Physical examination and chronic lower-extremity ischemia: a critical review

OBJECTIVE: To determine the clinical utility of physical examination in patients with suspected chronic ischemia of the lower extremities. DATA SOURCES: MEDLINE search (January 1966 to January 1997), personal files, and bibliographies of textbooks on physical diagnosis, surgery, and vascular surgery. STUDY SELECTION: Both authors independently graded the studies as level 1, 2, or 3, according to predetermined criteria. Criteria deemed essential for analysis of sensitivity, specificity, and likelihood ratios were (1) clear definition of study population, (2) clear definition of physical examination maneuver, and (3) use of an acceptable criterion standard test for comparison. RESULTS: The following positive findings help clinicians diagnose the presence of peripheral arterial disease: abnormal pedal pulses, a unilaterally cool extremity, a prolonged venous filling time, and a femoral bruit. Other physical signs help determine the extent and distribution of vascular disease, including an abnormal femoral pulse, lower-extremity bruits, warm knees, and the Buerger test. The capillary refill test and the findings of foot discoloration, atrophic skin, and hairless extremities are unhelpful in diagnostic decisions. Mathematical formulas, derived from 2 studies using multivariate analysis, allow clinicians to estimate the probability of peripheral arterial disease in their patients. CONCLUSION: Certain aspects of the physical examination help clinicians make accurate judgments about the presence of peripheral arterial disease and its distribution.     

Diagnosis of death in comatose patients under resuscitation treatment: a critical review of the Harvard report

In this Article, which draws primarily on continental West European views on death and dying, the author contends that the Harvard criteria for irreversible coma (1968) are not reliable for diagnosing death in comatose patients under resuscitation treatment. The Article suggests that use of the Harvard Criteria to diagnose death leaves such patients legally unprotected against surgical assaults such as organ removal and biomedical experiments while they still may be living and capable of perception, possibly including the perception of pain and the spoken word. An alternative to the Harvard Criteria--angiography--is offered, and several additional issues related to the definition and diagnosis of death are discussed. Finally, the author suggests that even prior to death, termination of resuscitation treatment of irreversibly comatose patients, though followed by death, should be lawful.     

Acupuncture in the treatment of asthma: a critical review

OBJECTIVES: This study was undertaken in the mid-1990s (1994) to describe the use of tobacco, alcohol, and non-institutionalized drugs among pre-adolescent and adolescent Spanish students. METHODS: Information was collected within the framework of a periodic transversal study of life styles among European students, with particular emphasis on health-related habits. In the current study we present the results of the last survey carried out in Spain within the context of this study (1994), which involved a representative sample of Spanish students 11, 13, 15, 17 and 18 years-old (n = 6,711). An anonymous questionnaire was completed by the students in class. The survey sampling uses proportionate stratification and multistage sampling. RESULTS: In 1994, 49% of the Spanish students in this age group had tried tobacco. Twenty-four percent were sporadic or regular smokers. There was a large proportion of female smokers than male smokers (27% vs 20%). The overall proportion of smokers increased from 3% at 11 years to 47% at 18 years. One third (33%) of the 18-year-old students smoked daily. Eighty-four percent of the students of this age indicated that they had tried one or more types of alcoholic beverage. Twenty-one percent consumed alcohol regularly (at least once a week). Regular alcohol use was somewhat more common among males (24%) than among females (19%). Forty-six percent of the 18-year-old students consumed alcoholic beverages regularly and 66% had been intoxicated one or more times. Almost one fifth (18%) of the 13-to-18 year-old students indicated that they had tried some type of non-institutionalized drug, although the current rate of consumption was 8%. Cannabis was the drug most frequently tried (18%) and the drug most often consumed at present (8%), followed by cocaine and heroin. More males than females had tried non-institutionalized drugs. DISCUSSION: Analysis of the data revealed that adolescent tobacco use is increasingly frequent among females. Alcohol use continues to be widespread among Spanish pre-adolescents and adolescents. Alcohol use begins in childhood and becomes consolidated in adolescence. The results suggest, in relation to gender differences in the use of tobacco, alcohol, and non-institutionalized drugs, that there is a strong tendency toward the homogenization of these habits between genders. It is necessary to emphasize the preventive measures of drug dependence among Spanish pre-adolescents and adolescents.     

Diagnosis of sclerotic arterial diseases of the lower limbs

Diagnosis and treatment of lower limbs arterial disease do not depend exclusively on functional staging. Fontaine's classification has to be replaced by a classification based on clinical and complementary investigations to understand better the evolutive risks, and guide management. Distal systolic pressures along with symptom analysis and clinical examination allow a more precise diagnosis. Complementary investigations aim at assessing, the localization and extension of atherosclerotic lesions; the severity of tissue ischaemia. The concept of critical ischaemia has tried to insure greater diagnostic homogeneity for patients with rest ischaemia. The role of complementary investigation can only increase for the diagnosis and management sclerotic arterial disease. The detection of the other localizations of atherosclerosis and arteriosclerosis are essential to prevent complications which are responsible for the prognosis of the disease. Sclerotic arterial diseases represent approximately 90 to 95% of the causes of arterial diseases. Identification of these other causes remains, however, essential as it can greatly influence prognosis.     

Preoperative imaging of varicose veins of the lower extremities. Classical pattern of insufficiency and its clinical use

Venous varicose are one of the most common diseases in industrial countries today. New surgical strategies, tailored to a patient's specific pattern of venous incompetence require more detailed preoperative imaging. METHODS: In this review of current literature we analyzed the value of ascending venography, color coded duplex sonography and descending venography for preoperative planning of varicose surgery. On the other hand, we describe variant anatomy of the superficial venous system like the different levels of escape points and perforating veins. RESULTS: Ascending venography and color coded duplex sonography are both excellent modalities for detection of reflux in the saphenofemoral and saphenopopliteal junction. The results of current literature indicate, that ascending venography is superior to color coded duplex sonography in the detection of incompetent perforators. CONCLUSIONS: Ascending venography and color coded duplex sonography provide improved information, that may be crucial for surgical planning. The high heterogeneity and broad distribution of valvular incompetence confirms the importance of detailed preoperative imaging.     

Our experience in using a synthetic prostacyclin analog in the treatment of critical ischemia of the extremities

The authors, after examination of pharmacologic profile of Iloprost, prostacyclin synthetic analogue, report their clinical experience from January 1992 to June 1997 on 105 patients with severe ischaemia of inferior limbs. They utilize two protocols: 0.5-2 ng/kg/min x 6 hs once a day x 28 days and 1-1.5 ng/kg/min x 6 hs twice a day x 12 days. The first protocol were practise along the first 2 years; the second on following period as long as today. The results, evaluated on clinical criteria, are referred entity and time of pain remission and decrease of analgesic use, performance status improvement, increase of gear autonomy and, if present, wound healing. The incidence of amputation was 4.76% (5 pts). The authors issue that Iloprost is a conservative treatment, often alternative with amputation, giving sometimes to patients a longtime functional "restitutio ad integrum".     

Hyperthermia and AIDS: a critical review

Torsade de pointes in the congenital long QT syndrome (LQTS) is often pause dependent. Thus, the main goal of pacemaker treatment in the LQTS may be the prevention of pauses that facilitate the onset of torsade de pointes. A pause prevention pacing algorithm (rate smoothing) was used for arrhythmia prevention in a 14 year old girl with congenital LQTS. By temporarily increasing the pacing rate after spontaneous premature beats, rate smoothing down of 18% prevented postextrasystolic pauses, pause related T-U changes, and recurrence of pause induced torsade de pointes. Rate smoothing is a potentially useful tool that ought to be evaluated for the prevention of torsade de pointes in the LQTS.     

Surgical treatment of an acute thrombophlebitis of the varicose veins of the lower extremities

The operation for an acute thrombophlebitis of the lower extremities varicose veins was conducted in 45 patients in an acute period of complication (1st group); in 22--after the durable ambulatory conservative therapy (2nd group); in 18--hospitalized for the next aggravation of the superficial veins chronical recurrent thrombophlebitis (3d group). Complications after the operation have occurred in the 1st group in 4.4% patients, in the 2nd group--in 13.6%, in the 3d group--in 22.2%. The duration of treatment of patients in stationary have constituted on average accordingly 7.6, 9.3 and 23.5 days. In elderly patients, having severe concurrent diseases, the segmental phlebothrombectomy conduction is indicated.