Background: There are indications that some features of gastric carcinoma are changing, with a possible impact on prognosis. The aim of this study was to examine any changes in type, location, stage, resection rate, postoperative mortality rate or prognosis for patients with gastric carcinoma in a well defined population. Methods: During 1974-1991, 1161 new cases of gastric adenocarcinoma were diagnosed in Ostergotland County, Sweden. Tumour location, Lauren histological type, tumour node metastasis (TNM) stage, radicality of tumour resection and postoperative complications were recorded after histological re-evaluation of tissue specimens and examination of all patient records. Dates of death were obtained from the Swedish Central Bureau of Statistics. Time trends were studied by comparing the intervals 1974-1982 (period 1) and 1983-1991 (period 2). Results: The proportion of diffuse type of adenocarcinoma increased (from 27 to 35 per cent), while that of mixed type decreased (from 16 to 9 per cent) and that of intestinal type was unchanged. The proportion of tumours located in the proximal two-thirds of the stomach increased (from 32 to 42 per cent) and the proportion of patients with tumours in TNM stage IV decreased (from 32 to 25 per cent). Overall tumour resection rates were unchanged, although the proportion of radical total gastrectomies increased (from 36 to 50 per cent). Excluding tumours of the cardia or gastric remnant after previous ulcer surgery, the 5-year relative survival rate after radical resection increased from 25 to 36 per cent and the postoperative mortality rate decreased for both radical (from 11 to 4 per cent) and palliative (from 18 to 6 per cent) resection. Conclusion: The patterns of tumour histology, location and stage of gastric carcinoma have changed in the authors' region. These changes were paralleled by a significant improvement in survival and postoperative mortality rates.

Objectives: To assess endothelial function and vascular mechanical properties in normotensive pregnant women with high resistance in the uteroplacental circulation. Design: Cross-sectional prospective study. Setting: Doppler ultrasound laboratory at university department of obstetrics and gynaecology referral centre for high risk pregnancies. Participants: Forty-two caucasian normotensive pregnant women: 23 with uncomplicated pregnancies and 19 with bilateral uterine artery notches. Methods: Flow-mediated dilatation of the brachial artery was measured by ultrasonography at 25 gestational weeks. Concentrations of nitrite and nitrate in the plasma were established at 25 and 32 gestational weeks. The elastic properties of the common carotid artery, abdominal aorta and popliteal artery were measured with an ultrasonic echo-tracking system. Results: Flow-mediated dilatation at two minutes after cuff deflation was significantly lower in the bilateral notch group compared with the control group, 8.3% and 13.7%, respectively (P = 0.0007). The ability to sustain vasodilatation was reduced in the bilateral notch group (P = 0.02). Lower values of nitrite and nitrate in the plasma were found at 32 gestational weeks in the bilateral notch group than in the control group (mean 24.76 ╡M/ L (SD 5.6) and 30.93 ╡M/L (8.2), respectively, P = 0.008). Nitrite and nitrate levels tended to be lower in the bilateral notch group even at 25 gestational weeks (29.45 ╡M/L (8.3) and 35.73 ╡M/L (11.0) in the bilateral notch and control group, respectively, P = 0.09). There was no difference in aortic, carotid or popliteal elasticity between the two groups. Conclusions: Healthy normotensive pregnant women with bilateral uterine artery notches show impaired endothelial function, but no differences in vascular mechanical properties.

Background. The use of left ventricular assist devices (LVADs) is established as a bridge to heart transplantation. Methods. All Swedish patients on the waiting list for heart transplantation, treated with LVAD since 1993 were retrospectively collected into a database and analyzed in regards to risk factors for mortality and morbidity. Results. Fifty-nine patients (46 men) with a median age of 49 years (range, 14 to 69 years), Higgins score median of 9 (range, 3 to 15), EuroScore median of 10 (range, 5 to 17) were investigated. Dominating diagnoses were dilated cardiomyopathy in 61% (n = 36) and ischemic cardiomyopathy in 18.6% (n = 11). The patients were supported with LVAD for a median time of 99.5 days (range, 1 to 873 days). Forty-five (76%) patients received transplants, and 3 (5.1%) patients were weaned from the device. Eleven patients (18.6%) died during LVAD treatment. Risk factor analysis for mortality before heart transplantation showed significance for a high total amount of autologous blood transfusions (p < 0.001), days on mechanical ventilation postoperatively (p < 0.001), prolonged postoperative intensive care unit stay (p = 0.007), and high central venous pressure 24 hours postoperatively and at the final measurement (p = 0.03 and 0.01, respectively). Mortality with LVAD treatment was 18.6% (n = 11). High C-reactive protein (p = 0.001), low mean arterial pressure (p = 0.03), and high cardiac index (p = 0.03) preoperatively were risk factors for development of right ventricular failure during LVAD treatment. Conclusions. The Swedish experience with LVAD as a bridge to heart transplantation was retrospectively collected into a database. This included data from transplant and nontransplant centers. Figures of mortality and morbidity in the database were comparable to international experience. Specific risk factors were difficult to define retrospectively as a result of different protocols for follow-up among participating centers. © 2003 by The Society of Thoracic Surgeons.

Objective: To find out whether we could identify prognostic factors for early failure of bypass to the foot in diabetic patients with critical ischaemia. Design: Retrospective series of consecutive patients. Setting: County hospital, Sweden. Patients: 43 diabetic patients who had 48 reconstructions for critical ischaemia between 1988 and 1994. Interventions: 48 elective vein bypass procedures to the feet. Main Outcome measures: Prognostic factors for primary patency. Results: Primary and secondary patency rates at one year were 72% (95% confidence interval (CI) 58 to 85) and 83% (95% CI 71 to 95), respectively. Limb salvage and survival rates at one year were 85% (95% CI 74 to 96) and 86% (95% CI 75 to 96), respectively. Vein graft of questionable quality, major wound healing problems, use of the reversed vein technique, and a narrow lumen (<1.5 mm) of the recipient artery increased the hazard for failed primary patency by 17.3 (p = 0.003), 6.0 (p = 0.02), 4.7 (p = 0.03), and 3.9 (p = 0.05) times, respectively. Short vein bypass (p = 0.70), translocated or composite veins (p = 0.61), major postoperative oedema of the leg (p = 0.46), or questionable quality of the wall of the recipient artery (p = 0.29), however, had no significant independent effect on the primary patency rate. Conclusion: Early primary patency after bypass to the foot in diabetic patients might improve if veins of questionable quality, major wound healing problems, thin reversed veins from the calf, and narrow recipient arteries can be avoided or handled more proficiently than in the present study.

The first part of this thesis consists of a population-based epidemiological study on symptomatic leg arterial disease in a Swedish community, based on a postal questionnaire and systolic ankle pressure measurements, with calculation of the ankle-brachial pressure index (ABPI; usually ≥ 1.0 in healthy subjects). The second part investigates alternative methods for ankle systolic pressure measurements, with the potential of automation.

(Papers I-III) A postal questionnaire on leg symptoms and concomitant diseases was distributed to all the inhabitants of Vadstena 50-89 years old (n=7,524). The response rate was 92% and of those reporting any leg pain, 80% (353/441) attended an examination with ABPI determination. Symptomatic leg ischaemia (SLI) was defined as leg pain on walking + ABPI ≤ 0.8. The prevalence was 4.1 %, increasing with age, with no major difference between men and women. Other manifestations of arteriosclerotic disease (previous angina pectoris, myocardial infarction or cerebrovascular incident), hypertension and diabetes mellitus were more prevalent among SLI cases than in healthy subjects. At a four-year follow-up, the age and sex adjusted mortality ratio was almost doubled in SLI subjects. Their relative risk of a myocardial infarction, cardiac death and death due to any cardiovascular event was 2.7, 2.0 and 1.9, respectively, compared to an age and sex matched control group. In SLI subjects without a previous history of ischaemic heart disease, the relative risk of a myocardial infarction was 3.1. Cardiovascular disease alone was mainly responsible for the increased risk of death. At a ten-year follow-up, a baseline ABPI up to 0.8 was inversely correlated with mortality. In a Cox regression model, a low ABPI was significantly and independently associated with an increased risk of death. An ABPI of 0.81-0.99 was not associated with an increased mortality risk. Over ten years, 1/7 of the SLI cases had a leg vascular reconstructive procedure, the majority within the first two years, and 1/14 underwent a major amputation. In conclusion, in spite of the good prognosis of the local disease, SLI can be looked upon as a marker for generalised arteriosclerotic disease and as a risk predictor for severe arteriosclerotic events and premature death.

(Papers IV-VI) Oscillometric technique, commonly used for automatic arm blood pressure measurements, was validated against the CW Doppler in systolic ankle pressure determination in healthy subjects and in patients with leg arterial disease. While performing adequately in healthy subjects, it was found to be invalid in leg arterial disease. The oscillometric technique was deemed as not suitable for use as an automatic ankle pressure recorder in the diagnosis ofleg arteriosclerotic disease.

A new technique, based on a two-channel photoplethysmographic (PPG) probe (880nm) placed underneath the pneumatic cuff, together with electronics, was developed and compared with both CW Doppler and intra-arterial recordings in subjects without vascular disease, and with the CW Doppler in leg arterial disease. On visual analysis of the PPG curves, the agreement was good. An automatic algorithm for analysis of PPG-data gave comparable results. The PPG method is a promising technique for future automation of systolic ankle pressure measurements, and for inclusion in a complete ABPI recorder.

Objective

To evaluate a new technique using a photoplethysmographic (PPG) probe for automatic ankle pressure measurements.

Design

Comparative study on two techniques for ankle pressure measurement.

Setting

University hospital.

Material

Thirty-five patients with leg arterial disease and eight healthy volunteers. Ankle-brachial indices (ABPI) were measured using conventional CW Doppler technique and PPG-based prototype equipment for the ankle pressure recordings.

Chief outcome measures

ABPIs calculated from CW Doppler and PPG ankle pressure measurements. The PPG signals were analysed both by visual judgement and by a software based, automatic algorithm.

Main results

The mean difference between ABPIs calculated from CW Doppler recordings and PPG (visual analysis) was −0.01 (limits of agreement (±two standard deviations) +0.16 to −0.19). The correlation coefficient was 0.93. When the algorithm was used, the mean difference (CW Doppler−PPG) was 0.05 (limits of agreement 0.28 to −0.18, r=0.89).

Conclusions

The PPG method is a promising technique with an inherent potential for automatisation of the ankle pressure measurements, thereby reducing the observer-dependency in ABPI recordings.

An automated method for ankle systolic pressure measurement, less operator dependent than the standard continuous wave (CW) Doppler technique, would imply an advantage both in patient measurements and in epidemiological studies. We present a new photoplethysmographic (PPG) probe that uses near-infrared light (880 nm) to detect pulsatory blood flow underneath the distal end of a standard pneumatic cuff. The probe is adapted to the anatomical conditions at the ankle, permitting recording of pressures in both ankle arteries separately. The validity of the equipment was tested with CW Doppler-derived systolic pressures and invasive blood pressure measurements for reference. In 20 healthy subjects, visual analysis of the PPG curves revealed a mean difference between CW Doppler and PPG measurements of –0.5 mmHg (SD 6.9). Corresponding results for the anterior and posterior tibial arteries separately were –1.8 mmHg (SD 6.2) and 0.9 mmHg (SD 7.3), respectively. A correct probe position was essential for the results. In direct recordings from the dorsalis pedis artery in 10 intensive care patients, PPG underestimated systolic pressure in the anterior tibial artery by 4.5 mmHg (SD 12.1). With further development, the PPG probe, integrated in the pneumatic cuff, may simplify measurements of ankle systolic pressures.

The objective of the study was to evaluate the validity of oscillometric systolic ankle pressure in symptomatic leg arterial occlusive disease. Ankle pressure measurements using oscillometric curves obtained using a standard 12-cm cuff with a specially designed device for signal processing were validated against the continuous wave (CW) Doppler technique. Thirty-four subjects without signs or symptoms of peripheral vascular disease (68 legs) and 47 patients with leg ischaemia (85 legs) varying from moderate claudication to critical ischaemia were examined. The oscillometric curves were analysed using several algorithms reported in the literature, based on the assumption that maximum oscillations are recorded near mean arterial pressure. In normals, reasonable agreement between CW Doppler and oscillometric methods was seen. When an algorithm that determined the lowest cuff pressure at which maximum oscillations occurred, and a characteristic ratio for systolic pressure of 0·52 was used, the mean difference between CW Doppler and oscillometry was 1·7 mmHg [range −19 to +27, limits of agreement (2 SD) 21·1 mmHg]. In ischaemic legs, oscillometry overestimated systolic ankle pressure by a mean of 28·8 mmHg [range –126 to +65, limits of agreement 82·8 mmHg]. The difference was more pronounced among patients with critical ischaemia compared with claudicants, and also more evident among diabetics. The error of oscillometric pressure determination in subjects with leg arterial disease inversely increased with CW Doppler ankle pressure. In 39% of the recordings in legs with a CW Doppler systolic pressure below 100 mmHg, the oscillometric mean arterial pressure was higher than the recorded CW Doppler systolic pressure. In conclusion, the oscillometric method to determine systolic ankle pressure, based on the concept of maximum cuff oscillations occurring near mean arterial pressure, is not reliable in leg arterial disease, usually overestimating ankle pressure.

Objective: to study the association between the ankle–brachial pressure index (ABPI), premature death and the need for surgical treatment for lower limb ischaemia.

Design: population based cohort study.

Subjects: three hundred and fifty-three men and women, 50–89 years old, underwent a leg pain questionnaire and measurement of ABPI and was then followed for 10 years.

Outcome Measures: all cause mortality, vascular procedures and major amputations.

Results: a low ABPI was independently associated with premature all cause mortality in the multiple regression analysis, carrying a relative risk of 3.4 (95% confidence interval 2.0–5.9) and 2.1 (1.3–3.3) for ABPIs ≤0.50 and 0.51–0.80, respectively, compared to those with ABPI ≥1.0. Individuals with an ABPI in the interval 0.81–0.99 suffered only a slight, not statistically significant risk increase compared to normals. A low ABPI at baseline implied a continuous constant increased risk of death throughout the study period. The same risk was observed among elderly (70–89, median 77 years), and in the middle aged (50–69, median 63 years) individuals. The vast majority of those subjected to vascular intervention or major amputation during follow-up had an ABPI≤0.8 at baseline (83 and 89%, respectively). However, within that group, the individual ABPI was not predictive for surgical intervention.

Conclusion: the association found between an ABPI ≤0.8 and premature mortality in this cohort of symptomatic subjects implies that the ABPI is a powerful, independent predictor for premature death. The prognostic information carried by an ABPI in the interval 0.81–0.99 remains uncertain. Septuagenarians and octogenarians carry the same risk increase associated with a low ABPI as those in the middle ages.

Objective:

To quantify cardiovascular morbidity and mortality including the incidence of vascular surgery and amputations, among individuals with symptomatic leg ischaemia.

Design:

Prospective cohort study.

Material:

Inhabitants 50–89 years of age (n = 2784) of Vadstena community, Östergötland, Sweden, with 4 years of follow-up. 107 subjects with symptomatic leg ischaemia (SLI), selected by a postal questionnaire and ankle pressure measurements, and an age and sex matched control group of 214 individuals.

Chief outcome measures:

Cardiovascular morbidity and mortality, all cause mortality, surgical procedures for leg ischaemia, major amputations, ankle brachial pressure index.

Main results:

Age and sex adjusted all-cause mortality risk in the SLI-group was increased by 1.9. This was most prominent among men in their sixties and women in their seventies. Cardiovascular mortality was increased by 1.9 (95% confidence interval 1.1–3.3). Relative risks for acute myocardial infarction and cerebrovascular events were 2.4 (1.1–5.1) and 1.7 (0.9–3.2), respectively. The increase in age and sex adjusted incidence of primary reconstructive surgery during the first year after initial examination was 67-fold compared to the total population of Vadstena 50–89 years old, and 18-fold for the whole observation period, while the increase in risk for major amputation during the observation period was 12-fold. Median ankle brachial index improved significantly during follow-up among the individuals alive and not subjected to vascular surgery.

Conclusions:

Among the SLI-subjects identified in a general population, the overall risk for cardiovascular morbidity and mortality over 4 years was significantly increased compared to normals.

A soft (silicone) probe, containing six light emitting diodes (880 nm) and three photo detectors, utilizes photoplethysmography (PPG) to monitor pulsations from the brachialis artery under an occluding cuff during deflation. When the arterial pulse returns, measured by PPG, the corresponding pressure in the cuff is determined. This pressure is assumed to equal the systolic pressure. An assessment trial was performed on 21 patients (9 women and 12 men, aged 27-69) at the Neuro-Intensive care unit. Since the patients were already provided with arterial needles, invasive blood pressure could be used as the reference. By choosing a threshold, for detecting pulses, as a fraction (4%) of the maximum amplitude, the systolic blood pressure was underestimated (-0.57 mmHg, SD 12.1). The range of systolic pressure for the patients was 95.5 - 199.0 mmHg, n=14. The method is promising, but improvements still have to be made in order to improve the technique.

Photoplethysmography (PPG) can be used to measure systolic blood pressure at the brachial artery. With a specially designed probe, positioned in the most distal position beneath a pressure cuff on the upper arm, this is possible. The distance between the light source (880 nm) and the photodetector was 20 mm. A test was performed on neuro-intensive care patients by determining blood pressure from the PPG curves, and, when it was compared with systolic blood pressure obtained from inserted indwelling arterial catheters, a correlation factor of r=0.95 was achieved. The difference between blood pressure obtained using PPG and invasive blood pressure measurement was 3.9±9.1 mmHg (mean±SD), n=19. The depth to the brachial artery was 13.9±4.1 mm (mean±SD), n=18. A digital PPG system utilising pulsating light was also developed.

Photoplethysmography (PPG) can be used to measure systolic blood pressure at the brachial artery. With a specially designed probe, positioned in the most distal position beneath a pressure cuff on the upper arm, this is possible. The distance between the light source (880 nm) and the photodetector was 20 mm. A test was performed on neuro-intensive care patients by determining blood pressure from the PPG curves, and, when it was compared with systolic blood pressure obtained from inserted indwelling arterial catheters, a correlation factor of r=0.95 was achieved. The difference between blood pressure obtained using PPG and invasive blood pressure measurement was 3.9±9.1 mmHg (mean±SD), n=19. The depth to the brachial artery was 13.9±4.1 mm (mean±SD), n=18. A digital PPG system utilising pulsating light was also developed.

The reason for the particularly increased risk for cardiovascular complications in diabetic women is still unclear. We have previously found decreased distensibility of elastic arteries in type I diabetic women, indicating increased cardiac load, not seen in type I diabetic men, which might be one contributing factor. Whether the effect of gender is different in muscular arteries in type I diabetic patients has not been assessed. As estimates of arterial distensibility we measured stiffness (▀) and pressure strain elastic modulus (Ep) in the muscular common femoral artery using echotracking sonography in 30 women (mean age 34 years, range 20-61) and 26 men (mean age 38 years, range 22-56) with type I diabetes. The results were compared with those of 89 healthy individuals of corresponding age and gender and with previously published results from elastic arteries in these patients obtained at the same occasion. The internal common femoral diameter was significantly decreased in both diabetic men and women. In sharp contrast to the highly significant decreased distensibility of the elastic abdominal aorta and common carotid artery in the type I diabetic women, the distensibility of the common femoral artery did not clearly differ between patients and controls, neither for women nor for men. Thus, the gender difference in changes of arterial distensibility found in elastic arteries was absent or far less obvious in the femoral artery. In conclusion, female gender seems to affect the mechanical properties of elastic, but not of large muscular arteries in type I diabetic patients. Thus, putative gender differences in arterial changes in type I diabetes are to be sought in elastic rather than muscular arteries.

The distensibility of elastic arteries has been extensively studied, while studies of muscular arteries are sparse. The influences of age and gender on the mechanical properties of the common femoral artery (CFA) were studied. The pulsatile diameter changes of the CFA were noninvasively measured using echo-tracking sonography in 173 healthy volunteers (95 females, 78 males, range 7-81 years). In combination with blood pressure measurements, stiffness (▀) and pressure strain elastic modulus (Ep) were calculated. Neither ▀ nor Ep was related to age or gender and a considerable interindividual variation was present. The CFA diameter increased with age. In conclusion, the distensibility of this muscular artery is not clearly affected by age or gender, although the diameter increases with age. This indicates remodelling of the arterial wall and an impact of vascular smooth muscles on long-term wall mechanics. Thus, there appear to be fundamental differences in the dynamic behaviour of the common femoral artery when compared to elastic arteries, such as the aorta and the common carotid artery. (E-mail:asa.ryden-ahlgren@klinfys.mas.lu.se) Copyright

[No abstract available]

The prevalence of symptomatic leg ischaemia (SLI) was studied using a standardised postal questionnaire and by measuring ankle systolic blood pressure among those with leg pain. All individuals, aged 50–89 years, of both sexes (n = 2748) in a community of 7524 inhabitants were included. The overall questionnaire response rate was 92%, of whom 441 (17%) reported any form of leg pain. Ankle systolic blood pressure (ASBP) was measured in 353 (80%) of those. Ankle/brachial index (ABI) ⩽0.8 was chosen as the criterion for verified SLI. One hundred and seven (30%) had a verified SLI (ABI ⩽0.8).Hospital records could be reviewed in 83% of the non-responders, and revealed corresponding distributions of risk factors among the non-responders and the questionnaire-responders. Risk factor frequencies among ASBP-examined and not examined individuals were also comparable. The overall prevalence of SLI in the age 50–89 years was 4.1%, ranging from 1.5% in the age decade of 50–59 years, to maximum 7.1% in the decade 70–79 years. A slight but not significant male predominance was recorded, except for the age decade 70–79 years. The prevalence of SLI in the whole community population was approximately 2000/100 000 of which 5% were possible candidates for vascular intervention.