Quantifying traffic, biomass burning and secondary source contributions to atmospheric particle number concentrations at urban and suburban sites.

In this study, we propose a new approach to determine the contributions of primary vehicle exhaust (N1ff), primary biomass burning (N1bb) and secondary (N2) particles to mode segregated particle number concentrations. We used simultaneous measurements of aerosol size distribution in the 12-600 nm size range and black carbon (BC) concentration obtained during winter period at urban and suburban sites influenced by biomass burning (BB) emissions. As expected, larger aerosol number concentrations in the 12-25 and 25-100 nm size ranges are observed at the urban site compared to the suburban site. However, similar concentrations of BC are observed at both sites due to the larger contribution of BB particles to the observed BC at suburban (34%) in comparison to urban site (23%). Due to this influence of BB emissions in our study area, the application of the Rodríguez and Cuevas (2007) method, which was developed for areas mainly influenced by traffic emissions, leads to an overestimation of the primary vehicle exhaust particles concentrations by 18% and 26% in urban and suburban sites, respectively, as compared to our new proposed approach. The results show that (1) N2 is the main contributor in all size ranges at both sites, (2) N1ff is the main contributor to primary particles (>70%) in all size ranges at both sites and (3) N1bb contributes significantly to the primary particles in the 25-100 and 100-600 nm size ranges at the suburban (24% and 28%, respectively) and urban (13% and 20%, respectively) sites. At urban site, the N1ff contribution shows a slight increase with the increase of total particle concentration, reaching a contribution of up to 65% at high ambient aerosol concentrations. New particle formation events are an important aerosol source during summer noon hours but, on average, these events do not implicate a considerable contribution to urban particles.

Impact of primary NO2 emissions at different urban sites exceeding the European NO2 standard limit.

A large part of the European population is still exposed to ambient nitrogen dioxide (NO2) levels exceeding the European Union (EU) air quality standards, being a key challenge to reduce NO2 concentrations across many European urban areas, particularly close to roads. In this work, a trend analysis of pollutants involved in NO2 processes was done for the period 2003-2014 in traffic sites from three Spanish cities (Barcelona, Madrid and Granada) that still exceed the European NO2 air quality standard limits. We also estimated the contributions of primary NO2 emissions and photo-chemically formed NO2 to the observed ambient NO2 concentrations in order to explore their possible role in the observed NO2 concentration trends. The NOx and NO concentrations at these traffic sites showed significant decreasing trends during the period 2003-2014, especially at Barcelona (BARTR) and Madrid (MADTR) traffic stations. The NO2 concentrations showed statistically significant downward trends at BARTR and MADTR and remained unchanged at Granada traffic station (GRATR) during the study period. Despite the significant decrease in NO2 concentrations in BCNTR and MADTR during the analysed period, the NO2 concentrations observed over these sites still above the annual NO2 standard limit of 40 µg m-3 and, therefore, more efficient measures are still needed. Primary NO2 emissions significantly influence NO2 concentrations at the three analysed sites. However, as no drastic changes are expected in the after-exhaust treatment technology that can reduce primary NO2 emissions to zero in the near future, only a substantial reduction in NOx emissions will help to comply with the NO2 European air quality standards. Reduction of 78%, 56% and 16% on NOx emissions in Barcelona, Madrid and Granada were estimated to be necessary to comply with the NO2 annual limit of 40 µg m-3.

Abortion in goats by Caprine alphaherpesvirus 1 in Spain.

An abortion outbreak occurred in a goat herd of Murciano-Granadina breed in Almeria Region in Spain where 80 pregnant females aborted. All bacteriological and parasitological examinations resulted negative, whereas virological investigations and real-time PCR assay showed the presence of Caprine alphaherpesvirus 1 DNA in the pathological specimens from aborted foetuses. Nucleotide sequence analysis revealed that the DNA was highly close related to the Swiss strain E-CH (99.7%) and a little less extent to the Italian BA.1 strain (99.4%). Histopathological examination revealed multifocal, well-circumscribed, 50- to 200-µm-diameter foci of coagulative necrosis in the liver, lungs and kidneys of three foetuses. In the periphery of the necrosis, there were frequently epithelial cells with the chromatin emarginated by large, round, amphophilic intranuclear viral inclusion bodies. The source of the infection in the herd could not clearly find out even some hypothesis were formulated. This seems to be the first report of an abortion outbreak due to Caprine alphaherpesvirus 1 in a goat herd in Spain.

Spatial and temporal variability of carbonaceous aerosols: Assessing the impact of biomass burning in the urban environment.

Biomass burning (BB) is a significant source of atmospheric particles in many parts of the world. Whereas many studies have demonstrated the importance of BB emissions in central and northern Europe, especially in rural areas, its impact in urban air quality of southern European countries has been sparsely investigated. In this study, highly time resolved multi-wavelength absorption coefficients together with levoglucosan (BB tracer) mass concentrations were combined to apportion carbonaceous aerosol sources. The Aethalometer model takes advantage of the different spectral behavior of BB and fossil fuel (FF) combustion aerosols. The model was found to be more sensitive to the assumed value of the aerosol Ångström exponent (AAE) for FF (AAEff) than to the AAE for BB (AAEbb). As result of various sensitivity tests the model was optimized with AAEff=1.1 and AAEbb=2. The Aethalometer model and levoglucosan tracer estimates were in good agreement. The Aethalometer model was further applied to data from three sites in Granada urban area to evaluate the spatial variation of CMff and CMbb (carbonaceous matter from FF or BB origin, respectively) concentrations within the city. The results showed that CMbb was lower in the city centre while it has an unexpected profound impact on the CM levels measured in the suburbs (about 40%). Analysis of BB tracers with respect to wind speed suggested that BB was dominated by sources outside the city, to the west in a rural area. Distinguishing whether it corresponds to agricultural waste burning or with biomass burning for domestic heating was not possible. This study also shows that although traffic restrictions measures contribute to reduce carbonaceous concentrations, the extent of the reduction is very local. Other sources such as BB, which can contribute to CM as much as traffic emissions, should be targeted to reduce air pollution.

Electrochemical characterization of MC3T3-E1 cells cultured on γTiAl and Ti-6Al-4V alloys.

Electrochemical impedance spectroscopy (EIS) was used to study the behavior of MC3T3-E1 cells cultured in an αMEM+FBS solution on two Ti-based alloys (Ti-6Al-4V and γTiAl) for 4, 7 and 14 days. EIS measurements were carried out at an open-circuit potential in a 1 mHz to 100 kHz frequency range. Results indicate a general increase in impedance on the Ti alloy surfaces with cells as a function of time. Bode plots indicate changes corresponding to the passive oxide film, adsorption of proteins and cell tissue on surfaces with the passage of time. Normal cellular activity based on the polygonal morphology, with long and fine cytoplasmic prolongations of the cells on Ti-6Al-4V and γTiAl was observed from SEM images. Similarly, mineralization nodules corresponding to cell differentiation associated with the osseogenetic process were observed confirmed by Alizarin Red S staining. Immunofluorescence analysis to detect the presence of collagen Type I showed an increase in the segregation of collagen as a function of time. The impedance values obtained from EIS testing are indicative of the corrosion protection offered to the Ti alloy substrates by the cell layer. This study shows that γTiAl has better corrosion resistance than that of Ti-6Al-4V in the αMEM+FBS environment in the presence of MC3T3-E1 cells.

[Rhabdomyomatous mesenchymal hamartoma]. / Hamartoma mesenquimal rabdomiomatoso.

Rhabdomyomatous mesenchymal hamartoma is an extremely rare congenital lesion, and very few cases have been reported even though its macroscopic and microscopic features make diagnosis easy. An 18-year-old woman consulted with a pedunculated mass in the medial region of her neck. The mass was surgically removed, and rhabdomyomatous mesenchymal hamartoma was diagnosed. The clinical, macroscopic, histologic, and immunochemical characteristics that allow diagnosis of this entity are discussed. Although association with congenital abnormalities is uncommon, this possibility should be assessed by the clinician.

[Cryptococcoma in the central nervous system of a non-immunocompromised patient]. / Criptococoma en el sistema nervioso central de un paciente no inmunoafectado.

INTRODUCTION: Central nervous system cryptococcosis is an important cause of morbidity and mortality in immunocompromised patients; nevertheless, its presentation in immuno-spared patients is extremely rare, giving rise to a hole different spectrum, since it is manifested like granulomatous masses named cryptococomas. AIM. To describe an intracerebral case of cryptococcoma in an immuno-spared woman in the Hospital Universitario de Santander and to discuss the most relevant topics of this pathology. CASE REPORT: A 24 years-old woman, coming to the service presenting generalized tonic-clonic seizure, fixed upward gaze, sialorrhea and lost, without any data suggesting immunosupression. The computarized tomography of skull demonstrates a mass of possible inflammatory vs. noeplasmic origin. After performing imaging the patient is taken to surgery for craniotomy with excisional biopsy. By means of hystological analysis the diagnosis of cerebral criptococcoma is made, and antimycotic therapy is started, with favorable response. Actually the patient evidences good health, and no evidence of active disease. CONCLUSIONS: The presence of masses of criptococcal origin located at the central nervous system, which origin is due to a chronic granulomatous reaction, is rarely reported; these appear in almost all cases in immunocompetent patients, in which there is of primary importance to discard all causes of cellular immune deficit. Also, the diagnosis of these injuries must be considered before the presence of intracerebral masses that show inflammatory characteristics.

Criptococoma en el sistema nervioso central de un paciente no inmunoafectado / Cryptococcoma in the central nervous system of a non-immunocompromised patient

La criptococosis del sistema nervioso central (SNC) es una causa importante de morbilidad y mortalidaden pacientes inmunoafectados; sin embargo, su presentación en pacientes inmunocompetentes es extremadamente rara, ocasionando un espectro clínico diferente, ya que se manifiesta predominantemente como masas granulomatosas denominadascriptococomas. Objetivo. Describir un caso de criptococoma intracerebral en una mujer inmunocompetente atendida en el Hospital Universitario de Santander y discutir los aspectos más relevantes de esta patología. Caso clínico. Mujer de 24 años de edad, que ingresa por presentar convulsión tonicoclónica generalizada, con desviación de la mirada hacia arriba,sialorrea y pérdida de conocimiento, sin datos que sugieran inmunosupresión. La tomografía axial computarizada de cráneo evidencia una masa de posible origen inflamatorio en vez de neoplásico. Se lleva a cirugía y se le practica craneotomía conbiopsia excisional. Mediante análisis patológico, se hace el diagnóstico de criptococoma cerebral y se inicia el tratamiento antimicótico, con evolución favorable. Actualmente, la paciente se encuentra en buen estado de salud. Conclusiones. La presencia de masas de origen criptocóccico del SNC, debidas a una reacción granulomatosa crónica, se notifican raramente. Se presentan en casi todos los casos en pacientes inmunocompetentes, en los cuales es importante descartar todas las causas de afectación inmune celular. También el diagnóstico de estas lesiones debe tenerse en cuenta ante la presencia de masas intracranealesque muestren características inflamatorias

Central nervous system cryptococcosis is an important cause of morbidity and mortality in immunocompromisedpatients; nevertheless, its presentation in immuno-spared patients is extremely rare, giving rise to a holedifferent spectrum, since it is manifested like granulomatous masses named cryptococomas. Aim. To describe an intracerebral case of cryptococcoma in an immuno-spared woman in the Hospital Universitario de Santander and to discuss the most relevant topics of this pathology. Case report. A 24 years-old woman, coming to the service presenting generalized tonicclonicseizure, fixed upward gaze, sialorrhea and lost, without any data suggesting immunosupression. The computarizedtomography of skull demonstrates a mass of possible inflammatory vs. noeplasmic origin. After performing imaging the patient is taken to surgery for craniotomy with excisional biopsy. By means of hystological analysis the diagnosis of cerebralcriptococcoma is made, and antimycotic therapy is started, with favorable response. Actually the patient evidences good health, and no evidence of active disease. Conclusions. The presence of masses of criptococcal origin located at the centralnervous system, which origin is due to a chronic granulomatous reaction, is rarely reported; these appear in almost all cases in immunocompetent patients, in which there is of primary importance to discard all causes of cellular immune deficit. Also,the diagnosis of these injuries must be considered before the presence of intracerebral masses that show inflammatory characteristics

Effects of melatonin on orofacial movements in rats.

RATIONALE: While reserpine-induced oral movements (OM), an animal model of tardive dyskinesia, are more persistent in old than in adult rats, old animals present spontaneous OM, which are phenomenologically similar to those presented by reserpine-treated adult rats. We postulate that these OM may be the result of oxidative stress induced by both age and reserpine treatment. OBJECTIVES: We intended to determine the preventative effects of exogenous melatonin (one of the most important endogenous antioxidants) as well as suppression of endogenous melatonin via continuous exposure to light on reserpine- or age-induced OM in rats. METHODS: Adult (4 months of age) male Wistar rats were repeatedly treated with saline or melatonin (5 mg/kg, IP) and saline or reserpine and kept under a 12-h light/dark cycle for quantification of reserpine-induced OM as well as oxidative stress (via quantification of lipid peroxidation). To verify the effects of endogenous melatonin suppression on reserpine-induced OM, adult rats were repeatedly treated with saline or reserpine and continuously exposed to light. To verify the effects of exogenous melatonin on age-induced OM older (20 months of age) rats were long-term treated with saline or melatonin and kept under a 12-h light/dark cycle. RESULTS: Melatonin attenuated both reserpine- and age-induced OM. Reserpine enhanced striatal lipid peroxidation, that was prevented by melatonin co-administration. Continuous exposure to light increased spontaneous as well as reserpine-induced OM, indicating that endogenous melatonin may be involved in this movement disorder. CONCLUSIONS: We suggested that melatonin attenuates both reserpine- and age-induced OM in rats.

The neutrophil as a cellular source of chemokines.

Neutrophils are known to play an important role in inflammatory responses by virtue of their ability to perform a series of effector functions that collectively represent a major mechanism of innate immunity against injury and infection. In recent years, however, it has become obvious that the contribution of neutrophils to host defence and natural immunity extends well beyond their traditional role as professional phagocytes. Indeed, neutrophils can be induced to express a number of genes whose products lie at the core of inflammatory and immune responses. These include not only Fc receptors, complement components, cationic antimicrobial and NADPH oxidase proteins, but also a variety of cytokines (including tumour necrosis factor-alpha, interleukin (IL)-1beta, IL-1R alpha, IL-12 and vascular endothelial growth factor), and chemokines such as IL-8, growth-related gene product, macrophage inflammatory protein (MIP)-1alpha, MIP-1beta, interferon-gamma-inducible protein of 10 kDa and monokine induced by interferon-gamma. Because these chemokines are primarily chemotactic for neutrophils, monocytes, immature dendritic cells and T-lymphocyte subsets, a potential role for neutrophils in orchestrating the sequential recruitment of distinct leukocyte types to the inflamed tissue is likely to occur. The purpose of this review is to summarize the essential features of the production of chemokines by polymorphonuclear neutrophil leukocytes and the contribution that we have made to characterize some aspects of this newly discovered crucial function of neutrophils.

[Predictive value of endometrial pattern and thickness in the result of in vitro fertilization and embryo transfer]. / Valor predictivo del patrón y del grosor endometrial en el resultado de fecundación in vitro y transferencia embrionaria.

In order to assess the relationship between echographic endometrial thickness and pattern and the probability of clinical pregnancy and delivery we analyzed retrospectively 51 cycles of IFV-ET. Patients were classified in three categories of endometrial thickness: < 9 mm, 9.1-11 mm and > 11 mm and in two types of endometrial pattern: type 1 (non triple line) or type 2 (triple line). The average endometrial thickness of patients who got pregnant and those who did not was 11.8 +/- 1.8 mm and 10.6 +/- 1.7 mm respectively (p = NS). There were no clinical pregnancies in patients with endometrial thickness < 9 mm (p < 0.01). The average endometrial thickness in patients with endometrial pattern type 1 and type 2 was 11.1 +/- 1.2 mm and 10.9 +/- 1.9 mm respectively (p = NS). Patients who presented type 2 endometrial pattern (n = 39) produced eleven clinical pregnancies (28.2%) and those with type 1 (n = 2) only one clinical pregnancy (8.3%), which ended in spontaneous abortion (p < 0.01). When both variables, thickness and pattern, were considered together, patients with endometrial pattern type 2 and thickness > 11 mm had a probability of clinical pregnancy and of delivery of 43.8% and 25%, respectively, who is statistically significant (p < 0.03). We conclude that endometrial thickness and pattern, taken together, offer a valuable prognostic value for the outcome of an IVF-ET cycle.

[The results of a program of in vitro fertilization and tubal embryo transfer (ZIFT)]. / Resultados de un programa de fertilización in vitro y transferencia de embriones a la trompa (ZIFT).

Twenty-one sterile couples, between September 1989, and August 1991, were treated for ovulation stimulation of their cycles, in order to practice in them, a in vitro fertilization and tube embryo transfer (ZIFT). Two protocols of ovulation induction were used, both with leuprolide acetate (Lupron), one in the luteal phase and the other in follicular phase and since the second or the fourth day of the cycle, respectively, gonadotropins were added (Metrodine and Pergonal). Out of all the twenty-nine initiated cycles, twenty-seven were aspirated (93.1%) and twenty-four reached an embryo transfer (82.8%). Seven clinic pregnancies were obtained (29.17% per transfer) and four deliveries (16.67% per transfer). The sterility period average was 69.64 +/- 36.6 months and the patients age average was 34.1 +/- 4.38 years. The global rate of fertilization was 63.53%. With luteal phase Lupron best results were got (pregnancy rate of 38.46% per transfer) and there were not considerable difference in the number of gonadotropins ampulla employed. When embryos were transfer to the tubes and the uteri the pregnant rate was 50% per transfer, in comparison to 18.75% when transfer was made only in the tubes.

[What results can be expected from in vitro fertilization and other technics of assisted fertilization?]. / Qué resultados se pueden esperar de la fertilización "in vitro" y de otras técnicas de fertilización asistida?

Results of assisted reproductive techniques (IV, GIFT and ZIFT) have improved progressively during the last years but they are still not satisfactory specially when they are analyzed in terms of cost efficacy. During 1990, in the world literature, the following successful results were reported: pregnancy rates of 20% and delivery rates of 15% for IVF-ET, 29% and 22% for GIFT and 21% and 16% for ZIFT. In spite of the small number of cases reported in Chile, results are similar to those of USA and Europe. Results of assisted fertilization techniques have improved with the use of Gn-RH agonists and are worse in patients older than 35 years of age than in younger ones. Pregnancies rates are higher when the number of transferred ovocytes increases although transfer of more than 3 or 4 ovocytes or embryos is contraindicated because of the risks of multiple pregnancies. When more than 3 or 4 embryos are obtained those not transferred are usually cryopreserved. IVF-ET is the first choice of treatment in cases of infertility due to severe tubal damage and/or extensive and dense pelvic adhesions. In cases of infertility with normal tubes, intrauterine inseminations in 3 to 4 controlled hyperstimulated cycles are recommended before indicating an assisted fertilization procedure. The most risky complication of assisted reproduction, besides multiple pregnancy, is severe ovarian hyperstimulation syndrome (SOHS). This syndrome is prevented by not injecting HCG or by not transferring ovocytes or embryos in cases of high estradiol levels after HMG and/or FSH administration.

Laser-excited atomic-fluorescence spectrometry with electrothermal tube atomization.

The performance of graphite-tube electrothermal atomizers is evaluated for laser-excited atomic-fluorescence spectrometry for several elements. Three pulsed laser systems are used to pump tunable dye lasers which subsequently are used to excite Pb, Ga, In, Fe, Ir, and Tl atoms in the hot graphite tube. The dye laser systems used are pumped by nitrogen, copper vapour and Nd:YAG lasers. Detection limits in the femtogram and subfemtogram range are typically obtained for all elements. A commercial graphite-tube furnace is important for the successful utilization of the laser-based method when the determination of trace elements is intended, especially when complicated matrices may be present.

[Clinico-echographic study of the ovulatory phase, spontaneous and induced, conceptional and non conceptional cycles]. / Estudio clínico-ecográfico de la fase ovulatoria, ciclos espontáneos e inducidos, concepcionales y no concepcionales.

We present the results obtained on 110 menstrual cycles of 87 patients; echography study of ovulation, immunologic LH determination, basal body register card and serial cervical mucus score, since -6 to 0 day. Echography study determined follicular diameter, endometrial bulk and the presence of liquid in the cul-de-sac. We considered only those patients in whom the disappearance of the follicle was observed 24 hours before; being this fact, the indicator of ovulation, related to all other variables. These patients presented spontaneous (47.3%), epimestrol (28.2%) or clomiphene induced (24.5%) cycles, and they turned out to be pregnant or not in that cycle, (34.6%, 25.8% and 37.0% respectively). It was 36 (32.7%) pregnant women in all the The three follicular diameter curves for pregnant cycles, were similar being the preovulatory follicular range 21.5 mm for spontaneous cycles, 18.9 mm for epimestrol induced cycles and 20.7 mm for clomiphene induced cycles. Conceptional range was from 15 to 22 mms, 15 to 22 mm, and 14 to 27 mms, respectively. We didn't observe free fluid in cul-de-sac in 5 pregnant cycles (13.9%). Most of positive LH, are about -2 and -1 (21% and 50%, respectively). There were one pregnant patient and 2 no pregnant patient with repetitive, negative LH. In 50% of patients who became pregnant, the Nadir was on -1 day. In spontaneous conceptional group, bad cervical score was not observed. The good cervical score period is longer on conceptional group than in those with epimestrol. On conceptional group, dissociation between best score day and the day of ovulations was not observed, fact that we observed in non-conceptional group.

[In vitro fertilization program. Preliminary results]. / Programa de fecundación in vitro. Resultados preliminares.

Three infertile couples were submitted to in vitro fertilization and uterine embryo transfer (IVF+ET) and 7 to in vitro fertilization and pronuclear stage tubal transfer (IVF+PROST). In order to programmed menstruation Norethisterone, 10 mg daily, were administered during the cycle preceding the one of controlled ovarian hyperstimulation. In order to inhibit endogenous production of FSH and LH, leuprolide acetate, a Gn-RH agonist, was injected subcutaneously 1 mg daily during 6 days and 0.5 mg fowardly from the luteal phase of the cycle proceeding the one of hyperstimulation until the day of HCG administration. To achieve superovulation pure FSH (Metrodine), HMG (Pergonal) and HCG (Endocorion) were used. Oocyte retrieval was performed through transvaginal puncture under ultrasonographic control. For oocyte and embryo identification and classification, spermatozoa separation and capacitation and gamete insemination and incubation procedures habitual techniques were employed. Pronuclear embryo tubal transfer was performed through a laparoscope 17 hours after insemination and embryo transfer to the uterine cavity after 48 hours. Nine of 10 patients responded to gonadotrophin hyperstimulation and were submitted to ovarian puncture. 69 oocytes (7, per patient) were obtained, 59 (81.15% of which were mature. 74.55% of the inseminated oocytes fertilized. Two patients got pregnant: one, submitted to IVF+PROST, presently has a multiple pregnancy with triplets and the second, submitted to IVF+UT, had a missed abortion at 8 weeks of pregnancy.

Transcutaneous electrical nerve stimulation and spinal cord stimulation for pain relief in reflex sympathetic dystrophy.

35 patients with the diagnosis of reflex sympathetic dystrophy in a late stage have been treated with transcutaneous electrical nerve stimulation (TENS). 6 out of the 35 were also submitted to spinal cord stimulation (SCS). The follow-up was from 10 to 36 months. The results obtained were TENS group: 25% excellent, 45% good, 10% fair, 20% poor; in the SCS group: 16.6% excellent; 66.6% good and 16.6% fair. In the long run these results are better than those obtained with sympathetic blocks and sympathectomy. TENS and SCS have no effect on osteoporosis or ankylosis.

Spinal cord stimulation for relief of chronic pain in vasospastic disorders of the upper limbs.

Eleven patients with chronic pain due to severe vasospastic disorders in the upper limbs were treated with cervical spinal cord stimulation. In 8 patients the pain was due to reflex sympathetic dystrophy in the late stage of the disease, and 3 patients had severe idiopathic Raynaud's disease. The mean follow-up for both groups was 27 months. A total of 10 patients (90.9%) had good or excellent results. Thermographic and plethysmographic changes were observed in both groups. There seems to be a very close relationship between the increase of blood flow and the amount of pain relief achieved. In an attempt to quantify the intensity of pain, the visual analog scale and McGill Pain Questionnaire were used. Stimulation proved to be harmless, with no mortality and very low morbidity. The latter centered around local infection and displacement of the electrodes. No objective changes occurred in trophic alterations such as bone decalcification and ankylosis, but there were improvements in the alterations in the nails and skin. In the reflex sympathetic dystrophy group, the amount of pain relief achieved enabled most patients to undergo subsequent physiotherapy and rehabilitation. In severe cases of reflex sympathetic dystrophy and idiopathic Raynaud's disease, spinal cord stimulation is an alternative treatment that can be used as primary therapy or as secondary therapy after unsuccessful sympathectomy or sympathetic blocks.