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1.
Mol Med ; 26(1): 58, 2020 06 16.
Artigo em Inglês | MEDLINE | ID: mdl-32546125

RESUMO

In light of the present therapeutic situation in COVID-19, any measure to improve course and outcome of seriously affected individuals is of utmost importance. We recap here evidence that supports the use of human recombinant erythropoietin (EPO) for ameliorating course and outcome of seriously ill COVID-19 patients. This brief expert review grounds on available subject-relevant literature searched until May 14, 2020, including Medline, Google Scholar, and preprint servers. We delineate in brief sections, each introduced by a summary of respective COVID-19 references, how EPO may target a number of the gravest sequelae of these patients. EPO is expected to: (1) improve respiration at several levels including lung, brainstem, spinal cord and respiratory muscles; (2) counteract overshooting inflammation caused by cytokine storm/ inflammasome; (3) act neuroprotective and neuroregenerative in brain and peripheral nervous system. Based on this accumulating experimental and clinical evidence, we finally provide the research design for a double-blind placebo-controlled randomized clinical trial including severely affected patients, which is planned to start shortly.


Assuntos
Betacoronavirus/patogenicidade , Infecções por Coronavirus/tratamento farmacológico , Síndrome da Liberação de Citocina/prevenção & controle , Eritropoetina/uso terapêutico , Fármacos Neuroprotetores/uso terapêutico , Pneumonia Viral/tratamento farmacológico , Fármacos do Sistema Respiratório/uso terapêutico , Tronco Encefálico/efeitos dos fármacos , Tronco Encefálico/imunologia , Tronco Encefálico/virologia , Infecções por Coronavirus/imunologia , Infecções por Coronavirus/patologia , Infecções por Coronavirus/virologia , Síndrome da Liberação de Citocina/imunologia , Síndrome da Liberação de Citocina/patologia , Síndrome da Liberação de Citocina/virologia , Método Duplo-Cego , Humanos , Pulmão/efeitos dos fármacos , Pulmão/imunologia , Pulmão/virologia , Pandemias , Nervo Frênico/efeitos dos fármacos , Nervo Frênico/imunologia , Nervo Frênico/virologia , Pneumonia Viral/imunologia , Pneumonia Viral/patologia , Pneumonia Viral/virologia , Estudo de Prova de Conceito , Ensaios Clínicos Controlados Aleatórios como Assunto , Proteínas Recombinantes/uso terapêutico , Músculos Respiratórios/efeitos dos fármacos , Músculos Respiratórios/imunologia , Músculos Respiratórios/virologia , Índice de Gravidade de Doença , Medula Espinal/efeitos dos fármacos , Medula Espinal/imunologia , Medula Espinal/virologia
2.
PLoS One ; 15(6): e0235132, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32584880

RESUMO

BACKGROUND: Phrenic nerve injury (PNI) remains one of the most frequent complications during cryoballoon-based pulmonary vein isolation (CB-PVI). Since its introduction in 2013, the use of compound motor action potential (CMAP) for the prevention of PNI during CB-PVI is increasing; however, systematic outcome data are sparse. METHODS: The CMAP technique was applied in conjunction with abdominal palpation during pacing manoeuvres (10 mV, 2 ms) from the superior vena cava for 388 consecutive patients undergoing CB-PVI between January 2015 and May 2017 at our tertiary arrhythmia centre. Cryoablation was immediately terminated when CMAP amplitude was reduced by 30%. RESULTS: Reductions in CMAP amplitude were observed in 16 (4%) of 388 patients during isolation of the right veins. Of these, 11 (69%) patients did not manifest a reduction in diaphragmatic excursions. The drop in CMAP amplitude was observed in 10 (63%) patients during ablation of the right superior pulmonary veins (PVs) and in 7 (44%) patients during ablation of the right inferior PVs. Postprocedural persistent PNI was observed in three of four patients for a duration of 6 months, with one of these patients remaining symptomatic at the 24-month follow-up. One of the four patients was lost to long-term follow-up. CONCLUSIONS: All PNIs occurred during right-sided CB-PVI and were preceded by a reduction in CMAP amplitude. Thus, the standardized use of CMAP surveillance during CB-PVI is easily applicable, reliable and compared with other studies, results in a lower number of PNIs.


Assuntos
Potenciais de Ação , Fibrilação Atrial , Criocirurgia/efeitos adversos , Monitorização Neurofisiológica Intraoperatória , Nervo Frênico , Veias Pulmonares , Idoso , Fibrilação Atrial/fisiopatologia , Fibrilação Atrial/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Nervo Frênico/lesões , Nervo Frênico/fisiopatologia , Veias Pulmonares/fisiopatologia , Veias Pulmonares/cirurgia
3.
Zhong Nan Da Xue Xue Bao Yi Xue Ban ; 45(3): 354-358, 2020 Mar 28.
Artigo em Inglês, Chinês | MEDLINE | ID: mdl-32386031

RESUMO

The performance of the second-generation cryoballoon has been greatly improved compared to the first-generation.But it has not reduced the incidence of phrenic nerve injury, and even increased the incidence of this complication during ablation of the right inferior pulmonary vein. Two cases of phrenic nerve injury occurred when right inferior pulmonary vein was ablated with the second-generation cryoballoon in Department of Cardiovascular Medicine, Second Xiangya Hospital, Central South University. Based on literature review, the possible causes for phrenic nerve injury in our report were summarized to provide helpful information for operators aiming to reduce the occurrence of this complication related to the second-generation cryoballoon.


Assuntos
Fibrilação Atrial , Ablação por Cateter , Veias Pulmonares , Criocirurgia , Humanos , Nervo Frênico , Resultado do Tratamento
4.
J Cardiothorac Surg ; 15(1): 54, 2020 Mar 30.
Artigo em Inglês | MEDLINE | ID: mdl-32228645

RESUMO

BACKGROUND: The first reported case of cardiac herniation was in 1948 and occurred following pericardiectomy during a lung cancer resection. Although rare, this potentially fatal surgical complication may occur following any operation in which a pericardial incision or resection is performed. The majority of literature on cardiac herniation involves case reports after intrapericardial pneumonectomy. Currently, there are no reports of cardiac herniation after thymectomy with pericardial resection. CASE PRESENTATION: A 44-year-old Asian female with symptomatic myasthenia gravis was referred for thymectomy. Originally thought to have Bell's Palsy, her symptoms began with right eyelid drooping and facial weakness. Over time, she developed difficulty holding her head up, upper extremity weakness, difficulty chewing and dysarthria. These symptoms worsened with activity. She was found to have positive acetylcholine receptor binding antibody on her myasthenia gravis panel. A preoperative CT scan demonstrated a 3.5 cm × 2 cm anterior mediastinal mass along the right heart border and phrenic nerve. A complete thymectomy, via right-sided robotic-assisted approach was performed en bloc with a portion of the right phrenic nerve and a 4 cm × 4 cm portion of pericardium overlying the right atrium and superior right ventricle. Upon undocking of the robot and closure of the port sites, the patient became acutely hypotensive (lowest recorded blood pressure 43/31 mmHg). The camera was reinserted and demonstrated partial cardiac herniation through the anterior pericardial defect toward the right chest. An emergent midline sternotomy was performed and the heart was manually reduced. The patient's hemodynamics stabilized. A vented Gore-Tex 6 cm × 6 cm patch was sewn along the pericardial edges with interrupted 4-0 prolene to close the pericardial defect. CONCLUSION: This potentially fatal complication, although rare, should always be considered whenever there is hemodynamic instability entry or resection of the pericardium during surgery. We now routinely sew in a pericardial patch using our robotic surgical system for any defect over 3 cm × 3 cm that extends from the mid- to inferior portions of the heart.


Assuntos
Cardiopatias/etiologia , Pericardiectomia/efeitos adversos , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Timectomia/efeitos adversos , Timoma/cirurgia , Neoplasias do Timo/cirurgia , Adulto , Feminino , Cardiopatias/cirurgia , Humanos , Miastenia Gravis/complicações , Pericárdio/cirurgia , Nervo Frênico/cirurgia , Complicações Pós-Operatórias/cirurgia , Esternotomia , Timectomia/métodos , Timoma/diagnóstico por imagem , Timo/diagnóstico por imagem , Timo/cirurgia , Neoplasias do Timo/diagnóstico por imagem , Tomografia Computadorizada por Raios X
5.
Am J Cardiol ; 125(11): 1738-1744, 2020 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-32295701

RESUMO

Transvenous neurostimulation of the phrenic nerve (PNS) is a potentially improved and unique approach to the treatment of central sleep apnea (CSA). There have been multiple studies with limited individuals evaluating the efficacy of PNS. Our aim was to review and pool those studies to better understand whether phrenic nerve stimulation is efficacious in the treatment of CSA. The initial search on Pubmed retrieved a total of 97 articles and after screening all articles, only 5 could be included in our quantitative analysis. Pooling of data from 5 studies with a total of 204 patients demonstrated a reduction of mean apnea hypopnea index with PNS compared to controls by -26.7 events/hour with 95% confidence interval and P value of [CI (-31.99, -21.46), I2 85, p 0.00]. The mean difference in central apnea index was -22.47 [CI (-25.19, -19.76), I2 0, p 0.00]. The mean reduction in the oxygen desaturation index of 4% or more demonstrated a decrease in PNS group by -24.16 events/hour [(CI -26.20, -22.12), I2 0, p 0.00] compared with controls. PNS resulted in mean reduction in arousal index of -13.77 [CI (-16.15, -11.40), I2 0, p 0.00]. The mean change in percent of time spent in rapid eye movement sleep demonstrated a nonsignificant increase in PNS group by 1.01 % [CI (-5.67, 7.86), I293, p 0.75]. In conclusion, PNS therapy for treating CSA demonstrated positive outcomes but larger randomized studies are needed to evaluate the safety and clinical outcomes.


Assuntos
Terapia por Estimulação Elétrica/métodos , Nervo Frênico , Apneia do Sono Tipo Central/terapia , Humanos , Hipóxia/fisiopatologia , Polissonografia , Apneia do Sono Tipo Central/fisiopatologia , Sono REM , Resultado do Tratamento
6.
Am J Physiol Regul Integr Comp Physiol ; 318(4): R730-R742, 2020 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-32022595

RESUMO

The two kidney-one clip (2K1C) renovascular hypertension depends on the renin-angiotensin system and sympathetic overactivity. The maintenance of 2K1C hypertension also depends on inputs from the carotid bodies (CB), which when activated stimulate the respiratory activity. In the present study, we investigated the importance of CB afferent activity for the ventilatory responses in 2K1C hypertensive rats and for phrenic and hypoglossal activities in in situ preparations of normotensive rats treated with angiotensin II. Silver clips were implanted around the left renal artery of male Holtzman rats (150 g) to induce renovascular hypertension. Six weeks after clipping, hypertensive 2K1C rats showed, in conscious state, elevated resting tidal volume and minute ventilation compared with the normotensive group. 2K1C rats also presented arterial alkalosis, urinary acidification, and amplified hypoxic ventilatory response. Carotid body removal (CBR), 2 wk before the experiments (4th week after clipping), significantly reduced arterial pressure and pulmonary ventilation in 2K1C rats but not in normotensive rats. Intra-arterial administration of angiotensin II in the in situ preparation of normotensive rats increased phrenic and hypoglossal activities, responses that were also reduced after CBR. Results show that renovascular hypertensive rats exhibit increased resting ventilation that depends on CB inputs. Similarly, angiotensin II increases phrenic and hypoglossal activities in in situ preparations of normotensive rats, responses that also depend on CB inputs. Results suggest that mechanisms that depend on CB inputs in renovascular hypertensive rats or during angiotensin II administration in normotensive animals increase respiratory drive.


Assuntos
Corpo Carotídeo/fisiologia , Hipertensão Renovascular/fisiopatologia , Ratos Sprague-Dawley , Angiotensina II/administração & dosagem , Angiotensina II/farmacologia , Animais , Nervo Hipoglosso/fisiologia , Masculino , Fenilefrina/administração & dosagem , Fenilefrina/farmacologia , Nervo Frênico/fisiologia , Ratos , Sistema Nervoso Simpático , Simpatomiméticos/farmacologia
7.
Am J Cardiol ; 125(8): 1170-1179, 2020 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-32087997

RESUMO

Pulmonary vein isolation is the cornerstone of atrial fibrillation (AF) ablation. Radiofrequency (RF) represents a standard of care for pulmonary vein isolation, whereas cryoballoon (CB) ablation has emerged as a valid alternative. The aim of our meta-analysis was to explore the efficacy and safety of CB compared with RF as first ablation procedure for AF. We searched the literature for studies that investigated this issue. The primary efficacy outcome was AF recurrence. The safety outcomes were: pericardial effusion, cardiac tamponade, phrenic nerve palsy, vascular complications, and major bleedings. Fourteen randomized controlled studies and 34 observational studies were included in the analysis. A total of 7,951 patients underwent CB ablation, whereas 9,641 received RF ablation. Mean follow-up was 14 ± 7 months. Overall, CB reduced the incidence of AF recurrence compared with RF ablation (relative risk [RR] 0.86; 95% confidence interval [CI] 0.78 to 0.94; p = 0.001), and this result was consistent across different study design and AF type. CB had a significantly higher rate of phrenic nerve palsy, whereas it was related to a lower incidence of pericardial effusion, cardiac tamponade (RR 0.58; 95% CI 0.38 to 0.88; p = 0.011) and vascular complications (RR 0.61; 95% CI 0.48 to 0.77; p <0.001) compared with RF. There was no significant difference in major bleedings between the 2 strategies. CB ablation had a shorter procedural time compared with RF (mean difference -20.76 minutes; p <0.001). In conclusion, considered its efficacy/safety profile and short procedural time, CB ablation represents the preferable option for first AF ablation procedure.


Assuntos
Fibrilação Atrial/cirurgia , Complicações Pós-Operatórias/epidemiologia , Veias Pulmonares/cirurgia , Tamponamento Cardíaco/epidemiologia , Ablação por Cateter , Criocirurgia , Fluoroscopia , Humanos , Duração da Cirurgia , Derrame Pericárdico/epidemiologia , Doenças do Sistema Nervoso Periférico/epidemiologia , Nervo Frênico , Hemorragia Pós-Operatória/epidemiologia , Recidiva , Resultado do Tratamento
8.
Neurology ; 94(12): e1314-e1319, 2020 03 24.
Artigo em Inglês | MEDLINE | ID: mdl-31992683

RESUMO

OBJECTIVE: To investigate the following among patients with phrenic neuropathy: (1) occurrences of water immersion activity-induced dyspnea; (2) clinical, electrophysiologic, sonographic, and pulmonary function test abnormalities; and (3) frequency of documented counseling regarding the risks of water immersion activities. METHODS: We identified all patients with test-confirmed phrenic neuropathy seen from January 1, 2000, to December 31, 2018, at Mayo Clinic. RESULTS: Of 535 patients with phrenic neuropathy, documentation of dyspnea with water activities was identified in 4% (22/535). The risks of water immersion were only documented in patients having experienced this problem. The majority had isolated phrenic neuritis or neuralgic amyotrophy syndrome (77.3%), mean age was 55 years (range 31-79), and most patients were men (81.9%). Patients had right-sided (45.5%) or bilateral (54.5%) phrenic neuropathy. None had isolated left phrenic involvement. Near-fatal drowning occurred in 18.2% (4/22), with persons needing assistance to be rescued from the water, following diving into water. Dyspnea with water immersion was the only symptom in 4.5% (1/22) and the presenting respiratory symptom in 36.4% (8/22). A range of electrophysiologic, sonographic, and pulmonary function test abnormalities including mild abnormalities were seen and not found to be significantly different from those in patients in whom water-induced dyspnea was not recorded. CONCLUSION: Respiratory distress with water immersion activities is a serious complication of phrenic neuropathies. Physician-documented counseling is lacking. Isolated phrenic neuritis, neuralgic amyotrophy, and right-sided and bilateral phrenic involvement are most commonly implicated, but the range of severity and testing abnormalities suggest that all patients with neuralgic amyotrophy or phrenic neuropathy should be warned especially about diving into water.


Assuntos
Dispneia/etiologia , Doenças do Sistema Nervoso Periférico/complicações , Nervo Frênico/patologia , Esportes Aquáticos , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
9.
World Neurosurg ; 137: e75-e82, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-31982596

RESUMO

BACKGROUND: Diaphragmatic paralysis after phrenic nerve injury is an infrequent but serious condition. The destruction of respiratory function after unilateral phrenic nerve injury has been the subject of many investigations. METHODS: In this study, we used a rat model of complete paralysis of the unilateral diaphragm to observe changes in pulmonary function. RESULTS: We found in young rats with complete paralysis of the unilateral diaphragm, the vital capacity and total lung capacity show compensation after 4 weeks, and contralateral phrenic nerve transfer can enhance pulmonary function. However, in the aged rats, respiratory function parameters do not show compensation until 16 weeks after injury. CONCLUSIONS: These findings suggest that contralateral phrenic nerve end-to-side anastomosis is a promising therapeutic strategy. In general, our results suggest that this surgical method may hold great potential to be a secure, feasible, and effective technique to rescue diaphragmatic function.


Assuntos
Diafragma/inervação , Transferência de Nervo/métodos , Nervo Frênico/lesões , Nervo Frênico/transplante , Paralisia Respiratória/cirurgia , Animais , Diafragma/fisiopatologia , Diafragma/cirurgia , Feminino , Pulmão/fisiopatologia , Ratos , Ratos Sprague-Dawley
11.
Ann Vasc Surg ; 62: 70-75, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31207398

RESUMO

BACKGROUND: The objective of this study was to characterize phrenic nerve and brachial plexus variation encountered during supraclavicular decompression for neurogenic thoracic outlet syndrome and to identify associated postoperative neurologic complications. METHODS: A multicenter retrospective review was performed to evaluate anatomic variation of the phrenic nerve and brachial plexus from November 2010 to July 2018. After initial characterization, the following two groups were identified: variant anatomy (VA) group and standard anatomy (SA) group. Complications were analyzed and compared between the two groups. RESULTS: In total, 105 patients were identified, and 100 patients met inclusion criteria. Any anatomic variation of the standard course or configuration of the phrenic nerve and/or brachial plexus was encountered in 47 (47%) patients. Phrenic nerve anatomic variations were identified in 28 (28%) patients. These included 9 duplicated nerves, 6 lateral accessory nerves, 8 medial displacement, and 5 lateral displacement. Brachial plexus anatomic variation was found in 34 (34%) patients. The most common variant configuration of a fused middle and inferior trunk was identified in 25 (25%) patients. Combined phrenic nerve and brachial plexus anatomic variation was demonstrated in 15 (15%) patients. The VA and SA groups consisted of 47 and 53 patients, respectively. Transient phrenic nerve injury with postoperative elevation of the ipsilateral hemidiaphragm was documented in 3 (6.4%) patients in the VA group and 6 (11.3%) patients in the SA group (P = 0.49). Permanent phrenic nerve injury was identified in 1 (2.1%) patient in the VA group (P = 0.47) and none in the SA group. Transient brachial plexopathy was encountered in 1 (1.9%) patient in the SA group (P = 1.0) with full recovery to normal function. CONCLUSIONS: Anatomic variability of the phrenic nerve and brachial plexus are encountered more frequently than previously reported. While the incidence of nerve injury is low, surgeons operating within the thoracic aperture should be familiar with variant anatomy to reduce postoperative complications.


Assuntos
Neuropatias do Plexo Braquial/etiologia , Plexo Braquial/anormalidades , Descompressão Cirúrgica/efeitos adversos , Traumatismos dos Nervos Periféricos/etiologia , Nervo Frênico/anormalidades , Síndrome do Desfiladeiro Torácico/cirurgia , Adulto , Plexo Braquial/lesões , Plexo Braquial/fisiopatologia , Neuropatias do Plexo Braquial/fisiopatologia , Feminino , Humanos , Masculino , Maryland , Traumatismos dos Nervos Periféricos/fisiopatologia , Philadelphia , Nervo Frênico/lesões , Nervo Frênico/fisiopatologia , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Síndrome do Desfiladeiro Torácico/diagnóstico por imagem , Síndrome do Desfiladeiro Torácico/fisiopatologia , Resultado do Tratamento
12.
Ann Anat ; 227: 151415, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31513915

RESUMO

BACKGROUND: The phrenicoabdominal branch of the left phrenic nerve passes between muscle fiber bundles within the costal part of the diaphragm near the pericardium. In most German textbooks of anatomy, however, its passage is described to be found in the esophageal hiatus. The aim of this study was to reevaluate its topography relative to the diaphragm in a multicentric study and to identify the initiation of this description. METHODS: In this multicentric study, the most dorsomedial branch of the left phrenic nerve was identified as the phrenicoabdominal branch in 400 embalmed anatomic specimens of Caucasian origin. The distance between its passage and the apex of the pericardium, the left border of the esophageal hiatus, and the inner aspect of the left sixth rib was measured on the cranial aspect of the diaphragm. Textbooks on human anatomy published in German language between 1700 and 2018 were reviewed for their description of the passage of the left phrenicoabdominal branch through the diaphragm. RESULTS: The first statement on the passage of the left phrenicoabdominal branch through the esophageal hiatus was given in 1791 by Sömmering. Since then, in German textbooks of anatomy, a duality in the description of the passage of the left phrenicoabdominal branch persists. In none of the individuals examined in this study, the left phrenicoabdominal branch passed through the esophageal hiatus. In 99.5% of all cases, it pierced the costal part of the diaphragm dorsal to or at the same level as the apex of the pericardium. The mean distances (standard deviations) were 3.4 (±1.5) cm to the apex of the pericardium, 5.8 (±2.2) cm to the esophageal hiatus, and 5.5 (±1.6) cm to the inner aspect of the left sixth rib. CONCLUSION: The findings on the position of the left phrenicoabdominal branch relative to the diaphragm help to improve topographical knowledge and prevent inadvertent nerve injury during surgical interventions on or near the diaphragm. Further to this, these results may form a substantial basis to adopt the correct description of the passage of the left phrenicoabdominal branch to anatomical textbook knowledge.


Assuntos
Diafragma/anatomia & histologia , Esôfago/anatomia & histologia , Nervo Frênico/anatomia & histologia , Anatomia/história , Cadáver , Embalsamamento , Grupo com Ancestrais do Continente Europeu , Feminino , Alemanha , História do Século XVIII , História do Século XIX , História do Século XX , História do Século XXI , Humanos , Masculino , Pericárdio/anatomia & histologia , Costelas/anatomia & histologia , Livros de Texto como Assunto/história
13.
Respir Physiol Neurobiol ; 271: 103305, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31553921

RESUMO

Spinal interneuron (IN) networks can facilitate respiratory motor recovery after spinal cord injury (SCI). We hypothesized that excitatory synaptic connectivity between INs located immediately caudal to unilateral cervical SCI would be most prevalent in a contra- to ipsilateral direction. Adult rats were studied following chronic C2 spinal cord hemisection (C2Hx) injury. Rats were anesthetized and ventilated and a multi-electrode array was used to simultaneously record INs on both sides of the C4-5 spinal cord. The temporal firing relationship between IN pairs was evaluated using cross-correlation with directionality of synaptic connections inferred based on electrode location. During baseline recordings, the majority of detectable excitatory IN connections occurred in a contra- to- ipsilateral direction. However, acute respiratory stimulation with hypoxia abolished this directionality, while simultaneously increasing the detectable inhibitory connections within the ipsilateral cord. We conclude that propriospinal networks caudal to SCI can display a contralateral-to-ipsilateral directionality of synaptic connections and that these connections are modulated by acute exposure to hypoxia.


Assuntos
Medula Cervical/lesões , Medula Cervical/fisiologia , Interneurônios/fisiologia , Rede Nervosa/fisiologia , Traumatismos da Medula Espinal/fisiopatologia , Potenciais de Ação/fisiologia , Animais , Feminino , Nervo Frênico/fisiologia , Ratos , Ratos Sprague-Dawley
14.
Exp Neurol ; 323: 113067, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31629857

RESUMO

Respiratory motor neuron survival is critical for maintenance of adequate ventilation and airway clearance, preventing dependence to mechanical ventilation and respiratory tract infections. Phrenic motor neurons are highly vulnerable in rodent models of motor neuron disease versus accessory inspiratory motor pools (e.g. intercostals, scalenus). Thus, strategies that promote phrenic motor neuron survival when faced with disease and/or toxic insults are needed to help preserve breathing ability, airway defense and ventilator independence. Adenosine 2A receptors (A2A) are emerging as a potential target to promote neuroprotection, although their activation can have both beneficial and pathogenic effects. Since the role of A2A receptors in the phrenic motor neuron survival/death is not known, we tested the hypothesis that A2A receptor antagonism promotes phrenic motor neuron survival and preserves diaphragm function when faced with toxic, neurodegenerative insults that lead to phrenic motor neuron death. We utilized a novel neurotoxic model of respiratory motor neuron death recently developed in our laboratory: intrapleural injections of cholera toxin B subunit (CtB) conjugated to the ribosomal toxin, saporin (CtB-Saporin). We demonstrate that intrapleural CtB-Saporin causes: 1) profound phrenic motor neuron death (~5% survival); 2) ~7-fold increase in phrenic motor neuron A2A receptor expression prior to cell death; and 3) diaphragm muscle paralysis (inactive in most rats; ~7% residual diaphragm EMG amplitude during room air breathing). The A2A receptor antagonist istradefylline given after CtB-Saporin: 1) reduced phrenic motor neuron death (~20% survival) and 2) preserved diaphragm EMG activity (~46%). Thus, A2A receptors contribute to neurotoxic phrenic motor neuron death, an effect mitigated by A2A receptor antagonism.


Assuntos
Antagonistas do Receptor A2 de Adenosina/farmacologia , Toxina da Cólera/toxicidade , Neurônios Motores/efeitos dos fármacos , Neurônios Motores/metabolismo , Nervo Frênico/efeitos dos fármacos , Nervo Frênico/metabolismo , Saporinas/toxicidade , Animais , Apoptose/efeitos dos fármacos , Diafragma/inervação , Masculino , Purinas/farmacologia , Ratos , Ratos Sprague-Dawley
15.
Rev. esp. anestesiol. reanim ; 66(10): 497-505, dic. 2019. ilus, tab
Artigo em Espanhol | IBECS | ID: ibc-192103

RESUMO

INTRODUCCIÓN: El marcapasos diafragmático (MD) ha demostrado su utilidad en la sustitución de la ventilación mecánica en pacientes afectos de lesiones medulares crónicas (LMC) y esclerosis lateral amiotrófica (ELA), mejorando la calidad de vida y reduciendo la morbimortalidad y los costes sanitarios asociados. El manejo anestésico de dichos pacientes y las particularidades del procedimiento quirúrgico suponen un reto anestésico. El objetivo de nuestro estudio es el análisis del manejo y las complicaciones intraoperatorias de los pacientes sometidos a MD en nuestra institución. METODOLOGÍA: Se trata de una revisión retrospectiva entre diciembre de 2007 y julio de 2018. Se recogieron datos sobre el estado previo del paciente, el manejo anestésico y las complicaciones intraoperatorias. RESULTADOS: Se incluyen 16 pacientes (5 pediátricos) con indicación de MD por LMC (63%), ELA (25%) y otras enfermedades neurológicas (12%). Se requirió anestesia general para la laparoscopia abdominal utilizando inducción intravenosa (87%) o inhalatoria (13%) y anestesia total intravenosa (50%) o balanceada (50%) para el mantenimiento anestésico. En un caso se administró rocuronio para un óptimo manejo de la vía aérea. Las complicaciones registradas incluyeron: hipotensión arterial (50%), dificultades en la ventilación mecánica durante la laparoscopia (31%), pneumotárax (12,5%) y disreflexia autonómica (6%). CONCLUSIONES: La colocación de MD bajo anestesia general es una intervención segura, tanto en el paciente adulto como en el pediátrico, en la que pueden aparecer complicaciones derivadas tanto de la enfermedad de base como de la técnica quirúrgica, siendo necesaria una rápida identificación y tratamiento de las mismas para el buen desarrollo del procedimiento


BACKGROUND: The diaphragm pacemaker (DP) has proven its utility in replacing mechanical ventilation in patients with chronic spinal cord injury (SCI) and amyotrophic lateral sclerosis (ALS). The DP improves patient quality of life and reduces morbidity and mortality and their associated health care costs. The anesthetic management of these patients and the particularities of the surgical procedure are challenging. The aim of our study is to analyze anesthetic management and intraoperative complications in patients undergoing DP placement in our hospital. METHODS: We performed a chart review of patients treated between December 2007 and July 2017, recording the patients' preoperative status, anesthetic management and intraoperative complications. RESULTS: The study included 16 patients (5 pediatric) undergoing DP implantation for chronic SCI (63%), ALS (25%) and other neurologic conditions (12%). Abdominal laparoscopy was performed under general anesthesia, with intravenous (87%) or inhalational (13%) induction and maintenance using total intravenous (50%) or balanced (50%) anesthesia. Rocuronium was administered in one case to permit airway management. Complications included: hypotension (50%), difficulties in mechanical ventilation during laparoscopy (31%), pneumothorax (12.5%) and autonomic dysreflexia (6%). CONCLUSIONS: DP placement under general anesthesia is a safe intervention in both adult and pediatric patients. Complications derived from both the underlying disease and the surgical technique may appear, and must be rapidly identified and treated to obtain a satisfactory surgical outcome


Assuntos
Humanos , Masculino , Feminino , Pré-Escolar , Criança , Adolescente , Adulto Jovem , Adulto , Pessoa de Meia-Idade , Idoso , Esclerose Amiotrófica Lateral/complicações , Anestesia Geral/métodos , Diafragma , Marca-Passo Artificial , Quadriplegia/complicações , Transtornos Respiratórios/terapia , Traumatismos da Medula Espinal/complicações , Disreflexia Autonômica/etiologia , Doença Crônica , Hipotensão/etiologia , Neuroestimuladores Implantáveis , Complicações Intraoperatórias/etiologia , Laparoscopia/efeitos adversos , Nervo Frênico/lesões , Pneumotórax/etiologia , Transtornos Respiratórios/etiologia , Respiração Artificial/efeitos adversos , Estudos Retrospectivos , Traqueotomia/estatística & dados numéricos
16.
Surg Technol Int ; 35: 265-270, 2019 11 10.
Artigo em Inglês | MEDLINE | ID: mdl-31687777

RESUMO

The diaphragm is the primary muscle of respiration and its injury can cause diaphragm dysfunction and respiratory deficits. Respiratory compromise has historically been managed with mechanical ventilation, however, its use has also been shown to result in poor functional outcomes. Therefore, stimulation of the phrenic nerve, called diaphragm pacing, has been used to replace and/or delay the need for mechanical ventilation. This article will review the relevant literature on diaphragm pacing, discuss the physiology of diaphragm dysfunction in a variety of patient populations, and address whether diaphragm pacing is a valuable and effective option for treatment of respiratory failure.


Assuntos
Diafragma , Terapia por Estimulação Elétrica , Insuficiência Respiratória , Diafragma/fisiopatologia , Humanos , Nervo Frênico , Respiração Artificial , Insuficiência Respiratória/terapia
17.
Sleep ; 42(11)2019 10 21.
Artigo em Inglês | MEDLINE | ID: mdl-31634407

RESUMO

STUDY OBJECTIVE: To evaluate long-term efficacy and safety of phrenic nerve stimulation (PNS) in patients with moderate-to-severe central sleep apnea (CSA) through 3 years of therapy. METHODS: Patients in the remede System Pivotal Trial were observed every 3 months after implant until US Food and Drug Administration approval. At the time of approval and study closure, all patients completed 24 months of follow-up; 33 patients had not reached the 36-month visit. Sleep metrics (polysomnography) and echocardiographic parameters are reported at baseline, 12, 18, and 24 months, in addition to available 36-month sleep results from polygraphy. Safety was assessed through 36 months; however, analysis focused through 24 months and available 36-month results are provided. RESULTS: Patients were assessed at 24 (n = 109) and 36 (n = 60) months. Baseline characteristics included mean age 64 years, 91% male, and mean apnea-hypopnea index 47 events per hour. Sleep metrics (apnea-hypopnea index (AHI), central apnea index, arousal index, oxygen desaturation index, rapid eye movement sleep) remained improved through 24 and 36 months with continuous use of PNS therapy. At least 60% of patients in the treatment group achieved at least 50% reduction in AHI through 24 months. Serious adverse events (SAEs) related to the remede System implant procedure, device, or therapy through 24 months were reported by 10% of patients, no unanticipated adverse device effects or deaths, and all events resolved. No additional related SAEs were reported between 24 and 36 months. CONCLUSION: These data suggest beneficial effects of long-term PNS in patients with CSA appear to sustain through 36 months with no new safety concerns. TRIAL REGISTRATION: NCT01816776.


Assuntos
Terapia por Estimulação Elétrica/métodos , Nervo Frênico/fisiopatologia , Apneia do Sono Tipo Central/terapia , Idoso , Terapia por Estimulação Elétrica/efeitos adversos , Feminino , Seguimentos , Humanos , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Polissonografia , Estudos Prospectivos , Qualidade de Vida , Apneia do Sono Tipo Central/fisiopatologia , Resultado do Tratamento
18.
Muscle Nerve ; 60(6): 679-686, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31566774

RESUMO

INTRODUCTION: The purpose of this study was to comprehensively evaluate respiratory muscle function in adults with facioscapulohumeral muscular dystrophy (FSHD). METHODS: Fourteen patients with FSHD (9 men, 53 ± 16 years of age) and 14 matched controls underwent spirometry, diaphragm ultrasound, and measurement of twitch gastric and transdiaphragmatic pressures (twPgas and twPdi; n = 10) after magnetic stimulation of the lower thoracic nerve roots and the phrenic nerves. The latter was combined with recording of diaphragm compound muscle action potentials (CMAPs; n = 14). RESULTS: The following parameters were significantly lower in patients vs controls: forced vital capacity (FVC); maximum inspiratory and expiratory pressure; peak cough flow; diaphragm excursion amplitude; and thickening ratio on ultrasound, twPdi (11 ± 5 vs 20 ± 6 cmH2 O) and twPgas (7 ± 3 vs 25 ± 20 cmH2 O). Diaphragm CMAP showed no group differences. FVC correlated inversely with the clinical severity scale score (r = -0.63, P = .02). DISCUSSION: In FSHD, respiratory muscle weakness involves both the diaphragm and the expiratory abdominal muscles.


Assuntos
Diafragma/fisiopatologia , Debilidade Muscular/fisiopatologia , Distrofia Muscular Facioescapuloumeral/fisiopatologia , Músculos Respiratórios/fisiopatologia , Potenciais de Ação/fisiologia , Adulto , Idoso , Estudos de Casos e Controles , Estudos Transversais , Diafragma/diagnóstico por imagem , Feminino , Humanos , Masculino , Pressões Respiratórias Máximas , Pessoa de Meia-Idade , Debilidade Muscular/etiologia , Distrofia Muscular Facioescapuloumeral/complicações , Condução Nervosa , Nervo Frênico , Raízes Nervosas Espinhais , Espirometria , Vértebras Torácicas , Ultrassonografia , Capacidade Vital
20.
J Card Surg ; 34(8): 747, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31412159
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