Different lasers reveal different skin microcirculatory flowmotion - data from the wavelet transform analysis of human hindlimb perfusion.

Laser Doppler flowmetry (LDF) and reflection photoplethysmography (PPG) are standard technologies to access microcirculatory function in vivo. However, different light frequencies mean different interaction with tissues, such that LDF and PPG flowmotion curves might have distinct meanings, particularly during adaptative (homeostatic) processes. Therefore, we analyzed LDF and PPG perfusion signals obtained in response to opposite challenges. Young healthy volunteers, both sexes, were assigned to Group 1 (n = 29), submitted to a normalized Swedish massage procedure in one lower limb, increasing perfusion, or Group 2 (n = 14), submitted to a hyperoxia challenge test, decreasing perfusion. LDF (Periflux 5000) and PPG (PLUX-Biosignals) green light sensors applied distally on both lower limbs recorded perfusion changes for each experimental protocol. Both techniques detected the perfusion increase with massage, and the perfusion decrease with hyperoxia, in both limbs. Further analysis with the wavelet transform (WT) revealed better depth-related discriminative ability for PPG (more superficial, less blood sampling) compared with LDF in both challenges. Spectral amplitude profiles consistently demonstrated better sensitivity for LDF, especially regarding the lowest frequency components. Strong correlations between components were not found. Therefore, LDF and PPG flowmotion curves are not equivalent, a relevant finding to better study microcirculatory physiology.

Focused Ultrasound PC-6 Stimulation Effects on Blood Flow Volume, Skin Temperature, and Coldness of the Finger and Toe.

INTRODUCTION: Focused ultrasound can stimulate a specific point of tissue and can be a noninvasive method for acupoint stimulation. The aim of this study was to clarify the effects of acupoint stimulation by focused ultrasound on blood flow volume and coldness of the fingers and toes. MATERIALS AND METHODS: Forty healthy volunteers were included in this experiment. The blood flow volume and the skin temperature of a finger and toe were measured before and after stimulation of the pericardium 6 acupuncture point (PC-6) by focused ultrasound. Subjective coldness of the fingers and toes was also assessed using a visual analog scale (VAS) before and after stimulation. RESULTS: The maximum blood flow volumes of the finger and toe were significantly larger (p < 0.01) than those before stimulation. The maximum skin surface temperatures of the fingers were significantly higher (p < 0.01) than those before stimulation. The VAS scores for subjective coldness of the toes after stimulation were significantly higher (p < 0.01). CONCLUSION: The blood flow volume and skin temperature tended to increase after PC-6 stimulation. The VAS scores also indicated a tendency toward a warmer sensation in the toes after stimulation.

The Effect of Transcutaneous Electrical Nerve Stimulation of Sympathetic Ganglions and Acupuncture Points on Distal Blood Flow.

Transcutaneous electrical nerve stimulation (TENS) is a widely-practiced method to increase blood flow in clinical practice. The best location for stimulation to achieve optimal blood flow has not yet been determined. We compared the effect of TENS application at sympathetic ganglions and acupuncture points on blood flow in the foot of healthy individuals. Seventy-five healthy individuals were randomly assigned to three groups. The first group received cutaneous electrical stimulation at the thoracolumbar sympathetic ganglions. The second group received stimulation at acupuncture points. The third group received stimulation in the mid-calf area as a control group. Blood flow was recorded at time zero as baseline and every 3 minutes after baseline during stimulation, with a laser Doppler flow-meter. Individuals who received sympathetic ganglion stimulation showed significantly greater blood flow than those receiving acupuncture point stimulation or those in the control group (p<0.001). Data analysis revealed that blood flow at different times during stimulation increased significantly from time zero in each group. Therefore, the application of low-frequency TENS at the thoracolumbar sympathetic ganglions was more effective in increasing peripheral blood circulation than stimulation at acupuncture points.

[Efficacy of hyperbaric oxygen therapy in the treatment of ischemic toe ulcer in a patient presenting systemic sclerosis]. / Efficacité de l'oxygénothérapie hyperbare dans le traitement d'un ulcère nécrotique d'orteil au cours d'une sclérodermie systémique.

BACKGROUND: The medical treatment of ischemic ulcers in patients with systemic sclerosis remains difficult. Despite the major help provided by vasodilator treatments, the risk of spontaneous or surgical amputation remains high. OBSERVATION: A 48-year-old female patient from Guadeloupe was treated in our department for diffuse systemic sclerosis present for 15 years complicated by lung, joint and digestive involvement, and associated with severe Raynaud's phenomenon. The clinical course was marked by the occurrence of multiple ischemic ulcers, which were resistant to conventional medical treatment and resulted in two surgical amputations (to the 2nd and 3rd interphalangeal joints of the toes of the left foot). Treatment with an endothelin-receptor antagonist and a calcium inhibitor was then introduced for secondary prevention. Two years later, the patient consulted for a further ischemic ulcer of the left 4th toe. She refused the proposed treatment with iloprost. Because of the unfavorable outcome and the absence of therapeutic alternative to amputation, hyperbaric oxygen therapy was initiated. Thirty 90-minutes sessions of pure oxygen at 2.5 ATA were conducted over a 10-week period. Complete healing was obtained after 8 months. DISCUSSION: We report herein a clinical case illustrating the efficacy of hyperbaric oxygen therapy for the treatment of ischemic ulcers of the toes in systemic sclerosis. It could offer an alternative therapeutic option, in particular for patients presenting resistant ischemic ulcers and a contraindication for or intolerance to the conventional medical treatment.

Peripheral embolisation after an abdominal massage.

A 65-year-old man presented with a history of acute onset pain in toes of the right foot immediately after an abdominal massage by a 'local healer'. General physical examination and systemic examination were normal except for discolouration of the fourth and fifth toes and cold toes. Investigations including complete blood count, erythrocyte sedimentation rate, renal function tests, liver profile, lipid profile, antinuclear antibody, antineutrophil cytoplasmic antibody, ECG, chest X-ray, ultrasound abdomen, cardiac echocardiography, lower limb Doppler and CT scan of the abdomen were normal. The patient was treated with regular heparin infusion, aspirin and tramadol. Recovery was complete in 5 days.

[Necrosis in fingers and toes following local anaesthesia with adrenaline--an urban legend?]. / Nekrose i fingre og tær etter lokalbedøvelse med adrenalin--en vandrehistorie?

BACKGROUND: It is often maintained that a local anaesthetic (usually lidocaine) with adrenaline must not be used in fingers and toes because it may cause necrosis due to vascular spasm in end arteries. This review article is an attempt to find evidence to support this warning. METHOD: Relevant literature was found by means of searches in PubMed limited downwards to 1946 and in EMBASE from 1980 to 2012, and in reference lists. RESULTS: Five review articles on finger necrosis following local anaesthesia concluded that lidocaine with adrenaline does not entail a risk of ischaemic injury. One article found 48 reported cases of finger necrosis in the period 1880 to 2000. Most were from the first half of the 1900s, and none involved lidocaine. Gangrene of part of the finger tip has subsequently been described in one patient with Raynaud's syndrome. No cases of necrosis have been described in a large number of reported accidents in which EpiPen injections contained the same quantity of adrenaline as is found in 60 ml lidocaine with adrenaline. Over a quarter of a million reports have been made of operations on feet, hands, fingers and toes anaesthetised with lidocaine with adrenaline without resulting necrosis. INTERPRETATION: There are no grounds for the warning against using lidocaine with adrenaline in fingers and toes. This anaesthetic offers considerable practical advantages. Care should be taken with infected fingers or fingers with poor circulation.

Symmetrical peripheral gangrene and the use of systemic hyperbaric oxygen therapy.

Symmetrical peripheral gangrene (SPG) is a rare but devastating condition when two or more distal sites become gangrenous, as the result of severe illness and treatment in critical care. The striking factor in SPG is that there is no occlusion of the major blood vessels to the affected limbs; the pathogenesis of the condition is not well understood and there are high reported mortality and amputation rates. Here we report the chronological progress report of a case of SPG, which affected both forefeet. This case report supports the view that early amputation should be avoided allowing for stabilisation of the gangrene so that no viable tissue is sacrificed. Further research is necessary to establish the pathogenesis and suitable treatment pathways.

Preliminary report of the safety and efficacy of hyperbaric oxygen therapy for specific complications of lung transplantation.

BACKGROUND: Lung transplantation (LTx) is a complex therapy requiring immunosuppression and is associated with significant infective morbidity and mortality. Hyperbaric oxygen (HBO) therapy has been used successfully in the treatment of specific serious infections, ischemic injuries and cerebral arterial gas embolism. The purpose of this study was to evaluate the efficacy and safety of HBO therapy after LTx, generally as indicated for refractory infectious complications. METHODS: This investigation was a retrospective study of all lung transplant recipients treated with HBO therapy at the Alfred Hospital between March 1990 and August 2005. RESULTS: In this study we describe 9 patients (1.7%) from a total of 544 overall lung transplants performed over the period. Indications included: sternal osteomyelitis (n = 4); refractory cellulitis (n = 2); refractory septic arthritis (n = 1); ischemic toes (n = 1); and cerebral arterial gas embolism (n = 1). The patients received 1 to 25 HBO treatments at 100% Fio(2) and 100 to 180 kPa for 100 minutes per treatment. The treatment was generally well tolerated, although 2 patients ceased therapy prematurely due to a seizure and ear barotrauma (n = 1 each). Five patients had complete resolution of these life-threatening complications. Long-term survival and graft function were excellent, although graft function temporarily fell. CONCLUSIONS: HBO is a safe therapy for traditional HBO indications after LTx and appears useful, particularly in the management of infectious complications, whereas other therapies have failed or are contraindicated.

Epinephrine in digital block: color Doppler flow imaging.

BACKGROUND: Epinephrine is currently added to local anesthetics for its advantageous vasoconstrictive effects. Traditionally, however, its use is not advised for digital block anesthesia due to the risk of digital gangrene. OBJECTIVE: To observe vasoconstrictive effect of epinephrine in digital block anesthesia. METHODS: Digital blocking with epinephrine containing lidocaine was performed in 24 subjects undergoing surgical procedure of their finger and toes. Digital artery blood flows were studied with color Doppler ultrasonography before digital blocking and at 10th, 60th, and if needed 90th minutes after blocking. Doppler parameters such as peak systolic velocity, end diastolic velocity, and resistive index values were studied. RESULTS: There were statistically significant decrease of blood flow rates and an increase of resistive index in all patients within 10 minutes. At the 10th minute of digital block, four patients had no measurable blood flow, which was restored within 60 or 90 minutes. Others showed diminished but persistent blood flow, which returned to normal within 60 minutes. No systemic or local complication related with epinephrine usage was observed. CONCLUSION: Vasoconstrictive effect of epinephrine in local anesthetics is not persistent and resolves within 60 or 90 minutes. Its use seems to be safe in selected patients.

Calciphylaxis in a patient with end-stage renal disease secondary to systemic lupus erythematosus associated with acral gangrene and mesenteric ischemia.

A patient with end stage renal disease secondary to systemic lupus erythematosus (SLE) ultimately required amputation of the four extremities and developed mesenteric ischemia. The patient presented with widespread medial calcification involving various small to medium sized arteries, although no noticeable secondary hyperparathyroidism was observed. We speculated that SLE associated with systemic vasculitis and uremic milieu over a number of years may represent the perfect preexisting condition for calcific arteriolopathy to occur following which several factors including chronic administration of corticosteroids, photosensitivity in lupus, and significant weight loss may have contributed to acral gangrene and mesenteric ischemia.

[Digital subtraction angiography with carbon dioxide in severe arterial ischemia and allergy to iodinated compounds]. / DIVAS con dióxido de carbono en isquemia arterial severe y alergia a compuestos yodados.

When in some selected patients, a direct arterial surgery (DAS) procedure or an endoluminal surgery (ES) are required for a chronic arterial ischemia (III or IV degrees), and an arteriography with contrast is absolutely contraindicated (because of severe renal failure without hemodialysis program or a severe congestive heart failure or a hyperthyroidism or a seriously demonstrated hypersensibility against the contrast agents); an angiography by digital subtraction with carbon dioxide (DIVAS-CO2) is indicated. This technique provides good quality images with minimal risks for the patient and an adequate study for ulterior treatment. We report a case of a 67-years-old woman, with diabetes-II, ischemic cardiopathy, arterial hypertension and a demonstrated hypersensibility against the iodide compounds. The patient was admitted because of a chronic ischemia (IV degree) with ischemic ulcerations on some fingers from the left foot. High doses of analgesic drugs were needed. Because the hypersensibility against the iodide compounds, an angiography with CO2 was carried out. The good quality images provided by this technique showed the factibility of a revascularization.

The effects of local anesthetics containing epinephrine on digital blood perfusion. 1978.

Digital perfusion research was conducted with two local anesthetics, lidocaine and bupivacaine. The studies were performed utilizing both anesthetic agents, plain and with various concentrations of epinephrine. The drugs' effects on blood perfusion over a 24-hr. period were recorded and discussed. The onset and duration of anesthesia were also compared.

Factors influencing the healing of distal amputations performed for lower limb ischaemia.

A total of 235 toes were amputated during 125 operations on 100 consecutive patients with lower limb ischaemia. The overall amputation wound healing rate for the series was 58.4 per cent and limb salvage was achieved in 66 patients. Toe amputation was performed under local anaesthesia in 57 cases and 32 (56 per cent) of these healed primarily, not significantly different from the healing rate of 41 (60 per cent) of 68 under general anaesthesia. Reconstructive arterial surgery was performed in conjunction with toe amputation in 39 patients; the healing rate with reconstruction was 32 (82 per cent) of 39, significantly better than the 41 (48 per cent) of 86 patients not undergoing bypass surgery (P less than 0.001). There was no difference in healing rates when comparing diabetic and non-diabetic patients. Multiple regression analysis demonstrated that reconstructive arterial surgery was the only factor which had an independent and significant influence on toe amputation healing. The use of local anaesthesia for distal amputation has no deleterious effects on wound healing.

[Clinical studies on various therapy for the intractable trauma of toes and fingers in cases of diabetes mellitus and peripheral ischemic diseases].

In cases of ischemic extremities and diabetes mellitus, the trauma on finger and toe is very intractable. For such injuries amputation of extremity is indicated very often because of severe necrosis. The number of such cases has been increasing recently because many cases of these patients have arteriosclerotic arterial occlusion and diabetes mellitus, and these are correlated with the changes of aging. The number of cases of Buerger's disease has been also increasing and it is another etiology of intractable trauma in ischemic extremity. The repeated hyperbaric oxygenation, sympathetic block, warfarin therapy and insulin bath with bubbling of hyperbaric oxygen, were applied to has been of such necrosis. By these procedures, the rate of amputation of extremity decreasing. It was concluded that the surgical reconstruction of artery for ischemic extremity has never any meaning as the therapy of such intractable injuries, if blood flow in the peripheral tissue is not kept physiologically, before vascular reconstruction. In order to increase peripheral tissue circulation, the hyperbaric oxygenation, sympathetic block and warfarin therapy wer performed in many cases and these methods were very effective for intractable injuries with severe necrosis.

Treatment of Raynaud's phenomenon with calcium channel blockers.

Raynaud's phenomenon may cause severe digital pain and functional disability, particularly in patients with underlying connective tissue diseases. The pathophysiology of Raynaud's phenomenon is varied, but digital ischemia is an essential element. Because calcium channel blockers cause arteriolar vasodilation and an increase in peripheral blood flow, they have been used to treat patients with Raynaud's phenomenon in several prospective, randomized, double-blind, placebo-controlled trials. Verapamil was ineffective in low doses, but both nifedipine and diltiazem produced subjective improvement. In placebo-controlled studies with nifedipine, the frequency of vasospastic episodes per two weeks decreased from 14.7 episodes during placebo therapy to 10.8 during nifedipine therapy (p less than 0.05). This response was more pronounced in patients without underlying vascular disease. Moderate or marked subjective improvement occurred in 60 percent of the patients receiving nifedipine and in only 13 percent of patients receiving placebo. Adverse effects were mild. It is concluded that nifedipine is an effective short-term therapy for most patients with Raynaud's phenomenon.

Hyperbaric oxygen in acute ischaemia due to allergic vasculitis.

A case of a child with allergic vasculitis to penicillin is presented. The patient received successful treatment with hyperbaric oxygen (HBO) therapy. The pathophysiological mechanism of acute peripheral anoxia and the infleunce of HBO treatment on it is described.

Modification of blood flow to the extremities by electrical stimulation of the nervous system.

Sixteen patients who had electrical stimulation applied to various portions of the nervous system were examined for increase in blood flow to the extremities. Clinical observations and a one-channel plethysmograph were used to measure arterial dilatation. Seven patients had transcutaneous stimulation applied over the cervical or thoracic spinal cord, peripheral nerves, or low lumbar region; eight had electrical stimulators implanted over the spinal cord in attempts to relieve intractable pain or some of the symptoms of multiple sclerosis; and one patient had electrical stimulators implanted over the C-6 dorsal roots for small artery disease of the upper extremities. Twelve of 13 patients who had electrical stimulation applied to the spinal cord or dorsal roots had significant arterial dilatation in one or more extremities. Electrical stimulation applied to the ulnar nerves did cause arterial dilatation. One patient did not show any change in the central arterial pressure curve during transcutaneous stimulation of the cervical spinal cord.