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Combined median and medial antebrachial cutaneous neuropathies: an upper-arm neurovascular syndrome.

The neurovascular bundle anatomy in the upper arm displays changing relationships of nerve and vascular structures along short segments. Fibrous tissues segregate these elements into enclosed compartments allowing for specific patterns of injury. We report a patient with a iatrogenic brachial artery injury in this region who featured combined median and MAC neuropathies, which were consistent with complete axonotmesis on neurophysiological assessment. Increased intracompartmental pressure may have led to nerve injury either thorough an ischemic mechanism or to focal compression. Recognition of this unusual pattern of nerve damage is important, since injury can be accurately localized to the midportion of the neurovascular compartment in the upper arm.

Aged↗

Necrobiotic xanthogranuloma with IgA paraproteinemia and extracutaneous involvement.

Numerous nodular xanthomatous lesions arose, gradually increasing in number on the back, chest, lips, tongue, and exposed "V" area of the chest on a 78-year-old man. Painful oral nodules and hoarseness developed subsequently. Histologic examination of the skin revealed a suppurative and granulomatous inflammation with an accumulation of acute polymorphonuclear neutrophils, nuclear dust, and xanthomatous histiocytes. Giant cells were rare and cholesterol clefts were absent. Biopsy of the oral mucosa and the larynx showed a similar process. Direct immunofluorescence was positive for vascular immune reactants at the basement membrane and fibrin in between collagen bundles. The patient had a serum IgA level of 432 mg/dl (normal level, up to 380), with normal IgG and IgM serum concentrations. A Raji cell assay was 240 micrograms/AHGEQ/ml (normal less than 5). CH-50 was decreased and C2, C4, and C3 were within normal limits. The dermatopathology was initially thought to be consistent with erythema elevatum diutinum, and the patient was treated with dapsone and prednisone, with a marginal response. There were no dermatopathologic findings of vasculitis. On review, the patient's dermatopathology was more consistent with necrobiotic xanthogranuloma (NXG). To our knowledge, this is the first report of an association of NXG with an IgA gammopathy and the second reported case of extracutaneous involvement with NXG.

Aged↗

The pedicle latissimus dorsi transfer for reconstruction of the plexus brachialis and brachium.

To reconstruct the area from the brachial plexus to the upper arm, pedicle latissimus dorsi muscle transfer was performed in 16 patients. Nine patients underwent functional bipolar transfer for reconstruction of elbow flexion. The surgical results were satisfactory in 6 patients, but were unsatisfactory in 3 because of an incorrect preoperative assessment of the strength of the latissimus dorsi muscle and an unsuitable length of transferred muscle in 2 patients, and because of progression of spastic paralysis caused by cervical myelopathy in the third patient. Seven patients with skin loss and an unstable scar underwent aesthetic unipolar transfer in which the exposed nerve, neurovascular bundle, bone, and joint were covered by a musculocutaneous flap with good vascularity. The surgical results were successful in all 7 patients. Infection was present before transfer in 4 of the 16 patients, but it was successfully treated by simultaneous radical debridement of the infected wound and latissimus dorsi transfer.

Adolescent↗

The repair of eyelid defect with free hard palate mucosal autograft.

OBJECTIVE: To investigate the free hard palate mucosal autograft as a new replacement in eyelid reconstruction. METHODS: (1) Animal experiment, 12 eyelid defects from 3 dogs were repaired with hard palate mucosal autograft, and after operation they had excellent eyelid appearance. The findings of pathological examination, the morphology and thickness of epithelium are the same as its original. The cells and vascularization in the connective tissue are normal. The arrangement of collagen fiber bundles is regular. (2) Clinical practice, 15 eyelid defects from 13 eyes included 3 upper eyelids, 8 lower eyelids and 2 of both upper and lower eyelids. 5 cases were of malignant tumor and 8 cases of trauma. 6 eyelids were of total defect, 4 eyelids of two-third defect and 5 eyelids of a half to one-third defect. The ages ranged from 22 to 79 years old. We used the intermediate split thickness of hard palate mucosal autograft to do the eyelid reconstruction. All the cases were followed for an average of 11.3 months after the reconstruction. RESULTS: 8 eyelid defects were cured, 3 were improved significantly and 4 improved. No severe complications were found. CONCLUSION: The hard palate mucosal autograft acts not only as a palpebral supporting tissue but also forms palpebral conjunctiva.

Adult↗

A comparative study on the innervation and the vascularization of the bulbus arteriosus in teleost fish.

The structure of the bulbus arteriosus of a wide range of teleost fish is described with particular reference to the vascularization and innervation. The adventitia of the organ consists of blood vessels and large nerve bundles in a collagen matrix. The nerve bundles contain monoamines, and fluorescence studies show small terminal bundles penetrating the muscular media; this is confirmed by electron microscopy. The media consists of an extensive elastic tissue matrix with a spiral arrangement of smooth muscle cells joined end to end by desmosomes and presumed electronic junctions. The muscles cells are innervated only at the adventitia/media boundary and the significance of this innervation is discussed. It is proposed that there is a correlation between the degree of vascularization and innervation and the activity of a particular species of fish.

Animals↗

cGMP-generating cells in the bladder wall: identification of distinct networks of interstitial cells.

OBJECTIVE: To identify cells which might contribute to the complex physiological responses of the guinea-pig bladder, and specifically to describe the distribution and types of cell in the bladder wall of the guinea pig which respond to nitric oxide (NO) with an increase in intracellular cGMP, i.e. putative interstitial cells (ICs). MATERIALS AND METHODS: The whole bladder was removed from 11 male guinea pigs killed by cervical dislocation. Sections of the bladder wall, from the dome lateral wall and base, were isolated and incubated separately in Krebs' solution at 36 degrees C, gassed with 95% O(2) and 5% CO(2), and containing 1 mmol/L of the nonspecific phosphodiesterase inhibitor isobutyl-methyl-xanthene. Individual pieces of tissue were then exposed to 100 micromol/L of the NO donor NONOate for 10 min; control tissues remained in Krebs' solution. Tissues were then fixed in 4% paraformaldehyde and processed for immunohistochemistry. cGMP and neuronal NO synthase (nNOS) were subsequently visualized using appropriate primary and secondary antibodies. RESULTS: Cells responding to NO with an increase in cGMP were detected in the dome, lateral wall and base, with positive cells in the thin outer surface of the wall (muscle coat), associated with muscle bundles in an outer layer of muscle, and in a region immediately beneath the urothelium. These cells (not urothelium, smooth muscle or vascular) are described as interstitial cells. Superficial urothelial umbrella cells were apparent and were strongly cGMP-positive. A high density of interstitial cells was associated with muscle bundles on the outer aspects of the wall, while few cells were detected on inner bundles. Thus there appeared to be two distinct types of muscle, inner and outer, with no obvious orientation of the fibres in each layer. Both muscle groups contained fibres expressing nNOS. In the outer muscle layer most of these fibres co-localized with cGMP, suggesting that different populations of nerves innervate each layer. There were more nNOS-positive fibres in the base of the bladder than in the dome. Three populations of cGMP-positive interstitial cells were associated with the outer muscle layer; cells in the outer surface (muscle coat interstitial cells, MC-ICs), cells on the surface of the bundles (superficial, SM-ICs) and cells within the muscle bundles (intramuscular, IM-ICs). The IM-ICs form a network in close apposition to the smooth muscle cells while the SM-ICs may connect adjacent muscle bundles and connect to the MC-ICs. Thus, there is a network linking potentially the muscle cells in the outer muscle bundles. cGMP-positive cells were also detected in the suburothelial layer (suburothelial, SU-ICs) which had a different structure to the cells associated with muscle, had a oval cell bodies with bifurcating processes and appeared to form a complex network; they were prevalent in the base and virtually absent in the dome. CONCLUSIONS: There are structures within the bladder wall that can be identified and categorized by the ability of the constituent cells to increase intracellular cGMP in response to NO; these cells have been defined as ICs. Two distinct networks were identified, one associated with the outer muscle layers and another lying immediately beneath the urothelium, predominantly in the base of the bladder. The functions of these cells and networks are unknown; their possible roles in complex motor activity, urothelial signalling and bladder pathophysiology are discussed.

Animals↗

The anatomy of the pulmonary vascular bed in the toad Bufo marinus.

1. The pulmonary vascular anatomy of the toad, Bufo marinus was studied by scanning electron microscopy of vascular corrosion casts and of tissues prepared for light microscopy. 2. The lung is divided by septa into three orders of alveoli. Arterial branches run in the septa and cannot be observed directly through the lung surface. 3. The capillary bed forms a meshwork over the lumenal surface of septa and lung walls. It is divided into longitudinal zones of arterial distribution; it is broken along primary septal margins into primary alveolar units; within alveoli, it is functionally divided by distortion over circum-alveolar smooth muscle bundles. 4. The capillaries form a network of tubes rather than a perforated sheet of vascular space. Capillary beds on either face of septa are interconnected through the septum. 5. There is no evidence of collateral ("bronchial") vessels or of anatomically definable shunt vessels. 6. Intrinsic pulmonary arterial branches have a muscular coat.

Animals↗

Feasibility study for robotic radical prostatectomy cautery-free neurovascular bundle preservation.

INTRODUCTION: Efforts continue to develop techniques that maintain the neurovascular bundles and minimize trauma for robotic laparoscopic radical prostatectomy. We evaluated the feasibility of preserving the nerve bundles without cautery or surgical clips. TECHNICAL CONSIDERATIONS: The seminal vesicles were dissected using scissors and bipolar cautery. After the rectum was mobilized, the vascular pedicles (VPs) were delineated. Laparoscopic bulldog clamps (30 mm) were placed at least 1 cm from the prostate. Using scissors, the VPs were divided right at the prostate. The neurovascular bundle was gently dissected off the prostatic capsule. After mobilizing the bundle, FloSeal was applied along its entire length. The FloSeal was then covered with a dry 1 x 4-cm sheet of Gelfoam. Once the prostate was removed, the bulldog clamps were sequentially withdrawn. The VPs were observed, and, if pulsatile bleeding was encountered, a 3-0 figure-of-eight suture was precisely placed for hemostasis. When hemostasis was complete, the anastomosis was performed. RESULTS: In 17 men, temporary vascular occlusion was applied to 27 VPs and FloSeal and Gelfoam was applied each time. In 4 cases (15%), hemostasis was inadequate because of continued arterial bleeding that was easily controlled with a superficial figure-of-eight ligature of 3.0 absorbable suture. The average estimated blood loss was 91 mL (range 75 to 150). CONCLUSIONS: Cautery-free, clip-free, nerve-sparing robotic laparoscopic radical prostatectomy is feasible using a combination of temporary occlusion of the thick posterior prostatic pedicles with bulldog clamps followed by application of FloSeal. The effect on potency needs further follow-up.

Adult↗

Monobloc resection of the upper extremity of the leg for bone tumor with distal vascular reconstruction.

A patient with juxtacortical osteosarcoma of the upper extremity of the left tibia which encased the popliteal neurovascular bundle was treated by monobloc resection of the superior extremity of the tibia and the tibial nerve. The knee joint was replaced by a Guepar prosthetic knee. Arterial and venous continuity was reestablished by a double bypass using the contralateral greater saphenous vein. One year later the patient had good lower limb function and was free of local or general disease. This observation confirms that preservation of lower limb function is possible using reconstruction techniques of bone, nerves, and vessels in sarcoma of the musculoskeletal system.

Adult↗

Neuropeptide Y- and substance P-like immunoreactive nerve fibers in the rat dura mater encephali.

Density and pattern of nerve fibers with neuropeptide Y-like immunoreactivity (NPY-LI) and substance P-like immunoreactivity (SP-LI) in the rat dura mater encephali were investigated by light and electron microscopy using whole-mount preparations. NPY-LI fibers are observed throughout the encephalic dura mater. A remarkable net of NPY-LI nerve fibers is located in the walls of the sagittal and transverse sinuses. Beyond that NPY-LI network, distinct NPY-LI nerve fibers or plexus occur in the rostral falx, parietal dura mater of the olfactory bulb, supratentorial dura mater, parietal dura mater of the cerebellum, tentorium cerebelli and the ventral dura mater. Electron microscopic studies reveal that NPY-LI is exclusively located in unmyelinated axons of small and large nerve fiber bundles, with or without a perineural sheath. Immunopositive C-fibers are predominantly associated with the vascular bed. SP-LI nerve fibers have a moderate and more uniform distribution in the encephalic dura mater. A distinct plexus of SP-LI fibers follows the branches of the middle meningeal artery and the adjacent dura mater. SP-LI fibers are most prominent in the parietal dura mater of the cerebellum. Fine beaded SP-LI fibers, arising from larger SP-LI fiber bundles, are observed in close association to the capillary bed. SP-LI axons are all unmyelinated. They are found in larger nerve fiber bundles with a perineural sheath or in Schwann cells lacking any perineural sheath. The function of NPY-LI and SP-LI nerve fibers in the rat dura mater is discussed in relation to their topography, density and termination.

Animals↗

Morphological variability of the human inferior alveolar nerve.

The aims of this study were: to compare the radiographic appearance of the neurovascular bundle and its surrounding bone with the actual situation revealed on dissection; to reveal the morphology of the neurovascular bundle in dentate and edentulous subjects; and to note any changes occurring following the removal of the teeth and the consequent resorption of alveolar bone. Twenty-nine human mandibles were examined; 20 were dry skeletal specimens that were examined radiographically and the remaining nine were radiographed then dissected after decalcification and the branches of the inferior alveolar nerve were identified, sketched, and photographed. Different patterns of identifying characteristics of the mandibular canal were noted on the radiographs, ranging from alternating bands of radiopacity and radiolucency to continuous radiopaque lines. Dissections indicated that the radiographic appearance related to the number, distribution, and pattern of trabeculae around the canal. The dissections revealed that in all cases, the main nerve divided into its incisive and mental branches in the molar area well before reaching the mental foramen. A branch to the molar teeth, and in two instances to the second premolar as well, was given off from the main trunk before it divided into incisive and mental branches. In the dentate specimens, the neurovascular bundle formed two distinct curvatures, one between the mandibular and mental foraminae and the other between the mental foramen and the incisor teeth apices. In the edentulous specimens, the neurovascular bundle was reduced in size and although some small nerve branches, notably to the molar areas, were distinguishable, the blood vessels seemed to have atrophied beyond macroscopic identification. This project confirmed the inaccuracy of descriptions repeated in many anatomical textbooks suggesting that the inferior alveolar branch of the trigeminal nerve divides at the mental foramen into its incisive and mental branches and that during their path through the body of the mandible they give off fibers to the individual teeth. It further confirmed that the neurovascular bundle reduces in size quite markedly after removal of teeth and that the vascular component cannot be clearly identified.

Aged↗

Fibronectin distribution in epithelial and associated tissues of the rat.

Specific antiserum was used to investigate the distribution of the extracellular glycoprotein, fibronectin, in rat skin and tongue tissue by light and electron microscopy with immunofluorescence and immunoperoxidase techniques. We conclude that fibronectin is absent from stable, differentiated parts of tissues, such as the sebaceous glands or the matrix, medulla, cortex, and cuticles of the hair and the inner and outer root sheaths, or even in tissues in which there is some cell movement, such as the epidermis. It is, however, characteristic of sites at which cell division is occurring in contact with an extracellular scaffolding, such as basement membrane or loose connective tissue. Conspicuous examples were in the glassy membrane and connective tissue sheath associated with the follicular epithelium, the basement membrane underlying vascular endothelial cells, the connective tissues surrounding and investing nerve and muscle fibre bundles, and the dermal connective tissue where fibronectin was often associated closely with collagen fibres. At the basement membrane of the dermal/epidermal junction, fibronectin occurred at the plasma membrane of the basal cells and in the lamina lucida area. There was no correlation with specific areas of cell-substrate adhesion, such as the hemidesmosomes. The endoplasmic reticulum of fibroblasts stained strongly suggesting that these cells represent a major site of synthesis.

Animals↗

The dorsomedial hypothalamic nucleus in autonomic and neuroendocrine homeostasis.

Median eminence and ventromedial hypothalamus have in the past been the principal foci of research in neuroendocrine and neurovisceral control mechanisms. The present report provides an overview of work involving the dorsomedial hypothalamic nucleus (DMV). This structure is located dorsal to the ventromedial hypothalamic nucleus (VMN) to the plane of the dorsal premammillary nucleus. Fibers from the DMN pass with the periventricular system and the dorsal longitudinal fasciculus of Schütz and have been traced to the midbrain tegmentum and reticular formation. Intrahypothalamic connections involve intensive networks between DMN, lateral hypothalamic nucleus (LHN) and VMN. Regarding neurotransmitters, recent studies indicate that the DMN receives noradrenergic innervation along two pathways, a dorsal and a ventral one. Monoamine-containing systems approach the DMN From the lateral hypothalamus and the bulk of these fibers are carried in the medium forebrain bundle from their cells of origin in the brain stem. Studies of the vascular supply indicate that both VMN and DMN receive their blood supply from the internal carotid artery...

Animals↗

Trauma-induced simulator of targetoid hemosiderotic hemangioma.

Reported here is a 15-year-old with lesions demonstrating histologic features of targetoid hemosiderotic hemangioma (THH) developing after trauma to inflammatory lesions. These lesions pose as simulators of THH. Targetoid hemosiderotic hemangioma is a benign vascular lesion first described by Santa Cruz and Aaronburg. It classically presents as a single, small, red/brown, targetoid lesion on the trunk or extremities of a young or middle-aged individual. Histologically, it is characterized by ectatic vascular lumina in the papillary dermis lined by a single layer of endothelial cells with an epithelioid or "hobnail" appearance. In the deeper dermis, vascular spaces become slit-like and angulated, appearing to dissect through collagen bundles. A commonly proposed etiology of THH is trauma to a preexisting hemangioma. This case is remarkable for its unusual clinical presentation, histologic simulation of THH, and for its support for the theory that trauma can induce the histologic changes seen in THH.

Adolescent↗

Urticarial vasculitis with papular lesions in a patient with type C hepatitis and cryoglobulinemia.

We describe a case of urticarial vasculitis accompanied by erythematous wheals, palpable pupura, and subsequent necrotic ulcerated papular lesions in a patient with type C chronic hepatitis and type II cryoglobulinemia (IgM-kappa and polyclonal IgG). A 56-year-old man developed recurrent urticarial lesions on his lower extremities and trunk. The histology revealed leukocytoclastic vasculitis with perivascular immunoglobulin deposits. Subsequently, multiple reddish papular lesions with necrotic ulcerations appeared on the extensor aspect of his extremities and buttocks. Histology of these lesions showed cryoglobulinemic vasculitis with prominent fibrinoid necrosis of the vascular walls and cryoprecipitate within the vasculature as well as increased hyalinized collagen bundles. These papular lesions have not previously been described as cutaneous necrotizing venulitis to the best of our knowledge. It is suggested that the immune response to hepatitis C virus infection and cryoglobulins may be responsible for severe necrotizing venulitis, resulting in unusual cutaneous lesions.

Chronic Disease↗

The autonomous innervation of the buffalo (Bubalus bubalis) testis. An immunohistochemical study.

The innervation pattern in the buffalo testis was determined by using histochemical and immunohistochemical methods. Nerves were concentrated in the tunica albuginea and septula testis, and did not show an uniform distribution. The tunica albuginea at the lateral and medial sides and at the free border of the testis is most densely innervated than at the epididymal border. At the cranial pole thick nerve bundles were observed between albugineal vessels and muscle bundles. Rare parenchymal nerves were found in perivascular position between seminiferous tubules and their occurrence is confined to lobules at the cranial and caudal testicular poles. An intense NPY immunoreactivity occurred in nerve bundles and in solitary varicose fibres. Nerves were concentrated in the tunica albuginea at the lateral and medial side and at the free border of the testis, and in the lobules at the cranial and caudal testicular poles. Sub P immunoreactivity was occasionally detected in some thicker nerve bundles and solitary fibers, in the tunica albuginea and in the wall of blood vessels, showing a similar distribution but less intensity and density than NPY immunoreactivity. TH immunoreactivity stained nerve fibers in the buffalo testis with a distribution pattern similar to that obtained with general neuronal markers. The histochemical reaction for AchE was negative, so cholinergic fibers cannot be detected in the buffalo testis. The histochemical NADPHd reaction stained rare nitrergic nerve bundles and solitary fibers. The majority of NADPHd activity was confined to the vascular endothelium, and rarely to the interstitial Leydig cells, whereas the Sertoli and germ cells did not show any reaction.

Acetylcholinesterase↗

[Clinico-pathological evaluation of keloids treated with intralesional injections of corticoid].

37 keloid patients were treated with triamcinolone intralesionally every 15 days, in all 6 inoculations. Histologically after the treatment we observed alterations in dermal vascularization, in morphology, in color characteristics and in the arrangement of the collagen bundles. The disappearance of mucin and the presence of palisade granulomas was observed in some cases probably because of the corticoid deposited. There was regression of pruritus and pain in all the patients. We believe that the intralesionally infiltration of corticoid is even today one of the best methods of treatment, and it may also be effected together with other technics.

Adolescent↗

[Ostium secundum atrial septal defect: report of a case with atypical auscultatory findings (author's transl)].

The wide and persistent splitting of S2 is commonly considered the auscultatory hallmark of uncomplicated ostium secundum atrial septal defect (ASD). We have recently observed a 31-year-old female with a variable splitting of S2 and a 2/6 systolic murmur at the second left intercostal space, who showed incomplete right bundle branch block on the ECG and normal heart shadow with increased pulmonary vascular markings on the chest film. Cardiac catheterization revealed an isolated ostium secundum atrial septal defect with significant left-to-right shunt, normal pulmonary pressures and normal ventricular function. Subsequently the patient underwent closure with patch of the ASD without complications. We feel our case is of interest since it demonstrates that the absence of a wide and persistent splitting of S2 in adults does not exclude the diagnosis of uncomplicated "ostium secundum" ASD, when ECG and x-ray findings suggest the disease.

Adult↗