The Impact of Extracorporeal Shock Wave Therapy on Microcirculation in Diabetic Feet: A Pilot Study.

BACKGROUND: Patients with diabetic foot commonly experience vascular insufficiency and compromised tissue perfusion. Extracorporeal shockwave therapy (ESWT) reportedly promotes wound healing and angiogenesis, but clinical studies on the effect of ESWT on angiogenesis are scarce and the exact mechanism remains unclear. OBJECTIVE: To investigate the effect of ESWT on cutaneous microcirculation in diabetic feet. METHODS: Ten patients with diabetic feet received ESWT twice weekly for a total of six sessions. Transcutaneous partial oxygen pressure (TcPO2) and cutaneous blood flow were measured before and after ESWT. MAIN RESULTS: The treated feet showed statistically significant improvements in the mean TcPO2 (P < .01) and cutaneous blood flow level (P < .05) compared with control feet. In treated feet, TcPO2 increased by 19.6%, from 41.4 ± 9.9 to 49.5 ± 8.7 mm Hg (P < .05). In control feet, TcPO2 decreased by 11.6%, from 39.5 ± 14.0 to 34.9 ± 14.5 mm Hg (P = .059). The average cutaneous blood flow level of treated feet before ESWT was 36.9 ± 25.6, which increased to 48.3 ± 32.4 AU after ESWT (30.9% increase; P = .646). In control feet, the cutaneous blood flow level decreased from 80.5 ± 36.7 to 60.4 ± 38.8 AU, a decrease of 25.0% (P = .241). CONCLUSIONS: These results demonstrate that ESWT may have beneficial effects on microcirculation in diabetic feet.

Clinical Analysis of Nasal Bone Fracture in Patients Who Have Previously Undergone Dorsal Augmentation Using Silicone Implants: A Pilot Study.

BACKGROUND: There are no studies about the treatment of nasal bone fractures in patients with dorsal augmentations using silicone implants. We aimed to describe the characteristics of nasal bone fracture in patients who underwent rhinoplasty and compare the difference between closed reduction and conservative treatment of nasal bone fractures in patients with a history of rhinoplasty. METHODS: Between January 2013 and June 2018, a total of 463 patients were admitted to our center for nasal bone fracture; 17 patients with nasal bone fractures who underwent rhinoplasty were included, of which, five underwent closed reduction in the nasal bone and 12 underwent conservative treatment. Three of 12 patients who were initially treated conservatively underwent a secondary rhinoplasty for esthetic improvements. All patients were classified according to fracture site and the presence of a nasal septal fracture-in accordance with the modified Murray classification-and were analyzed for the correlation between fracture type and disease course. RESULTS: The nasal bone fracture types per computed tomography findings were unilateral (n = 13), bilateral (n = 4), septal (n = 1), and M-type (n = 1). No significant differences in fracture site (P > 0.05) and the presence of a nasal septal fracture (P > 0.05) were found between the groups. Fracture type did not significantly differ among patients who underwent closed reduction, conservative treatment without secondary rhinoplasty, and secondary rhinoplasty (P > 0.05). CONCLUSIONS: Despite risking traumatic capsular rupture, implant removal is seldom required and closed reduction is recommended if visible deviations are present; otherwise, only conservative treatment is recommended. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Influence of Peripheral Neuropathy and Microangiopathy on Skin Hydration in the Feet of Patients With Diabetes Mellitus.

INTRODUCTION: Maintaining adequate skin hydration is crucial in the feet of patients with diabetes because xerotic skin may crack and develop fissures, thereby increasing vulnerability to ulceration and infection. The nervous system is considered the powerhouse for maintaining adequate skin hydration; however, no clinical study has assessed the effect of the nervous system on skin hydration. In addition, it is hypothesized that microcirculation may play an important role in maintaining adequate hydration in patients with diabetes. OBJECTIVE: This study aims to evaluate the influence of peripheral nerve function and microvascularity on skin hydration in the feet of patients with diabetes mellitus and compare the effects of these 2 functions on skin hydration. MATERIALS AND METHODS: This study included 266 patients with diabetic foot disease. Skin hydration was evaluated using corneometry and microvascularity by measuring the transcutaneous oximetry (TcpO2) of the foot. The Semmes-Weinstein 5.07/10-g monofilament test, electromyography, and nerve conduction velocity test were conducted to evaluate peripheral neuropathy. Patient data were divided into 3 subgroups according to test values, and statistical comparisons were performed using the linear-by-linear association trend and Pearson's chi-square tests. RESULTS: There was a significant correlation between skin hydration and TcpO2. However, there was no significant correlation between skin hydration and peripheral nerve function (P = .338). CONCLUSIONS: The results of this study demonstrated that skin hydration in the feet of patients with diabetes mellitus mainly is influenced by microcirculation rather than peripheral nerve function.

Comparison of perfusion values after percutaneous transluminal angioplasty according to the severity of ischaemia in the diabetic foot.

Percutaneous transluminal angioplasty (PTA) is now more frequently used to improve tissue perfusion in ischemic diabetic feet. However, there are concerns about its feasibility and effectiveness in severely ischaemic feet. This study aimed to compare the perfusion values after PTA according to the ischaemic degree of diabetic feet. This study included 133 ischaemic diabetic feet. The foot transcutaneous oxygen pressure (TcPO2 ) and toe pressure were measured before the procedure and every second postoperative week for 6 weeks. The patients were divided into three groups according to ischaemic severity on the basis of TcPO2 and toe pressures. In the "severely ischaemic" group, the TcPO2 increased from 7.5 ± 4.9 to 40.3 ± 11.3 mm Hg (5.4-fold) 6 weeks after the PTA (P < 0.001). The toe pressure increased from 8.5 ± 8.8 to 42.2 ± 19.3 mm Hg (5.0-fold, P < 0.001). In the "mild" group, the TcPO2 increased from 35.4 ± 2.5 to 41.8 ± 12.4 mm Hg (1.2-fold, P = 0.003), and the toe pressure increased from 45.7 ± 12.3 to 54.3 ± 31.3 mm Hg (1.2-fold, P > 0.05). Results of the "intermediate" group were in between. The most severely ischaemic group had the most dramatic increase of tissue perfusion after PTA. As such, PTA can be an effective method for increasing tissue perfusion even in the severely ischaemic diabetic feet.

Effects of Ultraviolet Irradiation on Cellular Senescence in Keratinocytes Versus Fibroblasts.

Aging is a biologic process characterized by time-dependent functional declines that are influenced by oxidative stress-induced inflammatory reactions. In particular, ultraviolet (UV) irradiation plays a key role in cellular senescence in photo-aged skin. However, the cellular senescence of epidermal keratinocytes and dermal fibroblasts by UV irradiation may differ depending on the exposure time and dosage of UV irradiation. Therefore, the purpose of the study was to evaluate and compare the effects of UV irradiation on cellular senescence in human epidermal keratinocytes (HaCaT) and human dermal fibroblasts (HDFs). After cell viability test, 200 mJ/cm UV irradiation was used in this study. To evaluate the reactive oxygen species and reactive nitrogen species production, the levels of glutathione (GSH) and nitrite (NO2) were measured. We also performed reverse transcription-polymerase chain reaction, Western blot analysis, and senescence-associated beta-galactosidase assay. An overall decrease in GSH and an increase in NO2 were observed in the HaCaT and HDF cells. However, the time-line and dose-dependent effects varied. Higher expressions of tumor necrosis factor-α, inducible nitric oxide synthase, and interleukin-1ß than that of the control group were observed in both cells. The HDF cells showed high levels of matrix metallopeptidase 9 and neutral endopeptidase protein but low levels of SIRT1 and procollagen I. The expression of nuclear factor kappa-light-chain-enhancer of activated B cell (NF-κB) was increased in the HaCaT cells, but not in the HDF cells. The NF-κB peaked at 1 hour after UV irradiation in the HaCaT cells. The "turning-on" signal was faster in the irradiated HaCaT cells.

Pharmacological thrombolysis: the last choice for salvaging free flaps.

Microvascular free flap transfer has become a prevailing surgery with a failure rate of <5%. However, pedicle thrombosis occurs more frequently than indicated by the failure rate. This difference is due to the successful salvage of failing flaps. During exploration, thrombi are often encountered at anastomotic sites, whereas these causes could not explain vascular compromise in other patients. Thus, we hypothesized that thrombogenic processes might occur at remote sites, specifically within microvessels of the transferred flap. This study retrospectively evaluated 323 patients who underwent microvascular free flap transfer between March 2012 and October 2016 at Korea University Guro Hospital. All patients requiring emergency exploration within 7 days after surgery were retrospectively reviewed. Of patients, 15 required explorative surgery for suspected circulatory compromise. Eight were diagnosed with thrombosis at the perianastomotic site and salvaged in accordance with our protocol. There was no detectable thrombosis at the anastomotic site in seven patients, including one patient in whom thrombosis resolved with topical papaverine application and heparinization. The remaining six patients were diagnosed with intra-flap microthrombosis without discernable thrombosis at the anastomotic site. All patients were treated following our urokinase administration protocol and salvaged without complications. Possible external causes should first be evaluated when salvaging free flaps; in the absence of such evidence, urokinase administration may be utilized as a last resort. This study is the first report describing the effectiveness of pharmacological thrombolysis in resolving intra-flap microthrombosis. Furthermore, a safe and efficient urokinase administration protocol is suggested for perianastomotic thrombosis and intra-flap microthrombosis.