Transient complete atrioventricular block in a preterm neonate with congenital myotonic dystrophy: case report

Congenital myotonic dystrophy (CMD) is an inherited neuromuscular disorder with cardiac rhythm abnormalities that may occur as a child grows. No report has described complete atrioventricular (AV) block detected in a neonate with CMD. We report a floppy infant of 31(+4) weeks gestation with complete AV block at birth, who was diagnosed with CMD by Southern analysis. She recovered from complete AV block 32 hr after temporary transcutaneous pacing was applied. To the best our knowledge, this is the first recorded case of a complete AV block accompanied by CMD during the neonatal period. When a newborn has a complete AV block, the physician should consider the possibility of the CMD and conduct a careful physical examination.

Compared to coverage by STSG grafts only reconstruction by the dermal substitute Integra® plus STSG increases TcPO2 values in diabetic feet at 3 and 6 months after reconstruction*

AIM

Purpose of this retrospective comparative study is to evaluate the results of reconstruction of diabetic feet by split thickness skin graft (STSG) and by dermal substitute Integra® covered by STSG in terms of vascularity of the reconstructed wound-bed by measurements of tissue oxygenation (TcPO2).

PATIENTS AND METHODS

23 patients were included into the study (12 were reconstructed by STSG only and 11 with Integra® and STSG three weeks later). In each patient TcPO2 measurements were performed at the same spot of the reconstructed area at 14 days, one month, 3 months, 6 months, 12 months and 24 months after reconstruction.

RESULTS

Wound beds reconstructed by Integra® showed on average 10 mmHg higher TcPO2.

CONCLUSIONS

Our study estimated in an objective way, by TcPO2 value measurements, the oxygenation of the wound bed in diabetic feet after reconstruction by STSG only and after adding dermal substitute Integra® to the wound bed before final STSG coverage. During first month after reconstruction no statistically significant differences were found. After 3 months TcPO2 studies revealed statistically significant higher oxygen tissue pressure in diabetic feet covered by Integra® plus STSG. These findings endorse in an objective way the clinical findings already reported while using the dermal substitute. It remains to explain the role of this increase of oxygen tissue pressure in redefine the indications for the use of dermal substitutes in reconstruction of poor vascularized regions.

[Anesthetic management for removal of a giant ovarian tumor using FloTrac x Vigileo monitoring system]

We successfully managed anesthesia in a patient with a giant ovarian tumor weighting 22 kg, using FloTrac x Vigileo monitoring system. A 43-year-old woman (67.2 kg, 154.5 cm and abdominal girth 111.3 cm) was admitted for removal of a giant ovarian tumor. Arterial blood pressure (ABP), heart rate, percutaneous arterial oxygen saturation, cardiac index (CI) and stroke volume variation (SVV) were monitored. General anesthesia was induced, with the patient in the supine position, using 50 mg propofol, 0.25 microgram x kg(-1) x min(-1) remifentanil. 30 mg rocuronium bromide and inhalation of 100% oxygen, and maintained with sevoflurane 1.5% and remifentanil administration between 0.1-0.3 microgram x kg(-1) x min(-1). Following 6 l fluid drainage from the ovarian tumor, ABP and CI decreased, but SVV remained within normal ranges. Therefore, we only decreased the drainage speed without increasing fluid administration rate. When the tumor was lifted up, both CI and SVV increased, but the increase of SVV was 10%, still within normal ranges. Therefore, we did not increase fluid administration rate to avoid excessive hydration. After tracheal extubation, respiratory and hemodynamic states were stable, and the patient had no postoperative complication. We conclude that FloTrac x Vigileo System is useful for monitoring cardiac performance parameters, and helps anesthesiologists adjust drainage speed of the content and infusion rate to maintain the stability of circulatory state, in removal of a giant cyst.

[Determination of efficacy of second application of Urokinase Medac in a diabetic foot syndrome]

The results of treatment of 37 patients, suffering diabetes mellitus, were analyzed, in 16 of whom--for critical ischemia of the lower extremities (LE) and purulent-necrotic form of a diabetic foot syndrome 2 courses of treatment using urokinase were done together with pathogenetic and symptomatic therapy. Second introduction of Urokinase Medac was effective for reduction of a fibrinogen level, as well as for increase in a blood supply of a LE tissues, what have promoted a better healing of the wounds. Reduction of a fibrinogen level have had occurred faster, a trustworthy improvement of a state was observed from a 10th day of treatment during the first and the second course. Rising of the oxygen partial pressure in a LE tissues (TcPO2) was more durable, trustworthy--in 20 days while doing the first and second courses of treatment. The higher TcPO2 have lasted in 3-4 mo also. Positive dynamics of the wounds healing was noted also after commitment of the first course of treatment, a majority of ulcers having reduced in size. At the end of the second course of treatment a complete healing or an active epithelization of the wounds were observed in 14 patients. Reduction of the fibrinogen level was connected with achievement of the diabetes mellitus compensation state, with local treatment of ulcers, elimination of an acute purulent-necrotic process.

[Value of transcutaneous monitoring of CO2 pressure in the diagnosis and treatment of sleep and breathing disorders]

OBJECTIVE

To evaluate the clinical value of transcutaneous carbon dioxide (TcPCO2) measurement during sleep respiratory monitoring.

METHODS

A total of 29 patients were prospectively recruited. Their age range was (49.5 ± 12.9) years and body mass index (BMI) (28.2 ± 3.6) kg/m(2). All of them underwent polysomnography (PSG) at Sleep Center, Peking University People's Hospital during the period of January-August 2013. TcPCO2 signal was entered into PSG systems and TcPCO2 (TCM4, Radiometer,Demark) measured simultaneously. Arterial blood gas (ABG) analysis for arterial pressure of CO2 (PaCO2) was undertaken to validate TcPCO2 measurement. The data were statistically analyzed by Pearson's product-moment correlation. Dynamic change of TcPCO2 was monitored during rapid eye movement (REM) and non-rapid eye movement (NREM) sleep stages. The effect of noninvasive positive airway pressure ventilation (NPPV) treatment on TcPCO2 during sleep was also observed.

RESULTS

TcPCO2 (44.2 ± 4.0) mmHg (1 mmHg = 0.133 kPa) was highly correlated with PaCO2 (43.2 ± 4.7) mmHg (Pearson's correlation, r = 0.896, P = 0.000), TcPCO2 (45.8 ± 5.4) mmHg level during wakefulness correlated significantly with that during N1, N2, N3 and REM sleep stages (r = 0.658, 0.871, 0.898,0.775; P = 0.009, 0.000, 0.003, 0.000). TcPCO2 levels during different sleep stages were all higher than that of wakefulness.However, TcPCO2 levels did not differ between two sleep stages. During both NREM and REM, elevated TcPCO2 returned to the level during wakefulness on NPPV treatment.

CONCLUSIONS

Continuous monitoring of PCO2 is well-tolerated during PSG testing. And the signal is stable. During whole night sleep, TcPCO2 monitoring provides more accurate and clinically acceptable estimation of PaCO2 so that it helps to titrate the NPPV pressure levels.

[Control of treatment efficacy in patients with diabetic foot syndrome and peripheral angiopathy]

The preparation of deproteinized hemoderivate, obtained from the calf blood, was used in complex of treatment of the patients, suffering the ischemic forms of the diabetic foot syndrome (DFS). The impact of treatment on a partial pressure of the oxygen (TcPO2) on the foot back was studied up. In noncritical ischemia of the lower extremities tissues there were established a trustworthy increase of TcPO2 in patients as well as a positive dynamics of the wounds healing. In a critical ischemia the results are heterogenous due to presence of coexistant factors, although a stable positive effect was noted.

Both autologous bone marrow mononuclear cell and peripheral blood progenitor cell therapies similarly improve ischaemia in patients with diabetic foot in comparison with control treatment

BACKGROUND

The aim of our study was to compare the effect of bone marrow mononuclear cell and peripheral blood progenitor cell therapies in patients with diabetic foot disease and critical limb ischaemia unresponsive to revascularization with conservative therapy.

METHODS

Twenty-eight patients with diabetic foot disease (17 treated by bone marrow cells and 11 by peripheral blood cell) were included into an active group and 22 patients into a control group without cell treatment. Transcutaneous oxygen pressure and rate of major amputation, as the main outcome measures, were compared between bone marrow cells, peripheral blood cell and control groups over 6 months; both cell therapy methods were also compared by the characteristics of cell suspensions. Possible adverse events were evaluated by changes of serum levels of angiogenic cytokines and retinal fundoscopic examination.

RESULTS

The transcutaneous oxygen pressure increased significantly (p < 0.05) compared with baseline in both active groups after 6 months, with no significant differences between bone marrow cells and peripheral blood cell groups; however, no change of transcutaneous oxygen pressure in the control group was observed. The rate of major amputation by 6 months was significantly lower in the active cell therapy group compared with that in the control group (11.1% vs. 50%, p = 0.0032), with no difference between bone marrow cells and peripheral blood cell. A number of injected CD34+ cells and serum levels of angiogenic cytokines after treatment did not significantly differ between bone marrow cells and peripheral blood cell.

CONCLUSIONS

Our study showed a superior benefit of bone marrow cells and peripheral blood cell treatments of critical limb ischaemia in patients with diabetic foot disease when compared with conservative therapy. There was no difference between both cell therapy groups, and no patient demonstrated signs of systemic vasculogenesis.

Treating hypoxia in a feeble breather with Rett syndrome

Rett syndrome (RS) is a unique X-linked dominant neurodevelopmental disorder affecting 1 in 10,000 females. Mutations in the MECP2 gene located on Xq28 have been identified. Many of the characteristic features evolve due to immaturity of the brain in RS. Cardiorespiratory function should be investigated early to characterise the clinical phenotype of the person with RS because each of the three cardiorespiratory phenotypes; apneustic, feeble and forceful breathers have unique and different management strategies. We report a case of a feeble breather showing a correlation between cortical function and tissue pO(2) and pCO(2). We conclude that subtle changes in the levels of blood gases significantly affect cortical function in RS.

Less variation of R-R interval of electrocardiogram in nonobese type 2 diabetes with nocturnal intermittent hypoxia

Obesity is a major risk factor for sleep-disordered breathing (SDB). However, many Japanese subjects with diabetes are less obese despite compared with Caucasian. We evaluated the relationship between SDB and clinical characteristics other than obesity, especially in relation to cardiac autonomic neuropathy (CAN) in Japanese subjects with diabetes. The study included a total of 261 consecutive Japanese subjects with type 2 diabetes, including nonobese subjects defined as BMI <25 kg/m² for Japanese. SDB was screened by 4% oxygen desaturation index (ODI) level of 5 or more events per hour, which was measured by nocturnal pulse oximetry. CAN was examined with the variation of R-R intervals (CVRR). The SDB were found in 24.5% of total subjects and 16.3% of nonobese subjects with type 2 diabetes, respectively. The nonobese type 2 diabetes subjects with SDB had significantly lower coefficient of CVRR than those without SDB. Multiple regression analysis revealed that BMI and heart rate were significant independent factors for SDB in total subjects with type 2 diabetes, but CVRR was the only significant independent factor for SDB in nonobese subjects with type 2 diabetes. These findings suggest that the presence of SDB should be kept in mind in type 2 diabetic patients with abnormality in CVRR variation in electrocardiogram even though they are not obese.

[Upper thoracic sympathectomy in treatment of upper limb ischaemia in distal lesions of the arterial bed]

Analysed herein was efficacy of 76 videothoracoscopic upper chest sympathectomies performed for upper limb ischaemia in a total of 61 patients. Of these, 15 patients were found to suffer bilateral lesions. The findings of clinical follow up and instrumental examinations (laser Doppler flowmetry, rheovasography, measuring transcranial oxygen tension in tissues) made it possible to draw a conclusion on efficacy of upper chest sympathectomy in distal lesions of the vascular bed of the upper extremities.

Effect of respiratory-induced intensity variations on finger SpO2 measurements in volunteers

Photoplethysmographic (PPG) signals were recorded from the fingers of 16 healthy volunteers with periods of timed and forced respiration. The aim of this pilot study was to compare estimations of arterial oxygen saturation (SpO2) recorded using a dedicated pulse oximetry system while subjects were breathing regularly with and without a mouthpiece containing a flow resistor. The experiments were designed to mimic the effects of mechanical ventilation in anesthetized patients. The effect of estimated airway pressures of ± 15 cmH2O caused observable modulation in the recorded red and PPG signals. SpO2 values were calculated from the pre-recorded PPG signals. Mean SpO2 values were 95.4% with the flow resistor compared with 97.3% with no artificial resistance, with statistical significance demonstrated using a Student's t-test (P = 0.006).

Polysomnography in stable COPD under non-invasive ventilation to reduce patient-ventilator asynchrony and morning breathlessness

BACKGROUND

Stable severe chronic obstructive pulmonary disease (COPD) patients with chronic hypercapnic respiratory failure treated by nocturnal bi-level positive pressure non-invasive ventilation (NIV) may experience severe morning deventilation dyspnea. We hypothesised that in these patients, progressive hyperinflation, resulting from inappropriate ventilator settings, leads to patient-ventilator asynchrony (PVA) with a high rate of unrewarded inspiratory efforts and morning discomfort.

METHODS

Polysomnography (PSG), diaphragm electromyogram and transcutaneous capnography (PtcCO(2)) under NIV during two consecutive nights using baseline ventilator settings on the first night, then, during the second night, adjustment of ventilator parameters under PSG with assessment of impact of settings changes on sleep, patient-ventilator synchronisation, morning arterial blood gases and morning dyspnea.

RESULTS

Eight patients (61 ± 8 years, FEV(1) 30 ± 8% predicted, residual volume 210 ± 30% predicted) were included. In all patients, pressure support was decreased during setting adjustments, as well as tidal volume, while respiratory rate increased without any deleterious effect on nocturnal PtcCO(2) or morning PaCO(2). PVA index, initially high (40 ± 30%) during the baseline night, decreased significantly after adjusting ventilator settings (p = 0.0009), as well as subjective perception of PVA leaks, and morning dyspnea while quality of sleep improved.

CONCLUSION

The subgroup of COPD patients treated by home NIV, who present marked deventilation dyspnea and unrewarded efforts may benefit from adjustment of ventilator settings under PSG or polygraphy.

Oxygen supplementation during awake fibreoptic bronchoscopy in a Nigerian tertiary hospital

BACKGROUND

Examination of the airway is necessary in a wide variety of conditions. This study was carried out to determine the need for oxygen supplementation during the conduct of flexible fibreoptic bronchoscopy on the awake patient.

STUDY DESIGN

A prospective study of consecutive consenting patients requiring awake flexible bronchoscopy between January 2010 and December 2011 using a fibreoptic bronchoscope in the study centre was conducted. With the aid of transcutaneous pulse oximetry, baseline oxygen saturation values were recorded as well as at the various stages of the procedure as well as during brush cytology, washings, biopsy, transbronchial biopsies and transbronchial needle aspirations and 5, 15 and 30 minutes post-procedure. Data was analysed using SPSS 16 and significant values were taken at pd"0.05.

RESULTS

Sixty-seven awake fibreoptic bronchoscopies were performed on 61 patients comprising 38 males and 29 females and a mean age of 51.9 ± 18.9 years. The lowest mean SPO2 of 91.2% was attained during brush cytology. Thirty- four patients (50.7%) had the procedure without oxygen supplementation. Supplemental oxygen was required in all seven patients with a baseline SPO2 of d"92% while it was required in 63.2% of patients with baseline SPO2 of 93- 96%. Baseline oxygen saturation was the most important predictor of the need for oxygen supplementation (p= 0.005).

CONCLUSION

Routine oxygen supplementation is not mandatory for the safe conduct of flexible bronchoscopy. The baseline oxygen saturation value accurately predicts the need for oxygen administration.

Why critical limb ischemia criteria are not applicable to diabetic foot and what the consequences are

Neuropathy, peripheral arterial occlusive disease and microvascular disturbances are important factors contributing to foot problems in diabetic patients. In the diabetic foot with ischemia, the alterations in skin microvascular function are pronounced including severely reduced capillary circulation and abolished hyperaemic responses. These microvascular disturbances, which are superimposed on the already existing structural diabetic microangiopathy, are compatible with a state of "chronic capillary ischemia" and an increased shunting of blood through arteriovenous channels. This maldistribution of blood in skin microcirculation is not detected by measurement of peripheral blood pressure (systolic ankle blood pressure, systolic toe blood pressure). As indicated in several studies toe blood pressure is a poor predictor of local tissue perfusion, tissue survival and healing of chronic foot ulcers. Consequently, the disturbances in peripheral tissue perfusion of the diabetic foot may be underestimated leading to delayed vascular interventions and/or medical treatment. Thus, measurements of peripheral blood pressure, e.g. toe blood pressure, should be combined with investigations of local tissue perfusion in order to get an adequate estimation of peripheral tissue perfusion in diabetic patients. For this purpose local skin microcirculation can be investigated by transcutaneous oxygen tension of the forefoot. Also, due to these reasons, the threshold for revascularization should be lower in diabetic patients with foot ulcer.

Spectrum of chronic lung disease in a population of newborns with extremely low gestational age

AIMS

To determine how the ability to oxygenate the blood develops after birth in infants of extremely low gestational age (ELGANs) and to find risk factors for chronic lung disease.

METHOD

A prospective, population-based, cohort study was undertaken in one tertiary-care centre. The alveolar-arterial oxygen pressure difference (AaDO(2)) was monitored.

RESULTS

Of 41 survivors, 21 had a period of normal lung function in the first week of life, after which oxygenation deteriorated. Low gestational age and low Apgar score at 5 min were found to be strong and independent predictors of AaDO(2) in the first month of life. Mechanical ventilation did not appear as a risk factor. Lung function at 36 weeks of gestation and duration of oxygen treatment could be better predicted by the severity of lung disease in the first month than by gestational age at birth.

CONCLUSIONS

Difficulty in oxygenation was a general observation in ELGANs and not only a particular subset. Gestational age and Apgar score were independent predictors of the degree of difficulty over the first month of life. As oxygenation failure often developed after a few days, the process may be possible to treat or prevent once the pathogenesis is known.

Timing of gangrene tissue debridement after autologous bone marrow cell implantation in patients with superficial femoral arterial occlusion: preliminary experiences

AIM

Although implantation of bone marrow mononuclear cells (BMI) was shown to improve outcomes in patients with severe peripheral arterial occlusive disease (PAOD), little experience has been reported in patients with an arterial occlusion level above the knee, ischemic gangrene, and high cardiovascular risk. This study sought to investigate the timing of gangrene tissue debridement and the safety of BMI in these patients.

METHODS

Six "no-option" PAOD patients were enrolled with an arterial occlusion level above the knee, ischemic gangrene, and 3 systemic diseases related to a high cardiovascular risk. The ischemic status was evaluated by measuring the ankle-brachial index (ABI), transcutaneous oxygen pressure (TcPO2), and wound healing after BMI.

RESULTS

All patients safely underwent the procedures with intravenous general anesthesia by titrating propofol. Major lower extremity amputation, minor debridement amputation, and debridement surgery were performed in 2 (33.3%), 1 (16.7%), and 2 (33.3%) patients, respectively, 3.1 2.8 months after BMI. Compared to the amputation group (N=3), the salvage group (N=3) had a significantly higher baseline ABI (P=0.02) and a shorter distance between the gangrene site and arterial occlusion site (P=0.01). In the 3 patients who underwent debridement, ABI and TcPO2 significantly improved 1 month after BMI, and gangrenous tissues were debrided 3.8 ± 3.6 (range, 1~8) months after BMI with complete healing within 1 month.

CONCLUSION

Autologous BMI therapy is safe in patients at high cardiovascular risk with an arterial occlusion level above the knee and ischemic gangrene. Effective predictors of BMI include the baseline ABI and distance to the ischemia. Gangrene tissue should be debrided at least 1 month after BMI.

[Noninvasive estimation of human tissue respiration with wavelet-analysis of oxygen saturation and blood flow oscillations in microvessels]

Laser Doppler flowmetry, laser spectrophotometry of oxygen saturation and fluorescence determination of NAD-H/FAD ratio were carried out at 30 humans in the upper extremity skin zones with and without arteriole-venule anastomoses (AVA). For the first time it was shown that wavelet-analysis of oxygen saturation and microvascular blood flow oscillations was an effective approach to noninvasive estimation of skin oxygen extraction (OE) and oxygen consumption rate (OC). OE = (SaO2--SvO2)/SaO2, where SaO2 (%) and SvO2(%) are the oxygen saturation of arterial and venular blood, correspondingly. If the ratio between amplitudes of cardiac rhythm (Ac, p.u.) and respiratory rhythm (Ar, p.u.) Ac/Ar < or = 1, SvO2 = SO2. In the case of Ac/Ar >1, SvO2 = SO2/(Ac/Ar). OC = Mnutr x (SaO2-SvO2) in p.u. x %O2, where Mnutr--value of nutritive perfusion (p.u.). Mnutr = M/SI, where SI--shunting index of blood flow in microvessels. The values of perfusion, OE and OC were higher in the skin with AVA than in the skin without AVA. The values of perfusion and oxygen saturation were more variable in the skin with AVA. The greatest significance for tissue metabolism have the oxygen diffused from the smallest arterioles and capillaries. The contribution increased to tissue metabolism of total perfusion and of oxygen diffused from arterioles in the conditions of tissue ischemia.

Primary and secondary amputation in critical limb ischemia patients: different aspects

The TASC II working group reports on primary amputation incidence rates vary between 12 and 50 per 100,000 per year. The primary amputation rate does not only depend on co-morbidities like diabetes and PAD, but also on local factors like the regional availability of vascular surgeons and interventional radiologists and their case load. Further-more, several studies could show that increasing revascularisation rates have drastically reduced amputation rates in the US, with a 50% decrease in amputation rates during a 10 year study period and a corresponding increase in surgical and endovascular revascularisation rates. An analysis of national and state US databases confirmed a drop in major amputations and open surgical revascularisations, in favour of an increase in endovascular interventions. The same study observed an increase in minor amputations during the same period. However, it remains unclear whether this trend is a consequence of the increased usage of endovascular procedures in high-risk patients who are unfit for open surgery or of earlier endovascular intervention in less critical lesions. This review gives an overview of the incidence, indication, amputation-level finding and outcome of major amputations performed in critical limb ischemia (CLI) patients.

[Measurement of carbon dioxide in emergency medicine]

Expiratory carbon dioxide (CO(2)) monitoring is a valuable tool in the prehospital setting. Recent reports of misplaced endotracheal tubes in the prehospital setting make it important to ensure that tube placement is verified by CO(2) monitoring. The Euronorm 2007:1789 made provision of capnometry mandatory for all medical vehicles. However, the frequency of utilization of CO(2) monitoring after securing the airway and in patients with respiratory insufficiency is low. This article covers the terminology, physiology, technology and clinical applications of CO(2) monitoring. Monitoring of cardiac output and the efficiency of cardiopulmonary resuscitation are described and the article also highlights the importance of CO(2) monitoring in patients with severe head trauma as well as restrictive and obstructive pulmonary disorders.

[Correlation of transcutaneous oxygen challenge test and central venous oxygen saturation in septic shock patients]

OBJECTIVE

To investigate the correlation of transcutaneous oxygen challenge test (OCT) [the degree of PtcO2 response to increased fractional inspired oxygen concentration (FiO2) of 1.0 is identified as transcutaneous OCT] and central venous oxygen saturation (ScvO2) in septic shock patients after resuscitation.

METHODS

A total of 49 septic shock patients were prospectively studied. They underwent PtcO2 monitoring and OCT (a temporary increase of FiO2 for 10 min). Baseline central venous blood gases, baseline arterial blood gases and post-OCT arterial blood gases were examined. The parameters of PtcO2 index (baseline PtcO2/PaO2), tissue oxygen index (baseline PtcO2/FiO2), 10 min OCT value [(PtcO2 after 10 min on FiO2 of 1.0) minus (baseline PtcO2)], oxygen challenge index [(10 min OCT value)/(PaO2 on FiO2 1.0 minus baseline PaO2)] were calculated during OCT. The patients were divided into 2 groups according to ScvO2 values: normal ScvO2 group (ScvO2 ≥ 70%) versus low ScvO2 group (ScvO2 < 70%). The parametric differences of transcutaneous OCT were compared between two groups.

RESULTS

(1) There was a significant correlation between baseline PtcO2 (r = 0.382, P = 0.007), tissue oxygen index (r = 0.355, P = 0.012), 10 min OCT value (r = 0.427, P = 0.002), oxygen challenge index (r = 0.5, P < 0.001) and ScvO2, but not with arterial blood lactate concentration; (2) there were 27 patients in the low ScvO2 group and 22 patients in the normal ScvO2 group. ScvO2 was significantly lower in the low ScvO2 group than in the normal ScvO2 group (61 ± 8 vs 77 ± 6, P < 0.05). No differences in age, severity score, vital signs, arterial blood lactate concentration, vasoactive drugs, PtcO2, PtcO2 index and tissue oxygen index were observed between these groups. Compared with those in the normal ScvO2 group, the patients in the low ScvO2 group had a lower 10 min OCT value and oxygen challenge index (P < 0.05); (3) the area under the receiver operating characteristic curve (ROC) for detecting the lower ScvO2 values was 0.621, 0.560, 0.589, 0.721 and 0.763 respectively according to baseline PtcO2, PtcO2 index, tissue oxygen index, 10 min OCT value and oxygen challenge index. The cutoff of 10 min OCT value was ≤ 57 mm Hg (1 mm Hg = 0.133 kPa) for detecting ScvO2 values under 70%, resulting in a sensitivity of 51.9% and a specificity of 95.5%.

CONCLUSION

OCT may improve the diagnostic accuracy of PtcO2 in assessing the low ScvO2 values in septic shock patients after resuscitation.

Improvement of ischemic non-healing wounds following hyperoxygenation: the experience at Rambam-Elisha Hyperbaric Center in Israel, 1998-2007

BACKGROUND

Wounds of the lower extremities are a significant public health problem, being severe and costly to treat. Adjunctive treatment with hyperbaric oxygenation (HBOT) has proven to be a useful and cost-effective means of treating ischemic wounds, mainly in diabetic patients.

OBJECTIVES

To describe patients with ischemic wounds treated at the Rambam and Elisha Hyperbaric Medical Center and their wound improvement following HBOT.

METHODS

We conducted a retrospective cohort study of all patients (N = 385) treated in the center during 1998-2007 for ischemic non-healing wounds in the lower extremities.

RESULTS

The mean age of the patients was 61.9 years (SD 13.97). Most of them were diabetic (69.6%) and male (68.8%). Half of the subjects had a wound for more than 3 months prior to undergoing pre-HBOT transcutaneous oximetry (TcPO2) testing. Most of the wounds were classified as Wagner degree 1 or 2 (39.1% and 46.2% respectively). The median number of treatments per patient was 29. Only 63.1% of patients had continuous treatments. Approximately 20% of patients experienced mild side effects. An improvement occurred in 282 patients (77.7%) following HBOT: 15.2% fully recovered, 42.7% showed a significant improvement (and were expected to heal spontaneously), and 19.8% a slight improvement.

CONCLUSIONS

HBOT can benefit the treatment of non-healing ischemic wounds (especially when aided by pretreatment TcPO2 evaluation; data not shown). Our experience shows that this procedure is safe and contributes to wound healing.

Noninvasive imaging of human skin hemodynamics using a digital red-green-blue camera

In order to visualize human skin hemodynamics, we investigated a method that is specifically developed for the visualization of concentrations of oxygenated blood, deoxygenated blood, and melanin in skin tissue from digital RGB color images. Images of total blood concentration and oxygen saturation can also be reconstructed from the results of oxygenated and deoxygenated blood. Experiments using tissue-like agar gel phantoms demonstrated the ability of the developed method to quantitatively visualize the transition from an oxygenated blood to a deoxygenated blood in dermis. In vivo imaging of the chromophore concentrations and tissue oxygen saturation in the skin of the human hand are performed for 14 subjects during upper limb occlusion at 50 and 250 mm Hg. The response of the total blood concentration in the skin acquired by this method and forearm volume changes obtained from the conventional strain-gauge plethysmograph were comparable during the upper arm occlusion at pressures of both 50 and 250 mm Hg. The results presented in the present paper indicate the possibility of visualizing the hemodynamics of subsurface skin tissue.

[Treatment of critical limb ischemia and diabetic foot disease by the use of autologous stem cells]

AIM

The aim of our study was to assess safety and effectiveness of therapy of critical limb ischaemia by autologous stem cells and evaluation of potential adverse events.

METHODS

Fourteen patients were included into the study (11 men, 3 women, mean age 61.9 +/- 9.6 years, mean diabetes duration 23.5 +/- 11.1 years, mean glycated hemoglobin 6 +/- 1%). Eight patients were treated by bone marrow stromal cells, 6 patients by peripheral blood progenitor cells after stimulation by filgrastim. The suspension of stem cells was then applied into the muscles of ischemic limbs. We evaluated transcutaneous oxygen tension (TcPO2), subjective pain sensation assessed by Visual Analog Scale (VAS) and wound healing.

RESULTS

TcPO2 significantly increased in all patients from 10 +/- 8.7 mm Hg before the treatment to 39.4 +/- 9.5 mm Hg after 6 months (p = 0.0005) after stem cell therapy. We also observed significant area defect reduction and pain decrease during the follow-up period. Median of area defect was reduced from 4.3 (0.7 - 31.7) before the treatment to 0.06 (0 - 0.5) cm2 after 6 months from the treatment (p = 0.0078). Decrease in rest pain was observed in all patients, mean VAS decreased from 5.3 +/- 1.8 to 1.1 +/- 1.3 after 6 months (p = 0.002).

CONCLUSION

Our study suggests that stem cell therapy of diabetic foot disease is an effective therapeutic option with no adverse events for patients with severe peripheral arterial disease. This treatment leads to increase of transcutaneous oxygen tension, improves wound healing and decreases the rest pain.