NEUROFIBROMATOSIS OF THE PELVIC AUTONOMIC PLEXUSES.
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Autonomic Nervous System↗
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Subthalamic nucleus deep brain stimulation in a patient with levodopa-responsive multiple system atrophy. Case report.
The authors report the clinicopathological findings in a patient in whom levodopa-responsive parkinsonism developed at 45 years of age. The patient experienced asymmetrical onset of symptoms, sustained benefit from levodopa, and motor fluctuations and dyskinesias, but there were no prominent autonomic, cerebellar, or pyramidal signs. He was diagnosed clinically with Parkinson disease (PD) and underwent bilateral subthalamic nucleus deep brain stimulation (DBS) surgery 9 years after symptom onset. He did not respond to stimulation or medication postoperatively, however, and died 12 weeks after surgery of repeated aspiration pneumonias. Postmortem examination revealed neuron loss in the substantia nigra and basal ganglia, and numerous alpha-synuclein-positive glial cytoplasmic inclusions in the subcortical nuclei, cerebellum, and brainstem, findings that established a neuropathological diagnosis of multiple system atrophy (MSA). Furthermore, there was an atypical and robust inflammatory reaction, as well as numerous glial cytoplasmic inclusions surrounding both DBS electrode termination sites. The authors speculate that the presence of alpha-synuclein in the striatum, combined with the inflammation surrounding the electrodes, contributed to the ineffectiveness of stimulation and dopaminergic medications postoperatively. This case demonstrates the ineffectiveness of DBS in MSA, even when the patient is responsive to levodopa, and emphasizes the need for diagnostic modalities that can be used to distinguish PD from MSA and other parkinsonian syndromes in which the levodopa response pattern is typical of PD.
Antiparkinson Agents↗
Evaluation of tuberculosis trends in Spain, 1991-1999.
SETTING: There are no reliable official data available on tuberculosis (TB) in Spain. OBJECTIVE: To ascertain the epidemiological trends of TB in Spain from 1991-1999. METHODS: In an annual survey conducted by the Tuberculosis and Respiratory Infections (TRI) Working Group of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR), data on tuberculosis disease and infection were solicited from two information sources: 1) the public health services of the 17 Autonomous Regions (AR), and 2) 60 TRI members in different parts of Spain. RESULTS: TB incidence declined from 36.4/100,000 in 1991 to 26.7 in 1999 according to the AR (average annual decline 3.3%), and from 45.6 to 26.8 according to TRI members (annual decline 5.1%). A similar observation was made for smear-positive cases (AR annual decline: 3.0%; TRI: 5.6%). Tuberculosis infection at 6 years of age also decreased according to both information sources (AR: 0.87% in 1991 to 0.5% in 1998, annual decline 6%, and TRI members: 1.00% in 1991 and 0.9% in 1997, annual decline 4.2%). CONCLUSIONS: The observed rates of TB are higher than stated in official figures. In spite of the decreasing trend, observed declines are small and the current rates continue to be among the highest among industrialised countries.
Adolescent↗
[Graduated autonomic block for reduction of postoperative complications].
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Anesthesia↗
[GANGLIONIC-BLOCKING AGENTS AND THEIR APPLICATION IN CLINICAL PRACTICE].
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Autonomic Nervous System↗
[TREATMENT OF MYOCARDIAL INFARCTION BY LIGATION OF THE INTERNAL MAMMARY ARTERY ASSOCIATED WITH BLOCK OF THE PRE-AORTIC NERVE PLEXUS].
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Aorta↗
[Modification of rehabilitation stage after inter-sphincter resection of the rectum].
Endoscopic ultrasonic examination for diagnosis of malignant tumors of a lower-ampullar part of the rectum determined indications to inter-sphincter resection consisting in total mesorectumectomy, resection of the rectum and internal sphincter. The method of creation of a globe-shape reservoir with artificial muscular sphincter was developed. Fourteen patients underwent surgery, the follow-up was up to 3,5 years. It is demonstrated that a globe-shape extensible reservoir and autonomic bloching function of muscular sphincter are the main conditions of repair of defecation functions in long-term period after inter-sphincter resection.
Anal Canal↗
Newborn pain cries and vagal tone: parallel changes in response to circumcision.
Clinical studies have demonstrated that the cries of chronically stressed, medically compromised infants are characteristically higher and more variable in pitch than those of healthy infants. Other studies have indicated that the vagal tone of chronically stressed infants is significantly reduced in comparison to that of normal infants. A neural model of cry production has been proposed which suggests that decreased vagal tone among infants at risk may, in fact, be related to these increases in cry pitch. Using routine, unanesthetized circumcision as a model of stress, we were able to examine the relation between cry acoustics and vagal tone in normal, healthy newborns undergoing an acutely stressful event. Vocalizations, heart, and respiratory waveforms were continuously recorded from 49 (32 experimental; 17 control) 1-2-day-old, full-term infants during preoperative, surgical, and postoperative periods. Vagal tone, as measured by the amplitude of respiratory sinus arrhythmia extracted from heart period data, was significantly reduced during the severe stress of circumcision, and these reductions were paralleled by significant increases in the pitch of the infants' cries. In addition, individual differences in vagal tone measured prior to circumcision surgery were predictive of physiological and acoustic reactivity to subsequent stress. These results emphasize the potential role of vagal control of the autonomic nervous system during stress.
Acoustics↗
Heparin inhibits phosphorylation and autonomous activity of Ca(2+)/calmodulin-dependent protein kinase II in vascular smooth muscle cells.
Vascular smooth muscle cell (VSMC) hyperproliferation is a characteristic feature of both atherosclerosis and restenosis seen after vascular surgery. A number of studies have shown that heparin inhibits VSMC proliferation in vivo and in culture. To test our hypothesis that heparin mediates its antiproliferative effect by altering Ca(2+) regulated pathways involved in mitogenic signaling in VSMC, we analyzed the effect of heparin on multifunctional Ca(2+)/calmodulin dependent protein kinase II (CaM kinase II) which is abundantly expressed in VSMC. Using activity assays, radioactive labeling, and immunoprecipitation it was found that heparin inhibits the overall phosphorylation of the delta-subunit of CaM kinase II which is consistent with inhibition of autophosphorylation-dependent, Ca(2+)/calmodulin-independent CaM kinase II activity. This effect was less evident in heparin-resistant cells, consistent with a role for CaM kinase II in mediating the antiproliferative effect of heparin. Finally, the effects of pharmacological inhibitors of phosphatases like okadaic acid, calyculin, and tautomycin suggest that heparin inhibits CaM kinase II phosphorylation by activating protein phosphatases 1 and 2A. These findings support the hypothesis that alterations in calcium-mediated mitogenic signaling pathways may be involved in the antiproliferative mechanism of action of heparin.
Animals↗
Effect of axillary brachial plexus blockade on baroreflex-induced skin vasomotor responses: assessing the effectiveness of sympathetic blockade.
BACKGROUND: The combination of laser Doppler flowmetry and non-invasive blood pressure monitoring allows the continuous observation of cutaneous vascular resistance (CVR). Continuous recording of unmodulated skin blood flow (SBF) is very sensitive to artefacts, rendering the method unreliable. In contrast, intermittent short lasting challenges of the CVR by cardiovascular autonomic reflexes may provide information about the responsiveness of the sympathetic nervous system in the skin. METHODS: Eleven patients with below-wrist hand surgery (six males and five females; aged 35.2+/-7.1 years) performed Valsalva maneuver following axillary blockade. Skin blood flow was continuously monitored on the forearm of the side axillary blockade, as well as on the contra-lateral forearm, which was used as the control. The responses were expressed as changes compared with the baseline level derived from a resting period of 30 s. The maximal change in CVR was determined during the late strain phase of the Valsalva maneuver on both sides. For numerical comparison the change in CVR on the axillary blockade and control sides were simultaneously calculated. RESULTS: During the Valsalva maneuver a significant increase in CVR was observed on the control side with a maximum value during the late strain phase (baseline 0.18+/-0.1 and late strain phase 0.42+/-0.2 relative units; P<0.01). In contrast, only minimal changes were detected on the side of axillary blockade in CVR (baseline 0.17+/-0.8 and late strain 0.16+/-0.2 relative units; P=NS). CONCLUSIONS: Our findings support the disputed hypothesis that the human skin microvasculature is involved in baroreflex regulation under thermoneutral conditions. The determination of baroreflex stimulus-induced microvascular responses may serve as a feasible method for monitoring the effectiveness of sympathetic blockade.
Adult↗
[Extracorporeal circulation with membrane oxygenation in high-risk coronary surgery].
The case of a patient operated for left main stem disease in which cardiopulmonary bypass (CPB) lasted 7 hours because of acute severe myocardial failure is reported. A satisfactory recovery of autonomous hemodynamic function was achieved. This case illustrates the technical progress which has been made in CPB: reduction of blood cell trauma in the bypass circuits, improved oxygenation reducing the disturbances of tissue perfusion usually associated with bubble oxygenators. The use of hypothermia in vasoplegic patients also contributes to the reduction in the incidence of complications. These improvements result in the optimal recovery of ischemic myocardial fibres and reduce the need for pharmacological support which is always difficult to manage and which is often associated with unwanted side effects.
Cardiopulmonary Bypass↗
Calcium channel blockers and cardiac surgery.
Calcium channel blockers have an important role in the pharmacotherapy of cardiovascular disorders. These agents act by inhibiting the slow inward current into excitable cells, exert direct negative inotropic, chronotropic, and dromotropic activity, and are potent vasodilators. These direct effects are modified by reflex autonomic stimulation and by pathologic states. Serious adverse effects of the calcium channel blockers are most frequently observed in patients with ventricular dysfunction, conduction system disease, or concomitant beta blockade. Calcium channel blockers are indicated in the treatment of angina pectoris, supraventricular arrhythmias, and hypertension. The use of these agents in patients with hypertrophic cardiomyopathy, congestive heart failure, and pulmonary hypertension is investigational. The calcium channel blockers are gaining increased importance in the management of patients undergoing cardiac surgery. Verapamil is indicated for the treatment of post-cardiac-surgical atrial flutter and fibrillation; however, the calcium antagonists are not effective as prophylaxis against postoperative supraventricular arrhythmias. Laboratory studies have shown that drug interactions exist between calcium channel blockers and inhalational anesthetics and nondepolarizing neuromuscular blocking agents; clinical studies have demonstrated that these interactions are rarely significant. Perioperative coronary spasm can be effectively treated with the calcium channel blockers. The timing of calcium antagonist withdrawal prior to surgery is controversial, but continuation of therapy until surgery is usually safe. The clinical significance of platelet function inhibition by the calcium antagonists is unknown. Protection of ischemic myocardium by calcium channel blockers has been demonstrated. Important interactions between the calcium antagonists, hypothermia, and the ionic constituents of cardioplegia require further study before the role of these agents as adjuncts to clinical cardioplegia is defined. Expanded indications and the introduction of new calcium channel blockers will result in increased use of these agents in the future.
Calcium Channel Blockers↗
Primary malignant melanocytic tumors of the sympathetic ganglia, with an ultrastructural study of one.
Three cases of melanocytic tumors arising in the sympathetic chain were studied. A metastasis from one of them was studied with electron microscopy. Both light and electron microscopy demonstrated the presence in these tumors of true melanogenesis and autophagic activity in melanocytes as well as phagocytosis of mature melanin by associated histiocytes. Review of the embryology, biochemistry and in vitro culture of sympathetic nervous tissue showed a close relationship between it and pigmented cells in other parts of the body which are also derived from neural crest. These findings support the clinical and morphological conclusion that these rare pigmented tumors are true melanocytic tumors originating from the sympathetic chain. The malignant potential of these tumors is emphasized by the fact that the two patients who survived initial surgery later died of metastatic disease.
Ganglia, Autonomic↗
Retroperitoneal abscess after neurolytic celiac plexus block from the anterior approach.
BACKGROUND AND OBJECTIVES: The anterior approach for celiac plexus block has the potential risks of infection, hemorrhage, and fistula formation. We report a case of a patient who developed a retroperitoneal abscess with the formation of a vascular-enteric fistula after a neurolytic celiac plexus block from the anterior approach. CASE REPORT: A 60-year-old female with a history of pain secondary to chronic idiopathic calcifying pancreatitis (VAS 7-8) underwent a subtotal resection of the head of the pancreas with an end-to-side pancreatojejunostomy using a Roux-en-Y loop. Pain continued secondary to chronic pancreatitis. Because of intolerance (vomiting and constipation) of morphine and transdermal fentanyl over a 2-month period, it was decided to perform a neurolytic celiac plexus block using the anterior approach with ultrasound guidance. The patient's pain was completely relieved, enabling withdrawal of oral analgesics. Pain reappeared after 2 years, and the same technique was repeated. Ten days later, she was admitted with diabetic ketoacidosis and lower gastrointestinal bleeding. Computed tomography showed a left paravertebral retroperitoneal abscess; arteriography suggested a fistula between the mesenteric vein and the jejunum. Urgent surgery was undertaken, revealing a leak of the pancreatojejunostomy and a large abscess around the celiac plexus. A distal pancreatectomy and partial resection of the Roux-en-Y loop was performed. The patient was discharged 1 month later in good clinical condition. Because of recurrent pain, she has required repeated neurolytic celiac plexus blocks via a posterior approach without complications. CONCLUSION: The posterior approach for neurolytic celiac plexus block should be considered in particular in patients with previous pancreatic surgery.
Abdominal Abscess↗
[Morphological changes in major pelvic ganglion neurons and histological structure of bladder using rat model of partial urethral ligation].
Ninety six rats were divided into 4 groups (normal control group (N = 4), ligation group (N = 20), ligation-removed group (N = 36), and sham surgery group (N = 36)). The neuronal size of the 4-week ligated rats returned to normal 6 weeks after removal of the ligation. Rats ligated for 7, 11 and 20 weeks also exhibited a significant increase in the mean area but they could not make a complete recovery after removal of ligation for 6 weeks. Only the rats in the 1- and 4-week ligation groups could recover their neuronal size. Area densities of smooth muscle: connective tissue (ADsc ratio) was calculated using Elastica van Gieson staining sections of bladder strips. When ligation was removed, the ratio dropped and became nearly equal to the value of the sham surgery group. Only the 7-week group showed a lower ADsc ratio than the sham surgery group after the ligation was removed. These findings suggest that the reversibility of neuronal hypertrophy might become irreversible when the period of partial urethral ligation persisted beyond 7 weeks. Irreversible hypertrophy of major pelvic ganglion (MPG) neurons might be greatly related with the irreversibly enlarged fibrous bladder which could not show the same ADsc ratio as was seen in the sham surgery groups.
Animals↗
[Anesthesiological management of pancreatectomy with curative intention in pancreatic carcinoma].
Pancreatectomy for pancreatic carcinoma makes high demands on the perioperative anesthesiologic management of these patients. This survey is centered on pathophysiological reflections related to the choice of the anesthesia and accompanying therapy, concerning the pathological mechanisms of intra- and postoperative complications. The influences of the surgical as well as the anesthesiological procedure on the autonomous nervous system and splanchnic blood flow, the organo-specific consequences of the resection and the possible influences on the immune system are discussed. Recommendations for perioperative medical care of these patients are derived from it. Central points are an anesthesiologic management adapted to the patient with regard to pathophysiological changes caused by surgery, monitoring and therapy of the disturbed fluid balance, postoperative intensive care as well as an optimal pain treatment.
Anesthesia↗
Ileoneorectal anastomosis: early clinical results of a restorative procedure for ulcerative colitis and familial adenomatous polyposis without formation of an ileoanal pouch.
OBJECTIVE: To evaluate a new surgical procedure, ileoneorectal anastomosis (INRA), in patients with ulcerative colitis (UC) and familial adenomatous polyposis (FAP). SUMMARY BACKGROUND DATA: Surgical treatment in UC and FAP aims to resect diseased colonic mucosa and restore oroanal continuity. The ileopouch anal anastomosis achieves this but has a 15% to 35% complication rate, a 10% failure rate, and an unpredictable functional outcome. An alternative surgical technique, INRA, has been developed in which the rectal mucosa is replaced by a vascularized ileal mucosa graft. METHODS: Eleven patients underwent an INRA procedure with a temporary diverting ileostomy. Clinical history, repeat endoscopy, histologic examination, and rectal compliance measurements were carried out before and after surgery. RESULTS: The INRA procedure was technically successful in all patients. Endoscopy showed ingrowth of ileal mucosa in the neorectum, with 100% coverage after 6 weeks. No patient had pelvic sepsis, neorectal-anal or -vaginal fistula, autonomic nerve damage, or fecal incontinence. Neorectal function improved with time. The median 24-hour defecation frequency decreased from 15 (range 9 to 25) to 7 (range 4 to 10) at 11 months follow-up, and the median maximum tolerated volume increased to 157 (range 130 to 225) ml. Anal manometry and electrosensitivity were not affected by the surgery. Histologic biopsy samples after 1 year showed a normal small intestinal mucous membrane, without inflammation or fibrosis. CONCLUSION: The combination of a low complication rate and good neorectal function at 1 year is a substantial improvement that justifies extension of the clinical application in patients with UC and FAP.
Adenomatous Polyposis Coli↗
Cardiovascular reflexes during anesthesia induction and tracheal intubation in elderly patients: the influence of thoracic epidural anesthesia.
STUDY OBJECTIVES: To determine whether thoracic epidural anesthesia performed prior to general anesthesia provides hemodynamic protection from the stress of laryngoscopy and tracheal intubation; to access the autonomic reflex response to epidural anesthesia, general anesthesia, and airway stimulation. DESIGN: Randomized unblind, controlled study. PATIENTS AND SETTING: 20 elderly (over 60) patients scheduled for colonic or gastric surgery at a university medical center. INTERVENTIONS: All patients (n = 10, in each group) underwent a standardized anesthesia induction sequence that included fentanyl 2 micrograms/kg, thiopental sodium 3 to 5 mg/kg (up to loss of eyelid reflex), and vecuronium 0.1 mg/kg followed by laryngoscopy and tracheal intubation. Before general anesthesia, thoracic epidural anesthesia was performed with plain 1% lidocaine in the epidural group. Preoperatively, baroreflex function was assessed by the Valsalva maneuver and the cough test. Spectral analysis of heart rate (HR) variability was performed before as well as during anesthesia. MEASUREMENTS AND MAIN RESULTS: There were no differences between the two groups in basal hemodynamics autonomic reflex status. Thoracic epidural anesthesia (median upper level at T2, median lower level at L2) was associated with stable hemodynamics, preservation of baroreflex sensitivity, and increased ratio of low to high frequency (LF/HF) components of HR variability, suggesting withdrawal of vagal activity. In both groups, general anesthesia induction was associated with decreased total HR variability and tracheal intubation was followed by increased LF/HF ratio, reflecting cardiac sympathetic activation. Patients with thoracic epidural anesthesia presented significant attenuation of the maximal rise in mean arterial pressure, and the increase in HR tended to be lower although not significantly. CONCLUSIONS: Thoracic epidural blockade combined with general anesthesia was associated with preserved baroreflex function, and it afforded hemodynamic protection during laryngoscopy and tracheal intubation.
Aged↗