Swelling, Stiffness, and Dysfunction Following Proximal Interphalangeal Joint Sprains.

PURPOSE: Proximal interphalangeal (PIP) joint sprains are common injuries that often result in prolonged swelling, stiffness, and dysfunction; however, the duration of these sequelae is unknown. The purpose of this study was to determine the duration of time that patients experience finger swelling, stiffness, and dysfunction following a PIP joint sprain. METHODS: This was a prospective, longitudinal, survey-based study. To identify patients with PIP joint sprains, the electronic medical record was queried monthly using International Classification of Disease, Tenth Revision, codes for PIP joint sprain. A five-question survey was emailed monthly for 1 year or until their response indicated resolution of swelling, whichever occurred sooner. Two cohorts were established: patients with (resolution cohort) and patients without (no-resolution cohort) self-reported resolution of swelling of the involved finger within 1 year of a PIP joint sprain injury. The measured outcomes included self-reported resolution of swelling, self-reported limitations to range of motion, limitations to activities of daily living, Visual Analog Scale (VAS) pain score, and return to normalcy. RESULTS: Of 93 patients, 59 (63%) had complete resolution of swelling within 1 year of a PIP joint sprain. Of the patients in the resolution cohort, 42% reported return to subjective normalcy, with 47% having self-reported limitations in range of motion and 41% having limitations in activities of daily living. At the time of resolution of swelling, the average VAS pain score was 0.8 out of 10. In contrast, only 15% of patients in the no-resolution cohort reported return to subjective normalcy, with 82% having self-reported limitations in range of motion and 65% having limitations in activities of daily living. For this cohort, the average VAS pain score at 1 year was 2.6 out of 10. CONCLUSIONS: It is common for patients to experience a prolonged duration of swelling, stiffness, and dysfunction following PIP joint sprains. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Wide-Awake Surgery With Local Anesthesia and Epinephrine Is Safe.

Hand and upper extremity surgery performed with the patient wide awake involves the use of a local anesthetic and epinephrine. Controversy persists as to whether epinephrine is safe for use in the hand. The goal of this study was to evaluate the safety of epinephrine in hand and upper extremity surgery. The hypothesis was that epinephrine is safe and can be used for a wide breadth of surgical procedures of the hand and upper extremity. A 4-year retrospective chart review was conducted of consecutive patients undergoing wide-awake surgery performed by 2 surgeons at a single institution. All procedures were performed with local anesthesia and epinephrine. Data collected included patient demographics, procedure volume, procedure type, surgical setting, and complications related to epinephrine use. During the study period, 4054 consecutive patients underwent 4287 wide-awake procedures with local anesthesia and epinephrine. Average patient age was 59 years, and 64% of patients were female. No complications occurred as a result of the use of epinephrine, and no tissue necrosis, phentolamine reversal, anaphylaxis, or readmissions occurred. No patients required conversion to general anesthesia or monitored anesthesia care. This analysis of more than 4000 consecutive patients undergoing wide-awake hand and upper extremity surgery with epinephrine confirmed that epinephrine use is safe, with no reported cases of tissue necrosis, reversal, readmission, anaphylaxis, or anesthetic conversion. Epinephrine is safe for use in the hand and upper extremity for patients undergoing wide-awake hand surgery with a local anesthetic. [Orthopedics. 2020;43(6):e529-e532.].

Predictors of Septic Wrist: A Dual-Center 10-Year Review of Risk Factors.

Introduction Expeditious and accurate diagnosis of septic wrist arthritis is essential to prevent further cartilage damage, systemic infection, osteomyelitis, and loss of limb. There is limited literature on the incidence and clinical factors that are predictive of septic wrist arthritis. Objective We aimed to investigate the incidence of septic wrist arthritis and identify risk factors and laboratory values associated with septic wrist arthritis. Materials and Methods Data were collected on adult patients presenting with a painful, swollen wrist to two level 1 urban hospitals from 2004 to 2014. Demographics, comorbidities, and laboratory values of patients who had wrist aspiration were collected. Results There was an overall incidence of 0.4%. Increased synovial white blood cells (WBC), being febrile, positive blood cultures, and smoking were significantly associated with septic wrist arthritis on univariate analysis. Synovial WBC was also found to be significant on multivariate analysis. A synovial WBC of 87,750 cells/µL had an optimal sensitivity and specificity of 73% and 86%, respectively, for diagnosing septic wrist arthritis. Conclusion Synovial WBC can be a useful diagnostic tool for septic wrist arthritis. In addition, positive blood cultures, being febrile, and smoking history can help predict septic wrist arthritis in patients with presenting with painful, swollen wrists.

Initial Debridement of Dorsal Hand Abscesses in the Operating Room Does Not Improve Outcomes.

Background: Hand infections frequently involve the dorsal aspect of the hand and often develop secondary to some traumatic mechanism. Although Staphylococcus aureus is most commonly isolated, anaerobic and polymicrobial infections are not uncommon. To date, treatment is largely anecdotal, with some surgeons preferring a formal debridement in the operating room, while others opt for an initial debridement at the bedside. The goals of this study were to compare outcomes between treatment modalities and to identify the most common causative organisms. Methods: A 10-year retrospective chart review was conducted to identify adult patients who presented with a dorsal hand infection to a single, level 1, urban trauma center. Demographic data were collected as well as the abscess size, location, duration of symptoms, treatment administered, number of formal debridements, length of hospital stay, and complications. Results: The number of formal debridements was significantly less in the initial bedside debridement group (P < .01), as was the hospital length of stay (P < .01). There was no significant difference in hospital readmissions, complications, or infection due to methicillin-resistant Staphylococcus aureus. There was also no significant difference in abscess size, duration of symptoms, or demographic data including age, sex, comorbidities, intravenous drug use status, and immunocompromised status. Conclusions: An initial debridement of dorsal hand infections at the bedside is at least as effective as formal debridement in the operating room. This decreases number of formal debridements and days in the hospital, without any increase in complications. This permits safe, expeditious, and cost-effective treatment for this common condition.

Orthopaedic Physician Attire Influences Patient Perceptions in an Urban Inpatient Setting.

BACKGROUND: Prior research suggests that physician attire has an important effect on patient perceptions, and can influence the patient-physician relationship. Previous studies have established the effect of specialty, location, and setting on patient preferences for physician attire, and the importance of these preferences and perceptions on both the physician-patient relationship and first impressions. To date, no studies have examined the influence of attire in the inpatient orthopaedic surgery setting on these perceptions. QUESTIONS/PURPOSES: (1) Do differences in orthopaedic physician attire influence patient confidence in their surgeon, perception of trustworthiness, safety, how caring their physician is, how smart their surgeon is, how well the surgery would go, and how willing they are to discuss personal information with the surgeon? (2) Do patients perceive physicians who are men and women differently with respect to those endpoints? METHODS: Ninety-three of 110 patients undergoing orthopaedic surgery at an urban academic medical center participated in a three-part survey. In the first part, each patient was randomly presented 10 images of both men and women surgeons, each dressed in five different outfits: business attire (BA), a white coat over business attire (WB), scrubs alone (SA), a white coat over scrubs (WS), and casual attire (CA). Respondents rated each image on a five-point Likert scale regarding how confident, trustworthy, safe, caring, and smart the surgeon appeared, how well the surgery would go, and the patient's willingness to discuss personal information with the surgeon. In the second part, the respondent ranked all images, by gender, from the most to least confident based on attire. RESULTS: Pair-wise comparisons for women surgeons demonstrated no difference in patient preference between white coat over business attire compared with white coat over scrubs or scrubs alone, though each was preferable to business attire and casual attire (WS versus WB: mean difference [MD], 0.1 ± 0.6; 95% CI, 0.0-0.2; p = 1.0; WS versus SA: MD, 0.2 ± 0.7; 95% CI, 0-0.3; p = 0.7; WB versus SA: 0.1 ± 0.9; 95% CI, -0.1 to 0.2; p = 1.0). The same results were found when rating the surgeon's perceived intelligence, skill, trust, confidentiality, caring, and safety. In the pair-wise comparisons for male surgeons, white coat over scrubs was not preferred to white coat over business attire, scrubs alone, or business attire (WS versus WB: MD, -0.1 ± 0.6; 95% CI, 0-0.1; p = 1.0; WS versus SA: MD, 0 ± 0.4; 95% CI, -0.2 to 0; p = 1.0; WS versus BA: MD, 0.2 ± 0.8; 95% CI, 0-0.4; p = 0.6). WB and SA were not different (MD, 0.0 ± 0.6; 95% CI, -0.1 to 0.2; p = 1.0), though both were preferred to BA and CA (WB versus BA: MD, 0.3 ± 0.8; 95% CI, 0.1-0.5; p = 0.02; WB versus CA: 1.0 ± 1.0; 95% CI, 0.8-1.2; p < 0.01). We found no difference between SA and BA (MD, 0.3 ± 0.7; 95% CI, 0.1-0.4; p = 0.06). We found that each was preferred to CA (SA versus CA: 0.9 ± 1.0; 95% CI, 0.7-1.2; p < 0.01; BA versus CA: 0.7 ± 1.0; 95% CI, 0.5-0.9; p < 0.01), with similar results in all other categories. When asked to rank all types of attire, patients preferred WS or WB for both men and women surgeons, followed by SA, BA, and CA. CONCLUSIONS: Similar to findings in the outpatient orthopaedic setting, in the inpatient setting, we found patients had a moderate overall preference for physicians wearing a white coat, either over scrubs or business attire, and, to some extent, scrubs alone. Respondents did not show any difference in preference based on the gender of the pictured surgeon. For men and women orthopaedic surgeons in the urban inpatient setting, stereotypical physician's attire such as a white coat over either scrubs or business attire, or even scrubs alone may improve numerous components of the patient-physician relationship and should therefore be strongly considered to enhance overall patient care. LEVEL OF EVIDENCE: Level II, therapeutic study.

Orthopaedic Surgery Resident Financial Literacy: An Assessment of Knowledge in Debt, Investment, and Retirement Savings.

Most orthopedic residents carry significant debt and may enter their practice with little knowledge of business management, minimal retirement savings, and overall poor financial literacy. This study aimed to gauge financial literacy, debt, and retirement planning in United States orthopedic surgery residents. Willingness to participate in formalized financial education was also assessed. Eighty-five allopathic orthopedic surgery residents in the United States completed a 14-question anonymous online survey in 2016. The survey assessed demographic data, self-assessed financial knowledge, amount of credit card debt and loans, preparation for retirement, and willingness to participate in formal didactic education on these topics. Most respondents derive their financial knowledge from personal research (51%), whereas only 4 per cent have a formal curriculum. Despite most respondents reporting more than $200,000 in outstanding loans, only 31 per cent create and stick to a budget. Few programs offer retirement advice, and 48 per cent of respondents save $0 toward retirement. Eighty-five per cent of residents expressed interest in learning about personal investment, savings, and retirement planning. Orthopedic surgery residents carry significant debt and do not achieve their high-income potential until disproportionately later in life. Only 4 per cent of residents have formal training in investing, personal finance, or retirement despite a majority who desire such a curriculum. In fact, almost 75 per cent of those surveyed felt less prepared for retirement than their peers outside of medical training. This study suggests a role for formal financial education in the orthopedic curriculum to prepare residents for retirement, improve financial literacy, and enhance debt management.

Isolated Compression of the Ulnar Nerve Motor Branch: A Case Series With 3 Unique Etiologies.

BACKGROUND: Although ulnar neuropathies are commonly encountered, isolated involvement of the motor branch is exceedingly rare. Previous reports of this entity describe compression as the deep motor branch passes through the piso-hamate hiatus and the adductor pollicis hiatus. This case series described 3 cases of motor branch compression due to unique etiologies which resolved after surgery. METHODS: A retrospective chart review identified patients with compression of the ulnar nerve motor branch. From these patients, 3 were selected with a unique etiology for compression. Patient demographics, objective and subjective findings, and pathology identified during surgery were recorded and analyzed. RESULTS: Eight patients had compression of the ulnar nerve motor branch and 3 unique etiologies were selected; an intraneural ganglion, a constricting leash of vessels, and a series of compressing fibrous bands. All required surgery, and each patient had full resolution of symptoms by 1 year postoperatively. DISCUSSION: Patients presenting with complaints of weakness with a positive Froment and Egawa signs but a negative Wartenberg sign and no sensory complaints can be a diagnostic dilemma. Compression of the ulnar nerve motor branch must be considered, and here we present 3 unique cases. Activity modification in those presenting early may be curative, although many ultimately require surgery. In the cases presented here, all patients experienced full resolution of their symptoms by 1 year after surgery.

Septic Arthritis of the Wrist.

Septic arthritis of the wrist is an uncommon condition, but one that can result in substantial morbidity. Timely identification and treatment is critical to patient care. No serum laboratory values have been shown to consistently confirm wrist joint infection. Thus, diagnosis is made based mainly on a thorough patient history, physical examination, and joint aspiration. When infection is suspected, aspiration of the wrist should be performed to confirm the diagnosis. Broad-spectrum antibiotics and joint aspiration or surgery are required to manage the infection and prevent sequelae.

Septic Arthritis of the Wrist: Incidence, Risk Factors, and Predictors of Infection.

Septic arthritis of the wrist can result in permanent damage to the joint, making timely diagnosis crucial to initiate empiric antibiotics and surgical intervention. Although septic arthritis is routinely included in the differential diagnosis of atraumatic wrist pain, the incidence is unknown. Unlike large joints, there is no consensus on cell count values considered pathognomonic for wrist septic arthritis. The goal of this retrospective study was to determine the incidence of wrist septic arthritis and to identify the clinical, serum, and joint fluid values that predict infection. The records of patients who presented to a single urban hospital with a swollen, painful wrist without trauma during a 10-year period were reviewed. For patients who had a joint fluid analysis, the records were examined for history as well as demographic and laboratory data. Joint fluid analysis consisted of cell count, Gram stain, and cultures. Of 892 patients who met the inclusion criteria, 1.5% had wrist septic arthritis. Variables associated with septic arthritis included serum white blood cell count above 11,000/µL, core temperature above 100.4°F within 24 hours of aspiration, history of intravenous drug abuse, and smoking. No joint cell count analysis predicted septic arthritis, although patients with septic wrists had an elevated joint white blood cell count above 97,000/µL. Wrist septic arthritis is uncommon; however, objective factors can help identify patients at risk. Because joint cell count analysis cannot reliably predict a septic wrist, priority for joint aspirations with limited fluid should be given instead to Gram stain, culture, and crystal analysis. [Orthopedics. 2017; 40(3):e526-e531.].

Triplanar Humeral Osteotomy for Restoration of Midline Function in Patients With Brachial Plexus Birth Palsy.

Brachial plexus birth palsy resolves spontaneously in a majority of patients, however, others may have serious permanent dysfunction. Although nerve transfers or grafts are early options for treatment, many children have residual deficits or present too late for such procedures. In these patients, rotational osteotomy of the humerus may restore improved function and motion. Unfortunately, traditional humeral osteotomies only provide correction in a single plane, therefore appropriate correction of the typical residual deformity is incomplete. Here, we describe a novel technique for obtaining a calculated correction in 3 planes using a single osteotomy of the humerus on the basis of a mathematical equation. Nine patients are described here with an average of 35.4 months follow-up. Corrections were obtained in adduction, extension, and either internal or external rotation depending on the initial deformity and Modified Mallet scores were collected for each patient. There was 1 case of transient radial nerve palsy with no long-term complications overall.

Physicians' Attire Influences Patients' Perceptions in the Urban Outpatient Orthopaedic Surgery Setting.

BACKGROUND: Previous work has established that physician attire influences patients' perceptions of their physicians. However, research from different specialties has disagreed regarding what kinds of physician attire might result in increased trust and confidence on the part of patients. QUESTIONS/PURPOSES: The purpose of this study was to investigate how surgeon attire affects patients' perceptions of trust and confidence in an urban orthopaedic outpatient setting. METHODS: Eighty-five of 100 patients solicited completed a three-part questionnaire in the outpatient orthopaedic clinic at an urban teaching hospital. In the first section, participants viewed eight images, four of a male surgeon and four of a female surgeon wearing a white coat over formal attire, scrubs, business attire, and casual attire, and rated each image on a five-level Likert scale. Participants were asked how confident, trustworthy, safe, caring, and smart the surgeon appeared, how well the surgery would go, and how willing they would be to discuss personal information with the pictured surgeon. The participant ranked all images from most to least confident in the second part and the last section obtained demographic information from the patients. Surveys were scored using a five-level Likert scale and a Friedman test was used to detect statistical significance when comparing all attires. For multiple pairwise comparisons, a Bonferroni correction was applied. RESULTS: The white coat on the male surgeon elicited modestly higher ratings in confidence (mean difference [MD], 0.367 ± 0.737; 95% CI, 0.202-0.532; p < 0.001), intelligence (MD, 0.216 ± 0.603; 95% CI, 0.077-0.356; p = 0.027), surgical skill (MD, 0.325 ± 0.658; 95% CI, 0.175-0.474; p < 0.001), trust (MD, 0.312 ± 0.613; 95% CI, 0.173-0.451; p < 0.001), ability to discuss confidential information (MD, 0.253 ± 0.742; 95% CI, 0.087-0.419; p = 0.023), caring (MD, 0.279 ± 0.655; 95% CI, 0.124-0.432; p = 0.006), and safety (MD, 0.260 ± 0.594; 95% CI, 0.125-0.395; p = 0.002) compared with business attire. Similarly, the white coat was preferred to casual attire in all categories (confidence: MD, 0.810 ± 0.921; smart: MD, 0.493 ± 0.801; surgical skill: MD, 0.640 ± 0.880; ability to discuss: MD, 0.564 ± 0.988; trust: MD, 0.545 ± 0.836; safety: MD, 0.581 ± 0.860; caring: MD, 0.479 ± 0.852; p < 0.001 for all comparisons). For the female surgeon, white coat and scrubs were not different, however the white coat was preferred to business attire in four of seven categories. Casual clothing was widely disliked in all categories for surgeons (men and women). When attire was compared for confidence on a scale, the white coat ranked higher than business (MD, 0.439 ± 1.491; p = 0.006) and casual attire (MD, 1.043 ± 2.054; p < 0.001), but not scrubs (MD, 0.169 ± 1.230; p = 1.000). CONCLUSIONS: In this urban outpatient orthopaedic practice, patients' preferences varied based on the sex of the pictured surgeon in the survey. Overall, however, modest preferences were observed for the white coat in terms of confidence, intelligence, trust, and safety. Furthermore patients are more willing to discuss personal information and believe that their surgery will go better if the surgeon wears a white coat or scrubs. These results are consistent with those of several studies in other settings and therefore may be generalizable in other locations and specialties. Given the increasing awareness and concern for physician-spread hospital infection, this study lends support to scrub attire over business or casual attire if physicians do not wear a white coat. LEVEL OF EVIDENCE: Level II, therapeutic study.

Management of Adult Elbow Fracture Dislocations.

Elbow fracture dislocations are complicated injuries that are difficult to manage and fraught with complications. A complete series of radiographs is typically complemented with CT scan to evaluate the elbow and assist preoperative planning. Typically, operative intervention is necessary and a systematic approach to the elbow injuries should be chosen. This article addresses the coronoid and proceeds to the radial head, lateral soft tissues, and finally the medial ligaments if elbow instability persists. With a focused, systematic surgical approach, improved outcomes have been demonstrated and patients may recover full function and range of motion in the affected elbow.

Application of Tranexamic Acid in Trauma and Orthopedic Surgery.

Tranexamic acid has gained recent interest in orthopedics and trauma surgery because of its demonstrated benefit in several clinical trials. It is inexpensive and effective at reducing blood loss and blood transfusion requirements without a significant increase in morbidity or mortality. The optimal timing, dosing, and route of administration in orthopedics are yet to be elucidated. Significant investigation of tranexamic acid use in joint replacement and spine surgery has promoted its incorporation into the everyday practice of many of these surgeons. The paucity of studies regarding its use in orthopedic trauma has limited its integration into a field that may stand to benefit most from the drug.

Intraoperative Fluoroscopy Improves Component Position During Anterior Hip Arthroplasty.

The goal of this retrospective review was to determine whether fluoroscopic guidance improves acetabular cup abduction and anteversion alignment during anterior total hip arthroplasty. The authors retrospectively reviewed 199 patients (fluoroscopy group, 98; nonfluoroscopy group, 101) who underwent anterior total hip arthroplasty at a single center with and without C-arm fluoroscopy guidance. Included in the study were patients of any age who underwent primary anterior approach total hip arthroplasty performed by a single surgeon, with 6-month postoperative anteroposterior pelvis radiographs. Acetabular cup abduction and anteversion angles were measured and compared between groups. Mean acetabular cup abduction and anteversion angles were 43.4° (range, 26.0°-57.4°) and 23.1° (range, 17°-28°), respectively, in the fluoroscopy group. Mean abduction and anteversion angles were 45.9° (range, 29.7°-61.3°) and 23.1° (range, 17°-28°), respectively, after anterior total hip arthroplasty without the use of C-arm guidance (nonfluoroscopy group). The use of fluoroscopy was associated with a statistically significant difference in cup abduction (P=.002) but no statistically significant difference in anteversion angles. In the fluoroscopy group, 80% of implants were within the combined safe zone compared with 63% in the nonfluoroscopy group. A significantly higher percentage of both acetabular cup abduction angles and combined anteversion and abduction angles were in the safe zone in the fluoroscopy group. Fluoroscopy is not required for proper anteversion placement of acetabular components, but it may increase ideal safe zone placement of components.

Systemic low-dose aspirin and clopidogrel independently attenuate reflex cutaneous vasodilation in middle-aged humans.

Chronic systemic platelet cyclooxygenase (COX) inhibition with low-dose aspirin [acetylsalicylic acid (ASA)] significantly attenuates reflex cutaneous vasodilation in middle-aged humans, whereas acute, localized, nonisoform-specific inhibition of vascular COX with intradermal administration of ketorolac does not alter skin blood flow during hyperthermia. Taken together, these data suggest that platelets may be involved in reflex cutaneous vasodilation, and this response is inhibited with systemic pharmacological platelet inhibition. We hypothesized that, similar to ASA, specific platelet ADP receptor inhibition with clopidogrel would attenuate reflex vasodilation in middle-aged skin. In a double-blind crossover design, 10 subjects (53+/-2 yr) were instrumented with four microdialysis fibers for localized drug administration and heated to increase body core temperature [oral temperature (Tor)] 1 degrees C during no systemic drug (ND), and after 7 days of systemic ASA (81 mg) and clopidogrel (75 mg) treatment. Skin blood flow (SkBF) was measured using laser-Doppler flowmetry over each site assigned as 1) control, 2) nitric oxide synthase inhibited (NOS-I; 10 mM NG-nitro-L-arginine methyl ester), 3) COX inhibited (COX-I; 10 mM ketorolac), and 4) NOS-I+COX-I. Data were normalized and presented as a percentage of maximal cutaneous vascular conductance (%CVCmax; 28 mM sodium nitroprusside+local heating to 43 degrees C). During ND conditions, SkBF with change (Delta) in Tor=1.0 degrees C was 56+/-3% CVCmax. Systemic low-dose ASA and clopidogrel both attenuated reflex vasodilation (ASA: 43+/-3; clopidogrel: 32+/-3% CVCmax; both P<0.001). In all trials, localized COX-I did not alter SkBF during significant hyperthermia (ND: 56+/-7; ASA: 43+/-5; clopidogrel: 35+/-5% CVCmax; all P>0.05). NOS-I attenuated vasodilation in ND and ASA (ND: 28+/-6; ASA: 25+/-4% CVCmax; both P<0.001), but not with clopidogrel (27+/-4% CVCmax; P>0.05). NOS-I+COX-I was not different compared with NOS-I alone in either systemic treatment condition. Both systemic ASA and clopidogrel reduced the time required to increase Tor 1 degrees C (ND: 58+/-3 vs. ASA: 45+/-2; clopidogrel: 39+/-2 min; both P<0.001). ASA-induced COX and specific platelet ADP receptor inhibition attenuate reflex vasodilation, suggesting platelet involvement in reflex vasodilation through the release of vasodilating factors.

Reflex vasoconstriction in aged human skin increasingly relies on Rho kinase-dependent mechanisms during whole body cooling.

Primary human aging may be associated with augmented Rho kinase (ROCK)-mediated contraction of vascular smooth muscle and ROCK-mediated inhibition of nitric oxide synthase (NOS). We hypothesized that the contribution of ROCK to reflex vasoconstriction (VC) is greater in aged skin. Cutaneous VC was elicited by 1) whole body cooling [mean skin temperature (T(sk)) = 30.5 degrees C] and 2) local norepinephrine (NE) infusion (1 x 10(-6) M). Four microdialysis fibers were placed in the forearm skin of eight young (Y) and eight older (O) subjects for infusion of 1) Ringer solution (control), 2) 3 mM fasudil (ROCK inhibition), 3) 20 mM N(G)-nitro-l-arginine methyl ester (NOS inhibition), and 4) both ROCK + NOS inhibitors. Red cell flux was measured by laser-Doppler flowmetry over each site. Cutaneous vascular conductance (CVC) was calculated as flux/mean arterial pressure and normalized to baseline CVC (%DeltaCVC(baseline)). VC was reduced at the control site in O during cooling (Y, -34 + or - 3; and O, -18 + or - 3%DeltaCVC(baseline); P < 0.001) and NE infusion (Y, -53 + or - 4, and O, -41 + or - 9%DeltaCVC(baseline); P = 0.006). Fasudil attenuated VC in both age groups during mild cooling; however, this reduction remained only in O but not in Y skin during moderate cooling (Y, -30 + or - 5; and O, -7 + or - 1%DeltaCVC(baseline); P = 0.016) and was not altered by NOS inhibition. Fasudil blunted NE-mediated VC in both age groups (Y, -23 + or - 4; and O, -7 + or - 3%DeltaCVC(baseline); P < 0.01). Cumulatively, these data indicate that reflex VC is more reliant on ROCK in aged skin such that approximately half of the total VC response to whole body cooling is ROCK dependent.

Ketorolac alters blood flow during normothermia but not during hyperthermia in middle-aged human skin.

In young healthy humans full expression of reflex cutaneous vasodilation is dependent on cyclooxygenase (COX)- and nitric oxide synthase (NOS)-dependent mechanisms. Chronic low-dose aspirin therapy attenuates reflex cutaneous vasodilation potentially through both platelet and vascular COX-dependent mechanisms. We hypothesized the contribution of COX-dependent vasodilators to reflex cutaneous vasodilation during localized acute COX inhibition would be attenuated in healthy middle-aged humans due to a shift toward COX-dependent vasoconstrictors. Four microdialysis fibers were placed in forearm skin of 13 middle-aged (53 +/- 2 yr) normotensive healthy humans, serving as control (Ringer), COX-inhibited (10 mM ketorolac), NOS-inhibited (10 mM N(G)-nitro-l-arginine methyl ester), and combined NOS- and COX-inhibited sites. Red blood cell flux was measured over each site by laser-Doppler flowmetry as reflex vasodilation was induced by increasing oral temperature (T(or)) 1.0 degrees C using a water-perfused suit. Cutaneous vascular conductance was calculated (CVC = flux/mean arterial pressure) and normalized to maximal CVC (CVC(max); 28 mM sodium nitroprusside). CVC(max) was not affected by localized microdialysis drug treatment (P > 0.05). Localized COX inhibition increased baseline (18 +/- 3%CVC(max); P < 0.001) compared with control (9 +/- 1%CVC(max)), NOS-inhibited (7 +/- 1%CVC(max)), and combined sites (10 +/- 1%CVC(max)). %CVC(max) in the COX-inhibited site remained greater than the control site with DeltaT(or) < or = 0.3 degrees C; however, there was no difference between these sites with DeltaT(or) > or = 0.4 degrees C. NOS inhibition and combined COX and NOS inhibition attenuated reflex vasodilation compared with control (P < 0.001), but there was no difference between these sites. Localized COX inhibition with ketorolac significantly augments baseline CVC but does not alter the subsequent skin blood flow response to hyperthermia, suggesting a limited role for COX-derived vasodilator prostanoids in reflex cutaneous vasodilation and a shift toward COX-derived vasoconstrictors in middle-aged human skin.