Toe Pressure Measurements in Patients Suspected of Critical Limb Ischemia

An objective hemodynamic assessment is mandatory to confirm Critical Limb Ischemia (CLI). Toe pressure measurement is recommended. We compared toe measurements obtained using the Laser Doppler method (LD) (PERIMED PeriFlux, Sweden) considered as the reference test, with those obtained with a portable device using photoplethysmography (PPG) (Sys Toe Atys Medical, France). A total of 93 (123 legs) patients from 3 French hospitals with a clinical suspicion of CLI were included and had measurements with each device carried out by skilled operators. PPG was unable to provide a measurement in 10 patients. Lin’s Coefficient correlation concordance (CCC) and Bland and Altman’s scatter plot were analyzed for the 83 remaining patients, CCC was .84 95%CI (.77–.89). For detection of CLI, Cohen’s kappa was .67 95%CI (.53–.81). The PPG device is fairly reliable for toe pressure measurement in patients suspected of CLI and could be useful when LD is not available. However, it fails to deliver a measurement in approximately 10% of cases. No conclusion should be made about CLI for these patients when no measurement is obtainable and other methods should be used (LD, transcutaneous oxygen pressure) to assess perfusion of the limbs.

Microcirculation and tissue oxygenation in the head and limbs during hyperbaric oxygen treatment

Introduction: Hyperbaric oxygen (HBO) exposure for 10−15 min has been shown to reduce peripheral blood flow due to vasoconstriction. However, the relationship between decreased peripheral blood flow and the therapeutic effects of HBO treatment on peripheral circulatory disorders remain unknown. Longer exposures have been reported to have vasodilatory effects and increase peripheral blood flow. This study investigated the effect of HBO treatment on blood flow and transcutaneous oxygen pressure (TcPO2). Methods: Twenty healthy volunteers aged 20-65 years (nine males) participated in this study. All participants breathed oxygen for 60 min at 253.3 kPa. Peripheral blood flow using laser Doppler flowmetry and TcPO2 on the ear, hand, and foot were continuously measured from pre-HBO exposure to 10 min post-exposure. Results: Peripheral blood flow in each body part decreased by 7-23% at the beginning of the HBO exposure, followed by a slow increase. Post-exposure, peripheral blood flow increased 4-76% in each body part. TcPO2 increased by 840-1,513% during the exposure period, and remained elevated for at least 10 min after the exposure. Conclusions: The findings of the current study suggest vasoconstriction during HBO treatment is transient, and even when present does not inhibit the development of increased tissue oxygen partial pressure. These findings are relevant to studies investigating changes in peripheral blood flow during HBO treatment in patients with circulatory disorders.

Long-term results of proximal and distal reconstructions in patients with lower limb arteries diffuse lesions and diabetes mellitus

Relevance . Treatment of diffuse lesions of the arteries of the lower extremities is often reduced to primary amputation at the hip level, since the healing of trophic ulcers is not guaranteed during arterial reconstruction. Profundoplasty without distal bypass surgery can be considered an alternative method. The aim of this study is to compare the long-term results of distal shunting and isolated profundoplasty in patients with diffuse lesions of the lower limb arteries and trophic ischemic ulcers. Materials and Methods . The study included 86 patients with diffuse lesions of the lower limb arteries. There were 52 (60.4%) men and 34 (39.6%) women. The average age was 67.3 16.8 years. All patients had diffuse lesions of the arteries below the pupar ligament, the state of the lower leg arteries was 5-8.5 points on the Rutherford scale, in all cases there were trophic ulcers. Group 1 included 48 patients who underwent reconstruction of the leg arteries. Group 2 consisted of 38 individuals who had limited intervention with endarcteriotomy from common femoral and deep femoral arteries. Results and Discussion . Amputations at the hip level were performed within a year in 11 (23.4%) patients of group 1 and in 3 (6.3%) patients within 30 days after surgery. Thus, 14 (29.7%) patients lost their limbs. A comparative analysis revealed that the group of patients with amputations had a more severe form of diabetes (p = 0.003), an outflow score on the Rutherford scale (p 0.001), and lower transcutaneous oxygen tension values before and after surgery. Within 12 months after the bypass surgery, the primary patency of the shunts was 65.9% (thrombosis occurred in 16 patients). Conclusion . The preservation of the limb in patients in our study by the end of 1 year after reconstruction is similar regardless of the reconstruction method. Given the minimal invasion during profundoplasty, this operation may be the method of choice for diffuse lesions of the arteries of the lower extremities.

The Outcomes of Patients Incidentally Confirmed with Covid-19 After Cardiac Surgery

Background: The aim of this study was to investigate the clinical outcomes of cardiac surgery in patients who were incidentally diagnosed with Covid-19 in the postoperative period. Patients and methods: We performed 826 open cardiac surgeries in five tertiary centers. Most of the surgeries were elective coronary artery bypass grafting (CABG) (93.8%). A preoperative RT-PCR test and transcutaneous oxygen saturation were routinely investigated prior to surgery. We also investigated whether the patients already received Covid-19 treatment or had any contact with a Covid-19 patient in the last two weeks. We analyzed high sensitive C-reactive protein (hs-CRP), d-dimer, and fibrinogen, which plays a main role in the activation of procoagulant state after surgeries. Results: Acute lung injury related to Covid-19 activation was observed in 48 out of 826 patients (5.8%). The median age of 48 patients was 63.9±12.4 years. Euro-Score and body mass index (BMI) were 6.1±1.1 and 29.2±4.1kg/m², respectively. RT-PCR test results were positive in 29 patients (60.4%). We performed thoracic computed tomography (CT) in all patients with or without positive RT-PCR test results. Thoracic CT images showed that there was a different degree of ARDS (mild, moderate, and serious). The median time of extracorporeal circulation (ECC) was 93.2±14.6 min. in on-pump surgery (IQR, 68-155 min.). Common symptoms included dyspnea (N = 22; 45.8%) and fever (N = 12; 25%). Eleven patients needed readmission to ICU. Compared with non-admitted to ICU patients, ICU patients were higher comorbidities and severe laboratory abnormalities (eg, high blood d-dimer and fibrinogen). We also detected significantly low oxygen saturation, hypercapnia, and severe acidosis in readmitted patients. Radiologic investigations showed that there were severe ARDS with bilateral pneumonic infiltration resistant to medical treatment in 6 out of 11 patients who died (54.5%). Conclusion: Diffuse pneumonic infiltration related to Covid-19 may develop in asymptomatic cardiac surgery patients with negative RT-PCR test results. Immunologic disorders resulting from ECC, physiologic distress, and anesthesia may activate Covid-19 during the incubation period. We need randomized clinical trials to explain Covid-19 activation in the latent period of the virus, and clinical outcomes in cardiac surgery.

An Observational Clinical Trial Examining the Effect of Topical Oxygen Therapy (Natrox™) on the Rates of Healing of Chronic DiAbetic Foot Ulcers (OTONAL Trial)

Natrox™ topical oxygen therapy (TOT) ( Inotec AMD Ltd, Hertfordshire, UK) employs a small battery-powered “oxygen generator” to concentrate atmospheric oxygen and feeds pure, moist, oxygen through a fine, soft tube to a dressing-like “oxygen distribution system”, which is placed over the wound and is held in place by a conventional dressing. The aim was to determine the effectiveness of Natrox™ for non-healing diabetic foot ulcers (DFU) over a 3-month period.Longitudinal, single-arm, open prospective registry study using 12 weeks of TOT using a 4 week run-in period. 20 patients recruited to OTONAL had chronic DFU greater than 3 months duration or minor amputation sites with less than 50% healing in 4 weeks.There were 13 (65%) males and the mean age was 65.7 (±11.6) years. The mean glycated haemoglobin (HbA1c) was 6.9 (±1.3) mmol mol−1 and mean wound duration before TOT was 114 (±79.1) days. 18/20 (90.0%) patients had concomitant lower limb revascularization angioplasty for chronic limb threatening ischaemia. The mean size of the foot ulcer at baseline was 11.3 ± 14.8 cm2 and mean transcutaneous oxygen measurement value was 34.1 (±19.6) mm Hg. Wound closure of >75% was observed in 14/20 (70.0%) patients. There was a 91.3% (±14.9%) wound area reduction by 3 months (P = .001) and mean time for 100% closure was 77.6 ± 32.5 days. Mean pain scores reduced from 2.4 (±1.8) at baseline to .5 (±1.0) at 3 months (P = .008). All patients were very satisfied using the ambulatory device. Use of TOT in chronic diabetic foot wounds stimulates a healing state, underpinning the concept that oxygen plays a central role in wound healing. Our results are more compelling if you consider they started with relatively large-sized DFUs and majority of patients were frail with underlying peripheral artery disease. (NCT03863054)

Incidence and Risk Factors of Diabetic Foot Syndrome in Patients Early After Pancreas or Kidney/Pancreas Transplantation and its Association with Preventive Measures

Diabetic foot (DF) can develop in diabetic patients after organ transplantation (Tx) due to several factors including peripheral arterial disease (PAD), diabetic neuropathy and inappropriate DF prevention. Aim: To assess the occurrence of DF and associated risk factors in transplant patients. Methods: Fifty-seven diabetic patients were enrolled as part of this prospective study. All patients underwent organ Tx (01/2013-12/2015) and were followed up for minimum of 12 months up to a maximum of 50 months. Over the study period we evaluated DF incidence and identified a number of factors likely to influence DF development, including organ function, presence of late complications, PAD, history of DF, levels of physical activity before and after Tx, patient education and standards of DF prevention. Results: Active DF developed in 31.6% (18/57) of patients after organ Tx within 11 months on average (10.7 ± 8 months). The following factors significantly correlated with DF development: diabetes control (p = .0065), PAD (p<0.0001), transcutaneous oxygen pressure (TcPO2;p = .01), history of DF (p = .0031), deformities (p = .0021) and increased leisure-time physical activity (LTPA) before Tx (p = .037). However, based on logistic stepwise regression analysis, the only factors significantly associated with DF during the post-transplant period were: PAD, deformities and increased LTPA. Education was provided to patients periodically (2.6 ± 2.5 times) during the observation period. Although 94.7% of patients regularly inspected their feet (4.5 ± 2.9 times/week), only 26.3% of transplant patients used appropriate footwear. Conclusions: Incidence of DF was relatively high, affecting almost 1/3 of pancreas and kidney/pancreas recipients. The predominant risk factors were: presence of PAD, foot deformities and higher LTPA before Tx. Therefore, we recommend a programme involving more detailed vascular and physical examinations and more intensive education focusing on physical activity and DF prevention in at-risk patients before transplantation.

Efficacy of eutectic mixture of local anesthetics in alleviating pain associated with lumbar puncture in newborns: a placebo compared randomized controlled trial

Background: Lumbar puncture (LP) is one of the most commonly encountered painful procedure in paediatric medicine. Research has shown that neonates too experience pain from noxious stimuli that can be more intense than what is experienced by an adult, and so have the right to receive safe, efficient and effective pain management. Objective was to determine efficacy of topical eutectic mixture of local anesthetics (EMLA) in alleviating pain associated with lumbar puncture among newborns admitted to sick newborn care unit (SNCU).Methods: The study was a one-year tertiary care teaching hospital-based randomised comparative double blinded trial among 42 neonates aged 32 weeks or more admitted to SNCU and required a diagnostic lumbar puncture, randomly assigned to one of two groups. Half hour before the procedure, 1 g of topical EMLA cream was applied to LP site in intervention group versus placebo in other group. At different stages, the heart rate, transcutaneous oxygen saturation level, and total behaviour score were captured on a video camera and rated using the neonatal facial coding system.Results: EMLA dramatically lowers pain sensitivity when compared to placebo. Total behavioural score means±standard deviation (SD) at the moment of needle insertion (EMLA: 1.05±1.24; placebo: 2.71±1.76, p≤0.001) and post procedural 5 minute later was (EMLA: 0.05±0.22; placebo: 0.81±0.92, p≤0.01). Similarly, oxygen saturation level when needle was in spinal place (EMLA: 96.76±2.45; placebo: 94.29±3.62, p=0.01) and post procedural 1 hour later was (EMLA: 98.81±1.94; placebo: 97.48±2.18, p=0.04). The heart rate of all newborns in both groups was greater than it was at baseline, although the difference was not significant.Conclusions: EMLA is an effective agent in reducing pain associated with LP among newborns.

Clinical Efficacy and Safety of Long-Term Compression in Patients with Mixed Arterial and Venous Etiology Ulcers in the Leg

Elastic compressions are standard treatment for leg ulcers of venous etiology. The effect of compressions on ulcers of mixed (arterial or venous) etiology, however, has rarely been studied. The objective of this study was to evaluate the variation in transcutaneous oxygen pressure (TcPO2) in patients with ulcers of mixed arterial or venous etiology treated with 1 month of compression. This prospective cohort study was conducted at a university hospital in France. Patient eligibility was for those attending a consultation of a work-up of a leg ulcer of mixed arterial-venous etiology lasting at least 4 to 6 weeks. Compressions were prescribed according to the hemodynamic status and were evaluated by the ankle-brachial index and toe-brachial index using a decision-making algorithm based on French national guidelines. Quality of life was assessed using the Short-Form 36-Item (SF-36) questionnaire. In total, 32 patients were included between September 30, 2018 and May 31, 2019. A difference was observed between TcPO2 before compression (49.3 ± 13.01 mm Hg) and after 1 month (51.2 ± 15.05 mm Hg), average change 1.9 ± 2.04 mm Hg (p = 0.025). The average ulcer size prior to compression was 49 ± 102 cm2 versus 37 ± 94 cm2 after 1 month of effective compression, corresponding to a reduction of 12 ± 8 cm2 (p < 0.001). There was a reduction in the bodily pain dimension of the SF-36. Compressions adapted to the hemodynamic status led to an increase in TcPO2, a reduction in wound size, and an improvement to bodily pain in patients with leg ulcers of mixed arterial-venous etiology.