Digital Ischemia Research Articles

Digital Ischemia and Necrosis: A Rarely Described Complication of Gemcitabine in Pancreatic Adenocarcinoma

Abstract Background: Gemcitabine, alone or in combination with other agents, has become an important part of the standard of care for treatment of both resectable and unresectable/advanced pancreatic adenocarcinoma. Gemcitabine is generally considered to have a favorable toxicity profile, with myelosuppression and hepatotoxicity as the most common adverse effects. There are just two prior published case reports of gemcitabine-associated digital toxicity in the treatment of pancreatic adenocarcinoma, and few case reports when considering all solid tumors. Presentation: A 70-year-old female developed hand numbness and tingling while receiving nab-paclitaxel plus gemcitabine for metastatic pancreatic adenocarcinoma. There was initial concern for Raynaud's or nab-paclitaxel-associated neuropathy, thus nab-paclitaxel was discontinued. However, her symptoms progressed to severe pain and her digits became dusky. An extensive evaluation revealed no alternative etiology except gemcitabine-associated digital ischem...

Presentation, clinical features, and results of intervention in upper extremity fibromuscular dysplasia

BackgroundWe present a case series of upper extremity fibromuscular dysplasia (UE FMD) consisting of 22 patients from two tertiary referral centers focusing on clinical presentation, diagnostic findings, and interventional outcomes. FMD is a noninflammatory, nonatherosclerotic arteriopathy that has a predisposition for middle-aged women. Involvement of the UE is thought to be rare. Patients with UE FMD can present with claudication or ischemia, or they can be incidentally diagnosed. The treatment approach is dictated by clinical presentation. MethodsData were collected of patients with UE FMD evaluated at two centers. Demographic data, presenting UE symptoms, UE arteries involved, FMD type, diagnostic method, physical examination findings, management, and outcomes were included. ResultsTwenty-two patients (29 limbs) were diagnosed with UE FMD. The brachial artery was most commonly involved (89.7% of affected limbs). More than half of limbs (n = 15 of 29 limbs [51.7%]) were asymptomatic, and of those who presented with symptoms, the most common symptoms were ischemic fingers or hand (31% of all affected limbs) and hand or arm claudication (27.6% of all affected limbs). UE FMD was noted on catheter angiography in 58.6% (n = 17 of 29 limbs), duplex ultrasound in 41.4% (n = 12 of 29 limbs), and computed tomography angiography in 27.6% (n = 8 of 29 limbs). Of the symptomatic limbs (n = 14), the majority were treated solely with medical therapy as the first intervention (57.1%). For symptomatic limbs treated with vascular intervention (n = 5), angioplasty was most commonly performed. Only 4 of the 14 limbs (28.6%) had complete symptomatic relief after the initial first intervention, in which 2 limbs were treated with medical therapy, 1 limb underwent angioplasty, and 1 limb had resolution of symptoms despite deferment of any therapy. Of the 10 limbs with residual symptoms after the first intervention, 6 limbs underwent a second intervention: angioplasty in 2 limbs initially treated medically (33.3%), surgical bypass in 2 limbs initially treated with angioplasty, surgical bypass in 1 limb initially treated with medical therapy, and sympathectomy in 1 limb (16.7%) initially treated with angioplasty. Both surgical bypass and angioplasty as secondary interventions resulted in complete symptom relief. ConclusionsPresenting symptoms for patients with UE FMD vary in severity from asymptomatic disease to digital ischemia. More than half of symptomatic limbs eventually require at least one invasive intervention for complete relief of symptoms.

Outcomes of sympathectomy and vascular bypass for digital ischaemia in connective tissue disorders

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The Therapeutic Efficacy of Botulinum Toxin in Treating Scleroderma-Associated Raynaud's Phenomenon: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial.

To assess the therapeutic efficacy of local injections of botulinum toxin type A (Btx-A) in improving blood flow to the hands of patients with Raynaud's phenomenon (RP) secondary to scleroderma. In this randomized, double-blind, placebo-controlled clinical trial, patients with scleroderma-associated RP received Btx-A (50 units in 2.5 ml sterile saline) in one randomly selected hand and sterile saline (2.5 ml) in the opposite hand. Follow-up at 1 and 4 months postinjection included laser Doppler imaging of hands, patient-reported outcomes, and physical examination. We compared outcomes using paired t-tests and population-average generalized models with generalized estimating equations. Of 40 patients enrolled, 25 had limited scleroderma and 15 had diffuse scleroderma. From baseline to 1-month follow-up, there was a greater reduction in average blood flow in Btx-A-treated hands compared to placebo-treated hands. The model estimated that this difference was statistically significant (average difference -30.08 flux units [95% confidence interval -56.19, -3.98], P for interaction = 0.024). This difference was mainly influenced by patients with longstanding RP and diffuse scleroderma. Change in blood flow at 4-month follow-up was not significantly different between groups. Clinical measures (QuickDASH, McCabe Cold Sensitivity Score, pain on a visual analog scale, and Raynaud's Condition Score) improved slightly for Btx-A-treated hands. Our laboratory-based laser Doppler imaging flow data do not support using Btx-A to treat RP in all scleroderma patients. The secondary clinical outcomes suggest some positive effect, but its clinical meaningfulness is questionable. The role of Btx-A in treating RP should be further studied with more homogeneous patient populations and in unique clinical situations such as acute digital ischemia.

Repetitive Blunt Trauma and Arterial Injury in the Hand.

Arterial injury in the hand is most often due to repetitive blunt trauma. Although not always associated with significant impairment, it may cause serious ischemic damage or considerable disability. As a cause of digital ischemia, the frequency of this disorder is widely under appreciated. This study reviews the clinical and angiographic features of this condition. An extensive literature review combined with the authors experience with arterial injury in the hand due to repetitive blunt hand trauma is summarized with emphasis on mechanisms of injury and pathologic changes to explain the angiographic findings and clinical presentations. Angiographic findings are related to severity of injury and underlying changes in the arterial wall. The clinical presentation varies from asymptomatic to digital necrosis and gangrene, related to severity of arterial injury, collateral circulation, and the highly variable arterial anatomy in the hand. Early recognition is important because compared to many other causes of digital ischemia in the upper extremities, traumatic arterial injury is frequently readily treatable. Angiographic findings and clinical presentation are often characteristic. The diagnosis should not be based on a clear history of repetitive hand trauma since the patient may be unaware of this occurrence.

Paraneoplastic acral vascular syndrome in a patient with metastatic melanoma under immune checkpoint blockade

BackgroundParaneoplastic acral vascular syndrome (PAVS) is a rare phenomenon which is observed in patients with adenocarcinomas and other malignancies. Various potential pathogenic mechanisms such as tumour invasion of sympathetic nerves, hyperviscosity, hypercoagulability, vasoactive tumour-secreted substances, and immunological mechanisms have been suggested.Case presentationWe report a 60-year-old Caucasian male attended our hospital with a bulky lymph node mass in the right axilla. Extirpation of a lymph node conglomerate revealed 5 melanoma lymph node metastases. Computed tomography showed a liver metastasis (diameter: 3.8 cm), several retroperitoneal metastases, bilateral metastases in the lung hilus, and prepectoral subcutaneous metastases (Stage IV; pTx, N3, M1c). Lactate dehydrogenase and S100B were slightly elevated. Combination therapy of nivolumab (1 mg/kg BW) and ipilimumab (3 mg/kg BW) was started. Three weeks after the first combination therapy he developed progressive erythema, paraesthesia and pain on the fingertips of both hands. Both cold and warmth was not well tolerated by the patient. Complete work-up excluded associated conditions or factors such as haematological disorders, rheumatologic disorders, hypertension, diabetes or smoking. Treatment was initiated with prostacyclin 20 μg twice daily and oral prednisolone 50 mg in tapering dosage. However, prostacyclin was stopped after the first applications because the pain increased during infusion. The second course of nivolumab and ipilimumab was administered. About 2 weeks later, the patient presented with increased pain and small subungual necrosis. We treated the patient with oral analgetics and intravenous prednisolone 500 mg in tapering dosage. On digital substraction angiography occlusion of all arteries of the fingers was demonstrated. Further rheologic and anti-melanoma treatments were refused by the patient. About 2 months after the second course of nivolumab and ipilimumab combination therapy several fingers showed severe gangrene which finally led to amputations of end phalanges of several fingers. Histopathology did not reveal evidence for vasculitis or other primary vascular pathologies. During the following 2 months the patient experienced dramatic progress of his metastatic disease and finally died at multi-organ failure.ConclusionPresence of rapidly progressive digital ischemia in an elderly patient with cancer should always raise clinical suspicion of a paraneoplastic phenomenon when other possible causes have been excluded. In patients treated with immune checkpoint inhibitors such as CTLA-4 and PD-L1 blockers PVAS-like events have not been reported so far. However, it is debatable whether immune checkpoint blockade may play a pathogenetic role in the development of PAVS in patients with malignancies.

Acute digital ischemia: A rare presentation of antisynthetase syndrome.

Antisynthetase syndrome (ASS) is recognized as a subgroup of idiopathic inflammatory myopathies (IIMs). It is associated with autoantibodies directed against aminoacyl-transfer ribonucleic acid (tRNA) synthetase enzymes. We report the first case of anti-PL-7/anti-SSA 52kD ASS presenting as acute digital ischemia, an association not described previously. Occlusive vasculopathy is a rare but serious manifestation that can be seen at presentation in patients with ASS and may herald the onset of severe interstitial lung disease (ILD). Comprehensive evaluation should be performed to confirm the presence of subclinical myositis. Extensive myositis-specific antibody testing is strongly recommended even if initial screening autoimmune serologies are unrevealing.

Sistemik Lupus Eritematozusa Bağlı Gelişen Gangrenin Hiperbarik Oksijen ile Başarılı Tedavisi

Necrotizing vasculopathy is a relatively uncommon and life-threatening condition in children. Raynaud phenomenon and digital ischemia are the most common symptoms. Although immunosuppressive treatments in combination with vasodilators are the first chosen therapies, hyperbaric oxygen therapy is also used as primary or adjuvant therapy. Herein, we present an adolescent female patient who has had gangrenous lesions at bilateral feet phalanges diagnosed with necrotizing vasculitis due to systemic lupus erythematosus. Effective treatment by hyperbaric oxygen therapy in combination with immunosuppressive and vasodilator drugs led to significant improvement without amputation. Adjunctive hyperbaric oxygen therapy should be considered in cases with progressive gangrenous lesions due to vasculopathies.

Effectiveness of Remote Ischaemic Conditioning in Critical Ischemia of the Digitals of Upper and Lower Limbs

`Aim: The aim of our study was to determine the effectiveness and safety of remote ischaemic conditioning (RIC) in combination with i.v. prostavasin as a method of treatment for patients with peripheral acral vasculopathy, presenting as critical ischemia of the digitals of upper and lower limbs at the time of presentation with either surgical nor interventional treatment option Method: 33 patients were included in this non-randomized, prospective pilot-study with compassionate use. Primary endpoints were healing of ulcerations and amputation free time, secondary endpoint was safety of RIC. For the RIC, a blood flow reduction in the extremities was held in 2 cycles for over 5 minutes (20 mmHg over the systolic blood pressure) with 5 minutes reperfusion. During this time the medical agents were infused through a superficial vein into index extremity transvenously. The medication included: 2500 i.e., Heparin bolus, 5 μg PGE-1 in a 50 mL syringe with an isotonic solution. In cases where a vascular occlusion was seen in angiography additionally to PGE-1, 20 mg rt-PA was infused. Results: In 33 cases, transcutaneous oxygen partial pressure (TcPO2) levels increased significantly from 33 ± 16 mmHg to 48 ± 13 mmHg (p=0.0005) after the therapy compared to baseline. In 33 cases there was an improvement from 55 ± 27 mmHg to 73 ± 27 mmHg (p ≤ 0.004) in the acral arterial pressure measurement. 31 patients showed significantly better perfusion and vascularisation of the ischemic extremity after the therapy demonstrated in acral oscillography (31/94%) and angiography (6/18%). In 16 cases ulcerations (n=20) healed after 15 sessions of RIC. There was no need of any major or minor amputation in all patients. Conclusion: The presented RIC therapy proved to be an effective and safe treatment in addition to best medical treatment for patients with acute acral vascular disorder, especially in acute digital ischaemia, without a surgical or an interventional option.

Acro-osteolysis.

Acro-osteolysis is an osteolysis of the distal phalanges of the hands and feet and can affect the terminal tuft or the shaft of the distal phalanx (transverse or band acro-osteolysis). It is often associated with distal digital ischemia, digital calcinosis, or severe sensory neuropathy. Acro-osteolysis has been associated with a heterogeneous group of disorders, including occupational activities, infections, rheumatic disorders (systemic sclerosis, psoriatic arthritis), endocrinopathies, genetic disorders, and lysosomal storage disorders. Plain radiography is the gold standard for the detection of acro-osteolysis.

Cholesterol Emboli Syndrome in the Setting of Left Ventricular Thrombus

SESSION TITLE: Student/Resident Case Report Poster - Critical Care IV SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Spontaneous cholesterol emboli syndrome (CES) is a rare presentation of distal digital ischemia. It is associated with livedo reticularis, renal failure, and eosinophilia. We present a case of spontaneous CES in a patient with atherosclerotic disease. CASE PRESENTATION: A 59-year-old man with history of coronary artery disease, ischemic cardiomyopathy with an ejection fraction of 25%, schizoaffective disorder, and hypertension, presented with altered mental status. He had been in usual state of health 5 days prior to the admission. In the emergency department, he was febrile but had stable vital signs with the exception of low oxygen saturation. He was ill-appearing, agitated, and did not follow commands. His lung exam revealed decreased breath sounds with no wheeze, crackles, or rhonchi. On cardiac examination he was tachycardic. His distal extremities felt cold. Livedo reticularis was present on both thighs. The tips of his fingers and toes looked cyanotic. Peripheral pulses were present. Interestingly, the tip of his nose was ecchymotic. Laboratory studies revealed leukocytosis and an elevated creatinine of 1.28 mg/dL (baseline 0.86 mg/dL). Other abnormal laboratory values included elevated lactic acid of 2.3 mmol/L, creatinine kinase (CK) of 1700 International Unit/L, and troponin of 0.140 ng/mL. Urine toxicology was negative. Chest radiograph showed bibasilar pneumonia. Computed tomography (CT) of the head was negative. Cerebrospinal fluid studies were unrevealing. The patient was admitted to the medical ward for treatment of community acquired pneumonia. Later, he developed worsening tachycardia, tachypnea and hypoxemia . Lactic acid increased to 3.5 mmol/L, and CK increased to 2900 International Unit/L. Due to poor mental status and worsening hypoxemia, he was transferred to the Intensive care unit and was intubated for respiratory failure. Echocardiography revealed a large left ventricular (LV) thrombus. Abdominal CT revealed a suprarenal thrombus. Antiphospholipid antibody syndrome, thrombotic thrombocytopenic purpura, and other secondary hypercoagulable states were excluded. He was started on anticoagulation. He improved clinically and was successfully extubated. DISCUSSION: Approximately 25% of CES cases occur spontaneously. Its risk is directly related to the severity of atherosclerosis. It occurs when cholesterol crystals embolize distally after disruption of atherosclerotic plaque. These crystals occlude small arterioles <200 micrometers in diameter. Although our patient had a LV thrombus, the distribution of the affected areas (tips of fingers and toes) support the diagnosis of CES. Infrarenal thrombus has more favorable outcome, though as shown in this case, patients with suprarenal involvement could improve. CONCLUSIONS: Spontaneous CES is a rare disease that requires careful history and physical exam to differentiate from thromboemobolic disease. Reference #1: Kronzon I, Saric M. Cholesterol Embolization Syndrome. Circulation 2010;122:631-41 DISCLOSURE: The following authors have nothing to disclose: Umama Gorsi, Patrick Koo, Taro Minami No Product/Research Disclosure Information

SUCCESSFUL OUTCOME IN A CASE OF CRITICAL DIGITAL ISCHEMIA. CASE REPORT AND LITERATURE ANALYSIS

Critical digital ischemia (CDI) remains a distinct, serious complication of peripheral vasculopathy in systemic sclerosis, macrovascular as well as microvascular disease, abnormal vascular remodeling, vasoconstriction-vasodilation imbalance and fibrosis being key underlying factors. Successful short- as well as long-term outcomes may arise from early diagnosis, broad assessment and prompt therapeutic intervention. However, current treatment options are far from ideal, indicating the need for a complex approach focused on pathobiologic issues. We report the case of a middle age postmenopausal woman with a recent onset of CDI and subsequent gangrene, evolving in a very early PM-Scl positive systemic sclerosis. Dramatic improvement with complete resolution of CDI as well as healing of digital gangrene with minimal tissue loss was rapidly achieved under vasodilating therapy, after two cycles of intravenous prostanoids.

Nailfold Videocapillaroscopic Features and Other Clinical Risk Factors for Digital Ulcers in Systemic Sclerosis: A Multicenter, Prospective Cohort Study

ObjectiveTo identify nailfold videocapillaroscopic features and other clinical risk factors for new digital ulcers (DUs) during a 6‐month period in patients with systemic sclerosis (SSc).MethodsIn this multicenter, prospective, observational cohort study, the videoCAPillaroscopy (CAP) study, we evaluated 623 patients with SSc from 59 centers (14 countries). Patients were stratified into 2 groups: a DU history group and a no DU history group. At enrollment, patients underwent detailed nailfold videocapillaroscopic evaluation and assessment of demographic characteristics, DU status, and clinical and SSc characteristics. Risk factors for developing new DUs were assessed using univariable and multivariable logistic regression (MLR) analyses.ResultsOf the 468 patients in the DU history group (mean ± SD age 54.0 ± 13.7 years), 79.5% were female, 59.8% had limited cutaneous SSc, and 22% developed a new DU during follow‐up. The strongest risk factors for new DUs identified by MLR in the DU history group included the mean number of capillaries per millimeter in the middle finger of the dominant hand, the number of DUs (categorized as 0, 1, 2, or ≥3), and the presence of critical digital ischemia. The receiver operating characteristic (ROC) of the area under the curve (AUC) of the final MLR model was 0.738 (95% confidence interval [95% CI] 0.681–0.795). Internal validation through bootstrap generated a ROC AUC of 0.633 (95% CI 0.510–0.756).ConclusionThis international prospective study, which included detailed nailfold videocapillaroscopic evaluation and extensive clinical characterization of patients with SSc, identified the mean number of capillaries per millimeter in the middle finger of the dominant hand, the number of DUs at enrollment, and the presence of critical digital ischemia at enrollment as risk factors for the development of new DUs.

Post-Traumatic Pseudoaneurysm of the Common Digital Artery in a Child.

Dear Sir, Pseudoaneurysm of the digital artery in the hand rarely occurs following hand injury. Since first described by Heuston in 1973, less than 25 cases have been described in the literature. Owing to the small caliber of digital artery, complete disruption of the digital artery is more common [1]. Hence, it is rarely suspected and misdiagnosis is common. A 15-year-old left hand dominant male was referred with increasing swelling and pain in the right palm for 3 days duration. Two weeks prior to this, he sustained a penetrating injury with a chisel in the school while doing woodwork. He attended his general practitioner on the day of injury and received wound care. He represented 2 weeks later with increasing pain and swelling, which restricted movement in the right hand. A 3 cm x 3 cm soft non-pulsatile discrete mass with surrounding ecchymosis on his right palm was identified. Mild altered sensation over the radial side of the right ring finger was elicited with palpation over the mass. Radiograph of the right hand was unremarkable. Wound exploration under general anaesthesia was performed via a limited Brunner’s incision. The swelling was identified at the level of the common digital artery supplying the third web space (ulnar and radial borders of the middle and ring fingers, respectively). The corresponding digital nerves and flexor tendon sheath were intact. A traumatic arteriotomy identified on the common digital artery was identified. The pseudoaneurysm and the traumatized vessel were isolated and excised under microscopic vision. End-to-end anastomosis of the common digital artery was performed with 9/0 Ethilon. The postoperative recovery was uneventful. Pseudoaneurysms are usually due to penetrating trauma that results in a traumatic arteriotomy. The formation of hematoma is followed by organization and subsequent recanalisation of the hematoma surrounding the injured vessel. The hematoma is eventually replaced by fibrous and scar tissue, and a false aneurysm remains. Signs of digital ischaemia may not occur in digital artery pseudoaneurysm as collateral circulation is usually sufficient. However, sensory disturbance may be present if the pseudoaneurysm is compressing the digital nerve, as presented in this case. Although one will expect to find a pulsatile mass, this does not always hold true as few cases involving non-pulsatile pseudoaneurysm has been reported in the literature [2]. Cases of pseudoaneurysm following repetitive blunt injury have also been reported, such as in baseball and softball players [1, 2]. The management of a pseudoaneurysm varied in the literature. Some authors performed ultrasonographic, CT angiography or MR angiography evaluation to define the lesion preoperatively. Excision of the pseudoaneurysm is always recommended and ligation of the affected artery is most commonly performed. When perfusion is not compromised, concern regarding long term digital cold intolerance is a motivating factor to reconstruct the digital artery. As microvascular techniques are becoming commonplace, microvascular reconstruction with end-to-end anastomosis [1], or reconstruction using a reversed interpositional vein [3] or arterial graft [4] had been described. Although pseudoaneurysm of the digital artery is rare, it should be suspected when a seemingly trivial hand injury represents with a new swelling days after the initial trauma. The pseudoanerysm must be isolated and excised, and where possible, reconstruction of the digital artery with microvascular technique is encouraged (Fig. ​(Fig.11). Fig. 1 Organised hematoma overlying the injured common digital artery and end-to-end anastomosis of the common digital artery following excision of the damaged segment

Calcinosis is associated with digital ischaemia in systemic sclerosis-a longitudinal study.

To determine if ischaemia is a causal factor in the development of calcinosis in SSc. Patients with SSc were assessed yearly. Physicians reported the presence of calcinosis, digital ischaemia (digital ulcers, digital necrosis/gangrene, loss of digital pulp on any digits and/or auto- or surgical digital amputation) and nailfold capillary dropout assessed using a dermatoscope. The number of digits with digital ischaemia was used as an assessment of the severity of digital ischaemia. SSc specific antibodies were detected with a line immunoassay. Multiple logistic regression and Cox proportional hazards models were generated to determine associations between calcinosis, digital ischaemia and capillary dropout. One thousand three hundred and five patients were included in this study, of whom 300 (23.0%) had calcinosis at study entry. In a cross-sectional multivariate analysis, at baseline, calcinosis was associated with digital ischaemia (odds ratio (OR) = 2.37, 95% CI: 1.66, 3.39), severity of ischaemia (OR = 1.12, 95% CI: 1.06, 1.18), capillary dropout (OR = 1.41, 95% CI: 1.05, 1.89), ACAs (OR = 1.68, 95% CI: 1.17, 2.43) and anti-RNA polymerase III antibodies (OR = 1.77, 95% CI: 1.08, 2.89). Current use of calcium channel blockers was inversely associated with the presence of calcinosis (OR = 0.70, 95% CI: 0.52, 0.96). Of the 805 patients with no calcinosis at study entry and at least one follow-up visit, 215 (26.7%) developed calcinosis during follow-up. Significant baseline predictors of the development of calcinosis in follow-up were digital ischaemia (hazard ratio (HR) = 1.82, 95% CI: 1.30, 2.54), capillary dropout (HR = 1.46, 95% CI: 1.08, 1.99), dcSSc (HR = 1.57, 95% CI: 1.11, 2.21), ACA (HR = 2.18, 95% CI: 1.50, 3.17) and anti-RNA polymerase III antibodies (HR = 2.58, 95% CI: 1.65, 4.04). Ischaemia may play a role in the development of calcinosis in SSc.

NonInvasive Vascular Testing for Diagnosis and Management of Hypothenar Hammer Syndrome

Hypothenar hammer syndrome (HHS) is a rare condition that may present as a palmar mass due to an aneurysm, or more frequently as digit ischemia due to thromboembolic or occlusive disease of the distal ulnar artery. Often, patients presenting with HHS are young male smokers with an occupational history of repetitive trauma because of working with machinery or engaging in sports where there is regular impact against the palm. Conditions that may present with similar complaints are vasospastic conditions and inflammatory processes. Noninvasive vascular laboratory studies can be used prior to direct arteriogram to help establish the diagnosis of HHS and guide the therapeutic options for treatment.

The Role of Botulinum Toxin A in the Treatment of Raynaud Phenomenon.

Raynaud phenomenon (RP) is a transient digital ischemia that occurs after exposure to cold temperature or emotional distress. It presents with a triphasic course: the initial white phase is followed by cyanotic discoloration and, subsequently, erythema. The attacks may be associated with pain, paresthesia, and complicate with nonhealing ulceration often leading to amputation. To date, there are no clear-cut therapeutic guidelines and many medications are used off-label. Encouraging results were reported with the use of botulinum neurotoxin-A (BoNT-A). However, there is still ongoing debate regarding indications, contraindications, best injection technique, and mechanism of action. The aim of this study was to address these issues by providing an up-to-date and detailed overview of the use of BoNT-A in RP.A PubMed database search was conducted. The available studies and techniques were evaluated and compared.The search yielded a total of 29 studies. Ten papers, published between 2004 and 2014, were considered relevant. A total of 128 patients underwent BoNT-A injections. Seventy-five percent to 100 % of the patients reported pain reduction after treatment. Healing of ulcers was reported in 75% to 100% of the affected patients. The most common complication was temporary hand weakness, with an average incidence of 14.1%. Injections targeting the neurovascular bundle at or slightly proximal to the A1 pulley were the most commonly performed.Botulinum neurotoxin-A injection proved to be a valid approach in both primary and secondary RP. The available evidence shows the achievement of both symptomatic and functional improvements in this debilitating condition. However, the patient should be adequately informed about the risk of transient hand weakness.

Test-retest reliability and agreement of the SPI-Questionnaire to detect symptoms of digital ischemia in elite volleyball players

ABSTRACTThe Shoulder posterior circumflex humeral artery Pathology and digital Ischemia – questionnaire (SPI-Q) has been developed to enable periodic surveillance of elite volleyball players, who are at risk for digital ischemia. Prior to implementation, assessing reliability is mandatory. Therefore, the test-retest reliability and agreement of the SPI-Q were evaluated among the population at risk.A questionnaire survey was performed with a 2-week interval among 65 elite male volleyball players assessing symptoms of cold, pale and blue digits in the dominant hand during or after practice or competition using a 4-point Likert scale (never, sometimes, often and always). Kappa (κ) and percentage of agreement (POA) were calculated for individual symptoms, and to distinguish symptomatic and asymptomatic players. For the individual symptoms, κ ranged from “poor” (0.25) to “good” (0.63), and POA ranged from “moderate” (78%) to “good” (97%). To classify symptomatic players, the SPI-Q showed “good” reliability (κ = 0.83; 95%CI 0.69–0.97) and “good” agreement (POA = 92%). The current study has proven the SPI-Q to be reliable for detecting elite male indoor volleyball players with symptoms of digital ischemia.

Evidence for the Use of Epoprostenol to Treat Raynaud's Phenomenon With or Without Digital Ulcers.

To review the evidence for using intravenous (IV) epoprostenol to treat Raynaud's phenomenon (RP). The databases MEDLINE (1946 to March 2016), PubMed, and International Pharmaceutical Abstracts were searched using the terms epoprostenol, Flolan, Raynaud's disease, and CREST syndrome. Further literature sources were identified by reviewing article citations. All English-language, clinical trials and case series evaluating IV epoprostenol for the management or treatment of RP were included. Lower-quality evidence were incorporated due to limited information. Seven small uncontrolled studies/case series, 1 small placebo controlled study, and 1 larger randomized trial were identified and included. There was no consistent measurement of efficacy utilized, but improvements in hand temperature, RP attack duration and frequency were commonly associated with IV epoprostenol treatment (5 trials). There were conflicting data regarding effect sustainability, with 5 trials showing long-term effects and 3 showing immediate effects. Fewer ischemic ulcers developed during treatment with IV epoprostenol in 1 trial compared to conventional treatment. Ulcer healing ocurred in 2 trials. Common adverse effects included hypotension, headache, flushing, gastrointestinal symptoms, and jaw pain. Available evidence supports the use of IV epoprostenol for treatment of severe RP in patients refractory or intolerant to standard therapies. The dose, titration schedule, and duration of IV epoprostenol utilized in studies varied, but a conservative approach to initiation should be considered. Patients who do not respond to intermittent infusions and have severe digital ischemia may require more aggressive regimens.

Jeopardized Digital Circulation From a Closed Phalangeal Fracture

Closed phalangeal fractures that accompany concomitant vascular injuries are not common. The mechanism of such vessel injuries vary, from direct vascular trauma by fractured bone segment, increased compartmental pressure or unintentional vascular traction during reduction procedures. Acute digital ischemia requires appropriate surgical intervention(s) to minimize complications. The authors present a case of a closed phalangeal fracture with concomitant digital artery injury, and a brief review of the related literature.