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Kobayashi M, Kato S, Demura S, Yokogawa N, Yokka A, Nakade Y, Annen R, Gabata T, Tsuchiya H. Evaluation of Conditions for the Development of Cryogenic Spinal Cord Injury Using a Canine Model: An Experimental Study on the Safety of Cryoablation for Metastatic Spinal Tumors. AJNR Am J Neuroradiol 2024; 45:424-431. [PMID: 38453412 DOI: 10.3174/ajnr.a8151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 12/18/2023] [Indexed: 03/09/2024]
Abstract
BACKGROUND AND PURPOSE Although the application of cryoablation to metastatic spinal tumors has been attempted, spinal cryoablation has the unique complication of cryogenic spinal cord injury. This study aimed to elucidate the conditions for the development of cryogenic spinal cord injury. MATERIALS AND METHODS Fifteen canines were used in this study. A metal probe was inserted into the 13th thoracic vertebral body. Cryoablation was performed for 10 minutes by freezing the probe in liquid nitrogen. The control canine underwent probe insertion only. Spinal cord monitoring, epidural temperature measurement, motor function assessment, and pathologic examination of the spinal cord were performed. RESULTS During the 10 minutes of cryoablation, the epidural temperature decreased and reached the lowest epidural temperature (LET) at the end of cryoablation. The LETs (degrees celsius [°C]) of each canine were -37, -30, -27, -8, -3, -2, 0, 1, 4, 8, 16, 18, 20, and 25, respectively. As the epidural temperature decreased, waveform amplitudes also decreased. At the end of cryoablation (10 minutes after the start of cryoablation), abnormal waves were observed in 92.9% (13/14) of canines. With epidural rewarming, the amplitude of the waveforms tended to recover. After epidural rewarming (2 hours after the start of cryoablation), abnormal waves were observed in 28.6% (4/14) of canines. The LETs (°C) of the canines with abnormal waves after epidural rewarming were -37, -30, -27, and -8. None of the canines with normal waves after epidural rewarming had any motor impairment. In contrast, all canines with remaining abnormal waves after epidural rewarming had motor impairment. In the pathologic assessment, cryogenic changes were found in canines with LETs (°C) of -37 -30, -27, -8, 0, and 1. CONCLUSIONS This study showed that 10-minute spinal cryoablation with LETs (°C) of -37, -30, -27, -8, 0, and 1 caused cryogenic spinal cord injury. There was no evidence of cryogenic spinal cord injury in canines with LET of ≥4°C. The epidural temperature threshold for cryogenic spinal cord injury is between 1 and 4°C, suggesting that the epidural temperature should be maintained above at least 4°C to prevent cryogenic spinal cord injury.
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Affiliation(s)
- Motoya Kobayashi
- From the Department of Orthopedic Surgery (M.K., S.K., S.D., N.Y., R.A., H.T.), Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Satoshi Kato
- From the Department of Orthopedic Surgery (M.K., S.K., S.D., N.Y., R.A., H.T.), Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Satoru Demura
- From the Department of Orthopedic Surgery (M.K., S.K., S.D., N.Y., R.A., H.T.), Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Noriaki Yokogawa
- From the Department of Orthopedic Surgery (M.K., S.K., S.D., N.Y., R.A., H.T.), Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Akira Yokka
- Department of Radiology (A.Y., T.G.), Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Yusuke Nakade
- Department of Clinical Laboratory (Y.N.), Kanazawa University Hospital, Kanazawa, Ishikawa, Japan
| | - Ryohei Annen
- From the Department of Orthopedic Surgery (M.K., S.K., S.D., N.Y., R.A., H.T.), Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Toshifumi Gabata
- Department of Radiology (A.Y., T.G.), Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
| | - Hiroyuki Tsuchiya
- From the Department of Orthopedic Surgery (M.K., S.K., S.D., N.Y., R.A., H.T.), Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Ishikawa, Japan
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Zafren K, Hollis S, Weiss EA, Danzl D, Wilburn J, Kimmel N, Imray C, Giesbrecht G, Tipton M. Prevention and Treatment of Nonfreezing Cold Injuries and Warm Water Immersion Tissue Injuries: A Supplement to the Wilderness Medical Society Clinical Practice Guidelines. Wilderness Environ Med 2023; 34:172-181. [PMID: 37130771 DOI: 10.1016/j.wem.2023.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 01/26/2023] [Accepted: 02/15/2023] [Indexed: 05/04/2023]
Abstract
We convened an expert panel to develop evidence-based guidelines for the evaluation, treatment, and prevention of nonfreezing cold injuries (NFCIs; trench foot and immersion foot) and warm water immersion injuries (warm water immersion foot and tropical immersion foot) in prehospital and hospital settings. The panel graded the recommendations based on the quality of supporting evidence and the balance between benefits and risks/burdens according to the criteria published by the American College of Chest Physicians. Treatment is more difficult with NFCIs than with warm water immersion injuries. In contrast to warm water immersion injuries that usually resolve without sequelae, NFCIs may cause prolonged debilitating symptoms, including neuropathic pain and cold sensitivity.
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Affiliation(s)
- Ken Zafren
- Department of Emergency Medicine, Alaska Native Medical Center, Anchorage, AK; Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA; International Commission for Mountain Emergency Medicine (ICAR MEDCOM), Zürich, Switzerland.
| | - Sarah Hollis
- Regional Occupational Health Team, Defence Medical Services MOD, Catterick Garrison, UK
| | - Eric A Weiss
- Department of Emergency Medicine, Stanford University Medical Center, Stanford, CA
| | - Daniel Danzl
- Department of Emergency Medicine, University of Louisville School of Medicine, Louisville, KY
| | - Jessie Wilburn
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | | | - Chris Imray
- Coventry National Institute for Health Research, Clinical Research Facility, University Hospital Coventry & Warwickshire, NHS Trust, Coventry, UK
| | - Gordon Giesbrecht
- Faculty of Kinesiology and Recreation Management and Departments of Emergency Medicine and Anesthesia, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mike Tipton
- Extreme Environments Laboratory, School of Sport, Health & Exercise Science, University of Portsmouth, Portsmouth, UK
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Stjernbrandt A, Vihlborg P, Wahlström V, Wahlström J, Lewis C. Occupational cold exposure and symptoms of carpal tunnel syndrome - a population-based study. BMC Musculoskelet Disord 2022; 23:596. [PMID: 35725430 PMCID: PMC9210706 DOI: 10.1186/s12891-022-05555-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 06/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cold exposure is an underrecognized occupational hazard that may increase the risk of peripheral nerve entrapment. The aim of this study was to determine if self-reported occupational exposure to contact and ambient cooling was associated with symptoms of carpal tunnel syndrome (CTS). METHODS In this mainly cross-sectional study, surveys were conducted on a population-based sample of men and women between 18 and 70 years of age, living in northern Sweden. Cold exposure and presence of symptoms suggestive of CTS were subjectively reported. Associations between exposure and outcome were evaluated using logistic regression. RESULTS The study included 2,703 women and 2,314 men, with a median age of 60 years (interquartile range 19). Symptoms of CTS were reported by 453 (9.2%). Being highly occupationally exposed (almost always) to contact cooling of the hands was associated with reporting CTS (OR 3.20; 95% CI 1.62-6.33), as was ambient cooling (OR 2.00; 95% CI 1.03-3.88) and severe ambient cooling (OR 4.02 95% CI 2.09-7.71), after adjusting for age, gender, body mass index, current daily smoking, diabetes mellitus, joint disease, and hand-arm vibration exposure. The point estimates increased with longer daily exposure duration. For workers exposed to severe ambient cooling for more than half of their working hours, in addition to performing heavy manual handling every day, the OR for reporting CTS was 7.25 (95% CI 3.88-13.53), with a positive additive interaction effect (expressed as relative excess risk due to interaction) of 4.67. CONCLUSIONS Self-reported occupational exposure to contact and ambient cooling was associated with symptoms suggestive of CTS. There were statistically significant positive exposure-response patterns for time spent exposed to contact and ambient cooling at work in relation to reporting symptoms of CTS. Positive additive interaction effects between cold exposure and heavy manual handling were also found. Since there was important potential uncontrolled confounding regarding repetitive wrist movements and forceful gripping, the results need to be confirmed by other studies, preferably with longitudinal design and more detailed exposure assessment.
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Affiliation(s)
- Albin Stjernbrandt
- Department of Public Health and Clinical Medicine, Section of Sustainable Health, Umeå University, 901 87, Umeå, Sweden.
| | - Per Vihlborg
- Department of Geriatrics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Viktoria Wahlström
- Department of Public Health and Clinical Medicine, Section of Sustainable Health, Umeå University, 901 87, Umeå, Sweden
| | - Jens Wahlström
- Department of Public Health and Clinical Medicine, Section of Sustainable Health, Umeå University, 901 87, Umeå, Sweden
| | - Charlotte Lewis
- Department of Public Health and Clinical Medicine, Section of Sustainable Health, Umeå University, 901 87, Umeå, Sweden
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Li B, Du C, Liu H, Yu W, Zheng J, Tan M, Jin Z, Li W, Wu J, Chen L, Yao R. Regulation of sensory nerve conduction velocity of human bodies responding to annual temperature variations in natural environments. INDOOR AIR 2019; 29:308-319. [PMID: 30506551 DOI: 10.1111/ina.12525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 11/20/2018] [Accepted: 11/24/2018] [Indexed: 06/09/2023]
Abstract
The extensive research interests in environmental temperature can be linked to human productivity/performance as well as comfort and health; while the mechanisms of physiological indices responding to temperature variations remain incompletely understood. This study adopted a physiological sensory nerve conduction velocity (SCV) as a temperature-sensitive biomarker to explore the thermoregulatory mechanisms of human responding to annual temperatures. The measurements of subjects' SCV (over 600 samples) were conducted in a naturally ventilated environment over all four seasons. The results showed a positive correlation between SCV and annual temperatures and a Boltzmann model was adopted to depict the S-shaped trend of SCV with operative temperatures from 5°C to 40°C. The SCV increased linearly with operative temperatures from 14.28°C to 20.5°C and responded sensitively for 10.19°C-24.59°C, while tended to be stable beyond that. The subjects' thermal sensations were linearly related to SCV, elaborating the relation between human physiological regulations and subjective thermal perception variations. The findings reveal the body SCV regulatory characteristics in different operative temperature intervals, thereby giving a deeper insight into human autonomic thermoregulation and benefiting for built environment designs, meantime minimizing the temperature-invoked risks to human health and well-being.
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Affiliation(s)
- Baizhan Li
- Joint International Research Laboratory of Green Buildings and Built Environments (Ministry of Education), Chongqing University, Chongqing, China
- National Centre for International Research of Low-carbon and Green Buildings, Ministry of Science and Technology), Chongqing University, Chongqing, China
| | - Chenqiu Du
- Joint International Research Laboratory of Green Buildings and Built Environments (Ministry of Education), Chongqing University, Chongqing, China
- National Centre for International Research of Low-carbon and Green Buildings, Ministry of Science and Technology), Chongqing University, Chongqing, China
| | - Hong Liu
- Joint International Research Laboratory of Green Buildings and Built Environments (Ministry of Education), Chongqing University, Chongqing, China
- National Centre for International Research of Low-carbon and Green Buildings, Ministry of Science and Technology), Chongqing University, Chongqing, China
| | - Wei Yu
- Joint International Research Laboratory of Green Buildings and Built Environments (Ministry of Education), Chongqing University, Chongqing, China
- National Centre for International Research of Low-carbon and Green Buildings, Ministry of Science and Technology), Chongqing University, Chongqing, China
| | - Jie Zheng
- Joint International Research Laboratory of Green Buildings and Built Environments (Ministry of Education), Chongqing University, Chongqing, China
- National Centre for International Research of Low-carbon and Green Buildings, Ministry of Science and Technology), Chongqing University, Chongqing, China
| | - Meilan Tan
- Joint International Research Laboratory of Green Buildings and Built Environments (Ministry of Education), Chongqing University, Chongqing, China
- National Centre for International Research of Low-carbon and Green Buildings, Ministry of Science and Technology), Chongqing University, Chongqing, China
| | - Zhenxing Jin
- Joint International Research Laboratory of Green Buildings and Built Environments (Ministry of Education), Chongqing University, Chongqing, China
- National Centre for International Research of Low-carbon and Green Buildings, Ministry of Science and Technology), Chongqing University, Chongqing, China
| | - Wenjie Li
- Joint International Research Laboratory of Green Buildings and Built Environments (Ministry of Education), Chongqing University, Chongqing, China
- National Centre for International Research of Low-carbon and Green Buildings, Ministry of Science and Technology), Chongqing University, Chongqing, China
| | - Jing Wu
- Joint International Research Laboratory of Green Buildings and Built Environments (Ministry of Education), Chongqing University, Chongqing, China
- National Centre for International Research of Low-carbon and Green Buildings, Ministry of Science and Technology), Chongqing University, Chongqing, China
| | - Lu Chen
- Joint International Research Laboratory of Green Buildings and Built Environments (Ministry of Education), Chongqing University, Chongqing, China
- National Centre for International Research of Low-carbon and Green Buildings, Ministry of Science and Technology), Chongqing University, Chongqing, China
| | - Runming Yao
- Joint International Research Laboratory of Green Buildings and Built Environments (Ministry of Education), Chongqing University, Chongqing, China
- National Centre for International Research of Low-carbon and Green Buildings, Ministry of Science and Technology), Chongqing University, Chongqing, China
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Khoshnevis S, Matthew Brothers R, Diller KR. Level of Cutaneous Blood Flow Depression During Cryotherapy Depends on Applied Temperature: Criteria for Protocol Design. JOURNAL OF ENGINEERING AND SCIENCE IN MEDICAL DIAGNOSTICS AND THERAPY 2018; 1:0410071-410079. [PMID: 35832308 PMCID: PMC8597570 DOI: 10.1115/1.4041463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 09/06/2018] [Indexed: 06/15/2023]
Abstract
Cryotherapy is commonly used for the management of soft tissue injury. The dose effect of the applied cooling temperature has not been quantified previously. Six subjects were exposed during five different experiments to local skin temperatures of 16.6 °C, 19.8 °C, 24.7 °C, 27.3 °C, and 37.2 °C for 1 h of active heat transfer followed by 2 h of passive environmental interaction. Skin blood perfusion and temperature were measured continuously at treatment and control sites. All treatments resulted in significant changes in cutaneous vascular conductance (CVC, skin perfusion/mean arterial pressure) compared to baseline values. The drop in CVC for cooling to both 19.8 °C and 16.6 °C was significantly larger than for 27.3 °C (P < 0.05 and P < 0.0005, respectively). The depression of CVC for cooling to 16.6 °C was significantly larger than at 24.7 °C (P < 0.05). Active warming at 37.2 °C produced more than a twofold increase in CVC (P < 0.05). A simulation model was developed to describe the coupled effects of exposure time and temperature on skin perfusion. The model was applied to define an equivalent cooling dose defined by exposure time and temperature that produced equivalent changes in skin perfusion. The model was verified with data from 22 independent cryotherapy experiments. The equivalent doses were applied to develop a nomogram to identify therapeutic time and temperature combinations that would produce a targeted vascular response. The nomogram may be applied to design cryotherapy protocols that will yield a desired vascular response history that may combine the benefits of tissue temperature reduction while diminishing the risk of collateral ischemic injury.
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Affiliation(s)
- Sepideh Khoshnevis
- Department of Biomedical Engineering, The University of Texas at Austin, 107 W. Dean Keeton Street, Stop C0800, Austin, TX 78712 e-mail:
| | - R Matthew Brothers
- Department of Kinesiology, University of Texas at Arlington, MAC 114, Arlington, TX 78229 e-mail:
| | - Kenneth R Diller
- Fellow ASME Department of Biomedical Engineering, The University of Texas at Austin, 107 W. Dean Keeton Street, Stop C0800, Austin, TX 78712 e-mail:
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Warrender WJ, Henstenburg J, Maltenfort M, Lutsky K, Beredjiklian PK. Seasonal Variation in the Prevalence of Common Orthopaedic Upper Extremity Conditions. J Wrist Surg 2018; 7:232-236. [PMID: 29922500 PMCID: PMC6005781 DOI: 10.1055/s-0037-1612637] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 11/20/2017] [Indexed: 12/16/2022]
Abstract
Introduction Seasonal variation in disease processes and injuries have been reported, but it is unclear if this variation exists in upper extremity disorders. The goal of this study is to characterize seasonal and weather variations in common upper extremity orthopaedic conditions. Methods This cross-sectional study reviewed 68,943 consecutive, new patient visits from January 2010 to September 2015 for carpal tunnel syndrome (CTS), trigger finger (TF), DeQuervain's tenosynovitis (DeQ), lateral epicondylitis (LE), hand arthritis (OA), and distal radius fractures (DRF). Presentation rates for each condition were compared across month, season, and various weather parameters. Results DRF, OA, and LE had a higher rate of presentation in the winter compared with all other seasons ( p < 0.001). TF and DeQ showed no statistically significant seasonal differences. Higher barometric pressures were associated with higher rates of all of the diagnoses. Higher humidity was associated with lower rates of CTS, TF, DeQ, LE, and DRF ( p < 0.001). There was no significant association between temperature levels or amount of precipitation. Discussion Although the precise mechanism remains unclear, there does appear to be an impact of winter, increased barometric pressure, and higher humidity on presentation rates. Further studies are needed to determine more conclusively why this occurs. Level of Evidence Level IV, cross-sectional study.
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Affiliation(s)
- William J. Warrender
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Jeffrey Henstenburg
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Kevin Lutsky
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
- Department of Hand Surgery, The Rothman Institute, Philadelphia, Pennsylvania
| | - Pedro K. Beredjiklian
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
- Department of Hand Surgery, The Rothman Institute, Philadelphia, Pennsylvania
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Vale TA, Symmonds M, Polydefkis M, Byrnes K, Rice ASC, Themistocleous AC, Bennett DLH. Chronic non-freezing cold injury results in neuropathic pain due to a sensory neuropathy. Brain 2017; 140:2557-2569. [PMID: 28969380 PMCID: PMC5841153 DOI: 10.1093/brain/awx215] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 07/04/2017] [Accepted: 07/06/2017] [Indexed: 01/03/2023] Open
Abstract
Non-freezing cold injury develops after sustained exposure to cold temperatures, resulting in tissue cooling but not freezing. This can result in persistent sensory disturbance of the hands and feet including numbness, paraesthesia and chronic pain. Both vascular and neurological aetiologies of this pain have been suggested but remain unproven. We prospectively approached patients referred for clinical assessment of chronic pain following non-freezing cold injury between 12 February 2014 and 30 November 2016. Of 47 patients approached, 42 consented to undergo detailed neurological evaluations including: questionnaires to detail pain location and characteristics, structured neurological examination, quantitative sensory testing, nerve conduction studies and skin biopsy for intraepidermal nerve fibre assessment. Of the 42 study participants, all had experienced non-freezing cold injury while serving in the UK armed services and the majority were of African descent (76.2%) and male (95.2%). Many participants reported multiple exposures to cold. The median time between initial injury and referral was 3.72 years. Pain was principally localized to the hands and the feet, neuropathic in nature and in all study participants associated with cold hypersensitivity. Clinical examination and quantitative sensory testing were consistent with a sensory neuropathy. In all cases, large fibre nerve conduction studies were normal. The intraepidermal nerve fibre density was markedly reduced with 90.5% of participants having a count at or below the 0.05 centile of published normative controls. Using the Neuropathic Pain Special Interest Group of the International Association for the Study of Pain grading for neuropathic pain, 100% had probable and 95.2% definite neuropathic pain. Chronic non-freezing cold injury is a disabling neuropathic pain disorder due to a sensory neuropathy. Why some individuals develop an acute painful sensory neuropathy on sustained cold exposure is not yet known, but individuals of African descent appear vulnerable. Screening tools, such as the DN4 questionnaire, and treatment algorithms for neuropathic pain should now be used in the management of these patients.
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Affiliation(s)
- Tom A Vale
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Mkael Symmonds
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Michael Polydefkis
- Cutaneous Nerve Laboratory, Neurology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Kelly Byrnes
- Cutaneous Nerve Laboratory, Neurology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Andrew S C Rice
- Pain Research Group, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital Campus, London, UK
- Pain Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - David L H Bennett
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Anand P, Privitera R, Yiangou Y, Donatien P, Birch R, Misra P. Trench Foot or Non-Freezing Cold Injury As a Painful Vaso-Neuropathy: Clinical and Skin Biopsy Assessments. Front Neurol 2017; 8:514. [PMID: 28993756 PMCID: PMC5626869 DOI: 10.3389/fneur.2017.00514] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 09/13/2017] [Indexed: 01/05/2023] Open
Abstract
Background Trench foot, or non-freezing cold injury (NFCI), results from cold exposure of sufficient severity and duration above freezing point, with consequent sensory and vascular abnormalities which may persist for years. Based on observations of Trench foot in World War II, the condition was described as a vaso-neuropathy. While some reports have documented nerve damage after extreme cold exposure, sensory nerve fibres and vasculature have not been assessed with recent techniques in NFCI. Objective To assess patients with chronic sensory symptoms following cold exposure, in order to diagnose any underlying small fibre neuropathy, and provide insight into mechanisms of the persistent pain and cold hypersensitivity. Methods Thirty soldiers with cold exposure and persistent sensory symptoms (>4 months) were assessed with quantitative sensory testing, nerve conduction studies, and skin biopsies. Immunohistochemistry was used to assess intraepidermal (IENF) and subepidermal (SENF) nerve fibres with a range of markers, including the pan-neuronal marker protein gene product 9.5 (PGP 9.5), regenerating fibres with growth-associated protein 43 (GAP43), and nociceptor fibres with transient receptor potential cation channel subfamily V member 1 (TRPV1), sensory neuron-specific receptor (SNSR), and calcitonin gene-related peptide (CGRP). von Willebrand factor (vWF), endothelial nitric oxide synthase (eNOS), and vascular endothelial growth factor (VEGF) were used for assessing blood vessels, and transient receptor potential cation channel, subfamily A member 1 (TRPA1) and P2X purinoceptor 7 (P2X7) for keratinocytes, which regulate nociceptors via release of nerve growth factor. Results Clinical examination showed pinprick sensation was abnormal in the feet of 20 patients (67%), and between 67 and 83% had abnormalities of thermal thresholds to the different modalities. 7 patients (23%) showed reduced sensory action potential amplitude of plantar nerves. 27 patients (90%) had decreased calf skin PGP 9.5 IENF (p < 0.0001), the remaining 3 patients had decreased nerve markers in subepidermis or foot skin. There were marked increases of all vascular markers (for vWF in calf skin, p < 0.0001), and increased sensory or regenerating SENF (for calf skin, GAP43, p = 0.002). TRPA1 (p = 0.0012) and P2X7 (p < 0.0001) were increased in basal keratinocytes. Conclusion A range of skin biopsy markers and plantar nerve conduction studies are useful objective assessments for the diagnosis of peripheral neuropathy in NFCI. Our results suggest that an increase in blood vessels following tissue ischaemia/hypoxia could be associated with disproportionate and abnormal nerve fibres (irritable nociceptors), and may lead to NFCI as a “painful vaso-neuropathy.”
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Affiliation(s)
- Praveen Anand
- Peripheral Neuropathy Unit, Centre for Clinical Translation, Hammersmith Hospital, Imperial College, London, United Kingdom
| | - Rosario Privitera
- Peripheral Neuropathy Unit, Centre for Clinical Translation, Hammersmith Hospital, Imperial College, London, United Kingdom
| | - Yiangos Yiangou
- Peripheral Neuropathy Unit, Centre for Clinical Translation, Hammersmith Hospital, Imperial College, London, United Kingdom
| | - Philippe Donatien
- Peripheral Neuropathy Unit, Centre for Clinical Translation, Hammersmith Hospital, Imperial College, London, United Kingdom
| | - Rolfe Birch
- Peripheral Neuropathy Unit, Centre for Clinical Translation, Hammersmith Hospital, Imperial College, London, United Kingdom
| | - Peter Misra
- Peripheral Neuropathy Unit, Centre for Clinical Translation, Hammersmith Hospital, Imperial College, London, United Kingdom
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Sundar R, Bandla A, Tan SSH, Liao LD, Kumarakulasinghe NB, Jeyasekharan AD, Ow SGW, Ho J, Tan DSP, Lim JSJ, Vijayan J, Therimadasamy AK, Hairom Z, Ang E, Ang S, Thakor NV, Lee SC, Wilder-Smith EPV. Limb Hypothermia for Preventing Paclitaxel-Induced Peripheral Neuropathy in Breast Cancer Patients: A Pilot Study. Front Oncol 2017; 6:274. [PMID: 28119855 PMCID: PMC5222823 DOI: 10.3389/fonc.2016.00274] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 12/23/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Peripheral neuropathy (PN) due to paclitaxel is a common dose-limiting toxicity with no effective prevention or treatment. We hypothesize that continuous-flow limb hypothermia can reduce paclitaxel-induced PN. PATIENTS AND METHODS An internally controlled pilot trial was conducted to investigate the neuroprotective effect of continuous-flow limb hypothermia in breast cancer patients receiving weekly paclitaxel. Patients underwent limb hypothermia of one limb for a duration of 3 h with every paclitaxel infusion, with the contralateral limb used as control. PN was primarily assessed using nerve conduction studies (NCSs) before the start of chemotherapy, and after 1, 3, and 6 months. Skin temperature and tolerability to hypothermia were monitored using validated scores. RESULTS Twenty patients underwent a total of 218 cycles of continuous-flow limb hypothermia at a coolant temperature of 22°C. Continuous-flow limb hypothermia achieved mean skin temperature reduction of 1.5 ± 0.7°C and was well tolerated, with no premature termination of cooling due to intolerance. Grade 3 PN occurred in 2 patients (10%), grade 2 in 2 (10%), and grade 1 in 12 (60%). Significant correlation was observed between amount of skin cooling and motor nerve amplitude preservation at 6 months (p < 0.0005). Sensory velocity and amplitude in the cooled limbs were less preserved than in the control limbs, but the difference did not attain statistical significance. One patient with a history of diabetes mellitus had significant preservation of compound muscle action potential in the cooled limb on NCS analysis. CONCLUSION This study suggests that continuous limb hypothermia accompanying paclitaxel infusion may reduce paclitaxel-induced PN and have therapeutic potential in select patients and warrants further investigation. The method is safe and well tolerated.
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Affiliation(s)
- Raghav Sundar
- Department of Haematology-Oncology, National University Health System , Singapore , Singapore
| | - Aishwarya Bandla
- Singapore Institute for Neurotechnology, National University of Singapore, Singapore, Singapore; Department of Biomedical Engineering, National University of Singapore, Singapore, Singapore
| | - Stacey Sze Hui Tan
- Singapore Institute for Neurotechnology, National University of Singapore , Singapore , Singapore
| | - Lun-De Liao
- Singapore Institute for Neurotechnology, National University of Singapore, Singapore, Singapore; Institute of Biomedical Engineering and Nanomedicine, National Health Research Institutes, Zhunan Township, Taiwan
| | | | - Anand D Jeyasekharan
- Department of Haematology-Oncology, National University Health System , Singapore , Singapore
| | - Samuel Guan Wei Ow
- Department of Haematology-Oncology, National University Health System , Singapore , Singapore
| | - Jingshan Ho
- Department of Haematology-Oncology, National University Health System , Singapore , Singapore
| | - David Shao Peng Tan
- Department of Haematology-Oncology, National University Health System , Singapore , Singapore
| | - Joline Si Jing Lim
- Department of Haematology-Oncology, National University Health System , Singapore , Singapore
| | - Joy Vijayan
- Department of Medicine, National University Health System , Singapore , Singapore
| | | | - Zarinah Hairom
- National University Cancer Institute, National University Health System , Singapore , Singapore
| | - Emily Ang
- National University Cancer Institute, National University Health System , Singapore , Singapore
| | - Sally Ang
- Department of Haematology-Oncology, National University Health System , Singapore , Singapore
| | - Nitish V Thakor
- Singapore Institute for Neurotechnology, National University of Singapore, Singapore, Singapore; Department of Biomedical Engineering, National University of Singapore, Singapore, Singapore; Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Soo-Chin Lee
- Department of Haematology-Oncology, National University Health System, Singapore, Singapore; Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
| | - Einar P V Wilder-Smith
- Singapore Institute for Neurotechnology, National University of Singapore, Singapore, Singapore; Department of Medicine, National University Health System, Singapore, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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Li H, Zhang L, Xu M. Dexamethasone prevents vascular damage in early-stage non-freezing cold injury of the sciatic nerve. Neural Regen Res 2016; 11:163-7. [PMID: 26981107 PMCID: PMC4774212 DOI: 10.4103/1673-5374.175064] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Non-freezing cold injury is a prevalent cause of peripheral nerve damage, but its pathogenic mechanism is poorly understood, and treatment remains inadequate. Glucocorticoids have anti-inflammatory and lipid peroxidation-inhibiting properties. We therefore examined whether dexamethasone, a synthetic glucocorticoid compound, would alleviate early-stage non-freezing cold injury of the sciatic nerve. We established Wistar rat models of non-freezing cold injury by exposing the left sciatic nerve to cold (3–5°C) for 2 hours, then administered dexamethasone (3 mg/kg intraperitoneally) to half of the models. One day after injury, the concentration of Evans blue tracer in the injured sciatic nerve of rats that received dexamethasone was notably lower than that in the injured sciatic nerve of rats that did not receive dexamethasone; neither Evans blue dye nor capillary stenosis was observed in the endoneurium, but myelinated nerve fibers were markedly degenerated in the injured sciatic nerve of animals that received dexamethasone. After dexamethasone administration, however, endoneurial vasculopathy was markedly improved, although damage to the myelinated nerve fiber was not alleviated. These findings suggest that dexamethasone protects the blood-nerve barrier, but its benefit in non-freezing cold injury is limited to the vascular system.
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Affiliation(s)
- Hao Li
- Department of Neurology, the First People's Hospital of Yibin, Yibin, Sichuan Province, China
| | - Lei Zhang
- Department of Pharmacy, the First People's Hospital of Yibin, Yibin, Sichuan Province, China
| | - Min Xu
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
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11
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Mejia N, Dedow K, Nguy L, Sullivan P, Khoshnevis S, Diller KR. An On-Site Thermoelectric Cooling Device for Cryotherapy and Control of Skin Blood Flow. J Med Device 2015; 9:0445021-445026. [PMID: 26421089 DOI: 10.1115/1.4029508] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Revised: 12/23/2014] [Indexed: 12/23/2022] Open
Abstract
Cryotherapy involves the surface application of low temperatures to enhance the healing of soft tissue injuries. Typical devices embody a remote source of chilled water that is pumped through a circulation bladder placed on the treatment site. In contrast, the present device uses thermoelectric refrigeration modules to bring the cooling source directly to the tissue to be treated, thereby achieving significant improvements in control of therapeutic temperature while having a reduced size and weight. A prototype system was applied to test an oscillating cooling and heating protocol for efficacy in regulating skin blood perfusion in the treatment area. Data on 12 human subjects indicate that thermoelectric coolers (TECs) delivered significant and sustainable changes in perfusion for both heating (increase by (±SE) 173.0 ± 66.0%, P < 0.005) and cooling (decrease by (±SE) 57.7 ± 4.2%, P < 0.0005), thus supporting the feasibility of a TEC-based device for cryotherapy with local temperature regulation.
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Affiliation(s)
- Natalia Mejia
- Department of Biomedical Engineering, The University of Texas at Austin, 107 West Dean Keeton Street, Austin, TX 78712-1081 e-mail:
| | - Karl Dedow
- Department of Biomedical Engineering, The University of Texas at Austin, 107 West Dean Keeton Street, Austin, TX 78712-1081 e-mail:
| | - Lindsey Nguy
- Department of Biomedical Engineering, The University of Texas at Austin, 107 West Dean Keeton Street, Austin, TX 78712-1081 e-mail:
| | - Patrick Sullivan
- Department of Biomedical Engineering, The University of Texas at Austin, 107 West Dean Keeton Street, Austin, TX 78712-1081 e-mail:
| | - Sepideh Khoshnevis
- Department of Biomedical Engineering, The University of Texas at Austin, 107 West Dean Keeton Street, Austin, TX 78712-1081 e-mail:
| | - Kenneth R Diller
- Fellow ASME Department of Biomedical Engineering, The University of Texas at Austin, 107 West Dean Keeton Street, Austin, TX 78712-1081 e-mail:
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12
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Olson Z, Kman N. Immersion Foot: A Case Report. J Emerg Med 2015; 49:e45-8. [DOI: 10.1016/j.jemermed.2015.02.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 02/18/2015] [Accepted: 02/27/2015] [Indexed: 10/23/2022]
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13
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Garibyan L, Cornelissen L, Sipprell W, Pruessner J, Elmariah S, Luo T, Lerner EA, Jung Y, Evans C, Zurakowski D, Berde CB, Rox Anderson R. Transient Alterations of Cutaneous Sensory Nerve Function by Noninvasive Cryolipolysis. J Invest Dermatol 2015; 135:2623-2631. [PMID: 26099028 PMCID: PMC4640987 DOI: 10.1038/jid.2015.233] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Revised: 05/09/2015] [Accepted: 06/09/2015] [Indexed: 12/27/2022]
Abstract
Cryolipolysis is a noninvasive, skin cooling treatment for local fat reduction that causes prolonged hypoesthesia over the treated area. We tested the hypothesis that cryolipolysis can attenuate nociception of a range of sensory stimuli, including stimuli that evoke itch. The effects of cryolipolysis on sensory phenomena were evaluated by quantitative sensory testing (QST) in 11 healthy subjects over a period of 56 days. Mechanical and thermal pain thresholds were measured on treated and contralateral untreated (control) flanks. Itch duration was evaluated following histamine iontophoresis. Unmyelinated epidermal nerve fiber and myelinated dermal nerve fiber densities were quantified in skin biopsies from six subjects. Cryolipolysis produced a marked decrease in mechanical and thermal pain sensitivity. Hyposensitivity started between two to seven days after cryolipolysis and persisted for at least thirty-five days post treatment. Skin biopsies revealed that cryolipolysis decreased epidermal nerve fiber density, as well as dermal myelinated nerve fiber density, which persisted throughout the study. In conclusion, cryolipolysis causes significant and prolonged decreases in cutaneous sensitivity. Our data suggest that controlled skin cooling to specifically target cutaneous nerve fibers has the potential to be useful for prolonged relief of cutaneous pain and might have a use as a research tool to isolate and study cutaneous itch-sensing nerves in human skin.
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Affiliation(s)
- Lilit Garibyan
- Wellman Center for Photomedicine, Massachusetts General Hospital; Department of Dermatology, Harvard Medical School, Boston, USA.
| | - Laura Cornelissen
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital; Department of Anesthesia, Harvard Medical School, Boston, USA
| | - William Sipprell
- Wellman Center for Photomedicine, Massachusetts General Hospital; Department of Dermatology, Harvard Medical School, Boston, USA
| | - Joachim Pruessner
- Wellman Center for Photomedicine, Massachusetts General Hospital; Department of Dermatology, Harvard Medical School, Boston, USA
| | - Sarina Elmariah
- Cutaneous Biology Research Center, Massachusetts General Hospital; Department of Dermatology, Harvard Medical School, Boston, USA
| | - Tuan Luo
- Cutaneous Biology Research Center, Massachusetts General Hospital; Department of Dermatology, Harvard Medical School, Boston, USA
| | - Ethan A Lerner
- Cutaneous Biology Research Center, Massachusetts General Hospital; Department of Dermatology, Harvard Medical School, Boston, USA
| | - Yookyung Jung
- Wellman Center for Photomedicine, Massachusetts General Hospital; Department of Dermatology, Harvard Medical School, Boston, USA
| | - Conor Evans
- Wellman Center for Photomedicine, Massachusetts General Hospital; Department of Dermatology, Harvard Medical School, Boston, USA
| | - David Zurakowski
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital; Department of Anesthesia, Harvard Medical School, Boston, USA
| | - Charles B Berde
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital; Department of Anesthesia, Harvard Medical School, Boston, USA
| | - R Rox Anderson
- Wellman Center for Photomedicine, Massachusetts General Hospital; Department of Dermatology, Harvard Medical School, Boston, USA
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Vascular responses of the extremities to transdermal application of vasoactive agents in Caucasian and African descent individuals. Eur J Appl Physiol 2015; 115:1801-11. [PMID: 25840674 DOI: 10.1007/s00421-015-3164-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 03/24/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Individuals of African descent (AFD) are more susceptible to non-freezing cold injury than Caucasians (CAU) which may be due, in part, to differences in the control of skin blood flow. We investigated the skin blood flow responses to transdermal application of vasoactive agents. METHODS Twenty-four young males (12 CAU and 12 AFD) undertook three tests in which iontophoresis was used to apply acetylcholine (ACh 1 w/v %), sodium nitroprusside (SNP 0.01 w/v %) and noradrenaline (NA 0.5 mM) to the skin. The skin sites tested were: volar forearm, non-glabrous finger and toe, and glabrous finger (pad) and toe (pad). RESULTS In response to SNP on the forearm, AFD had less vasodilatation for a given current application than CAU (P = 0.027-0.004). ACh evoked less vasodilatation in AFD for a given application current in the non-glabrous finger and toe compared with CAU (P = 0.043-0.014) with a lower maximum vasodilatation in the non-glabrous finger (median [interquartile], AFD n = 11, 41[234] %, CAU n = 12, 351[451] %, P = 0.011) and non-glabrous toe (median [interquartile], AFD n = 9, 116[318] %, CAU n = 12, 484[720] %, P = 0.018). ACh and SNP did not elicit vasodilatation in the glabrous skin sites of either group. There were no ethnic differences in response to NA. CONCLUSION AFD have an attenuated endothelium-dependent vasodilatation in non-glabrous sites of the fingers and toes compared with CAU. This may contribute to lower skin temperature following cold exposure and the increased risk of cold injuries experienced by AFD.
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Li H, Jia JP, Xu M, Zhang L. Changes in the blood-nerve barrier after sciatic nerve cold injury: indications supporting early treatment. Neural Regen Res 2015; 10:419-24. [PMID: 25878590 PMCID: PMC4396104 DOI: 10.4103/1673-5374.153690] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2014] [Indexed: 11/04/2022] Open
Abstract
Severe edema in the endoneurium can occur after non-freezing cold injury to the peripheral nerve, which suggests damage to the blood-nerve barrier. To determine the effects of cold injury on the blood-nerve barrier, the sciatic nerve on one side of Wistar rats was treated with low temperatures (3-5°C) for 2 hours. The contralateral sciatic nerve was used as a control. We assessed changes in the nerves using Evans blue as a fluid tracer and morphological methods. Excess fluid was found in the endoneurium 1 day after cold injury, though the tight junctions between cells remained closed. From 3 to 5 days after the cold injury, the fluid was still present, but the tight junctions were open. Less tracer leakage was found from 3 to 5 days after the cold injury compared with 1 day after injury. The cold injury resulted in a breakdown of the blood-nerve barrier function, which caused endoneurial edema. However, during the early period, the breakdown of the blood-nerve barrier did not include the opening of tight junctions, but was due to other factors. Excessive fluid volume produced a large increase in the endoneurial fluid pressure, prevented liquid penetration into the endoneurium from the microvasculature. These results suggest that drug treatment to patients with cold injuries should be administered during the early period after injury because it may be more difficult for the drug to reach the injury site through the microcirculation after the tissue fluid pressure becomes elevated.
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Affiliation(s)
- Hao Li
- Department of Neurology, the First People's Hospital of Yibin, Yibin, Sichuan Province, China
| | - Jian-ping Jia
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Min Xu
- Department of Neurology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Lei Zhang
- Department of Pharmacy, the First People's Hospital of Yibin, Yibin, Sichuan Province, China
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16
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Jang JH, Lim YS, Jang JY, Woo JH, Park WB. Reversible common peroneal nerve palsy as a complication of therapeutic hypothermia using surface cooling device. Am J Emerg Med 2014; 33:599.e5-6. [PMID: 25440234 DOI: 10.1016/j.ajem.2014.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 09/01/2014] [Indexed: 11/28/2022] Open
Affiliation(s)
- Jae Ho Jang
- Department of Emergency Medicine, Gachon University Gil Medical center
| | - Yong Su Lim
- Department of Emergency Medicine, Gachon University Gil Medical center.
| | - Jee Yong Jang
- Department of Emergency Medicine, Gachon University Gil Medical center
| | - Jae Hyug Woo
- Department of Emergency Medicine, Gachon University Gil Medical center
| | - Won Bin Park
- Department of Emergency Medicine, Gachon University Gil Medical center
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17
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Maley MJ, Eglin CM, House JR, Tipton MJ. The effect of ethnicity on the vascular responses to cold exposure of the extremities. Eur J Appl Physiol 2014; 114:2369-79. [PMID: 25081130 DOI: 10.1007/s00421-014-2962-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 07/17/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE Cold injuries are more prevalent in individuals of African descent (AFD). Therefore, we investigated the effect of extremity cooling on skin blood flow (SkBF) and temperature (T sk) between ethnic groups. METHODS Thirty males [10 Caucasian (CAU), 10 Asian (ASN), 10 AFD] undertook three tests in 30 °C air whilst digit T sk and SkBF were measured: (i) vasomotor threshold (VT) test--arm immersed in 35 °C water progressively cooled to 10 °C and rewarmed to 35 °C to identify vasoconstriction and vasodilatation; (ii) cold-induced vasodilatation (CIVD) test--hand immersed in 8 °C water for 30 min followed by spontaneous warming; (iii) cold sensitivity (CS) test--foot immersed in 15 °C water for 2 min followed by spontaneous warming. Cold sensory thresholds of the forearm and finger were also assessed. RESULTS In the VT test, vasoconstriction and vasodilatation occurred at a warmer finger T sk in AFD during cooling [21.2 (4.4) vs. 17.0 (3.1) °C, P = 0.034] and warming [22.0 (7.9) vs. 12.1 (4.1) °C, P = 0.002] compared with CAU. In the CIVD test, average SkBF during immersion was greater in CAU [42 (24) %] than ASN [25 (8) %, P = 0.036] and AFD [24 (13) %, P = 0.023]. Following immersion, SkBF was higher and rewarming faster in CAU [3.2 (0.4) °C min(-1)] compared with AFD [2.5 (0.7) °C min(-1), P = 0.037], but neither group differed from ASN [3.0 (0.6) °C min(-1)]. Responses to the CS test and cold sensory thresholds were similar between groups. CONCLUSION AFD experienced a more intense protracted finger vasoconstriction than CAU during hand immersion, whilst ASN experienced an intermediate response. This greater sensitivity to cold may explain why AFD are more susceptible to cold injuries.
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Affiliation(s)
- Matthew J Maley
- Extreme Environments Laboratory, Department of Sport and Exercise Science, University of Portsmouth, Portsmouth, PO1 2ER, UK,
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18
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Kurup AN, Morris JM, Schmit GD, Atwell TD, Weisbrod AJ, Murthy NS, Woodrum DA, Callstrom MR. Neuroanatomic considerations in percutaneous tumor ablation. Radiographics 2014; 33:1195-215. [PMID: 23842979 DOI: 10.1148/rg.334125141] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Percutaneous ablation is increasingly being used as focal therapy for tumors in the chest, abdomen, and pelvis, including tumors in proximity to neural structures. To ensure that tumor ablation is performed safely, knowledge of the regional neuroanatomy is particularly important because most relevant nerves are not visualized with the conventional imaging techniques used to guide ablation procedures. Familiarity with the expected course of nerves in commonly targeted areas is helpful in preventing inadvertent nerve injury and in accurately informing the patient of potential risks. In the chest and shoulder girdle, the brachial plexus as well as the phrenic, recurrent laryngeal, intercostal-subcostal, long thoracic, dorsal scapular, and suprascapular nerves may be encountered. Vulnerable neural structures in the abdomen and pelvis arise from the lumbar and sacral plexuses and include the femoral, obturator, sciatic, and pudendal nerves. Nerve protection and monitoring techniques should be used, when appropriate, to minimize the risk of neural injury during percutaneous tumor ablation and depend on the vulnerable nerve, the location of the targeted tumor, and the ablation device used for treatment. Nerves may be protected using displacement techniques, including instillation of air or fluid, insertion and insufflation of angioplastic or endoscopic balloons, and mechanical manipulation of the ablation device. Nerves may be monitored with cross-sectional imaging evaluation of the critical nerve or ablation zone, or with functional evaluation using electromyographic equipment or focused clinical examination. Supplemental material available at http://radiographics.rsna.org/lookup/suppl/doi:10.1148/rg334125141/-/DC1.
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Affiliation(s)
- A Nicholas Kurup
- Department of Radiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905 USA.
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19
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Kurup AN, Woodrum DA, Morris JM, Atwell TD, Schmit GD, Welch TJ, Yaszemski MJ, Callstrom MR. Cryoablation of recurrent sacrococcygeal tumors. J Vasc Interv Radiol 2013; 23:1070-5. [PMID: 22840806 DOI: 10.1016/j.jvir.2012.05.043] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 05/08/2012] [Accepted: 05/10/2012] [Indexed: 10/28/2022] Open
Abstract
PURPOSE To review the safety and efficacy of cryoablation of recurrent sacrococcygeal tumors. MATERIALS AND METHODS The radiology departmental ablation database was retrospectively searched for cases of cryoablation performed to treat recurrences of sacrococcygeal tumors between January 1, 2010, and August 1, 2011. Patient demographics, procedure technical parameters, and patient outcomes were reviewed. RESULTS Five cases of recurrent chordoma and one recurrent myxopapillary ependymoma were treated with cryoablation in six patients whose ages ranged from 31 to 80 years. The tumors measured 14-39 mm in maximal dimension. Cryoablation was performed with the use of computed tomography guidance (n = 5) or a combination of ultrasound and magnetic resonance imaging guidance (n = 1). Sterile fluid was instilled to displace adjacent bowel and/or vagina in four cases, and electromyography monitoring was performed in two cases with adjacent nerve roots. Two patients with recurrent chordoma were treated for palliation of pain, with complete pain relief in one patient (pain recurred after 6 wk) and immediate reduction in pain from a score of six to a score of two on a 10-point scale in the other (pain recurred after 7 mo). Four tumors were treated for local control, with no evidence of recurrence on follow-up imaging at 3, 6, 12, and 15 months. No serious complication occurred. CONCLUSIONS Limited results suggest cryoablation to be a safe and relatively effective means of treating recurrent sacrococcygeal neoplasms for local control or palliation of pain in this small series with short-term follow-up.
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Affiliation(s)
- Anil Nicholas Kurup
- Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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20
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Collier T, Patel A, Rinaldi R. Hypothermia-Induced Peripheral Polyneuropathy After an Episode of Drowning. PM R 2012; 4:230-3. [DOI: 10.1016/j.pmrj.2011.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 10/09/2011] [Accepted: 10/18/2011] [Indexed: 10/28/2022]
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Imray CHE, Richards P, Greeves J, Castellani JW. Nonfreezing cold-induced injuries. J ROY ARMY MED CORPS 2011; 157:79-84. [PMID: 21465916 DOI: 10.1136/jramc-157-01-14] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Non-freezing cold injury (NFCI) is the Cinderella of thermal injuries and is a clinical syndrome that occurs when tissues are exposed to cold temperatures close to freezing point for sustained periods. NFCI is insidious in onset, often difficult to recognize and problematic to treat, and yet the condition accounts for significant morbidity in both military and civilians who work in cold conditions. Consequently recognition of those at risk, limiting their exposure and the appropriate and timely use of suitable protective equipment are essential steps in trying to reduce the impact of the condition. This review addresses the issues surrounding NFCI.
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Affiliation(s)
- C H E Imray
- Warwick Medical School, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.
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22
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Franceschi F, Dubuc M, Guerra PG, Delisle S, Romeo P, Landry E, Koutbi L, Rivard L, Macle L, Thibault B, Talajic M, Roy D, Khairy P. Diaphragmatic electromyography during cryoballoon ablation: a novel concept in the prevention of phrenic nerve palsy. Heart Rhythm 2011; 8:885-91. [PMID: 21256978 DOI: 10.1016/j.hrthm.2011.01.031] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2010] [Accepted: 01/18/2011] [Indexed: 11/30/2022]
Abstract
BACKGROUND Hemidiaphragmatic paralysis is the most frequent complication associated with cryoballoon ablation for atrial fibrillation. To date, no preventive strategy has proved effective. OBJECTIVE We sought to assess the feasibility of diaphragmatic electromyography during cryoballoon ablation, explore the relationship between altered signals and phrenic nerve palsy, and define characteristic changes that herald hemidiaphragmatic paralysis. METHODS Cryoballoon ablation was performed in the right superior pulmonary vein or superior vena cava in 16 mongrel dogs weighing 37.7 ± 2.4 kg, at sites determined by phrenic nerve capture. During ablation, the phrenic nerve was paced at 60 bpm from the superior vena cava while recording diaphragmatic compound motor action potentials (CMAPs) by esophageal decapolar catheters. Diaphragmatic excursion was monitored by fluoroscopy and abdominal palpation. RESULTS Before ablation, the CMAP amplitude was 592 (interquartile range 504, 566) μV, initial latency 21.5 ± 4.2 ms, peak latency 64.7 ± 21.1 ms, and duration 101.7 ± 13.3 ms. Hemidiaphragmatic paralysis was obtained in all dogs 62 ± 34 seconds into the cryoapplication. The CMAP amplitude decreased exponentially, with no patterned changes in latencies and duration. Discriminatory analyses by receiver-operating curve characteristics identified a 30% reduction in CMAP amplitude as the most predictive cutoff value for hemidiaphragmatic paralysis (c-statistic 0.965; P<.0001). This criterion presaged diaphragmatic paralysis, as detected by abdominal palpation, by 31 ± 23 seconds. CONCLUSION Diaphragmatic electromyographic signals could be reliably recorded during cryoballoon ablation. An exponential decrease in CMAP amplitude precedes diaphragmatic paralysis, with a 30% reduction yielding the best discriminatory potential. A promising safety margin was detected, which merits prospective validation.
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Affiliation(s)
- Frédéric Franceschi
- Electrophysiology Service, Montreal Heart Institute, Université de Montréal, Montreal, Canada
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Cold exposure exacerbates the development of diabetic polyneuropathy in the rat. EXPERIMENTAL DIABETES RESEARCH 2010; 2009:827943. [PMID: 20130819 PMCID: PMC2814234 DOI: 10.1155/2009/827943] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Revised: 08/24/2009] [Accepted: 10/11/2009] [Indexed: 01/09/2023]
Abstract
Diabetic polyneuropathy (DPN) and cold-induced nerve injury share several pathogenic mechanisms. This study explores whether cold exposure contributes to the development of DPN. Streptozotocin-induced diabetic rats and controls were exposed to a room temperature (23°C) or cold environment (10°C). H-reflex, tail and sciatic motor, and sensory nerve conduction studies were performed. Analyses of sural nerve, intraepidermal nerve fibers, and skin and nerve nitrotyrosine ELISAs were performed. Diabetic animals exposed to a cold environment had an increased H-reflex four weeks earlier than diabetic room temperature animals (P = .03). Cold-exposed diabetic animals also had greater reduction in motor conduction velocities at 20 weeks (P = .017), decreased skin nerve fiber density (P = .037), and increased skin nitrotyrosine levels (P = .047). Cold exposure appears to hasten the development of DPN in the rat STZ model of diabetes. These findings support that further study into the relationship between ambient temperature and DPN is warranted.
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Govindaraju SR, Curry BD, Bain JLW, Riley DA. Effects of temperature on vibration-induced damage in nerves and arteries. Muscle Nerve 2006; 33:415-23. [PMID: 16372319 DOI: 10.1002/mus.20478] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Vasospastic episodes in hand-arm vibration syndrome are more prevalent among power-tool workers in cold climates. To test whether cold enhances vibration-induced damage in arteries and nerves, tails of Sprague-Dawley rats were vibrated at room temperature (RT) or with tail cooling (<15 degrees C). Cold vibration resulted in a colder tail than either treatment alone. Vibration at both temperatures reduced arterial lumen size. RT vibration generated more vacuoles in arteries than cold vibration. Vibration and cold induced nitration of tyrosine residues in arteries, suggesting free-radical production. Vibration and cold generated similar percentages of myelinated axons with disrupted myelin. Cold with and without vibration caused intraneural edema and dilation of arterioles and venules with blood stasis, whereas vibration alone did not. The similarities, differences, and interactive effects of cold and vibration on nerve and artery damage indicate that temperature is involved mechanistically in the pathophysiology of hand-arm vibration syndrome.
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Affiliation(s)
- Sandya R Govindaraju
- Department of Cell Biology, Neurobiology & Anatomy, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, Wisconsin 53226, USA
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Rutkove SB, Chapman KM, Acosta JA, Larrabee JE. Foot temperature in diabetic polyneuropathy: innocent bystander or unrecognized accomplice? Diabet Med 2005; 22:231-8. [PMID: 15717867 DOI: 10.1111/j.1464-5491.2005.01486.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To explore mechanisms by which temperature could influence the pathogenesis and symptoms of diabetic polyneuropathy. METHODS We conducted a literature review attempting to identify mechanisms by which diabetic polyneuropathy could be affected by temperature. RESULTS Cooling can theoretically hasten the progression of diabetic polyneuropathy through several different mechanisms. Specifically, cooling can enhance neuronal ischaemia, increase formation of reactive oxygen species, slow axonal transport, increase protein kinase C activity, and interfere with immune function. Short-term temperature fluctuations (both warming and cooling) can initiate and exacerbate neuropathic pain by causing neuronal hyperexcitability and functional deafferentation. Although normal fluctuations of distal extremity temperature may be sufficient for these effects, impaired thermoregulation may make the distal extremities more susceptible to temperature extremes. Eventually, a 'vicious cycle' may ensue, resulting in neuronal deterioration with further disruption of temperature regulation. Limited epidemiological data suggest a higher prevalence of diabetic polyneuropathy in populations living in colder locations, supporting our hypothesis. CONCLUSIONS Variations in foot temperature may play an important but as yet unrecognized role in the development and symptoms of diabetic polyneuropathy. Further basic and clinical research exploring this concept could help elucidate the natural history of diabetic polyneuropathy and lead to novel therapeutic strategies.
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Affiliation(s)
- S B Rutkove
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
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Kang PB, Hoffman SN, Krimitsos E, Rutkove SB. Ambulatory foot temperature measurement: a new technique in polyneuropathy evaluation. Muscle Nerve 2003; 27:737-42. [PMID: 12766986 DOI: 10.1002/mus.10379] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Complaints of abnormal foot temperature are common among patients with polyneuropathy. However, there is no published method of ambulatory foot temperature measurement to identify possible thermoregulatory disturbances in these patients. We configured a digital electronic thermometer and thermocouple to measure and record distal foot and ambient temperatures simultaneously every minute for 24 to 48 h. Sixteen patients with polyneuropathy and 5 normal subjects were studied; 12 patients with polyneuropathy and 4 normal subjects had at least 24 h of successful recording. The data obtained from these patients were consistent and easily summarized by standard statistical methods. In the others, technical difficulties produced nonphysiological readings. In the patients with polyneuropathy, changes in foot temperature mirrored ambient temperature fluctuations more closely than in normal subjects. This technique shows promise in studying temperature regulation in the feet and may provide new insights into neuropathy-associated pain and the pathogenesis of polyneuropathy.
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Affiliation(s)
- Peter B Kang
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, TCC-810, Boston, Massachusetts, USA
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Rutkove SB. Focal cooling improves neuronal conduction in peroneal neuropathy at the fibular neck. Muscle Nerve 2001; 24:1622-6. [PMID: 11745971 DOI: 10.1002/mus.1197] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Heat can induce conduction block (CB) in demyelinated neurons; whether cooling can reverse CB and increase strength is uncertain. In six patients with electrophysiologic evidence of peroneal neuropathy at the fibular neck with definite motor CB, standard motor nerve conduction studies were performed at 32 degrees C and then after the fibular neck region was cooled with an ice pack to 8 degrees -12 degrees C. In all patients, cooling increased the amplitude and area of the compound motor action potential obtained with popliteal fossa stimulation, decreasing the relative amplitude drop across the fibular neck from a mean of 78% to 55%. A concomitant increase in foot dorsiflexor strength was clearly observed in three of the six patients. Both the electrophysiologic and clinical changes readily reversed upon rewarming. These data support the belief that, in compressive neuropathies, cooling relieves conduction block in selected motor neurons, improving strength.
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Affiliation(s)
- S B Rutkove
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, TCC-810, Boston, Massachusetts 02215, USA.
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Abstract
Like nearly all biologic structures, the peripheral nervous system is remarkably temperature sensitive. Clinical neurophysiologists are most aware of the untoward effects of cooling on nerve conduction studies, including reduced conduction velocity, prolonged distal latency, and increased response amplitude and duration. However, familiarity with the effects of temperature variation on the peripheral nervous system can also provide a deeper understanding of the physiological mechanisms underlying the function of nerve, muscle, and neuromuscular junction in health and disease. Intentional temperature alteration can also improve the diagnostic accuracy of certain electrophysiologic tests, such as the use of heat when performing repetitive nerve stimulation in myasthenia gravis or the use of cold during needle electromyography in some of the myotonic disorders. Finally, extremes of temperature have long been known to produce permanent neuronal dysfunction; recent investigations are beginning to elucidate the mechanisms of such injury.
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Affiliation(s)
- S B Rutkove
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, TCC-810, Boston, MA 02215, USA
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Abstract
Clinically nonfreezing cold nerve injury (NFCNI) is often preceded by fluctuating ambient temperatures. To simulate this we exposed the sciatic nerve of Wistar rats to intermittent cooling and rewarming. This paradigm was contrasted with one in which the sciatic nerve was continuously cooled. Despite an identical duration and degree of sciatic nerve cooling in both experiments, the pathology, as assessed neurophysiologically and morphologically, was much more severe when the nerve was intermittently cooled. It is likely that this exaggerated pathology is a result of repeated reperfusion injury. These experimental results suggest the need for a trial of free radical scavengers or antioxidants in models of NFCNI.
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Affiliation(s)
- J Jia
- Department of Neurology, University of Otago Medical School, Dunedin, New Zealand
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Jasmin L, Kohan L, Franssen M, Janni G, Goff JR. The cold plate as a test of nociceptive behaviors: description and application to the study of chronic neuropathic and inflammatory pain models. Pain 1998; 75:367-82. [PMID: 9583773 DOI: 10.1016/s0304-3959(98)00017-7] [Citation(s) in RCA: 153] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A cold plate apparatus was designed to test the responses of unrestrained rats to low temperature stimulation of the plantar aspect of the paw. At plate temperatures of 10 degrees C and 5 degrees C, rats with either chronic constriction injury (CCI) of the sciatic nerve or complete Freund's adjuvant (CFA) induced inflammation of the hindpaw displayed a stereotyped behavior. Brisk lifts of the treated hindpaw were recorded, while no evidence of other nociceptive behaviors could be discerned. The most consistent responses were obtained with a plate temperature of 5 degrees C in three 5-min testing periods, separated by 10-min intervals during which the animals were returned to a normal environment. Concomitantly to cold testing, the rats were evaluated for their response to heat (plantar test) and mechanical (von Frey hairs) stimuli. In both injury models, while responses to heat stimuli had normalized at 60 days post-injury, a clear lateralization of responses to cold was observed throughout the entire study period. Systemic lidocaine, clonidine, and morphine suppressed responses to cold in a dose-related fashion. At doses that did not affect motor or sensory behavior, both lidocaine and its quaternary derivative QX-314 similarly reduced paw lifts, suggesting that cold hyperalgesia is in part due to peripheral altered nociceptive processing. Clonidine was more potent in CCI then in CFA rats in reducing the response to cold. Paradoxically, clonidine increased the withdrawal latencies to heat in the CCI hindpaw at 40 days and thereafter, at a time when both hindpaws had the same withdrawal latencies in control animals. Morphine was also more potent on CCI than CFA cold responses, indicating that, chronically, CFA-induced hyperalgesia might be opiate resistant. Evidence for tonic endogenous inhibition of cold hyperalgesia was obtained for CFA rats, when systemic naltrexone significantly increased the number of paw lifts; this was not found in rats with CCI. At 60 days, neither morphine nor naltrexone affected cold-induced paw lifting in CFA rats, suggesting that the neuronal circuit mediating cold hyperalgesia in these animals had become opiate insensitive. In conclusion, the cold plate was found to be a reliable method for detecting abnormal nociceptive behavior even at long intervals after nerve or inflammatory injuries, when responses to other nociceptive stimuli have returned to near normal. The results of pharmacological studies suggest that cold hyperalgesia is in part a consequence of altered sensory processing in the periphery, and that it can be independently modulated by opiate and adrenergic systems.
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Affiliation(s)
- L Jasmin
- Department of Neurosurgery, Georgetown University Medical Center, Washington, DC 20007, USA.
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