'Real angiosome' assessment from peripheral tissue perfusion using tissue oxygen saturation foot-mapping in patients with critical limb ischemia.

OBJECTIVES: The "tissue oxygen saturation (StO2) foot-mapping" method was developed using a non-invasive near-infrared tissue oximeter monitor to classify the foot regions as ischemic and non-ischemic areas. The purpose of this study was to evaluate StO2 foot-mapping as a reliable method to detect ischemic areas in the feet of patients with critical limb ischemia (CLI), and to compare the results with assessments from the angiosome model. METHODS: The foot areas of 20 CLI patients and 20 healthy controls were classified into four regions: (1) 0 ≤ StO2 < 30%, (2) 30 ≤ StO2 < 50%, (3) 50 ≤ StO2 < 70%, and (4) 70 ≤ StO2 ≤ 100% to perform StO2 foot-mapping. Each area occupancy rate was compared between the two groups, and the threshold StO2 value for detecting ischemia was set. Next, the locations of ulcers (in 16 patients) were compared to the predicted ischemic regions by the StO2 foot-mapping and by the angiosome model and angiography. RESULTS: In regions (1) and (2) (StO2 < 50%), the area occupancy rate was significantly higher in the CLI group and almost zero in the control group, so that the threshold StO2 value for detecting ischemia was set at 50%. The locations of ulcers were compatible with StO2 foot-mapping in 87.5% of the cases (14/16), while they were compatible with the assessment from the angiosome model in 68.8% of the cases (11/16). CONCLUSIONS: This study suggests that StO2 foot-mapping can successfully and non-invasively detect ischemic areas in the peripheral tissue of the foot, and also more appropriately than the assessment provided by the angiosome model. StO2 foot-mapping can be used to evaluate the real angiosome: the real distribution of the peripheral tissue perfusion in the CLI patient's foot, which is determined by the peripheral microvascular blood flow, rather than the main arterial blood flow.

Topical negative pressure therapy for para-ileostomal ulceration in a patient with Behçet's disease.

BehCet's disease is a chronic, relapsing, inflammatory disorder. This case report describes how use of an improvised topical negative pressure (TNP) device in a patient with a non-healing para-ileostomal ulcer with Behçet's disease.

Elastic plasma protein film blended with platelet releasate accelerates healing of diabetic mouse skin wounds.

BACKGROUND AND OBJECTIVES: The growth factors derived from platelets and plasma proteins mediate the wound-healing process that is characterized by the sequential migration and differentiation of several cell populations that give rise to angiogenesis, collagen synthesis, wound contraction, and re-epithelialization. To evaluate the efficacy of the blood-derived factors in wound healing, we examined a novel wound dressing consisting of concentrated human plasma proteins and platelet releasate (CPPP). MATERIALS AND METHODS: To generate CPPP, plasma proteins and platelets in the peripheral blood (n = 5) were concentrated with the cold ethanol precipitation method. The thrombin obtained from the same blood unit and calcium chloride (CaCl(2)) were mixed to a concentrate. The CPPP has enough strength to dress cutaneous wounds and contains large amounts of cytokines and fibronectin. We applied the CPPP to excisional skin wounds in genetically healing-impaired model mice (n= 5) and the wounds were evaluated 10 days after the operation. RESULTS: The area of CPPP-treated wounds decreased significantly compared with that of the control wounds (65% vs. 94% of the original size, respectively, P= 0.032). The immunostained section revealed a striking effect of CPPP on vascularization compared with the control wounds (13.2 vs. 2.7 vessels per mm(2) as mean vascular density observed in the sections, respectively, P= 0.013). CONCLUSIONS: Our results suggest that CPPP is a promising biologically active dressing for full-thickness skin wounds. CPPP can be an entirely autologous biological dressing, suggesting that it is free from the risk of transmission of pathogens through blood products.

Efficacy of a skin-protection powder for use as a dressing for intractable ulcers.

OBJECTIVE: Stomahesive skin-protection powder has been reported to be useful as a skin-care and skin-barrier product for the management of stomas. This study aimed to evaluate its efficacy, in terms of wound healing, moisture retention and pain management, as an alternative to conventional dressing materials. Both clinical and animal studies were undertaken. METHOD: The efficacy of the Stomahesive powder was tested by measuring the thickness of granulation tissue formed in a total skin defect in a db/db mouse model. We then compared the healing process using either the skin-protection powder or a conventional film dressing material. In the clinical study 17 patients with various intractable ulcers were treated with Stomahesive powder, and healing was evaluated. RESULTS: In the mouse model, granulation tissue in the wounds treated with the powder was 2.86 times thicker than that of the wounds treated with the film dressing. In the clinical study, 16 out of 17 wounds healed completely. CONCLUSION: The Stomahesive powder could be an effective treatment modality for contact ulceration, superficial ulcers with complex contours and morphology, and superficial ulcers contaminated by liquid faeces or vaginal discharge that have not responded to conventional dressings. DECLARATION OF INTEREST: None.

Evaluating dressing materials for the prevention of shear force in the treatment of pressure ulcers.

OBJECTIVE: Shear force is believed to affect pressure ulceration. Therefore, dressing materials that reduce shear force may prevent ulceration and facilitate healing. METHOD: We measured the following three properties: the coefficient of friction between the outer layer of the dressings and the patient's clothes; the degree of adhesiveness between the inner layer of the dressing and the patient's skin; the transmissibility of shear force of the dressing. RESULTS: The coefficients of static friction were 1.01 for hydropolymer, 0.72 for hydrofoam and 0.48 for hydrocolloid. Adhesiveness was tested by rolling different sized ball bearings down a slope and over the adhesive lining under both wet and dry conditions. Under dry conditions, the heaviest ball bearing that stopped rolling for five seconds was 111.9g for both hydrofoam and hydrocolloid. Under wet condition, it was 11.9g for hydrofoam and under 1g for hydrocolloid. Tests showed the very low transmissibility (I N buffer) of shear force for hydrofoam, with significant differences between the dressings. Clinical observation has identified good results for hydrofoam when used under highly exuding conditions and for hydrocolloid when used with relatively slight or decreased exudate. CONCLUSION: Existing dressing materials are being developed and evaluated for wound healing. However, if innovations in the raw materials from which dressings are manufactured could lead to a reduction in shear force and the prevention of pressure ulcers, then dressing materials could be discussed from a viewpoint that is quite different from wound healing.

Benefits of surgical reconstruction in pressure ulcers with a non-advancing edge and scar formation.

OBJECTIVE: To highlight the difficulty in treating pressure ulcers associated with scar formation and the benefits of surgical treatment in these cases by presenting a series of clinical cases. METHOD: Nine sacral ulcers surrounded by significant scar formation and 14 sacral ulcers without significant scars were treated using the same conservative management protocol. Healing status was quantitatively estimated using an assessment tool called DESIGN, which classifies pressure ulcer severity and allows healing to be monitored; a decreasing score indicates progressive improvement. RESULTS: Ulcers with scar formation showed little response to the treatment, while those without remarkable scars exhibited a significant decrease of the DESIGN scores. Surgical reconstruction was conducted in five ulcers surrounded by scar formation, and all showed complete healing within extremely short periods. CONCLUSION: Conservative treatment of pressure ulcers with a non-advancing edge surrounded by scar formation presents considerable difficulties. Surgical reconstruction offers many benefits for non-healing ulcers.

The positive experience of using a growth factor product on deep wounds with exposed bone.

Trafermin, a form of basic fibroblast growth factor, has been used in Japan since 2001. This study investigates whether it can facilitate closure in wounds with deep soft-tissue defects and exposed bone, where surgical closure is not possible.

Clinical use of amrinone (a selective phosphodiesterase III inhibitor) in reconstructive surgery.

Amrinone is a selective phosphodiesterase III inhibitor that increases cyclic adenosine monophosphate by preventing its breakdown. It is effective in the treatment of congestive heart failure because of its ability to increase myocardial contractility and vascular smooth muscle relaxation. This study was designed to clarify the potential efficacy of amrinone in plastic surgery by clinically assessing its ability to enhance flap blood flow after reconstructive surgery and relieve intraoperative vasospasm. Its effects were compared with those of prostaglandin E1 and lidocaine, which are widely approved agents for improving the hemodynamics of flaps. In the first clinical study, the effects on flap blood flow after flap transfers were investigated. Twenty-six patients underwent reconstructive surgery with vascularized free or pedicled flaps. Blood flow was measured before and 60 minutes after intravenous infusion of lactated Ringer solution (control), amrinone (10 microg/kg/min), or prostaglandin E1 (10 ng/kg/min) using a laser Doppler flowmeter. In the second study, the effects on relief of vasospasm during operation were evaluated. The blood flow of 28 island flaps was measured by laser Doppler flowmetry immediately after flap elevation and 10 minutes after topical application of saline (control), amrinone (5 mg/ml), or lidocaine (10%) to the pedicle in an attempt to resolve the vasospasm. In both clinical studies, the effects of amrinone were statistically no less than those of prostaglandin E1 and lidocaine. The results show that amrinone positively influences the microcirculatory blood flow of transferred flaps and relieves intraoperative vasospasm in clinical cases. The present study suggests that amrinone could be useful for postoperative and intraoperative care in reconstructive surgery.

Sp1-mediated downregulation of P2X4 receptor gene transcription in endothelial cells exposed to shear stress.

Endothelial purinoceptors play an important role in vascular responses to extracellular adenine nucleotides and hemodynamic forces. Here we report that P2X4 purinoceptor expression in human umbilical vein endothelial cells is transcriptionally downregulated by fluid shear stress. When human umbilical vein endothelial cells were subjected to a laminar shear stress of 15 dyn/cm(2), P2X4 mRNA levels began to decrease within 1 h and further decreased with time, reaching 60% at 24 h. Functional analysis of the 1.9-kb P2X4 5'-promoter indicated that a 131-bp segment (-112 to +19 bp relative to the transcription start site) containing a consensus binding site for the Sp1 transcription factor was critical for the shear stress responsiveness. Mutations of the Sp1 site decreased the basal level of transcription and abolished the response of the P2X4 promoter to shear stress. Electrophoretic mobility shift assays showed a marked decrease in binding of Sp1 to the Sp1 consensus element in shear-stressed cells, suggesting that Sp1 mediates the shear stress-induced downregulation of P2X4 gene transcription.

Topical application of amrinone (a selective phosphodiesterase III inhibitor) for relief of vasospasm.

BACKGROUND: Amrinone, a selective phosphodiesterase III inhibitor, is an agent that possesses a combination of positive inotropic and vasodilating properties as a result of preventing the degradation of cAMP, and it has recently been licensed for the treatment of heart failure. The aim of this study was to investigate the potential therapeutic application of amrinone to resolve vasospasm, which is the major problem in reconstructive surgery. In this study its effect was compared with that of lidocaine, the most commonly used topical vasodilating agent clinically. MATERIALS AND METHODS: The probe of an ultrasonic transit-time volume flowmeter was applied to the femoral artery of rats to measure blood flow. After a baseline recording was obtained, 0.03 ml of epinephrine was applied topically to induce vasospasm. The vessels were then immersed in 1 ml of amrinone (5 mg/ml), 10% lidocaine hydrochloride, or normal physiological saline solution for 1 min in an attempt to resolve the spasm. In another group of animals, no solution was used following administration of epinephrine to allow observation of spontaneous resolution of the vasospasm over time. RESULTS: The results showed an essentially immediate spasm-resolving effect in both the amrinone group and the lidocaine group. The amrinone group showed a significantly greater degree of maximum increase in blood flow than the lidocaine group. The effect of lidocaine decreased with time, whereas amrinone had a more lasting effect. CONCLUSIONS: The findings suggest that amrinone could be used as an effective topical vasodilating agent to resolve vasospasm in reconstructive surgery.

Avoiding ectropion by using the Mitek Anchor System for flap fixation to the facial bones.

The application of the Mitek Anchor System for bony fixation of the flap in the cheek area is described. The cervicofacial rotation-advancement flap is fixated to the malar bone using Mini Anchors for the purpose of diminishing the downward traction on the lower eyelid. They reduced the tension in the distal part of the flap and avoided distal-edge necrosis and ectropion. In another patient the free vascularized musculocutaneous flap, which had been grafted previously for a surgical defect in the cheek and resulted in ectropion of the lower eyelid, was fixated to the malar bone, and the ectropion was corrected. The Mitek Anchor System is useful in flap fixation to the bone because it provides a simple, fast, and reliable method for flap fixation with minimal dissection and precise placement.