GelMA-Encapsulated hDPSCs and HUVECs for Dental Pulp Regeneration

Pulpal revascularization is commonly used in the dental clinic to obtain apical closure of immature permanent teeth with thin dentinal walls. Although sometimes successful, stimulating bleeding from the periapical area of the tooth can be challenging and in turn may deleteriously affect tooth root maturation. Our objective here was to define reliable methods to regenerate pulp-like tissues in tooth root segments (RSs). G1 RSs were injected with human dental pulp stem cells (hDPSCs) and human umbilical vein endothelial cells (HUVECs) encapsulated in 5% gelatin methacrylate (GelMA) hydrogel. G2 RSs injected with acellular GelMA alone, and G3 empty RSs were used as controls. White mineral trioxide aggregate was used to seal one end of the tooth root segment, while the other was left open. Samples were cultured in vitro in osteogenic media (OM) for 13 d and then implanted subcutaneously in nude rats for 4 and 8 wk. At least 5 sample replicates were used for each experimental group. Analyses of harvested samples found that robust pulp-like tissues formed in G1, GelMA encapsulated hDPSC/HUVEC-filled RSs, and less cellularized host cell-derived pulp-like tissue was observed in the G2 acellular GelMA and G3 empty RS groups. Of importance, only the G1, hDPSC/HUVEC-encapsulated GelMA constructs formed pulp cells that attached to the inner dentin surface of the RS and infiltrated into the dentin tubules. Immunofluorescent (IF) histochemical analysis showed that GelMA supported hDPSC/HUVEC cell attachment and proliferation and also provided attachment for infiltrating host cells. Human cell-seeded GelMA hydrogels promoted the establishment of well-organized neovasculature formation. In contrast, acellular GelMA and empty RS constructs supported the formation of less organized host-derived vasculature formation. Together, these results identify GelMA hydrogel combined with hDPSC/HUVECs as a promising new clinically relevant pulpal revascularization treatment to regenerate human dental pulp tissues.

Whole genome sequencing and phylogenetic analysis of West Nile virus lineage 1 and lineage 2 from human cases of infection, Italy, August 2013

A human outbreak of West Nile virus (WNV) infection caused by WNV lineage 2 is ongoing in northern Italy. Analysis of six WNV genome sequences obtained from clinical specimens demonstrated similarities with strains circulating in central Europe and Greece and the presence of unique amino acid changes that identify a new viral strain. In addition, WNV lineage 1 Livenza, responsible for a large outbreak in north-eastern Italy in 2012, was fully sequenced from a blood donor during this 2013 outbreak.

Human cases of West Nile Virus Infection in north-eastern Italy, 15 June to 15 November 2010

In 2010, for the third consecutive year, human cases of West Nile virus (WNV) infection, including three confirmed cases of neuroinvasive disease and three confirmed cases of West Nile fever, were identified in north-eastern Italy. While in 2008 and 2009 all human cases of WNV disease were recorded in the south of the Veneto region, cases of WNV disease in 2010 additionally occurred in two relatively small northern areas of Veneto, located outside those with WNV circulation in the previous years. WNV IgG antibody prevalence in blood donors resident in Veneto was estimated as ranging from 3.2 per 1,000 in areas not affected by cases of WNV disease to 33.3 per 1,000 in a highly affected area of the Rovigo province. No further autochthonous human cases of WNV disease were notified in Italy in 2010. The recurrence of human cases of WNV infection for the third consecutive year strongly suggests WNV has become endemic in north-eastern Italy.

Human cases of West Nile Virus infection in north-eastern Italy, 15 June to 15 November 2010

In 2010, for the third consecutive year, human cases of West Nile virus (WNV) infection, including three confirmed cases of neuroinvasive disease and three confirmed cases of West Nile fever, were identified in north-eastern Italy. While in 2008 and 2009 all human cases of WNV disease were recorded in the south of the Veneto region, cases of WNV disease in 2010 additionally occurred in two relatively small northern areas of Veneto, located outside those with WNV circulation in the previous years. WNV IgG antibody prevalence in blood donors resident in Veneto was estimated as ranging from 3.2 per 1,000 in areas not affected by cases of WNV disease to 33.3 per 1,000 in a highly affected area of the Rovigo province. No further autochthonous human cases of WNV disease were notified in Italy in 2010. The recurrence of human cases of WNV infection for the third consecutive year strongly suggests WNV has become endemic in north-eastern Italy.

Prevalence of IgM and IgG antibodies to West Nile virus among blood donors in an affected area of north-eastern Italy, summer 2009

Following reports of West Nile neuroinvasive disease in the north-eastern area of Italy in 2009, all blood donations dating from the period between 1 August and 31 October 2009 in the Rovigo province of the Veneto region were routinely checked to exclude those with a positive nucleic acid test for West Nile virus (WNV). Only one of 5,726 blood donations was positive (17.5 per 100,000 donations; 95% confidence interval (CI): 0.4–97.3). In addition, a selection of 2,507 blood donations collected during the period from 20 July to 15 November 2009 were screened by ELISA for IgG and IgM antibodies against WNV. A positive result was received for 94 of them. The positive sera were further evaluated using immunofluorescence and plaque reduction neutralisation test (PRNT), in which only 17 sera were confirmed positive. This corresponds to a prevalence of 6.8 per 1,000 sera (95% CI: 4.0–10.9). In a case-control study that matched each of the 17 PRNT-positive sera with four negative sera with the same date of donation and same donation centre, we did not find a significant association with age and sex of the donor; donors who worked mainly outdoors were significantly more at risk to have a positive PRNT for WNV.

Genome sequence analysis of the first human West Nile virus isolated in Italy in 2009

In 2009, six new human cases of West Nile neuroinvasive disease (WNND) were identified in Veneto region, following the six cases already reported in 2008. A human West Nile virus (WNV) isolate was obtained for the first time from an asymptomatic blood donor. Whole genome sequence of the human WNV isolate showed close phylogenetic relatedness to the Italy-1998-WNV strain and to other WNV strains recently isolated in Europe, with the new acquisition of the NS3-Thr249Pro mutation, a trait associated with avian virulence, increased virus transmission, and the occurrence of outbreaks in humans.

Genome sequence analysis of the first human West Nile virus isolated in Italy in 2009

In 2009, six new human cases of West Nile neuroinvasive disease (WNND) were identified in Veneto region, following the six cases already reported in 2008. A human West Nile virus (WNV) isolate was obtained for the first time from an asymptomatic blood donor. Whole genome sequence of the human WNV isolate showed close phylogenetic relatedness to the Italy-1998-WNV strain and to other WNV strains recently isolated in Europe, with the new acquisition of the NS3-Thr249Pro mutation, a trait associated with avian virulence, increased virus transmission, and the occurrence of outbreaks in humans.

West Nile virus infection in Veneto region, Italy, 2008-2009

We report here an update on human cases of West Nile virus (WNV) infection in Veneto region, northeastern Italy. In addition to two cases of WNV neuroinvasive disease notified through a surveillance programme started in September 2008, further four cases were retrospectively identified (in May 2009) by investigating patients with aseptic meningoencephalitis of unknown aetiology occurring in Veneto region in June-September 2008. All six patients had symptom onset in August-September 2008 and were resident in a wetland area close to the Po river delta in Rovigo province. Further five cases of asymptomatic WNV infection, including four residents of the same area in Rovigo, were identified in a seroprevalence study in farm workers from Veneto region. To date, no human cases have been notified in 2009.

Changes in the tonic activity of wrist extensor motor units induced by stimulating antagonistic group I afferents in humans

The question as to whether the firing patterns of low- and high-threshold motor units in the extensor carpi radialis muscles are affected differently by group I afferents from the wrist flexors depending on the motor task being performed was investigated in six subjects. The motor units were voluntarily activated during a task consisting of either selectively contracting the wrist extensor muscles or co-activating the wrist and finger antagonist muscles by clenching the hand around a manipulandum. The motor units (n=40) were identified on the basis of their firing thresholds, their macro-potential areas, and their twitch contraction times. The effects on the motor-unit tonic activity of stimulating the wrist flexor afferents were assessed in terms of the changes in the firing probability, which were analysed after computing peri-stimulus time histograms using the cumulative sum procedure. Median nerve stimulation induced four main changes in the tonic firing pattern of the extensor motor units. An early, short-lasting increase in the firing probability (event E1) was found to occur in the high-threshold motor units, either in both tasks (6/13) or only during hand clenching (2/13). A short-latency decrease in the firing probability (event E2) was found to occur in all the motor units, the amount of which increased from the fast- to slowly contracting motor units, especially during hand clenching. A later decrease (event E3) followed by a large, late increase (event E4) in the tonic activity of the motor units was found to occur in all the motor units, without any task-dependent effects. All these various events were consistently observed in 12 pairs of motor units, each consisting of one slowly and one fast-contracting motor unit, which were tested simultaneously. These findings suggest that median nerve stimulation may selectively alter the tonic firing patterns of identified extensor motor units, depending on their functional characteristics (recruitment threshold, motor unit macro-potential area, contraction time) rather than on the excitatory drive to the motoneurone pool. The possible origins of these various events are discussed, and it is argued that, in the wrist extensor and flexor muscles that act as synergists during manipulatory finger movements and gripping tasks, the spinal pathways which assist the voluntary command may selectively modulate the firing patterns of identified motor units, to fit the requirements of the on-going motor task.

Successful VATS ligation of a large anomalous branch producing IMA steal syndrome after MIDCAB

The occurrence of a flow "steal phenomenon" from a large branch of the internal mammary artery (IMA) is rare and its pathogenesis is still controversial. We describe a case of a patent large anomalous left IMA branch which produced recurrent angina 3 years post MIDCAB. Transcatheter coil obliteration of the vessel produced symptomatic relief. However, six months later, chest pains recurred in association with unwinding of the coil and recannulization of the collateral vessel. Successful ligation of the culprit branch using a VATS approach is presented.

Dual task-related changes in the synchronous activity of wrist extensor type-identified motor units in humans

The coupling between the firings of 33 pairs of motor units tested in the extensor carpi radialis muscles was evaluated by cross-correlation analysis and compared during isometric wrist extension and hand clenching. A slightly greater amount of synchrony was observed during hand clenching (0.042 +/- 0.024 vs 0.035 +/- 0.017 synchronous impulses per trigger). This trend did not reach however the level of significance and the changes were actually found to be heterogeneous: in 15 out of the 33 pairs tested, synchronous activity with a narrow coupling (4.6 +/- 2.4 ms) consistent with short-term synchrony was greater during hand clenching whereas in nine other pairs, synchronous activity with a broader dispersion (9.0 +/- 4.5 ms) was reduced. These opposite changes could not be explained in terms of changes in the firing pattern of the motor units and were found instead to correlate with the motor units' biomechanical properties. Motor units with high recruitment thresholds and fast rising twitches showed predominantly an increase in synchrony; whereas the motor unit pairs with low recruitment thresholds and slow twitches showed either an increase or a decrease. The enhanced short-term synchrony suggests that common inputs distributed to motoneurones of all types were more effective during hand clenching whereas the decrease in weakly coupled synchronous activity suggests that other inputs synchronized at a pre-synaptic level and distributed more specifically to motor units recruited at low force levels were less effective. The possible origins of the inputs reflected in the dual changes are discussed in terms of the supra-spinal and peripheral pathways controlling the wrist extensor motoneurones during wrist extension and hand clenching.

Selective enhancement of motoneurone short-term synchrony during an attention-demanding task

Recent experiments on monkeys suggest that attention-related changes in the synchronous activity of neurones occur in the motor cortex. In humans, the clinical data available suggest that the weak synchronization of the motor unit firing observed during voluntary contraction might reflect the activity of the motoneurone cortico-spinal afferents. The present study was therefore designed to investigate how the synchronous motor-unit activity might depend on the attention required in performing a motor task. Twenty-five motor unit pairs were tested in the right extensor carpi radialis muscles of five right-handed subjects, who were instructed to keep both motor units firing tonically while trying to maintain the extension force as constant as possible using visual feedback set either at low or high gain. Fifteen motor unit pairs (60%) showed a greater amount of synchronous activity, without any consistent changes in the motor unit firing rates, when the subjects were monitoring the force at high gain. In addition, the mean value and the steadiness of the force did not differ significantly between the two tasks. The amplitude of the motor units' contractile force extracted by spike-triggered averaging did not change consistently despite the slight increase in the synchronous impulse probability observed under the high-gain conditions. Changes in synchrony affected slowly contracting, low-threshold motor units as well as fast-contracting, high-threshold motor units. The most noteworthy finding was that these changes actually focused on a narrow component of the synchronous activity (within a period of less than 4 ms) in keeping with the short-term synchronization process. This suggests that common inputs, possibly of cortical origin, may have contributed more greatly to controlling the motoneurone firing pattern in the motor task which required the subjects to pay more attention.

Inhibition versus facilitation of the reflex responsiveness of identified wrist extensor motor units by antagonist flexor afferent inputs in humans

The question of whether Ia reciprocal inhibition might depend on the motor task and on the type of motor unit activated was investigated in the human extensor carpi radialis muscles. Ia reciprocal inhibition induced by stimulating the median nerve (conditioning stimulation) was estimated by measuring the changes in the firing probability of 37 extensor motor units in response to the radial nerve stimulation (100 test stimuli) delivered 1 ms after the conditioning stimulation. Six subjects were asked to perform a task consisting of either selectively contracting their wrist extensor muscles or co-activating their wrist and finger antagonist muscles by clenching their hand around a manipulandum. In the control recordings (test stimulation alone), the mean response probability of the 37 motor units was found to be greater during hand clenching. The motor units were identified on the basis of their force thresholds, their macro-potentials, and their twitch contraction times. The data obtained in the control recordings were consistent with the size principle. In the recordings where the responses were conditioned by applying median nerve stimulation, the response probability of the motor units with low force thresholds, small macro-potential areas, and long twitch contraction times tended to decrease, in line with the presence of Ia reciprocal inhibition, whereas the response probability of the motor units with higher force thresholds, larger macro-potential areas, and shorter twitch contraction times tended to increase. The median nerve stimulation may therefore have altered the efficiency with which the extensor Ia inputs recruited the homonymous motoneurones in the pool. The flexor group I afferents activated while the median nerve was stimulated had inhibitory effects on the slow contracting motor units, and facilitatory effects mainly on the fast contracting motor units. Both of these effects were stronger during hand clenching, in which the numerous cutaneous receptors of the palm and fingertips are liable to be activated. Besides their own effects on the excitability of the various types of motor units, cutaneous inputs are known to potentiate the Ib interneurones. In addition, the effects of the conditioning stimulation were superimposed on the tonic activity of the Ia and Ib afferents from the flexor wrist and finger muscles. This may explain why both the inhibitory and facilitatory effects of the median nerve stimulation were enhanced during hand clenching.

Task dependence of Ia presynaptic inhibition in human wrist extensor muscles: a single motor unit study

OBJECTIVE

Task-dependent changes in the Ia presynaptic inhibition generated by flexor group I afferents were investigated in 25 identified motor units (MUs) located in human extensor carpi radialis (ECR) muscles.

METHODS

Seven subjects had to voluntarily contract their ECR muscles either alone during isometric wrist extension or concurrently with their wrist and finger flexor muscles while clenching their hand around a manipulandum. The MU reflex responses to the radial nerve stimulation (test stimulation) yielded narrow peaks in the post-stimulus time histograms (PSTH). The Ia presynaptic inhibition induced while stimulating the median nerve (conditioning stimulation) 20 and 40 ms before the radial nerve was assessed from the changes in the contents of the first 0.5 ms in the peaks.

RESULTS

With both stimulation intervals, the Ia presynaptic inhibition, as assessed from the first 0.5 ms of the PSTH peaks, was consistently weaker during hand clenching. With both motor tasks, the Ia presynaptic inhibition was strongest at the 20 ms interval, in which it showed a downward gradient, working from slow to fast contracting MUs. With both intervals, the presynaptic inhibition was consistently weaker during hand clenching. The decrease in the Ia presynaptic inhibition observed at the 40 ms conditioning-test interval was less pronounced during wrist extension.

CONCLUSION

It is suggested that the reason why Ia presynaptic inhibition was weaker during hand clenching may have been that this task involved numerous cutaneous inputs originating from the palm and finger tips. During gripping tasks, these cutaneous inputs may therefore contribute to adjusting the wrist stiffness by relieving the presynaptic inhibition.

Distribution of presynaptic inhibition on type-identified motoneurones in the extensor carpi radialis pool in man

The question was addressed as to whether the magnitude of Ia presynaptic inhibition might depend on the type of motor unit activated during voluntary contraction in the wrist extensor muscles. For this purpose, we investigated the effects of applying electrical stimulation to the median nerve on the responses of 25 identified motor units to radial nerve stimulation delivered 20 ms after a conditioning stimulation. The reflex responses of the motor units yielded peaks in the post-stimulus time histograms with latencies compatible with monosynaptic activation. Although median nerve stimulation did not affect the motoneurone net excitatory drive assessed from the mean duration of the inter-spike interval, it led to a decrease in the contents of the first two 0.25 ms bins of the peak. This decrease may be consistent with the Ia presynaptic inhibition known to occur under these stimulation conditions. In the trials in which the median nerve was being stimulated, the finding that the response probability of the motor units, even in their monosynaptic components, tended to increase as their force threshold and their macro-potential area increased and as their twitch contraction time decreased suggests that the median nerve stimulation may have altered the efficiency with which the Ia inputs recruited the motoneurones in the pool. These effects were consistently observed in seven pairs of motor units each consisting of one slow and one fast contracting motor unit which were simultaneously tested, which suggests that the magnitude of the Ia presynaptic inhibition may depend on the type of motor unit tested rather than on the motoneurone pool excitatory drive. The present data suggest for the first time that in humans, the Ia presynaptic inhibition may show an upward gradient working from fast to slow contracting motor units which is able to compensate for the downward gradient in monosynaptic reflex excitation from 'slow' to 'fast' motor units. From a functional point of view, a weaker Ia presynaptic inhibition acting on the fast contracting motor units may contribute to improving the proprioceptive assistance to the wrist myotatic unit when the contraction force has to be increased.

Mechanical cutaneous stimulation alters Ia presynaptic inhibition in human wrist extensor muscles: a single motor unit study

Reflex responses were evoked by radial nerve stimulation in 25 single motor units in the extensor carpi radialis muscles of seven subjects during voluntary isometric wrist extension. The responses consisted of narrow peaks in the post-stimulus time histograms with latencies compatible with monosynaptic activation. When the skin of the palm and finger tips was continuously swept using a soft rotating brush, the purely monosynaptic components of the motor unit responses, as assessed from the contents of the first two 0.25 ms bins of the peak, were found to increase. This increase did not affect the motoneurone net excitatory drive, as assessed by measuring the mean duration of the inter-spike intervals. The cutaneous inputs activated by the brush may have reduced the tonic presynaptic inhibition exerted on the Ia afferents homonymous to the extensor motor units tested. To further investigate whether Ia presynaptic inhibition was involved, the responses of the extensor motor units were conditioned by stimulating the median nerve 20 ms earlier, using a protocol which is known to induce Ia extensor presynaptic inhibition originating from flexor Ia afferents. The median nerve stimulation did not affect the motoneurone excitatory drive, but led to a decrease in the responses of the extensor motor units to the radial nerve stimulation, especially in the purely monosynaptic components. This decrease was consistent with the Ia presynaptic inhibition known to occur under these stimulation conditions. The cutaneous inputs activated by the brush were found to reduce the Ia presynaptic inhibition generated by the median nerve stimulation, without affecting the distribution of the Ia presynaptic inhibition among the various types of motor units tested. The present data suggest that cutaneous inputs from the palm and finger tips may relieve the Ia presynaptic inhibition exerted on the wrist extensor motor nuclei, and thus enhance the proprioceptive assistance to fit the specific requirements of the ongoing motor task.

Ia presynaptic inhibition in human wrist extensor muscles: effects of motor task and cutaneous afferent activity

The task-dependence of the presynaptic inhibition of the muscle spindle primary afferents in human forearm muscles was studied, focusing in particular on the modulation associated with the co-contraction of antagonist muscles and the activation of cutaneous afferents. The changes known to affect the motoneuron proprioceptive assistance during antagonist muscle co-activation in human leg and arm muscles were compared. The evidence available so far that these changes might reflect changes in the presynaptic inhibition of the muscle spindle afferent is briefly reviewed. The possible reasons for changes in presynaptic inhibition during the antagonist muscle co-contraction are discussed. Some new experiments on the wrist extensor muscles are briefly described. The results showed that the changes in the Ia presynaptic inhibition occurring during the co-contraction of the wrist flexor and extensor muscles while the hand cutaneous receptors were being activated (the subject's hand was clenched around a manipulandum) could be mimicked by contracting the wrist extensor muscles alone while applying extraneous stimulation to the hand cutaneous receptors. It is concluded that besides the possible contribution of inputs generated by the co-contraction of antagonist muscles and by supraspinal pathways, cutaneous inputs may play a major role in modulating the proprioceptive assistance during manipulatory movements.

Proprioceptive control of wrist extensor motor units in humans: dependence on handedness

The effectiveness of the monosynaptic proprioceptive assistance to the wrist extensor motoneurone activity was investigated during voluntary contraction in relation to the subjects' handedness. The reflex responses of 411 single motor units to homonymous tendon taps were recorded in the wrist extensor carpi radialis muscles in both arms of five right-handed and five left-handed subjects. In the right-handed subjects, the motor unit reflex responses were clearly lateralized in favour of their right arm, whereas no side-related differences were observed in the left-handed subjects, whatever the motor units' mechanical properties and firing rates. When the muscle spindle sensitivity was by-passed by electrically stimulating the primary afferents in both arms of three right-handed and three left-handed subjects, no side-related differences were observed in the Hoffmann reflex (H-reflex) amplitude in either of the two lateralization groups. The effectiveness of the primary afferent synapses on to the motoneurones therefore does not seem to depend on the subject's handedness. Without excluding the possibility of structural changes being involved at the periphery, the comparisons carried out on the data obtained using electrical vs mechanical stimulation suggest that the asymmetrical effectiveness of the proprioceptive assistance observed in favour of the right arm in the right-handed subjects might result from either the gamma or beta drive being more efficient. This asymmetry might result from the preferential use of the right hand in skilled movements. In a predominantly right-handed world, however, left-handed people might tend to develop the ability to use their right arm almost as skillfully as their preferred left arm, which could explain the symmetrical effectiveness of the proprioceptive assistance observed here in the left-handers' wrist extensor muscles.

Sarcoma of the main pulmonary artery: an unusual etiology for recurrent pulmonary emboli

We describe a case of primary pulmonary artery (PA) trunk spindle cell sarcoma in an 86 year old female presenting clinically with debilitating signs of recurrent pulmonary embolism. Further extensive work aroused suspicion for pulmonary artery malignancy. Palliative wide surgical resection, pulmonary artery tumor embolectomy and reconstruction of the proximal pulmonary artery and right ventricle outflow tract (RVOT) with bovine pericardial tissue were performed. She survived the procedure with an improved quality of life, but expired due to recurrence at 6 months postoperatively. Albeit uncommon, pulmonary artery sarcoma is nowadays a more frequently preoperatively diagnosed and surgically treated malignancy. With a modern low perioperative mortality, aggressive surgical resection remains as the single most effective modality for its treatment and can result in short term palliation in selected patients.

Primary aorto-duodenal fistula secondary to infected abdominal aortic aneurysms: the role of local debridement and extra-anatomic bypass

Gastrointestinal bleeding secondary to spontaneous rupture of an infected abdominal aortic aneurysm into the duodenum is a rare and highly lethal clinical occurrence, representing roughly a third of all primary aortoduodenal fistulas. Diagnosis is problematic due to the subtleties in the clinical presentation and course, and surgical treatment is usually delayed, representing a challenge even for the experienced vascular surgeon. The overall mortality is over 30% and the operative approaches are still controversial. Two cases of ruptured infrarenal aortic aneurysms complicated with aortoduodenal fistula were recently treated at our institution. Bacterial aortitis was documented by arterial wall cultures positive for Klebsiella and Salmonella species respectively. The clinical courses and outcomes of the two patients (one survivor ) treated with retroperitoneal debridement and extra-anatomic bypass and a review of the modern surgical treatment are herein described.

Clinical experience with the video-assisted saphenectomy procedure for coronary bypass operations

BACKGROUND

Leg wound complications after saphenectomy are frequent after coronary bypass operations and have a detrimental effect on postoperative quality of life and treatment cost. To reduce morbidity, we evaluated a new technique of video-assisted vein harvest.

METHODS

Between March 1996 and October 1996, 50 patients had video-assisted saphenectomy (VAS) and 40 patients had the standard open technique (control group). An additional 13 patients had both procedures (hybrid group). Level of pain, edema, and wound complications were evaluated at discharge and at 2, 4, and 6 weeks postoperatively.

RESULTS

The mean operating time for VAS patients was slightly higher than for control (60.6+/-24.7 minutes versus 53.2+/-21.1 minutes; p > 0.05). The average incision length in VAS patients was 13.8+/-8.8 cm for an average of 3.3 grafts per patient. Three VAS procedures were aborted, two because of time constraints, and one because of bleeding, and a segment of vein was lost to injury. The VAS group had considerably less early postoperative pain than the control group (1.7+/-1.2 versus 4.1+/-1.4 [1 = mild, 10 = severe]; p < 0.005) and edema was similar for both groups. Patients in the hybrid group reported less pain in the VAS-operated leg. Serious wound infection occurred in 4 patients, with 2 patients in the control group requiring reoperation for drainage and flap reconstruction.

CONCLUSIONS

Based on this initial experience, VAS harvesting, although initially more time consuming, is a rapidly mastered technique, results in shorter overall incision length, and is associated with considerably less postoperative pain than the standard open technique.

Pulmonary resection for malignancy in the elderly: is age still a risk factor?

OBJECTIVE

There is an increasing number of elderly patients presenting with potentially-resectable lung malignancy. The objective of this study is to evaluate the modern perioperative morbidity and mortality in patients undergoing oncologic lung resection and to analyse the trend over a 26-year period in our experience.

METHODS

Between 1971 and 1996, 1506 patients underwent lung resection for malignancy. We reviewed the 30-day perioperative risk in a group of 385 (25.6%) patients aged 70 years and older operated on for intended cure of lung malignancy. Operations included 293 (77%) lobectomies, 24 pneumonectomies (6%), 16 bilobectomies (4%) and 52 wedge or segmental resections (13%). The pathology was bronchogenic carcinoma in 89% and metastasis or other tumours in 11% of patients. We compared the 30-day perioperative risk between the elderly group (age 70 or greater) and a cohort of 180 patients (control) 69 years and younger.

RESULTS

The mortality for all resections in elderly group was 4.2% (16/385) and was 1.6% for the control group. Mortality in the octogenarian group was 2.8%. Female gender correlated with a decreased risk of death, with only two of 16 deaths in females (P < 0.005). Overall morbidity was higher in the study than in control patients (34% vs. 25%, n.s.), although major morbidity was similar in both groups (13.2% vs. 13%). Abnormal pulmonary-function testing and positive cardiac history did not correlate with increase overall or specific risk. Pneumonectomy carried a higher risk for death, with three of 24 deceased (12.5%; P < 0.05). Changes in outcome were analysed over two time periods: the mortality in the early period (1971-1982), 11.1% (8/72), was significantly elevated above the control group, while mortality in the modern period (1983-1994) was not, with a rate of 2.6% (8/313).

CONCLUSIONS

In our series, mortality associated with operative treatment for lung malignancy in the elderly declined, so age alone no longer appears to be a risk factor. Age remains a risk factor for overall, but not major, morbidity. Pneumonectomy should undertaken cautiously in this age group. Based on this data, functional elderly patients should not be denied curative lung resection based on age alone.

Serious wound infections after minimally invasive coronary bypass procedures

BACKGROUND

Minimally invasive coronary artery bypass grafting has become an increasingly accepted therapy for selected patients with single-vessel coronary artery disease. Reported morbidity has focused on anastomotic problems, but the occurrence of serious wound complications after these procedures has not been well documented.

METHODS

We reviewed our institutional experience with 35 patients to look for the incidence of serious wound complications.

RESULTS

Three patients had serious wound problems after minithoracotomy for coronary artery bypass graft procedures. This represents an overall 9% wound morbidity rate and a 100% rate in the obese women.

CONCLUSIONS

Wound complications at the incision site after minithoracotomy coronary artery bypass graft procedures seem to occur distinctly in obese women with redundant breasts.

Atherosclerotic aneurysm of the proximal subclavian artery: a case report

Aneurysms of the upper extremities, and particularly the intrathoracic segment of the subclavian artery, are unusual. Surgical approach and timing of repair remain controversial. We successfully treated a case of a large proximal subclavian artery aneurysm, atherosclerotic in origin. In spite of the size, the symptoms were vague. The patient underwent partial resection of the lesion located in the proximal third of the right subclavian artery, and repair using 8 mm dacron interposition graft. She did well postoperatively and remains symptom free at 1 year. A discussion of this disorder with the relevant literature review is herein included.

Double grafting of the left anterior descending artery: is the distance between the internal mammary artery and supplemental vein graft anastomoses relevant in graft survival?

INTRODUCTION

Under certain conditions (small internal mammary artery (IMA) or large runoff), double grafting of the left anterior descending (LAD) artery system is necessary to avoid the ominous consequences of myocardial hypoperfusion. Previous studies have shown that a saphenous vein (SVG) adjacent to an IMA graft leads to failure of the IMA. This study compares IMA flow patterns when adjacent ( < 1 cm) and separated (3-4 cm) from a SVG placed on a proximally occluded LAD.

METHODS

A SVG and right IMA (PIMA) to proximal LAD (2.5-3 mm) coronary bypass were performed in 12 mongrel dogs. The left IMA (DIMA) was anastomosed to the distal LAD (1.5 mm). All anastomoses were carried out without cardiopulmonary bypass. The native LAD was occluded proximally to the PIMA anastomosis, and all graft flows were measured in competitive and non-competitive flow conditions.

RESULTS

Isolated graft to LAD flows were similar for the three conduits. There was a drop in flow in both the PIMA and DIMA when placed in competition with the SVG (10.1+/-3.0 vs. 19.1+/-4.6 ml/min; P < 0.05). The total drop in flow was significantly greater in the PIMA (67.6 vs. 39.9%; P < 0.05). Diastolic flow was better preserved in the distal IMA graft (19.6 + 5.6 vs. 10.2+/-3.0 ml/min; P < 0.05). The patterns of flow were much different during competition and there was significant retrograde systolic flow in all PIMA grafts while there was no (n = 5) or minimal retrograde flow (n = 7) in the DIMA grafts.

CONCLUSION

An IMA graft, when adjacent to a SVG, sustains a significant decrease in both total and diastolic flows and develops an oscillating pattern of flow in early systole (retrograde then antegrade). Placing the IMA more distally on the LAD improves flow and decreases retrograde flow. In clinical situations requiring double grafting on the LAD, distance between grafts may be an important factor in maintaining IMA patency.

Evidence for improved cerebral function after minimally invasive bypass surgery

BACKGROUND

Neurological impairment is a major cause of morbidity after cardiac surgery and may be associated with occurrence of cerebral microemboli generated during cardiopulmonary bypass (CPB). This study evaluates cerebral dysfunction following coronary artery surgery on-pump and off-pump.

METHODS

Neurological outcome was evaluated in 322 patients with a coronary artery bypass graft (CABG). Conventional CPB was used (on-pump) in 305 patients and in 17 patients no CPB was used (off-pump). Intraoperatively, a pulsed-wave transcranial Doppler with a 2-MHZ probe measured high-intensity transient signals (HITS) by ultrasonic insonnation of the middle cerebral artery indicating the presence of emboli within the vessel lumen. Transcranial near-infrared spectroscopy measured cerebral venous oxygen saturation for adequate perfusion. Postoperatively, all patients were subjected to the antisaccadic eye movement (ASEM) test, a sensitive indicator of neurocognitive deficits secondary to frontal lobe dysfunction.

RESULTS

While there was no significant difference in O2 saturation, the number of microemboli HITS generated was significantly higher in the on-pump group than the off-pump group. In the off-pump group, 16 (94%) of 17 patients had perfect scores on the ASEM test, while only 108 (35.4%) of 305 patients achieved a perfect score in the on-pump group (p < 0.01). Furthermore, while all patients in the off-pump group achieved at least 90%, 28% (86/305) in the on-pump group scored "zero" on the ASEM test.

CONCLUSION

Cerebral dysfunction as evidenced by ASEM errors is common following coronary bypass on-pump, but rare with off-pump bypass surgery. Cerebral microemboli generated during CPB may account for this difference.

Firing pattern of type-identified wrist extensor motor units during wrist extension and hand clenching in humans

1. Single motor unit activity was investigated in the extensor carpi radialis muscles during voluntary isometric contraction involving either the coactivation of the wrist agonist extensor muscles (wrist extension) or the coactivation of the wrist and finger antagonist extensor and flexor muscles (hand clenching). 2. The motor units were found to be activated at a similar level of motoneurone pool drive during both wrist extension and hand clenching, as indicated by the fact that the EMG activity at which they were recruited was practically the same in both cases (mean +/- S.D.: 20 +/- 26 and 21 +/- 25 mV, respectively). In addition, the net excitatory drive exerted on the motoneurones, as assessed from the mean interspike intervals, did not differ significantly between the two tasks (mean +/- S.D.: 104.57 +/- 17.24 and 103.01 +/- 16.26 ms, for wrist extension and hand clenching, respectively). 3. However, the discharge variability, in terms of the coefficient of variation of the interspike intervals, was slightly but significantly greater during hand clenching than during wrist extension (0.213 +/- 0.049 and 0.198 +/- 0.045, respectively). This increase involved all types of motor units, regardless of their contractile force. 4. We suggest that the greater motoneurone discharge variability observed during hand clenching may be attributable to an increase in the synaptic noise. This increase might be due to the activation of numerous afferent pathways mediating reciprocal interactions between antagonist motoneurone pools, as well as to the activation of hand cutaneous receptors that play a major role in the regulation of handling and gripping motor activities.

What in-vitro method should surgeons use to evaluate the clinical behavior of arterial bypass conduits

Surgeons have traditionally relied on ring preparations to predict how arterial bypass conduits will behave in the postoperative circulation.

OBJECTIVE

This study compared pharmacologic [norepinephrine (NE) challenge] and physiologic [arterial preload] responses of gastroepiploic (GEA) and internal thoracic (ITA) arteries in a standard static ring preparation and a dynamic perfusion system.

METHODS

Six GEAs (1.0-1.5 mm dia.) and six ITAs (1.5-2.0 mm dia.) 11 cm long were harvested from adult pigs and mounted on a computer controlled perfusion system. Inflow pressure was set at 80 mmHg and outflow resistance was adjusted to simulate high (80-90 ml/min) and low (15-20 ml/min) flow demands. NE response (10(-9)-10(-5) M) was measured under low flow conditions and at high flow conditions when distal arterial pressure (load) was reduced. NE response (10(-9)-10(-5) M) was also evaluated in arterial rings (ITA N = 6, GEA N = 6) with tensions adjusted to simulate the loads occurring at low flow (80 mmHg) and high flow (60 mmHg) situations.

RESULTS

In the static ring preparation, NE response [ED50] was similar for both GEA and ITA and was not affected by load. The dynamic preparation demonstrated that the GEAs were significantly more responsive to NE than the ITAs [ED50 high flow ITA 6.1 +/- 0.3**, GEA 7.2 +/- 0.3***; *P < 0.05 versus baseline, **P < 0.05 versus low flow values, ***P < 0.05 versus ITA]. Furthermore, in the dynamic preparation, NE response was profoundly affected by reduced load which occurs under high flow conditions [7.18 +/- 0.3 versus 6.1 +/- 0.3 under high flow and 5.8 +/- 0.1 versus no response under low flow conditions].

CONCLUSION

Static ring preparations do not discern differences between ITA and GEA susceptibility to spasm and fail to detect the effect of load. The dynamic preparation demonstrated significant differences between the GEA and ITA potential to spasm which is consistent with widespread clinical experience. Furthermore a dynamic preparation is highly sensitive to reduced load which occurs under high flow conditions. Although it is more demanding, the dynamic preparation provides superior information to the surgeon in predicting the behavior of arterial bypass grafts.

Factors affecting internal mammary artery graft survival: how is competitive flow from a patent native coronary vessel a risk factor?

Recent studies have suggested that competitive flow is an important factor in early internal mammary artery (IMA) graft failure. Flow competition from minimally diseased native coronary vessels has been implicated in the failure of IMA grafts, but does not seem to affect saphenous vein grafts (SVG). The objective of this study was to determine the effects of competitive flow on SVG and IMA grafts and to compare the patterns of flow dynamics and pressure on proximal and distal grafts to the left anterior descending (LAD) artery; factors that may be involved in graft failure. Twelve mongrel dogs underwent coronary artery bypass grafting using IMAs and a SVG to an open LAD artery. The right IMA (PIMA) and the SVG were anastomosed in the proximal LAD and the left IMA (DIMA) was anastomosed at a more distal location. The procedure was performed through a left thoracotomy, using an "off pump" technique. Graft flows were measured isolated and in competition. The IMAs and SVG provided flow levels similar to the native LAD when each one was the sole inflow to the LAD. During competitive flow conditions, total and diastolic SVG flows were reduced 54.4 and 50.5%, respectively (P < 0.05). Total and diastolic PIMA and DIMA flows were reduced more drastically (68.6-73.3 and 69.5-68.1%, respectively; P < 0.05). The DIMA had better preservation of diastolic flow compared to PIMA. A delay in the pressure wave was noted in the isolated IMAs, but not in the SVG. This pattern of flow disappeared during competition due to the large, systolic retrograde flow up the IMA grafts. In conclusion, IMAs compared to the SVG are longer and narrower conduits with lower levels of flow during competition. Low levels of flow and oscillating flow (retrograde/ antegrade) may be poorly tolerated by the IMA endothelium and may be factorial to graft failure. These data suggest that a more distal placement of the IMA graft may be protective to the arterial graft under competitive flow conditions.

ITA versus SVG: a comparison of instantaneous pressure and flow dynamics during competitive flow

OBJECTIVE

Competitive flow from patent native coronary vessels is implicated in the failure of internal thoracic artery (ITA) grafts, but it is not thought to affect saphenous vein graft (SVG) patency. This study examines instantaneous pressure and flow dynamics in left ITA and SVG grafts in competition with a patent left anterior descending (LAD) artery.

METHODS

SVG (3.0-4.0 mm) and ITA (1.5-2.0 mm) to proximal LAD (2.5-3.0 mm) coronary bypass was performed in 10 mongrel dogs. Flow and pressure were measured in the occluded (No Competition) and opened (Competition) ITA, SVG and LAD.

RESULTS

The ITA and SVG, when each was the sole inflow to the LAD, provided similar flow as the native LAD. During competitive flow, total LAD flow was preserved and flow in the ITA and SVG were reduced (8.20 +/- 1.25 and 10.00 +/- 1.73 ml/min; P < 0.005). SVG diastolic flow was reduced to 11.52 +/- 2.17 ml min (55.5%); P < 0.003. Flow in the SVG remained predominantly antegrade. In contrast, ITA diastolic flow was reduced more drastically, to 5.37 +/- 1.25 ml/min (80.7%); P < 0.0001. When the ITA was the only inflow to the LAD, there was delay in the LAD pressure wave. This delay disappears during competition due to the large, systolic retrograde flow up the ITA.

CONCLUSION

The ITA, compared to the SVG, is a longer and narrower conduit with lower levels of flow during competition. Due to a delay in the pressure wave, the ITA flow is retrograde during early systole. Low levels of flow, with a markedly decreased diastolic phase, and the oscillating pattern in systole (retrograde/antegrade) may be poorly tolerated by the ITA endothelium and lead to graft deterioration.

Anastomotic complications in minimally invasive coronary bypass grafting

BACKGROUND

Anterior wall myocardial revascularization through a left anterior minithoracotomy is an increasingly accepted procedure. Technical failure at the anastomotic site, promoting persistent or recurrent angina, is known to occur and may be underrecognized. This report summarizes the incidence of technical failure in an initial clinical experience and describes potential causes of early postoperative complications.

METHODS

Between December 1995 and May 1996, 15 patients underwent left internal mammary artery-to-left anterior descending artery revascularization without extracorporeal circulation. The surgical indication was single-vessel coronary disease in all patients. We exposed the left anterior descending artery target site through a 10-cm left anterior fourth space thoracotomy. The fourth costal cartilage was resected and the left internal mammary artery was harvested under direct visualization. Two 4-0 polypropylene sutures snared in tourniquets proximal and distal to the anastomotic site were used to obtain a bloodless field and stabilization of the left anterior descending artery.

RESULTS

All patients had procedures initially deemed successful based on disappearance of angina or postoperative transthoracic Doppler examination of the internal mammary artery 3 to 5 days postoperatively. However, 3 patients presented with recurrent angina at 2, 6, and 8 weeks. Angiography or direct visualization at operation demonstrated the technical complication (stenosis at the anastomotic site in 2 and snare injury in the native vessel in 1). Two patients required reoperation.

CONCLUSIONS

Initial results with minimally invasive coronary bypass grafting have generated great enthusiasm worldwide, but there is no consensus on how the procedure should be performed. These results suggest that a nonstabilized anastomosis results in an unacceptable failure rate. Furthermore, sutures encircling the left anterior descending artery should not be used for vessel stabilization as injury of the artery may occur.

Instrumentation for minimally invasive internal thoracic artery harvest

The anterior fourth interspace minithoracotomy is our current choice for exposure of the anterior myocardial wall for minimally invasive coronary bypass grafting procedures. This approach provides direct access to the left anterior descending coronary artery for anastomosis, and good exposure of the midsegment of the internal thoracic artery. We describe the use of instrumentation that facilitates the harvest of the left internal thoracic artery under direct vision. The use of this retractor system, which elevates the third and fourth and depresses the second and first ribs, permits better visualization of the internal thoracic artery and allows for proximal internal thoracic artery harvest without rib resection.

Task-dependence of muscle afferent monosynaptic inputs to human extensor carpi radialis motoneurones

The task-dependence of homonymous muscle afferent inputs was investigated in motor units of the extensor carpi radialis muscles during voluntary isometric contraction involving either the activation of agonist extensor muscles (wrist extension) or the co-activation of antagonist extensor and flexor muscles (hand clenching). The effectiveness of the muscle afferent monosynaptic inputs was tested by delivering either tendon taps or electrical stimulation to the radial nerve. In both cases, the motor unit responses, which took the form of narrow peaks in the peri-stimulus time histograms, were found to be significantly greater during hand clenching. The parallel enhancement of the responses to both mechanical and electrical stimulations observed during hand clenching could not be explained in terms of changes in the muscle spindle responsiveness. The enhancement of the motor units' responsiveness was apparent during the first 0.5 ms of the peaks in the peri-stimulus time histograms, taken to be uncontaminated by any polysynaptic components. It may therefore have reflected an increase in the amplitude of the excitatory monosynaptic potentials generated by the muscle spindle primary afferents. This is interpreted in terms of changes in the presynaptic inhibition, which might be depressed as the result of the large-scale activation of palm and finger cutaneous afferents liable to occur during hand clenching.

Ruptured aortic pseudo-aneurysm: a rare presentation as aortocaval fistula

Pseudo-aneurysms after abdominal aortic replacement are rare, occurring in less than 1% of operated patients. Usually asymptomatic, they may present clinically as a pulsatile mass or less commonly complicated with rupture. Aortocaval fistulas are rare, usually related to ruptured aortic aneurysms or trauma. A case of aortocaval fistula secondary to a ruptured pseudoaneurysm in a 81 year old woman is reported. After an infrarenal aortic aneurysm repair, the patient remained asymptomatic for 7 years, but abdominal pain and syncope developed and promoted further investigation. She was found to have a 6 cm by 6 cm retroaortocaval false aneurysm which had ruptured into the inferior vena cava. Computed tomography with intravenous contrast suggested the diagnosis and color Doppler ultrasound failed to confirm it. The etiology and management of this rare case are discussed.

Pulmonary resection for lung cancer in octogenarians

BACKGROUND

Octogenarians often present with potentially resectable bronchogenic carcinoma. Older reports noting prohibitive mortality and recent surveys documenting continued substantial risk raise concerns about the applicability of operation in this age group.

METHODS

We reviewed the short-term and long-term results of pulmonary resection for intended cure of lung cancer in patients 80 years and older operated on from 1980 through 1995. Our surgical philosophy favored lobectomy over lesser resection and generally avoided pneumonectomy in the elderly.

RESULTS

Fifty-four octogenarians underwent resection: 43 lobectomies, 2 extended lobectomies, 2 bilobectomies, 3 segmentectomies, 3 wedge excisions, and 1 pneumonectomy. There were two perioperative deaths (3.7%). The overall nonfatal complication rate was 42%, with a major complication rate of 11%. Postoperative stay decreased from 8.1 days overall to 6.3 days in the last 3 years. Only 3 patients required temporary convalescent care after discharge. Actuarial survival at 1,3, and 5 years was 86%, 62%, and 43%, respectively, for all discharged patients (n = 52) and 97%, 78%, and 57% for stage I cases (n = 39). Patients with tumors beyond stage I fared poorly.

CONCLUSIONS

Advanced age per se in neither a contraindication to curative resection nor a routine indication for nonanatomic operations in healthy octogenarians with stage I lung cancer. With proper selection, acute risk should be low. Pneumonectomy, extended resection, and operation for stage II or III disease should be considered only in exceptional cases.

The "size principle" and synaptic effectiveness of muscle afferent projections to human extensor carpi radialis motoneurones during wrist extension

The question of whether muscle spindle afferents might control human motoneurone activity on the basis of the "size principle" during voluntary contraction was investigated by recording the discharge of single motor units (n = 196) in wrist extensor muscles while stimulating the homonymous muscle spindles by means of tendon taps. The mechanical stimuli were delivered with a constant post-spike delay of 80 ms so that the resulting afferent volleys could be expected to reach the motoneurones towards the end of the inter-spike interval (mean +/- SD duration: 124.7 +/- 11.9 ms). In the six subjects tested, the response probability was found to be significantly correlated with the motor units' functional parameters. Differences in twitch rise times, twitch amplitudes, recruitment thresholds and macro-potential areas were found to account for 18%, 9%, 6% and 2% of the differences in the response probability observed within the whole population of motor units tested. These differences could not be due to differences in firing rate for two reasons: first, the motor units were found to discharge with a similar range of inter-spike intervals whatever their functional characteristics; secondly, the weak positive correlation observed between the response probability and the motor unit firing rate showed parallel regression lines between the late-recruited fast-contracting motor units and the first-recruited slowly contracting motor units, but the y-intercept was significantly higher in the latter case. This confirmed that the responses of the first-recruited slowly contracting motor units tended to be larger whatever the firing rates. In most of the pairs tested in the same experiment, the motor units which had the lowest recruitment thresholds, longest contraction times, smallest contraction forces or smallest motor unit macro-potentials tended to produce the largest responses, which also had the longest latencies. Taking the response latency to be an index of a motoneurone's conduction velocity and therefore of its size, the data obtained with this index and with other functional indices such as the twitch rise times and amplitudes, the macro-potential areas and the recruitment thresholds-can be said to be fully consistent with the "size principle", as previously found in anaesthetized animals. It can be inferred that the presynaptic inhibition which is liable to take action during voluntary contraction does not seem to alter the graded distribution of the muscle afferent projections to human wrist extensor motoneurones.

Takayasu's arteritis: the middle aortic syndrome

An isolated, long segment abdominal aortic coarctation is an infrequent occurrence. Although different names have been given to this entity, it is believed that all represent different stages of nonspecific inflammatory arteritis, or Takayasu's disease. Usually involving the arch and descending aorta, occasionally an isolated segment of the abdominal aorta is involved. Morbid presentation reflects the involvement with narrowing of visceral branches and aortic occlusive disease, as illustrated in this case. Operative intervention with aortic bypass and visceral revascularization is the treatment of choice for recurrent or extensive aortic involvement.

Simple technique for the treatment of strictured colorectal anastomosis

A transanal alternative to open surgery is described for opening strictured colorectal anastomoses with an EndoGia stapler.

Human spinal lateralization assessed from motoneurone synchronization: dependence on handedness and motor unit type

1. Motoneurone synchronization as a means of investigating synaptic connectivity was studied in the extensor carpi radialis muscles of the preferred and non-preferred arms of healthy right- and left-handed human subjects. The activities of pairs of motor units recorded during voluntary isometric contractions were analysed by cross-correlation to detect any synchronous motor unit firing in the form of central peaks in the cross-correlation histograms. 2. The synchronization peaks were compared first in the case of 273 motor unit pairs tested in the preferred and non-preferred arms of two left-handed subjects and two right-handed subjects. The percentage of synchronized motor unit pairs was found to be significantly higher in the preferred arm with synchronization peaks significantly larger and broader than in the non-preferred arm. The narrow peaks (< 7.5 ms) likely to reflect the activity of common inputs to motoneurones were also found to be significantly larger in the preferred arm of all four subjects. 3. The handedness-related differences in synchronization were definitely confirmed in a total of 275 pairs of motor units tested in the left extensor carpi radialis muscles of fourteen right-handed subjects using their non-preferred arm and six left-handed subjects using their preferred arm. In order to determine whether the differences in synchronization were dependent on the motor unit type, each motor unit was characterized on the basis of its recruitment threshold and on the basis of the contraction time of its twitch extracted from the overall muscle force using the spike-triggered averaging method. Two populations of motor units were distinguished, namely the 'slow' motor units (recruitment thresholds < 0.4 N, contraction times > 40 ms) and the 'fast' motor units (recruitment thresholds > 0.6 N, contraction times < or = 40 ms). 4. In the non-preferred arm, the synchronization peaks were always fairly narrow, whatever the motor unit's biomechanical properties; whereas in the preferred arm, broad peaks were found to be particularly common among the pairs including one or two fast motor units, which also showed the largest rate of synchronization occurrence. 5. The narrow peaks (< 7.5 ms) were found to be consistently larger in the preferred than the non-preferred arm whatever the categories of motor unit pairs. In both arms, however, the amplitude of the narrow peaks tended to increase as the recruitment threshold of the motor unit decreased and as their contraction time increased.(ABSTRACT TRUNCATED AT 400 WORDS)

Comparison of fluctuations of motor unit recruitment and de-recruitment thresholds in man

Recruitment and de-recruitment thresholds of motor units in the wrist extensor muscles can undergo important random fluctuations, even when they are measured during stereotyped contractions and relaxations. These fluctuations were statistically quantified and compared. The statistical analysis indicated that recruitment and de-recruitment thresholds display the same kind of fluctuations, and that the successive measurements are randomly distributed following a quasi-normal law. We suggest that the notion of force threshold for motor unit recruitment and de-recruitment might be oversimplified and that a motor unit seems to have a range of force in which it can be recruited or de-recruited. Comparison of the mean values of recruitment and de-recruitment thresholds of the motor units in the extensor carpi radialis muscles showed that de-recruitment thresholds were significantly lower than recruitment thresholds. This difference in the thresholds, together with the difference in the motor unit discharge frequency during a contraction and a relaxation, suggests a differential control of the motoneurone activity during contractions and relaxations.

Effects of tonic vibration reflex on motor unit recruitment in human wrist extensor muscles

Tonic vibration reflex was used to investigate the effects of muscle spindle Ia afferent activation on motor unit (MU) recruitment in human wrist extensor muscles. The MU force recruitment threshold recorded in the extensor carpi radialis muscles were quantitatively compared under two experimental situations: (1) during tonic isometric reflex contractions induced by mechanical tendon vibration and during voluntary contractions performed at the same velocity; (2) during two voluntary imposed ramp contractions (0.25 N.s-1) performed the one immediately before, and the other immediately after a tonic vibration reflex. In the first situation, it was observed that the Ia afferents activated by tendon vibration exerted a strong homonymous facilitatory action on their bearing muscles (extensor carpi radialis longus and brevis), while their heteronymous action on the synergistic muscle (extensor carpi ulnaris) was very weak. The MU recruitment thresholds in the extensor carpi radialis muscles were therefore significantly lower during the tonic reflex contraction than during the voluntary contraction. In the second situation, the tonic vibration reflex induced a facilitatory after-effect which decreased the MU recruitment thresholds during the subsequent voluntary imposed ramp contraction. It is suggested that this post-vibratory effect may have been due either to a postsynaptic potentiation of the motoneurones or to a reflex sensitization of the muscle spindles increasing their response to voluntary isometric contraction and consequently, increasing their facilitatory reflex action on the motoneurone pool.

On the role of interleukin-2 (IL-2) in multiple sclerosis (MS). IL-2-mediated endothelial cell activation

Increased serum levels of IL-2 and sIL-2R can be demonstrated in patients with active MS, a finding that strongly supports the hypothesis of a systemic T cell activation in such patients. However, IL-2 may play a crucial role in MS immunopathology by activating endothelial cells, as suggested by the vascular leak syndrome complicating hrIL-2 therapy. Early BBB impairment and focal perivascular edema that characterize MS lesions may be the effect of an IL-2-induced cytokine cascade.

Growth factor (M-CSF) and antigenic properties of macrophages in meningioma

In meningiomas, transformed meningeal cells can share morphological aspects (in hemangiopericytic meningioma) and antigenic properties (i.e.: HLA-DR antigens expression) with elements of the monocyte/macrophage lineage. In this report, we describe a case of a highly vascular meningioma where numerous tumor cells, studied with immunohistochemical methods, present phenotypic properties of macrophages. Moreover, the cerebrospinal fluid (CF) analysis disclosed, using a biological assay, a high level of a growth factor for monocytic elements, the Macrophages Colony Stimulating Factor (M-CSF). Our findings may confirm that transitional aspects between different mesenchymal cells could be present in meningiomas.

Differential activation of motor units in the wrist extensor muscles during the tonic vibration reflex in man

1. Single motor unit activity was recorded in the extensor carpi radialis longus and extensor carpi radialis brevis muscles of five healthy human subjects, using metal microelectrodes. 2. Motor units were characterized on the basis of their twitch contraction times and their force recruitment thresholds during voluntary imposed-ramp contractions. 3. The discharge patterns of forty-three motor units were studied during tonic vibration reflex elicited by prolonged (150 s) trains of vibration (30 Hz) applied to the distal tendons of the muscles. The temporal relationships between the individual small tendon taps of the vibratory stimulus and the motor unit impulses were analysed on dot raster displays and post-stimulus time histograms. 4. After tendon taps, the impulses of motor units with long twitch contraction times (mean +/- S.D., 47.2 +/- 10.7 ms) and low recruitment thresholds (0.88 +/- 0.6 N) formed a single narrow peak (P1) with a latency (22.7 +/- 1.4 ms) which was comparable to that of the tendon jerk in the extensor carpi radialis muscles. These motor units were named 'P1 units'. On the other hand, the response of motor units with shorter twitch contraction times (31.1 +/- 3.3 ms) and higher recruitment thresholds (3.21 +/- 1.3 N) showed two peaks: a short latency (23.4 +/- 1.3 ms) P1 peak similar to the previous one and a P2 peak occurring 9.4 +/- 1.2 ms later. These motor units were named 'P1-P2 units'. 5. When the reflex contraction increased slowly, the P1 peaks of 'P1-P2 units' were clearly predominant at the beginning of the contraction, during the rising phase of the motor unit discharge frequency, while the P2 peaks became predominant when the units had reached their maximal discharge frequency. 6. Increasing the tendon vibration frequency (35, 55, 75, 95 Hz) did not modify the 'P1 unit' discharge pattern. Due to interference between vibration period and peak latencies, increasing the vibration frequency caused the P1 and P2 peaks of 'P1-P2 units' to overlap. 7. Superficial cutaneous stimulation of the dorsal side of the forearm during tendon vibration noticeably decreased the P1 peaks in both types of motor units. In the P2 peaks it could result in either a decrease or an increase but the average effect was a slight increase. 8. When applied 10 s before tendon vibration, cutaneous stimulation considerably suppressed the tonic vibration reflex.(ABSTRACT TRUNCATED AT 400 WORDS)