Sample size determination in the laser-Doppler measurements of skin blood flow.

Pre-study calculations of the required sample size are vital to a large majority of studies. Using the method based on the Monte-Carlo simulations, we have illustrated how the sample size is related to the statistic power value, the significance level, the variability of observations and the minor magnitude of the effect of interest under study. If the study has been already completed, one should not perform any 'post hoc' power calculations. In this case, calculation of confidence intervals is a better choice. We assessed the confidence intervals given in a number of publications where microcirculation is studied by LDF techniques using different protocols. We have found that types I and II errors are frequently encountered in the LDF studies, which is a consequence of an inappropriate sample size.

Local Heating Test for Detection of Microcirculation Abnormalities in Patients with Diabetes-Related Foot Complications.

OBJECTIVE: In this study, authors used a wavelet analysis of skin temperature (WAST) to assess the mechanisms of microvascular tone regulation during the local heating test in patients with diabetic foot syndrome (DFS). PARTICIPANTS: The participants included control subjects and 36 hospitalized patients with DFS between 52 and 79 years old (68 ± 8 years old). They were distributed among 5 groups: 15 control subjects, 8 patients with DFS who did not develop ulcerative or necrotic disorders, 10 patients who developed the neuroischemic form of DFS complicated by foot ulceration, 12 patients with DFS complicated by toe necrosis, and 6 patients with DFS and foot gangrene. OUTCOME MEASURES: A comparison among the groups was made using a nonparametric Mann-Whitney U test. Spearman correlation coefficients were used to assess the relationship between WAST results, aortoarteriography, and ultrasonic dopplerography data. MAIN RESULTS: In control subjects, a local increase in temperature (up to 42° C) causes a more than 3-fold increase in the amplitude of foot skin temperature oscillations. In patients with DFS, the response to the local heating test was much weaker. High correlations of WAST results to arterial patency of the lower extremities and the state of the vascular walls were established. CONCLUSIONS: The WAST technique may have considerable value in evaluating the progression of DFS and the effectiveness of therapeutic interventions. The low cost of an individual test makes the WAST technique suitable for routine use in most healthcare facilities.

Early differential diagnosis of the severity of acute pancreatitis.

There is a great need for early verification of the severity of acute pancreatitis (AP). The early stage of pathogenesis of AP is characterized by endothelial dysfunction which could be determined by wavelet analysis of skin temperature (WAST) technique. The aim is to investigate whether the dysregulation of microvascular tone caused by endothelial dysfunction and detected by WAST can be a significant indicator in early differential diagnosis of AP severity. The WAST performed in the frequency range of 0.0095-0.02 Hz during the contralateral cold test. Forty nine patients with AP aged 19-65 participated in this study. The control group included 12 healthy volunteers aged 20-65. Dysregulation of vascular tone during the contralateral cold test was observed in all patients with AP. The basal amplitudes of skin temperature oscillations in patients with AP were much lower than in healthy volunteers and progressively decreased as the disease severity increased. In patients with mild and moderate AP only the vasodilator component is destroyed, but vasoconstriction still operates. In patients with severe AP both mechanisms of endothelial vascular tone regulation are destroyed. Patients with AP have abnormal microvascular reactions related to the endothelial mechanism of vascular tone regulation. Based on the initial values of amplitudes and the indices of vasoconstriction and postcold vasodilatation, the WAST method makes it possible to evaluate two related but different characteristics of the endothelial dysfunction in patients with AP on admission which can be a significant indicator in early differential diagnosis of AP severity.

Relationship of oscillating and average components of laser Doppler flowmetry signal.

Signals from laser Doppler flowmeters widely used in intravital studies of skin blood flow include, along with a slowly varying average component, an oscillating part. However, in most clinical studies, pulsations are usually smoothed by data preprocessing and only the mean blood flow is analyzed. To reveal the relationship between average and oscillating perfusion components measured by a laser Doppler flowmeter, we examined the microvascular response to the contralateral cold pressor test recorded at two different sites of the hand: dorsal part of the arm and finger pad. Such a protocol makes it possible to provide a wide range of perfusion. The average perfusion always decreases during cooling, while the oscillating component demonstrates a differently directed response. The wavelet analysis of laser Doppler flowmetry (LDF) signals shows that the pulsatile component is nonlinearly related to the average perfusion. Under low perfusion, the amplitude of pulsations is proportional to its mean value, but, as perfusion increases, the amplitude of pulsations becomes lower. The type of response is defined by the basal perfusion and the degree of vasoconstriction caused by cooling. Interpretation of the results is complicated by the nonlinear transfer function of the LDF device, the contribution of which is studied using artificial examples.

Assessment of cardiac time intervals by wavelet transform of the impedance cardiogram.

BACKGROUND: Impedance cardiography (ICG) is an inexpensive, noninvasive technique for estimating hemodynamic parameters. ICG can be used to obtain the ejection fraction of the left atrium and to monitor systolic time intervals. Traditional ICG technique does not enable unambiguous detection of the left ventricle ejection time (LVET) and the time relationships between specific marker points. OBJECTIVE: This work aims to approbate a new approach for ICG signal processing using wavelet transform (WT) and to investigate the possibilities of this approach for determination of the parameters which are related to the stroke volume (SV), in particular LVET. METHODS: Thoracic tetrapolar polyrheocardiography method for simultaneous registration of ECG, ICG and phonocardiograms has been used. A control group consisted of eight healthy men aged 20-25 years. In addition, four patients with essential hypertension participated in the study. Wavelet representation of the ICG data produced local maxima in a two dimensional distribution of the wavelet coefficient. Each extremum point was characterized by the amplitude, scale and time, which determine SV. RESULTS: LVET was defined as the scale corresponding to the E-wave maximum related to the systolic phase of the cardiac cycle. Also, we defined the initial systolic time interval (ISTI) as the time interval between R peak in the ECG and E-wave maximum on the wavelet plane. During functional test LVET and ISTI values defined by WT demonstrated a proper hemodynamic response to loading for the control group and patients with essential hypertension. CONCLUSION: The proposed approach demonstrates the ability of ICG-WT technique for adequate assessment of SV parameters, including cardiac time intervals.

Detection of Endothelial Dysfunction Using Skin Temperature Oscillations Analysis During Local Heating in Patients With Peripheral Arterial Disease.

OBJECTIVE: The purpose of this study was to examine correlations between laboratory markers of ED and the degree of endothelium-dependent vasodilation using WAST during a local heating test in patients with PAD. MATERIALS AND METHODS: The study population consisted of 17 healthy subjects and 38 patients with PAD. The ST on the plantar surface of the first toe was measured during the test, and the inverse wavelet transform was applied to reconstruct the ST signals in three frequency bands corresponding to myogenic, neurogenic, and endothelial mechanisms of vascular tone regulation. RESULTS: In healthy subjects, a local increase in temperature of up to 42°C caused a greater than threefold increase in the amplitudes of foot ST oscillations. Among patients with PAD, the response to the test was much weaker in all frequency ranges. The level of vasodilation dysfunction correlated with the level of artery stenosis in the lower extremities and with laboratory markers of ED (endothelin, homocysteine, and von Willebrand factor). CONCLUSION: WAST can be considered as a low cost, portable, and easy to use technique for the noninvasive assessment of ED.

Quantifying the correlation between photoplethysmography and laser Doppler flowmetry microvascular low-frequency oscillations.

Photoplethysmography (PPG) and laser Doppler flowmetry (LDF) are two recognized optical techniques that can track low-frequency perfusion changes in microcirculation. The aim of this study was to determine, in healthy subjects, the correlation between the techniques for specific low-frequency bands previously defined for microcirculation. Twelve healthy male subjects (age range 18 to 50 years) were studied, with PPG and LDF signals recorded for 20 min from their right and left index (PPG) and middle (LDF) fingers. Wavelet analysis comprised dividing the low-frequency integral wavelet spectrum (IWS) into five established physiological bands relating to cardiac, respiratory, myogenic, neurogenic, and endothelial activities. The correlation between PPG and LDF was quantified using wavelet correlation analysis and Spearman correlation analysis of the median IWS amplitude. The median wavelet correlation between signals (right-left side average) was 0.45 (cardiac), 0.49 (respiratory), 0.86 (myogenic), 0.91 (neurogenic), and 0.91 (endothelial). The correlation of IWS amplitude values (right-left side average) was statistically significant for the cardiac (ρ = 0.64, p < 0.05) and endothelial (ρ = 0.62, p < 0.05) bands. This pilot study has shown good correlation between PPG and LDF for specific physiological frequency bands. In particular, the results suggest that PPG has the potential to be a low-cost replacement for LDF for endothelial activity assessments.

Skin blood flow and temperature oscillations during cold pressor test.

We study the relationship between the blood flow and skin temperature variations under a cold pressor test (CPT). The simultaneous laser Doppler flowmetry (LDF) and skin temperature (ST) measurements were carried out for 8 healthy subjects on the skin surface of the distal phalanx of the second (LDF) and third (ST) fingers. The skin blood perfusion decreases stepwise about twice during contralateral CPT for all 8 subjects. The temperature of the finger pad decays monotonically during the test and dropped about 1°C in mean. The power spectral densities of LDF flow and ST variations are also affected by the CPT, but subjects under study demonstrate two different types of reaction. LDF pulsations at the frequency about 0.1 Hz, which corresponds to the myogenic mechanism of vascular tone regulation, decreases in 5 subjects and increases in other 3 subjects. However in all subjects the ST pulsations behave contradictory, namely, the changes in amplitude of blood perfusion and ST pulsations due to cold pressor test are strongly anticorrelated. We discuss possible mechanisms of vascular reaction that can cause the behavior observed.

Wavelet-analysis of skin temperature oscillations during local heating for revealing endothelial dysfunction.

Skin microvessels have proven to be a model to investigate the mechanisms of vascular disease; in particular, endothelial dysfunction. To analyze skin blood flow, high-resolution thermometry can be used because low-amplitude skin temperature oscillations are caused by changes in the tone of skin vessels. The aim of our study was to test the possibilities of wavelet analysis of skin temperature (WAST) for the diagnosis of impaired regulation of microvascular tone in patients with type 2 diabetes. A local heating functional test was used for the assessment of microvascular tone regulation. A control group consisted of healthy male and female volunteers (n=5 each), aged 39.1±5.3years. A group of patients with type 2 diabetes comprised thirteen people, seven men and six women, aged 36 to 51years old (43.2±3.4years). The diagnosis of diabetes was made according to the criteria of the World Health Organization (WHO). The mean disease duration was 7.36±0.88years. Skin temperature oscillations, reflecting intrinsic myogenic activity (0.05-0.14Hz), neurogenic factors (0.02-0.05Hz) and endothelial activity (0.0095-0.02Hz) increase greatly during local heating for healthy subjects. In the group of patients with type 2 diabetes, no statistically significant differences in the amplitudes in the endothelial range were observed. Relative changes in the oscillation amplitudes in patients with type 2 diabetes were markedly lower compared to the control group. The latter indicates that the WAST method enables assessment of the state of vascular tone and the effects of mechanisms responsible for regulation of blood flow in the microvasculature.

Assessment of endothelial dysfunction in patients with impaired glucose tolerance during a cold pressor test.

The objective of this study is to explore changes in microvascular tone during a contralateral cold pressor test and to compare the results obtained in healthy subjects and in patients with impaired glucose tolerance (IGT) and type 2 diabetes. Low-amplitude fluctuations of skin temperature in the appropriate frequency ranges were used as a characteristic for the mechanism for vascular tone regulation. In total, 13 adults with type 2 diabetes aged 40-67 years and 18 adults with IGT aged 31-60 years participated in this pilot study. The control group included 12 healthy men and women aged 39-60 years. The response to the cold pressor test in patients with type 2 diabetes and with IGT differs essentially from that of healthy subjects in the endothelial frequency range. Endothelial dysfunction occurs in the preclinical stage of diabetes and manifests, in particular, as a disturbance of the endothelial part of vascular tone regulation.

Finger microvascular responses to deep inspiratory gasp assessed and quantified using wavelet analysis.

The physiological changes following a deep inspiratory gasp (DIG) manoeuvre have been described in the literature. However, the lack of a reliable signal processing technique to visualize and quantify these physiological changes has so far limited the applicability of the test to the clinical setting. The main aim of this study was to assess the feasibility of using wavelet analysis to quantify the pulse arrival time (PAT) and its changes during the DIG manoeuvre. Vascular responses were extracted from cardiac (electrocardiogram, ECG) and peripheral pulse (photoplethysmography, PPG) waveforms. Wavelet analysis characterized their cardiovascular responses in healthy adult subjects in the time-frequency space, and for the ECG-PPG inter-relationship in terms of the PAT. PAT showed a characteristic biphasic response to gasp, with an increase of 59 ± 59 ms (p = 0.001) compared to the maximum value reached during quiet breathing, and a decrease of -38 ± 55 ms (p < 0.01) compared to the minimum value during quiet breathing. The response measures were repeatable. This pilot study has successfully shown the feasibility of using wavelet analysis to characterize the cardiovascular waveforms and quantify their changes with DIG.

Wavelet-based correlations of skin temperature and blood flow oscillations.

The wavelet transform-based correlation analysis has been used to study skin temperature fluctuations caused by periodic changes in blood flow resulting from oscillations in vasomotor smooth muscle tone. We considered two cases, one in which temperature measurements and blood flow recordings by laser Doppler flowmetry are made simultaneously and another in which two temperature signals are measured concurrently. Twelve healthy subjects participated in our study. The gapped wavelet technique was used to suppress artifacts caused by boundary effects. Simultaneous recordings of skin temperature fluctuations and the signal of the laser Doppler flowmeter provided correlation coefficients essentially exceeding the values obtained for noise signals within three spectral ranges corresponding to myogenic (0.05-0.14 Hz), neurogenic (0.02-0.05 Hz), and endothelial (0.0095-0.02 Hz) regulation mechanisms. Within the frequency range from 0.14 to 2 Hz the values of the correlation function are compatible with the values of noise correlations. The same results were obtained for two concurrently measured temperature signals. Reduction in the amplitude of temperature fluctuations and in the level of correlations with the frequency arises because the skin has the properties of a low-frequency filter. As temperature fluctuations propagate their amplitude decays as an exponential function of frequency. Hence small oscillations in the spectral range reflecting the influence of heartbeat and respiration cannot be distinguished from external thermal noise.