Exercise treadmill testing in patients with claudication, with and without diabetes

AIM

To compare symptoms and walking capacities of patients with and without diabetes reporting vascular-type claudication.

METHODS

We recorded self-reported maximal walking distance, maximal walking distance on treadmill test (3.2 km h(-1) , 10% slope), exercise transcutaneous oxygen pressure DROP index [limb transcutaneous oxygen pressure (TcpO2) changes from rest minus chest TcpO2 changes from rest] and symptoms on treadmill in 230 patients with diabetes and 982 patients without diabetes. Exercise-induced proximal and distal symptoms were analysed in the perspective of underlying proximal and distal ischaemia (DROP value < negative 15 mmHg).

RESULTS

Self-reported maximal walking distance did not differ between groups, whereas maximal walking distance on treadmill test was lower in patients with diabetes vs. patients without diabetes (261 ± 257 and 339 ± 326 m, respectively; P < 0.05 when adjusted for potential confounders). In patients with ischaemia, the number of ischaemic areas (proximal and/or distal on right and/or left) was comparable between the two groups. Patients with diabetes had more distal ischaemia than patients without diabetes (38 vs. 29%, respectively; P < 0.01), whereas proximal ischaemia was similar between groups. The prevalence of lower-limb exercise-related symptoms without ischaemia was comparable between groups. There were more symptoms other than lower-limb pain in patients with diabetes than patients without diabetes (29.6 vs. 18.3%, respectively; P < 0.01).

CONCLUSIONS

Patients with diabetes show more severe limitation on the treadmill and more non-limb symptoms than patients without diabetes, although self-reported walking capacity is comparable between the two groups. Using TcpO2, we confirm that patients with diabetes reporting claudication show more distal ischaemia than patients without diabetes, with no difference at the buttock level. Treadmill testing is of interest in patients with peripheral artery disease and diabetes.

Different effects of diabetic autonomic neuropathy on regional transcutaneous oxygen tension in patients with peripheral arterial disease

BACKGROUND

Diabetic autonomic neuropathy (DAN) is thought to reduce skin nutritive perfusion through increase of arteriovenous shunting flow, resulting in foot ulceration. However, the correlation between skin tissue oxygenation and DAN has not been fully elucidated. Transcutaneous oxygen tension (TcPO2) is a reliable indicator of skin nutritional microcirculation. The aim of this study was to evaluate the influence of DAN on skin microcirculation by using TcPO2 measurements.

METHODS

The resting TcPO2 (REST-TcPO2) and post-exercise TcPO2 (Ex-TcPO2) of the calf and dorsalis pedis regions were measured simultaneously in 52 patients (104 limbs), including 41 diabetes patients. All patients underwent angiography, and the presence of arterial stenosis was evaluated.

RESULTS

TcPO2 levels were compared among the groups of patients with no neuropathy, sensory neuropathy alone, and DAN. In both the calf and dorsalis pedis regions, Ex-TcPO2 levels in diabetes patients with DAN were significantly lower than those in diabetes patients without any neuropathy. However, there was no difference in REST-TcPO2 levels among these groups. We then performed multiple regression analysis to evaluate the influence of DAN on each TcPO2 after adjustment for multiple clinical factors. DAN was a significant determinant of REST- and Ex-TcPO2 in the calf region, and it was independent of arterial stenosis and sensory neuropathy. In contrast, DAN was not an independent determinant of REST- and Ex-TcPO2 in the dorsalis pedis region.

CONCLUSIONS

We, for the first time, showed that DAN has significant effects on skin microcirculation of the calf region but not of the dorsalis pedis region.

Chest physiotherapy in preterm infants with lung diseases

BACKGROUND

In neonatology the role of chest physiotherapy is still uncertain because of the controversial outcomes.

METHODS

The aim of this study was to test the applicability in preterm infants of 'reflex rolling', from the Vojta method, in preterm neonates with lung pathology, with particular attention to the effects on blood gases and oxygen saturation, on the spontaneous breathing, on the onset of stress or pain. The study included 34 preterm newborns with mean gestational age of 30.5 (1.6) weeks - mean (DS) - and birth weight of 1430 (423) g - mean (DS) -, who suffered from hyaline membrane disease, under treatment with nasal CPAP (continuous positive airways pressure), or from pneumonia, under treatment with oxygen-therapy. The neonates underwent phase 1 of 'reflex rolling' according to Vojta method three times daily. Respiratory rate, SatO2, transcutaneous PtcCO2 e PtcO2 were monitored; in order to evaluate the onset of stress or pain following the stimulations, the NIPS score and the PIPP score were recorded; cerebral ultrasound scans were performed on postnatal days 1-3-5-7, and then weekly.

RESULTS

In this population the first phase of Vojta's 'reflex rolling' caused an increase of PtcO2 and SatO2 values. No negative effects on PtcCO2 and respiratory rate were observed, NIPS and PIPP stress scores remained unmodified during the treatment; in no patient the intraventricular haemorrhage worsened in time and none of the infants developed periventricular leucomalacia.

CONCLUSIONS

Our experience, using the Vojta method, allows to affirm that this method is safe for preterm neonates, but further investigations are necessary to confirm its positive effects and to evaluate long-term respiratory outcomes.

Impaired peripheral micro- and macrocirculation during hemodialysis in uremic patients

AIM

Acute hemodynamic changes during hemodialysis may jeopardize the peripheral blood circulation in patients with end-stage renal disease (ESRD). The aim of the present study was to investigate the effects of three consecutive hemodialyses on peripheral micro- and macrocirculation in patients with ESRD.

METHODS

Twenty patients with ESRD were investigated, i.e. 10 diabetic and 10 non-diabetic patients, before and during three consecutive hemodialysis during one week. Skin microcirculation was evaluated by transcutaneous oxygen tension (tcPO2) at the chest and foot levels, and maximum microvascular hyperemia (MMH) at the foot by laser Doppler fluxmetry before and during local warming of skin to 44 oC. Macrocirculation was measured by systolic and diastolic arm blood pressure (BP), and by systolic toe BP.

RESULTS

MMH, tcPO2 (foot) and tcPO2 (chest) decreased significantly (P=0.01) during hemodialysis, and so did systolic arm BP and toe BP (P=0.02). No significant differences were found between the different hemodialysis days, nor between the diabetic and non-diabetic patients.

CONCLUSION

The study shows that peripheral micro- and macrocirculation are impaired during hemodialysis in patients with ESRD. The effects of hemodialysis on peripheral blood perfusion are reproducible, and the same reaction pattern was seen in diabetic and non-diabetic patients. Patients with peripheral arterial occlusive disease seem more susceptible to BP reduction during hemodialysis, and in some patients toe BP and tcPO2 (foot) decreased to levels indicating high risk of gangrene.

[Application of capnography and SpO2 measurement in the evaluation of respiratory failure in patients with chronic obstructive pulmonary disease]

OBJECTIVE

To investigate the accuracy and potential error range of noninvasive estimation of CO2 pressure (PCO2), arterial O2 pressure (PaO2), and oxygenation index (OI) by measuring the end-tidal CO2 pressure (PETCO2) and pulse oxygen saturation (SpO2) in patients with chronic obstructive pulmonary disease (COPD) and respiratory failure, and assess the feasibility of this method for dynamic monitoring of arterial CO2 pressure (PaCO2) and PaO2 in the primary care facilities where arterial blood gases analysis is not available.

METHODS

All the 30 patients with COPD and respiratory failure received routine clinical treatment including bronchodilators, mucolytics, glucocorticosteroid, antibiotics and oxygen therapy (titrated to keep SpO2 above 90%) for 5-7 days. A subgroup of the patients also received NIPPV treatment. All the patients were tested with both the eupnea method and prolonged expiratory method before and after the treatment to obtain the data of PCO2 and SpO2 were respectively performed before and after treatment.

RESULTS

The PETCO2 with eupnea (PETCO2(Q)) was 50.72-/+8.93 mmHg, significantly lower than PaCO2 (71.25-/+9.08 mmHg, Plt;0.01), but the PETCO2(P) (70.35-/+8.91 mmHg) was comparable with PaCO2 (P>0.05). Similar results were obtained after the treatment. The PETCO2(P) before treatment and after treatment was positively correlated to PaCO2 (r=0.96 and 0.97, respectively, P<0.01). The PaO2(Y) before the treatment derived from the oxygen dissociation curve based on SpO2 measurement was close to SpO2 (59.96-/+1.42 mmHg vs 59.07-/+2.22 mmHg, P>0.05). The OI derived from PaO2 and OI(Y) from PaO2 (Y) was also similar (215.70-/+22.77 vs 219.15-/+24.63, P>0.05). Linear regression analysis showed positive correlations between PaO2(Y) to PaO2 (r=0.81, P<0.01) and between OI(Y) and OI (r=0.95, P<0.01).

CONCLUSIONS

In patients with COPD (especially those with also type II respiratory failure), the modified monitoring method of PCO2 and maintenance of SpO2 above 90% can precisely estimate PaCO2 and PaO2. This method is feasible for clinical noninvasive and dynamic evaluation of respiratory failure in COPD patients, especially in primary care facilities where arterial blood gases analysis is not available.

[Validation of the transcutaneous carbon dioxide tension measurements in critical paediatric patients]

OBJECTIVE

To estimate the accuracy of the transcutaneous carbon dioxide tension measurement (PtCO(2)) compared to the measurement of the arterial carbon dioxide tension (PaCO(2)).

MATERIAL AND METHODS

An analytical, longitudinal, prospective and observational study, of a dynamic cohort taken from the in-patients of a Paediatric Intensive Care Unit (PICU). The PtCO(2) was measured with the SenTec AG analyzer, and the sensor was applied with the specific Multi-Site Attachment Ring. PtCO(2) and PaCO(2) were recorded at the same time. The statistical significance of the association between paired measurements was evaluated with the Snedecor's F test, the Pearson's r(2) correlation coefficient and the Interclass Correlation Coefficient (ICC). The degree of agreement was evaluated with the Bland & Altman method. The consistency of the results was evaluated with the ANalysis Of the VAriance (ANOVA).

RESULTS

One hundred and six paired measurements, PtCO(2) and PaCO(2), from twelve patients, were compared. The means of the PaCO(2) and PtCO(2) were 51.0+/-13mmHg and 50.1+/-14mmHg, respectively; r(2)=0.87 (p<0.001), ICC=0.96, (95% CI: 0.94-0.97). The Bland-Altman analysis showed a mean difference of-0.9mmHg (95% CI:-2.0 to 0.2mmHg). The correlation was better in cases with no respiratory disease, with low respiratory assistance, with PaCO(2)>50mmHg and with the sensor applied on the forehead. The results were consistent. No side effects derived from the use of the ring were observed.

CONCLUSION

The correlation between PtCO(2) and PaCO(2) is excellent and stable. The ring sensor was safe and easy to use.

Correlation and agreement between the bispectral index vs. state entropy during hypothermic cardio-pulmonary bypass

BACKGROUND

The bispectral index (BIS) and spectral entropy enable monitoring the depth of anaesthesia. Mild hypothermia has been shown to affect the ability of electroencephalography monitors to reflect the anaesthetic drug effect. The purpose of this study was to investigate the effect of hypothermia during a cardio-pulmonary bypass on the correlation and agreement between the BIS and entropy variables compared with normothermic conditions.

METHODS

This prospective clinical study included coronary artery bypass grafting patients (n=25) evaluating correlation and agreement (Bland-Altman analysis) between the BIS and both spectral and response entropy during a hypothermic cardio-pulmonary bypass (31-34 degrees C) compared with nomothermic conditions (34-37.5 degrees C). Anaesthesia was maintained with propofol and sufentanil and adjusted clinically, while the anaesthetist was blinded to the monitors.

RESULTS

The BIS and entropy values decreased during cooling (P<0.05), but the decrease was more pronounced for entropy variables compared with BIS (P<0.05). The correlation coefficients (bias+/-SD; percentage error) between the BIS vs. spectral state entropy and response entropy were r(2)=0.56 (1+/-11; 42%) and r(2)=0.58 (-2+/-11; 43%) under normothermic conditions, and r(2)=0.17 (10+/-12; 77%) and r(2)=0.18 (9+/-11; 68%) under hypothermic conditions, respectively. Bias was significantly increased under hypothermic conditions (P<0.001 vs. normothermia).

CONCLUSION

Acceptable agreement was observed between the BIS and entropy variables under normothermic but not under hypothermic conditions. The BIS and entropy variables may therefore not be interchangeable during a hypothermic cardio-pulmonary bypass.

Treatment of farm dairy effluent with hybrid upflow multilayer bioreactor and activated sludge module

Biological removal of nitrogen and carbon from farm dairy effluent (FDE) was studied with two laboratory-scale systems following nitrification and denitrification processes. Each system consisted of an upflow multilayer bioreactor (UMBR) as a pre-denitrification unit, an aeration tank (AT) as nitrification unit and a secondary clarifier. The optimization of two operational variables, total hydraulic retention time (HRT) and internal recycle (IR) rate with both real-FDE and a synthetic-wastewater were investigated. First, HRTs of 2, 3, 4 and 5 days were tested with synthetic-wastewater at uniform IR rate. The HRT of 4 days proved optimum with high efficiencies for nitrification (>90%), denitrification (>90%) and total chemical oxygen demand (COD) removal ( approximately 90%). The lowest efficiency was recorded at 2 days HRT with 7% nitrification efficiency. This was followed by experimentation with IR rates of 200%, 300% and 400% on both real-FDE and synthetic-wastewater at optimized HRT. The increase in IR to 300% improved the denitrification potential and overall performance with continuous high nitrification efficiency and COD removal whereas IR of 400% retarded the process. The application of combined UMBR and activated sludge system showed good potential for biological removal of nitrogen from FDE.

Transcutaneous oxygen pressure measurements in diabetic and non-diabetic patients clinically suspected of severe limb ischemia: a matched paired retrospective analysis

AIM

It was recently suggested that a 6 mmHg difference exists in both chest and foot transcutaneous oxygen pressure (TcPo2) between diabetic and non-diabetic volunteers apparently free from vascular disease. If a difference can also be found in diabetic and non-diabetic patients with clinically suspected critical limb ischemia (CLI), this may question the use of the same 30 mmHg threshold proposed by the "TASC" in the definition of CLI. We analyse whether a difference can be found for chest and foot TcPo2 respectively between diabetic and non-diabetic patients referred for clinically suspected CLI.

METHODS

A retrospective matched paired study was performed among 60 diabetic and 60 non-diabetic subjects with peripheral artery disease and suspected critical limb ischemia. Results are presented as median [25-75 centiles].

RESULTS

Groups were comparable in terms of gender, age, height, systolic blood pressure and treatments (except for renin-angiotensin inhibitors). Chest-TcPo2 was 53 [43-57] mmHg in diabetic and 60[49-65] mmHg in non-diabetic patients (P<0.01). Foot-TcPo2 was 12[3-34] mmHg in diabetic and 15[3-36] mmHg in non-diabetic patients (Non significant). A multi-parametric step by step regression analysis showed that chest-TcPo2 was inversely associated with weight, then with diabetes and gender.

CONCLUSIONS

TcPo2 is lower at the chest but not at the foot level in diabetic than in non-diabetic patients with suspected CLI. Then, the "30 mmHg threshold" proposed in the definition of lower-limb CLI is likely applicable in both diabetic and non-diabetic patients.

[Safety and efficacy of carbon dioxide insufflation during colonoscopy]

OBJECTIVE

To assess the safety and efficacy of carbon dioxide (CO(2)) in colonoscopy examination.

METHODS

We randomized 349 patients to undergo colonoscopy with insufflation of air (n=175) or CO(2) (n=174). At colonoscopy, p (ET CO(2)) was observed at 4 time points: before the exam, arrived caecum, back rectum, and after the exam. Patient's experience of pain in the end and after the examination at 1, 3, 6, and 24 h was registered using a visual analog scale (VAS). Sedation was not used routinely.

RESULTS

The groups were similar in age, sex, inspection time, and caecal intubation rate (all P>0.05). There were no significant differences in p (ET CO(2)) values between the 2 groups before and after the procedure (all P>0.05). VAS scores in the CO(2) group at various time points after the examination were significantly lower than those in the air group (all P<0.05). The percent of VAS scores of 0 in the CO(2) group after 1, 3, 6, and 24 h was significantly higher than that in the air group (all P<0.01).

CONCLUSION

Injection of CO(2) for colonoscopy will not cause CO(2) retention, and it may significantly reduce the pain, which is safe and effective.

Clinical results of below-the knee intervention using pedal-plantar loop technique for the revascularization of foot arteries

AIM

Recent registries and randomized trials support the role of percutaneous revascularization in patients with critical limb ischemia (CLI) due to below-the-knee (BTK) atherosclerotic disease, as percutaneous transluminal angioplasty (PTA) for BTK disease has shown to be feasible and safe in this setting. Nonetheless, succes rates remain suboptimal with current techniques. The authors aimed to appraise clinical results following PTA of foot vessels exploiting a novel technique, based on the recanalization of both pedal and plantar arteries and their anatomical anastomosis in order to restore direct arterial in-flow from both anterior and posterior tibial vessels, defined as the pedal-plantar loop technique.

METHODS

Baseline, procedural and mid-term outcome data of all consecutive patients with CLI due to BTK disease in which PTA was attempted using the pedal-plantar loop technique were prospectively collected between January 2007 and September 2008. The primary end-point was acute success (i.e. the composite of technical, angiographic and procedural success). Secondary end-points included limb salvage rate, major (above the ankle) and minor (below the ankle) amputation, change in Rutherford class and transcutaneous oxygen tension, reocclusion/restenosis, rehospitalization, and repeat revascularization after 12 months.

RESULTS

A total of 1331 consecutive patients with CLI were treated using BTK PTA and 135 (10.1%) were approached with the pedal-plantar loop technique in order to recanalize the foot arteries. Target lesions were mostly occlusive and diffusely diseased, involving in most cases the tibial arteries as well as the in-flow and out-flow vessels. Acute success was achieved for tibial PTA in 100% of the cases, with ability to position and inflate the balloon and achieve adequate angiographic results without peri-procedural complications in all, whereas acute success for the pedal-plantar loop technique was 85%. Clinical improvement in functional status was obtained and maintained after an average of 12 months, with a significant improvement of transcutaneous oxygen tension after 15 days, 59+/-16 mmHg in the group of patients in which the foot arteries revascularization was successfully feasible, versus 42+/-12 mmHg in patients achieving patency of two BTK vessels at the ankle level with partial out-flow in the foot (P<0.001).

CONCLUSIONS

Percutaneous revascularization of foot arteries in patients with CLI is feasible and safe, and appears to provide positive clinical results at both acute and mid-term follow-up.

Quantitative assessment of therapeutic effects in the critically ischemic limb using (99m)Tc-diethylene-triamine-pentaacetic acid human serum albumin

PURPOSE

To investigate the reliability and limitations of a new radioisotope method using (99m)Tc-diethylenetriamine-pentaacetic acid human serum albumin (Tc-99m-DTPA-HSA) and to evaluate the diagnostic ability of isotope infusion for assessing hemodynamic changes in the foot before and after treatment.

METHODS

Hemodynamic changes before and after treatment were assessed in 21 limbs with ulcer or gangrene, by analyzing changes in the time-activity curve, the uptake ratio, and the values obtained with noninvasive techniques.

RESULTS

There were significant differences between each pair of the three types of time-activity curve and their uptake counts. The uptake ratio was correlated with ankle blood pressure (ABP) and toe blood pressure (TBP), but not with transcutaneous oxygen pressure (tcPO(2)) or skin perfusion pressure (SPP). The hemodynamic change induced by pharmacotherapy was subtle, but that induced by arterial reconstruction was remarkable. Although there was not always a good correlation between the degree of hemodynamic change and the clinical outcome in limbs treated with pharmacotherapy, the hemodynamic change was quantitatively assessed.

CONCLUSION

Our study suggests that this isotope technique is a useful quantitative method to evaluate hemodynamic change from a different perspective to conventional noninvasive methods.

Clinical implications of a quality assessment of transcutaneous CO2 monitoring in preterm infants in neonatal intensive care

More than 1% of infants are born premature. Many of these children require special treatment because of immature organs and body functions. CO2 is an important parameter to monitor in order to avoid serious brain damage. Blood sampling of CO2 has several shortcomings and non-invasive transcutaneous CO2 is being investigated in order to assess its potential to contribute with the same type of information as blood CO2 measurements. The present study assesses the quality of transcutaneous CO2 data by comparing it to the "golden standard" blood CO2 data, in order to provide clinicians with a better understanding of the usefulness and limitations of transcutaneous CO2 data in neonatal care. The study shows that for low transcutaneous CO2 the error is relatively high and in most cases the true CO2, represented by the blood CO2, which can be regarded as the "gold standard", is higher than the measured transcutaneous CO2. The opposite is the case for high transcutaneous CO2. It is discussed how this is not due to any systematic error in the equipment, but due to the natural behaviour of noisy data.

Hyperbaric oxygen, oxidative stress, NO bioavailability and ulcer oxygenation in diabetic patients

BACKGROUND

Hyperbaric oxygen therapy (HBO2) increases tissue oxygenation, thus serving as an adjunct therapy for diabetic wounds. However, in some patients there is insufficient increase in tissue O2.

AIMS

To investigate the pathophysiology of insufficient HBO2 and the possible role of N-acetylcysteine (NAC).

METHODS

Prospective, randomized, cross-over trial included 50 diabetic patients with non-healing ulcers. Each patient received two treatments with 100% oxygen/2ATA. NAC was administered i.v. at one of the two treatments. Basal and post-treatment peri-wound transcutaneous O2 (TcPO2) pressure, malondialdehyde (MDA), total anti-oxidant status (TAOS) and nitric oxide (NO) were assessed. An ulcer oxygenation increase above 200 mmHg was accepted as sufficient.

RESULTS

During HBO2, 17 patients (34%) demonstrated insufficient increase in TcPO2. Concomitantly, their TAOS and NO decreased, while MDA increased. NAC administration attenuated these parameters, thus improving the HBO2 outcome. In those affected by NAC, the cure rate was 75%. By contrast, in 66% of patients with sufficient increase in TcPO2 TAOS was increased and MDA decreased irrespective of NAC administration. The cure rate in this subgroup was 82%.

CONCLUSIONS

Insufficient increase of ulcer oxygenation during HBO2 results from exaggerated oxidative stress and decreased NO bioavailability. NAC administration-induced modulation of both parameters and may improve ulcer oxygenation during HBO2.

Severe respiratory distress caused by central airway obstruction treated with self-expandable metallic stents

We investigate retrospectively the efficacy of self-expandable metallic stents (SEMS) for severe respiratory distress (SRD) in patients with central airway obstruction (CAO). Thirty three patients with CAO were treated with SEMS using fiberoptic bronchoscopy method. We found an intraluminal obstruction present in 7, extraluminal compression in 10, and combined stenosis in 16 cases. Tumor infiltration occupied more than 90% of the endoluminal diameter in 21, 70% in 9, and 50% in 3 cases. Obstruction was caused by primary cancer of lung in 23, thyroid in 5, and esophagus in 5 patients. Up to 3 stents per patient were placed. Double stenting (esophagus and trachea) was required in five patients. All patients exhibited symptomatic and arterial blood gas improvement. The mean follow-up was 65 (5 to 752) days. SEMS are useful for the treatment of SRD caused by CAO. The overall effect is related to the degree of tumor progression itself.

Cardiac chemoreflex sensitivity in critically ill patients

Chemoreflexes are important mechanisms for regulating ventilatory and cardiovascular function. The aim of this study was to determine the meaning of autonomic dysfunction for the pathophysiology and outcome in critical ill patients. For the determination of the chemoreflex sensitivity (ChRS), the ratio of the RR interval shift and the shift of oxygen partial pressure during a 5-min inhalation of oxygen with a nose mask was formed. Pathological chemoreflex sensitivity was predefined as a ChRS below 3.0 ms/mmHg. Out of the 27 critical ill patients included into the study, 17 had a sepsis and 10 a cardiogenic shock. In these patients, chemoreflex sensitivity was significantly reduced compared with a control group (sepsis: 2.1 +/- 1.68, cardiogenic shock: 0.4 +/- 0.27, controls: 5.0 +/- 2.8 ms/mmHg; P<0.05 vs. sepsis or cardiogenic shock). There was a significant negative correlation (r=-0.6; P<0.01) between the chemoreflex sensitivity and the severity of illness described by the SOFA-score. We conclude that cardiac reflex mechanisms are changed toward increased sympathetic activity reflected by reduced chemoreflex sensitivity in critical ill patients. Moreover, there is a close negative correlation between the ChRS and the SOFA-score.

Evaluation of apoptotic cells and immunohistochemical detection of FAS, FAS-L, Bcl-2, Bax, p53 and c-Myc in the skin of patients with chronic venous leg ulcers

In the present study we were interested, if apoptosis plays a role in the surrounding skin of venous ulcers, where microcirculatory disorders were already observed. For this purpose laser Doppler flow and partial oxygen pressure were measured in 17 patients at the ulcer edge, the transitional area of the lower leg and the thigh. Subsequently biopsies were taken from the respective sites and subjected to terminal deoxynucleotidyl transferase labelling (TUNEL) and immunohistochemistry using antibodies to determine the protein expression of Fas, Fas-L, Bax, Bcl-2, p53 and c-Myc. Laser Doppler flow was increased and transcutaneous oxygen partial pressure was decreased, with significant differences at the ulcer edge and the lower leg compared to the thigh. The skin biopsies did not show any differences when labelling for apoptotic cells. Keratinocytes of basal and spinous layer stained with antibodies against Fas, Fas-L and Bax in all probes of the three sites. c-Myc and p53 were negative in all keratinocytes of the skin probes. However, staining with Bcl-2 was significantly decreased at the ulcer edge in comparison to the lower leg and the thigh (p=0.017). Our study revealed that a disturbed microcirculation does not increase the number of apoptotic cells at the ulcer edge in patients with venous disease. The reduced staining pattern with Bcl-2 at the ulcer edge seems not to result in higher susceptibility to apoptosis, but it remains to be proven whether it is involved in epidermal acanthosis.

Autologous intra-arterial infusion of bone marrow mononuclear cells in patients with critical leg ischemia

AIM

The injection of bone marrow mononuclear cells (BMMC) into the gastrocnemius muscle has given promising results in patients with critical limb ischemia (CLI). In this article, we have assessed whether a less invasive procedure, i.e. intravascular BMMC infusion, could be effective in this population of patients.

METHODS

A total of 28 limbs in 24 patients with CLI were treated. An amount of 276-700 mL of marrow blood was harvested from posterior iliac crests and BMMC were obtained by standard procedure used for bone marrow transplantation. After performance of digital subtraction angiography, BMMC were injected laterally through a 4 Fr sheet. Primary outcome was efficacy of the procedure measured as healing of defects, frequency of high amputations and change of ischemia grade; among secondary outcomes were safety of the procedure, angiographic changes and changes in quality of life.

RESULTS

One year after treatment, all patients were alive and only 2 patients have undergone high amputation. Eleven of 14 defects have healed (78%) and Fontaine grade of ischemia has changed from median grade 3.5 to median grade 2 (P<0.0001). Collateral vessel development has improved by mean 1.13 and 1.3 points on a four-point semiquantitative scale in calf and foot, respectively (P<0.0001). There were no grade III-IV adverse events. According to the SF-36 quality of life questionnaire, 1 year after the procedure patients have reported significant improvement in all measured items.

CONCLUSION

Intra-arterial infusion of BMMC can lead to significant and long-lasting subjective and objective improvements in patients with CLI. The results merit validation by randomized controlled studies in patients with less critical limb ischemia.

Transcutaneous carbon dioxide monitoring in spontaneously breathing, nonintubated patients in the early postoperative period

BACKGROUND

The authors investigated the accuracy of transcutaneous capnometry (TcPCO(2)) in estimating arterial blood carbon dioxide partial pressure (PaCO(2)) during spontaneous breathing in patients admitted to our surgical intensive care unit (ICU).

METHODS

Serial TcPCO(2) and PaCO(2) measurements were taken in stable patients undergoing postoperative monitoring after major abdominal, vascular, or thoracic surgery. Patients were enrolled 12 hours after extubation. Exclusion criteria were pulmonary dysfunction, hemodynamic instability, or anemia. Linear regression, mixed models, and Bland-Altman analyses were used to compare accuracy and correlation between the two variables. Data are presented as means (95% confidence intervals).

RESULTS

PaCO(2) values ranged between 26 mmHg and 52 mmHg. Mean values for TcPCO(2) and PaCO(2) were 35.3 (33.8-36.8) mmHg and 39.2 (37.6-40.7) (P<0.001). Bland-Altman analysis showed a bias of -3.8 (-5.1-2.5) mmHg with upper and lower limits of agreement of 5.6 (3.4-7.9) mmHg and -13.3 (-15.6 -11.1) mmHg, respectively. Thirty-one (55.4%) measurements disagreed by 3 mmHg or more. Linear mixed model analysis with adjustment for repeated measurements showed low correlation (r=0.63; P<0.0005). There were small but significant differences between patients in the correlation coefficient (P=0.04).

CONCLUSION

TcPCO(2) showed moderate bias with wide limits of agreement when compared to PaCO(2) in our patients. The regression model showed low correlation of the measurements when adjusting for repeated measurements and between-subject variances. TcPCO(2) may not provide an accurate quantitative estimation of PaCO(2) in stable, spontaneously breathing, nonintubated patients in the early postoperative period.

Transplantation of autologous bone marrow mononuclear cells for patients with lower limb ischemia

BACKGROUND

Many treatment options for lower limb ischemia are difficult to apply for the patients with poor arterial outflow or with poor general conditions. The effect of medical treatment alone is far from ideal, especially in patients with diabetic foot. A high level amputation is inevitable in these patients. This study aimed to explore the effect of transplantation of autologous bone marrow mononuclear cells on the treatment of lower limb ischemia and to compare the effect of intra-arterial transplantation with that of intra-muscular transplantation.

METHODS

In this clinical trial, 32 patients with lower limb ischemia were divided into two groups. Group 1 (16 patients with 18 affected limbs) received transplantation of autologous bone marrow mononuclear cells by intra-muscular injection into the affected limbs; and group 2 (16 patients with 17 affected limbs) received transplantation of autologous bone marrow mononuclear cells by intra-arterial injection into the affected limbs. Rest pain, coldness, ankle/brachial index (ABI), claudication, transcutaneous oxygen pressure (tcPO(2)) and angiography (15 limbs of 14 patients) were evaluated before and after the mononuclear cell transplantation to determine the effect of the treatment.

RESULTS

Two patients died from heart failure. The improvement of rest pain was seen in 76.5% (13/17) of group 1 and 93.3% (14/15) of group 2. The improvement of coldness was 100% in both groups. The increase of ABI was 44.4% (8/18) in group 1 and 41.2% (7/17) in group 2. The value of tcPO(2) increased to 20 mmHg or more in 20 limbs. Nine of 15 limbs which underwent angiography showed rich collaterals. Limb salvage rate was 83.3% (15/18) in group 1 and 94.1% (16/17) in group 2. There was no statistically significant difference in the effectiveness of the treatment between the two groups.

CONCLUSIONS

Transplantation of autologous bone marrow mononuclear cells is a simple, safe and effective method for the treatment of lower limb ischemia, and the two approaches for the implantation, intra-muscular injection and intra-arterial injection, show similar results.

Clinical findings of the patients with legal pulmonary disability--short-term follow-up at a tertiary university hospital in Korea

BACKGROUND/AIMS

Legal pulmonary disability in Korea is decided for chronic respiratory patients who have been diagnosed for a year or more, and the patients haven't gotten better after more than 2 months of sufficient treatment and they have shown no change in their pulmonary function within the two years after their original diagnosis. The purpose of this study was to investigate the clinical features and progress of those patients who have been diagnosed as having pulmonary disability.

METHODS

We reviewed retrospectively the medical records of the patients who had been decided as having pulmonary disability at a tertiary university hospital from 2003 to 2004, and these patients could be followed up for more than 6 months.

RESULTS

The number of enrolled patients was 118 (male : female = 95 : 23) and their mean age was 60+/-10 years. Their major underlying diseases were chronic obstructive pulmonary disease (n=45, 38%), tuberculous destroyed lung (n=29, 25%), and bronchial asthma (n=27, 23%). Of them, the number of patients with a class 1 pulmonary disability were 24 (20%), there were 28 class 2 patients (24%) and 66 class 3 patients (56%). The FEV1 could be followed up for 42 of these patients, of whom 20 patients showed no change or a decrease in their FEV1 but 22 showed an increased FEV1. Especially, some of them showed the increase of their FEV1 of 10% or more, and the 50% of them were patients with bronchial asthma. During the follow-up period, 6 patients died; 3 were class 1, 1 was class 2 and 2 were class 3. Five of these patients died of their underlying pulmonary diseases or combined pneumonia.

CONCLUSIONS

It is necessary to decide the pulmonary disability after sufficient treatment and to perform periodic follow-up testing even after the disability decision for confirming that the disability is stable and also to adjust the class of the disability. Further studies are needed to observe the clinical progress and prognosis of patients with pulmonary disability by performing long-term follow-up for a large number of patients.