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[Pleuropneumonectomy with thymectomy for invasive thymoma with pleural disseminations--a case report].

A case of invasive thymoma with pleural disseminations, treated with pleuropneumonectomy and thymectomy , is presented. A 30-year-old woman was admitted with abnormal shadows in left lung field and mediastinum. On chest CT examination, the tumor shadows were located anterior mediastinum and left chest wall. Thymoma with pleural disseminations was the most likely consideration by the needle biopsy specimen of the tumor under left chest wall. Preoperative radiotherapy for anterior mediastinum mass was effective. Pleuropneumonectomy and thymectomy combined with partial resections of intercostal muscles and diaphragm were performed. Histologically, the tumor was arranged in lobular structure, composed of epithelial cells, with poorly infiltration of lymphocytes, and invaded into intercostal muscles or lung. Postoperative radiotherapy for mediastinum and left chest wall was added. Tumors may be removed completely by pan-pleuropneumonectomy and thymectomy for invasive thymoma with pleural disseminations.

Adult↗

[New reconstruction method for defect of chest wall using composite graft].

In the case of a 64-year-old man squamous cell carcinoma in the left lung with metastasis to the rib, we excised the affected portion of the chest wall and used a composite graft, a combination hydroxyapatite (HAP) filler, for reconstruction with good results. HAP filler is a ceramic that combines the calcium phosphate apatite hydroxide with 3-calcium phosphate. The Dacron fabric used was made of polyethylene terephthalate fiber. Two layers of Dacron fabric were laid together, stitched to the rib with nylon thread, and the resulting tubular cavity packed with HAP filler to create an artificial rib. The intercostal muscle was sandwiched between the layers of Dacron fabric and the ends of the natural rib laid across those of the artificial one. We used the periosteum and intercostal muscle to integrate the graft and complete reconstruction. Postoperative recovery was good, and there was no visible sign of deformation at the graft site. Even in palpation we were unable to tell that the rib was artificial.

Biocompatible Materials↗

Mitochondrial electron transport chain function is enhanced in inspiratory muscles of patients with chronic obstructive pulmonary disease.

In chronic obstructive pulmonary disease, inspiratory muscles face increased resistive and elastic workloads and therefore increased energy requirements. The adaptive response of these muscles to this higher energy demand includes increased oxidative enzymes and changes in contractile protein expression but the consequences on mitochondrial function and energy metabolism have not been assessed so far. We investigated the in situ properties of the mitochondria of costal diaphragm and external intercostal muscles using the skinned fiber technique in 9 emphysematous and 11 age-matched control patients. Biopsies obtained during thoracic surgery were placed in an oxygraphic chamber to measure maximal oxygen uptake. We observed that the maximal oxidative capacity of diaphragm and external intercostal muscles increased significantly in the emphysematous group compared with the control group (+135 and +37%, respectively). Significant correlations were found between the maximal oxidative capacity and patients' pulmonary indexes of obstruction (diaphragm: r = -0.637, intercostal: r = -0.667, p < 0.005) and hyperinflation (diaphragm: r = 0.639, p < 0.003, intercostal: r = 0.634, p < 0.01). Slow myosin heavy chain isoform increased in the diaphragm of the emphysematous group, with significant relationships between indexes of obstruction and hyperinflation and activities of biochemical mitochondrial markers. Thus, severe emphysema was associated with increased mitochondrial capacity and efficiency in the inspiratory muscles, supporting an endurance training-like effect.

Adaptation, Physiological↗

Central and peripheral respiratory electrophysiological studies in myotonic dystrophy.

Acute and chronic respiratory failure is a common and potentially life-threatening feature in patients with myotonic dystrophy (MD). The causes may be varied, and can involve both the central and peripheral nervous system. To evaluate the incidence of respiratory muscle involvement and the function of the central motor inspiratory pathway to phrenic motor neurons we performed magnetic stimulation of the cortex and cervical spinal cord, phrenic nerve conduction studies and needle EMG of diaphragm and intercostal muscles in 25 patients with MD. The results were compared with those from 35 healthy subjects. In addition, pulmonary function tests, blood gas analyses and static mouth pressures were evaluated. Abnormalities in response to magnetic stimulation, including a reduced compound muscle action potential (CMAP) from the diaphragm and increased excitability threshold, indicated impaired central inspiratory drive in 20% of cases. Phrenic nerve conduction showed a reduced diaphragmatic CMAP amplitude in 20%, and a delayed negative peak onset latency in 4% of cases. Abnormalities in diaphragm and intercostal muscle needle EMG were found in 76% of cases, these were mainly myotonic discharges (68%) and a decrease in the number of active motor units (36%). Patients with abnormal respiratory electrophysiological parameters had a significantly lower functional vital capacity (FVC; P = 0.005). The duration of the disease correlated negatively with diaphragmatic CMAP amplitude to phrenic nerve, but not magnetic, stimulation. Our results demonstrate that the involvement of the central inspiratory pathway is common in MD patients. Central and peripheral electrophysiological studies of the diaphragm should be considered in the diagnosis and management of patients with MD and dyspnoea.

Adult↗

[Regulation of respiration under conditions of inhibition of carbonic anhydrase activity by diamox].

The functional state of the respiratory center and the mechanism of increase in pulmonary ventilation before and after inhibition of activity of carbonic anhydrase by diamox were studied in anesthetized cats. During the inhibition, activity of bulbar inspiratory neurons functionally connected with motoneurons of the diaphragm was markedly reduced and that of the neurons connected with motoneurons of intercostal muscles was sharply increased. A steady thoracic respiration occurred. The aferents from the carotid sinus nerve and vagus nerve did not affect the steady thoracic respiration. Increased efferent influence upon the intercostal muscles led to forced thoracic respiration which ensured a high pulmonary ventilation during the whole period of action of the diamox.

Acetazolamide↗

Bilateral phrenic-nerve paralysis treated by thoracoscopic diaphragmatic plication in a neonate.

Traditionally, diaphragmatic plication (DP) is performed via a thoracotomy that includes incision of the lower intercostal muscles, which are involved in respiratory movement. This may adversely affect ventilation by causing deterioration of respiratory function and making ventilation less efficient. These problems do not occur with thoracoscopic DP (TDP), since the lower intercostal muscles are left intact. We describe a full-term newborn infant with bilateral phrenic-nerve paralysis (PNP) who was treated by TDP and conclude that this method may be effective in the treatment of PNP even in small infants.

Diaphragm↗

Diaphragmatic injuries in children after blunt abdominal trauma.

BACKGROUND: Traumatic rupture of the diaphragm resulting from blunt abdominal trauma remains a challenging clinical entity. Description of such type of injuries in children is scarce in the literature. PURPOSE: The aim of this study was to present this special form of injury in the pediatric age group and compare the different aspects of diaphragmatic injury with that occurring in adults. PATIENTS AND METHODS: Ten cases of diaphragmatic rupture after blunt trauma in children were reported. The presentations, findings, and management were described. RESULTS: This study included 7 boys and 3 girls aged 3 to 16 years. Trauma in 8 cases resulted from motor vehicle or auto-pedestrian accidents and 2 from falling from a height. Chest radiograph shows suggestive signs of diaphragmatic injuries in 7 occasions including intrathoracic visceral herniation in 4 cases and hemothorax in 3 cases. Associated injuries were found in 5 cases in the form of rib fractures in 3 cases and lung contusion in 2 cases. Lung tear, gut perforation, and liver tear were each reported once. Isolated diaphragmatic injury is reported in 5 cases. Three cases were repaired via thoracotomy or laparo-thoracotomy and 7 cases via midline laparotomy. On exploration, we found diaphragmatic avulsion of the costal origin in 5 cases, 3 left and 2 right contrary to tears, of which 4 were left sided and 1 right sided. Primary repair was conducted in 7 cases and an intercostal muscle flap was used in 3 cases. No mortalities were reported. CONCLUSIONS: This series of diaphragmatic rupture in children reveals the following: (1) Avulsion of the costal origin of the diaphragm is a peculiar type of injury described in children (5 of 10). (2) The intercostal muscle flap is a useful tool to bridge diaphragmatic defects. (3) Isolated diaphragmatic injuries do occur in children more frequently than in adults. (4) As in adults, diaphragmatic rupture prevails in the left side, and purposeful surgical diagnosis and early management determine the effectiveness of treatment.

Abdominal Injuries↗

Relationship between respiratory nerve and muscle activity and muscle force output.

To demonstrate the most satisfactory way of using electrical activities of respiratory nerves and muscles, activities of phrenic nerve and external intercostal muscle (ICM) and the airway pressure changes generated by respiratory muscle contraction were recorded in anesthetized cats during complete airway occlusion. Electrical activities were rectified, integrated and processed in terms of peak and average inspiratory rates per 0.1 s and of total activity per breath. Peak rate of phrenic nerve activity exhibited a high linear correlation (r = 0.974) with peak inspiratory pressure. Average phrenic rate showed a similar high correlation (r = 0.973). Peak rate of external ICM was linearly related to peak pressure but the correlation was less good (r = 0.915). Total phrenic activity per breath was too dependent upon inspiratory duration to be a satisfactory correlate (r = 0.674). In this experiment occlusion pressure was an index of muscle force generation and respiratory control system output. It is concluded that peak or average rates of phrenic activity provide an electrical index of output changes. On theoretical grounds, peak rate is probably better.

Airway Obstruction↗

HI-6: reactivation of central and peripheral acetylcholinesterase following inhibition by soman, sarin and tabun in vivo in the rat.

HI-6, ([[[(4-aminocarbonyl)pyridino]methoxy]methyl]-2-] (hydroxyimino)methyl]-pyridinium dichloride), is an oxime which, when combined with atropine, is an extremely effective therapy against organophosphate poisoning. It was found that, following soman (287 micrograms/kg) poisoning, HI-6 reactivated acetylcholinesterase in the diaphragm and intercostal muscles but not in the brain. At a lower dose of soman (110 micrograms/kg), HI-6 reactivated sarin-inhibited acetylcholinesterase in the brain and in the respiratory musculature but did not reactivate tabun-inhibited acetylcholinesterase. It was also found that soman produced a differential inhibition of diaphragm and intercostal muscle acetylcholinesterase in vivo, whereas the in vitro I50 for soman was the same in both areas. HI-6 was capable of reactivating soman-inhibited acetylcholinesterase when administered up to 30 min post-soman, indicating that the rate of aging of the soman-acetylcholinesterase complex is slower than previously reported. The above results suggest that, in severe soman poisoning, the primary lesion occurs in peripheral acetylcholinesterase in the respiratory musculature (specifically the diaphragm).

Acetylcholinesterase↗

Pulmonary resection after curative intent radiotherapy (>59 Gy) and concurrent chemotherapy in non-small-cell lung cancer.

BACKGROUND: Pulmonary resection after chemotherapy and concurrent full-dose radiotherapy (>59 Gy) has previously been associated with unacceptably high morbidity and mortality. Subsequently neoadjuvant therapy protocols have used reduced and potentially suboptimal radiotherapy doses of 45 Gy. We report a series of 40 patients with locally advanced non-small-cell lung cancer who successfully underwent pulmonary resection after receiving greater than 59 Gy radiation and concurrent chemotherapy. Operative results and midterm survival follow-up are presented. METHODS: Data were reviewed from 40 consecutive patients who underwent lung resection after receiving high-dose radiotherapy and concurrent platinum-based chemotherapy between January 1994 and May 2000. The follow-up closing interval for this study was until August 2003 or time of death. RESULTS: Preoperative stage was IIb (7 patients), IIIA (21 patients), IIIB (10 patients), and IV (2 patients with isolated brain metastasis). Thirteen patients exhibited Pancoast tumors. Median time from completion of induction therapy to surgery was 53 days. Twenty-nine lobectomies and 11 pneumonectomies (7 right, 4 left) were performed. There were no postoperative deaths. Intercostal muscle flaps were used prophylactically in all but one pneumonectomy patient. Seven patients required perioperative transfusions. Median intensive care unit (ICU) time averaged 2 days and the total length of stay was 6 days. One patient exhibited postpneumonectomy pulmonary edema and a bronchopleural fistula developed in another patient (not receiving an intercostal muscle flap). Thirty-four of 40 patients (85%; 95% CI: 70%-94%) were downstaged pathologically, 33 out of 40 patients (82.5%, 95% confidence interval [CI]: 67%-93%) indicated no residual lymphadenopathy, and 18 out of 40 patients (45%, 95% CI: 29%-61%) exhibited a complete pathologic response. Median follow-up was 2.8 years. The 1-, 2-, and 5-year overall survival rates were 92.4%, 66.7%, and 46.2%, respectively. Disease-free 1-, 2-, and 5-year survival rates were 73.0%, 67.2%, and 56.4%, respectively. Median disease-free survival has not been reached. CONCLUSIONS: Pulmonary resection may be performed safely after curative intent concurrent chemotherapy and radiotherapy to greater than 59 Gy. High pathologic complete response rates and sterilization of mediastinal lymph nodes were observed accompanied by highly favorable survival rates. This experience, though promising, will require confirmation in a prospective multiinstitutional clinical trial.

Adult↗

Pontine carbachol elicits multiple rapid eye movement sleep-like neural events in urethane-anaesthetized rats.

Microinjection of a cholinergic agonist, carbachol, into the pontine reticular formation of chronically instrumented intact or acutely decerebrate rats and cats has been used extensively to study rapid eye movement sleep mechanisms. In this study, we sought to develop a reduced carbachol model of rapid eye movement sleep-like neural events exhibiting multiple physiological markers of this state, and allowing for the use of invasive electrophysiological techniques. Accordingly, we investigated whether pontine carbachol could produce rapid eye movement sleep-like motor atonia and electrocortical changes in urethane-anaesthetized rats. We recorded cortical and hippocampal electroencephalograms and genioglossus and inspiratory intercostal muscle activities in 13 urethane-anaesthetized, spontaneously breathing, tracheotomized and vagotomized rats. In steady-state periods with high-voltage/low-frequency electroencephalogram activity, carbachol microinjections (15-40 nl, 10 mM) were placed in the medial pontine reticular formation. In 12 rats, carbachol elicited episodes of stereotyped hypotonia of genioglossus but not intercostal muscle activity, typical of rapid eye movement sleep, with a latency and duration of 2.2+/-0.3min (mean+/-S.E.M.) and 11.0+/-2.9 min, respectively. In four of these rats, also similar to rapid eye movement sleep, the major suppression of genioglossus activity (-74+/-9%) was accompanied by electroencephalogram desynchronization, appearance of hippocampal theta rhythm, and a respiratory rate increase (+ 14+/-3%). In the remaining eight rats, the stereotyped suppression of genioglossus activity (-48+/-3%) occurred without electroencephalogram desynchronization and hippocampal theta, and was accompanied by a respiratory rate decrease (-6+/-2%); a pattern of response typical of decerebrate animals. Within a rat, similar patterns of response to repeated carbachol injections at the same anatomical site were obtained. Pontine atropine prevented responses to subsequent carbachol injections. Thus, in urethane-anaesthetized rats, pontine carbachol consistently produced a differential suppression of pharyngeal versus respiratory pump muscle activity, and in a subset of animals, this was also accompanied by cortical and hippocampal electrographic changes typical of rapid eye movement sleep. This shows that complex and stereotyped neuronal events underlying both ascending and descending signs of rapid eye movement sleep can be pharmacologically activated under general anaesthesia. Such a reduced preparation may be useful for studies into the central neuronal mechanisms underlying generation of rapid eye movement sleep; particularly for studies requiring techniques that are difficult to implement in intact, naturally sleeping animals. The acceleration of the respiratory rate observed only when carbachol induced electroencephalogram desynchronization suggests that neural events associated with electrocortical changes contribute to the respiratory rate increases observed in natural rapid eye movement sleep.

Anesthesia↗

Analysis of activity of motor units in the biceps brachii muscle after intercostal-musculocutaneous nerve transfer.

We examined respiratory activity of motor units (MUs) in the internal intercostal nerves (IICNs)-transferred biceps brachii muscle (IC-biceps) in cats. MUs of IC-biceps showed respiratory discharges in inspiratory and expiratory phases, and these were enhanced by CO2 inhalation. Narrowing the airway also enhanced inspiratory and expiratory MUs activity. A mechanical load to the thorax immediately enhanced inspiratory MUs activity and weakened expiratory MUs activity. We analyzed the cross-correlation of MUs activity in interchondral muscle and IC-biceps to characterize the respiratory spinal descending inputs to motoneurons. We confirmed the short-term synchronization from interchondral muscles indicating divergence of a single respiratory presynaptic axon to thoracic motoneurons, but could not find synchronization from IC-biceps. The motor axonal conduction velocity (axonal CV) of IC-biceps MUs was lower than that of interchondral muscles. There was no correlation between the respiratory recruitment order of IC-biceps MUs and their axonal CV. These results indicate that IC-biceps shows the respiratory activities and afferent inputs from intercostal muscle spindles in the neighboring segments remain influential on activity of IC-biceps. In addition, the short-term synchronization from IC-biceps could not be found, suggesting that the intercostal nerve transfer alters the respiratory spinal descending inputs to thoracic motoneurons.

Action Potentials↗

Respiratory muscle fibres: specialisation and plasticity.

Skeletal muscles are composed of fibres of different types, each type being identified by the isoform of myosin heavy chain which is expressed as slow 1, fast 2A, fast 2X, and fast 2B. Slow fibres are resistant to fatigue due to their highly oxidative metabolism whereas 2X and 2B fibres are easily fatiguable and fast 2A fibres exhibit intermediate fatigue resistance. Slow fibres and fast fibres are present in equal proportions in the adult human diaphragm while intercostal muscles contain a higher proportion of fast fibres. A small fibre size, abundance of capillaries, and a high aerobic oxidative enzyme activity are typical features of diaphragm fibres and give them the resistance to fatigue required by their continuous activity. Because of their fibre composition, intercostal muscles are less resistant to fatigue. The structural and functional characteristics of respiratory muscle fibres are not fixed, however, and can be modified in response to several physiological and pathological conditions such as training (adaptation to changes in respiratory load), adaptation to hypoxia, age related changes, and changes associated with respiratory diseases. The properties of respiratory muscle fibres can also be modified by pharmacological agents such as beta2 agonists and corticosteroids used for the treatment of respiratory diseases.

Adrenergic beta-Agonists↗

Experimental autoimmune myasthenia gravis: the rabbit as an animal model.

Rabbits immunized with acetylcholine (ACh) receptor purified from Torpedo electroplax were studied after they were paralyzed and exhibiting respiratory distress. Intercostal muscles from the immunized rabbits had reduced amplitude of miniature end-plate potentials (MEPPs) as well as reduced junctional ACh sensitivity. However, a large percentage of the cells studied (40%), which exhibited no MEPPs, had junctional ACh sensitivity that was 45% of normal. It is suggested that, unlike myasthenic patients, such paralyzed and dying rabbits may have, in addition to postsynaptic damage, neurons that are damaged or separated from the muscle. Serums from six paralyzed rabbits inhibited binding of [3H]ACh and [125I]alpha-bungarotoxin to Torpedo ACh-receptor to varying degrees: 18.8--95.5% and 42.5--86.1%, respectively. Immune serums also inhibited the carbamylcholine-induced 22Na efflux from Torpedo microsacs, but neither they nor the immunoglobulins inhibited neuromuscular transmission when applied to intercostal muscles from a control rabbit. The data suggest that homology between receptor and antibody is important for inhibition of ACh binding to its receptor and its function. The role of complement in pathogenesis is also discussed, and so is the relationship of the ACh-receptor to its ionic channel.

Animals↗

[A case of tracheal fistula after operation for esophageal cancer].

We have experienced a case of mediastinal abscess and tracheal fistula after operation for esophageal cancer and successfully closed by using intercostal muscle pedicle flap. A 61-year-old male underwent esophagectomy for advanced esophageal cancer. On the 12th postoperative day, mediastinal abscess caused by leakage was detected, and drainage of the mediastinal and thoracic cavity was performed. On the 29th postoperative day, tracheal fistula was detected, and operation was performed in order to close the fistula by using of intercostal muscle pedicle flap. His postoperative course was fair and general condition was improvement, esophageal reconstruction using of free jejunal graft was performed and oral ingestion was started.

Aged↗

Selective activation of parasternal muscle fibers according to breathing rate.

The activity of single parasternal intercostal muscle fibers of rabbits was recorded during control breathing and during heat tachypnea at near-constant tidal volume. In order to identify with high probability the type of fibers on the basis of available knowledge, differences in firing pattern were enhanced by occluding the airways during an inspiration or adding dead space. Under both conditions the percentage of fibers with relatively high values of peak firing rate (fp) and rising rate of firing frequency (delta f/delta t) was greater during tachypnea. Fibers with relatively low values of fp and delta f/delta t during control breathing showed little or no increase of these parameters during tachypnea. Fibers with low fp and delta f/delta t should be slow, and others fast. Hence, the greater percentage of fibers with high fp and delta f/delta t during tachypnea indicates a recruitment of fast fibers. these findings support our previous hypothesis of selective activation of inspiratory muscle fibers according to the speed of movements.

Animals↗

Subarachnoid-pleural fistula after resection of thoracic tumors.

OBJECT: Little has been written about the appropriate diagnosis, investigation, and management of subarachnoid-pleural fistula (SPF). The authors report a series of patients with SPF that developed after resection of spinal tumor and discuss the diagnosis and treatment of this entity. METHODS: Between 1993 and 2002, nine patients with SPF observed after spinal surgery at the M. D. Anderson Cancer Center were prospectively followed. In all patients the tumors were located in the thoracic region, and the most common entity was vertebral body metastasis (six cases), with renal cell carcinoma being the most common form of the disease (three cases). All but one patient underwent surgery via a transthoracic approach; in only one patient an intradural approach was performed. The most common presentation was overt cerebrospinal fluid (CSF) leakage, manifesting as chest tube drainage (four cases) or as leakage through the wound (one case). A definitive diagnosis of SPF was established in four patients, with evidence of extraspinal leakage on an 111In-radionuclide CSF study. Although all patients initially underwent a trial of lumbar CSF drainage, all but one required open repair, including creation of intercostal muscle (three cases) and omental (one case) flaps. CONCLUSIONS: After spinal surgery in which the thorax is entered, a diagnosis of SPF should be considered in any patient with abnormal chest tube output, persistent pleural effusion, or clinical evidence of intracranial hypotension. The diagnosis should be confirmed by performing a radionuclide-labeled CSF study. Definitive open repair is required in most cases and preferentially consists of a vascularized tissue graft, which is most easily obtained from an intercostal muscle flap.

Adult↗