Occlusive arterial disease of the hand due to repetitive blunt trauma: a review with illustrative cases

OBJECTIVE: to increase clinical awareness of the role of repetitive blunt trauma, often occupational, in the development of occlusive arterial disease of the hand. STUDY DESIGN: illustrative cases are presented to emphasize the varied etiology and clinical features of occlusive arterial disease of the hand resulting from repetitive blunt trauma and an historical review of the literature is presented. RESULTS: Occlusive arterial disease of the hand due to repetitive blunt trauma is a common but often preventable disorder. The superficial location of many of the arteries of the hands and digits plus their close proximity to the bones of the hand makes them uniquely susceptible to injury from repetitive blunt trauma. An ever increasing number of occupations and leisure activities have been causally related to occlusive arterial disease of the hand. The diagnosis of occupational occlusive arterial disease due to blunt trauma is suggested by eliciting a history of repetitive blunt trauma to the hand in a patient with symptoms and/or signs of digital ischemia. The dominant hand is most commonly involved, but the non-dominant hand or both hands are affected in certain occupations. Possible predisposing or aggravating factors include tobacco use and working in a cold environment. The diagnosis of occlusive arterial disease confined to the hand or digits is confirmed by non-invasive studies in the vascular laboratory and demonstrated by arteriography. Conservative measures and protection of the hand from further trauma is sufficient for most patients, with surgical therapy being reserved for patients refractory to medical therapy or those with more severe ischemia. CONCLUSION: occlusive arterial disease of the hand may be more common than formerly thought and is often preventable by the proper use of hand tools or instruments and hand protection. This is another type of occlusive arterial disease in which tobacco may be a predisposing or aggravating factor.     

Update on clinical trials in the rheumatic diseases

The etiopathogenesis of multiple spongy necrosis (MSN) of the pontine base was analyzed by examining the spatial relationship with intra- and extrafascicular vascular structures by reconstruction of serial sections of nine lesions from three autopsy cases. All nine lesions in the fascicles were distributed without any spatial relationship to the intrafascicular vessels. Instead, these lesions were distributed in parallel with arterial and venous transverse main branches between the anteromedial and anterolateral groups of the pontine vessels. On the other hand, all lesions in the middle cerebellar peduncle were arranged obliquely along the arterial and venous main trunks of the lateral group vessels with sparing of the perivascular narrow zone of the white matter. Moreover, narrow fascicles, even though located in the dorsomedial region of the pontine base, which is consistently involved in MSN, were spared, and thick transverse and longitudinal fascicles were selectively involved. The marginal zone of fascicles was spared, and focal coagulation necrosis was sometimes found in MSN lesions. Additionally, normal fascicles did not have their own nutritional arteries, and were nourished by arterioles and capillaries from the surrounding pontine gray matter. Neither severe organic stenosis nor occlusion of pontine vessels was found. On the basis of the close topographical relationship of MSN lesions with the pontine vascular architecture in addition to preferential involvement of thick fascicles with sparing of the marginal zone and inclusion of focal coagulation necrosis, it is proposed that the etiopathogenesis of MSN is pontine ischemia on a background of the characteristic parenchymal and vascular architecture of the pontine base. As to the cause of the ischemia, it is proposed that some functional disorder such as arterial vasoconstriction in the pontine base or the vertebrobasilar artery is responsible, rather than organic changes in the vessels.     

A potential pitfall in bronchial artery embolization

Two cases of patients with massive haemoptysis undergoing bronchial arteriography are described. Both had collateral vessels which filled the right subclavian artery from the right intercosto-bronchial trunk. Such vessels form a potential route for the passage of embolic material into the subclavian artery and its branches during therapeutic bronchial artery embolization. To avoid this potential complication, super selective catheterization with the positioning of the catheter tip well into the bronchial artery beyond the origin of the intercostal artery and any large collateral vessels is recommended.     

Coronary atherosclerosis in subjects with mitral stenosis

The coronary arteries were examined in 60 specimens from patients with mitral stenosis. In three, localized obstruction was nonatherosclerotic in nature (in one, arterial dysplasia; in two, embolic). In 18 of the remaining 57 cases (31.5%), significantly obstructive atherosclerosis in one or more segments of the coronary arterial system was found. This represented 46% of the males and 27% of the females. The incidence of involvement of three or more arteries by significantly obstructive atherosclerosis was 39%, while in a cited series of subjects with angina pectoris three or more vessels were involved in 79% of the cases. It may be concluded that, on the average, the distribution of lesions in patients with mitral stenosis and significant coronary atherosclerosis is less wide than in subjects with clinical coronary disease.     

Angiographic aspects of tumors of renal pelvis and ureter

Selective renal arteriography was done in 5 patients with transitional cell carcinoma of the renal pelvis and upper ureter. In 2 cases, the presence of tumor vessels was unequivocally diagnostic. In the remaining 3 cases, the arteriographic changes were not as prominent but were suggestive of neoplasm and were helpful in differentiating other causes of filling defects in the collecting system.     

Refining the indications for arteriography in penetrating extremity trauma: a prospective analysis

PURPOSE: Five hundred fourteen consecutive patients with an isolated upper or lower extremity penetrating injury were entered into a prospective study designed to refine the indications for diagnostic arteriography. METHODS: Twenty-two (4%) patients with limb-threatening ischemia who required immediate operation and 23 (4%) who refused arteriography were excluded from subsequent analyses. The remaining 469 patients were classified as being at high, intermediate, or low risk for an arterial injury. RESULTS: Two hundred thirteen patients who were at low risk were observed for 24 hours, discharged, and monitored as outpatients. No delayed complications of an arterial injury developed in any patient in this group. The intermediate-risk group of 151 patients and the high-risk group of 105 patients underwent arteriography. Seventy-seven injuries were identified; 24 were major (limb-threatening) and 53 were minor. Fourteen major injuries required operative repair or transcatheter embolization; the remaining 10 nonocclusive major injuries were observed without sequelae. CONCLUSIONS: By step-down logistic regression only pulse deficit (p < 0.01) and an ankle/brachial or wrist/brachial index less than 1.00 in the injured extremity (p < 0.03) were found to be significant predictors of an arterial injury. The presence of either of these two clinical variables successfully predicted all major arterial injuries. This prospective study supports the proposition that arteriography that is limited only to those patients who have either a pulse deficit or minimum ankle/brachial or wrist/brachial index less than 1.00 successfully detects all significant arterial injuries.     

Macrodactyly of the feet and hands

We reviewed the records of 16 patients with true macrodactyly and analyzed the typical clinical features and methods of treatment. Fourteen feet were involved in 13 patients (one was bilaterally affected). Three hands were involved in three patients. Clinically, all lesions in the hands and lesions in 11 of 14 feet involved the preaxial side. There was multiple digit involvement in two hands and 11 feet. Progressive macrodactyly (10 feet and two hands) was more common than the static type (four feet and one hand). Proximal involvement of the sole or palm occurred in seven feet and one hand; all cases were of progressive macrodactyly. Enlargement of the metatarsals or the metacarpals was frequent (11 feet and two hands). The growth behavior and extent of bony involvement were similar in patients with hand involvement and those with foot involvement. Fourteen patients had additional clinodactyly, either medial or lateral. The toes of eight feet had angular deformities in the sagittal plane; most were angulated dorsally. Nine patients underwent surgery and two had repeated surgery. The reduction procedures included debulking, ray resection, toe resection, phalangeal resection, and phalangeal epiphysiodesis; the corrective procedures included wedge osteotomy, interdigitalization, and split thickness skin graft. Of the nine patients surgically treated, five had good results and four had fair results. Of the seven patients without surgical repair, three had fair results and four had poor results. Surgical debulking, phalangeal resection, ray resection, and phalangeal epiphysiodesis produced significant improvement in macrodactyly of the feet and hands. Toe resection was not as beneficial.     

Photofrin increases murine spleen cell transferrin receptor expression and responsiveness to recombinant myeloid and erythroid growth factors

In a retrospective study, data from the Guéra Leprosy and Disability Control Project in Chad, covering the years from 1992 to 1996, were analysed in order to determine whether there was any indication that the quality of care provided to female leprosy sufferers is inferior to the care provided for male patients. Data from a total of 741 patient registered for MDT, of whom 351 were newly diagnosed cases, are presented and discussed. The data indicate that women have access to diagnosis and treatment and health education. They do not present for treatment later than men, disability rates are lower and they have slightly higher treatment completion rates. Both women and men benefit from footwear and loan programs. More women than men are involved in patient self-help groups. The study shows that in this part of central Chad, there is no evidence of disadvantage for women with leprosy in either diagnosis, treatment or follow-up, but more qualitative data is needed to confirm these findings.     

Laser Doppler perfusion imaging of skin blood flow using red and near-infrared sources

At present, scanning laser Doppler imaging uses a 633-nm helium-neon laser (RED) as the only light source, but this restricts its ability to measure blood flow (i) at darkly pigmented skin and (ii) from deeper or subdermal structures. Because near-infrared (NIR) light is known to penetrate deeper into tissue and to be less absorbed than RED, two imagers were adapted to include a NIR laser diode source (one of 830 nm for UK studies; one of 780 nm for leprosy field trials) in parallel with the existing RED source. In human hands representing a range of skin pigmentations, RED scans were unobtainable at the darkest areas of skin, but intact NIR scans could be collected in all cases. In experiments at the rat knee and the dorsal human hand, NIR and RED values were similar on normal skin. Over underlying vessels, however, NIR values greatly exceeded RED values, an effect abolished by occlusion. Similarly, in patients with leprosy and in healthy controls in Spain, fingerpulp NIR values exceeded RED values to the greatest degree when thermoregulatory flow was highest, i.e., when the deeper-lying arteriovenous anastomoses were open. Over areas of experimental inflammation, NIR gave higher values and also exhibited a greater degree of spatial heterogeneity than RED. We conclude that some current limitations of laser Doppler imaging technology can be overcome by the use of NIR laser diode sources.     

A simple quantitative method to determine short chain fatty acid levels in biological fluids

The pseudocholinesterase levels and the nature of the enzyme as shown by the dibucaine number (D.N.) were estimated in 720 controls and 420 lepromatous leprosy patients, and 301 tuberculoid leprosy patients. There was no statistical difference in the esterase levels between leprosy patients and normal controls. But the distribution of D.N. was significantly different in the leprosy patients compared to the normal population studied. The D.N. below 40 indicates the samples with the atypical pseudocholinesterase--the presence of which is genetically determined. The distribution of samples with D.N. below 40 was significantly higher in the lepromatous leprosy patients compared to the normal population or tuberculoid leprosy patients. It is proposed that since there is a greater incidence of the atypical enzyme in lepromatous leprosy cases, the presence of this enzyme or the deficiency of the typical enzyme may make a person more susceptible to leprosy.     

Effects of BQ-123 on systemic and renal hemodynamic responses to endothelin-1 in the rat split hydronephrotic kidney

OBJECTIVE: To assess the site of action of endothelin-1 in vessels of different sizes in the kidney in vivo and investigate the function of endothelin A (ET(A)) receptors in mediating renal and systemic vasoconstriction. DESIGN: The luminal diameters of different vessels were measured and glomerular blood flow in cortical glomeruli was determined by intravital videomicroscopy in the split hydronephrotic kidney of anesthetized female Wistar rats. METHODS: The rats were infused with endothelin-1 (40 pmol/kg per min) with or without pretreatment with the selective ET(A)-receptor antagonist BQ-123 (0.5 mg/kg). Aortic clamping was used to control renal blood pressure during the endothelin-1 infusion. RESULTS: Exogenous endothelin-1 induced a significant rise (30+/-3%) in mean arterial pressure and a marked, long-lasting fall in glomerular blood flow (53+/-3%) related to reduction of the inner diameter of arcuate (-30%), interlobular arteries (-33%) and afferent arterioles (-17%). Aortic clamping to normalize renal blood pressure did not attenuate the vasoconstriction and reduction in glomerular blood flow. Pretreatment with BQ-123 significantly reduced both the endothelin-1-induced rise in mean arterial pressure (12+/-1%) and the fall in glomerular blood flow (-23+/-11%). BQ-123 blunted the response to endothelin-1 in arcuate (-12%), interlobular (-11%) and afferent vessels (-5%). Acetylcholine and nitroprusside completely reversed the vasoconstriction in BQ-123-pretreated animals. CONCLUSIONS: BQ-123 largely prevented the hemodynamic effects of exogenously administered endothelin-1. Our direct in-vivo techniques showed that ET(A) receptors are, at least in part, involved in endothelin-1 -mediated vasoconstriction in the rat kidney, and support the hypothesis that ET(A) receptors may help to control arterial pressure in anesthetized rats.     

6-n-Propylthiouracil: a genetic marker for taste, with implications for food preference and dietary habits

OBJECTIVE: We evaluated the usefulness of carbon dioxide as the primary contrast material for renal transplant arteriography. CONCLUSION: Carbon dioxide accurately showed artery pathology including anastomotic and intrarenal stenoses, arteriovenous shunting, and diffuse arterial disease from chronic transplant rejection. Using carbon dioxide as a contrast agent reduced the volume of iodinated contrast material that needed to be used. There was no procedure-associated nephrotoxicity.     

Delayed-type hypersensitivity to Mycobacterium leprae soluble antigens as a test for infection with the leprosy bacillus

BACKGROUND: Mycobacterium leprae (M. leprae) soluble antigen (MLSA) reagents have been developed with the aim of finding a reagent, comparable to tuberculin, which could identify individuals infected with the leprosy bacillus. They have yet to be evaluated fully in human populations. METHODS: More than 15000 individuals living in a leprosy endemic area of northern Malawi were skin tested with one of five batches of MLSA prepared using two different protocols. The main difference in preparation was the introduction of a high G centrifugation step in the preparation of the last three ('second-generation') batches. RESULTS: The prevalence of skin-test positivity (delayed-type hypersensitivity (DTH)) and association with the presence of a BCG scar were greater for first (batches A6, A22) than second (batches AB53, CD5, CD19) generation reagents. The association of positivity with M. leprae infection was investigated by comparing results among known (household) contacts of leprosy cases, and among newly diagnosed leprosy patients with those in the general population. While positivity to 'first-generation' antigens appeared to be associated with M. leprae infection, positivity to later antigens was unrelated either to exposure to leprosy cases or presence of leprosy disease. There were geographical differences in the prevalence of DTH to the various batches, probably reflecting exposure to various mycobacteria in the environment. CONCLUSIONS: Our results suggest that the 'second-generation' batches have lost antigens that can detect M. leprae infections, but that they retain one or more antigens which are shared between M. leprae and environmental mycobacteria. Natural exposure to these both sensitizes individuals and provides natural protection against M. leprae infection or disease. Identification of antigens present in these groups of skin test reagents may assist in production of improved skin test reagents.     

Effect of aminophylline on frequency of blood flow in utero-placental and fetal circulation, on arterial blood pressure and on cardiotocography

Aminophylline was given (125 mg i.v.) in 24 cases with fetal hypotrophy. Blood flow was measured (Doppler technique) before aminophylline injection, 30 min. and 3-4 hours after. Blood pressure was monitored continuously, CTG was performed many times before and after administration of aminophylline. After administration of aminophylline diastolic blood pressure decreased during 3-4 hours and blood flow in the arcuate artery increased. There were no changes in the blood flow in the umbilical artery and fetal aorta after administration of aminophylline. We didn't observe any changes in CTG before and after administration of aminophylline.     

Household and dwelling contact as risk factors for leprosy in northern Malawi

Data on household and dwelling contact with known leprosy cases were available on more than 80,000 initially disease-free individuals followed up during the 1980s in a rural district of northern Malawi. A total of 331 new cases of leprosy were diagnosed among them. Individuals recorded as living in household or dwelling contact with multibacillary patients at the start of follow-up were at approximately five- to eightfold increased risk of leprosy, respectively, compared with individuals not living in such households or dwellings. Individuals living in household or dwelling contact with paucibacillary cases were both at approximately twofold increased risk. The higher risk associated with multibacillary contact and the fact that dwelling contact entailed a greater risk than household contact if the association was with multibacillary, but not with paucibacillary, disease suggest that paucibacillary cases may not themselves be sources of transmission, but rather just markers that a household has had contact with some (outside) source of infection. When household contact was considered alone, the risks of disease were appreciably higher for younger than for older contacts and for male compared with female contacts. Despite the elevated risk of leprosy associated with household or dwelling contact, only 15% of all incidence cases arose among recognized household contacts. Given the dynamic nature of household membership and consequent misclassification of contact status, the true contribution to overall incidence of contact within household or dwelling settings is likely to be much higher than this, perhaps 30% or higher. Considering the predilection of males for infectious multibacillary forms of the disease, the transmission of Mycobacterium leprae at an early age, in particular to males, may be of particular importance for the persistence of leprosy in endemic communities. Although residential contact with a multibacillary case is the strongest known determinant of leprosy risk, the vast majority of such contacts never manifest disease, which indicates a crucial role for genetic and/or environmental factors in the transmission of M. leprae infection and/or the pathogenesis of clinical leprosy.     

Arterial complications of pancreatitis: diagnostic and therapeutic aspects in 104 cases

PURPOSE: A retrospective study of 104 cases of arterial lesions related to pancreatitis was undertaken to examine the diagnostic and therapeutic benefits of arteriography compared with ultrasonography (US) and computed tomography (CT). PATIENTS AND METHODS: Data were acquired from responses to a questionnaire. Eighty-seven patients were men, 17 were women (age range, 21-80 years; mean, 48 years). These lesions were usually revealed by hemorrhage (70 cases), pain (69 cases), or both (46 cases). RESULTS: Arteriography was immediately positive in 90 of 93 patients in whom it was performed, but US and CT may also permit incidental discovery of silent lesions (17 cases). These lesions are often single (90%) and related to an arterial rupture in a pseudocyst (60%) or a pseudoaneurysm (48%). They involved the splenic (42%), the gastroduodenal (22%), and the small pancreatic arteries (25%). Of 32 cases in which embolization was performed, immediate success was achieved in all cases but bleeding recurred in 12 cases (37%). Treatment in 25 patients was a definitive success (78%), and five patients died of hemorrhage (16%). CONCLUSION: Arteriography remains essential for diagnosis of arterial lesions, and embolization may be indicated as a stabilizing preoperative procedure and also for immediately stopping hemorrhage.     

Carotid stenosis--is arteriography necessary in investigation and treatment

The present study was undertaken in order to evaluate whether arteriography changed the planned treatment (carotid endarterectomy) of patients with symptomatic carotid artery disease, who had been investigated primarily by ultrasound Duplex scanning. The material was comprised of 50 consecutive patients admitted for arteriography. All patients were symptomatic and were by ultrasound examination found to have lesions of the relevant internal carotid artery (ICA). In three cases arteriography was performed because ultrasound examination was inconclusive. Of the remaining 47 cases, arteriography only changed the planned treatment in three. In one case, arteriography showed a long stenosis continuing into the intracranial part of the ICA, which was not observed by ultrasound. In two cases of minor disease ultrasound overestimated the degree of stenosis. The study concludes that carotid endarterectomy may be performed based on ultrasound duplex scanning, without prior arteriography, if the degree of stenosis is 70% or greater and if the distal end of the stenosis is clearly extracranial.     

Effect of 6-hydroxydopamine injection into the arcuate hypothalamic nucleus on the osmotic release of vasopressin in conscious rats

The aim of the present study was to evaluate a role in vasopressin secretion of the catecholaminergic neurons, including the tuberohypophysial dopaminergic neurons situated in the arcuate hypothalamic nucleus. A neurotoxin, 6-hydroxydopamine (6 g/l), was injected locally into the arcuate nucleus and its effects on catecholamine levels of the hypothalamic tissue and the neurointermediate lobe, and on the plasma vasopressin concentrations before and during i.v. infusion (0.1 ml kg-1 min-1) of isotonic (0.15 mol/l) or hypertonic saline (2.5 mol/l), were examined in conscious rats. The infusion of hypertonic saline produced increases of plasma vasopressin 15 and 30 min later, accompanied by elevations of plasma osmolality, sodium, chloride and arterial pressure. The vasopressin response was potentiated markedly by the 6-hydroxydopamine injection performed 8 days before, which hardly affected the responses of the other variables. Histological examination indicated that the injection sites of 6-hydroxydopamine in those rats had been located in the area ranging from rostral to medial arcuate nucleus. The i.v. infusion of isotonic saline did not change plasma vasopressin, osmolality, sodium, chloride or arterial pressure, regardless of the presence or absence of pretreatment with 6-hydroxydopamine. It was confirmed that when 6-hydroxydopamine was injected into the arcuate nucleus region 8 days before, noradrenaline and adrenaline concentrations of the hypothalamic tissue containing the injection site were decreased remarkably, although we could not detect any significant alteration in the dopamine concentration of the hypothalamic tissue or the neurointermediate lobe. On the basis of these results, we concluded that catecholaminergic neurons in the arcuate nucleus may act to inhibit osmotic vasopressin secretion.     

Gastroduodenal arterial aneurysm and chronic pancreatitis. A case and review of the literature

A case of pseudoaneurysm of the gastroduodenal artery due to chronic pancreatitis is reported. Pancreatitis causing splanchnic arterial aneurysm is more likely to affect the splenic artery than the gastroduodenal artery. Ten percent of cases of chronic pancreatitis are associated with splanchnic aneurysm. Hemorrhage occurs in 50% of cases. Color Doppler ultrasound is the best diagnostic tool, indicating the need for coeliac arteriography. In our case report, transcatheter embolization was performed with stainless steel coils and the pseudoaneurysm was successfully occluded.