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Background. Despite the availability of evidence-based guidelines to diagnose and treat acute low-back pain, practical application is nonuniform and physician uncertainty regarding best practices is widespread. Objective. The objective of this study was to further optimal treatment choices for screening, diagnosing, and treating acute low-back pain caused by paraspinous muscle spasm. Methods. Four experts in pain medicine (three family physicians and one physiatrist) participated in a roundtable conference call on October 18, 2010, to examine current common practices and guidelines for diagnosing and treating acute low-back pain and to offer commentary and examples from their clinical experience. Results. Participants discussed the preferred choices and timing of diagnostic and imaging tests, nonpharmacologic therapies, nonopioid and opioid medication use, biopsychosocial evaluation, complementary therapies, and other issues related to treatment of acute low-back pain. Principal clinical recommendations to emerge included thorough physical exam and medical history, early patient mobilization, conservative use of imaging tests, early administration of muscle relaxants combined with nonsteroidal anti-inflammatory medications to reduce pain and spasm, and a strong emphasis on patient education and physician-patient communication. Conclusions. Early, active management of acute low-back symptoms during the initial onset may lead to better patient outcomes, reducing related pain and disability and, possibly, preventing progression to chronicity. [ABSTRACT FROM AUTHOR]

The objectives of the present study were to test the hypothesis that the costal diaphragm contracts during ipsilateral rotation of the trunk and that such trunk rotation increases the motor output of the muscle during inspiration. Monopolar electrodes were inserted in the right costal hemidiaphragm in six subjects, and electromyographic (EMG) recordings were made during isometric rotation efforts of the trunk to the right ("ipsilateral rotation") and to the left ("contralateral rotation"). EMG activity was simultaneously recorded from the parasternal intercostal muscles on the right side. The parasternal intercostals were consistently active during ipsilateral rotation but silent during contralateral rotation. In contrast, the diaphragm was silent in the majority of rotations in either direction, and whenever diaphragm activity was recorded, it involved very few motor units. In addition, whereas parasternal inspiratory activity substantially increased during ipsilateral rotation and decreased during contralateral rotation, inspiratory activity in the diaphragm was essentially unaltered and the discharge frequency of single motor units in the muscle remained at 13–14 Hz in the different postures. It is concluded that 1) the diaphragm makes no significant contribution to trunk rotation and 2) even though the diaphragm and parasternal intercostals contract in a coordinated manner during resting breathing, the inspiratory output of the two muscles is affected differently by voluntary drive during trunk rotation. [ABSTRACT FROM AUTHOR]

Abstract: An important factor for successful therapy of poisoning with organophosphorus compounds (OP) is the rapid restoration of blocked respiratory muscle function. To achieve this goal, oximes are administered for reactivation of inhibited acetylcholinesterase (AChE). Unfortunately, clinically used oximes, e.g. obidoxime and pralidoxime, are of limited effectiveness in poisoning with different OP nerve agents requiring the search for alternative oximes, e.g. HI 6. In view of substantial species differences regarding reactivation properties of oximes, the effect of HI 6 was investigated with sarin, tabun and soman exposed human intercostal muscle. Muscle force production by indirect field stimulation and the activity of the human muscle AChE was assessed. 30μM HI 6 resulted in an almost complete recovery of sarin blocked muscle force and in an increase of completely inhibited muscle AChE activity to approx. 30% of control. In soman or tabun exposed human intercostal muscle HI 6 (50 and 100μM) had no effect on blocked muscle force or on inhibited human muscle AChE activity. In addition, HI 6 up to 1000μM had no effect on soman blocked muscle force indicating that this oxime has no direct, pharmacological effect in human tissue. These results emphasize that sufficient reactivation of AChE is necessary for a beneficial therapeutic effect on nerve agent blocked neuromuscular transmission. [Copyright &y& Elsevier]

Abstract: Objective: TAP is a regional anaesthetic technique where local anaesthesic (LA) is injected between the internal oblique and the transversus abdominis muscles in order to block intercostal nerves. The technique originally described, is based on the identification of the lumbar triangle of Petit as the area where to insert the needle before the LA injection. We performed a study to determine, using ultrasonography, the actual location of the LA when TAP block was performed using landmark-based technique. Study design: Prospective and observational study. Methods: Fifty-two patients scheduled for ileostomy closure surgery under general anaesthesia received a TAP block (20mL 0.75% ropivacaine) based on standard anatomical landmarks technique. Ultrasonography was used immediately after the block to determine the LA placement. Failed blocks were considered when the patient required intravenous morphine in the immediate postoperative period for pain localised at the operative site. Results: LA solution was injected in the right place in 14 cases out of 52. Only one of these patient received morphine in the postoperative period. In the remaining 38 blocks, the LA was administered in adjacent anatomical structures and 25 failed. Two injections in the peritoneum were observed. Conclusion: The localization of LA after the TAP block being performed by landmark-based techniques is highly variable. In the majority of patients, the LA was injected in adjacent anatomical structures with unpredictable block results. This may promote the use of ultrasound-guided technique to perform the TAP block. [Copyright &y& Elsevier]

Purpose: In a descriptive, inventorial anatomical study we mapped the course of the 10th and 11th intercostal nerves, and the subcostal nerve in the abdominal wall to determine a safe zone for lumbotomy. Materials and Methods: We dissected 11 embalmed cadavers, of which 10 were analyzed. The 10th and 11th intercostal nerves, and the subcostal nerve were dissected from the intercostal space to the rectus sheath. Analysis was done using computer assisted surgical anatomy mapping. A safe zone and an incision line with a minimum of nerve crossings were determined. Results: The 10th and 11th intercostal nerves were invariably positioned subcostally. The subcostal nerve lay subcostally but caudal to the rib in 4 specimens. The main branches were located between the internal oblique and transverse abdominal muscles. The nerves branched and extensively varied in the abdominal wall. A straight line extended from the superior surface of the 11th and 12th ribs indicated a zone with lower nerve density. In 5 specimens the 10th and 11th intercostal nerves crossed this line from the superior surface of the 11th rib. In 5 specimens neither the 11th intercostal nerve nor the subcostal nerve crossed this extended line from the superior surface of the 12th rib up to 15 cm from the tip of the rib. Conclusions: Damage is inevitable to branches of the 10th or 11th intercostal nerve, or the subcostal nerve during lumbotomy. However, an incision extending from the superior surface of the 11th or 12th rib is less prone to damage these nerves. Closing the abdominal wall in 3 layers with the transverse abdominal muscle separately might prevent damage to neighboring nerves. [Copyright &y& Elsevier]

Rationale Patients with suboptimal asthma control often have nocturnal symptoms which wake them, causing sleep fragmentation. Objectives It was hypothesised that symptomatic patients were more accurately identified by measuring respiratory effort using chest wall electromyography than by pulmonary function testing. Methods Nocturnal electrical activity of the parasternal intercostal muscles (EMGpara) in the second intercostal space was measured in subjects with controlled (diurnal peak expiratory flow (PEF) variability <20%, n=12) and uncontrolled (diurnal PEF variability >20%, n=12) asthma, and it was compared with that in normal subjects (n=12). Results Subjects with controlled and uncontrolled asthma did not differ significantly in age (mean (SD) 42 (17) vs 46 (17) years, p=0.64), body mass index (BMI; 26.6 (2.9) vs 27.5 (3.5) kg/m2, p=0.48) or gender distribution (males:females, 6:6 vs 7:5, p=0.68); the normal subject group was younger (27 (11) years, p=0.011) and slimmer (BMI 21.1 (2.9) kg/m2, p<0.001). An elevated respiratory disturbance index (RDI) was associated with poor asthma control (RDI in normals 0.5 (0.9), in controlled asthma 4.0 (1.9), p<0.001, and in poorly controlled asthma 7.4 (4.3) h-1; p<0.021). Similarly, EMGpara%max (normals 4.9 (3.2)% max evening, 4.9 (3.5)%max morning) was higher in controlled asthma (7.2 (2.3)%max evening, 8.1 (4.0)% max morning, p=0.049) and higher still in uncontrolled asthma (16.8 (14.2)%max in the evening, 18.4 (11.6)% max in the morning, p<0.008). Conclusions Nocturnal respiratory effort is increased in those with asthma and neural respiratory drive is more variable in patients with poorly controlled asthma. Changes in the EMGpara inversely reflect changes in pulmonary function tests. Measuring the EMGpara offers a method to monitor asthma breath-by-breath while subjects are asleep, which could be adapted for home use. [ABSTRACT FROM AUTHOR]

Emerging evidence indicates that, besides dyspnea relief, an improvement in locomotor muscle oxygen delivery may also contribute to enhanced exercise tolerance following normoxic heliox (replacement of inspired nitrogen by helium) administration in patients with chronic obstructive pulmonary disease (COPD). Whether blood flow redistribution from intercostal to locomotor muscles contributes to this improvement currently remains unknown. Accordingly, the objective of this study was to investigate whether such redistribution plays a role in improving locomotor muscle oxygen delivery while breathing heliox at near-maximal [75% peak work rate (WRpeak)], maximal (100%WRpeak), and supramaximal (115%WRpeak) exercise in COPD. Intercostal and vastus lateralis muscle perfusion was measured in 10 COPD patients (FEV1 = 50.5 ± 5.5% predicted) by near-infrared spectroscopy using indocyanine green dye. Patients undertook exercise tests at 75 and 100%WRpeak breathing either air or heliox and at 115%WRpeak breathing heliox only. Patients did not exhibit exercise-induced hyperinflation. Normoxic heliox reduced respiratory muscle work and relieved dyspnea across all exercise intensities. During near-maximal exercise, quadriceps and intercostal muscle blood flows were greater, while breathing normoxic heliox compared with air (35.8 ± 7.0 vs. 29.0 ± 6.5 and 6.0 ± 1.3 vs. 4.9 ± 1.2 ml∙min-1∙100 g-1, respectively; P < 0.05; mean ± SE). In addition, compared with air, normoxic heliox administration increased arterial oxygen content, as well as oxygen delivery to quadriceps and intercostal muscles (from 47 ± 9 to 60 ± 12, and from 8 ± 1 to 13 ± 3 mlO2∙min-1∙100 g-1, respectively; P < 0.05). In contrast, normoxic heliox had neither an effect on systemic nor an effect on quadriceps or intercostal muscle blood flow and oxygen delivery during maximal or supramaximal exercise. Since intercostal muscle blood flow did not decrease by normoxic heliox administration, blood flow redistribution from intercostal to locomotor muscles does not represent a likely mechanism of improvement in locomotor muscle oxygen delivery. Our findings might not be applicable to patients who hyperinflate during exercise. [ABSTRACT FROM AUTHOR]

The respiratory central pattern generator distributes rhythmic excitatory input to phrenic, intercostal, and hypoglossal premotor neurons. The degree to which this input shapes motor neuron activity can vary across respiratory muscles and motor neuron pools. We evaluated the extent to which respiratory drive synchronizes the activation of motor unit pairs in tongue (genioglossus, hyoglossus) and chest-wall (diaphragm, external intercostals) muscles using coherence analysis. This is a frequency domain technique, which characterizes the frequency and relative strength of neural inputs that are common to each of the recorded motor units. We also examined coherence across the two tongue muscles, as our previous work shows that, despite being antagonists, they are strongly coactivated during the inspiratory phase, suggesting that excitatory input from the premotor neurons is distributed broadly throughout the hypoglossal motoneuron pool. All motor unit pairs showed highly correlated activity in the low-frequency range (1-8 Hz), reflecting the fundamental respiratory frequency and its harmonics. Coherence of motor unit pairs recorded either within or across the tongue muscles was similar, consistent with broadly distributed premotor input to the hypoglossal motoneuron pool. Interestingly, motor units from diaphragm and external intercostal muscles showed significantly higher coherence across the 10-20-Hz bandwidth than tongue-muscle units. We propose that the lower coherence in tongue-muscle motor units over this range reflects a larger constellation of presynaptic inputs, which collectively lead to a reduction in the coherence between hypoglossal motoneurons in this frequency band. This, in turn, may reflect the relative simplicity of the respiratory drive to the diaphragm and intercostal muscles, compared with the greater diversity of functions fulfilled by muscles of the tongue. [ABSTRACT FROM AUTHOR]

Autologous breast reconstruction with the latissimus dorsi (LD) musculocutaneous flap has several problems including scarcity of tissue and postoperative atrophy of muscles. We report a modification of the flap based on a re-evaluation of the intramuscular and perforating vascular anatomy focused on the intercostal vascular system. Our anatomical study confirmed the following technical improvements: splitting of the muscle oriented along the 10th posterior intercostal artery; siting the axis of the flap on the centre of the 10th lateral intercostal artery perforator to obtain ample subcutaneous fat cranial to the iliac crest; and enclosing the dermoadipofascial flap around the split muscular pedicle. These flaps were used in 12 patients who required reconstruction without implants. The results showed a consistent volume of tissue and shape, and less donor site morbidity. Our modifications can be used to improve the three-dimensional potential of the LD flap in autologous breast reconstruction. [ABSTRACT FROM AUTHOR]

Objective: It is difficult to cover a large skin and soft tissue defect with exposure of the ilium. We therefore performed a new reconstruction technique, using a reverse latissimus dorsi muscle flap fed by perforating branches of only the 10th intercostal artery. Methods: A 45-year-old man had a large traumatic defect located on the hip with exposure of the iliac crest. After confirming and preserving perforating branches of the 10th intercostal artery, the latissimus dorsi muscle flap was turned over just proximal to the perforating branch, and a split-thickness skin graft was performed over the flap. Results: The skin graft took place well and there were no circulation problems. Conclusions: This flap covered a larger area on the hip than the musculocutaneous flap. Furthermore, this is easier to perform and is less invasive than a vascularized free flap. Skin and soft tissue defects that expose bones of the lumbar or hip region can be reconstructed with a local flap; however, the deficit is small for this coverage and usually there is little skin and soft tissue to cover the wound defect in the surrounding area. Thus, it is often difficult to deal with large defects. We performed a reconstruction, using a reverse latissimus dorsi flap fed by perforating branches of the 10th intercostal artery for a large skin and soft tissue defect of the hip with exposure of the iliac crest, resulting in a good outcome. This technique is thought to be useful for reconstruction when the ilium is exposed, and we report the case and surgical procedure. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The video-assisted thoracoscopic approach (video-assisted thoracic surgery (VATS)) to lobectomy for non-small-cell lung cancer (NSCLC) is not standardised. Although three to four incisions are usually made, with the right surgical technique, the operation can be successfully carried out using only two incisions. We have analysed retrospectively, the characteristics and postoperative evolution of patients undergoing VATS lobectomies using two ports. Methods: From June 2007 to November 2009, we carried out 131 major pulmonary resections by VATS, of which 40 (February 2009 to November 2009) were realised using only two incisions: one 1-cm incision through the 7th/8th intercostal space in the mid-axillary line, and a 3–5-cm anterior utility incision in the 5th intercostal space. The patients’ mean age was 60.8±11.4 years (75% male, 25% female). Results: The conversion rate was 10% (four patients). Of the remaining 36 cases, the diagnosis in six patients was benign, and in four was metastatic disease. Of the 26 cases with NSCLC, the most frequent stage was that of interactive application (IA) (58%) and histology mostly revealed adenocarcinoma (33%). Mean duration of surgery in the 36 resections completed by VATS was 168.6±54.0min (range 80–300min). The median chest tube duration was 2.5 days and the median length of stay in hospital was 3 days. There was no perioperative mortality in completed VATS cases, and no patient needed to be re-operated. Those patients with chronic obstructive pulmonary disease (COPD) needed longer hospital stays (p =0.046). Similarly, extreme cases of adhesion during surgery needed more days of thoracic drainage (p =0.040) and longer hospital stays (p =0.011), as well as displaying a higher percentage of postoperative complications (p =0.008). If the group of patients is divided in two periods (February to July 2009 and August to November 2009), more extended lymphadenectomies are observed among those performed during the latter period. Conclusions: VATS lobectomy with two incisions is a safe and reliable procedure producing good postoperative results. As we obtain more experience over time, results improve, especially in the performance of more extended lymphadenectomies. [Copyright &y& Elsevier]

Background: Internal mammary node (IMN) metastasis has a similar prognostic importance as axillary nodal involvement. However, sampling of IMN is not performed routinely. Aims: To evaluate a simplified method for internal mammary sentinel node (IMSN) biopsy of breast cancer patients. Methods: A combination of simultaneous perilesional and intradermal radiocolloid injections over the lesion was used. All IMSNs were confirmed by lymphoscintigraphy and Carbon Nanoparticles Suspension Injection preoperatively and excised extrapleurally through the intercostal muscles. Results: Twenty-three of the 94 patients were found to have metastatic disease in the IMSNs. Four of 65 patients had metastases in the IMNs but not in the axilla. All 23 patients with positive IMSN were upstaged and received radiation to the internal mammary chain. The time from separating the pectoral major muscle to touch the node was ranged 21-48 min. The detecting sensitivity combined with preoperative lymphoscintigraphy, intraoperative gamma probe detection, and intraoperative black dye methods for IMSN was 100%. Conclusions: The approach used is a reliable surgical technique for removing IMSN. It can improve the nodal staging in breast cancer with IMN metastases. [ABSTRACT FROM AUTHOR]

Objective: Constrictive pericarditis (CP) requires pericardiectomy but the choice of surgical approach remains controversial. Hence we have reviewed our experience of pericardiectomy carried out for CP and compared the results of pericardiectomy performed by median sternotomy versus left thoracotomy with regard to functional outcomes. Methodology: The study group consisted of 33 patients with CP who underwent pericardiectomy from May 1999 to January 2010 at our institution. There were 22 female and 11 male patients, ranging in age from 5 to 57 years with a mean age of 45 years. Pericardiectomy was performed via median sternotomy in 17 patients (Group A). In the remaining 16 patients (Group B), pericardiectomy was performed via a left anterolateral thoracotomy in the fifth intercostal space. Results: During the subsequent follow-up, both groups of patients showed a similar and significant improvement in New York Heart Association (NYHA) functional class. In the group A, the mean NYHA functional class decreased from 3.3 ± 0.7 to 1.8 ± 0.5 (P = 0.0004). In group B, the mean functional class decreased from 3.2± 0.9 to 1.6 ± 0.6 (P = 0.00005). Also, both groups had a similar and significant improvement in their mean CVP. In the group A, the mean central venous pressure (CVP) decreased from 15.2±3.1 mmHg to 8.3±3.2 mmHg (P<0.005). In the group B, the mean CVP decreased from 15.1±4.9 mmHg to 7.7±2.4 mmHg (P<0.004). Conclusion: Constrictive physiopathology is a problem primarily of the ventricles and can be alleviated by decorticating both the right and left ventricles. Therefore, CP could be relieved through the left thoracotomy or median sternotomy in most cases. However, echocardiographic findings should be considered to prefer thoracotomy or sternotomy approach. [ABSTRACT FROM AUTHOR]

We report a case of an 11-year-old girl who presented with a slowly enlarging mass in the right posterolateral chest wall. Computed tomography showed a soft-tissue mass 8.5 x 7.5 x 5.5 cm in size, arising from the right posterolateral 9th, 10th, and 11th intercostal spaces. Magnetic resonance imaging confirmed a vascular mass. The patient underwent complete resection of the tumor, together with the right 8th, 9th, 10th, 11th, and 12th ribs and their intercostal muscles. Reconstruction of the chest wall was performed with methyl methacrylate and Marlex mesh. Histopathologic examination of the tumor confirmed an intercostal cavernous hemangioma. At last examination, 6 months after the operation, the child was doing well, with no evidence of recurrence. [ABSTRACT FROM AUTHOR]

We investigated whether expiratory muscle loading induced by the application of expiratory flow limitation (EFL) during exercise in healthy subjects causes a reduction in quadriceps muscle blood flow in favor of the blood flow to the intercostal muscles. We hypothesized that, during exercise with EFL quadriceps muscle blood flow would be reduced, whereas intercostal muscle blood flow would be increased compared with exercise without EFL. We initially performed an incremental exercise test on eight healthy male subjects with a Starling resistor in the expiratory line limiting expiratory flow to ~ 1 1/s to determine peak EFL exercise workload. On a different day, two constant-load exercise trials were performed in a balanced ordering sequence, during which subjects exercised with or without EFL at peak EFL exercise workload for 6 min. Intercostal (probe over the 7th intercostal space) and vastus lateralis muscle blood flow index (BFI) was calculated by near-infrared spectroscopy using indocyanine green, whereas cardiac output (CO) was measured by an impedance cardiography technique. At exercise termination, CO and stroke volume were not significantly different during exercise, with or without EFL (CO: 16.5 vs. 15.2 l/min, stroke volume: 104 vs. 107 ml/beat). Quadriceps muscle BFI during exercise with EFL (5.4 nM/s) was significantly (P = 0.043) lower compared with exercise without EFL (7.6 nM/s), whereas intercostal muscle BFI during exercise with EFL (3.5 nM/s) was significantly (P = 0.021) greater compared with that recorded during control exercise (0.4 nM/s). In conclusion, increased respiratory muscle loading during exercise in healthy humans causes an increase in blood flow to the intercostal muscles and a concomitant decrease in quadriceps muscle blood flow. [ABSTRACT FROM AUTHOR]

Purpose: to analyze the definition of breath support, as well as the strategies used to achieve it and their benefits according to both singing teachers and Speech Language Pathologists (SLP). Methods: six professionals experienced in singing voice answered an interview on issues pertaining to singing breath support. The answers were submitted to content analysis from where four categories were derived: definition of breathing support, type of support, strategies and benefits. Results: the aspects that were most often reported by the professionals are: the definition of breath support is related to the participation of the diaphragm and intercostal muscles; the most adequate type of support is intercostal and diaphragmatic; among the strategies used to improve breathing support, the most commonly mentioned were body perception, awareness of the muscles involved in the process, air flow balance, tension relief and posture alignment. There are discrepancies as for the abdominal contraction, use of different objects as guidelines, mental imagery, and use of singing exercises - vocalizes. According to the interviewed subjects, the greatest benefit of breath support lies in the relief of laryngeal tensions and improvement of respiratory coordination. There was a low level of agreement about the benefits of support, especially with regards to the improvement of the singing voice. Conclusion: the results point out to a convergence of opinions as for most of the interviewed subjects when considering the definition, approach strategies and benefits of breathing support, however, still with no consensus on the subject. [ABSTRACT FROM AUTHOR]

Abstract: High frequency spinal cord stimulation (HF-SCS) is a novel and more physiologic method of inspiratory muscle activation which involves stimulation of spinal cord pathways. In the present study, we determined if activation of the inspiratory intercostal muscles alone by this technique could be utilized to maintain artificial ventilation. In 7 anesthetized dogs, following C2 spinal cord section and bilateral phrenicotomy, trains of electrical stimulation (12times/min) were applied at the T2 level. Eucapnea was maintained during an initial 5.5h period of continuous stimulation. During a subsequent 0.5h period, stimulus parameters were increased to induce hyperventilation resulting in a sustained fall in end-tidal to 29.3±0.4mmHg. Single motor unit peak firing frequencies of the intercostal muscles during HF-SCS were similar to those occurring during spontaneous breathing. This technique holds promise as a method to restore ventilation in ventilator-dependent tetraplegics who do not have adequate phrenic nerve function for diaphragm pacing. [Copyright &y& Elsevier]

In this review, we discuss the central non-neuraxial regional anaesthesia blocks of the abdomen, including intercostal and intrapleural blocks, rectus sheath and ilioinguinal-iliohypogastric blocks, transversus abdominis plane blocks and paravertebral blocks. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Intracostal suture or intercostal muscle flap can reduce post-thoracotomy pain through the preservation of intercostal nerves below or above the incision. This study aims to test whether combining intracostal suture with intercostal muscle flap might achieve better pain relief than intracostal suture alone. Methods: This study included 144 consecutive patients who underwent pulmonary resection. Eighty patients entered the trial but eight were excluded. Seventy-two patients were randomly assigned to a muscle flap group, in which the fifth intercostal muscle and neurovascular bundle were raised and intracostal suture on the sixth rib was applied. For the control group, only intracostal suturing on the sixth rib was done. All patients had a functional epidural placed, which were removed 24h after surgery. Differences on average numeric rating scale (aNRS) scores were assessed in an early post-operative period from day 1 to day 7 and a later period from week 2 to week 12, when patients were resting or coughing. The doses of oxycodone demand and hyperalgesia-related intercostal dermatomes (HIDs) were recorded for analysis. Results: No differences were noted between the two groups in terms of length and width of the incision, or duration of rib retraction. Neither in different time periods (early or late) nor the activity status (while resting or coughing) yielded a statistical difference on aNRS scores between the muscle flap group and the control group (muscle flap group vs control group: mean (95% confidence intervals) from d ay 1 to day 7, 4.42 (1.56–7.28) vs 4.79 (2.03–7.55) on coughing (p =0.282); median (inter-quartile range, IQR) from day 1 to day 7, 1.71 (0.86–3) vs 2.50 (1.16–3.12) while resting (p =0.279); median (IQR) from week 2 to week 12, 0.43 (0–0.86) vs 0.48 (0.06–1.20) on coughing (p =0.595); median (IQR) from week 2 to week 12, 0 (0–0.14) vs 0.05 (0–0.14) while resting (p =0.856)). No differences were found in total oxycodone consumption from day 1 to day 7 between the two groups (Z =−1.821, p =0.069). The rate of HIDs in each intercostal space and median number of HIDs were similar between the two groups on day 1 (p >0.05) and day 7 (p >0.05). Conclusions: The combination of intracostal suture with intercostal muscle flap may not necessarily achieve better post-thoracotomy pain control than using intracostal suture alone. [Copyright &y& Elsevier]

Background: Long-term postoperative pain in open thoracotomy patients could be related to injured intercostal nerves, and several methods have been devised to protect these nerves. Methods: We retrospectively reviewed 184 consecutive patients who underwent posterolateral or anteroaxillary thoracotomy. Postoperative pain was routinely evaluated using an 11-point numerical pain rating scale (0 [no pain] to 10 [most severe pain]) at 1 to 2 weeks; 2 weeks to 1 month; and 1 to 2, 2 to 4, 4 to 6, 6 to 9, and 9 to 12 months after surgery. The following steps were considered to protect the intercostal nerves. During chest retraction, an intercostal muscle flap was harvested before using the retractor to prevent compression of the cranial intercostal nerve in posterolateral thoracotomy patients who needed buttressing of the bronchial stump. During closure, the thin space between the inferior edge of caudal rib and the intercostal neurovascular bundle was sutured to prevent strangulation of the intercostal nerve and vessels on the caudal side (edge closure technique). Subjects included 141 posterolateral and 43 anteroaxillary thoracotomies, 72 intercostal muscle flaps, and 87 conventional closures and 97 edge closures. Results: During a year postoperatively, posterolateral thoracotomy patients experienced more pain (range, 1.2 to 4.6) than anteroaxillary thoracotomy patients (range, 1.1 to 3.7; p = 0.038 for all periods). Patients with the intercostal muscle flap tended to experience less pain than those without the flap during the first month postoperatively. The scores of patients having edge closure (range, 0.9 to 3.8) were significantly lower than those of patients undergoing conventional closure (range, 1.6 to 5.1; p < 0.001 for all periods). Conclusions: The edge closure technique, which preserved the caudal intercostal neurovascular bundle, successfully reduced pain. [Copyright &y& Elsevier]

Near-infrared spectroscopy (NIRS) with the tracer indocyanine green (ICG) may be used for measuring muscle blood flow (MBF) during exercise, if arterial ICG concentration is measured simultaneously. Although pulse dye densitometry allows for noninvasive measurement of arterial dye concentration, this technique is sensitive to motion and may not be applicable during exercise. The aim of this study was to evaluate a noninvasive blood flow index (BFI), which is derived solely from the muscle ICG concentration curve. In 10 male cyclists 5 mg ICG were injected into an antecubital vein at rest and during cycling at 30, 60, 70, 80, 90, and 100% of previously determined maximal work load. Simultaneously blood was withdrawn through a photodensitometer at 20 mI/mm from the radial artery to measure arterial ICG concentration. To measure muscle tissue ICG concentrations, two sets of NIRS optodes were positioned on the skin, one over the left seventh intercostal space and the other over the left vastus lateralis muscle. MBF was calculated from the arterial and muscle concentration data according to Fick's principle. BFI was calculated solely from the muscle concentration curve as ICG concentration difference divided by rise time between 10 and 90% of peak. During exercise mean BFI values changed similarly to MBF in both intercostal and quadriceps muscles and showed excellent correlations with MBF: r = 0.98 and 0.96, respectively. Individual data showed some scattering among BFI and MBF values but still reasonable correlations of BFI with MBF: r = 0.73 and 0.72 for intercostal and quadriceps muscles, respectively. Interobserver variability, as analyzed by Bland-Altman plots, was considerably less for BFI than MBF. These data suggest that BFI can be used for measuring changes in muscle perfusion from rest to maximal exercise. Although absolute blood flow cannot be determined, BFI has the advantages of being essentially noninvasive and having low interobserver variability. [ABSTRACT FROM AUTHOR]

The pancreas is a challenge for the beginner in ultrasonography, but patience, perseverance and experience will lead to a complete and correct evaluation of the organ in almost all cases. A correct examination of the pancreas requires the patient's fasting 7 to 8 hours before the examination. Transverse and longitudinal upper epigastric sections are used to visualize the pancreas, as well as oblique intercostal and subcostal sections (especially for the head and tail). The best ultrasound windows are obtained by using high epigastric sections (that avoid the colon), also by using transgastric sections and sections that use the left liver lobe as an acoustic window. In order to better visualize the pancreas, it is useful to invite the patient to drink 500-700 ml of still water 10-15 minutes before the examination. To highlight the pancreas, we will start by viewing the landmarks: posterior - the porto-splenic axis and anterior - the gastric antrum and/or the left liver lobe. The echogeneity of the normal pancreas can vary, from hypoechoic to hyperechoic, all normal, provided that the pancreatic parenchyma structure is fine and homogeneous. The Wirsung duct can be visualized in some of the cases, especially in thin patients, its normal maximum diameter should be < 2mm. For a correct evaluation of the pancreas all its segments must be visualized: head, uncinate process, body, and tail - the latter being the most difficult to visualize. [ABSTRACT FROM AUTHOR]

During isolated phrenic nerve stimulation, the muscles of the diaphragm shorten by 40-50% of their optimal length, and the force in the muscle and transdiaphragmatic pressure (Pdi) depend on the final muscle length. The muscle shortening depends on the load imposed on the diaphragm by pleural and abdominal pressures during a particular maneuver. The mechanics of the interaction between the diaphragm and the load is well understood, but the force-length properties of the diaphragm are nonlinear, and an algebraic analysis of the interaction is clumsy. Here we describe a graphical analysis of the interaction. The variable muscle length is transformed into an equivalent variable, i.e., volume displaced by the diaphragm (Vdi), to obtain the characteristic line for the diaphragm, a graph of Pdi vs. Vdi for a given level of activation. The load is described by the same variables. Therefore, load lines can be drawn on the same graph, and the equilibrium point for the diaphragm is given by the intersection of the load line with the characteristic line of the diaphragm. Graphical analyses of the volume dependence of the respiratory effects of diaphragm and intercostal muscle activation and for the interaction between them are shown. [ABSTRACT FROM AUTHOR]

Objective: There has been no study on the measurement of blood flow of the intercostal artery (ICA) or lumbar artery (LA) with the use of transthoracic Doppler sonography. Here, the method of the ICA depiction and flow measurement were described, and we suggested the clinical usage of this method. Methods: Twelve healthy subjects were examined. The performance of transthoracic Doppler sonography was approached from the back on lateral decubitus position. The intercostal artery was depicted by two-dimension mode with color flow, and the inner diameter was measured. Peak systolic velocity (PSV), end-diastolic velocity (EDV), velocity-time integral (VTI), and heart rate (HR) were measured with pulsed Doppler, and the blood flow was calculated. Results: Bilateral ICAs and LAs from Th4 to L4 were measurable with this method. The PSV of Lt Th9 was the fastest at 43.3 ± 10.1 cm/sec and the PSV of the ICAs gradually decreased as distance from Th9 increased. As for the flow volume, the left Th11 was the greatest at 99.7 mL/min, and the flow volume of the ICA gradually decreased as distance from Th11 increased. The velocity and blood flow of right ICA tended to be lower than the left in the same spinal level. Conclusions: Evaluation technique of serial ICAs and LAs was shown. We think that it may be a clinically useful method in the study of spinal cord circulation in the repair of cases of descending thoracic or thoracoabdominal aortic aneurysm. (Echocardiography 2010;27:17-20) [ABSTRACT FROM AUTHOR]

Background: Intercostal nerve damage is often suggested to be the cause of pain after thoracotomy. Methods: This was a prospective randomized study of 120 patients who had posterolateral thoracotomy. They were equally divided into two groups, the first in which intercostal muscle flap and intracostal sutures were used, and the other group in which the usual pericostal sutures were used. These two groups were compared regarding operative time, rib fracture, postoperative pulmonary functions, time to ambulation, pain score in the first week, doses of analgesics injected in the epidural catheter, postoperative complications, chest tube drainage, hospital stay, return to daily activities, and pain score and use of analgesics at 1, 3, and 6 months. Results: Postoperative pain score throughout the first week was significantly lower in the patients in the intercostal muscle flap group, who had also a significantly earlier postoperative ambulation and return to normal daily activities, and received significantly lower doses of postoperative analgesics. After 1 month, patients in the intercostal muscle flap group had a significantly lower pain score and use of analgesics. After 3 months, pain score was not significantly different between both groups, but the use of analgesics was significantly lower in the intercostal muscle flap group. After 6 months, no significant difference was present between both groups with regard to pain score or the use of analgesics. Conclusions: Intercostals muscle flap and intracostal sutures are rapid, safe, and effective procedures in decreasing early pain after thoracotomy with subsequent earlier return to normal daily activities and lesser use of analgesics. [Copyright &y& Elsevier]

Abstract: Transcatheter arterial chemoembolization is one of the most common treatment modalities for hepatocellular carcinoma. Transcatheter arterial chemoembolization is considered to be a relatively safe procedure, but transcatheter arterial chemoembolization is associated with a number of disastrous complications. Among the ischaemic complications caused by transcatheter arterial chemoembolization, spinal cord injury is very rare, but can occur via the intercostal or lumbar arteries. We report two cases of extremely rare spinal cord injuries after transcatheter arterial chemoembolization in patients with hepatocellular carcinoma. The patients had sensory loss below the T9 or T10 dermatomes and paraparesis or paraplegia within 6–8h after transcatheter arterial chemoembolization. One patient sustained paraplegia until death 2 months after transcatheter arterial chemoembolization and the other patient recovered almost completely 2 months after transcatheter arterial chemoembolization. [Copyright &y& Elsevier]

Sternal foramina (SF) constitute developmental defects of the sternum and are usually radiologic or postmortem accidental findings. A rare case is presented, concerning the dried sternum of Greek origin and unknown age. The manubrium, sternal body and xiphoid process were fused and ossified, while two SF of undocumented size were present. The proximal SF was located at the sternal body extending between the fourth and fifth intercostal spaces, whereas the distal SF was located at the xiphoid process being surrounded by a thin 'ring-like' osseous rim. Computed tomography was utilized for further investigation. Awareness of this variation is essential for the radiologist to avoid misdiagnosis and interpret with accuracy the current combination of normal anatomic variants. Moreover, SF existence is associated with clinical and forensic implications that are shortly discussed. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 65-year-old woman diagnosed with intercostal schwannoma caused by persistent back pain. Topics discussed include the medical history of the patient, the diagnosis of her disease, the results of her medical examinations, and the improvement of her health condition following her treatment.

Copyright of Brazilian Journal of Pulmonology / Jornal Brasileiro de Pneumologia is the property of Sociedade Brasileira de Pneumologia e Tisiologia and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract: Phrenic nerve pacing (PNP) is a clinically useful technique to restore inspiratory muscle function in patients with respiratory failure secondary to cervical spinal cord injury. In this review, patient evaluation, equipment, methods of implementation, clinical outcomes, and the complications and side effects of PNP are discussed. Despite considerable technical development, and clinical success, however, current PNP systems have significant limitations. Even in patients with intact phrenic nerve function, PNP is successful in achieving full-time support in ∼50% of patients. Inadequate inspired volume generation may arise secondary to incomplete diaphragm activation, reversed recruitment order of motor units, fiber type conversion resulting in reduced force generating capacity and lack of coincident intercostal muscle activation. A novel method of pacing is under development which involves stimulating spinal cord tracts which synapse with the inspiratory motoneuron pools. This technique results in combined activation of the intercostal muscles and diaphragm in concert and holds promise to provide a more physiologic and effective method of PNP. [Copyright &y& Elsevier]

Objectives: To establish the efficacy of nephrolithotripsy via intercostal access route vs subcostal access route with respect to attained stone-free status, operating time, and complications. Methods: Percutaneous nephrolithotripsies via the upper pole were performed in 142 patients (93 male, 49 female, age 24-78 years) from 1998 to 2005 at our 4 academic medical centers. Selection criteria for nephrolithotripsy via upper pole access were staghorn calculi ≥5.5 cm3, upper pole calyx calculi ≥2.5 cm, and abnormal or high lying kidney, often in combination with obesity. Of 68 staghorn calculi, 49 were accessed via intercostal and 19 via subcostal route. Of 57 upper calyx calculi 38 were accessed via intercostal and 19 via subcostal route; all calculi in the upper ureter considered easily accessible via the intercostal route. Results: Of 103 patients with intercostal access, 91 attained a stone-free status. There were 4 major and 6 minor complications. Depending on stone location, mean operating times varied from 42 to 152 minutes. Of 39 patients in whom a subcostal access route was chosen, 29 were made stone-free. There were 3 major and 8 minor complications. The mean operating time varied from 108 to 145 minutes. Conclusions: The significantly higher rate of achieving stone-free status, lower rate of complications, and markedly reduced operating time when using intercostal access make this the route of choice for upper pole nephrolithotripsy. [Copyright &y& Elsevier]

Abstract: Objective: Chronic empyaema deteriorates lung function and causes thoracic asymmetry due to intercostal narrowing in the diseased hemithorax. This study aims to investigate the rates of improvement in the pulmonary function tests (PFTs) and the thoracic deformity in late postoperative period of lung decortication, performed for chronic empyaema. Methods: A total of 50 patients who underwent standard open decortication for empyaema were included. The PFTs and computed tomographic (CT) scans of the chest were analysed in all patients after 6–58 months postoperatively. The measurements of antero-posterior and transverse diameters of both hemithoraxes were performed on both preoperative and postoperative chest CTs. The thoracic asymmetry was calculated as the ratio of the measurements of the diseased side to the normal side. The pre- and postoperative parameters were compared statistically. Results: The mean preoperative forced expiratory volume in first second (FEV1) and forced vital capacity (FVC) increased from 61.40% and 60.89% to 78.92% and 77.48%, respectively, in the late postoperative period (p <0.001). The mean preoperative transverse diameter of affected hemithorax increased from 11.22cm to 11.98cm (p <0.001) and, the transverse asymmetry improved from 11.52% to 5.94%, postoperatively (p <0.001). The mean preoperative antero-posterior chest diameter improved from 15.58cm to 16.67cm (p <0.001), and the antero-posterior asymmetry improved from 11.42% to 5.42% (p <0.001) in the late postoperative period. Conclusions: The open decortication for chronic pleural empyaema significantly increases FEV1 and FVC. Due to the re-expansion of the lung and enlargement of the intercostal spaces, the chest wall deformity also improves considerably after the operation. [Copyright &y& Elsevier]

Respiratory muscles with dual respiratory and non-respiratory functions (e.g. the pharyngeal and intercostal muscles) show greater suppression of activity in sleep than the diaphragm, a muscle almost entirely devoted to respiratory function. This sleep-related suppression of activity is most apparent in the tonic component of motor activity, which has functional implications of a more collapsible upper airspace in the case of pharyngeal muscles, and decreased functional residual capacity in the case of intercostal muscles. A major source of tonic drive to respiratory motoneurons originates from neurons intimately involved in states of brain arousal, i.e. neurons not classically involved in generating respiratory rhythm and pattern per se. The tonic drive to hypoglossal motoneurons, a respiratory motor pool with both respiratory and non-respiratory functions, is mediated principally by noradrenergic and glutamatergic inputs, these constituting the essential components of the wakefulness stimulus. These tonic excitatory drives are opposed by tonic inhibitory glycinergic and γ-amino butyric acid (GABA) inputs that constrain the level of respiratory-related motor activity, with the balance determining net motor tone. In sleep, the excitatory inputs are withdrawn and GABA release into the brainstem is increased, thus decreasing respiratory motor tone and predisposing susceptible individuals to hypoventilation and obstructive sleep apnoea. [ABSTRACT FROM AUTHOR]

Introduction: Type 1 Brugada ECG is essential for the diagnosis of Brugada syndrome. We aimed to evaluate the usefulness of multichannel Holter ECG recording in the third intercostal space for detecting type 1 Brugada ECG. Methods and Results: We enrolled 60 consecutive individuals with type 1 Brugada ECG and 31 individuals with type 2 or 3 Brugada ECG, in the presence or absence of Na+ channel blockers. All individuals underwent 12-lead ECGs recorded in the standard position and the third intercostal space at least 5 times every 3 months (4L-ECGs, 3L-ECGs, respectively) and multichannel Holter ECG. On multichannel Holter ECG, the precordial electrodes were attached at standard positions (4L-Holter) and the third intercostal space (3L-Holter) for leads V1 and V2. Among the 60 individuals, type 1 Brugada ECG in 4L-ECGs, 3L-ECGs, 4L-Holter, and 3L-Holter was detected in 15 (25%), 26 (43.3%), 23 (38.3%), and 33 individuals (55%), respectively, whereas detected in none of the 31 individuals. The documented duration of type 1 Brugada ECG on 3L-Holter was significantly longer than that on 4L-Holter (700 ± 467 vs 372 ± 422 min; P = 0.01, 3L-Holter vs 4L-Holter, respectively), and type 1 Brugada ECG was most frequently observed between 6 pm and 12 pm. Neither the presence nor the duration of the appearance of type 1 Brugada ECG differed significantly between symptomatic and asymptomatic individuals. Conclusion: Multichannel Holter ECG recording in the third intercostal space is more sensitive and useful for the diagnosis of type 1 Brugada ECG than repeated 12-lead ECGs or multichannel Holter ECG in the standard position. [ABSTRACT FROM AUTHOR]

One of the major challenges in the treatment of primary muscle disorders, which often affect many muscle groups, is achieving efficient, widespread transgene expression in muscle. In utero gene transfer can potentially address this problem by accomplishing the gene delivery when the tissue mass is small and the immune system is immature. Earlier studies with systemic in utero adeno-associated viral (AAV) vector serotype 1 gene delivery to embryonic day 16 (E-16) pups resulted in high levels of transduction in diaphragm and intercostal muscles, but no detectable transgene expression in limb muscles. Recently, newer AAV serotypes, such as AAV8, have shown widespread and high transgene expression in skeletal muscles and diaphragm by systemic delivery in adult and neonatal mice. We tested AAV8 vector gene delivery by intraperitoneal administration in E-16 mice in utero. Using an AAV8 vector carrying a lacZ reporter gene, we observed high-level transduction of diaphragm and intercostal muscles and more moderate transduction of multiple limb muscles and heart. Our current studies show the potential of AAV8 to achieve widespread muscle transduction in utero and suggest its therapeutic potential for primary muscle disorders. [ABSTRACT FROM AUTHOR]

The scalene is a primary respiratory muscle in humans; however, in dogs, EMG activity recorded from this muscle during inspiration was reported to derive from underlying muscles. In the present studies, origin of the activity in the medial scalene was tested in rabbits, and its distribution was compared with the muscle mechanical advantage. We assessed in anesthetized rabbits the presence of EMG activity in the scalene, sternomastoid, and parasternal intercostal muscles during quiet breathing and under resistive loading, before and after denervation of the scalene and after its additional insulation. At rest, activity was always recorded in the parasternal muscle and in the scalene bundle inserting on the third rib (medial scalene). The majority of this activity disappeared after denervation. In the bundle inserting on the fifth rib (lateral scalene), the activity was inconsistent, and a high percentage of this activity persisted after denervation but disappeared after insulation from underlying muscle layers. The sternomastoid was always silent. The fractional change in muscle length during passive inflation was then measured. The mean shortening obtained for medial and lateral scalene and parasternal intercostal was 8.0 ± 0.7%, 5.5 ± 0.5%, and 9.6 ± 0.1%, respectively, of the length at functional residual capacity. Sternomastoid muscle length did not change significantly with lung inflation. We conclude that, similar to that shown in humans, respiratory activity arises from scalene muscles in rabbits. This activity is however not uniformly distributed, and a neuromechanical matching of drive is observed, so that the most effective part is also the most active. [ABSTRACT FROM AUTHOR]

The detrimental effect of ascites on the lung-expanding action of the diaphragm is partly compensated for by an increase in the inspiratory elevation of the ribs, but the mechanism of this increase is uncertain. To identify this mechanism, the effect of ascites on the response of rib 4 to isolated phrenic nerve stimulation was first assessed in four dogs with bilateral pneumothoraces. Stimulation did not produce any axial displacement of the rib (Xr) in the control condition and caused a cranial rib displacement in the presence of ascites. This displacement, however, was small. In a second experiment, the effects of ascites on the pleural pressure swing (ΔPpl), intercostal activity, and Xr during spontaneous inspiration were measured in eight animals. As the volume of ascites increased from 0 to 200 mI/kg body wt, Xr increased from 3.5 ± 0.5 to 7.5 ± 0.9 mm (P < 0.001), ΔPpl decreased from -6.4 ± 0.4 to -3.6 ± 0.3 cmH20 (P < 0.001), and parasternal intercostal activity increased 61 ± 19% (P < 0.001). The role of the decrease in ΔPpl in causing the increase in Xr was then separated from that of the increase in intercostal muscle force using the relation between Xr and ΔPpl during passive lung inflation. The loss in ΔPpl accounted for two-thirds of the increase in Xr. These observations indicate that 1) the increased inspiratory elevation of the ribs in ascites is not the result of the increase in the rib cage-expanding action of the diaphragm and 2) it is due mostly to the decrease in ΔPpl and partly to the increase in the force exerted by the parastemal intercostals on the ribs. These observations also suggest, however, that the rib cage expansion caused by ascites makes the parasternal intercostals less effective in pulling the ribs cranially. [ABSTRACT FROM AUTHOR]

Despite clinically available methods of diaphragm pacing, most patients with ventilator-dependent tetraplegia are still dependent on mechanical ventilation. Given the significant disadvantages of these devices, additional pacing options are needed. The objective of this study was to evaluate a novel and potentially more physiological method of inspiratory muscle activation, which involves the application of high-frequency (>200 Hz) stimulation to the ventral surface of the spinal cord in the high thoracic region. Studies were performed in 13 anesthetized dogs. High-frequency spinal cord stimulation (HF-SCS) results in the activation of both the diaphragm and inspiratory intercostal muscles, in concert, at physiological firing frequencies and the generation of large inspired volumes. Mean maximum firing frequencies of motor units in the parasternal (2nd interspace), the external intercostal (3rd interspace), and the diaphragm muscles were 10.6 ± 0.4, 11.7 ± 0.4, and 10.4 ± 0.3 Hz, respectively. These values were not significantly different from those occurring during spontaneous breathing at comparable inspired volumes. Maximum inspired volume was 0.93 ± 0.01 liter, which approximates the inspiratory capacity of these animals. Moreover, ventilation can be maintained on a chronic basis by this method (6 h) without evidence of system fatigue. Our results suggest that HF-SCS results in activation of spinal cord tracts that synapse with the inspiratory motoneuron pools, allowing processing of the stimulus and consequent physiological activation of the inspiratory muscles. HF-SCS has the potential to provide an effective method of inspiratory muscle pacing. [ABSTRACT FROM AUTHOR]

When the lung is inflated acutely, the capacity of the diaphragm to generate pressure, in particular pleural pressure (Ppl), is impaired because the muscle during contraction is shorter and generates less force. At very high lung volumes, the pressure-generating capacity of the diaphragm may be further reduced by an increase in the muscle radius of curvature. Lung inflation similarly impairs the pressure-generating capacity of the inspiratory intercostal muscles, both the parasternal intercostals and the external intercostals. In contrast to the diaphragm, however, this adverse effect is largely related to the orientation and motion of the ribs, rather than the ability of the muscles to generate force. During combined activation of the two sets of muscles the change in Ppl is larger than during isolated diaphragm activation, and this added load on the passive diaphragm reduces the shortening of the muscle and increases muscle force. In addition, activation of the diaphragm suppresses the cranial displacement of the passive diaphragm that occurs during isolated intercostal contraction and increases the respiratory effect of the intercostals. As a result, the change in Ppl generated during combined diaphragm-intercostal activation is greater than the sum of the pressures generated during separate muscle activation. Although this synergistic interaction becomes particularly prominent at high lung volumes, lung inflation, either bilateral or unilateral , places a substantial stress on the inspiratory muscle pump. [ABSTRACT FROM AUTHOR]

Copyright of Archivos de Bronconeumología (English Edition) is the property of Sociedad Espanola de Neumologia y Cirugia Toracica (SEPAR) and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract: The present study was designed to test the hypothesis that the expansion of a particular lung during breathing is partly related to the action of the hemidiaphragm on the opposite side. Two endotracheal tubes were inserted in the right and left main stem bronchi of anesthetized dogs, and the changes in pleural pressure (ΔPpl) over the two lungs were assessed separately, first before and then after section of one phrenic nerve, by measuring the changes in airway opening pressure (ΔPao) in the two tubes during occluded breaths. After phrenic nerve section, ΔPao in the ipsilateral lung decreased 28±2%, and ΔPao in the contralateral lung decreased 16±2% (P <0.01 for both). Parasternal intercostal activity, however, increased 15% on either side of the chest (P <0.05), thus indicating that the neural inspiratory drive was greater. Analysis of the results also suggested that after phrenic section, the contralateral (intact) hemidiaphragm still contributed nearly a third of the ΔPpl over the ipsilateral lung. These observations indicate, in agreement with the hypothesis, that hemidiaphragmatic paralysis in the dog has a direct detrimental effect on the expansion of both lungs. They may account for the fact that in patients with hemidiaphragmatic paralysis, ventilation is reduced in both lung bases. [Copyright &y& Elsevier]

Abstract: Objective: An intercostal muscle (ICM) flap is used to buttress the bronchial stump or bronchial anastomosis during thoracic surgery for airway reconstruction. Such flaps sometimes show ossification after surgery. Previous reports have suggested that such ossification requires a functional periosteum and good vascularization. We examined the background of ICM flap ossification and its relationship with complications and pain after surgery. Methods: We surveyed the clinical records of 47 patients who underwent bronchial stump reinforcement with an ICM flap during thoracic surgery at Kansai Medical University Hospital between January 2003 and December 2005. We reviewed the post-surgical chest computed tomography (CT) scans of 42 patients, and examined the degree of ICM ossification. We classified patients into two groups: those with ossification of the ICM flap (O group) and those without (non-O group). We compared the two groups for age, gender, the site of ICM flap placement, disease, type of lymph node dissection, and pretreatment. We also compared the two groups for pain levels and complications after surgery. Eight (19%) of the 42 patients showed ossification of the ICM after surgery. There were statistically significant differences between the O and non-O groups in gender (p =0.029), lymph node dissection (p =0.024) and pain levels after surgery (p =0.034). There were no complications attributable to ICM ossification in this series. Conclusion: Ossification of an ICM flap may be related to gender, lymph node dissection and pain after surgery. Ossification does not cause any complication after surgery when an ICM is used to reinforce bronchial stumps. [Copyright &y& Elsevier]

Lung and spigelian hernia are both extremely rare diseases, and their combined and simultaneous appearance in the same patient, causing the small bowel to shift from the abdomen towards the thorax external to the ribcage is even more unusual. Here, we report such a case, supported by comprehensive iconography and a detailed discussion of the hypothetical pathogenesis. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To assess the value of whole body MR imaging in patients with neurofibromatosis type 1 (NF1). Materials and methods: 24 patients (15–59 years; mean and median 36 years; 7 males; 17 females) with genetically proven neurofibromatosis type 1 were examined with whole body MR imaging. Axial and coronal T1- and fat-suppressed T2-weighted images (slice thickness 6–12mm) were acquired on a 1.5T MR unit (Symphony; Siemens, Erlangen, Germany). The images were reviewed by 2 radiologists: 1 senior, 1 junior. The criterion for a neurofibroma was a mass lesion with low signal intensity on T1 and high signal intensity on T2, along the course of a nerve. The location, size, general morphology and course along plexuses and nerves were evaluated. Cutaneous and subcutaneous neurofibromas were defined as “superficial” neurofibromas. The other neurofibromas were regarded as “deep” neurofibromas. Results: There were no major problems to differentiate neurofibromas from lymph nodes, vessels or cysts. The latter three were easily recognised by their typical shape and location, whereas neurofibromas occurred in regions where no mass lesion was anatomically expected. There was no relation between age and total number of neurofibromas throughout the body. Classification according to location and number of neurofibromas: 8 patients had only superficial neurofibromas, 1 only deep and 15 both superficial and deep lesions. Twelve patients had less than 15 neurofibromas and 12 had more. Classification according to course: in 8 patients the neurofibromas occurred along plexuses or proximal part of the intercostal nerves; in 16 patients the lesions were more peripheral. Classification according to morphology: 4 patients had plexiform neurofibromas and 20 patients had multiple solitary lesions. Twelve of these 20 patients had less than 15 lesions, and 8 had more. In 2 patients multiple solitary neurofibromas occurred along the nerve in a chain configuration. In one patient a clinically unsuspected brain tumour was found. Conclusion: Whole body MR imaging is a reliable method to evaluate the distribution, size and morphology of neurofibromas in patients with NF1. [Copyright &y& Elsevier]

Derivative of 6-methyluracil, selective cholinesterase inhibitor C- 547 potentiates miniature endplate currents (MEPCs) in rat external intercostal muscles (external ICM) more effectively than in internal intercostal muscles (internal ICM). Effect of the C-547 on intercostal muscles was compared with those on extensor digitorum longus (EDL) and diaphragm muscles. Half-effective concentrations for t of MEPC decay arranged in increasing order were as follows: EDL, locomotor muscle, most sensitive = 1.3 nM, external ICM, inspiration muscle = 6.8 nM, diaphragm, main inspiration muscle = 28 nM, internal ICM, expiration muscle = 71 nM. External ICM might therefore be inhibited, similarly as the limb muscles, by nanomolar concentrations of the drug and do not participate in inspiration in the presence of the C-547. Moreover, internal ICM inhibition can hinder the expiration during exercise-induced fast breathing of C-547- treated experimental animals. [ABSTRACT FROM AUTHOR]

Summary: The body contour deformities that develop in morbidly obese patients following bariatric surgery often involve the breasts. Mastopexy is virtually always required in the female massive weight loss patient, and breast augmentation is often an important adjunct to breast-lifting procedures. The lateral intercostal artery perforator (LICAP) pedicled flap provides ample material for autogenous breast augmentation in such patients. Between June 2001 and June 2005, bilateral LICAP flaps were used as a method of autologous breast augmentation in six patients after massive weight loss. Of the 12 pedicled LICAP flaps raised, the average flap dimension was 23.6×10.6cm. Mean flap harvesting time was 60min (range 45–75min) for a single flap. All but two flaps were based on one perforator. All donor sites were closed primarily. Complete flap survival was achieved in all cases. A minor wound dehiscence occurred in two cases both of which healed secondarily. Patient satisfaction with both the appearance of their breasts and lateral axillary-thoracic region was high. The improved contour of the lateral axillary region was frequently noted as a significant benefit. In massive weight loss patients, harvesting the lateral skin-fat excess based on the LICAP provides supple tissue for breast augmentation, while simultaneously improving the contour of this area frequently affected by skin excess. Additionally, harvesting these flaps without sacrifice of the underlying muscle eases postoperative recovery and reduces donor site morbidity. [Copyright &y& Elsevier]

Although reduced blood lactate concentrations ([lac−]B) have been observed during whole-body exercise following inspiratory muscle training (IMT), it remains unknown whether the inspiratory muscles are the source of at least part of this reduction. To investigate this, we tested the hypothesis that IMT would attenuate the increase in [lac−]B caused by mimicking, at rest, the breathing pattern observed during high-intensity exercise. Twenty-two physically active males were matched for 85% maximal exercise minute ventilation $$ \left( {\dot V_{{\text{E}}} \max } \right) $$ and divided equally into an IMT or a control group. Prior to and following a 6 week intervention, participants performed 10 min of volitional hyperpnoea at the breathing pattern commensurate with 85% $$ \dot V_{{\text{E}}} \max . $$ The IMT group performed 6 weeks of pressure-threshold IMT; the control group performed no IMT. Maximal inspiratory mouth pressure increased (mean ± SD) 31 ± 22% following IMT and was unchanged in the control group. Prior to the intervention in the control group, [lac−]B increased from 0.76 ± 0.24 mmol L−1 at rest to 1.50 ± 0.60 mmol L−1 ( P < 0.05) following 10 min volitional hyperpnoea. In the IMT group, [lac−]B increased from 0.85 ± 0.40 mmol L−1 at rest to 2.02 ± 0.85 mmol L−1 following 10 min volitional hyperpnoea ( P < 0.05). After 6 weeks, increases in [lac−]B during volitional hyperpnoea were unchanged in the control group. Conversely, following IMT the increase in [lac−]B during volitional hyperpnoea was reduced by 17 ± 37% and 25 ± 34% following 8 and 10 min, respectively ( P < 0.05). In conclusion, increases in [lac−]B during volitional hyperpnoea at 85% $$ \dot V_{{\text{E}}} \max $$ were attenuated following IMT. These findings suggest that the inspiratory muscles were the source of at least part of this reduction, and provide a possible explanation for some of the IMT-mediated reductions in [lac−]B, often observed during whole-body exercise. [ABSTRACT FROM AUTHOR]

The double sigmoidal nature of the mouse pressure-volume (PV) curve is well recognized but largely ignored. This study systematically examined the effect of inflating the mouse lung to 40 cm H2O transrespiratory pressure (Prs) in vivo. Adult BALB/c mice were anesthetized, tracheostomized, and mechanically ventilated. Thoracic gas volume was calculated using plethysmography and electrical stimulation of the intercostal muscles. Lung mechanics were tracked during inflation-deflation maneuvers using a modification of the forced oscillation technique. Inflation beyond 20 cm H2O caused a shift in subsequent PV curves with an increase in slope of the inflation limb and an increase in lung volume at 20 cm H2O. There was an overall decrease in tissue elastance and a fundamental change in its volume dependence. This apparent "softening" of the lung could be recovered by partial degassing of the lung or applying a negative transrespiratory pressure such that lung volume decreased below functional residual capacity. Allowing the lung to spontaneously recover revealed that the lung required ∼1 h of mechanical ventilation to return to the original state. We propose a number of possible mechanisms for these observations and suggest that they are most likely explained by the unfolding of alveolar septa and the subsequent redistribution of the fluid lining the alveoli at high transrespiratory pressure. [ABSTRACT FROM AUTHOR]