Hemorheological and cardiovascular effects of exercise training in the rehabilitation of elderly patients with chronic obstructive pulmonary disease

The purpose of this study is to evaluate hemorheological effects of a single exercise respiratory session (SERS), in the rehabilitation of elderly patients with chronic obstructive pulmonary disease (COPD). Fifteen elderly patients with COPD and 15 controls, matched for demographic variables and body habitus, were submitted to a single session of relaxation and unsupported upper-extremity exercise, coordinated with breathing. We measured hemogasanalytical and cardiovascular parameters: hematocrit value, platelet aggregation, beta-TG and PF(4) plasma levels, blood viscosity and erythrocyte filterability. In both groups, SERS significantly decreased platelet aggregation (P<0.05), beta-TG and PF(4) plasma levels (P<0.05). Erythrocyte filterability and diastolic blood pressure showed a trend to increase in both groups but reached a significant difference in patients with COPD only. Respiratory exercise has a positive influence on platelet and hemorheological parameters in the elderly with COPD. The increase of diastolic blood pressure requires active surveillance.

[Subcutaneous "wash-out" in extravasations]

Extravasations of chemotherapeutic drugs may lead to large soft-tissue losses in the hand and forearm and necessitating surgical excision with secondary flap coverage. Unfortunately, a delayed referral to a hand and plastic surgical unit with an already established soft-tissue defect is most common. Nevertheless, in our unit the method of choice is early emergency subcutaneous "wash-out", which facilitates dilution and reduction of concentration of the extravasation and therefore reliably avoids the development of soft-tissue defects. The aim of this paper is to present the surgical technique.

[Individual perforator flaps of the upper extremity]

Perforator flaps allow an individual flap design on the basis of a preoperative ultrasound examination. Aim of the present study is a preliminary evaluation of results and technical pitfalls of this new technique in the use for flap coverage on the dorsum of the hand and the elbow region. Since 1999, seven individually designed pedicled perforator flaps were prepared on the upper extremity. In four cases, defects on the dorsum of the hand and in a further three defects in the elbow region were treated. In the latter cases the flaps were harvested in a mainly epifascial plane, without dissecting the perforating vessels down to their origin. Five flaps were based on perforating vessels of the interosseous arteries, a further two from the lateral collateral humeral artery. Three out of four pedicled perforator flaps used on the dorsum of the hand healed completely. One flap was lost because of venous insufficiency due to the lack of wrist immobilisation. In the elbow region, two out of three defects were successfully covered with an individual perforator flap. One flap was lost due to venous insufficiency, a further needed an additional split-skin graft with a partial flap loss. The main advantage of the presented technique remains the possibility of individual flap design. However, the donor-site defect is almost negligible since in most cases a primary closure of the donor site was possible. The main arteries remained untouched leaving the blood supply to the hand unchanged. Nevertheless, the mainly epifascial harvest of the perforating vessels in the elbow region has the disadvantage of a short pedicle together with a high degree of torsion which leads to an increased risk of flap loss due to venous insufficiency.

Ozonized autohemotransfusion improves hemorheological parameters and oxygen delivery to tissues in patients with peripheral occlusive arterial disease

Twenty-seven subjects suffering from peripheral occlusive arterial disease (POAD, clinical stage II-III according to Fontaine) were enrolled in this study to evaluate the effect of oxygen-ozone therapy upon hemorheological parameters and hemoglobin-oxygen affinity in patients with POAD. All patients underwent a major ozonized autohemotransfusion consisting of the slow reinfusion of 100 ml of autologous blood, previously exposed to a O(2)-O(3) mixture in a glass box for 10 min. Whole blood viscosity, erythrocyte filterability, hematocrit, and fibrinogen levels were assessed at the basal time and 30 min after the reinfusion of ozonized blood. At the same time p50 standard (p50std) values (an indicator of hemoglobin-oxygen affinity) and plasma values of malonyl dialdehyde (MDA, an indicator of lipid peroxidation) were evaluated. At the baseline, patients had significantly higher ( p<0.05- p<0.001) whole blood viscosity, MDA, and p50std values and significantly lower blood filterability ( p<0.01) as compared with 20 matched healthy volunteers (controls). Thirty minutes after the end of a major autohemotransfusion, whole blood viscosity significantly decreased ( p<0.01). This was accompanied by a significant fall in plasma fibrinogen level ( p<0.01) with no change in hematocrit. Blood filterability, MDA plasma level, and p50std values increased significantly at the same time ( p<0.01- p<0.005). The 2,3-DPG value did not change significantly. No significant changes occurred when the same patients received a non-ozonized autohemotransfusion (control test). In conclusion, ozonized autohemotransfusion may be useful to improve both the poor rheological properties of the blood and the oxygen delivery to tissues in patients suffering from POAD.

Clinical classification of free-flap perfusion complications

Free-tissue transfer is a standard procedure in hand and other plastic and reconstructive surgery. The aim of the present article was to present a new clinical classification of disturbances of the circulation, and to assess the results of treating the specific complication at each of the stages described. Within a period of 29 months, 194 free microvascular flaps were prepared and evaluated in a prospective study. Postoperative monitoring was carried out from a purely clinical point of view. A distinction was made between arterial and venous circulatory disturbances and, in both cases, four stages were characterized, according to the time required for recapillarization, the color of the transfer, and bleeding on puncture. Complications occurred in 69 cases (36 percent), including intraoperative revisions during a first operation. The ratio of arterial to venous insufficiency was 33:35. In the presence of arterial disturbances of the circulation, the proportion of losses increased in progressive stages to 41 percent. With venous disturbances, losses which occurred in stages 1 and 2 were predominantly partial. In 164 cases (85 percent), the flaps remained undamaged. In 15 cases (8 percent), there was partial loss of the transfer and, in a further 13 cases (6 percent), there was complete loss. The authors' results confirmed that the presented clinical classification is, indeed, a measurement of the severity of circulatory impairment. Despite the relatively high complication rate, the use of various methods of treatment finally led, in the overwhelming majority of cases, to a positive result.

[Late onset immunodeficiency with hypo-IgG and hyper-IgM, T CD4+ lymphocytopenia and vitiligo]

The Authors report the clinical case of a patient with a deficit of humoral immunity who developed infections since puberty. The serum levels of IgG and IgA decreased progressively in the fourth decade of life, while serum IgM increased. Moreover, the patient developed a marked CD4+ T lymphocytopenia and a meager B lymphocytopenia, vitiligo, positivity for anti-SSA/Ro autoantibodies and granulomatous phlogosis of the knee. The heterogeneity of the clinical and laboratory data suggests that this patient might present an overlap immunodeficiency syndrome with some of the clinical and immunological features typical of the hyper-IgM syndrome (in the X-linked or autosomal forms) and others that can be referred to a nosologically distinct humoral immunodeficiency such as the common variable immunodeficiency.

Herpes zoster infection and Ogilvie's syndrome in non-Hodgkin's lymphoma with hypogammaglobulinemia

The case of a 43-year-old male with non-Hodgkin's lymphoma (stage IV B), and hypo-IgG and IgM, who developed acute colonic pseudo-obstruction or Ogilvie's syndrome during chemotherapy, is presented. The simultaneous occurrence of a unilateral segmental vesicular rash indicative of herpes zoster infection suggests an etiopathogenetic relationship between the colonic pseudo-obstruction and herpetic involvement of the motor celiac sympathetic ganglia. The rapid resolution of the abdominal dilation and the functional recovery from the colonic pseudo-obstruction after anti-viral therapy is also consistent with the diagnostic hypothesis.

[Perforator flap-plasty and applications to hand surgery]

In contrast to the classical fasciocutaneous and musculocutaneous flaps, perforator flaps are supplied only by a single perforating branch. The aim of this paper is to present the surgical technique and to discuss the use of perforator flaps in hand surgery. Our previous studies have demonstrated the reliability of a preoperative Doppler for planning perforator flaps in reconstructive surgery of the breast: With 286 preoperatively localized perforating branches, a total of 162 were confirmed in intraoperative dissection. In 37 out of these 46 perforator flaps (80%), a preoperatively localized perforating branch could be used. Based on these results, the individual design of perforator flaps harvested on the forearm for defects on the dorsum of the hand is possible. In a preoperative Doppler exam, a perforating branch, i.e. of the posterior interosseous artery, can be localized. The intraoperative confirmation of the perforating branch allows the successful defect coverage with a distally pedicled flap without taking fascia or septum. In our experience, this possibility of planning an individually designed perforator flap is the major advantage for applications of the perforator flap technique in hand surgery. This is especially true in cases where the harvest of a fasciocutaneous flap is unreliable or impossible due to anatomic variations. On the other hand, the dissection of the pedicle is technically demanding and the individual distribution of the perforating branches requires a high degree of flexibility. However, we do consider this new technique to be a further extension in the armamentarium for soft-tissue coverage of the hand.

The hypothenar fat-pad flap for reconstructive repair after scarring of the median nerve at the wrist joint

Because of the loss of mobility, scarring of the median nerve in the carpal tunnel can lead to chronic pain syndrome of the wrist joint, with reduced sensation, muscular dystrophy and severe limitation of the use of the hand. This syndrome most often appears following open carpal tunnel release. Nine patients with scarring of the median nerve in the carpal tunnel were treated with a hypothenar fat-pad flap. Eight of them showed a significant reduction in pain, with improved sensation, trophism and strength. The procedure is suitable as a salvage procedure for restoring a sliding pathway and for cushioning the median nerve in the presence of recurrent lesions in the carpal tunnel.

Circulating adhesion molecules in humans: role of hyperglycemia and hyperinsulinemia

BACKGROUND

We assessed the role of glucose and insulin in the regulation of circulating levels of soluble intercellular adhesion molecule-1 (sICAM-1) and vascular adhesion molecule-1 (sVCAM-1) in normal subjects and in patients with type 2 diabetes.

METHODS AND RESULTS

Plasma glucose concentrations were acutely raised in 10 normal subjects and 10 newly diagnosed, complication-free type 2 diabetic patients and maintained at 15 mmol/L for 2 hours. In normal subjects, plasma sICAM-1, but not sVCAM-1, levels rose significantly (P<0.01) at 1 hour and returned to basal values at 2 hours. In another study, octreotide was infused during the hyperglycemic clamp to block the release of endogenous insulin; this prevented the late fall of plasma sICAM-l levels observed in under control clamp conditions. The diabetic patients had plasma sICAM-1 levels significantly higher (P<0.01) than those of the control subjects; plasma sVCAM-1 levels were similar. Both sICAM-l and sVCAM-1 concentrations did not change significantly during the control hyperglycemic clamp; however, octreotide infusion increased plasma sICAM-1 levels, which remained significantly (P<0.05) above baseline during the whole clamp. In an additional 10 type 2 diabetic patients, overnight euglycemia (plasma glucose 5.5 mmol/L) obtained with the aid of an artificial pancreas or supplementation with l-arginine (10 g PO for 30 days), the natural precursor of NO, normalized the increased plasma sICAM-1 levels.

CONCLUSIONS

Acute hyperglycemia increases circulating sICAM-1 levels in normal subjects, whereas the correction of hyperglycemia with insulin or l-arginine supplementation restored to normal levels the increased plasma sICAM-1 levels of type 2 diabetic patients.

[Treatment and outcome of complications after free flap-plasty]

Free tissue transplantation is a routine procedure in reconstructive surgery. Although a lot of free flap techniques have been described, the postoperative management of complications has gained only little interest. Nevertheless, complications of perfusion after free tissue transplantation are not rare and require a systematic approach. The aim of this study is to classify perfusion failures with a simple grading system prospectively on a large clinical series and to evaluate the results of treatment to improve management. In the past ten months, 70 consecutive free flaps have been performed. By the end of the operation, the operating surgeon gave a prognosis concerning the probability of a possible perfusion complication. Postoperative monitoring was done exclusively by clinical examination (colour, time for recapillarisation and bleeding after puncture). According to these parameters, arterial and venous insufficiencies have been classified into four grades. After recording type, time and treatment of a postoperative complication, the result of treatment was rated subjectively and a cause was noted when possible. The final result was classified either as total flap loss, partial flap loss or successful tissue transplantation. A total of 28 (40%) complications, which were treated with an average of 2.1 options, were recorded. The ratio between arterial and venous failure was 15:13. In 21 cases surgical intervention became necessary (intraoperative n = 12, postoperative n = 9). The arising complication was diagnosed correctly in nine cases by the operating surgeon. In ten cases, the cause of the complication remained unclear. In 18 cases, the complication was treated successfully without any flap loss. In six cases partial flap loss was observed and in four cases a total flap loss had to be accepted. Our results confirm that only few objective criteria for treatment options with perfusion failures after free tissue transplantation exist. Nevertheless, the presented classification is a useful tool for standardized evaluation of the results. The various salvage techniques result in positive outcomes for most of the patients.

Arterial crush injury causes decrease in tissue perfusion at the level of the microcirculation in skeletal muscle flap

This study was designed to evaluate the effects of crush injuries to the feeding arteries of a muscle flap on microcirculatory haemodynamics. Eighteen male Sprague-Dawley rats were divided into three experimental groups for intravital microscopy of the cremaster muscle flap. Group 1 served as control. In group 2 the common iliac artery and in group 3 additionally the lower abdominal aorta was crushed with a Kocher clamp (17.4 N) over 5 min. Microcirculatory parameters (red blood cell velocity, vessel diameter, and capillary perfusion) were monitored before and 2 h after crush. In the one-level crush group, red blood cell velocities significantly decreased by 39.17% (P=0.046) in first order arterioles and by 32. 91% (P=0.0106) in second order arterioles. In capillary perfusion, a drop of 48.02% (P=0.0039) was noted. In the two-level crush group, red blood cell velocities significantly dropped over 32.06% (P=0. 0250) in first order arterioles, 35.91% (P=0.0065) in second order arterioles, and 45.69% (P=0.0782) in first order venules. Capillary perfusion was reduced by 20.16% (P=0.374). Arterial crush injuries as possible thrombogenic insults may result in a significant decrease in skeletal muscle perfusion although the blood supply through the crushed supplying vessel is maintained.

[Relocation of the median nerve after scarring along the carpal tunnel with hypothenar fatty tissue flap-plasty]

In our study, we present the data of eleven patients suffering from scarring of the median nerve, predominantly after open decompression of the carpal tunnel. Dysaesthesia in the palmar region and loss of grip strength prevented performing normal daily activities. All patients except one were relieved of the palmar discomfort and experienced an increase of grip strength allowing their return to work. The hypothenar fat flap has been shown to be a reliable source of local tissue to cover the median nerve. The sprouting of nerve fibers to the skin is prevented as well as median nerve readherence. We believe that the hypothenar fat flap provides sufficient regenerative conditions and coverage of the median nerve within the carpal tunnel in the surgical treatment of abundant scarring.

Impossible harvest of the posterior interosseous artery flap: a report of an individualised salvage procedure

Although the posterior interosseous artery flap represents a reliable technique to provide vascularised skin cover for the dorsum of the hand, the dissection of the flap is often very difficult because of anatomical variants. The weakest part of the vascularisation is the middle third of the posterior interosseous artery. Whenever it is discovered during the operation that such a flap is impossible to harvest, or likely to be unreliable, there is an immediate need to choose an alternative. Such a case is reported here. The individual anatomical situation allowed the dissection of a flap, the pedicle of which carried its blood supply from a perforating branch of the anterior interosseous artery. The technique described offers an individual solution to the problem of skin coverage when the harvest of the posterior interosseous artery is impossible.

[Stress on the wrist joint in semilunar bone necrosis--a morphologic study in vivo]

The distribution of subchondral mineralization of the distal articular surface of the radius was examined by CT osteoabsorptiometry in both wrists of twelve patients showing different stages of Kienböck's disease. The pattern of density distribution had already been demonstrated in previous studies to be an adequate parameter for assessing axial loading across the wrist joint in the patients. Contrary to the anticipated presence of predominant stress in the lunate compartment, some patients showed identical stress in the compartment of the scaphoid, and the balanced loading of both compartments, as before. Even when in early stages of the disease the lunate type of mineralization appeared more often, it was still not possible to demonstrate general excessive stress on the lunate. We have therefore concluded that the main stress in the scaphoid compartment might be a secondary effect, which is to be regarded as the expression of the advancing destruction of the lunate and consequent loss of load transmission through this compartment. This hypothesis is also supported by the fact that, in progressive stages of Kienböck's disease, the density maximum in the fovea lunata, generally present in healthy people, is absent. Furthermore, in patients with necrosis of the lunate, the total mineralization in terms of the maximal density values in the distal joint surface of the radius is in the majority of cases less than in the normal subject. In two cases, even the density maximum was absent from the fovea lunata of the contralateral wrist joint, without there being any clinical signs suggesting a possible lunate necrosis on this side. We interpret these pathological changes in the unaffected wrist joint as a further indication that we are dealing with a congenital predisposition which affects both wrist joints.

Effects of perindopril and carvedilol on endothelium-dependent vascular functions in patients with diabetes and hypertension

OBJECTIVE

To compare the effects of the ACE inhibitor perindopril and the beta-blocker carvedilol on blood pressure and endothelial functions in NIDDM patients with hypertension.

RESEARCH DESIGN AND METHODS

We conducted a double-blind randomized trial in 26 patients with NIDDM and mild hypertension. A 4-week run-in placebo period preceded the active 12-week treatment with perindopril (4-8 mg daily) or carvedilol (25-50 mg daily). Endothelial functions were assessed by evaluating the hemodynamic (mean blood pressure, leg blood flow) and rheological (platelet aggregation, blood viscosity, and blood filterability) responses to an intravenous bolus of 3 g L-arginine, the natural precursor of nitric oxide.

RESULTS

Both perindopril and carvedilol significantly reduced mean blood pressure (P < 0.001) and increased leg blood flow (P < 0.05) to the same extent; blood filterability remained unchanged in both perindopril- and carvedilol-treated groups. Carvedilol reduced platelet aggregation and blood viscosity significantly (P < 0.05) but perindopril did not. Before treatment, the hemodynamic and rheologic responses to L-arginine were significantly lower in patients (P < 0.05-0.01) than in 20 nondiabetic nonhypertensive control subjects. After 12 weeks of treatment, both drugs normalized the hemodynamic responses to L-arginine. Platelet aggregation response to L-arginine was ameliorated by carvedilol and remained unchanged in the perindopril group.

CONCLUSIONS

At the doses used, both drugs effectively reduce blood pressure and normalize the hemodynamic responses to L-arginine. The implications of the ameliorated endothelial function for the poor cardiovascular outlook of the NIDDM hypertensive patient need further assessment.

Vascular effects of acute hyperglycemia in humans are reversed by L-arginine. Evidence for reduced availability of nitric oxide during hyperglycemia

BACKGROUND

Acute hyperglycemia may increase vascular tone in normal humans via a glutathione-sensitive, presumably free radical-mediated pathway. The objective of this study was to investigate whether or not the vascular effects of hyperglycemia are related to reduced availability of nitric oxide.

METHODS AND RESULTS

Acute hyperglycemia (15 mmol/L, 270 mg/dL) was induced in 12 healthy subjects with an artificial pancreas. Systolic and diastolic blood pressures, heart rate, and plasma catecholamines showed significant increases (P < .05) starting after 30 minutes of hyperglycemia; leg blood flow decreased significantly (15%; P < .05) at 60 and 90 minutes. Platelet aggregation to ADP and blood viscosity also showed significant increments (P < .05). The infusion of L-arginine (n = 7, 1 g/min) but not D-arginine (n = 5, 1 g/min) or L-lysine (n = 5, 1 g/min) in the last 30 minutes of the hyperglycemic clamp completely reversed all hemodynamic and rheological changes brought about by hyperglycemia. Infusion of NG-monomethyl-L-arginine (L-NMMA; 2 mg/min) to inhibit endogenous nitric oxide synthesis in 8 normal subjects produced vascular effects qualitatively similar to those of hyperglycemia but quantitatively higher (P < .05); however, heart rate and plasma catecholamine levels decreased during L-NMMA infusion, presumably as a consequence of baroreflex activation. Infusion of L-NMMA during hyperglycemia produced changes not different from those obtained during infusion of L-NMMA alone.

CONCLUSIONS

The results show that acute hyperglycemia in normal subjects causes significant hemodynamic and rheological changes that are reversed by L-arginine. Moreover, the effects of hyperglycemia are mimicked to a large extent, but not entirely, by infusion of L-NMMA. This suggests that hyperglycemia may reduce nitric oxide availability in humans.

Altered patterns of subchondral bone mineralization in Kienböck's disease

The pattern of subchondral bone density, which is supposed to reflect the long-term distribution of stress, was investigated in both wrist joints of nine healthy young subjects and seven patients suffering from Kienböck's disease by means of CT osteoabsorptiometry. Two density maxima were found on the distal articular surface of the radius in the healthy subjects, corresponding to the position of the scaphoid and the lunate. Our relative quantitative results showed three different physiological types of stress indicated by the predominantly monocentric density maxima either on the scaphoid or the lunate surface of the radius and the symmetrical distribution of the mineralization. In Kienböck's disease no type of mineralization predominated. In the progressive stages the lunate density maximum was absent. The overall mineralization was generally less than in controls. Changes in the pattern of mineralization were also found on the contralateral side.