Characterizing human skin blood flow regulation in response to different local skin temperature perturbations.

Small nerve fibers regulate local skin blood flow in response to local thermal perturbations. Small nerve fiber function is difficult to assess with classical neurophysiological tests. In this study, a vasomotor response model in combination with a heating protocol was developed to quantitatively characterize the control mechanism of small nerve fibers in regulating skin blood flow in response to local thermal perturbation. The skin of healthy subjects' hand dorsum (n=8) was heated to 42°C with an infrared lamp, and then naturally cooled down. The distance between the lamp and the hand was set to three different levels in order to change the irradiation intensity on the skin and implement three different skin temperature rise rates (0.03°C/s, 0.02°C/s and 0.01°C/s). A laser Doppler imager (LDI) and a thermographic video camera recorded the temporal profile of the skin blood flow and the skin temperature, respectively. The relationship between the skin blood flow and the skin temperature was characterized by a vasomotor response model. The model fitted the skin blood flow response well with a variance accounted for (VAF) between 78% and 99%. The model parameters suggested a similar mechanism for the skin blood flow regulation with the thermal perturbations at 0.03°C/s and 0.02°C/s. But there was an accelerated skin vasoconstriction after a slow heating (0.01°C/s) (p-value<0.05). An attenuation of the skin vasodilation was also observed in four out of the seven subjects during the slow heating (0.01°C/s). Our method provides a promising way to quantitatively assess the function of small nerve fibers non-invasively and non-contact.

Reproducibility of axon reflex-related vasodilation assessed by dynamic thermal imaging in healthy subjects.

INTRODUCTION: Small nerve fiber dysfunction is an early feature of diabetic neuropathy. There is a strong clinical need for a non-invasive method to assess small nerve fiber function. Small nerve fibers mediate axon reflex-related vasodilation and play an important role in thermoregulation. Assessing the reflex vasodilation after local heating might elucidate some aspects of small fiber functioning. In this study, we determined the reproducibility of the reflex vasodilation after short local heating in healthy subjects, assessed with thermal imaging and laser Doppler imaging. METHODS: Healthy subjects underwent six heating rounds in one session (protocol I, N=10) or spread over two visits (protocol II, N=20). Reflex vasodilation was elicited by heating the skin to 42°C with an infrared lamp. Skin temperature and skin blood flow were recorded during heating and recovery with a thermal imaging camera and a laser Doppler imager. Skin temperature curves were fitted with a mathematical model to describe the heating and recovery phase with time constant tau (tauHeat and tauCool1). RESULTS: The reproducibility of tau within a session was moderate to excellent (intra-class correlation coefficient 0.42-0.86) and good (0.71-0.72) between different sessions. Within one session the differences in tauHeat were small (bias±SD -1.3±18.9s); the bias between two visits was -1.2±12.2s. For tauCool1 the differences were also small, 1.4±6.6s within a session and between visits -1.4±11.6s. CONCLUSIONS: The heat induced axon reflex-related vasodilation, assessed with thermal imaging and laser Doppler imaging, was reproducible both within a session and between different sessions. Tau describes the temporal profile in one parameter and represents the effects of all changes including blood flow and as such, is an indicator of the vasodilator function. TauHeat and tauCool1 can accurately describe the dynamics of the axon reflex-related vasodilator response in the heating and recovery phase respectively.

Coaching Reduced the Radiation Dose of Pain Physicians by Half during Interventional Procedures.

The increased use of C-arm fluoroscopy in interventional pain management has led to higher radiation exposure for pain physicians. This study investigated whether or not real-time radiation dose feedback with coaching can reduce the scatter dose received by pain physicians. Firstly, phantom measurements were made to create a scatter dose profile, which visualizes the average scatter radiation for different C-arm positions at 3 levels of height. Secondly, in the clinical part, the radiation dose received by pain physicians during pain treatment procedures was measured real-time to evaluate (1) the effect of real-time dose feedback on the received scatter dose, and (2) the effect of knowledge of the scatter dose profile and active coaching, on the scatter dose received by the pain physician. The clinical study included 330 interventional pain procedures. The results showed that real-time feedback of the received dose did not lead to a reduction in scatter radiation. However, visualization of the scatter dose in a scatter dose profile and active coaching on optimal positions did reduce the scatter radiation received by pain physicians during interventional pain procedures by 46.4% (P = 0.05). Knowledge of and real-time coaching with the scatter dose profile reduced the dose of pain physicians by half, caused by their increased awareness for scatter radiation and their insight into strategic positioning.

Cold-induced vasodilatation in cold-intolerant rats after nerve injury.

PURPOSE: Cold-induced vasodilatation (CIVD) is a cyclic regulation of blood flow during prolonged cooling of protruding body parts. It is generally considered to be a protective mechanism against local cold injuries and cold intolerance after peripheral nerve injury. The aim of this study was to determine the role of the sympathetic system in initiating a CIVD response. METHODS: Eight rats were operated according to the spared nerve injury (SNI) model, eight underwent a complete sciatic lesion (CSL) and six underwent a sham operation. Prior to operation, 3, 6 and 9 weeks postoperatively, both hind limbs were cooled and the skin temperature was recorded to evaluate the presence of CIVD reactions. Cold intolerance was determined using the cold plate test and mechanical hypersensitivity measured using the Von Frey test. RESULTS: No significant difference in CIVD was found comparing the lateral operated hind limb for time (preoperatively and 3, 6 and 9 weeks postoperatively; p = 0.397) and for group (SNI, CSL and Sham; p = 0.695). SNI and CSL rats developed cold intolerance and mechanical hypersensitivity. CONCLUSION: Our data show that the underlying mechanisms that initiate a CIVD reaction are not affected by damage to a peripheral nerve that includes the sympathetic fibres. We conclude that the sympathetic system does not play a major role in the initiation of CIVD in the hind limb of a rat. CLINICAL RELEVANCE: No substantial changes in the CIVD reaction after peripheral nerve injury imply that the origin of cold intolerance after a traumatic nerve injury is initiated by local factors and has a more neurological cause. This is an important finding for future developing treatments for this common problem, as treatment focussing on vaso-regulation may not help diminish symptoms of cold-intolerant patients.

Pulse transit time as a quick predictor of a successful axillary brachial plexus block.

BACKGROUND: It can take up to 30 min to determine whether or not axillary block has been successful. Pulse transit time (PTT) is the time between the R-wave on electrocardiography (ECG) and the arrival of the resulting pressure pulse wave in the fingertip measured with photoplethysmography. It provides information about arterial resistance. Axillary block affects vasomotor tone causing loss of sympathetic vasoconstriction resulting in an increased PTT. Early objective assessment of a block can improve efficacy of operating room time and minimize patient's fear of possible conversion to general anesthesia. This study explores whether PTT can objectively, reliably and quickly predict a successful axillary block. METHODS: Forty patients undergoing hand surgery under axillary block were included. A three-lead ECG and photoplethysmographic sensors were placed on both index fingers. Measurements were made from 2 min before until 30 min after induction of the block or less if the patient was transferred for operation. Afterwards, PTT was calculated as the time between the R-wave on ECG and a reference point on the photoplethysmogram. To assess the change in PTT caused by the block, the PTT difference between the control and blocked arm was calculated. Sensitivity and specificity of PTT difference were calculated using receiver operating characteristic analysis. RESULTS: In a successful block, the mean PTT difference significantly increased after 3 min by 12 (standard error of the mean 3.9) ms, sensitivity 87% and specificity 71% (area under the curve 0.87, P = 0.004). CONCLUSIONS: PTT is a reliable, quick and objective method to assess whether axillary block is going to be successful or not.

Thermoregulation in peripheral nerve injury-induced cold-intolerant rats.

PURPOSE: Cold intolerance is defined as pain after exposure to non-painful cold. It is suggested that cold intolerance may be related to dysfunctional thermoregulation in upper extremity nerve injury patients. The purpose of this study was to examine if the re-warming of a rat hind paw is altered in different peripheral nerve injury models and if these patterns are related to severity of cold intolerance. METHODS: In the spared nerve injury (SNI) and complete sciatic lesion (CSL) model, the re-warming patterns after cold stress exposure were investigated preoperatively and at 3, 6 and 9 weeks postoperatively with a device to induce cooling of the hind paws. Thermocouples were attached on the dorsal side of the hind paw to monitor re-warming patterns. RESULTS: The Von Frey test and cold plate test indicated a significantly lower paw-withdrawal threshold and latency in the SNI compared to the Sham model. The CSL group, however, had only significantly lower paw-withdrawal latency on the cold plate test compared to the Sham group. While we found no significantly different re-warming patterns in the SNI and CSL group compared to Sham group, we did find a tendency in temperature increase in the CSL group 3 weeks postoperatively. CONCLUSION: Overall, our findings indicate that re-warming patterns are not altered after peripheral nerve injury in these rat models despite the fact that these animals did develop cold intolerance. This suggests that disturbed thermoregulation may not be the prime mechanism for cold intolerance and that, other, most likely, neurological mechanisms may play a more important role. CLINICAL RELEVANCE: There is no direct correlation between cold intolerance and re-warming patterns in different peripheral nerve injury rat models. This is an important finding for future developing treatments for this common problem, since treatment focussing on vaso-regulation may not help diminish symptoms of cold-intolerant patients.

Digital rewarming patterns after median and ulnar nerve injury.

PURPOSE: Posttraumatic cold intolerance (CI) is a frequent and important sequel after peripheral nerve injury. In this study, it is hypothesized that altered rewarming patterns after peripheral nerve injury are related to the degree of posttraumatic CI. This hypothesis is tested by quantitatively comparing rewarming patterns of the digits in controls and in median or ulnar nerve injury patients and by investigating relationships between rewarming patterns, sensory recovery, and CI. METHODS: Twelve median or ulnar nerve injury patients with a follow-up of 4 to 76 months after nerve repair and 13 control subjects had isolated cold stress testing of the hands. Video thermography was used to analyze and compare rewarming patterns of the injured and uninjured digits after cold stress testing. Temperature curves were analyzed by calculating the Q value as an indicator of heat transfer (temperature added during the first 10 minutes after start of active rewarming) and the maximum slope. RESULTS: Test-retest reliability was 0.64 and 0.79, respectively, for the Q value and maximum slope. High Q values and maximum slopes were interpreted as the presence of active rewarming. Patients with return of active rewarming had better sensory recovery and lower Blond McIndoe Cold Intolerance Severity Scale (CISS) scores. Better sensory recovery was correlated with lower CISS scores. CONCLUSIONS: Test-retest reliability of cold stress testing was good, and we found a difference in rewarming patterns between nerve injury patients and controls. The presence of active rewarming in the nerve injury patients was related to sensory recovery and fewer complaints of posttraumatic CI.