Mirror visual feedback alleviates deafferentation pain, depending on qualitative aspects of the pain: a preliminary report.

OBJECTIVES: Following lesions in somatosensory pathways, deafferentation pain often occurs. Patients report that the pain is qualitatively complex, and its treatment can be difficult. Mirror visual feedback (MVF) treatment can improve deafferentation pain. We sought to classify the qualities of the pain in order to examine whether the potential analgesic effect of MVF depends on these qualities. METHODS: Twenty-two patients with phantom limb pain, or pain related to spinal cord or nerve injury, performed a single MVF procedure. Before and after the MVF procedure, we evaluated phantom limb awareness, movement representation of the phantom or affected/paralysed limb, pain intensity on an 11-point numerical rating scale (0-10) and the qualities of the pain [skin surface-mediated (superficial pain) vs deep tissue-mediated (deep pain)] using lists of pain descriptors for each of the two categories. RESULTS: Fifteen of the patients perceived the willed visuomotor imagery of the phantom or affected/paralysed limb after the MVF procedure. In most of the patients, a reduction in pain intensity and a decrease in the reporting of deep-pain descriptors were linked to the emergence of willed visuomotor imagery. CONCLUSIONS: In this pilot study, we roughly classified the pain descriptor items into two types for evaluating the qualities of deafferentation pain. We found that visually induced motor imagery by MVF was more effective for reducing deep pain than superficial pain. This suggests that the analgesic effect of MVF treatment does depend on the qualities of the pain. Further research will be required to confirm that this effect is a specific consequence of MVF.

[Anesthetic management of a neonate with esophageal atresia with double tracheoesophageal fistulae].

We reported the anesthetic management of a 1-day-old female neonate (2,110 gm) with esophageal atresia combined with double tracheoesophageal fistulae, which is classified as Gross type D. Though Gross type C was suspected preoperatively, the proximal fistula was found coincidentally during the preparation of the upper pouch. Because, for one thing, the origin of the proximal fistula was close to the end of the upper pouch (1cm), and for another, the distance between the both fistulae was short (1cm). As for the proximal fistula, it was 2 mm in diameter, and it was easily sealed with the side of the endotracheal tube. No other respiratory managements were needed except frequent suctionings of copious intratracheal secretions. On the other hand, the distal fistula, 10 mm in diameter, caused hypercapnea due to hypoventilation before gastrostomy. It was so big that it is easily intubated. This type of tracheoesophageal fistula is extraordinarily rare and its proximal fistula is difficult to find before, during, and even after operation. The missing of the proximal fistula often provokes severe respiratory infections and furthermore, sepsis postoperatively. It is concluded that in all the cases of tracheoesophageal fistula, the existence of the proximal fistula should be considered without fail and managed accordingly. To diagnose correctly, the use of preoperative bronchofiberscopy is also recommended.

[Neonatal apnea after general anesthesia--effects of intraoperative hyperventilation and serum ionized Ca concentration].

The relationship between neonatal apnea following general anesthesia and serum ionized calcium (Ca2+) concentration was examined in 13 neonates who had received intraoperative hyperventilation. In all cases, preoperative serum Ca2+ concentration was within normal limits. The anesthesia was maintained by nitrous oxide and oxygen. At the end of anesthesia, the incidence of abnormal breathing such as apnea, periodic breathing or subcostal retraction and their activity were investigated. Five minutes after intravenous administration of 2% CaCl2 solution (16 mg.kg-1), the same parameters were compared with the values before CaCl2 administration. As we used only Ca2+ free solution for fluid therapy during operation, serum Ca2+ concentration decreased gradually under general anesthesia, but after CaCl2 administration, it increased and the incidence of abnormal breathing decreased. To determine the relationship between hyperventilation and the incidence of abnormal breathing, the data were analyzed by dividing the patients into two groups based on PaCO2 level, a lower PaCO2 group (intraoperative PaCO2 < 30 mmHg, n = 5) and a higher PaCO2 group (PaCO2 > or = 30 mmHg, n = 8). But there was no significant relationship between them. In conclusion, this study demonstrates that the Ca administration has a favorable effect on respiratory system and motor activity, but we cannot relate the incidence of postoperative abnormal breathing to the degree of hyperventilation.

[Two cases of tension pneumothorax caused by tracheal suction during the operation of pectus excavatum].

Rehbein's method is one of the surgical procedures for pediatric pectus excavatum, which constructs thorax by lifting and fixating the sternum using metal strut inserted into bone marrow of bilateral ribs. We experienced two pediatric cases of tension pneumothorax caused by tracheal suctioning during the operation by this method. The etiology of tension pneumothorax was thought to be as follows. A small pleural hole was made during separation of ribs from surrounding tissues and a large amount of air entered into the pleural space and check valve mechanism worked at the pleural hole when the lung was collapsed on tracheal suctioning. In anesthetic management of pectus excavatum by Rehbein's method, we should always be cautious of the possible occurrence of tension pneumothorax.

[Serum catecholamine concentrations and hemodynamics during operations on 23 children with neuroblastoma].

The purpose of the present report is to reveal the relation between hemodynamic changes and serum catecholamine concentrations during operation of 23 neuroblastoma patients. The patients were aged from 6 months to 7 years (mean 1.2 year), and 20 patients (86%) were under 1 year of age. All the patients were in early stage of tumor development because they were diagnosed as neuroblastoma mainly by mass screening test for VMA and HVA in urine utilizing HPLC. This urinary mass screening test for infants is performed routinely in Japan. Operative manipulation of tumor provoked the significant elevation of blood pressure, and the increasing tendency of heart rate and rectal temperature. The mean concentrations of three kinds of serum catecholamine, epinephrine, norepinephrine and dopamine, were all very high during manipulation of tumor. Especially, the norepinephrine concentration was 90.2 times higher than the preoperative value. The children who showed high blood pressure, over 70% of the control level, showed high urinary VMA and VMA/HVA ratio preoperatively and a high norepinephrine secretion during operation. We conclude that for the anesthetic management of neuroblastoma, it is necessary to control the elevation of blood pressure even in small children, especially in the patients who have showed high values of urinary VMA and VMA/HVA ratio preoperatively.

[Evaluation of medical teaching of clinical medicine in 6th year internship-Medical School of USP]. / Avaliação do ensino médico de clínica médica no internato de sexto ano--Faculdade de Medicina da USP.

The authors analyzed the performance of student's during their stay at the University Hospital of São Paulo. The study was based on: theoretical evaluation (tests), number of hours dispensed on standard textbook study, and participation in seminars and/or classes. The opinion of the students about the quality of the study of the internal medicine was also analyzed. The average number of hours designated to study the textbook's was 5.8 +/- hours/week. There was an increase in the presence at seminars from 10% to 72%.

Tissue-specific regulation of IRS-2/PI 3-kinase association in aged rats.

We have examined the insulin-stimulated IRS-2 association with PI 3-kinase and the phosphorylation of AKT/PKB, which is functionally located downstream of the PI 3-kinase, in aged (obese) rats. The IRS-2 protein levels were similar in 2 and 20 month-old rats in both tissues, liver and muscle. There were reductions in insulin-induced IRS-2 tyrosine phosphorylation in liver and muscle, accompanied by a decrease in IRS-2/PI 3-kinase association and in AKT/PKB phosphorylation only in muscle tissue of aged rats. This regulation may be important in the altered glucose metabolism observed in aged (obese) rats.

Effect of thymine glycol on transcription elongation by T7 RNA polymerase and mammalian RNA polymerase II.

Thymine glycols are formed in DNA by exposure to ionizing radiation or oxidative stress. Although these lesions are repaired by the base excision repair pathway, they have been shown also to be subject to transcription-coupled repair. A current model for transcription-coupled repair proposes that RNA polymerase II arrested at a DNA lesion provides a signal for recruitment of the repair enzymes to the lesion site. Here we report the effect of thymine glycol on transcription elongation by T7 RNA polymerase and RNA polymerase II from rat liver. DNA substrates containing a single thymine glycol located either in the transcribed or nontranscribed strand were used to carry out in vitro transcription. We found that thymine glycol in the transcribed strand blocked transcription elongation by T7 RNA polymerase approximately 50% of the time but did not block RNA polymerase II. Thymine glycol in the nontranscribed strand did not affect transcription by either polymerase. These results suggest that arrest of RNA polymerase elongation by thymine glycol is not necessary for transcription-coupled repair of this lesion. Additional factors that recognize and bind thymine glycol in DNA may be required to ensure RNA polymerase arrest and the initiation of transcription-coupled repair in vivo.

Defects in insulin signal transduction in liver and muscle of pregnant rats.

Pregnancy is known to induce resistance, but the exact molecular mechanism involved is unknown. In the present study, we have examined the levels and phosphorylation state of the insulin receptor and of insulin receptor substrate 1 (IRS-1), as well as the association between IRS-1 and phosphatidylinositol 3-kinase (PI 3-kinase) in the liver and muscle of pregnant rats (day 20 of gestation) by immunoprecipitation and immunoblotting with anti-insulin receptor, anti-IRS-1, anti-PI 3-kinase and anti-phosphotyrosine antibodies. There were no changes in the insulin receptor concentration in the liver and muscle of pregnant rats. However, insulin stimulation of receptor autophosphorylation, as determined by immunoblotting with antiphosphotyrosine antibody, was reduced by 30 +/- 6% (p < 0.02) in muscle and 36 +/- 5% (p < 0.01) in liver at day 20 of gestation. IRS-1 protein levels decreased by 45 +/- 6% (p < 0.002) in liver and by 56 +/- 9% (p < 0.002) in muscle of pregnant rats. In samples previously immunoprecipitated with anti-IRS-1 antibody and blotted with antiphosphotyrosine antibody, the insulin-stimulated IRS-1 phosphorylation levels in the muscle and liver of pregnant rats decreased by 70 +/- 9% (p < 0.01) and 75 +/- 8% (p < 0.01), respectively. The insulin-stimulated IRS-1 association with PI 3-kinase decreased by 81 +/- 6% in muscle (p < 0.01) and 79 +/- 11% (p < 0.01) in the liver during pregnancy. These data suggest that changes in the early steps of insulin signal transduction may have a role in the insulin resistance observed in pregnancy.

Vasculite urticariforme.Relato de caso e revisao de literatura. / Urticarial vasculitis. A case report and review of the literature

Relatamos o caso do paciente do sexo masculino, de 27 anos, com urticaria cronica como manifestacao de vasculite necrosante cutanea, associada a artrite, febre, emagrecimento e hipocomplementemia. A sindrome caracterizada neste paciente e semelhante aos casos previamente relatados como "vasculite hipocomplementemica", "vasculite necrosante associada a urticaria cronica" e "vasculite urticariforme". Apresentamos revisao de literatura e discussao do diagnostico diferencial e tratamento. Acreditamos que essa nova sindrome constitui uma subpopulacao distinta de patologia colageno-vascular