[ON NERVOUS SYSTEM DISORDERS IN AORTIC COARCTATION].
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Aortic Coarctation↗
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[OPERATIVE TREATMENT OF THE ATONIC BLADDER].
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Autonomic Nervous System Diseases↗
[Total parathyroidectomy with forearm graft in tertiary hyperparathyroidism].
Autonomic and persistent hypersecretion of PTH is a frequent and tormenting complication of the patients with chronic renal dialysis for end stage renal disease (ESRD). In these cases, surgery remains a therapy option with real effects on clinical status of patients, especially in perspective of a renal transplant. The authors present the case of a patient with tertiary hyperparathyroidism for which a total parathyroidectomy followed by autotransplantation of small glandular fragments in forearm muscles was performed. The postoperative clinical and immunological statuses were favorable with the disappearance of pruritus and osteoartralgia with improvement of psychic behavior and normalization of calcium blood level. Considering the parathyroidectomy as a palliative stage in the treatment of ESRD, the authors discussed a hierarchy system of both indications and surgical alternatives to be considered in this condition. In well selected cases this surgical method represents an attractive and easy possibility to control and later adjustment of the hyperfunction of remained parathyroid tissue, avoiding in this way a very risky intervention.
Forearm↗
[Clinical experiences with a new reusable pressure transducer].
Invasive blood pressure monitoring is increasing in anesthesia and intensive care. Compared to noninvasive methods, it has some decisive advantages: (1) blood pressure trends can be assessed beat by beat, which is important especially in situations of cardiac arrhythmia; (2) respiratory changes in blood pressure as one sign of hypovolemia can be detected easily; and (3) pressure changes induced by the autonomic nervous system become apparent. We studied a new, reusable pressure transducer system, the Medex Novatrans-MX800 in routine intra- and postoperative monitoring of patients undergoing cardiac surgery using the following criteria: (1) handling; (2) accuracy of measurement; (3) durability; and (4) costs. The system is easy to use and has a low susceptability to breakdown. In 29 of 31 transducers tested, the error of measurement over a range of 0-150 mmHg was less than 2% as reported by the manufacturer. Two transducers showed errors of measurement over 5% after 60 times of reuse. The mean reusability rate until the transducer became defective was 75.8 +/- 17.3 in the operating room (19 transducers tested) and 59.7 +/- 29 in the intensive care unit (12 transducers tested, 11 still in use). A comparison of costs shows that the Novatrans-MX800 system is the cheapest system for invasive pressure monitoring available at this time.
Blood Pressure Determination↗
[Evaluation of the clinical benefit of decompression hemicraniectomy in intracranial hypertension not controlled by medical treatment].
Through the findings in the literature on the basis of 9 personal cases, we review the indications and value of decompressive hemicraniectomy with plasty of the dura mater in cases of medically uncontrolled and decompensated intracranial hypertension. Seven patients had a pseudo-tumoral brain infarction. Five patients survived and their functional recovery is consistent with an autonomous daily life. Another patient with acute traumatic sub-dural haemorrhage died. The ninth patient had presuppurative encephalitis and recovered with no disability. At the time of surgery, all the patients were comatose with herniation of the mesencephalon (n = 3), uncal transtentorial herniation which was either unilateral (n = 4) or bilateral (n = 2). ICP was between 25 and 60 mmHg before the operation. After flap removal, ICP decreased by 15% and, after opening of the dura, it fell a further 70%. In 6 patients we were able to carry out continued post-operative monitoring of ICP, which stayed below 50% of initial values. Decompressive hemicraniectomy is an effective means of treating ICH caused by carotid cerebrovascular accidents with a high degree of edema, where mortality rises to 70-85% when only medical treatment is administered. No haemorrhagic complications, which can occur during hemispherectomies, were observed during decompression.
Adolescent↗
Viagra, surgery and anesthesia: a dangerous cocktail with a risk of blindness.
Since the launch in 1998 of the anti-impotence drug sildenafil (viagra), the American food and drug administration has identified 50 cases of drug-related blindness, the so-called nonarteritic anterior ischemic optic neuropathy. This, very serious, side effect frequently leads to sudden, mostly irreversible loss of vision, and there is no proven effective treatment to cure patients or to prevent recurrence. The mechanism of ischemic optic neuropathy is not clear, but it could be related to the fact that the ophthalmic and central retinal arteries have an autoregulation of their own blood flow without any autonomic nerve supply; vasoreactivity could be lower albeit efficient, and therefore more vulnerable to systemic modifications of the circulation. But decreased visual acuity and loss of visual ability also are, although uncommon, anesthesiological and surgical complications. These data are consistent with the hypothesis that sildenafil, surgery and anesthesia, taken together, could be a potentially dangerous cocktail of risk factors for sudden irreversible loss of vision. To reduce the risk, sildenafil use should be avoided at least one week before surgical operations, since the reported cases of blindness developed 36h after drug ingestion.
Anesthesia↗
Influences of splanchnic nerve blockade on endocrine-metabolic responses to upper abdominal surgery.
Twelve patients undergoing gastrectomy received combined epidural and splanchnic nerve blockade (Group E&S), and changes in plasma ACTH, cortisol, glucose and FFA were compared with those undergoing gastrectomy under general anaesthesia (Group G) or epidural analgesia alone (Group E). Plasma ACTH increased in all groups on the day of operation and was significantly higher in Group G than the other groups. Levels of ACTH in Group E&S were lower than Group E, but the differences were not significant. Cortisol response in Group G was most pronounced and prolonged. This cortisol response was significantly attenuated in Group E and was further inhibited in Group E&S. Blood glucose and FFA increased in Groups G and E during the operation but the increase was significantly less in Group E. In Group E&S, glucose and FFA concentrations showed practically no change throughout the study, being significantly lower than in Group E. The results indicated that the splanchnic nerve is responsible for producing endocrine-metabolic responses to gastric surgery even under epidural blockade.
Adrenocorticotropic Hormone↗
Inadvertent intra-arterial injection of phentaramine: a complication of drug abuse.
A female drug abuser inadvertently injected an intravenous injection of an oral anorexiant, phentaramine (Preludin), into her own brachial artery. Severe hand pain, vasospasm, and ischemia occurred. Treatment with regional axillary block, intravenous dextran, intra-arterial priscoline, and salicylate anticoagulation may have influenced a favorable outcome. Intimal damage, vasospasm, and various additive effects after intra-arterial injection contribute to the potential for serious sequelae. Prompt diagnosis, vasodilatation, elevation and compression, pain relief and, in some cases, surgery appear to improve salvage of what is frequently a major extremity injury.
Adult↗
Emotional fainting and the psychophysiologic response to blood and injury: autonomic mechanisms and coping strategies.
This experiment was designed to examine the psychophysiologic response pattern associated with emotional fainting. A survey was carried out among students, from which 30 volunteers who reported that they felt faint at the sight of blood or injury were recruited, together with 26 nonfainters. Blood pressure, heart rate, and respiration rate were monitored while subjects viewed a film depicting open-heart surgery and a neutral control film. Parasympathetic cardiac control was indexed by respiratory sinus arrhythmia (RSA), and coping was assessed by questionnaire. Responders (n = 17, group FPOS) were defined by a positive survey rating plus marked lightheadedness during the surgery film, and they were compared with nonresponders (group FNEG). Group FPOS showed a classic diphasic response with increases in heart rate and systolic blood pressure early in the surgery film followed by decreases in both variables, and the pattern was significantly different from that found in group FNEG. Data from three subjects who fainted corroborate these observations, although there were marked individual differences in response. The two groups did not differ in RSA, although RSA was smaller in both groups early in the surgery film than at other points. The positive fainting response group reported focusing their attention on bodily sensations, while those who showed little distress used intellectual coping strategies. The results are discussed in terms of the psychophysiologic mechanisms involved in fainting.
Adaptation, Psychological↗
Endoscopic thoracic sympathicotomy for Raynaud's phenomenon.
PURPOSE: For many years, thoracic sympathectomy via open surgery was not used to treat Raynaud's phenomenon because of the invasiveness of this procedure and the poor long-term outcomes associated with it. However, with the introduction of endoscopic surgery, thoracic sympathectomy (or sympathicotomy) has been performed by some surgeons as a less invasive surgical option for patients with Raynaud's phenomenon. The less invasive procedure has the possibility of emphasizing merits of sympathectomy. The purpose of this study was to reevaluate the efficacy of sympathicotomy for Raynaud's phenomenon with endoscopic technique and its range of applicability. METHODS: Between December 1992 and August 2001, endoscopic thoracic sympathicotomy (ETS) was performed in 28 patients with Raynaud's phenomenon (of a total of 502 patients with autonomic disorders who underwent ETS) at National Kanazawa Hospital. We considered indications for surgical treatment of Raynaud's phenomenon to include severe chronic symptoms or nonhealing digital ulceration refractory to intensive medical therapy. All patients were mailed a self-assessment questionnaire after surgery to determine the immediate and long-term results of the procedure. Data from both initial and long-term follow-up examinations were obtained. RESULTS: Fifty-four ETS procedures were performed in 28 patients. No operative mortality was seen, and no occurrence of major complications necessitated open surgery. Initial resolution or improvement of symptoms was achieved in 26 of 28 patients (92.9%). However, later in the postoperative period, symptoms recurred in 23 of 28 patients (82.1%), although no recurrence of digital ulceration was seen throughout our observation. At the final follow-up examination (median follow-up period, 62.5 months), 25 patients (89.3%) reported overall improvement of the frequency and severity of their symptoms. CONCLUSION: Despite the high rate of recurrence, ETS clearly produced a high rate of initial relief. ETS did indeed promote healing of digital ulcers, and the procedure shows potential for reducing the severity of refractory symptoms. We consider ETS to be the method of choice for treatment of severe or refractory Raynaud's phenomenon, and especially for Raynaud's involving digital ulcer, because of its safety and efficacy.
Adult↗
Testosterone has potent, selective effects on the morphology of pelvic autonomic neurons which control the bladder, lower bowel and internal reproductive organs of the male rat.
Although gonadal steroids are important determinants of the development and activity of various neuronal circuits in the brain and spinal cord, their function has been relatively poorly studied in the peripheral nervous system. In the present work, the effects of pre- and postpubertal castration were examined on the morphology of autonomic neurons that supply pelvic visceral organs in male rats. These neurons were identified by peripheral injection of fluorescent retrograde tracers and, in the major pelvic ganglion, were further classified as sympathetic or parasympathetic by means of immunostaining for tyrosine hydroxylase. Sizes of ganglion cell somata were indicated by areas of nucleated profiles in cryosections. The results show that, irrespective of whether castration was carried out at two or seven weeks-of-age, noradrenergic pelvic neurons that supply the vas deferens, prostate gland, urinary bladder or colon achieved only approximately 60% of the size of those in unoperated controls. In contrast, cholinergic pelvic neurons were unaffected by castration unless they supplied reproductive targets. Pre- and paravertebral sympathetic neurons that supplied the pelvic viscera were only slightly smaller following castration or were unchanged, depending on their target. All effects of castration were prevented by testosterone replacement following surgery. Androgen receptor-immunoreactivity was particularly prevalent in the nuclei of some pelvic ganglion neurons. The studies suggest that circulating androgens are essential for the maturation and maintenance of the structure of select groups of autonomic neurons that supply the viscera. The presence of androgen receptor immunoreactivity in many of these neurons indicates that direct neuronal effects of androgens are possible. However this does not exclude other less direct mechanisms of steroid action on neurons, such as by an effect on target organs, neurotrophic factor release or peripheral vascular supply. These studies point to the androgenic steroids as potentially important determinants of autonomic reflex function.
Aging↗
A case of primitive floor of the mouth paraganglioma in a child: an embryological theory unifying viscerocranium appended paragangliomas.
BACKGROUND: Paragangliomas are unusual tumors in the head and neck originating from the paraganglia or glomus cells of neural crest origin. METHODS: We describe the first case of a primitive paraganglioma of the floor of the mouth presenting in childhood. RESULTS: Complete surgical removal was performed after embolization of the left lingual artery. There was no evidence of either persistent or recurrent disease 5 years after surgery. The embryologic and anatomic origins of head and neck paragangliomas are reviewed. CONCLUSIONS: An embryologic theory based on the common neural crest origin and migration pathways of both autonomic viscerocranium appended ganglias and paragangliomas is proposed that unifies the topographically heterogeneous group of viscerocranium-appended paragangliomas.
Child↗
Altered smooth muscle development and innervation in the lower genitourinary and gastrointestinal tract of the male human fetus with myelomeningocele.
PURPOSE: We determine whether smooth and skeletal muscle or nerve density is altered in the lower genitourinary or gastrointestinal tract of male human fetuses with myelomeningocele at 20 weeks of gestation. MATERIALS AND METHODS: We serially cross sectioned the lower genitourinary and gastrointestinal tracts in 7 male fetuses (mean age 20 weeks of gestation) with myelomeningocele and 4 age matched controls. Immunohistochemical staining was performed using Masson's trichrome stain and antibodies to smooth and skeletal muscle actin. S-100 protein staining for Schwann cell localization and neurofilament protein was also done. Fluorescein and rhodamine double immunolabeling was used to demonstrate the co-expression of smooth and skeletal muscle. RESULTS: Peripheral neural innervation of the bladder, prostate and rectum was markedly decreased in myelomeningocele. Masson's trichrome and smooth muscle actin staining also demonstrated that smooth muscle was less well differentiated in myelomeningocele specimens. Scant smooth muscle was present in the myelomeningocele bladder and bladder neck with an excess of collagen in an interfascicular and intrafascicular distribution. Double immunofluorescence staining revealed persistent co-expression of smooth and skeletal muscle actin by myocytes in the myelomeningocele detrusor, while in the control bladder there was only smooth muscle expression. The skeletal muscle component of structures in fetuses with myelomeningocele, including the external sphincter, was similar to that in controls. Prostatic size, ductal morphogenesis and smooth muscle were decreased compared to those in controls. CONCLUSIONS: A global defect exists in the development of smooth muscle in myelomeningocele in the lower genitourinary and gastrointestinal tracts by 20 weeks of gestation. Peripheral nerve density is decreased in smooth muscle in myelomeningocele, suggesting that an intact nervous system is important for the development of normal smooth muscle. Fetal surgery with coverage of the spinal cord in select cases may prevent progressive environmental injury to the somatic nervous system during the second half of gestation. However, achieving normal autonomic function is unlikely due to the extent of early global organ maldevelopment.
Digestive System↗
Sympatho-adrenal and pituitary hormone responses during and immediately after thoracic surgery--modulation by four different pain treatments.
Four different pain treatments (single intercostal block with bupivacaine, repeated intercostal block, epidural morphine and epidural bupivacaine infusions) were compared in 39 patients subjected to lung surgery under general anaesthesia. The patients' own estimate of the postoperative pain was not significantly different between the groups, but the epidurally treated patients required fewer doses of supplementary analgesic than those given just a single dose of intercostal bupivacaine. Bupivacaine levels in blood were below the toxic range in all groups. The concentration of antidiuretic hormone in blood was increased early during the operation, and had only partly returned to normal on the first postoperative morning. Growth hormone in plasma was increased only at the end of the operation. Catecholamine levels in blood increased gradually, reaching their peak postoperatively. There were only slight differences between the groups in these posterior and anterior pituitary and sympatho-adrenal responses to surgical stress. Thus, neither repeated intercostal blockade nor epidural administration of morphine or bupivacaine could prevent the endocrine responses to thoracic surgery, in spite of significant, albeit incomplete, pain relief. This was probably caused in part by residual pain, and also by poor access of the extradural medications to the autonomic afferent pathways mediating nociceptive signals from thoracic organs and tissues.
Aged↗
[Teaching evaluation at Medical School, UNAM].
The purpose of this article is to offer a synthesis of what has been done in the Teaching Evaluation Program at the Medical School of the Autonomous National University of Mexico (UNAM). The Program involves three questionnaires of the students' opinion that evaluate professors of the basic and sociomedical areas, microbiology and parasitology laboratory and surgery. Between 1994 and 2003, 134,811 questionnaires were answered to evaluate the teaching performance of 6262 professors of pregraduate students. Although the evaluation of teaching through a single way is insufficient, the results obtained allow us to affirm that the Medical School at UNAM has a good professor staff, as well as they are useful for the design of programs dedicated to the acknowledgment of excellence and the needs for teaching education.
Mexico↗
Back pain and spinal changes in microgravity.
We believe that investigations into back pain and spinal changes in microgravity will contribute significantly to our knowledge and understanding of factors that cause back pain and the influence of spinal cord distraction on sensory and autonomic dysfunction. This information may have clinical implications for the treatment and rehabilitation of patients with spinal cord injury, for the care of patients during and after corrective spinal surgery, for the care and treatment of patients with chronic pain syndromes, and may potentially provide us with the opportunity to learn more about demyelinating diseases.
Back Pain↗
[Clinical anatomy of collateral varicose veins (essential varicose veins of the legs)].
Performance of ambulatory phlebectomies has greatly enhanced the anatomo-clinical description of collateral varicosities (CV), permitting a better understanding of their physio-pathological role, and acknowledging, in some instances, their true autonomy. Physio-pathological role:--Reflux transfer--The function of CV is not limited to a mere acknowledgment (vector function) of the refluxes from the long pathological axes on which they branch. This function also consists in ensuring the diversion (transfer function) from one territory to another.--Pathology transfer--This reflux transfer is sometimes accompanied with a pathology transfer in the new territory (pathology steals). Anatomo-clinical description:--Supra-limb collaterals--These are CV with a parieto-abdominal course and pelvic CV, developed below the origin of the limb.--Proximity collaterals--These are "ladder-shaped" collaterals with oblique bars!, uniting adjacent long axes.--Inter-axial collaterals--These are crural, tibial of cruro-tibial CV, uniting distant long axes and providing junctions between medial and lateral saphenous veins, lateral and medial saphenous veins, saphenous veins-peroneal axis... Situations of autonomy: Independence regarding long axes, is demonstrated by the autonomous nature of the original reflux and affects, more especially: the antero-lateral crural slings, the lateral pudental vessels, the popliteal veins. The treatment of collateral varicosities involves surgery, ambulatory phlebectomy, sclerosis with could be implemented separately or concomitantly.
Collateral Circulation↗
A semi-active milling procedure in view of preparing implantation beds in robot-assisted orthopaedic surgery.
Bone cutting in total joint reconstructions requires a high accuracy to obtain a well-functioning and long-lasting prosthesis. Hence robot assistance can be useful to increase the precision of the surgical actions. A drawback of current robot systems is that they autonomously machine the bone, in that way ignoring the surgeon's experience and introducing a safety risk. This paper presents a semi-active milling procedure to overcome that drawback. In this procedure the surgeon controls robot motion by exerting forces on a force-controlled lever that is attached to the robot end effector. Meanwhile the robot constrains tool motion to the planned motion and generates a tool feed determined by the feed force that the surgeon executes. As a case study the presented milling procedure has been implemented on a laboratory set-up for robot-assisted preparation of the acetabulum in total hip arthroplasty. Two machining methods have been considered. In the first method the surgeon determines both milling trajectory and feed by the forces that he/she executes on the force-controlled lever. In the second method the cavity is machined contour by contour, and the surgeon only provides the feed. Machining experiments have shown that the first method results in large surface irregularities and is not useful. The second method, however, results in accurate cavity preparation and has therefore potential to be implemented in future robot systems.
Acetabulum↗