Pulsed electromagnetic field [PEMF]: effective adjuvant therapy in venous and vasculitic leg ulcers

Chronic leg ulcers occur in 1% of the adult population with considerable associated morbidity and tend to follow a chronic course of recurrent healing and breakdown. Venous insufficiency is the commonest cause of chronic leg ulcers in the community, but vasculitic ulcers are known to be more resistant to treatment and also more painful than ulcers of other aetiologies. A proportion of leg ulcers will heal on conservative treatment, those which do not respond cause considerable distress. Many modalities have been used for conservative treatment of leg ulcers and pulsed electromagnetic field [PEMF] was used for wound healing as it has a number of well-documented physiological effects on cells and tissues. A total of 48 patients with 53 resistant venous and vasculitic leg ulcers unresponsive to medical treatment were enrolled in this study. The patients were randomly divided into control group who received standard wound care and active group who received standard wound care plus active [PEMF] therapy 3 days per week for 12 weeks for a total of 36 sessions. Ulcer size, appearance of the ulcer and surrounding skin, and pain intensity were assessed at the entry of the study, at 6 weeks and at the end of the treatment. At week 12 the active group showed a 56.4% reduction in the ulcer surface area for venous ulcers, and 48.6% for vasculitic ulcers compared to only 17.2% in controls [P=0.01, 0.007, respectively]. A significant decrease in pain intensity was seen in the active group [P= 0.007, 0.006 respectively]. No adverse events were reported. PEMF therapy improve the rate and degree of healing and reduces pain in resistant venous and vasculitic leg ulcers, this suggests that it could be a useful addition as an effective adjuvant treatment to non surgical therapy of leg ulcers. There is need for further studies in a larger population to determine the optimal treatment dose, timing and duration of electromagnetic therapy and applicability of using it in resistant ulcers of other aetiologies

Inching technique and comparative tests in the diagnosis of mild carpal tunnel syndrome

Introduction: Carpal tunnel syndrome [CTS] is the most common entrapment neuropathy. Its diagnosis depends on its typical clinical signs and symptoms and confirmed by electrophysiologic studies. Routine motor and sensory conduction studies failed to diagnose CTS in about 25% of cases [mild cases with distal motor latencies less than 4.2 ms]. The aim of the work: was to study the sensitivity and reliability of inching sensory technique of median nerve around wrist as well as comparative nerve conduction tests in diagnosis of mild CTS. and hence early application of suitable lines of treatments

Subjects and methods: This study comprised fifty apparently healthy subjects as a control group and patients group included one hundred and fifteen patients with mild CTS in 150 affected hands. Patients were thoroughly selected from 379 patients with 512 affected hands diagnosed clinically as having typical CTS and referred from Outpatient Clinics in Mansoura University Hospitals. Cases with mild CTS were selected according to conventional motor and sensory nerve conduction studies [NCS] and were having distal motor latencies less than 4.2 ms. All the studied groups were subjected to; sensitive NCV tests: mediansecond lumbrical versus ulnar-inrosseous test, median versus ulnar digit 4 sensory latencies test [ringdiff], median versus ulnar palm-to-wrist mixed nerve latencies test [palmdiff], median versus radial digit one antidromic sensory latencies [thumbdiff], combined sensory index [CSI] and inching sensory technique for median nerve at wrist. different surgical approaches were planned to relieve nerve compression after failure of other therapeutic modalities depending on accurate diagnosis using inching sensory test and other comparative tests

Results: Mild CTS was diagnosed in 29.3% of all cases of CTS. In comparative tests, median versus ulnar palm-to-wrist mixed nerve latencies [palmdiff] was the most sensitive [93.33%] with specificity of 99.3%. CSI was the most sensitive test in our study [sensitivity=99.33% and specificity =100%] followed by inching sensory test as its sensitivity was 94% and specificity 100%

Conclusion: Comparative studies and CSI are easily applied, non painful, sensitive and specific tests can be applied firstly in diagnosis of mild CTS and followed by inching sensory technique which is also, very sensitive and specific but it may be painful and time consuming. We can approach to diagnosis of mostly all cases of mild CTS by this regimen so early diagnosis with selection of suitable lines of treatment will improve the results of patient's outcome

Management of venous hypertension complicating haemodialysis access in patients with chronic renal failure

As survival for patients with renal failure continues to improve, the complexity of vascular access procedures and the complications from these procedures will continue to increase. Venous hypertension is one of the most distressing complication in patients creating ar-teriovenous fistula resulting in swelling of the ipsilaterai arm, cyanosis as well as formation of collaterals on the chest wail when associated with central venous stenosis or obstruction. From April 2002, to April 2004, 519 patients with end stage renal disease [ESRD] on regular haemodialysis with already functioning vascular access. There were 21 patients [4.2%] presented with variable degrees of oedema and venous hypertension. The patients were classified clinically into three groups: Group A : included cases with mild oedema. Group B : cases presented with moderate and painful oedema Group C : cases presented with extensive oedema of the whole limb, oedema of the ipsilateral breast, congestion, discolouration of the affected limb and cases with collaterals on the shoulder and anterior chest wall of the affected side, 21 patients representing [4.2%] of the studied cases presented with variable degrees of venous hypertension, 7 males [33%] and 14 females [67%]. All patients presented with oedema, 12 patients associated with bluish discolouration of the skin, 6 patients with increased venous pressure and one patients with venous ulcer. 14 patients had AVF without central venous line and 7 patients with history of ipsilateral central venous line. Venous dialysis pressure was > 150mmHg in 6 patients and normal in 8 patients, not measured in 6 patients. Management of patients by limb elevation and compression therapy lead to improvement of symptoms in only 4 cases. Endovascular procedures were done in 10 cases using PTA without stent in 9 cases and PTA with stent in one case. Surgery was applied for 16 cases, 3 patients underwent surgical bypass using synthetic graft for one patient and autogenous vein graft for 2 cases. Ligation of the distal veins was performed for 7 cases. Ligation of the fistula was done in 5 cases and surgical revision in one case. Venous hypertension resulted from proximal venous obstruction or stenosis or by distal venous reflux. Early detection and treatment of venou hypertension is essential to provide adequate care for chronic renal failure patients. Percutaneous Angioplasty for stenosed central vein is the method of choice in management of venous hypertension in well selected cases and surgical bypass using autogenous vein or synthetic graft is a good alternative when complete obstruction of central vein or failed endovascular technique