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BACKGROUND: Chronic ischemia of the hand can lead to intractable pain, cold intolerance, and digital necrosis, affecting up to 4.8 percent of patients undergoing vascular surgery. Treatment of patients suffering from chronic hand ischemia, in particular, the subset of patients with a nonreconstructible distal arterial tree, can be a significant challenge for hand surgeons. The purpose of this systematic review is to analyze the outcomes of surgical therapies in an effort to define the efficacy of each intervention. The authors also revisit the treatment algorithm for nontraumatic chronic hand ischemia. METHODS: A systematic search of the literature published since 1990 in the PubMed/MEDLINE database was performed using keywords. Articles were eligible if they described clinical studies of human patients with nontraumatic chronic hand ischemia who underwent sympathectomy, arterial bypass, or venous arterialization. Pain improvement, wound healing, and new ulcerations were primary outcome measures. Primary patency rates and limb salvage data were also collected as primary outcome measures in the bypass and arterialization study arms. RESULTS: For sympathectomy, arterial bypass, and venous arterialization, pain relief was achieved in 89, 100, and 100 percent of patients, respectively; whereas wound healing occurred in 74, 93, and 75 percent, respectively. Postoperative ulcerations were 0, 3, and 8 percent, respectively. No secondary amputations were reported in these 33 studies. Complication rates were moderately high (2.1 to 30.8 percent). CONCLUSION: This systematic review confirms that sympathectomy, arterial bypass, and venous arterialization are efficacious treatments, and allows for an algorithmic approach to the surgical treatment of chronic hand ischemia. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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O fenômeno de Raynaud (FRy) caracteriza-se por episódios reversíveis de vasoespasmos de extremidades, que ocorrem usualmente após estresse ou exposição ao frio. O FRy pode ser primário ou secundário a uma série de condições, principalmente a doenças do espectro da esclerose sistêmica (ES). Na ES, o FRy costuma ser mais grave, e lesões isquêmicas de extremidades são frequentes. Nos últimos anos, avanços no estudo da fisiopatologia do FRy e da doença vascular na ES propiciaram o surgimento de novas opções terapêuticas para esta manifestação. Os bloqueadores de canal de cálcio devem ser utilizados como tratamento de primeira escolha para o FRy. Novas drogas, como os inibidores da fosfodiesterase V e os prostanoides, podem ser utilizados em pacientes com FRy grave, e a bosentana (antagonista do receptor da endotelina-1) é indicada para a prevenção de úlceras digitais recorrentes.

Raynaud's phenomenon (RP) is characterized by episodic vasospasm of the extremities, usually in response to stress or cold exposure. It can be primary or secondary to several conditions, especially systemic sclerosis-related diseases. In systemic sclerosis (SSc), RP is usually more severe and digital ischemic lesions are a frequent problem. In recent years, advances in the understanding of the pathophysiology of RP and of SSc vasculopathy led to the development of new therapeutic options for this condition. Calcium-channel blockers are the first choice for the treatment of RP. New drugs including phosphodiesterase type V inhibitors and prostanoids can be used for severe RP, and bosentan (endothelin-1 receptor antagonist) for prevention of recurrent digital ulcers.

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En Venezuela se utiliza la inmunoterapia por su bondad terapéutica y operacional en el tratamiento de la leishmaniasis cutánea y se aprecian diferencias de su efectividad entre los servicios locales de salud que la emplean. En el estado Mérida, donde se tiene un bajo nivel de falla terapéutica, se desconocen los factores de riesgo ó de protección que la determinan. Por ello se planteó realizar un estudio epidemiológico de casos y controles para evaluar los factores individuales demográficos, clínicos, inmunológicos y adherencia terapéutica que influyen en dicha efectividad. El ajuste con regresión logística determinó según definición: a) Demográfica: como riesgo las edades extremas, tabaquismo y de oficio doméstico, con protección en el alfabeto educativamente, b) Clínica: como riesgo la forma intermedia, cinco o más lesiones, infección secundaria y ubicación en pié, con protección en la forma localizada y tamaño menor a 60 mm, c) Inmunológica: de riesgo las bajas respuestas a leishmánina y PPD, d) Adherencia terapéutica: son riesgo la aplicación tópica y aseo local inadecuados. Se concluye, hay factores de riesgo y protección que modelan la eficacia de la inmunoterapia, lo que en consecuencia demanda una dinámica vigilancia clínico-epidemiológica para potenciar dicha terapéutica.

Immunotherapy is used in Venezuela as treatment of cutaneous leishmaniasis and there are differences among the health services that use it. In Merida State there are a low proportion of failures, but the factors that are related to this failure are unknown. A case-control study was planned to evaluate the demographics, clinical, immunological factors and the treatment compliance that can be related to the effectiveness. Logistic regression showed that the factors related to failure were: a) demographics: lower and older ages, smoking, domestic labor and illiteracy; b) clinical: intermediate leishmaniasis, five or more lesions, aggregated infection, lesions in feet, and lesion size above 60 mm; c) Immunology: low reactivity to Montenegro and tuberculin tests; d) treatment compliance: use of incorrect topical substances and inadequate cleaning of ulcer. As a conclusion, there are several factors that influence treatment response, that require clinical and epidemiological surveillance to increase the effect of therapy.

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PURPOSE: To evaluate in vitro the antibacterial effect of diode laser light of wavelength 650 nm, in association with the photosensitive substance toluidine blue, on the bacteria in infected skin ulcers. METHODS: Samples were collected by means of swabs containing a medium for transporting infected material from skin ulcers. The material was inoculated into culturing medium containing azide blood agar for the growth of Gram-positive bacteria, and MacConkey agar for Gram-negative bacteria, and incubated for 48 hours. The results obtained from counting the colony-forming units were correlated and subjected to statistical analysis, adopting the significance level of p > or = 0.05. RESULTS: From analysis of variance (ANOVA), the result for the general mean was p = 0.0215. Using the t test with post-hoc test, the result for TBO vs. Control was p = 0.0186, and for TBO + Laser vs. Control it was p = 0.0039. CONCLUSION: There was a significant reduction in colony-forming units when the cultures were subjected to photodynamic therapy.(AU)

OBJETIVO: Avaliar in vitro o efeito antibacteriano do laser diodo com comprimento de onda de 650nn, associado a substancia fotossensível azul de toluidina sobre as bactérias de ulceras cutâneas infectadas. MÉTODOS: Foram coletadas amostras através de um swab com meio de transporte, de material infectado de úlceras cutâneas. Os materiais foram inoculadas em meios de cultura contendo ágar sangue azida para o crescimento de bactérias gram-positivas e agar Mac Conkey para as gram-negativas, e incubadas por 48 horas. Os resultados obtidos da contagem das unidades formadoras de colônias foram relacionados e submetidos a analise estatística adotando como nível de significância p > ou = 0.05. RESULTADOS: Os resultados da análise de variância ANOVA para a media geral foi p= 0,0215 e para o post hoc test teste t. TBO x Controle p=0,0186, TBO + Laser x Controle p=0,0039. CONCLUSÃO: Houve redução, significativa das unidades formadoras de colônias quando submetidas à terapia fotodinâmica.(AU)

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The action of an anti-loxosceles serum on in vitro human red blood cell hemolysis and on the development of ulcer-necrotic lesions in rabbit skin, induced by loxosceles laeta venom, was studied. An 81ñ 3 per cent hemolysis was obtained after 72 h incubation of a 2.5 per cent Rh+ red blood cell solution with the equivalent of one Loxosceles laeta venom gland. This parameter was not modified adding anti-loxosceles serum before, along with or after the venom (79.7 ñ 0.8, 77.3 ñ 2.1 and 80.7 ñ 0.7 per cent respectively). After the intradermic injection of a minimal necrotizing venom dose in rabbits, a skin necrotic lesion appeared. This lesion did not appear if anti-loxosceles serum was injected together with the venom; if the serum was injected one hour after the venom, the resulting skin lesion was inflammatory but not necrotic. It is conclude that anti-loxoscles serum does not inhibit loxosceles venom induced hemolysis and causes a time dependent inhibition on skin necrotic lesions

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