Martha Holden

Arterial reconstruction in the ischemic hand and wrist: Effects on microvascular physiology and health-related quality of life

Patients were evaluated before and after arterial reconstruction surgery (1) to define the physiology of the digital microcirculation in chronic subcritical ischemia, (2) to demonstrate the short-term effects of successful arterial reconstruction on microvascular flow, and (3) to document the effects of surgery on symptoms, function, and health-related quality of life. Arterial insufficiency was the result of a proximal reconstructible occlusive lesion, 1 or more distal unreconstructible occlusions, and secondary reactive vasospasm. Microvascular physiology was evaluated by monitoring digital temperatures, microvascular perfusion (laser Doppler fluxmetry) and perfusion patterns (laser Doppler perfusion patterns (laser Doppler perfusion imaging). Following successful vascular reconstruction, digital temperatures and microvascular perfusion improved significantly, approaching control levels. Although cold sensitivity was unchanged, symptoms decreased and upper extremity function and health-related quality of life improved after successful proximal reconstruction in patients with 2-level arterial occlusion.

Measurement of hand microvascular blood flow with isolated cold stress testing and laser Doppler fluxmetry

Isolated cold stress testing applies cold thermal stress to an extremity for noninvasive study of skin surface temperature as an index of digital microcirculation. In this study, laser Doppler fluxmetry was combined with isolated cold stress testing to examine the relationship between digital thermoregulation (measured by isolated cold stress testing) and digital microcirculatory blood flow (measured by laser Doppler fluxmetry) in 50 healthy men and women. After a 5-minute baseline period, both hands were subjected to cold stress (average, 8 degrees C) for 20 minutes and then returned to room temperature for 20 minutes. Digital temperatures and laser Doppler measurements were graphed to document individual responses. The 25 women had lower digital temperatures, lower laser Doppler fluxmetry values, and less average rewarming than the 25 men. Statistical cluster analysis revealed a cold pattern, found predominantly in women, and a warm pattern, found predominantly in men. These patterns of response may help to elucidate the pathogenesis of the vascular occlusive syndromes occurring predominantly in women.

Building a clinical research network in trauma orthopaedics: The major extremity trauma research consortium (METRC)

Objectives: Lessons learned from battle have been fundamental to advancing the care of injuries that occur in civilian life. Equally important is the need to further refine these advances in civilian practice, so they are available during future conflicts. The Major Extremity Trauma Research Consortium (METRC) was established to address these needs. Methods: METRC is a network of 22 core level I civilian trauma centers and 4 core military treatment centers—with the ability to expand patient recruitment to more than 30 additional satellite trauma centers for the purpose of conducting multicenter research studies relevant to the treatment and outcomes of orthopaedic trauma sustained in the military. Early measures of success of the Consortium pertain to building of an infrastructure to support the network, managing the regulatory process, and enrolling and following patients in multiple studies. Results: METRC has been successful in maintaining the engagement of several leading, high volume, level I trauma centers that form the core of METRC; together they operatively manage 15,432 major fractures annually. METRC is currently funded to conduct 18 prospective studies that address 6 priority areas. The design and implementation of these studies are managed through a single coordinating center. As of December 1, 2015, a total of 4560 participants have been enrolled. Conclusions: Success of METRC to date confirms the potential for civilian and military trauma centers to collaborate on critical research issues and leverage the strength that comes from engaging patients and providers from across multiple centers.

Anatomic and physiologic evaluation of upper extremity ischemia.

This study assessed the accuracy of arteriography and laser Doppler perfusion imaging (LDPI) as predictors of digital ischemia and correlated upper extremity symptoms, function, and nutritional flow with arteriographic and laser Doppler assessments. Multiple‐level occlusive disease was documented in 25 hands (23 patients) by arteriography. LDPI demonstrated one or more hypoperfused digits in 17 hands. Patient questionnaires were used to assess upper extremity symptoms, pain, cold sensitivity, and function. Spearman correlation coefficients indicated that arteriography is a poor indicator of nutritional perfusion as measured by LDPI. Neither arteriography or laser Doppler perfusion imaging served as an indicator of the severity of cold intolerance. However, upper extremity symptoms and functional status correlated with both laser Doppler measurements and the level of cold sensitivity. Laser Doppler perfusion imaging and arteriographic analysis provide complimentary data in the evaluation of upper extremity ischemia.

Periarterial Sympathectomy of the Foot for the Treatment of Necrotizing Raynaud's Phenomena

Patients with critical peripheral vascular disease and nonhealing toe ulcers secondary to collagen vascular disease often require toe amputation when nonsurgical measures fail to control their symptoms. The aim of this study was to evaluate the effectiveness of periarterial sympathectomy (PAS) of the foot/ankle in patients with unreconstructable vaso-occlusive disease and nonhealing digit ulcers unresponsive to nonsurgical measures. Five patients (seven feet and nine toe ulcers) were treated with PAS of their involved foot and followed for a minimal of 3 years (3 to 7 years). The technique included PAS of the dorsalis pedis, posterior tibial and anterior tibial arteries. Eight toe ulcers healed uneventfully within 3 months after surgery. Only one patient developed a new ulcer 5 years after PAS. The mean visual analog pain scale improved from 5.7 to 1 (P<0.03). The mean Wake Forest University (WFU) scale improved from 1.8 to 0.5 (P=0.07). There was no change in the WFU numbness score or the McCabe Cold sensitivity scale. The results suggest that foot/ankle PAS is a beneficial salvage treatment option for patients with non-reconstructable, vaso-occlusive disease that ameliorates foot symptoms, facilitates healing of toe ulcerations, and reduces the incidence of toe amputations.

Waveform analysis of laser Doppler signals from normal and diabetic feet

Cutaneous perfusion of the feet of normal volunteers and diabetic patients were measured by laser Doppler fluxmetry. A test paradigm was followed in which the feet were studied at room temperature, during cooling, and during rewarming after cooling. The data files were analyzed using sequential Fourier techniques on serial 20 second segments. Contour plots were generated from the resulting 120 Fourier spectra and compared between the diabetic patients and the normal volunteers. The use of contour plots was found to be helpful in differentiating the diabetic from normal foot plots during this type of stress testing. Significant portions of the power spectra were found in the low frequencies (0.1-0.2 Hz) but there was also a strong component corresponding to the cardiac cycle with at least one harmonic of that cycle observed at two times the heart rate. Diabetic patients exhibited reductions in cutaneous perfusion with cooling in both the low frequency and heart rate frequencies. Sequential spectral analyses arranged in contour plots provide significant information about cutaneous perfusion using laser Doppler fluxmetry and prove useful in evaluating other pathologies characterized by cutaneous perfusion abnormalities.<<ETX>>