Passive mechanical properties of human gastrocnemius muscle tendon units, muscle fascicles and tendons in vivo.

This study provides the first in vivo measures of the passive length-tension properties of relaxed human muscle fascicles and their tendons. A new method was used to derive passive length-tension properties of human gastrocnemius muscle-tendon units from measures of ankle stiffness obtained at a range of knee angles. Passive length-tension curves of the muscle-tendon unit were then combined with ultrasonographic measures of muscle fascicle length and pennation to determine passive length-tension curves of the muscle fascicles and tendons. Mean slack lengths of the fascicles, tendons and whole muscle-tendon units were 3.3+/-0.5 cm, 39.5+/-1.6 cm and 42.3+/-1.5 cm, respectively (means +/- s.d., N=6). On average, the muscle-tendon units were slack (i.e. their passive tension was zero) over the shortest 2.3+/-1.2 cm of their range. With combined changes of knee and ankle angles, the maximal increase in length of the gastrocnemius muscle-tendon unit above slack length was 6.7+/-1.9 cm, of which 52.4+/-11.7% was due to elongation of the tendon. Muscle fascicles and tendons underwent strains of 86.4+/-26.8% and 9.2+/-4.1%, respectively, across the physiological range of lengths. We conclude that the relaxed human gastrocnemius muscle-tendon unit falls slack over about one-quarter of its in vivo length and that muscle fascicle strains are much greater than tendon strains. Nonetheless, because the tendons are much longer than the muscle fascicles, tendons contribute more than half of the total compliance of the muscle-tendon unit.

Selective recruitment of single motor units in human flexor digitorum superficialis muscle during flexion of individual fingers.

Flexor digitorum superficialis (FDS) is an extrinsic multi-tendoned muscle which flexes the proximal interphalangeal joints of the four fingers. It comprises four digital components, each with a tendon that inserts onto its corresponding finger. To determine the degree to which these digital components can be selectively recruited by volition, we recorded the activity of a single motor unit in one component via an intramuscular electrode while the subject isometrically flexed each of the remaining fingers, one at a time. The finger on which the unit principally acted was defined as the 'test finger' and that which flexed isometrically was the 'active' finger. Activity in 79 units was recorded. Isometric finger flexion forces of 50% maximum voluntary contraction (MVC) activated less than 50% of single units in components of FDS acting on fingers that were not voluntarily flexed. With two exceptions, the median recruitment threshold for all active-test finger combinations involving the index, middle, ring and little finger test units was between 49 and 60% MVC (60% MVC being the value assigned to those not recruited). The exceptions were flexion of the little finger while recording from ring finger units (median: 40% MVC), and vice versa (median: 2% MVC). For all active-test finger combinations, only 35/181 units were activated when the active finger flexed at less than 20% MVC, and the fingers were adjacent for 28 of these. Functionally, to recruit FDS units during grasping and lifting, relatively heavy objects were required, although systematic variation occurred with the width of the object. In conclusion, FDS components can be selectively activated by volition and this may be especially important for grasping at high forces with one or more fingers.

A new method for measuring passive length-tension properties of human gastrocnemius muscle in vivo.

The study of muscle growth and muscle length adaptations requires measurement of passive length-tension properties of individual muscles, but until now such measurements have only been made in animal muscles. We describe a new method for measuring passive length-tension properties of human gastrocnemius muscles in vivo. Passive ankle torque and ankle angle data were obtained as the ankle was rotated through its full range with the knee in a range of positions. To extract gastrocnemius passive length-tension curves from passive torque-angle data it was assumed that passive ankle torque was the sum of torque due to structures which crossed only the ankle joint (this torque was a 6-parameter function of ankle joint angle) and a torque due to the gastrocnemius muscle (a 3-parameter function of knee and ankle angle). Parameter values were estimated with non-linear regression and used to reconstruct passive length-tension curves of the gastrocnemius. The reliability of the method was examined in 11 subjects by comparing three sets of measurements: two on the same day and the other at least a week later. Length-tension curves were reproducible: the average root mean square error was 5.1+/-1.1 N for pairs of measurements taken within a day and 7.3+/-1.2 N for pairs of measurements taken at least a week apart (about 3% and 6% of maximal passive tension, respectively). Length-tension curves were sensitive to mis-specification of moment arms, but changes in length-tension curves were not. The new method enables reliable measurement of passive length-tension properties of human gastrocnemius in vivo, and is likely to be useful for investigation of changes in length-tension curves over time.

Measurement and nature of firing rate adaptation in turtle spinal neurons.

There is sparse literature on the profile of action potential firing rate (spike-frequency) adaptation of vertebrate spinal motoneurons, with most of the work undertaken on cells of the adult cat and young rat. Here, we provide such information on adult turtle motoneurons and spinal ventral-horn interneurons. We compared adaptation in response to intracellular injection of 30-s, constant-current stimuli into high-threshold versus low-threshold motoneurons and spontaneously firing versus non-spontaneously-firing interneurons. The latter were shown to possess some adaptive properties that differed from those of motoneurons, including a delayed initial adaptation and more predominant reversal of adaptation attributable to plateau potentials. Issues were raised concerning the interpretation of changes in the action potentials' afterhyperpolarization shape parameters throughout spike-frequency adaptation. No important differences were demonstrated in the adaptation of the two motoneuron and two interneuron groups. Each of these groups, however, was modeled by its own unique combination of action potential shape parameters for the simulation of its 30-s duration of spike-frequency adaptation. Also, for a small sample of the very highest-threshold versus lowest-threshold motoneurons, the former group had significantly more adaptation than the latter. This finding was like that shown previously for cat motoneurons supplying fast- versus slow twitch motor units.

Forces consistent with plateau-like behaviour of spinal neurons evoked in patients with spinal cord injuries.

Percutaneous electrical stimulation over tibialis anterior and triceps surae was performed in 14 patients with traumatic spinal cord injury (SCI) to look for evidence that 'extra contractions' can develop, beyond those due to activation of the motor axons beneath the stimulating electrodes. Criteria for the extra contractions included marked asymmetry of force with respect to stimulation, progressively rising force during stimulation of constant amplitude and frequency, and force remaining high after stimulation frequency had returned to the control level following a high-frequency burst. Twelve of the 14 patients showed evidence of such behaviour, more frequently in triceps surae than tibialis anterior. Force or electromyographic activity commonly outlasted the stimulation in these patients. There was no apparent correlation between the completeness or level of injury and the ability to induce the behaviour. Evidence of force potentiation and 'habituation' was also seen. Eleven of the 14 patients exhibited hyper-reflexia and reported spontaneous spasms, but there was no obvious association with the extra contractions. It is concluded that non-classical behaviour of neurons within the spinal cord can contribute to the extra contractions evoked by electrical stimulation over muscles in spinal cord-injured subjects. This central contribution is less easy to obtain than in intact healthy subjects, all of whom showed the phenomenon. These contractions are consistent with the activation of plateau potentials in spinal neurons and, if so, plateau potentials may contribute to a patient's clinical manifestations.

Distribution of the forces produced by motor unit activity in the human flexor digitorum profundus.

In humans, the flexor digitorum profundus (FDP), which is a multi-tendoned muscle, produces forces that flex the four distal interphalangeal joints of the fingers. We determined whether the force associated with activity in a single motor unit in the FDP was confined to a single finger or distributed to more than one finger during a natural grasp. The discharge of single low-threshold motor units (n = 69) was recorded at sites across the muscle during weak voluntary grasping involving all fingers and spike-triggered averaging of the forces under each of the finger pads was used to assess the distribution pattern. Spike-triggered averaging revealed that time-locked changes in force occurred under the 'test' finger (that finger on which the unit principally acted) as well as under the 'non-test' fingers. However, for the index-, middle- and ring-finger units, the changes in force under non-test fingers were typically small (< 20 % of those under the test finger). For little-finger units, the mean changes in force under the adjacent ring finger were large (>50 % of those under the test finger). The distribution of forces by little-finger units differed significantly from that for each of the other three fingers. Apart from increases in force under non-test fingers, there was occasional unloading of adjacent fingers (22/267 combinations), usually affecting the index finger. The increases in force under the test finger correlated significantly with the background force for units acting on the middle, ring and little fingers. During a functional grasp, the activity of single units in the FDP allows for a relatively selective control of forces at the tips of the index, middle and ring fingers, but this is limited for little-finger units.

Estimation of diaphragm length in patients with severe chronic obstructive pulmonary disease.

In patients with advanced chronic obstructive pulmonary disease (COPD) diaphragm function may be compromised because of reduced muscle fibre length. Diaphragm length (L(Di)) can be estimated from measurements of transverse diameter of the rib cage (D(Rc)) and the length of the zone of apposition (L(Zapp)) in healthy subjects, but this method has not been validated in patients with COPD. Postero-anterior chest radiographs were obtained at total lung capacity (TLC), functional residual capacity (FRC) and residual volume (RV) in nine male patients with severe COPD (mean [S.D.]; FEV(1), 23 [6] %pred.; FRC, 199 [15] %pred.). Radiographs taken at TLC were used to identify the lateral costal insertions of the diaphragm (L(Zapp) assumed to approach zero at TLC). L(Di) was measured directly and also estimated from measurements of L(Zapp) and D(Rc) using a prediction equation derived from healthy subjects. The estimation of L(Di) was highly accurate with an intraclass correlation coefficient of 0.93 and 95% CI of approximately +/-8% of the true value. L(Di) decreased from 426 (64) mm at RV to 305 (31) mm at TLC. As there were only small and variable changes in D(Rc) across the lung volume range, most of the L(Di) changes occurred in the zone of apposition. Additional studies showed that measurements of L(Di) from PA and lateral radiographs performed at different lung volumes were tightly correlated. These results suggest that non-invasive measurements of L(Zapp) in the coronal plane (e.g. using ultrasonography) and D(Rc) (e.g. using magnetometers) can be used to provide an accurate estimate of L(Di) in COPD patients.

Effects of increased ventilatory drive on motor unit firing rates in human inspiratory muscles.

This study was designed to determine whether increased neural drive increases firing rates of inspiratory motoneurons uniformly in humans. The discharge of single motor units in the diaphragm, parasternal intercostal and scalene muscles was recorded with monopolar electrodes. Ventilation was increased threefold with an external dead space. The discharge of 516 motor units was sampled in four subjects. All but 4 units increased their discharge rate during inspiration with only 46 discharging tonically during expiration. With increased dead space, discharge frequencies of diaphragmatic motor units increased from 11.0 +/- 2.7 to 17.7 +/- 3.3 Hz (mean +/- SD; p < 0.001). However, firing rates increased for parasternal intercostals from 10.0 +/- 1.6 to only 11.9 +/- 1.9 Hz (p < 0.001), and for scalenes from 8.7 +/- 1.8 to only 9.5 +/- 1.2 Hz (p < 0.05). Proportionate increases in rib cage and abdominal expansion accompanied the increased ventilation with added dead space. These results suggest that previously reported predominant increase in firing rates of diaphragmatic motor units in patients with chronic airflow limitation reflects the normal response of respiratory motor output to increased neural drive. The motoneuron pools of the parasternal intercostals and scalenes may show more prominent recruitment than frequency modulation.

Task failure, breathing discomfort and CO2 accumulation without fatigue during inspiratory resistive loading in humans.

Task failure during inspiratory resistive loading has been attributed to inspiratory muscle fatigue. Six subjects breathed at their own rate and duty cycle through an inspiratory resistive load to a target mouth pressure of 80% maximal inspiratory pressure (MIP) until task failure, when breathing discomfort (measured with a modified Borg scale) was maximal. Six protocols were used to vary ventilatory parameters and hence the rate of rise, of end-tidal CO2. MIP did not decline during resistive loading in any protocol, but there were significant increases in end-tidal CO2 (ranging from 1.0 to 3.9). Time to task failure increased in protocols that enabled subjects to reduce the rate of CO2 accumulation. Differences in endurance times between subjects were related to their sense of breathing discomfort with rising CO2 measured in separate rebreathing studies. Task failure was due to breathing discomfort associated with CO2 accumulation and sensations related to the generation of large inspiratory pressures, rather than inspiratory muscle fatigue.

Electrophysiological and morphological properties of neurons in the ventral horn of the turtle spinal cord.

In this report, we present recent findings on the electrophysiological and morphological properties of spinal motoneurons (MNs) and interneurons (INs) of the adult turtle which were studied in slices of the spinal cord. The range of values for the measured electrophysiological parameters in 96 tested cells included: resting potential, -57 to -83 mV; input resistance, 2.5-344 M omega; time constant, 2.5-63 ms; rheobase current, 0.04-5.3 nA; after-hyperpolarization (AHP) duration, 72-426 ms; AHP half-decay time; 11-212 ms; and, slope of the stimulus current-spike frequency relationship, 3.4-235 Hz/nA. For another 20 cells, we made both morphological and electrophysiological measurements (the latter values within the above ranges). Their ranges in morphological properties included: soma diameter, 20-54 microm; soma surface area, 299-2045 microm2; soma volume, 2.3-45 microm3 x 10(4); rostro-caudal dendritic projection distance, 150-1200 microm; and, sum of dendritic lengths, 1.5-16 microm x 10(3). The emphasized findings include: 1) the quality and robustness of the intracellular recordings, which enabled accurate measurement of the action potential's shape parameters (spike, afterhyperpolarization [AHP]); 2) the substantial AHP of the INs' AP; 3) no single action-potential shape parameter (nor combination of parameters) being cardinal for its (or their combined) changes matching the profile of the initial and later phases of spike-frequency adaptation; 4) the utility and flexibility of a cluster analysis (using varying combinations of passive, transitional and active cell properties) for providing a provisional classification of low (like cat S) and high (like cat F) threshold MNs, and groups of INs with non-spontaneous versus spontaneous discharge; 5) the clear-cut morphological confirmation of the provisional classification strategy; 6) the basis for testing the possibility that one of the provisionally classified MN types innervates non-twitch muscle fibers; and 7) the heuristic value of comparing the properties of MNs versus INs across vertebrate species, with an emphasis on the lamprey, turtle, and cat.

Human respiratory muscles: sensations, reflexes and fatiguability.

1. Given the importance of the ventilatory 'pump' muscles, it would not be surprising if they were endowed with both sensory and motor specializations. The present review focuses on some unexpected properties of the respiratory muscle system in human subjects. 2. Although changes in blood gas tension were long held not to influence sensation directly, studies in subjects who are completely paralysed show that increases in arterial CO2 levels elicit strong sensations of respiratory discomfort. 3. Stretch reflexes in human limb muscles contain a monosynaptic spinal excitation and a long-latency excitation. However, inspiratory muscles show an initial inhibition when tested with brief airway occlusions during inspiration. This inhibition does not depend critically on input from pulmonary or upper airway receptors. 4. Human inspiratory muscles (including the diaphragm) have been considered to fatigue during inspiratory resistive loading. However, recent studies using phrenic nerve stimulation to test the force produced by the diaphragm show that carbon dioxide retention (hypoventilation) and voluntary cessation of loading occur before the muscles become overtly fatigued.

Properties of spinal motoneurons and interneurons in the adult turtle: provisional classification by cluster analysis.

The purpose of the present study was to compare, in motoneurons (MNs) vs. interneurons (INs), selected passive, transitional, and active (firing) properties, as recorded in slices of lumbosacral spinal cord (SC) taken from the adult turtle. The cells were provisionally classified on the basis of (1) the presence (in selected INs) or absence (MNs and other INs) of spontaneous discharge, (2) a cluster analysis of selected properties of the nonspontaneously firing cells, (3) a comparison to previous data on turtle MNs and INs, and (4) a qualitative comparison of the results with those reported for other vertebrate species (lamprey, cat). The provisional nomenclature accommodated properties appropriate for solely MNs (Main MN group) vs. nonspontaneously firing INs (Main IN-N) vs. spontaneously firing INs (IN-S) and for neurons with two degrees of intermediacy between the Main MN and the Main IN-N groups (Overlap MN, Overlap MN/IN). Morphological reconstructions of additional cells, which had been injected with biocytin during the electrophysiological tests, were shown to provide clear-cut support for the provisional classification procedure. The values for the measured parameters in the 96 tested cells covered the spectrum reported previously across adult vertebrate species and were robust in measurements made on different SC slices up to 5 days after their removal from the host animal. The interspecies comparisons permitted the predictions that (1) our Main MN and Overlap MN cells would be analogous to two MN types that innervate fast-twitch and slow-twitch skeletomotor muscle fibers, respectively, in the cat, and (2) the MNs in our Overlap MN/IN group probably innervate slow (nontwitch, tonic) muscle fibers whose presence has recently been established in the turtle hindlimb. In summary, the results bring out the utility of the SC slice preparation of the turtle for study of spinal motor mechanisms in adult tetrapod vertebrates, particularly as an adjunct to the in vivo cat, because of the ease with which robust measurements can be made of the active properties of both MNs and INs.

Double-blind randomized evaluation of intercostal nerve blocks as an adjuvant to subarachnoid administered morphine for post-thoracotomy analgesia.

BACKGROUND AND OBJECTIVES: Thoracotomy is associated with pain and compromised pulmonary function. Intercostal nerve blocks (INB) and subarachnoid morphine (SM) act on different portions of the pain pathway. Each is effective for post-thoracotomy pain relief. The combination of these two modalities in relieving post-thoracotomy pain and improving postoperative pulmonary function has not been investigated. METHODS: In a double-blind study, 20 patients undergoing lateral thoracotomy for lung resection were randomized to receive 0.5 mg SM preoperatively and INB with bupivacaine (INB+) prior to wound closure or 0.5 mg SM with INB using saline (INB-). Visual analog scale pain scores at rest, with cough, and with movement of the ipsilateral arm, forced expiratory volume in 1 second (FEV1), and forced vital capacity (FVC) were measured at 4, 24, 48, and 72 hours after the operation. Opioid use was measured during the initial 24 hours after the operation. RESULTS: At 4 hours, the INB+ group demonstrated better FEV1 (56.6% vs. 40.4% of baseline, P < .05) and FVC values (54.6% vs. 39.6% of baseline, P < .05) and less resting and cough pain (P < .05). However, FEV1 continued to decline in the INB+ group at 24 hours to lower than the INB- group although pain scores were similar beyond 4 hours. Opioid usage during the first 24 hours was similar (INB-, 16.7 mg vs. INB+, 13.2 mg, P = .7). CONCLUSIONS: Although postoperative INB provided modest improvements in pain and pulmonary function when used as an adjuvant to 0.5 mg SM for post-thoracotomy analgesia, the benefits were transient. The authors do not recommend adding INB for patients undergoing lateral thoracotomy who receive 0.5 mg SM.

Multivariate determinants of early postoperative oxygen consumption in elderly patients. Effects of shivering, body temperature, and gender.

BACKGROUND: Previous investigators have proposed that postoperative shivering may be poorly tolerated by patients with cardiopulmonary disease because of the associated significant increase in total-body oxygen consumption. However, the often-quoted 300-400% increase in oxygen consumption with shivering was derived from relatively few studies performed in a small number of younger persons specifically selected on the basis of clinically recognizable shivering. We hypothesized that the average elderly postoperative patient has a shivering response that is associated with a relatively small increase in total-body oxygen consumption. METHODS: One hundred eleven elderly patients (age > 60 yr) undergoing surgery were studied to assess the determinants of shivering and total-body oxygen consumption in the early postoperative period. Anesthetic technique, postoperative analgesia, and thermal management were controlled by protocol. The clinical variables associated with shivering and increased total-body oxygen consumption were determined by univariate and multivariate analyses. RESULTS: Mean total-body oxygen consumption in shivering patients was 38% greater than in nonshivering patients. Regardless of whether data from shivering patients were included in the analysis, oxygen consumption was directly proportional to mean body temperature. Despite similar core temperatures, men had a greater incidence of clinically recognizable shivering and greater total-body oxygen consumption than did women. CONCLUSIONS: The metabolic demands associated with postoperative shivering in elderly patients are less than those reported previously in younger persons. These findings suggest that if hypothermia predisposes to cardiovascular complications in the postoperative period, these complications are not likely to be mediated by shivering and increased metabolism.

Software compensation for lung volume in assessment of inspiratory muscle strength and endurance.

BACKGROUND: To increase the sensitivity of measurements of maximal inspiratory pressure (MIP) as a test of inspiratory muscle strength and endurance, software was developed to correct for variation in lung volume. METHODS: Using a body plethysmograph to determine absolute lung volume during each manoeuvre, values for MIP were expressed as a percentage of the pressure "expected" from the unfatigued MIP/lung volume relation in each subject. RESULTS: The method reduced the variance in peak and average pressure during a series of 18 MIP manoeuvres of 10 seconds duration separated by rest intervals of 10 seconds. CONCLUSIONS: The correlation between average pressure and contraction number was improved significantly by the MIP/lung volume correction. This simple correction has many applications in measurements of the MIP.

The catecholamine, cortisol, and hemodynamic responses to mild perioperative hypothermia. A randomized clinical trial.

BACKGROUND: Unintended hypothermia occurs frequently during surgery and may have adverse effects on the cardiovascular system. Although the mechanisms responsible for the cardiovascular manifestations of hypothermia are unclear, it is possible that they are sympathetically mediated. In this prospective study, relationships between body temperature, the neuroendocrine response, and hemodynamic changes in the perioperative period were examined. METHODS: Seventy-four elderly patients, undergoing abdominal, thoracic, or lower extremity vascular surgical procedures, were randomly assigned to either "routine care" (n = 37) or "forced-air warming" (n = 37) groups. Throughout the intraoperative and early postoperative periods, the routine care group received standard thermal care, and the forced-air warming group received forced-air skin-surface warming. Core temperature, forearm minus fingertip skin-surface temperature gradient, and plasma concentrations of epinephrine, norepinephrine, and cortisol were measured throughout the perioperative period, and the two groups were compared. In addition, heart rate and arterial blood pressure were compared between groups. RESULTS: The routine care and forced-air warming groups did not differ with regard to age, sex, type of surgical procedures, anesthetic techniques, or postoperative analgesia. Mean core temperature was lower in the routine care group on admission to the postanesthetic care unit (routine care, 35.3 +/- 0.1 degree C; forced-air warming, 36.7 +/- 0.1 degree C; P = 0.0001) and remained lower during the early postoperative period. Forearm minus fingertip skin-surface temperature gradient (an index of peripheral vasoconstriction) was greater in the routine care group in the early postoperative period. The mean norepinephrine concentration (pcg/ml) was greater in the routine care group immediately after surgery (480 +/- 70 vs. 330 +/- 30, P = 0.02) and at 60 min (530 +/- 50 vs. 340 +/- 30, P = 0.002) and 180 min (500 +/- 80 vs. 320 +/- 30, P = 0.004) postoperatively. Mean epinephrine concentrations were not significantly different between groups. Mean cortisol concentrations were increased in both groups during the early postoperative period (P < 0.01), but the differences between groups were not significant. Systolic, mean, and diastolic arterial blood pressures were significantly higher in the routine care group. CONCLUSIONS: Compared with patients in the forced-air warming group, patients receiving routine thermal care had lower core temperatures, a greater degree of peripheral vasoconstriction, higher norepinephrine concentrations, and higher arterial blood pressures in the early postoperative period. These findings suggest a possible mechanism for hypothermia-related cardiovascular morbidity in the perioperative period.

Dynamic changes in the zone of apposition and diaphragm length during maximal respiratory efforts.

BACKGROUND: Clinical tests of diaphragmatic strength are limited by the wide normal variation in maximal pressure which result, in part, from changes in diaphragmatic length. During relaxation at different lung volumes diaphragmatic length (LDI) can be estimated from the length of the zone of apposition (LZapp) and the transverse diameter of the rib cage (DRC). A study was carried out in two subjects using sequential digital radiography at six frames/second to determine whether these relations apply during maximal respiratory efforts which distort the rib cage and diaphragm. METHODS: The length of the anteroposterior contour of the diaphragm and DRC were determined by curve fitting. LZapp was measured with a millimetre rule. RESULTS: A significant correlation was found between LDI and LZapp during both maximal inspiratory and expulsive manoeuvres (R2 = 0.88 and 0.52). LDI was estimated from the measurements of LZapp and DRC using a multiple regression equation derived from measurements during static relaxation. Despite the complex dynamic events at the onset of these "static" manoeuvres, actual LDI correlated strongly with derived LDI using all data for the two manoeuvres in each subject (R2 = 0.95 and 0.84). Measurements with ultrasonography (12 cm linear probe) and magnetometers confirmed the changes in LZapp and DRC during inspiratory and expulsive efforts. CONCLUSIONS: Non-invasive measurements of LZapp and DRC can be used to derive an accurate estimate of diaphragmatic length under dynamic conditions.

Moderate hypothermia, with partial bypass and segmental sequential repair for thoracoabdominal aortic aneurysm.

PURPOSE: Ischemic injury to the spinal cord, kidneys, and viscera occurs in a significant number of patients undergoing surgical repair of thoracoabdominal aortic aneurysms. Partial bypass has been used to perfuse the arterial system distal to the cross-clamp, but the primary determinant of ischemic morbidity remains the duration of aortic cross-clamping. Hypothermia may favorably affect outcome during these procedures, but moderate or deep hypothermia has traditionally required full cardiopulmonary bypass with cardiac arrest. METHODS: In a series of patients undergoing thoracoabdominal (n = 14) or thoracic (n = 4) aneurysm repair, we used moderate hypothermia (30 degrees C) and partial bypass (aortofemoral or atriofemoral) while maintaining an intrinsic cardiac rhythm. Body temperature was controlled with a heat exchanger in the bypass circuit, which allowed for rapid cooling and rewarming. In addition to hypothermia and bypass, a segmental sequential surgical repair was used to minimize the duration of ischemia to any given vascular bed. RESULTS: All patients survived the surgical procedure, and 16 patients survived until discharge from the hospital. None of the 18 patients had paraplegia or significant renal dysfunction. The only complication related to hypothermia was atrial fibrillation, which occurred in three patients and was amenable to therapeutic measures. CONCLUSIONS: We conclude that moderate hypothermia, partial bypass, and segmental sequential repair may reduce ischemic injury. This combination of adjuncts was not associated with significant complications in this series of patients.

Motoneuronal output and gradation of effort in attempts to contract acutely paralysed leg muscles in man.

1. The study was designed to determine the degree to which normal subjects can control motoneurones innervating a leg muscle when acutely deprived of muscle afferent feedback. Microneurographic recordings were made from eighteen motor fascicles in the common peroneal nerve, of which thirteen innervated tibialis anterior and five toe dorsiflexor muscles. The nerve was then blocked completely at a distal site near the fibular head with local anaesthetic. A sequence of tests was performed with each fascicle to determine the degree to which the subject could control the motoneuronal drive to the paralysed muscle. 2. During a complete distal block of the common peroneal nerve, motoneurones innervating tibialis anterior were frequently activated during weak attempted contraction of the synergist toe extensors and vice versa. 3. When subjects attempted contractions of the paralysed muscles at a constant effort, pressure applied to the dorsum of the foot caused relatively small changes in the level of neural output, producing a small increase in motoneuronal drive to tibialis anterior, but no consistent change in the drive to toe extensor fascicles. 4. Subjects were able to increase the motoneuronal drive to the paralysed tibialis anterior in five steps of effort each lasting 10 s. The level of motor output increased linearly with step number, but declined as the step was maintained, more so when auditory feedback was withdrawn. 5. There was hysteresis in the relationship between motoneuronal output and force (measured on the contralateral side) during attempts to make slowly increasing then decreasing ramps of effort on both sides over 20-120 s. Motor drive to the paralysed muscle increased disproportionately rapidly compared with contralateral force when subjects attempted bilaterally symmetrical increasing efforts. 6. Subjects attempted to activate the paralysed muscle group maximally for 20-30 s with auditory feedback of the neurogram and verbal encouragement. There was a small statistically significant reduction in the motoneuronal output 5-10 s into the 30 s effort but, with further encouragement, it recovered towards the end of the effort. 7. When compared directly in the same recording sequences, attempts to make rapid brief maximal efforts (2-3 s duration) produced the same motoneuronal output as attempts to make sustained efforts. 8. Similar results occurred when the motoneuronal output to tibialis anterior was recorded during a selective distal block of tibialis anterior sparing toe dorsiflexors.(ABSTRACT TRUNCATED AT 400 WORDS)