Restoring movement representation and alleviating phantom limb pain through short-term neurorehabilitation with a virtual reality system.

BACKGROUND AND OBJECTIVE: We developed a quantitative method to measure movement representations of a phantom upper limb using a bimanual circle-line coordination task (BCT). We investigated whether short-term neurorehabilitation with a virtual reality (VR) system would restore voluntary movement representations and alleviate phantom limb pain (PLP). METHODS: Eight PLP patients were enrolled. In the BCT, they repeatedly drew vertical lines using the intact hand and intended to draw circles using the phantom limb. Drawing circles mentally using the phantom limb led to the emergence of an oval transfiguration of the vertical lines ('bimanual-coupling' effect). We quantitatively measured the degree of this bimanual-coupling effect as movement representations of the phantom limb before and immediately after short-term VR neurorehabilitation. This was achieved using an 11-point numerical rating scale (NRS) for PLP intensity and the Short-Form McGill Pain Questionnaire (SF-MPQ). During VR neurorehabilitation, patients wore a head-mounted display that showed a mirror-reversed computer graphic image of an intact arm (the virtual phantom limb). By intending to move both limbs simultaneously and similarly, the patients perceived voluntary execution of movement in their phantom limb. RESULTS: Short-term VR neurorehabilitation promptly restored voluntary movement representations in the BCT and alleviated PLP (NRS: p = 0.015; 39.1 ± 28.4% relief, SF-MPQ: p = 0.015; 61.5 ± 48.5% relief). Restoration of phantom limb movement representations and reduced PLP intensity were linearly correlated (p < 0.05). CONCLUSIONS: VR rehabilitation may encourage patient's motivation and multimodal sensorimotor re-integration of a phantom limb and subsequently have a potent analgesic effect. SIGNIFICANCE: There was no objective evidence that restoring movement representation by neurorehabilitation with virtual reality alleviated phantom limb pain. This study revealed quantitatively that restoring movement representation with virtual reality rehabilitation using a bimanual coordination task correlated with alleviation of phantom limb pain.

[Pneumothorax and abdominal free air occurred after percutaneous tracheostomy (PCT)].

We report a case of pneumothorax and abdominal free air after percutaneous tracheostomy (PCT). A 80-year-old female was intubation for upper respiratory stenosis. We thought tracheal stenosis recurrence after extubation. PCT was performed. Respiratory insufficiency and subcutaneous emphysema appeared rapidly at face, neck and precordia Subcutaneous emphysema was pushed away. PCT was performed once more. Chest X-ray showed pneumothorax in right thoracic cavity. Thoracostomy tube was intubation. Chest computed tomography (CT) scan showed pneumothorax another thoracic cavity and abdominal free air. Vital signs was not worse, so observation. Postoperative course was uneventful. The patient was recovered. We thought that PCT was effective under bronchofiber.

Effects of the pollution by petroleum on the tracheids along the stem of Podocarpus lambertii Klotzsch ex Endl., Podocarpaceae.

Podocarpus lambertii Klotzsch ex Endl. (Podocarpaceae) is native and a member of the Pinophyta (Gymnosperm) of southern Brazil, locally known as 'pinheiro-bravo'. The present work aims to investigate the effects of petroleum on the tracheids dimensions. Wood samples from twenty individuals were studied along the stem, ten being exposed to pollution and ten used as a control set. The wood samples were collected from incisions at three levels: at the ground level, and one and two metres above the ground level. From these samples, sub-samples were selected at the border of the growth layers in the vascular cambium-medulla direction. The methodology followed that traditionally recommended for plant anatomy studies, with analyses done by light microscopy (OLYMPUS - BX41) assisted by the software Image Pro-plus for measurements. Comparison of the individuals exposed to petroleum with the control set, showed that the length, diameter and cell wall width of the tracheids of the former were smaller, a trend which was statistically significant according to the Student's t-test. These traits were observed mainly on the tracheids of the last growth layer, corresponding to the year in which the individuals were exposed to petroleum.

Effects of the pollution by petroleum on the tracheids along the stem of Podocarpus lambertii Klotzsch ex Endl., Podocarpaceae / Efeitos da poluição por petróleo nas traqueídes ao longo do caule de Podocarpus lambertii Klotzsch ex Endl., Podocarpaceae

Podocarpus lambertii Klotzsch ex Endl. (Podocarpaceae) is native and a member of the Pinophyta (Gymnosperm) of southern Brazil, locally known as "pinheiro-bravo". The present work aims to investigate the effects of petroleum on the tracheids dimensions. Wood samples from twenty individuals were studied along the stem, ten being exposed to pollution and ten used as a control set. The wood samples were collected from incisions at three levels: at the ground level, and one and two metres above the ground level. From these samples, sub-samples were selected at the border of the growth layers in the vascular cambium-medulla direction. The methodology followed that traditionally recommended for plant anatomy studies, with analyses done by light microscopy (OLYMPUS - BX41) assisted by the software Image Pro-plus for measurements. Comparison of the individuals exposed to petroleum with the control set, showed that the length, diameter and cell wall width of the tracheids of the former were smaller, a trend which was statistically significant according to the Student's t-test. These traits were observed mainly on the tracheids of the last growth layer, corresponding to the year in which the individuals were exposed to petroleum.

Podocarpus lambertii Klotzsch ex Endl. (Podocarpaceae), popularmente conhecida por pinheiro-bravo, é uma espécie que pertence ao pequeno grupo de Pinophyta (Gimnospermas) nativas da região Sul do Brasil. O presente estudo teve como objetivo investigar os efeitos da poluição por petróleo nas dimensões das traqueídes que compõem o lenho dessa espécie. Para tanto, amostras do lenho de vinte indivíduos foram coletadas, dez deles expostos à poluição por petróleo e dez usados como controle (coletados em região livre de contaminação). As amostras foram obtidas por meio de incisões paralelas à superfície do solo em três alturas (nível do solo, 1 metro e 2 metros do nível do solo). As subamostras para o estudo da variação estrutural do lenho foram selecionadas no limite das camadas de crescimento no sentido câmbio-medula. A metodologia utilizada para desenvolver o trabalho foi aquela tradicionalmente recomendada para estudos em anatomia vegetal. As mensurações das traqueídes em material macerado, como comprimento, diâmetro e espessura da parede celular, foram feitas pelo software Image Pro-plus em Fotomicroscópio (OLYMPUS - BX41). Nos indivíduos expostos à poluição, o comprimento, diâmetro e espessura da parede das traqueídes foram menores quando comparados aos indivíduos controle e demonstraram diferenças estatisticamente significativas pelo teste t-student. Essas tendências foram observadas, principalmente, nas traqueídes da última camada de crescimento, correspondente ao ano em que os indivíduos permaneceram expostos ao petróleo.

[Spinal cord protection during thoracoabdominal aortic aneurysm repair; efficacy of distal aortic perfusion and segmental aortic clamping].

Despite improvement in adjuncts for thoracoabdominal aortic aneurysms (TAAA) repairs, many devastating complications remains after the surgery. Our experience with these aneurysms has been reviewed in order to identify those methods at risk of major morbidity, as well as which further improvements required. During last 16 years, 53 consecutive patients were operated on TAAA. The mean age was 58 years. Twenty patients had dissecting aneurysms and 13 patients had had prior aortic surgery. A femoro-femoral bypass was used to maintain distal aortic perfusion in most patients. Reimplantation of intercostal or lumbar arteries under the multi-segmental aortic clamping is consistent in our technique. Motor evoked potentials (MEP) were measured to monitor spinal cord protection since 2000. The hospital mortality was 9.4% (5/53), 22.2% (2/9) for emergency operation and 15.4% (2/13) for patients with prior aortic surgery. The mortality for the first and elective operations was 3.2% (1/31). No any neurologic dysfunction was observed in all patients including the hospital deaths. In view of clinical results, our adjuncts and techniques are useful for prevention of spinal cord ischemia during the TAAA surgery.

Role of tetrahydrobiopterin on ischemia-reperfusion injury in isolated perfused rat hearts.

AIM: It has recently been shown that nitric oxide synthase in the presence of suboptimal levels of tetrahydrobiopterin (BH(4)), an essential cofactor of nitric oxide synthase, may favor increased production of oxygen free radicals. This study was designed to define the role of BH(4) in myocardial ischemia-reperfusion injury. METHODS: Isolated perfused rat hearts were subjected to 37 degrees C ischemia and reperfusion. Hearts were received with BH(4) or vehicle for 5 min just before ischemia and during the first 5 min of the reperfusion period. The effects of BH(4) on left ventricular function, myocardial contents of lipid peroxidation and high energy phosphates, and levels of lactate dehydrogenase and nitrite plus nitrate in perfusate before ischemia and after reperfusion were estimated. Moreover, the effect of BH(4) given with 2,4-diamino-6-hydroxypyrimidine (DAHP), a selective inhibitor of BH(4) production, intraperitoneally 24 h before the experiments were estimated. RESULTS: BH(4) improved contractile and metabolic abnormalities in reperfused hearts. Furthermore, BH(4) significantly alleviated ischemic contracture during ischemia, and restored diminished perfusate levels of nitrite plus nitrate after reperfusion. On the other hand, DAHP-treatment aggravated ischemia-reperfusion induced functional and metabolic abnormalities. Administration of BH(4) improved DAHP-induced functional and metabolic abnormalities. CONCLUSION: Results demonstrated that BH(4) lessens ischemia-reperfusion injury in isolated perfused rat hearts. Conversely, deficiency of BH(4) seems to accelerate endothelial dysfunction and myocardial ischemia-reperfusion injury. Present data may be compatible with the hypothesis that nitric oxide synthase in the presence of insufficiency of BH(4) serve as the cause of oxidative injury.

Blood distribution to the anterior spinal artery from each segment of intercostal and lumbar arteries.

AIM: Prevention of paraplegia, a serious complication of surgery for thoracoabdominal aortic aneurysm, has been well documented. However no assured prophylaxis against this complication has yet been found. Spinal ischemia is believed to be the major cause of paraplegia. We conducted an experimental study to define the development of paraplegia with regard to the blood supply to the spinal cord. METHODS: A porcine model was used to evaluate blood distribution to the anterior spinal artery. Colored silastic agent was selectively injected into the intercostal and lumbar arteries, and distribution to the anterior spinal artery was evaluated on 50 animals. The intercostal and lumbar arteries were ligated in the segments where the blood supply to the anterior spinal artery would be interrupted. Whether or not paraplegia developed was checked 2 days later. RESULTS: Colored silastic agent arrived at the anterior spinal artery from all segments of the 8th intercostal to 4th lumbar arteries. Two of 9 pigs (22.2%) that underwent ligation of the segments from the 9th intercostal to 2(nd) lumbar artery suffered paraplegia. In 3 non-paraplegic pigs, colored silastic agent injected into the preserved arteries was found to have covered a wider range. CONCLUSION: All the intercostal and lumbar arteries supplied blood to the anterior spinal artery. When large segments of intercostal and lumbar arteries were ligated, the blood flow from the preserved segments acquired increased dominance. The possibility exists that any intercostal and lumbar artery can supply blood to the spinal cord and become collateral circulation to the anterior spinal artery.

[Impact of multi-segmental aortic clamping and distal aortic perfusion on the prevention of postoperative paraplegia during thoracoabdominal aortic graft replacement]. / Multisegmentale Aortenabklemmung und distale Aortenperfusion zur Verhinderung der postoperativen Paraplegie bei thorakoabdomineller Aortenprothesenimplantation.

OBJECTIVE: We present the impact of multisegmental aortic clamping under distal aortic perfusion and segmental artery reimplantation on the prevention of postoperative paraplegia during thoracoabdominal aortic graft replacement. PATIENTS: During the last 14 years in 47 patients (age range: 22 to 82 years; average: 57,9 +/- 13,2 years; 16 females and 31 males) with thoracoabdominal aortic aneurysm a graft replacement was performed with adjuncts of normothermic partial bypass and multisegmental aortic clamping. As many patent segmental arteries as possible were reimplanted. RESULTS: Five patients died during hospitalization, for an in-hospital mortality rate of 10,6 %. In the elective patients (n = 40), the hospital mortality rate was 7,5 %. The average number of segmental aortic clampings per patient was 2,83 +/- 1,19 times. In 39 patients (82,9 %), 117 segmental arteries were reimplanted or preserved by beveled anastomosis. Eighty-three out of 117 segmental arteries (70,9 %) were located between TH9 and L2. Postoperative paraplegia/paraparesis did not occur in any patient. CONCLUSION: In view of our results reimplantation of as many segmental arteries as possible under multisegmental aortic clamping with adequate distal aortic perfusion can be recommended for effective prevention of spinal cord ischemia in TAAA surgery.

Left ventricular pseudoaneurysm after sutureless repair of subacute left ventricular free wall rupture: a case report.

A 65-year-old woman presenting with a left ventricular pseudoaneurysm 27 months after sutureless repair of a subacute left ventricular free wall rupture complicating acute myocardial infarction is described. An autologous pericardial patch and gelatin resorcin formaldehyde (GRF) glue were used in the repair. A small pseudoaneurysm bulged out over the true aneurysm of the left ventricle. We performed a Dor operation and concomitant bypass grafting to the right coronary artery. Although sutureless repair is an effective procedure for subacute left ventricular free wall rupture, left ventricular pseudoaneurysm in the late postoperative period may be a rare problem after this repair.

Optical determination of low-level water concentrations in organic solvents using fluorescent acridinyl dyes and dye-immobilized polymer membranes.

The fluorescent acridinyl indicators 4-(9-acridinyl)-N-(5-hexenyl)-N-methylaniline (KD-F0011), 6-(9-acridinyl)-1,2,2,3-tetramethyl-2,3-dihydro- 1H-perimidine (KD-F0021), and 6-(9-acridinyl)-2-(3-butenyl)-1,2,3-trimethyl-2,3-dihydro-1H-perimidine (KD-F0022) were designed, synthesized, and applied for highly sensitive optical determination of low-level water in organic solvents. All these dyes were found useful as fluorescence indicators for the detection of water below 1% (v/v) in different solvent media with a low detection limit of 0.002% (v/v) or 20 mg/L (22 ppm by weight) for KD-F0021 in THF solution. Sensing membranes made from poly(ethylene glycol) dimethacrylate by photocopolymerization with the indicator KD-F0011 were also prepared. Using the membrane sensor, the lowest detection limit of 0.001% (v/v) or 14 mg/L (20 ppm) water was achieved in diethyl ether samples. This system enables the continuous monitoring of the water content in a flow-through arrangement, where single-wavelength excitation (404 nm) and single-wavelength detection (532 mm) can be used for the fluorescence determination, allowing a simple measurement setup. In a continuous-flow experiment using THF samples, fully reversible and fast signal changes with t95% = 1-2 min for water concentrations up to 0.50% (v/v) were observed. A detection limit of 0.004% (v/v) or 40 mg/L (45 ppm) water in THF was achieved. These characteristics make this type of sensor a useful tool for the online continuous monitoring of water present as an impurity in organic media, which is difficult to achieve using a Karl Fischer instrument.

Acute aortic dissection associated with Sheehan's syndrome.

A 69-year-old woman with Sheehan's syndrome who suffered acute Stanford type A aortic dissection had received corticosteroids and thyroid hormones for over 20 years. The entire ascending aorta was replaced in emergency graft replacement. We administered twice the usual dose of methylprednisolone during cardiopulmonary bypass and twice the patient's usual dose of prednisolone from postoperative day 1 to 6. The usual 100 micrograms of levothyroxine sodium was given orally from postoperative day 1. The patient's postoperative course was uneventful. This case emphasizes the importance of early active supplementary treatment with steroids and thyroid hormones for major surgery in patients with Sheehan's syndrome.

Cardiac reoperation in a patient with osteogenesis imperfecta: a case report.

A case of a 40-year-old man with dehiscence of the prosthetic aortic valve and recurrence of mycotic aneurysm of the left ventricular outflow tract with osteogenesis imperfecta is presented. He had an operation of aortic valve replacement and direct closure of the mycotic aneurysm for infective endocarditis twenty-one months ago. We performed reoperation of prosthetic aortic valve, patch closure of the mycotic aneurysm and graft replacement of the ascending aorta. He was complicated with multiple fractures of bilateral scapla and dislocation of left shoulder one postoperative day. Fortunately, cardiac reoperation was performed successfully in this patient despite anticipated difficulties with tissue friability with osteogenesis imperfecta.

One-stage operation for descending thoracic aortic aneurysm and left lung cancer: a case report.

We performed concomitant graft replacement for descending thoracic aortic aneurysm and pulmonary resection for squamous cell carcinoma of the left upper lobe in a 79-year-old man. The tumor reached the parietal pleura. No distance metastasis was found, and the tumor was diagnosed preoperatively as a stage IIB (N0, M0, T3) tumor. The descending thoracic aortic aneurysm was saccular, with greatest diameter being 55 mm, and extending from TH5 to TH8. A left upper lobectomy was performed, and after irrigation with a large volume of saline diluted with povidone iodine, graft replacement for the aortic aneurysm was performed under femoro-femoral partial bypass. To prevent postoperative graft infection, the greater omentum was dissected and placed over the resected pulmonary hilum and the graft. The patient's postoperative course was uneventful. There was no sign of infection, and the patient was discharged 1 month after surgery. Artificial graft wrapping with the greater omentum was useful for the prevention of the postoperative graft infection in this case of surgical treatment of lung cancer and descending thoracic aortic aneurysm.

Management of the heart rate during coronary artery bypass grafting on the beating heart: newly devised methods of decreasing heart rate--a preliminary report-.

BACKGROUND: To develop new methods for achieving bradycardia, we studied the feasibility of producing transient, reversible bradycardia with atrial stimulation and cooling of the sinoatrial node. METHODS: In an animal study, the atrium was stimulated electrically during the refractory period of the atrioventricular node. Alternatively, an area of the sinoatrial node was cooled regionally. The two methods were also performed in combination. In a clinical study, atrial stimulation was applied in seven consecutive patients who underwent coronary artery bypass grafting (CABG). RESULTS: In the animal study, atrial stimulation was effective only when 2 mg/kg of diltiazem was administered. Such atrial stimulation decreased heart rate (beats/minute) from 95.8+/-16.9 to 64.2+/-20.0 (the average reduction from the control value 66.1+/-10.3%). Cooling the sinoatrial node decreased heart rate, and was effective with or without administration of diltiazem. Heart rate was decreased from 156.6 31.7 to 110.7+/-21.7 (average reduction from control value 71.3+/-9.2%) before using diltiazem and from 102.0+/-11.9 to 63.5+/-13.9 (average reduction from control value 62.0+/-10.4%) after administration of diltiazem. By combining the two methods, heart rate was decreased from 102.0+/-12.3 to 44.6+/-9.1 (average reduction from control value 43.5+/-6.3%). In our clinical study, the atrial stimulation method was effective. CONCLUSION: Atrial stimulation or regional cooling of the sinoatrial node slowed the heart rate. By combining the two methods, the heart rate was slowed to 40. Clinically, atrial stimulation was effective in CABG patients.

Surgical treatment of multiple inflammatory aortic aneurysms of the aortic arch and thoracoabdominal aorta.

A 67-year-old woman hospitalized with pleuritis was treated with antibiotics. Although the inflammation was resolved, saccular aneurysms in the aortic arch and thoracoabdominal aorta enlarged rapidly. We conducted graft replacement of the aortic arch, but despite careful blood pressure control, the thoracoabdominal aneurysm rapidly enlarged even further. We conducted graft replacement of the thoracoabdominal aorta on day 25 after the first operation. The postoperative course was uneventful and no exacerbation was found 18 months after the second operation. These multiple aortic aneurysms were diagnosed as inflammatory because bacterial tests of blood and aneurysmal walls were all negative and cells infiltrating aneurysmal walls were pathologically plasma cells.

Sutureless technique for subacute left ventricular free wall rupture: A case report of an 85-year-old.

This case was an 85-year-old female who developed left ventricular free wall rupture (LVFWR) of the anterior wall 13 days after an acute myocardial infarction. She was further complicated with an ascending aortic aneurysm and severe aortic regurgitation. The wall was repaired using a sutureless technique with an autologous pericardial patch and GRF glue without cardiopulmonary bypass. Although the complication of a left ventricular aneurysm was seen, the postoperative course was uneventful. Nevertheless, she is doing well 9 months after surgery.

Successful surgical treatment of impending rupture of thoracoabdominal aortic aneurysm in an elderly patient with severe pulmonary emphysema.

In a case of successful surgery for impending thoracoabdominal aortic aneurysmic rupture, an 83-year-old man with severe pulmonary emphysema was transferred to our hospital diagnosed with impending aneurysmic rupture. The aneurysm had been pointed out 2.5 years ago but surgical repair was not undertaken due to the patient's severe pulmonary emphysema. After admission, computed tomography showed an enlarging saccular thoracoabdominal aortic aneurysm. Emergency surgery was conducted because of severe pain below the left costal margin. We resected the wall of the saccular aortic aneurysm and reconstructed the aorta with an on-lay patch under femoro-femoral bypass and selective visceral organ perfusion. Tracheostomy provided respiratory care on the day following surgery. The patient was weaned from respiratory support 6 days after surgery. Postoperative aortography showed that the reconstructed thoracoabdominal aorta functioned satisfactorily. The patient remains in good health 18 months after surgery.

Two-stage operation for multiple aneurysms of the thoracic aorta, abdominal aorta, and left common iliac artery in an octogenarian.

Multiple aortic aneurysms are well described in the surgical literature. However, there are many problems related to surgical treatment of elderly patients with such aneurysms. This report presents the case, an octogenarian with multiple aortic aneurysms that were successfully treated by graft replacement. An 82-year-old man with a descending aortic aneurysm was referred to our institution for surgery. In addition to the previously diagnosed aneurysm, computed tomography and aortography showed an abdominal aortic aneurysm and a left common iliac aneurysm. Since the patient was an elderly man with chronic obstructive pulmonary disease, a two-stage operation was performed. The abdominal aortic aneurysm and left common iliac aneurysm were resected first due to the risk of thromboembolism from the abdominal aortic aneurysm during surgery involving replacement of the descending aorta under femoro-femoral (F-F) bypass. Fifty-two days after the first operation, a second operation was performed to repair the descending aortic aneurysm. The postoperative course was uneventful. Angiography after the operation showed satisfactory replacement of the multiple aortic aneurysms. The patient was discharged 25 days after the second operation.