[Rehabilitation after flexor tendon injuries of the hand]. / Rehabilitation nach Beugesehnenverletzungen an der Hand.

BACKGROUND: Advances in basic research evaluating suture material, techniques, and maximum tendon load with regard to repair site failure help to decide between rehabilitation protocols after the repair of flexor tendon injuries. OBJECTIVES: The presentation and choice of rehabilitation protocols depending on the mechanism of injury and knowledge of the influencing factors concerning tendon load. Expected outcome after flexor tendon repair. METHODS: Evaluating recent literature and basic research investigations, and presenting expert opinions. RESULTS: Based on the mechanism of injury, the suture technique, the compliance of the patient, and the latest knowledge on tendon capacity help to choose from the basic principles of rehabilitation protocols: passive or early motion protocols, such as those described by Duran-Houser and Kleinert, in the majority of cases lead to good and fair results according to the Hand Functional Score of the American Society for Surgery of the Hand. A larger number of excellent functional results are seen after the rehabilitation of flexor tendon injuries using combined passive/active or completely active motion protocols, e.g., according to Small. In addition to choosing a specific protocol and considering different zones of injury, it is essential to thoroughly supervise therapy and to monitor the adjustment of splints. It is widely recommended that patients should be provided with additional scar treatment and physical therapy throughout their entire rehabilitation. CONCLUSIONS: Flexor tendon injuries, especially in zone 2, are still a challenge with regard to operative treatment and rehabilitation, with an unpredictable outcome. Further knowledge and advances in suture techniques and material will support the use of active motion protocols and improve functional results in the future.

Morphometric analysis of phrenic motoneurons in the cat during postnatal development.

The dendritic geometry of 20 phrenic motoneurons from four postnatal ages (2 weeks, 1 and 2 months, and adult) was examined by using intracellular injection of horseradish peroxidase. The number of primary dendrites (approximately 11-12) remained constant throughout postnatal development. In general, postnatal growth of the dendrites resulted from an increase in the branching and in the length and diameter of segments at all orders of the dendritic tree. There was one exception. Between 2 weeks and 1 month, the maximum extent of the dendrites increased in parallel with the growth of the spinal cord; however, there was no increase in either combined dendritic length or total membrane surface area. In addition, there was a significant decrease in the number of dendritic terminals per cell (59.8 +/- 9.3 vs. 46.4 +/- 7.4 for 2 weeks and 1 month, respectively). The distance from the soma, where the peak number of dendritic terminals per cell occurred, ranged from 700-900 microns at 2 weeks and 2 months to 1,300-1,700 microns in the adult. The diameter of dendrites as a function of distance from the soma along the dendritic path increased with age. The process of maturation tended to increase the distance from the soma over which the surface area and dendritic trunk parameter (sigma d1.5/D1.5) remained constant. The three-dimensional distribution of dendrites was analyzed by dividing space into six equal volumes or hexants. This analysis revealed that the postnatal growth in surface area in the rostral and caudal hexants was proportionately larger than that in either the medial, lateral, dorsal, or ventral hexants. Strong linear correlations were found between the diameter of the primary dendrite and the combined length, surface area, volume, and number of terminals of the dendrite at all ages studied.

Influences from laryngeal afferents on expiratory bulbospinal neurons and motoneurons.

The purpose of this study is to analyze the reflex effects of laryngeal afferent activation on respiratory patterns in anesthetized, vagotomized, paralyzed, ventilated cats. We recorded simultaneously from the phrenic nerve, T10 internal intercostal nerve, and single bulbospinal expiratory neurons of the caudal ventral respiratory group (VRG). Laryngeal afferents were activated by electrical stimulation of the superior laryngeal nerve (SLN) or by cold-water infusion into the larynx. Both types of stimuli caused inhibition of phrenic activity and facilitation of internal intercostal nerve activity, indicating expiratory effort. The activity of 46 bulbospinal expiratory cells was depressed during SLN electrical stimulation, and 13 of them were completely inhibited. In 44 of 56 neurons tested, mean firing frequency (FFmean) was decreased in response to cold-water infusion and 8 others responded with increased FFmean; in the remaining 4 neurons, FFmean was unchanged. Possible reasons for different neuronal responses to SLN electrical stimulation and water infusion are discussed. We conclude that bulbospinal expiratory neurons of VRG were not the source of the reflex motoneuronal expiratory-like activity produced by SLN stimulation. Other, not yet identified inputs to spinal expiratory motoneurons are activated during this experimental condition.

Prolongation in expiration evoked from ventrolateral pons of adult rats.

Activation of neurons in the ventrolateral (vl) pons was hypothesized to alter the breathing pattern because previous studies demonstrated apneusis after inhibiting neuronal activity with bilateral muscimol (10 mM) microinjections into the vl pons (17). The excitatory amino acid L-glutamate (10 mM) was microinjected (10-100 nl) into the vl pons in anesthetized, vagotomized, paralyzed, and ventilated adult rats (n = 8). In four of these animals, the target site was approached from the ventral surface of the pons to avoid penetrating the dorsolateral (dl) pons. The expiratory phase was prolonged transiently and concurrently with the microinjection. The location of the injection sites included the A5 area, was independent of the approach, and was distinct from the dl pons. These results complement our previous data and indicate that neurons located in the vl pons influence respiration specifically by prolonging expiration when activated and by delaying the inspiratory-to-expiratory phase transition when inhibited.

Decreased excitability of respiratory motoneurons during hypercapnia in the acute spinal cat.

This study was undertaken to examine the effects of hypercapnia on the excitability of respiratory motoneurons. The action of CO2 on phrenic (inspiratory) and internal intercostal (expiratory) motoneurons was compared with that exerted on non-respiratory motoneurons of the musculocutaneous nerve. The experiments were performed on spinalized (C1 segment), partially deafferented cats that were exposed to different CO2/O2 mixtures (end-tidal CO2 3 +/- 0.3, 6 +/- 0.5 and 9 +/- 0.5%). Changes in neuronal excitability were assessed by: measuring the amplitudes of antidromic field potentials recorded from a population of motoneurons; analysis of the amplitude and latency of the orthodromic response recorded from a given nerve and evoked by microstimulation within the corresponding motor nucleus; monitoring the membrane potentials during intracellular recordings from phrenic motoneurons; and recording ongoing activity of the phrenic and internal intercostal nerves. Hypercapnia (end-tidal CO2 6 +/- 0.5 or 9 +/- 0.5%) decreased the excitability of phrenic and musculocutaneous motoneurons, the effect being larger at the higher CO2 level. Internal intercostal motoneurons were generally more resistant to the effects of CO2. A depression of their excitability was observed only at end-tidal CO2 9 +/- 0.5%. The decreased excitability of phrenic motoneurons was associated with membrane hyperpolarization. It is concluded that the depressant action of CO2 is present in both respiratory and non-respiratory spinal motoneurons. The action of hypercapnia on respiratory motoneurons may oppose the excitatory effects exerted through specific chemoreflexes.

Synaptic action of R beta neurons on phrenic motoneurons studied with spike-triggered averaging.

The functional role of dorsal medullary inspiratory neurons with excitatory input from lung stretch receptors (R beta neurons) is a matter of controversy. The present study, performed on chloralose-anesthetized and paralyzed cats, ventilated mainly with a phrenic-controlled servorespirator, deals with the spinal projection of these neurons, a property which suggests their involvement in the efferent part of the medullary respiratory complex. Out of 37 inspiratory neurons which could be excited antidromically following microstimulation within the contralateral C6 phrenic nucleus (latency 2.0 ms +/- 0.4, S.D.), 17 were classified by the 'no-inflation' test as R beta. Intracellular recording of synaptic potentials from phrenic motoneurons using the 'spike-triggered averaging' technique were made. In 10 phrenic motoneurons, the averaging revealed individual EPSPs (peak amplitude 150 +/- 110 microV, rise time 0.5 +/- 0.2 ms) time-locked to action potentials of 5 out of 7 R beta neurons tested. Cross-correlation of the R beta neurons firing with the activity of C5 and C6 phrenic rootlets indicated a divergence of excitatory action within the phrenic nucleus. For comparison, in 3 phrenic motoneurons individual EPSPs were recorded when the activity of 3 R alpha cells was used to trigger the averaging. It is concluded that at least some R beta neurons, similarly to R alpha neurons, project to the contralateral phrenic nucleus and can make monosynaptic excitatory connections with phrenic motoneurons. The finding that individual EPSPs were similar when averaging was triggered by the activity of either R beta or R alpha neurons provides new evidence for our earlier hypothesis that bulbospinal inspiratory neurons of the solitary tract nucleus may be subdivided into two categories only on a quantitative basis.

The activity pattern of phrenic motoneurons during the aspiration reflex: an intracellular study.

Membrane potential trajectories and discharge characteristics were measured intracellularly in 29 phrenic motoneurons of anesthesized, paralyzed and artificially ventilated cats during hypercapnic respiration and the aspiration reflex. Fifteen 'active' cells discharged spontaneously during inspiration, and the remaining 14 'quiescent' cells exhibited no discharge in spite of strong central respiratory drive. The mean membrane potential of the quiescent cells during inspiration (-62 +/- 4 mV) was significantly lower than the threshold level determined for the active cells -52 +/- 4 mV). The mean axonal conduction velocity was slower for the active (60.4 +/- 8.7 m/s) than quiescent cells (67.4 +/- 6.9 m/s). All phrenic motoneurons discharged during the aspiration reflex with maximum instantaneous frequencies ranging from 6 to 357 Hz. No differences were found for the maximum discharge frequency during the reflex between the active and quiescent cells. Although there were differences in the slopes of the depolarization during inspiration between the groups of cells, no such difference existed in the slopes during the aspiration reflex. The threshold level for the first spike during the reflex was the same as that during inspiration but the level for successive spikes became progressively less negative while spike amplitude decreased and duration increased. Stimulation of the nasopharynx to elicit the aspiration reflex was found to alter the timing of the subsequent respiratory cycles.

Projections and terminations of single respiratory axons in the cervical spinal cord of cat.

Position, divergence, branching, and termination patterns of single, respiratory axons were studied in cat cervical spinal cord by injecting horseradish peroxidase (HRP) intra-axonally. We stained 12 axons which were characterized by their firing patterns and by electrical stimulation. Five axons discharged during inspiration (I); the remaining 7 discharged during expiration (E). No injected axon was evoked by stimulating ipsilateral phrenic nerve roots while 7 (4 I, 3 E) of 12 were excited at a short latency from stimulating at a medullary site (on the midline, 1-2 mm rostral to the obex, approximately 3 mm below the dorsal medullary surface) where many bulbospinal respiratory axons decussate. All injected stem axons were located in the ventral and ventrolateral funiculi, traversed in a rostrocaudal direction, and were stained for lengths ranging from 3.6 to 12.4 mm. Mean axonal diameter was 2.9 microns. In 6 axons (4 I, 2 E), 14 collaterals were stained: 1 on each E axon, 2 on one I axon, 3 each on 2 others and 4 on another I axon. Collaterals emerged perpendicularly from the descending stem axon and projected directly to the ventral horn. The average distance between neighboring collaterals was 1.0 mm (n = 7). Collaterals did not arborize until they were near or within the ventral horn. Both en passant and terminaux types of presynaptic boutons were found primarily within the rostrocaudal cylinder that defined the phrenic motor column. In addition, some boutons were located dorsomedial to the phrenic motor column. We conclude that I axons, presumably of medullary origin, have multiple collaterals which terminate primarily in the phrenic motor column. However, the same axon can have terminals in different regions of the ventral horn, which are known to contain dendrites of phrenic motoneurons.

A 'pneumotaxic centre' in rats.

Electrical and chemical lesions in the ventrolateral pons produced apneustic breathing in anesthetized, vagotomized, paralyzed, ventilated adult rats (n = 13). Apneustic breathing did not develop if the vagi remained intact and was reversed partially with vagal (proximal end) stimulation. Physiologically, these data are similar to those obtained following dorsolateral pontine lesion in rat and other mammalian species and support the hypothesis that pontine neurons influence breathing similarly across mammalian species.

Statistical analysis of a liquid phase radioimmunoassay for immune complex determination.

A computer program is presented which enables iterative determination of the weighted standard curve and the quality control parameters calculation for the liquid phase radioimmunoassay which employs binding of labelled C1q as a measure of the presence of immunological complexes in serum samples. 22 independently performed laboratory tests were evaluated with respect to the presence of relationship between the dose (standardized human IgG aggregates) and response (fraction of radiolabelled C1q bound). On 14 occasions the plotted curve was sigmoidal in shape, the rest of the curves did not reach lower or upper asymptote. When the logistic transformation of this data was used the dose-response curve was linear and could be plotted with the use of the least square method. This allows calculation of the two other parameters of the sigmoidal curve (slope and midpoint). The slope of the weighted regression line, intercept point with the axis of ordinates and correlation coefficient were determined by means of the least square method for weighted linear regression with repetitions. When the iterative procedure was completed, content of immunological complexes in sera was calculated. The program is written in Fortran for the ODRA 1300 computer series. The printout consist of three parts. First part contains the original data, parameters and information about the form of input data. The second part of the printout consist of the results, obtained from non-weighted and weighted regression lines and the plotted regression line. The third part of the printout contains the final results of immune complexes determination.

[Angioplasty in acute and chronic occlusion of the coronary arteries]. / Angioplastyka w ostrej i przewleklej niedroznosci tetnic wiencowych.

An attempt of mechanical restoration of coronary artery patency and its angioplasty was carried out in 37 patients including 9 with acute myocardial infarction within 5 hours after the onset of an angina pain. The procedure was effective in 17 patients (45.9%), including 6 with acute myocardial infarction (66.7%). Mean time of a coronary artery occlusion was 5.1 weeks in the group with a good result in comparison with 17.2 weeks in the group with the unsuccessful procedure. In patients in whom restoration of a coronary artery patency was carried out within up to 3 months after its occlusion the procedure was effective in 64 per cent of them. Effectiveness of restoration of a coronary artery patency and its dilatation depends on the time from its occlusion to the procedure. The early attempt of the restoration of a coronary artery patency is effective in the majority of patients. In cases of the unsuccessful recanalization of a coronary artery occluded for a short time the main limitation of the procedure effectiveness was the vessel anatomy. The follow-up of 17 patients after a successful procedure showed restenosis or reocclussion in 6 of them (35%). It was referred in 1 case to the patient in whom restoration of a vessel patency was carried out during acute myocardial infarction (17%), and in 5 others to patients with a chronic occlusion of a coronary artery (45.5%).

[Treatment of 3 patients with arrhythmias using "radiofrequency" ablation]. / Leczenie 3 chorych z zaburzeniami rytmu serca metada "radiofrequency".

In 3 patients radiofrequency (RF) ablation of AV node (n = 2) and left sided accessory pathway (n = 1) was performed because of intractable tachyarrhythmias. RF ablation was made in the first patient (ablation of AV node) using 135 Watts during 72 sec., in the second patient (AV node ablation) 331 Watts during 185 sec., and in the last patient 883 Watts during 695 sec. In the last patient ablation of accessory pathway was unsuccessful and the patient has been successfully operated. AV conduction was interrupted in 2 cases. No complications were noted. General anesthesia was not required. All the patients were discharged in a good state.

[Complications of percutaneous transluminal coronary angioplasty (PTCA)]. / Powiklania zabiegów przezskórnej sródnaczyniowej koronaroplastyki (PTCA).

Between 1981 and 1990, 714 patients underwent 756 percutaneous transluminal coronary angioplasty (PTCA) procedures. A total of 52 patients (6.9%) had major in-hospital complications: 5 patients (0.66%) died, Q-wave or non Q-wave myocardial infarction were observed in 13 patients (1.66%) during procedure and in 8 (1%) outside the catheterization laboratory, before discharge. Because of periprocedural occlusion 11 patients (1.5%) were managed with bypass surgery, 8 (1%) had a transient occlusion that was reopened with PTCA. 21 patients (2.8%) were not ++re-dilated but managed pharmacologically. Dissection, intracoronary thrombus and previous thrombolytic treatment were often associated with occlusion. The risk of dissection was related to lesion morphology. Long-(more than 1 cm) lesion, eccentric stenosis and tortuosity of the vessel segment undergoing dilatation were risk factors for occlusive dissection. There was a high risk of side branch occlusion if its take-off was narrowed and side branch originated from the target lesion. One of the most important risk predictors is the amount of jeopardized myocardium supplied by the target coronary artery. Acute closure of an artery supplying large amount of myocardium may cause abrupt hemodynamic collapse. Hypotension secondary to the artery occlusion may cause a decrease of the flow in the other coronary arteries, leading to cardiogenic shock. Although it is important to note that patients with unstable angina, intracoronary thrombus, long and complex lesion, severe multivessel disease and compromised left ventricular function are at higher risk of acute complication, PTCA is a relatively safe procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Coronary ultrasonography. More exact than coronary angiography? Description of two case histories]. / Ultrasonografia sródnaczyniowa tetnic wiencowych. Dokladniejsza niz koronarografia? Opis dwóch przypadków.

Coronary angiography as the "golden standard" in diagnostic imaging, guiding and assessing the results of interventional therapy has well known limitations inherent to the two dimensional imaging of three dimensional structures. Intravascular ultrasonography provides cross-sectional images of coronary artery, allowing an accurate calculation of cross-sectional luminal area and assessment of the degree of eccentricity of plaque and its structure including fissures, dissections and intracoronary thrombi. Case 1: Coronary angiography was performed in a 60 y. male patient with unstable angina revealing only a 40% stenosis in proximal LAD. The inconsistency of clinical presentation with angiography findings led to perform an intravascular ultrasound (IVUS) examination of LAD. The angiographic 40% stenosis was found to be over 80% on IVUS. Subsequent PTCA procedure led to a good IVUS and clinical result with no obvious changes in angiography. Case 2: PTCA of 80% Cx stenosis was performed with good immediate angiographic result, without dissection nor residual stenosis. However, IVUS immediately after PTCA assessed a dissection of the plaque with a flap protruding into the lumen. The patient was sent back to coronary angiography several hours later with clinical and ecg symptoms of acute myocardial ischemia. An important, occlusive dissection was found at the PTCA site. Angioplasty was performed again restoring a wide lumen at intervention site. IVUS was able to clarify the ambiguous angiographic findings with an important impact on interventional therapy. The immediate results of invasive procedures were readily and safely assessed by intravascular ultrasound.

[Percutaneous transluminal coronary angioplasty in patients with high risk bypass surgery]. / Przezskórna angioplastyka wiencowa u chorych z wysokim ryzykiem leczenia operacyjnego.

The purpose of this study was to assess the immediate and long-term results of incomplete percutaneous transluminal coronary angioplasty (PTCA) in high-risk coronary artery bypass surgery (CABG) patients. 24 pts (male-22, female-2, age - 39-60 years) were divided into 2 groups: I-8 pts with unstable angina pectoris who were definitely not CABG candidates because of very low ejection fraction (LVEF < 24%) and/or diffuse coronary atherosclerosis; II-16 pts selected for CABG only after failed PTCA. From this group 12 pts with unstable angina pectoris and history of myocardial infarction were at higher CABG risk because of LVEF < 40% and diffuse coronary atherosclerosis. 4 pts were poor surgical candidates because of coexistent medical disorders. The strategy of PTCA was to dilate first the most critical (culprit) lesion, responsible for the patient symptoms, usually situated in the artery supplying large area of viable myocardium. We did not achieve: complete revascularization in all our pts (incomplete revascularization by intent). Initial success rate of the PTCA in both groups was 100%. There were no serious complications. During follow-up (6 months--4 yrs) long-term clinical improvement was observed in 7 pts from group I (87.5%) and 14 pts from group II (87.5%). We conclude, that in most pts with unstable angina pectoris and with high-risk of CABG good immediate and long-term results of incomplete PTCA can be achieved.

[Complex angioplasty (PTCA) in the treatment of coronary artery stenosis]. / Kompleksowa koronaroplastyka (PTCA) w leczeniu kilku zwezen tetnic wiencowych.

56 patients with more than one stenotic coronary artery were treated by complex PTCA with success rate of 96.4%. Complications occurred in 3.6% of pts. Restenoses were found in 9.4% of pts; only one of the dilated arteries were restenosed. 11.3% of pts had repeated PTCA, because of progression of stenosis in other than previously treated artery. Angina occurred earlier in pts with restenoses than in pts with progression of stenoses. Late efficacy (mean 19 months) of complex PTCA was high (90.7%).