined 159 patients with primary and secondary lymphedema, chronic venous insufficiency, and lipedema and compared the findings to normal individuals. A variety of characteristic patterns were uncovered. The technique causes little patient discomfort and takes on the average only 30 minutes.

[Heparin in deep venous thrombosis of the leg--effectiveness and safety]. / Heparin bei tiefer Beinvenenthrombose--Effizienz und Sicherheit.

The aim of this retrospective study was to evaluate the adequacy of heparin treatment in deep venous thrombosis and the rate of symptomatic complications under the everyday conditions of a hospital. The investigation was carried out in 200 consecutive patients, 117 women and 83 men (mean age 61 +/- 17 years) with verified deep venous thrombosis. Na-heparin was given over 12 +/- 7 days; the initial daily dosage amounting to 31700 IU followed by a maintenance dosage of 36150 IU. 153 patients were treated exclusively or predominantly by the subcutaneous route (3 times daily) and 47 by continuous i.v. infusion. In the i.v. group 47% of thrombin times (TT) were prolonged to values exceeding 48 seconds in comparison with only 39% in the subcutaneous group (p less than 0.001). 34 patients developed thromboembolic complications (pulmonary embolism in 33), causing death in 13 cases. Patients with thromboembolic complications differed from those without in respect to the rate of a therapeutically prolonged TT (10% vs 44%, p less than 0.001) and signs of pulmonary embolism on admission (44% vs 8%, p less than 0.001), but not with respect to heparin dosage. Thromboembolic complications appeared in only 3 patients receiving i.v. therapy. Patients with thrombosis of the iliac or femoral veins appeared twice as likely to develop pulmonary embolism than patients with calf vein thrombosis (n.s.). Bleeding was registered in 11 patients. One patient died from retroperitoneal haemorrhage. At the time of bleeding 10 patients were on subcutaneous heparin and in 9 patients the TT was prolonged to over 2 minutes.(ABSTRACT TRUNCATED AT 250 WORDS)

[Congestive lymphostatic papillomatosis]. / Lymphostatische Stauungspapillomatose.

In seven patients with papillomatosis cutis in chronically congested lower extremities (lymphoedema, chronic venous insufficiency, chronic cardiac insufficiency) indirect lymphography revealed abnormalities of dermal lymph drainage. In four of these patients punch biopsies were taken from the papillomas. Microscopic examination revealed hyperplasia of the epidermis and dilated capillary-like vessels. Papillomatosis cutis in chronically congested lower extremities can be distinguished from pseudoepitheliomatose and carcinomatose alterations by both clinical and histological examination. Impaired local lymph transport seems to be the decisive trigger mechanism for the development of these papillomas.

[Etiology of erysipelas]. / Zur Atiologie des Erysipels.

Bacterial cultures were taken from 31 patients by scarification from the dermal compartment of recent erysipelas foci. Pathogenic organisms were isolated from the dermis while cultures from the skin surface remained sterile in 5 patients; Streptococcus pyogenes was cultured in 2 of these patients and Staphylococcus aureus in the other 3 patients. Our findings indicate that staphylococcal erysipelas does exist and we suppose that Staphylococcus aureus is able to induce erysipelas, above all in the presence of dysfunction of lymph vessels. When treatment with penicillin G is not successful, erysipelas caused by staphylococci has to be considered. In these cases treatment has to be changed to penicillinase-resistant penicillin.

[Erysipelas and lymphedema--egg or hen?]. / Erysipel und Lymphödem--Ei oder Henne?

The initial lymphatics and peripheral lymph-collectors of both legs of 16 patients were visualized by means of indirect lymphography, after the patients had undergone a rash of erysipelas on their lower extremities. 14 out of 19 legs showed clinical signs of lymphedema after one or several erysipelas. In 16 out of 19 legs after erysipelas, but also in 6 out of 11 healthy contralateral extremities, we found pathological initial lymphatics and changes in size, irregularities of the course, and pathological stops of peripheral lymph-collectors. These findings indicate that in the majority of the patients with erysipelas--contrary to the common opinion--resulting lymphedema should not be termed as secondary. In fact, they are primary lymphedemas deteriorated by erysipelas, with the typical pathological findings in indirect lymphography, as they are seen in simple primary forms.

[Indirect lymphangiography and transcutaneous measurement of oxygen pressure in white atrophy]. / Lymphographie indirecte et mesure de la pression transcutanée d'oxygène dans l'atrophie blanche.

The measurement of the TCPO2 and indirect lymphography help us to understand the pathogeny of white atrophy, especially when their results are compared with discoveries produced by other intra-vital methods such as the laser-Doppler and biomicroscopy.

[Syncope as a misinterpreted leading symptom of pulmonary embolism]. / Die Synkope als verkanntes Leitsymptom einer Pulmonalembolie.

One or several syncopes were the reason for hospitalization in 31 of 155 in-patients with proven pulmonary embolism. In all of them there were at least two further pointers to acute pulmonary embolism: all had tachypnoea, 28 had dyspnoea, 25 had sinus tachycardia (more than 100 beats/min), 24 had congested neck veins and 16 had deep leg-vein thrombosis. In 21 patients the ECG had signs of right heart strain, in 15 of 20 in whom it was measured the arterial oxygen partial pressure was below 70 mm Hg. In 23 patients the chest X-ray was largely unremarkable despite dyspnoea. In 23 patients there had been a massive embolus and 16 patients had died. Although syncope is only rarely caused by pulmonary embolism, its ominous significance in this connection should stimulate a search for further diagnostic pointers to such an occurrence.

[The importance of local factors in recurrent erysipelas]. / Die Bedeutung der Lokalfaktoren beim rezidivierenden Erysipel.

We report on 366 patients suffering from erysipelas who have been treated in 1977 to 1981. 263 of them had primary infections, 103 showed relapsing erysipelas. In the course of treatment, sex, age, localisation, as well as local terrain factors have been evaluated. Therapy consisted of high dosage antibiotic treatment and correction of the local predisposing terrain factors. 41 of the 103 patients with relapsing erysipelas have been controlled during an observation period between 2 and 6 years. 27 patients of these 41 (63.9%) did not suffer a relapse within the observation period, 14 (34.1%) reported relapses. Local predisposing factors were found more frequently in patients with recurrence of the disease. Therefore, strict therapeutic control of terrain factors seems to be much more important than long-term antibiotic treatment.