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Jung I, Kravitz S, Linabury J. Hereditary cold-induced palmar erythema with dysesthesia: A novel entity with response to onabotulinumtoxinA injections. JAAD Case Rep 2024; 51:56-58. [PMID: 39165632 PMCID: PMC11334728 DOI: 10.1016/j.jdcr.2024.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2024] Open
Affiliation(s)
- Injae Jung
- School of Medicine, Uniformed Services University, Bethesda, Maryland
| | - Shena Kravitz
- Department of Dermatology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - John Linabury
- Department of Dermatology, Walter Reed National Military Medical Center, Bethesda, Maryland
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Ture HY, Lee NY, Kim NR, Nam EJ. Raynaud's Phenomenon: A Current Update on Pathogenesis, Diagnostic Workup, and Treatment. Vasc Specialist Int 2024; 40:26. [PMID: 39040029 PMCID: PMC11266082 DOI: 10.5758/vsi.240047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/18/2024] [Accepted: 06/23/2024] [Indexed: 07/24/2024] Open
Abstract
Raynaud's phenomenon (RP) is a condition characterized by episodic, excessive vasoconstriction in the fingers and toes, triggered by cold or stress. This leads to a distinctive sequence of color changes in the digits. Pallor indicates reduced blood flow due to oxygen deprivation, while erythema appears as reperfusion. RP can be primary, with no identifiable underlying cause, or secondary, associated with other conditions. These conditions include autoimmune diseases, most commonly systemic sclerosis, vascular diseases; and neurological conditions. While the exact cause of RP remains unclear, genetic and hormonal (estrogen) factors are likely contributors. The pathogenesis of RP involves a complex interaction between the vascular wall, nerves, hormones, and humoral factors, disrupting the balance between vasoconstriction and vasodilation. In primary RP, the vascular abnormalities are primarily functional. However, in secondary RP, both functional and structural components occur in blood vessels. This explains why digital tissue damage frequently occurs in secondary RP but not primary RP. Diagnosis of RP is primarily clinical. Recent advancements in imaging techniques have aided in diagnosis and monitoring, but nail fold capillaroscopy remains the gold standard for distinguishing between primary and secondary RP. If there are signs of acute ischemic injury, vascular imaging, particularly preoperatively, is crucial to rule out other vaso-occlusive conditions. Management of RP focuses on alleviating symptoms and preventing tissue damage. Vasodilator medications are the first-line treatment when general measures like warmth and stress management are not sufficient. Dihydropyridine calcium channel blockers (CCBs), such as nifedipine, are commonly used for vasodilation. Phosphodiesterase-5 inhibitors and prostaglandin analogs are alternative options for patients who do not respond to CCBs or have ischemic tissue damage. Bosentan, an endothelin-1 receptor antagonist, has shown effectiveness in treating and preventing digital ulcers, especially in patients with multiple ulcers. For severe cases, botulinum toxin injections or sympathectomy surgery can be used to control RP symptoms. However, botulinum toxin injections require repeated administration, and sympathectomy's long-term effectiveness is uncertain. Fat grafting is a promising surgical therapy for promoting healing and preventing tissue injury.
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Affiliation(s)
- Hirut Yadeta Ture
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Nan Young Lee
- Department of Clinical Pathology, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Na Ri Kim
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Eon Jeong Nam
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
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Geary E, Wormald JCR, Cronin KJ, Giele HP, Durcan L, Kennedy O, O'Brien F, Dolan RT. Toxin for Treating Raynaud Conditions in Hands (The TORCH Study): A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5885. [PMID: 38881966 PMCID: PMC11177805 DOI: 10.1097/gox.0000000000005885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Accepted: 04/22/2024] [Indexed: 06/18/2024]
Abstract
Background Raynaud disease of the hands is a complex disorder resulting in inappropriate constriction and/or insufficient dilation in microcirculation. There is an emerging role for botulinum toxin type A (BTX-A) in the treatment armamentarium for refractory Raynaud disease. The aim of this systematic review was to critically evaluate the management of primary and secondary Raynaud disease treated with BTX-A intervention. Methods We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of clinical studies assessing treatment of primary or secondary Raynaud disease with BTX-A by searching Ovid MEDLINE and Embase databases from inception to first August 2023. The review protocol was prospectively registered on the PROSPERO database (CRD42022312253). Results Our search strategy identified 288 research articles, of which 18 studies [four randomized controlled trials (RCTs), two non-RCTs, five case series, and seven retrospective cohort studies] were eligible for analysis. Meta-analysis demonstrated that the probability of pain visual analog scale score improvement with BTX-A intervention was 81.95% [95% confidence interval (74.12-87.81) P = 0.19, heterogeneity I 2 = 26%] and probability of digital ulcer healing was 79.37% [95% confidence interval (62.45-89.9) P = 0.02, heterogeneity I 2 = 56%]. Conclusions Delivery of BTX-A to digital vessels in the hand may be an effective management strategy for primary and secondary Raynaud disease. A definitive, appropriately-powered RCT with objective functional and patient-reported outcome measures is required to accurately assess and quantify the efficacy of BTX-A in Raynaud disease of the hands.
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Affiliation(s)
- Ellen Geary
- From the Department of Plastic and Reconstructive Surgery, Beaumont Hospital, Dublin, Ireland
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Justin C R Wormald
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
- Department of Plastic and Reconstructive Surgery, John Radcliffe Hospital, Oxford, United Kingdom
| | - Kevin J Cronin
- Department of Plastic and Reconstructive Surgery, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Henk P Giele
- Department of Plastic and Reconstructive Surgery, John Radcliffe Hospital, Oxford, United Kingdom
| | - Laura Durcan
- Department of Rheumatology, Beaumont Hospital, Dublin, Ireland
| | - Oran Kennedy
- Department of Anatomy and Regenerative Medicine, Tissue Engineering Research Group, Royal College of Surgeons in Ireland, Dublin, Ireland
- Advanced Materials and Bioengineering Research Centre (AMBER), Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fergal O'Brien
- Department of Anatomy and Regenerative Medicine, Tissue Engineering Research Group, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Roisin T Dolan
- From the Department of Plastic and Reconstructive Surgery, Beaumont Hospital, Dublin, Ireland
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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4
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Stearns SA, Xun H, Haddad A, Rinkinen J, Bustos VP, Lee BT. Therapeutic Options for Migraines in the Microsurgical Patient: A Scoping Review. Plast Reconstr Surg 2024; 153:988e-1001e. [PMID: 37337332 DOI: 10.1097/prs.0000000000010861] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
BACKGROUND There exists an increasing array of treatments proposed to prevent, alleviate, and abort symptoms of a migraine; however, for patients who undergo reconstructive microsurgery, caution must be taken to preserve vascular integrity. This study is the first-to-date scoping review of vascular and bleeding risk of current migraine therapies, with the purpose of identifying potential therapeutic agents for postoperative migraine management appropriate for microsurgical patients. METHODS Currently available migraine therapeutics were compiled from the UpToDate software system and the American Academy of Family Physicians. A PubMed literature review was performed for each therapeutic's effect on bleeding or vascular involvement. Data were compiled into tables of abortive, symptom-controlling and prophylactic, and nonpharmacologic treatments. Expert microsurgeons reviewed the data to provide recommendations for optimized patient care. RESULTS Triptans and other ergot derivatives demonstrated strong evidence of vasoconstriction and were greatly advised against for immediate postmicrosurgical use. Novel pharmaceutical therapies such as lasmiditan and calcitonin gene-related peptide antagonists have no literature indicating potential for vasoconstriction or hematoma and remain an investigational option for abortive medical treatment. For symptom control, acetaminophen appears the safest option, with clinical judgment and further research needed for use of nonsteroidal antiinflammatory drugs. Alternative treatment techniques may include migraine prophylaxis with botulinum toxin injection or nutraceutical treatment by means of magnesium supplementation or coenzyme Q10 administration, minimizing the need for additional medication in the postoperative setting. CONCLUSIONS Patients undergoing reconstructive microsurgery have a unique medical profile limiting the therapeutic options available to treat migraines. This review provides preliminary evidence to be considered as a guide for prescribing therapeutics for migraine in the postoperative setting.
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Affiliation(s)
| | - Helen Xun
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Anthony Haddad
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Jacob Rinkinen
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Valeria P Bustos
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Bernard T Lee
- the Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School
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5
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Dehghani M, Pourmontaseri H. Aetiology, risk factors and treatment of typical and atypical pressure ulcers in patients with traumatic brain injury: A narrative review. Int Wound J 2024; 21:e14788. [PMID: 38420873 PMCID: PMC10902764 DOI: 10.1111/iwj.14788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 02/02/2024] [Indexed: 03/02/2024] Open
Abstract
Pressure ulcers are one of the leading complications in bedridden patients that result in multiple burdens on healthcare systems and patients (11 billion dollars/year). The prevalence of pressure ulcers in traumatic brain injury patients is 1.5-fold compared with the other bedridden patients. Moreover, critical traumatic brain injury patients who are admitted to the intensive care unit experience severe pressure ulcers and further complications. The motor/sensory disabilities and low supplementation and oxygenation to the pressured side were the main mechanisms of the typical pressure ulcers. Intellectual evaluation is the first essential step to prevent the development of pressure ulcers in high-risk patients. Till now, different scales, including Injury Scale Score and Braden Scale Score, have been provided to assess the pressure ulcer. Since low stages of pressure ulcers heal rapidly, traumatic brain injury patients require a periodical assessment to prevent further developments timely. Alongside different procedures provided to prevent and treat any pressure ulcer, traumatic brain injury patients required additional specific protections. For the first line, fast and efficient rehabilitation repairs motor/sensory disabilities and decreases the chance of pressure ulcer. Our review indicated that pressure ulcer in traumatic brain injury had several complex mechanisms that demand special care. Therefore, further studies are required to address these mechanisms and prevent their progression to typical and atypical pressure ulcers.
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Affiliation(s)
- Mohammadreza Dehghani
- Student Research Committee, Fasa University of Medical SciencesFasaIran
- Projects Support Division, Medical Students AssociationFasa University of Medical SciencesFasaIran
| | - Hossein Pourmontaseri
- Student Research Committee, Fasa University of Medical SciencesFasaIran
- Projects Support Division, Medical Students AssociationFasa University of Medical SciencesFasaIran
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6
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Kadian-Dodov D. Cold Hands or Feet: Is It Raynaud's or Not? Med Clin North Am 2023; 107:829-844. [PMID: 37541711 DOI: 10.1016/j.mcna.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Abstract
Raynaud's phenomenon is an exaggerated response to cold stimuli that may be primary or secondary. The diagnosis relies on patient history and physical examination to distinguish RP from other vasomotor dysfunction (e.g. acrocyanosis, pernio, small fiber neuropathy with vasomotor symptoms, and complex regional pain syndrome). Achenbach syndrome, or spontaneous venous hemorrhage, may also be mistaken for RP but is a self-limiting phenomenon. Laboratory evaluation and vascular diagnostic testing may identify SRP causes. Regardless of etiology, treatment includes warming with trigger avoidance, and consideration of vasodilators (eg. calcium channel, alpha-1 blockers). SRP with digital ulceration may require PDE5i, endothelin-1 receptor blockers, and prostanoids. Refractory cases may require pneumatic arterial pumps, botulinum toxin administration, or surgical sympathectomy.
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Affiliation(s)
- Daniella Kadian-Dodov
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, 1190 Fifth Avenue, Box 1030, New York, NY 10029, USA.
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7
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Greene BHC, Gudimella R, Corkum JP, Boone H, Samargandi OA, Williams J. Managing cold intolerance after hand injury: A systematic review. HAND SURGERY & REHABILITATION 2023; 42:109-114. [PMID: 36720347 DOI: 10.1016/j.hansur.2023.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 01/30/2023]
Abstract
OBJECTIVES This systematic review seeks to understand whether cold intolerance (CI) improves with time and if there is any role for management strategies such as behavioural therapy, surgery, or pharmacotherapy. METHODS Two independent reviewers used a predefined search strategy to query MEDLINE, PubMed, Embase, CINAHL, Cochrane Library, Web of Science and Google Scholar databases. Articles written in English, Studies of interventions (such as pharmacotherapy or behavioural therapy) for cold intolerance in adult patients with a history of hand injury along with prevalence over time were included for review. RESULTS Seventeen studies were included, with twelve prognostic studies of the effect of time on CI, four studies of self management/behavioural therapies, and a single study of surgical treatment of neuromas. No studies of pharmacotherapies were identified for inclusion in the hand injury literature. Most studies (76.4%) were either prevalence or prospective cohort studies; no level I or II evidence studies were included. CONCLUSIONS Cold intolerance does not resolve over time for the vast majority of patients. Behavioral and self-management studies have low efficacy and studies presented had a high risk of bias. There is a lack of evidence for the use of pharmacotherapy in CI and this could be considered for future studies.
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Affiliation(s)
- Bradley H C Greene
- Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada.
| | - Rakesh Gudimella
- Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Joseph P Corkum
- Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Hannah Boone
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Osama A Samargandi
- Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Surgery, King Abduaziz University, Jeddah, Saudi Arabia
| | - Jason Williams
- Division of Plastic and Reconstructive Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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8
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Goldberg SH, Gehrman MD, Graham JH. Botulinum Toxin A and B Improve Perfusion, Increase Flap Survival, Cause Vasodilation, and Prevent Thrombosis: A Systematic Review and Meta-analysis of Controlled Animal Studies. Hand (N Y) 2023; 18:22-31. [PMID: 33645294 PMCID: PMC9806538 DOI: 10.1177/1558944721994250] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND A systematic review and meta-analysis of case-control animal model studies will help clarify the vascular effects of botulinum toxin (BTX). METHODS Preferred Reporting Items of Systematic reviews and Meta-Analyses guidelines were used to identify all animal case-control studies published before September 13, 2020, evaluating the vascular effects of BTX. Primary parameters included the following: perfusion, flap survival, arterial and venous dilation, and arterial and venous thrombosis. RESULTS Thirty-six studies with 1032 animals met the systematic review inclusion criteria. Twenty-nine studies had quantifiable data for statistical analysis. Statistically significant increases in perfusion with BTX over saline were detected within 1 day and sustained up to 8 weeks. The following represent weighted mean data from the meta-analysis. The administration of BTX has a 26% increase in both random pattern and pedicled flap survival area over controls. Botulinum toxin causes vasodilation. Botulinum toxin increases vessel diameter in arteries by 40% and in veins by 46% compared with saline controls. The administration of BTX reduces thrombosis by 85% in arteries and by 79% in veins compared with saline controls. Vascular effects were consistent across both BTX-A and BTX-B serotypes, multiple animal species, and various doses. No clear relationships between vascular effects and BTX pretreatment time were identified. CONCLUSIONS Perivascular BTX administration intraoperatively or as a chemical delay pretreatment several days before surgery in multiple animal species and models shows multiple changes to the vascular system. Extrapolation of lessons learned from this systematic review and meta-analysis of animal models could expand research and clinical use of BTX in human vascular disease and surgery.
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Affiliation(s)
- Steven H. Goldberg
- Bellin Health Systems, Green Bay, WI,
USA
- Geisinger Medical Center, Danville, PA,
USA
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9
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De May H, Laarakker AS, Borah G. Botulinum Toxin A for the Treatment of Sympathomimetic Pressor-Induced Digital Hand Ischemia in the Critically Ill Intensive Care Unit Patient. Hand (N Y) 2022; 17:NP6-NP9. [PMID: 35189717 PMCID: PMC9465786 DOI: 10.1177/15589447221075666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Vasopressor-induced ischemia of the hand, while relatively rare, is a severe complication in critically ill intensive care unit (ICU) patients requiring high concentrations of sympathomimetic pressors and often results in digit necrosis and amputation. Currently, there are no widely accepted approaches for treating this cause of peripheral digital ischemia. Case reports have demonstrated that reducing the concentration of vasopressors that patients are given may reverse the progression of ischemic events prior to necrosis. While this approach is at odds with the principle of "life over limb," it demonstrates that digit necrosis can be reversed, resulting in improved outcomes. Here, we present a therapeutic strategy for treating digital limb ischemia in the septic ICU patient without the need to lower systemic vasopressor dose by using locally injected botulinum toxin A into ischemic hands.
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10
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Hakami LM, Forster GL, Jones MK, DeGeorge BR. Scleroderma and Raynaud Phenomenon: The Cold Truth Regarding the Use of Operative Management. Plast Reconstr Surg 2022; 150:105e-114e. [PMID: 35544320 DOI: 10.1097/prs.0000000000009187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Raynaud phenomenon, with and without scleroderma, is a common vasospastic condition that manifests with extremity pain and skin discoloration. When conservative management fails, complications such as ischemia, ulceration, and gangrene may warrant surgical intervention. The purpose of this study was to determine the risk factors and use of surgical intervention in this population. METHODS A national insurance claims-based database with patient records from the Centers for Medicare and Medicaid Services was used for data collection. Patients with first diagnoses of Raynaud phenomenon, scleroderma, or both between 2005 and 2014 were identified. Primary outcomes included the presence of upper extremity amputation or vascular procedure, and history of amputation within 5 years of a vascular procedure. Secondary outcomes included hospital admissions, upper extremity wounds, and amputation within 1 year of diagnosis. RESULTS The Raynaud phenomenon, scleroderma, and Raynaud phenomenon with scleroderma cohorts consisted of 161,300, 117,564, and 25,096 patients, respectively. A diagnosis of both Raynaud phenomenon and scleroderma increased the odds of upper extremity amputation by 5.4-fold, vascular procedure by 4.8-fold, and amputation within 5 years of a vascular procedure by 1.5-fold. Patients with Raynaud phenomenon or scleroderma alone were 3.1 and 5.6 times less likely to undergo amputation within 5 years of a vascular procedure, respectively. CONCLUSIONS Patients with both Raynaud phenomenon and scleroderma have higher likelihoods of having upper extremity amputations, vascular procedures, and amputations following vascular procedures compared to each diagnosis alone. Vascular procedures are rarely being performed. Further research is necessary to establish a standard of care and determine whether early and more frequent intervention with vascular procedures can decrease amputation rates in this patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Affiliation(s)
- Lee M Hakami
- From the Department of Plastic Surgery, the School of Medicine, and the Claude Moore Health Sciences Library, University of Virginia
| | - Grace L Forster
- From the Department of Plastic Surgery, the School of Medicine, and the Claude Moore Health Sciences Library, University of Virginia
| | - Marieke K Jones
- From the Department of Plastic Surgery, the School of Medicine, and the Claude Moore Health Sciences Library, University of Virginia
| | - Brent R DeGeorge
- From the Department of Plastic Surgery, the School of Medicine, and the Claude Moore Health Sciences Library, University of Virginia
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11
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Adler M, Pellett S, Sharma SK, Lebeda FJ, Dembek ZF, Mahan MA. Preclinical Evidence for the Role of Botulinum Neurotoxin A (BoNT/A) in the Treatment of Peripheral Nerve Injury. Microorganisms 2022; 10:microorganisms10050886. [PMID: 35630331 PMCID: PMC9148055 DOI: 10.3390/microorganisms10050886] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/29/2022] [Accepted: 04/17/2022] [Indexed: 01/27/2023] Open
Abstract
Traumatic peripheral nerve injuries tend to be more common in younger, working age populations and can lead to long-lasting disability. Peripheral nerves have an impressive capacity to regenerate; however, successful recovery after injury depends on a number of factors including the mechanism and severity of the trauma, the distance from injury to the reinnervation target, connective tissue sheath integrity, and delay between injury and treatment. Even though modern surgical procedures have greatly improved the success rate, many peripheral nerve injuries still culminate in persistent neuropathic pain and incomplete functional recovery. Recent studies in animals suggest that botulinum neurotoxin A (BoNT/A) can accelerate nerve regeneration and improve functional recovery after injury to peripheral nerves. Possible mechanisms of BoNT/A action include activation or proliferation of support cells (Schwann cells, mast cells, and macrophages), increased angiogenesis, and improvement of blood flow to regenerating nerves.
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Affiliation(s)
- Michael Adler
- Neuroscience Department, Medical Toxicology Division, U.S. Army Medical Research Institute of Chemical Defense, 8350 Ricketts Point Rd., Aberdeen Proving Ground, MD 21010, USA
- Correspondence: ; Tel.: +1-410-436-1913
| | - Sabine Pellett
- Department of Bacteriology, University of Wisconsin-Madison, 1550 Linden Drive, Madison, WI 53706, USA;
| | - Shashi K. Sharma
- Division of Microbiology, Center for Food Safety and Applied Nutrition, Food and Drug Administration, College Park, MD 20740, USA;
| | - Frank J. Lebeda
- Biotechnology, Protein Bioinformatics, Zanvyl Krieger School of Arts & Sciences, Johns Hopkins University, Advanced Academic Programs, 9601 Medical Center Drive, Rockville, MD 20850, USA;
| | - Zygmunt F. Dembek
- Department of Military and Emergency Medicine, Uniformed Services University of Health Sciences, 3154 Jones Bridge Rd., Bethesda, MD 20814, USA;
| | - Mark A. Mahan
- Department of Neurosurgery, Clinical Neurosciences, University of Utah, 175 N Medical Drive East, Salt Lake City, UT 84132, USA;
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12
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Goldberg SH, Akoon A, Kirchner HL, Deegan J. The Effects of Botulinum Toxin A on Pain in Ischemic Vasospasm. J Hand Surg Am 2021; 46:513.e1-513.e12. [PMID: 33431193 DOI: 10.1016/j.jhsa.2020.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 09/03/2020] [Accepted: 11/03/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose was to describe the impact of botulinum toxin A (BTX-A) administration in patients with ischemic vasospasm on the magnitude and timing of pain relief and subsequent effect on opioid use. The secondary purposes were to determine the role of photoplethysomgraph (PPG) testing on treatment decisions, effect on patient-reported outcomes, and additional procedures. METHODS A retrospective analysis of patients who received BTX-A injections was performed. Botulinum toxin type A was injected subcutaneously in symptom-specific 2-level patterns. Pain, shortened version of the Disabilities of the Arm, Shoulder, and Hand (QuickDASH), and opioid use (quantified by median morphine equivalents) were recorded and the need for repeat injections or unplanned surgeries was assessed. RESULTS All patients (n = 20 patients; 31 hands) had ischemic pain from vasospasm and failed multiple pharmacological options. Average follow-up was 10.5 months. All patients had abnormal PPG amplitude (mean, 6.43 mm) at room temperature and increased amplitude (mean, 19.55 mm) after immersion in warm water. All patients (n = 12) with a PPG amplitude increase of 4 mm or greater had clinical success. Eleven of 13 patients had a clinically relevant decrease in pain at 20 minutes after injection. Clinically significant pain relief was sustained for 3 months (visual analog scale decreased by a mean of 4). Median morphine equivalent usage view decreased from 82.5 to 0 after injection. Patient-reported disability (QuickDASH) improved from 49 before treatment to 29 and 26 at 6 weeks and 6 months after BTX-A injection, respectively. Three patients were retreated for recurrent symptoms. Four patients required unplanned secondary procedures. CONCLUSIONS Botulinum toxin type A administration can result in rapid (within 20 minutes) and sustained pain relief for several months with a reduction in opioid prescriptions. Botulinum toxin type A administration also improved patient-reported disability for 6 months. Use of PPG testing to determine baseline perfusion deficit and capacity to improve after warm water immersion was helpful in consideration of BTX-A use. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
| | - Anil Akoon
- Muscuoskeletal Institute, Geisinger Medical Center, Danville, PA
| | - H Lester Kirchner
- Department of Biomedical and Translational Informatics, Geisinger Medical Center, Danville, PA
| | - John Deegan
- Muscuoskeletal Institute, Geisinger Medical Center, Danville, PA
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13
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Botulinum Toxin in the Treatment of Vasopressor-associated Symmetric Peripheral Gangrene. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3582. [PMID: 34036024 PMCID: PMC8140772 DOI: 10.1097/gox.0000000000003582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/23/2021] [Indexed: 11/26/2022]
Abstract
Symmetric peripheral gangrene (SPG) affects peripheral tissues of critically ill patients and can have severe disfiguring and debilitating effects. It can occur in the setting of multiple conditions, and it is associated with the use of vasopressors. There are no evidence-based treatments available for patients who develop SPG. Botulinum toxin has emerged as a potential therapy in vasospastic disorders, and we hypothesized that it may be used in the treatment of tissue ischemia in critically ill patients on vasopressors. We present a case of a patient who developed vasopressor-associated SPG and who experienced complete resolution after local injection with botulinum toxin. While the action of botulinum toxin on skeletal muscle is best understood, it has also been demonstrated to attenuate the release of multiple vasoconstrictive factors that impact vascular smooth muscle and modulate calcium and nitric oxide. These effects may result in vasodilation and improvement of cutaneous ischemia when injected locally. Clinicians may consider this local therapy in the treatment of vasopressor-associated symmetric peripheral gangrene.
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Ennis D, Ahmad Z, Anderson MA, Johnson SR. Botulinum toxin in the management of primary and secondary Raynaud's phenomenon. Best Pract Res Clin Rheumatol 2021; 35:101684. [PMID: 33965340 DOI: 10.1016/j.berh.2021.101684] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Raynaud's phenomenon (RP) is common in rheumatic diseases. In the setting of systemic sclerosis (SSc), it can be complicated by digital ischemia that includes ulceration and gangrene. Systemic adverse effects may preclude the use of oral or topical vasodilators for the treatment of RP and its complications. In this article, we review effectiveness/efficacy of botulinum toxin injection in primary and secondary RP. We discuss botulinum toxin formulations, dosage, sites of administration, and adverse effects. The evidence for botulinum toxin in the treatment of primary and SSc-associated RP is promising. Consistency across patient populations, treatment options (botulinum serotype, dose, and injection site), and outcome measures will be essential for further research.
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Affiliation(s)
- Daniel Ennis
- Mary Pack Vasculitis Clinic, Division of Rheumatology, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Zareen Ahmad
- Toronto Scleroderma Program, Division of Rheumatology, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Melanie A Anderson
- University Health Network Library and Information Services, Toronto, Ontario, Canada.
| | - Sindhu R Johnson
- Toronto Scleroderma Program, Division of Rheumatology, Department of Medicine, Mount Sinai Hospital, Toronto Western Hospital, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
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Abstract
BACKGROUND Raynaud's phenomenon (RP) is a clinical syndrome characterized by recurrent episodes of digital vasospasm triggered by exposure to physical and chemical agents or emotional stress. Although many pharmacologic treatments have been tested, there is still no cure or gold standard therapy. Botulinum toxin treatment has been proved to reduce pain and increase arterial blood flow in treated hands of adult patients with RP. OBJECTIVE The aim of this study is to evaluate the efficacy of botulinum toxin A on younger than 18-year-old patients with primary and secondary RP. MATERIALS AND METHODS A single-center prospective study was performed, including 8 patients aged 14 to 17 years who were clinically diagnosed with primary or secondary RP. BTX was injected into each hand without sedation or anesthetic blockade. The primary outcome was pain reduction after BTX injection. Pain intensity was evaluated at baseline and in the first follow-up. Secondary outcomes included variations in the number and severity of RP episodes after the BTX injection. RESULTS All patients stated significant pain reduction and decreased cold sensitivity, except one patient who did not feel any changes. No patients reported any loss of strength on thumb-index finger. CONCLUSION BTX injection is a simple, noninvasive, and cost-effective treatment alternative, offering an important nonsurgical therapeutic option for the pediatric population. It could also help optimize the dose of other treatments used in these patients. The most commonly observed positive effect is a reduction in the pain associated with RP attacks. Further studies are needed to confirm these results.
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Abstract
Raynaud's phenomenon, which is characterized by episodic digital pallor, cyanosis and rubor upon exposure to cold environment or to stress, is relatively common, although the prevalence depends on the climate. Still, it is under-diagnosed, under-treated, and often confused with other conditions. Primary Raynaud's phenomenon (i.e., Raynaud disease) must be distinguished from secondary Raynaud's phenomenon (i.e., Raynaud syndrome) as long-term morbidity and outcomes differ vastly between the two conditions. Additionally, the practitioner must differentiate between Raynaud's phenomenon and related vascular disorders, such as acrocyanosis, pernio, and livedo reticularis. In this article, we review differences between the conditions and suggest an approach to diagnosis and treatment strategy for these disorders.
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Affiliation(s)
- Eunjung Choi
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Stanislav Henkin
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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17
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Potluri TK, Lee FG, Song E, Wallace SJ, Miller N. Use of Botulinum Toxin A to Treat Chemotherapy-Induced Raynaud's Phenomenon. Cureus 2021; 13:e12511. [PMID: 33564517 PMCID: PMC7863048 DOI: 10.7759/cureus.12511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Raynaud’s phenomenon (RP) is a vasospastic disorder of the digital blood vessels leading to pain, paresthesias, and pallor in response to cold or stress. RP can develop secondary to a number of pathologies or factors, including the use of chemotherapy agents. Typical first-line therapies for secondary RP may be contraindicated in patients with certain comorbidities. Here, we discuss a case in which botulinum toxin A (BTX-A) was used to treat chemotherapy-induced RP in a patient with non-small cell lung cancer (NSCLC). We provide a review of the existing literature on the clinical course and treatment modalities, including the use of BTX-A, for patients with secondary RP. A 56-year-old female with NSCLC received treatment with bevacizumab and pemetrexed. Her initial symptoms included progressive discoloration and pain in her fingertips, which hastily progressed to ischemia and subsequent dry gangrene. She was diagnosed with chemotherapy-induced RP, but traditional management options were complicated by acute congestive heart failure. BTX-A injections were administered at key locations on the wrist and hand, significantly improving her symptoms and slowing the progression of the gangrenous changes. RP can develop as sequelae of chemotherapy regimens. Clinical management may be complicated by underlying pathology and/or patient symptoms. BTX-A injections are an excellent non-operative therapeutic option for patients with secondary RP in cases where mainstay therapies may be contraindicated, thus decreasing pain, improving patient quality of life, and slowing the progression of gangrenous changes.
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Affiliation(s)
- Thrisha K Potluri
- Department of Plastic Surgery and Reconstructive Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Frank G Lee
- Department of Plastic Surgery and Reconstructive Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Ethan Song
- Department of Plastic Surgery and Reconstructive Medicine, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Sean J Wallace
- Division of Plastic & Reconstructive Surgery, Lehigh Valley Health Network, Allentown, USA
| | - Nathan Miller
- Division of Plastic & Reconstructive Surgery, Lehigh Valley Health Network, Allentown, USA
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18
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Gallegos JE, Inglesby DC, Young ZT, Herrera FA. Botulinum Toxin for the Treatment of Intractable Raynaud Phenomenon. J Hand Surg Am 2021; 46:54-59. [PMID: 32948347 DOI: 10.1016/j.jhsa.2020.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/23/2020] [Accepted: 07/18/2020] [Indexed: 02/02/2023]
Abstract
Raynaud phenomenon (RP) is a condition causing vasospasm in the fingers and toes of patients that can have a significant negative impact on quality of life. This can lead to pain, ulceration, and possible loss of digits. Several pharmacological options are available for treatment. However, RP can often be refractory to traditional modalities, leaving surgery or injections as the next available options. This article provides a review and update on the use of botulinum toxin as an effective therapy for the treatment of RP refractory to medical management.
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Affiliation(s)
- Jose E Gallegos
- College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Dani C Inglesby
- College of Medicine, Medical University of South Carolina, Charleston, SC
| | - Zachary T Young
- College of Medicine, Medical University of South Carolina, Charleston, SC; Division of Plastic and Reconstructive Surgery, Medical University of South Carolina, Charleston, SC
| | - Fernando A Herrera
- College of Medicine, Medical University of South Carolina, Charleston, SC; Division of Plastic and Reconstructive Surgery, Medical University of South Carolina, Charleston, SC; Department of Surgery, Ralph H Johnson Veterans Affairs Medical Center, Charleston, SC.
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Livesey M, Jauregui JJ, Hamaker MC, Pensy RA, Langhammer CG, Eglseder WA. Management of vasopressor induced ischemia. J Orthop 2020; 22:497-502. [PMID: 33100742 DOI: 10.1016/j.jor.2020.10.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 09/06/2020] [Accepted: 10/15/2020] [Indexed: 12/21/2022] Open
Abstract
Purpose We evaluated a cohort of patients who developed vasopressor-induced limb ischemia and the management options to prevent progression or minimize morbidity of digital necrosis. Methods We reviewed all current literature on pressor-induced limb ischemia and report options for the management of patients requiring vasopressors who developed limb ischemia. We then retrospectively reviewed presentation, treatment, and short-term outcomes for patients at our tertiary referral academic medical center that developed this complication. Finally, we recommend guidelines for the tiered management of these complex patients. Results Thirty-six patients were included. Twenty-six patients (72%) required resuscitation with more than one vasopressor. Vasopressors were initiated for septic-shock (52.7%), cardiogenic-shock (16.7%), hypovolemic-shock (13.9%), acute transplant rejection (13.9%), and neurogenic-shock (2.8%). According to the tiered management recommendations, patients were managed with phase 1 care (19%), phase 2 care (8.3%), phase 3 care (50%) or phase 4 care (5.6%). The patient expired in the acute setting in 13.9% of cases. Conclusion Life-saving vasopressors risk digital ischemia and necrosis. Early recognition, reporting, and treatment of this complication are important in minimizing morbidity. Using a tiered approach helps organize the healthcare team's management of this iatrogenic complication while respecting the treatment paradigm of "life over limb," and may be safely performed with acceptable outcomes.
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Affiliation(s)
- Michael Livesey
- University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Department of Orthopaedic Surgery, USA
| | - Julio J Jauregui
- University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Department of Orthopaedic Surgery, USA
| | - Max C Hamaker
- University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Department of Orthopaedic Surgery, USA
| | - Raymond A Pensy
- University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Department of Orthopaedic Surgery, USA
| | - Christopher G Langhammer
- University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Department of Orthopaedic Surgery, USA
| | - W Andrew Eglseder
- University of Maryland Medical Center, R Adams Cowley Shock Trauma Center, Department of Orthopaedic Surgery, USA
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Abstract
Scleroderma is derived from Latin meaning hard skin. It is an uncommon, noninflammatory connective tissue disorder characterized by increased fibrosis of the skin and in certain variants, multiple other organ systems. Scleroderma involves a spectrum of pathologic changes and anatomic involvement. It can be divided into localized and systemic scleroderma. Hand involvement is common and can include calcium deposits within the soft tissues, digital ischemia, and joint contracture. Nonsurgical management consists of lifestyle modifications, biofeedback, therapy for digital stiffness/contracture, and various pharmacologic medications. When nonsurgical measures are unsuccessful, certain surgical options may be indicated, each with their inherent advantages and pitfalls. Patients with scleroderma who are undergoing surgical intervention pose unique difficulties because of their poorly vascularized tissue and deficient soft-tissue envelopes, thus increasing their susceptibility to wound healing complications and infection. Some subgroups of patients are frequently systemically ill, and specific perioperative measures should be considered to reduce their surgical risk. The spectrum of hand manifestations seen in patients with scleroderma will be reviewed with the focus on evaluation and management.
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21
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Winter AR, Camargo Macias K, Kim S, Sami N, Weinstein D. The Effect of Abobotulinum Toxin A on the Symptoms of Raynaud's Phenomenon: A Case Series. Cureus 2020; 12:e8235. [PMID: 32582494 PMCID: PMC7306670 DOI: 10.7759/cureus.8235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Raynaud's phenomenon (RP) is a relatively common syndrome occurring alone or in combination with autoimmune and inflammatory diseases. It is characterized by pain and ulceration due to vasospasm in response to cold and stress, most often affecting the digits. Although pharmacologic treatment for this condition exists, it is not always efficacious. Our case series demonstrates the use of abobotulinum toxin A in the treatment of RP. We report the cases of four patients who received injections of abobotulinum toxin A to treat their mild to severe RP symptoms. They experienced clinical improvement for up to one year after treatment.
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Affiliation(s)
- Amelia R Winter
- Internal Medicine, University of Central Florida College of Medicine, Orlando, USA
| | | | - Sun Kim
- Internal Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - Naveed Sami
- Internal Medicine, University of Central Florida College of Medicine, Orlando, USA
| | - David Weinstein
- Dermatology, University of Central Florida College of Medicine, Orlando, USA
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22
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The Use of Ultrasound Guidance for the Treatment of Raynaud Disease of the Hand With Botulinum Toxin. Ann Plast Surg 2020; 84:S386-S388. [PMID: 32356950 DOI: 10.1097/sap.0000000000002303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study sought to examine the feasibility and effectiveness of the use of ultrasound (US) as a clinical adjunct in the delivery of botulinum toxin for the treatment of Raynaud disease of the hand. METHODS One cadaver hand was injected with a colored simulation material using the current traditional surface anatomy approach, whereas an additional cadaver hand was injected using US guidance. The hands were dissected and areas of distribution of the simulation material were evaluated. Five patients diagnosed with Raynaud disease were treated with botulinum toxin using US guidance and data using the Patient-Reported Outcomes Measurement Information System Upper Extremity were collected. RESULTS The cadaver hand injected with a colored simulation material using US guidance demonstrated significantly reduced surface area of muscle infiltrated compared with the cadaver hand injected using the traditional surface anatomy approach (16 cm vs 37 cm, P < 0.001).All 5 patients treated with botulinum toxin using US guidance reported significant improvement in symptoms and function after injection (P < 0.05), where zero patients reported intrinsic hand weakness. CONCLUSIONS The use of US significantly improves the accuracy of delivery of a surrogate dye in a cadaver model of Raynaud disease, whereas its use clinically results in at least as effective a treatment as the landmark approach, but with less botulinum toxin required to achieve the clinical effect.
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23
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Gupta AD, Addison S. Healing hand ulcers caused by focal spasticity. Int Wound J 2020; 17:774-780. [PMID: 32135027 DOI: 10.1111/iwj.13335] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 02/20/2020] [Indexed: 11/28/2022] Open
Abstract
Spasticity is a common manifestation of many upper motor neuron lesions such as stroke, traumatic brain injury, and multiple sclerosis. In some cases, spastic fingers in the hand press hard into the palm, resulting in skin breakdown and atypical pressure ulcerations. We treated 10 such patients living in the nursing homes with long-standing treatment-resistant hand ulcers in our spasticity clinic first, with Botulinum toxin A (BoNTA) injection into the spastic muscles followed by dressing, splinting, and hand therapy. These ulcers failed to respond to standard treatment, causing significant pain, offensive smell, increased carer burden, and difficulty in maintaining hygiene as hands could barely be opened for dressing and therapy. We noted complete healing of ulcers with significant improvement in the following outcome measures-Modified Ashworth Scale for spasticity, Visual Analog Scale for pain, pressure ulcer grading for the ulcers, Fingertip to Palm distance for hand opening, Carer Burden Scale, and in the Goal Attainment Scale pre, 4 weeks, and 3 months postinjection with P values of .003, .003, .004, .005, .004, and .004, respectively. Reducing spasticity with BoNTA should be the first step in treating hand ulcerations caused by focal spasticity, followed by dressing, splinting, and hand therapy.
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Affiliation(s)
- Anupam D Gupta
- Department of Rehabilitation Medicine, The Queen Elizabeth Hospital, University of Adelaide, Woodville South, South Australia, Australia
| | - Samantha Addison
- Department of Rehabilitation Medicine, The Queen Elizabeth Hospital, University of Adelaide, Woodville South, South Australia, Australia
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24
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The Use of Botulinum Toxin in Pain Management: Basic Science and Clinical Applications. Plast Reconstr Surg 2020; 145:629e-636e. [DOI: 10.1097/prs.0000000000006559] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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25
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Mines ML, Pacheco T, Castel-Lacana E, de Boissezon X, Marque P, Montastruc F. Venous thrombosis after botulinum therapy in lower limb: A case report and literature review. Ann Phys Rehabil Med 2019; 62:457-458. [PMID: 31707008 DOI: 10.1016/j.rehab.2019.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 11/04/2019] [Accepted: 11/04/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Marie-Luce Mines
- Service de pharmacologie médicale, faculté de médecine, centre de pharmacovigilance, pharmacoépidémiologie et d'informations sur le médicament de Toulouse, CHU, Toulouse, France; Service de médecine physique et de réadaptation, CHU, Toulouse, France
| | - Tatiana Pacheco
- Service de pharmacologie médicale, faculté de médecine, centre de pharmacovigilance, pharmacoépidémiologie et d'informations sur le médicament de Toulouse, CHU, Toulouse, France; Department of Pharmacology, Universidad de la Sabbana, Bogota, Colombia
| | - Evelyne Castel-Lacana
- Service de pharmacologie médicale, faculté de médecine, centre de pharmacovigilance, pharmacoépidémiologie et d'informations sur le médicament de Toulouse, CHU, Toulouse, France; Service de médecine physique et de réadaptation, CHU, Toulouse, France
| | | | - Philippe Marque
- Service de médecine physique et de réadaptation, CHU, Toulouse, France
| | - François Montastruc
- Service de pharmacologie médicale, faculté de médecine, centre de pharmacovigilance, pharmacoépidémiologie et d'informations sur le médicament de Toulouse, CHU, Toulouse, France; UMR Inserm 1027 Pharmacoepidemiology, Assessment of drug utilization and drug safety, faculté de médecine, Université Paul-Sabatier, Toulouse, France; CIC 1436, CHU, Toulouse, France.
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Colen DL, Ben-Amotz O, Stephanie T, Serebrakian A, Carney MJ, Gerety PA, Levin LS. Surgical Treatment of Chronic Hand Ischemia: A Systematic Review and Case Series. J Hand Surg Asian Pac Vol 2019; 24:359-370. [DOI: 10.1142/s2424835519500462] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Chronic hand ischemia refers to progressive, non-acute ischemic symptoms such as cold intolerance, rest pain, ulceration, tissue necrosis, and digit loss and poses a significant challenge in management. Conservative treatment begins with medical optimization and pharmacologic therapy, but when symptoms persist, surgical intervention may be required. Various operations exist to improve circulation including sympathectomy, arterial bypass, or venous arterialization. The purpose of this study is to systematically review published outcomes and present our experience with each surgical technique.Methods: A systematic review of literature regarding surgical treatment of chronic hand ischemia published between 1990 and 2016 was conducted using PRISMA guidelines. A retrospective-review of surgical interventions for chronic hand ischemia from 2010 to 2016 was then conducted. Primary outcomes included improvement in pain, wound-healing, and development of new ulcerations.Results: The review included 38 eight studies, showing all three techniques were effective in treating chronic hand ischemia. Sympathectomy had the lowest rate of new ulcerations (0.8%); bypass had the highest rate of healing existing ulcerations (89%). Arterialization was associated with consistent pain improvement pain (100%) but more complications (30.8%). Our series included 18 patients with 21 affected hands, 18 sympathectomies, 6 ulnar artery bypasses, and 1 arterialization. Most hands had improvement of wounds (89.5%) and pain (78.9%). No patients developed new ulcerations, but one required secondary amputation.Conclusions: When conservative measures fail to improve chronic hand ischemia, surgical intervention is an effective last line treatment. An algorithmic approach can determine the best operation for patients with chronic hand ischemia.
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Affiliation(s)
- David L. Colen
- Division of Plastic and Reconstructive Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Oded Ben-Amotz
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Thibaudeau Stephanie
- Division of Plastic and Reconstructive Surgery, McGill University, Montreal, QC, Canada
| | - Arman Serebrakian
- Division of Plastic and Reconstructive Surgery, Harvard Medical School, Boston, MA, UK
| | - Martin J. Carney
- Division of Plastic and Reconstructive Surgery, Yale Medical School, New Haven, CT, USA
| | - Patrick A. Gerety
- Division of Plastic Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - L. Scott Levin
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Herrick AL. Raynaud's phenomenon. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 4:89-101. [PMID: 35382391 PMCID: PMC8922643 DOI: 10.1177/2397198319826467] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 11/27/2018] [Indexed: 09/05/2023]
Abstract
Raynaud's phenomenon can be either primary (idiopathic) or secondary to underlying disease including systemic sclerosis. Primary Raynaud's phenomenon is very common, affecting approximately 3%-5% of the general population. Although much rarer, systemic sclerosis-related Raynaud's phenomenon can be particularly severe, progressing to digital ulceration in approximately 50% of patients. Raynaud's phenomenon can have a major impact on quality of life. This review has a focus on the systemic sclerosis-related Raynaud's phenomenon (which is the most researched form of Raynaud's phenomenon and probably the most challenging to treat) and on recent advances. Epidemiology (including transition from 'isolated' to systemic sclerosis-related Raynaud's phenomenon), pathogenesis, diagnosis and assessment are discussed, followed by the treatment of both 'uncomplicated' and 'complicated' Raynaud's phenomena (i.e. Raynaud's phenomenon which has progressed to digital ulceration and/or critical ischaemia). Finally, some of the major challenges for the next 5-10 years are highlighted.
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Affiliation(s)
- Ariane L Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- NIHR Manchester Biomedical Research Centre, Manchester, UK
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28
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Ravina K, Strickland BA, Rennert RC, Carey JN, Russin JJ. Role of botulinum neurotoxin-A in cerebral revascularization graft vasospasm prevention: current state of knowledge. Neurosurg Focus 2019; 46:E13. [PMID: 30717063 DOI: 10.3171/2018.11.focus18514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 11/07/2018] [Indexed: 11/06/2022]
Abstract
Graft stenosis and occlusion remain formidable complications in cerebral revascularization procedures, which can lead to significant morbidity and mortality. Graft vasospasm can result in early postoperative graft stenosis and occlusion and is believed to be at least partially mediated through adrenergic pathways. Despite various published treatment protocols, there is no single effective spasmolytic agent. Multiple factors, including anatomical and physiological variability in revascularization conduits, patient age, and comorbidities, have been associated with graft vasospasm pathogenesis and response to spasmolytics. The ideal spasmolytic agent thus likely needs to target multiple pathways to exert a generalizable therapeutic effect. Botulinum toxin (BTX)-A is a powerful neurotoxin widely used in clinical practice for the treatment of a variety of spastic conditions. Although its commonly described paradigm of cholinergic neural transmission blockade has been widely accepted, evidence for other mechanisms of action including inhibition of adrenergic transmission have been described in animal studies. Recently, the first pilot study demonstrating clinical use of BTX-A for cerebral revascularization graft spasm prevention has been reported. In this review, the mechanistic basis and potential future clinical role of BTX-A in graft vasospasm prevention is discussed.
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Affiliation(s)
| | | | - Robert C Rennert
- 4Department of Neurosurgery, University of California, San Diego, California
| | - Joseph N Carey
- 3Division of Plastic and Reconstructive Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles; and
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29
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Zhong J, Lan Y, Fu S, Zhang J, Lu S, He Y, Zhang JM. Botulinum Toxin A Injection for Treatment of Chronic Skin Ulcer: A Case Series and Literature Review. INT J LOW EXTR WOUND 2019; 18:97-103. [PMID: 30696317 DOI: 10.1177/1534734618816589] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Chronic skin ulcer (CSU) often combines with a variety of refractory factors that respond poorly to routine treatments. Botulinum toxin A (BTX-A) can be injected subcutaneously to improve the local blood supply, to reduce pain, and to promote wound healing. At present, few reports have mentioned BTX-A injection for chronic skin ulcer treatment. We observed the effect of four cases that used BTX-A to treat CSU and provided a brief review of the literature. Four cases of CSUs with 4 different causes were treated with BTX-A injection (4 U/cm2). The specific operation is as follows: local, multipoint, cyclic, equidistant, and subcutaneous injections with a depth of 6 to 8 mm. The ulcer area was significantly reduced. Subsequently, the ulcer healed within 20 to 48 days. Botulinum toxin A is recommended as an important treatment for chronic skin ulcer that can improve healing of skin ulcers with various etiologies.
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Affiliation(s)
- Jiaojiao Zhong
- 1 Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yu Lan
- 1 Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shuying Fu
- 1 Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jing Zhang
- 1 Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Sha Lu
- 1 Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yunan He
- 1 Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jun-Min Zhang
- 1 Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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30
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Vien Toh V, Akhtar A, Shariff Z. Botulinum toxin type A injections for cold intolerance following finger revascularization. J Hand Surg Eur Vol 2019; 44:110-111. [PMID: 30261789 DOI: 10.1177/1753193418801306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Vi Vien Toh
- Department of Plastic Surgery, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Ali Akhtar
- Department of Plastic Surgery, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Zakir Shariff
- Department of Plastic Surgery, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
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Medina S, Gómez-Zubiaur A, Valdeolivas-Casillas N, Polo-Rodríguez I, Ruíz L, Izquierdo C, Guirado C, Cabrera A, Trasobares L. Botulinum toxin type A in the treatment of Raynaud's phenomenon: A three-year follow-up study. Eur J Rheumatol 2018; 5:224-229. [PMID: 30501848 PMCID: PMC6267752 DOI: 10.5152/eurjrheum.2018.18013] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 05/06/2018] [Indexed: 01/18/2023] Open
Abstract
Objective Raynaud’s phenomenon consists of vasospastic disease of the digital arteries after exposure to cold or stress. It causes an important reduction in the patient’s quality of life when severe. The available treatments do not always offer favorable results. Methods A 3-year retrospective study was presented. A total of 15 patients with severe Raynaud’s phenomenon who required infiltration with botulinum toxin type A participated in the study. In the first and follow-up visits (30 min, 7 days, 3 months, 6 months, and annual), the overall response by the patient was assessed as was the reduction in the number of weekly episodes of Raynaud’s phenomenon, improvement in pain by means of the Visual Analogue Scale, and resolution of ulcers and necrosis as efficacy variables. Results A total of 15 patients were included in the study. After 30 min of infiltration, the immediate results showed a very good perception of response in four patients. After 1 month of treatment, eight patients had obtained and maintained a very good response, persisting throughout the study. A statistically significant reduction in pain was obtained, as well as the number of weekly episodes of Raynaud’s phenomenon. Of the seven patients with basal ulcers, five were completely healed at 3 months. Of the patients, 64.3% showed an overall satisfaction level of >8 at the end of treatment. No serious adverse events were observed. Conclusion Botulinum toxin is a useful treatment for severe Raynaud’s phenomenon that is generally well tolerated. Its mechanism of action is not based exclusively on vasodilation. Further studies are necessary to define the ideal patient for this treatment, the most appropriate method of administration, and the number of units and frequency of the infiltrations.
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Affiliation(s)
- Susana Medina
- Department of Dermatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Alba Gómez-Zubiaur
- Department of Dermatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | | | - Isabel Polo-Rodríguez
- Department of Dermatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Lucia Ruíz
- Department of Rheumatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Carmen Izquierdo
- Department of Radiology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Cristina Guirado
- Department of Dermatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Alicia Cabrera
- Department of Dermatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - Lidia Trasobares
- Department of Dermatology, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
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Yoon J, Yoon ES, Lee BI, Park SH, Kim JW. Anti-vasospastic effects of botulinum toxin B pretreatment in animal models. J Plast Surg Hand Surg 2018; 53:25-30. [DOI: 10.1080/2000656x.2018.1523179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jeongmin Yoon
- Department of Plastic and Reconstructive Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Eul-Sik Yoon
- Department of Plastic and Reconstructive Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Byung-Il Lee
- Department of Plastic and Reconstructive Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Seung-Ha Park
- Department of Plastic and Reconstructive Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Jin Woo Kim
- Department of Plastic and Reconstructive Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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Abstract
BACKGROUND Periarterial sympathectomy is a proposed surgical treatment for patients with refractory Raynaud syndrome; however, there is debate regarding the indications and extent of dissection. Due to the segmental arterial sympathetic innervation, we favor an extended sympathectomy in concert with vein graft reconstruction of occluded vessels when necessary. The purpose of this study is to examine outcomes of extended periarterial sympathectomy in our patients. METHODS A retrospective chart review was performed on 46 patients who underwent 58 periarterial sympathectomies (12 bilateral) since 1981. The data collected include demographics, comorbidities, previous therapy, operative details, and surgical outcomes. In addition, we contacted available patients for a phone survey. RESULTS Of 58 cases, 68.9% were female, 29.3% were current smokers, and 58.6% had known connective tissue disease. Thirty-three vein graft reconstructions were performed with a long-term patency of 77.4%. Sustained improvement of ischemic pain was reported in 94.8% of cases, and 78% of patients with ulcers completely healed. For the most symptomatic fingertip, mean Semmes-Weinstein monofilament measurements improved from 4.15 preoperatively to 3.29 postoperatively ( P ≤ .05). Mean follow-up was 3.97 years. Of 10 patients contacted by telephone, all reported a decrease in frequency and severity of Raynaud attacks, while 9 reported a long-term decrease in pain an average of 11.6 years after surgery. CONCLUSIONS Extended periarterial sympathectomy is an effective and safe procedure for patients with refractory Raynaud syndrome. Our data demonstrate long-term improvement in ischemic pain and sensibility, along with a high rate of ulcer healing and patient satisfaction.
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Herrick AL. Evidence-based management of Raynaud's phenomenon. Ther Adv Musculoskelet Dis 2017; 9:317-329. [PMID: 29201156 PMCID: PMC5700788 DOI: 10.1177/1759720x17740074] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 09/07/2017] [Indexed: 12/18/2022] Open
Abstract
Raynaud's phenomenon (RP) is relevant to the rheumatologist because it may signify an underlying connective tissue disease and also because it can be very challenging to treat, especially when it has progressed to digital ulceration or critical ischaemia. This review article discusses diagnosis (does this patient have an underlying connective tissue disease?), including the role for nailfold capillaroscopy, and treatment. Management of 'uncomplicated' RP is first described and then treatment of RP complicated by progression to digital ulceration or critical ischaemia, highlighting recent advances (including phosphodiesterase type 5 inhibition, and endothelin 1 receptor antagonism) and the evidence base underpinning these. Possible future therapies are briefly discussed.
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Affiliation(s)
- Ariane L. Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester UK, M13 9PT and NIHR Manchester Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester, UK
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Abstract
INTRODUCTION Raynaud's phenomenon (RP) can be either primary (idiopathic) or secondary to a number of different diseases/conditions, when vasopasm can be superimposed upon structural vascular abnormality or a hyperviscosity state and may then lead to severe ischaemia with tissue damage. Treatment must be tailored to the individual. Areas covered: This review discusses how increased understanding of the pathogenesis of RP has driven and is driving new approaches to therapy, and how we are now better able to predict which patients presenting with RP are likely to have an underlying disease requiring specific intervention. Medline searches (1946 to August 2016) were conducted for 'Raynaud's' in combination with relevant terms including different drugs. All papers identified were English language, with abstracts. Expert commentary: Randomised controlled trials of RP present particular challenges. The major aim must continue to be development of safe, effective treatments for patients across the spectrum of RP.
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Affiliation(s)
- Ariane L Herrick
- a Division of Musculoskeletal and Dermatological Sciences , The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester , UK.,b NIHR Manchester Musculoskeletal Biomedical Research Unit , Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre , Manchester , UK
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Recent advances in the pathogenesis and management of Raynaud's phenomenon and digital ulcers. Curr Opin Rheumatol 2016; 28:577-85. [DOI: 10.1097/bor.0000000000000332] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Differential diagnosis of critical digital ischemia in systemic sclerosis: Report of five cases and review of the literature. Semin Arthritis Rheum 2016; 46:209-216. [DOI: 10.1016/j.semarthrit.2016.05.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Revised: 04/11/2016] [Accepted: 05/09/2016] [Indexed: 12/20/2022]
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Affiliation(s)
- Fredrick M Wigley
- From the Division of Rheumatology (F.M.W.) and the Department of Anesthesiology and Critical Care Medicine (N.A.F.), Johns Hopkins University School of Medicine, Baltimore
| | - Nicholas A Flavahan
- From the Division of Rheumatology (F.M.W.) and the Department of Anesthesiology and Critical Care Medicine (N.A.F.), Johns Hopkins University School of Medicine, Baltimore
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Gunnarsson R, Hetlevik SO, Lilleby V, Molberg Ø. Mixed connective tissue disease. Best Pract Res Clin Rheumatol 2016; 30:95-111. [DOI: 10.1016/j.berh.2016.03.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Iannuzzi NP, Higgins JP. Acute Arterial Thrombosis of the Hand. J Hand Surg Am 2015; 40:2099-106. [PMID: 26408378 DOI: 10.1016/j.jhsa.2015.04.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Revised: 04/08/2015] [Accepted: 04/10/2015] [Indexed: 02/08/2023]
Abstract
Arterial thrombosis of the hand occurs infrequently but may result in considerable morbidity and compromise of hand function. The hand surgeon may be called upon to direct management in cases of acute arterial thrombosis of the hand and should have an understanding of the available diagnostic tools and treatment modalities. This article discusses the vascular anatomy of the hand and clinical manifestations of arterial thrombosis. Differences between isolated thrombosis and diffuse intravascular injury are detailed, and treatment options for these conditions are described. Appropriate care often requires coordination with interventional radiologists or vascular surgeons. Outcomes after treatment of arterial thrombosis of the hand are variable, and prognosis may be related to whether isolated thrombosis or diffuse intravascular injury is present.
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Affiliation(s)
| | - James P Higgins
- Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
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