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A missing denture's misadventure!

We report a late onset, benign, tracheoesophageal fistula in a 51-year-old man, due to an accidentally swallowed denture. In view of the extensive peri-esophageal sepsis and fibrosis, he was managed by a subtotal esophagectomy and a cervical esophagogastric anastomosis. The tracheal defect was closed with the help of an intercostal muscle flap. This report also highlights the difficulty in identifying swallowed prosthetic dental material radiologically, when no metallic component is present. This fact was also responsible for the delay in diagnosis, eventually leading to the rare complication of a tracheoesophageal fistula.

Anastomosis, Surgical↗

Contribution of somitic cells to the avian ribs.

The traditional view that all parts of the ribs originate from the sclerotome of the thoracic somites has recently been challenged by an alternative view suggesting that only the proximal rib derives from the sclerotome, while the distal rib arises from regions of the dermomyotome. In view of this continuing controversy and to learn more about the cell interactions during rib morphogenesis, this study aimed to reveal the precise contributions made by somitic cells to the ribs and associated tissues of the thoracic cage. A replication-deficient lacZ-encoding retrovirus was utilized to label cell populations within distinct regions of somites 19-26 in stage 13-18 chick embryos. Analysis of the subsequent contributions made by these cells revealed that the thoracic somites are the sole source of cells for the ribs. More precisely, it is the sclerotome compartment of the somites that contributes cells to both the proximal and distal elements of the ribs, confirming the traditional view of the origin of the ribs. Results also indicate that the precursor cells of the ribs and intercostal muscles are intimately associated within the somite, a relationship that may be essential for proper rib morphogenesis. Finally, the data from this study also show that the distal ribs are largely subject to resegmentation, although cell mixing may occur at the most sternal extremities.

Animals↗

[Immunohistochemical detection of complement factors: a reliable method for the diagnosis of myasthenia gravis].

A 57-year-old woman suffered from generalized muscular weakness without diplopia or dysphagia for about 2 years. An abnormal decremental response on low frequency nerve stimulation and improvement upon administration of edrophonium chloride suggested a diagnosis of myasthenia gravis. However, this diagnosis remained uncertain, since repeated tests for antiacetylcholine receptor antibodies were negative. In addition, the patient reported that she was never able to keep up with peers in prolonged physical activities since childhood. For this reason, a congenital myasthenic syndrome was suspected and an intercostal muscle biopsy performed for special end-plate studies. Immunohistochemistry of the muscle biopsy revealed membrane attack complex deposits at the end-plates. This finding definitely confirmed the diagnosis of autoimmune myasthenia gravis. In conclusion, immunohistochemistry for complement deposits at the end-plates is a simple and reliable method of confirming the diagnosis of myasthenia gravis in uncertain cases.

Biopsy↗

Ventilatory responses to mechanical loads in cervical cord-injured humans.

Load compensation in 29 cervical cord-injured men was inferred from the difference between actual first-breath responses to graded elastic and resistive loads and those calculated assuming identical respiratory muscle pressure (Pmus) wave forms in the unloaded and loaded states (i.e., the passive prediction). At every load, respiratory frequency (f) and tidal volume (VT) responses from different individuals formed a continuum ranging from a weak VT defense coupled with an increased f to a strong VT defense coupled with a decreased f. Individual VT responses ranged from values smaller than the passive prediction to values exceeding control, suggesting that phrenic motoneuron output was not constant but decreased in some subjects and increased in others. In support of this hypothesis, 1) individual VT responses varied with inspiratory duration (TI; P less than 0.01); 2) TI responses indicated some subjects prematurely terminated their phrenic motoneuron output, whereas others prolonged it; 3) VT/TI responses suggested that some subjects modified the discharge frequency of their phrenic output; and 4) rib cage instability contributed insignificantly to these responses. These findings, which are similar to those reported for normal men, indicate that 1) afferent pathways from the rib cage and intercostal muscles are not required for the initiation of a range of ventilatory responses to loads; and 2) afferent pathways from the mouth, lung, and/or diaphragm are sufficient, by themselves, to modulate the duration, intensity, and timing of the phrenic discharge during the first loaded breath.

Afferent Pathways↗

[Criteria for quantitative assessment of respiratory system reactions].

In anesthetized cats and in healthy humans, lung ventilation, activity of diaphragmal motoneurons and intercostal muscles, shift of the intrathoracic pressure, inspiratory occlusional pressure, and maximal rate of the initial increase in inspiratory pressure, were studied. Depending on conditions of the respiratory system functioning, any one from among the above parameters can reflect the efferent output of the respiratory center. Each of them, however, has limitations of its own.

Animals↗

Intercostal expiratory activity in an in vitro brainstem-spinal cord-rib preparation from the neonatal rat.

1. We examined whether expiratory activity can be observed when central chemoreceptors are activated by a decrement in the extracellular pH in an isolated brainstem-spinal cord-rib preparation from 0- to 3-day-old rats. Expiratory activity was defined as the burst activity that occurs in an internal intercostal muscle (IIM) during the silent period between the periodic inspiratory bursts in the C4 ventral root (which contains phrenic motor axons). 2. During perfusion with modified Krebs solution (26 mM HCO3-, 5 % CO2, pH 7.4), there was no consistent activity in IIM, though rhythmic inspiratory motor activity always appeared in the C4 ventral root. 3. When the pH of the perfusate was lowered from about 7.4 to 7.1 by reducing [HCO3-] from 26 to 10 mM, the frequency of the C4 inspiratory rhythm increased, and rhythmic activity appeared in IIM. In most cases, the rhythmic burst in IIM started just after the cessation of the C4 inspiratory burst and coincided with movement of the ribs in a caudal direction. This intercostal expiratory burst was limited to the first half of the expiratory phase. 4. The coordinated reciprocal motor activity between the C4 ventral root and IIM changed to a largely overlapping pattern when strychnine (5-10 microM), a glycine receptor antagonist, was added to the perfusate. 5. These results suggest (i) that the neuronal mechanisms responsible for expiratory motor activity are preserved in this in vitro preparation and (ii) that the glycinergic inhibitory system plays an important role in the coordination between inspiratory and expiratory motor activity during respiration.

Animals↗

Propriospinal myoclonus: a neurophysiologic analysis.

We are reporting a neurophysiologic analysis of two patients presenting with thoracoabdominal spontaneous muscle jerks. Polymyographic recordings showed myoclonic bursts with onset in the upper rectus abdominis or lower intercostal muscles followed by rostral propagation to the upper intercostal and caudal propagation to the abdominal muscles by slowly conducting pathways. Jerk-locked back-averaging did not show time-locked cortical or premovement potentials. Peroneal somatosensory evoked response, C-reflex, and intercostal nerve conduction were normal. These findings suggest a generator for the myoclonus in the midthoracic region of the spinal cord with up and down propagation by slowly conducting pathways, such as propriospinal fibers. This type of spinal myoclonus may thus be termed "propriospinal myoclonus," as suggested by Brown et al.

Aged↗

Pulmonary sympathetic denervation does not increase airway resistance in patients with chronic obstructive pulmonary disease (COPD).

Whether or not neural blockade of pulmonary sympathetic innervation is of relevance for airway resistance in patients with chronic obstructive pulmonary disease (COPD) is unknown. Accordingly we evaluated airway resistance during sympathetic blockade by high thoracic epidural anaesthesia in patients with COPD. Before and 45 min after thoracic epidural injection of bupivacaine 0.75% (6-8 ml; n = 10) total respiratory resistance (oscillometry, ROS), vital capacity (VC), forced expiratory vital capacity in 1 s (FEV1, [%VC]), functional residual capacity (FRC; helium dilution method), and arterial blood gases were measured. Three additional patients received bupivacaine intravenously (1.2 mg.min-1 for 45 min), another three received saline epidurally. Sensory blockade covered segment C5 through T8. As an indicator of widespread sympathetic blockade including the lungs, skin temperature increased significantly on thumb and little toe. Despite pulmonary sympathetic denervation ROS, FEV1, and FRC remained unchanged, while VC decreased slightly, probably due to intercostal muscle blockade. Blood gases remained constant. Neither intravenous bupivacaine nor epidural saline evoked directional changes. Since, in contrast to beta-adrenoceptor blockade, pulmonary sympathetic denervation did not increase airway resistance in patients with COPD, neural sympathetic blockade seems to be of no relevance for airway resistance in these patients.

Airway Resistance↗

The synaptic connexions to intercostal motoneurones as revealed by the average common excitation potential.

1. The hypothesis is advanced that the joint occurrence of unitary e.p.s.p.s evoked in motoneurones by branches of common stem presynaptic fibres causes, on average, transient depolarization in one motoneurone at the time of discharge in another motoneurone of the same pool. 2. The hypothesis was tested in anaesthetized, paralysed cats by averaging the naturally occurring synpatic noise of thoracic inspiratory motoneurones with an averager triggered by spikes from other inspiratory motoneurones. These spikes were obtained as efferent discharges in nerve filaments supplying the proximal regions of the external intercostal muscles. 3. A transient depolarization centred around the time of the trigger spikes was consistently observed and was designated the average common excitation (a.c.e.) potential. 4. The peak depolarization lay between -1.0 and +4.6 msec (mean +0.7 msec) with respect to the trigger spikes and the rise times of its most prominent component ranged from 4 to 16 msec (mean 8.4 msec). 5. The amplitudes of the a.c.e. potentials ranged from 6 to 104 muV (mean 32 muV) when the trigger spikes were derived from a filament in the same segment as the relevant motoneurones, and from 3 to 42 muV (mean 19 muV) when the filament was two segments rostral to the motoneurone. 6. Cells innervating the proximal region of the intercostal space gave larger a.c.e. potentials than those innervating more distal regions and also showed larger central respiratory drive potentials. 7. A.c.e. potentials were observed for either alpha or gamma spikes as triggers. The potentials were usually smaller for the gamma than for the alpha spikes, the mean ration being about 0.6. The presence of the a.c.e. potentials from the gamma spikes was taken as evidence for alpha-gamma coactivation by common presynaptic axons. 8. A theory is developed which quantitatively accounts for the main features of both the a.c.e. potential and the short term synchrony observed by Sears & Stagg (1976). 9. The theory includes the proposition that the raised probability of firing of a motoneurone due to a unitary e.p.s.p. has a time course which may be described by the sum of the e.p.s.p. time course and its time differential. Thus, via the measurements, the theory predicts at least to a first approximation the expected probability of firing due to e.p.s.p.s of various shapes and sizes.

Action Potentials↗

Evaluation of thoracic myelopathy by transcranial magnetic stimulation.

It is sometimes difficult to determine the appropriate surgical site in patients with thoracic myelopathy with diffuse or multisegmental lesions. To solve this problem, a magnetic stimulation study was carried out. Seven patients with myelopathy and 10 healthy control subjects were examined. Transcranial magnetic stimulation was applied and the motor evoked potentials (MEPs) of the intercostal muscles were recorded. The MEP latencies for the two groups were then compared. In patients with thoracic myelopathy, the MEP latencies caudal to the lesion were more extended than those of the control subjects. This method could identify the levels at which myelopathy originates in patients with a radiologically visible lesion. This method has the potential to be used for deciding the surgical site at the level responsible for myelopathy in cases with multiple or diffused compression.

Adult↗

Internal mammary artery use. Sternal revascularization and experimental infection patterns.

We have described previously the acute sternal devascularization produced by mobilization of one or both internal mammary arteries (IMAs). The present experiments were conducted to examine the time course of sternal revascularization and infection patterns after IMA use. Twenty-four 8-week-old domestic pigs were obtained from a herd in which active Streptococcus faecalis had been detected in recent litters. After control blood flow procedures (microspheres) were completed, each pig underwent a median sternotomy; one or both IMAs were mobilized as a pedicle, and the sternotomy was repaired. Repeat blood flow determinations were made in half the pigs at 1 week and in the remainder after 2 weeks. The pigs were killed, the wound was examined, cultures were taken as indicated, and tissue was harvested for blood flow analysis. Despite the retention of an intact IMA on the contralateral side, persistent, significant sternal ischemia existed 2 weeks after repair. However, when both IMAs were used, the extent of devascularization was exaggerated, and revascularization was impaired further. Revascularization of intercostal muscle occurred more rapidly and was essentially returned to normal 2 weeks after sternotomy and IMA harvest. Active mediastinitis with erosion of the sternum was found in one (17%) of six pigs at 1 week and in four (67%) of six pigs at 2 weeks when the IMAs had been rotated bilaterally. No wound infections were detected in the single IMA resection group. These data suggest that bilateral IMA mobilization may delay an already slow revascularization process and predispose to infectious complications.

Animals↗

[Mechanism of the fast neurogenic component of the respiratory response to muscular work].

Dynamics of pulmonary ventilation, electric activity of the intercostal muscles and of the alveolar gas composition was studied in 12 healthy men during dosaged muscular work; these men were given different gas mixtures to breathe. The respiratory response at the initial period of work in inhalation of the hypoxic-hypercapnic gas mixture was greater than that in persons who breathed room air. This response practically disappeared after oxygen hyperventilation. Apparently the rapid component of the ventilation response to the muscular work was largely due to increased sensitivity of the respiratory centre to the chemoreceptive drive.

Adult↗

The slow channel syndrome. Two new cases.

Two patients are described with a myasthenic syndrome that presented in early adult life. One patient had 2 asymptomatic first degree relatives with similar electrophysiological findings. Both patients had abnormal fatiguability, arm weakness being prominent; neither of them responded to anticholinesterase medication. An abnormal decrement at 3 Hz stimulation was present, and a single stimulus evoked a repetitive response. Electrophysiological studies on biopsied intercostal muscle showed miniature endplate potentials of normal amplitudes but with prolonged rise and decay times. Anticholinesterase staining (Case 1) was not reduced, and showed elongation of some endplates. Ultrastructural studies (Case 2) showed degeneration of junctional folds and diffusely thickened endplate basal lamina. Calcium deposits were not observed and myopathic changes were slight. The findings are consistent with a prolonged open time of the ACh-induced ion channel.

Acetylcholinesterase↗

Short-term synchronization of intercostal motoneurone activity.

1. The hypothesis is advanced that the joint occurrence of unitary excitatory post-synaptic potentials e.p.s.p.s) evoked in motoneurones by branches of common stem pre-synaptic fibres causes short-term synchronization of their discharge during the rising phases of the unitary e.p.s.p.s. 2. This hypothesis was tested using the pre- and post-stimulus time (PPST) histogram to detect synchronized firing among groups of intercostal motoneurones discharging in response to their natural synaptic drives. 3. Motor nerve action potentials were recorded monophasically from nerve filaments of the external intercostal muscles of anaesthetized, paralysed cats maintained on artificial ventilation. 4. Computer methods were used to measure peak spike amplitude, spike amplitude, spike interval and filament identification for simultaneous recordings from four filaments. The spike amplitude histograms were derived for each filament and groups of spikes were selected for analysis. 5. With spikes of one group designated as 'stimuli' (occurring at zero time) and those of a second as 'response' the PPST histogram was computed with different time bin widths. 6. With bin widths of 100 and 10 msec the central respiratory periodicity was apparent in the PPST histogram. With 1.0 msec bins the PPST histogram showed a narrow central peak extending to +/- 3.0 msec at its base. This 'short-term synchronization' supports the hypothesis of joint firing due to common presynaptic connectivity. 7. It was shown that detection of short-term synchronization was critically dependent on a sufficient quantity of data but that provided a simple criterion of adequate counts per bin in the PPST histogram was met, short-term synchronization could be detected between intercostal motoneurones of the same and adjacent segments.

Action Potentials↗

Rnx deficiency results in congenital central hypoventilation.

The genes Tlx1 (Hox11), Enx (Hox11L2, Tlx-2) and Rnx (Hox11L2, Tlx-3) constitute a family of orphan homeobox genes. In situ hybridization has revealed considerable overlap in their expression within the nervous system, but Rnx is singularly expressed in the developing dorsal and ventral region of the medulla oblongata. Tlx1-deficient and Enx-deficient mice display phenotypes in tissues where the mutated gene is singularly expressed, resulting in asplenogenesis and hyperganglionic megacolon, respectively. To determine the developmental role of Rnx, we disrupted the locus in mouse embryonic stem (ES) cells. Rnx deficient mice developed to term, but all died within 24 hours after birth from a central respiratory failure. The electromyographic activity of intercostal muscles coupled with the C4 ventral root activity assessed in a medulla-spinal cord preparation revealed a high respiratory rate with short inspiratory duration and frequent apnea. Furthermore, a coordinate pattern existed between the abnormal activity of inspiratory neurons in the ventrolateral medulla and C4 motorneuron output, indicating a central respiratory defect in Rnx mice. Thus, Rnx is critical for the development of the ventral medullary respiratory centre and its deficiency results in a syndrome resembling congenital central hypoventilation.

Abnormalities, Multiple↗

Effects of hypercapnia on tracheal pressure, diaphragm and intercostal electromyograms in unanaesthetized fetal lambs.

1. The electromyographic (e.m.g.) activity of the diaphragm and intercostal muscles has been recorded during breathing movements of unanaesthetized lambs in utero (109-135 days), and compared with the changes of tracheal pressure.2. The diaphragm e.m.g. was irregular in size, shape and timing, with a variable rate of rise during inspiration, often with a flattening of integrated activity before the end of a breath and with little or no post-inspiratory activity.3. The diaphragm e.m.g. gave the most reliable measurements of breath interval and incidence: in eucapnia mean T(I) was 0.45+/-0.02 (S.E. of mean) and T(E) was 0.74+/-0.05 sec, and 58-100% of the diaphragm bursts were associated with identifiable and appropriate changes of tracheal pressure.4. During fetal hypercapnia, produced by increasing the maternal inspired CO(2) in a single change or series of step changes, tracheal pressure amplitude and its rate of change during inspiration increased progressively over the P(a, CO2) range of 37-87 mmHg.5. In eucapnia the area, amplitude and inspiratory slope of the integrated diaphragm e.m.g. were not always correlated with tracheal pressure amplitude, and in hypercapnia they increased only in the lower part of the P(a, CO2) range. Inspiratory intercostal activity increased progressively as the P(a, CO2) was raised.6. The frequency histograms of variables derived from the tracheal pressure, diaphragm and intercostal e.m.g.s were skewed to the left in eucapnia but became normalized during hypercapnia. The rate and depth of breathing became regular.7. The response to mild asphyxia was a combination of the responses to hypercapnia and hypoxia.8. The interpretation of the tracheal pressure and diaphragm e.m.g. as measures of the ;depth' of breathing and respiratory ;drive' in the fetal lamb is discussed.

Animals↗

The dynamic sodium current of human skeletal muscle.

The dynamic sodium current (INa) was investigated in intact external intercostal muscle bundles dissected from 5 volunteers. Only fibres with a resting membrane potential negative to -80 mV were used. Stepwise changes were imposed on the membrane potential using the "loose-patch" clamp technique. The following results concerning INa are means +/- SD obtained from 27 fibres: threshold at -42.7 +/- 5.2 mV; maximal amplitude of 9.7 +/- 7.8 mA/cm2 at -1 +/- 13 mV. Inactivation: starting from the resting potential, maximally 90% of INa max could be activated; 50% of INa max were inactivated at Eh = -66.2 +/- 5.8 mV; the slope of the inactivation (h infinity -) curve at this potential was kh = 7.1 +/- 1.6 mV.

Action Potentials↗

Evaluation of intercostal cryoanalgesia versus conventional analgesia in postthoracotomy pain.

The objective of the study was to evaluate the effects of cryoanalgesia in patients undergoing posterolateral thoracotomy. A double-blind randomized and prospective study was performed in 100 patients undergoing thoracotomy. They were randomized into two groups: Group A, 55 patients, who had undergone an intercostal cryoanalgesia and group B, control, 45 patients treated only with pharmacological analgesia ad libitum. In both groups we assessed pain in the first 7 postsurgical days, the amount of analgesia required, electromyography of the intercostal muscles involved and recording of maximal static respiratory pressures. Postsurgical pain was significantly lower (p < 0.001) in group A. No patient in group A needed major analgesia and the amount of aminopyrines required was significantly lower (p < 0.001) than those used in group B. Maximal static inspiratory pressure (PImax) showed no significant changes and no significant differences were found between the two groups. Maximal static expiratory pressure (PEmax) significantly decreased (p < 0.001) in the 1st and 2nd week and it was not related to the type of analgesia used. We advocate the use of cryoanalgesia since it significantly reduces pain as well as the doses of analgesia.

Adult↗