Recovery of post-tetanic and train-of-four responses at the first dorsal interosseous and adductor pollicis muscles in patients receiving vecuronium

PURPOSE: To compare recovery of accelographical responses to post-tetanic twitch (PTT) and train-of-four (TOF) stimuli obtained at the first dorsal interosseous muscle (DI) with those at the adductor pollicis muscle (AP) after administration of vecuronium 70 micrograms.kg-1. METHODS: Sixty adult patients were randomly assigned to one of four groups: PTT-DI (n = 15), PTT-AP (n = 15), TOF-DI (n = 15), or TOF-AP (n = 15) group. In PTT-DI and PTT-AP groups, responses to PTT were measured accelographically at the DI and at the AP, respectively. In TOF-DI and TOF-AP groups, responses to TOF were measured at the DI and at the AP, respectively. RESULTS: The T1/T0 (T0 = control) was greater in the TOF-DI than in TOF-AP group throughout recovery (P < 0.05), and the T4/T1 was greater in the TOF-DI than in TOF-AP group during the 30-40 min after vecuronium injection (P < 0.05). Time to the return of the first response to PTT (post-tetanic count(1), PTC1) was less in the PTT-DI than in the PTT-AP group (17.7 +/- 4.2 vs 21.7 +/- 5.6 min, mean +/- SD, P = 0.0341). The post-tetanic count PTC (number of single twitch stimuli in response to PTT) was greater in the PTT-DI than in the PTT-AP group during the 10-30 min after vecuronium (P < 0.05). Time to the return of T1 was less in the TOF-DI than in the TOF-AP group (23.1 +/- 6.0 vs 27.6 +/- 4.9 min, P = 0.0334). CONCLUSION: Recovery of responses to PTT and TOF stimuli occurred earlier at the DI than at the AP.     

Assessing neuromuscular block at the larynx: the effect of change in resting cuff pressure and a comparison with video imaging in anesthetized humans

Neuromuscular block (NMB) at the larynx has been assessed by measuring the cuff pressure (CP) in an endotracheal tube (ETT) placed between the vocal cords. In this study, we evaluated the decrease in resting cuff pressure (RCP) after the administration of rocuronium and the effect of this decrease on the assessment of NMB, and we compared CP measurement with an alternative technique, video imaging (VI). In 20 patients, NMB was determined at the hand by mechanomyography and at the larynx initially by CP and subsequently by VI, recording images using a fiberoptic bronchoscope via a laryngeal mask. Train-of-four stimuli were applied at both sites. After baseline measurements, the ETT was replaced, and rocuronium was infused to achieve a steady-state 50% (n = 10) or 75% (n = 10) block at the hand. CP measurements were recorded before and after restoration of RCP to prerocuronium pressure, followed by further VI measurements. The mean RCP decreased from 21 +/- 4 to 12 +/- 5 mm Hg after rocuronium. At 50% block at the hand, the CP estimate of block at the larynx with reduced RCP was 62% +/- 18%, and that after restoring RCP was 29% +/- 13%; VI estimated 27% +/- 14% block. At 75% block at the hand, CP and VI estimated 52% +/- 11% and 46% +/- 9% block, respectively (RCP maintained). We conclude that RCP decreases after the administration of rocuronium, that restoring RCP significantly alters CP estimates of NMB, and that VI is in agreement with CP measurement if RCP is maintained at prerelaxant values. Implications: In this study, we show that a muscle relaxant-induced decrease in resting tension at the larynx may confound the assessment of neuromuscular block by cuff pressure measurement. The preliminary data suggest that video imaging may provide a suitable alternative to cuff pressure measurement to assess neuromuscular block at the larynx.     

Anatomy of the adductor pollicis muscle. A basis for release procedures for adduction contractures of the thumb

Release of the origins of the adductor pollicis muscle is used to treat adduction contractures of the thumb. A knowledge of the anatomy of the adductor pollicis muscle is therefore the basis for this technique. A study of 20 specimens showed that the origins of the adductor pollicis are more extensive than generally described. This must be taken into account in release procedures in the first web space.     

Delay of clinical recovery from paralysis induced by atracurium: comparison between orbicularis oculi and adductor pollicis

OBJECTIVE: To compare with train-of-four stimulation the delays of the beginning of the spontaneous recovery of the orbicularis oculi and of the adductor pollicis after profound neuromuscular blockade with atracurium. STUDY DESIGN: Prospective, comparative open study. PATIENTS AND METHODS: Twenty-eight physical class ASA 1 and 2 patients under general anaesthesia (propofol, N2O, fentanyl) and profound neuromuscular blockade with atracurium. Train-of-four stimulation, every 10 s, of the ulnar nerve at the wrist (for assessing by tactile means the response of the adductor pollicis) and of the temporal branch of the facial nerve (for assessing visually the response of the orbicularis oculi). On each site, measurement of the delay between the end of the maintenance of deep neuromuscular blockade (last dose of atracurium) and the beginning of the recovery (first response to train-of-four stimulation). RESULTS: In each case, the recovery of the orbicularis oculi began earlier than the recovery of the adductor pollicis (26 +/- 9 min vs 34 +/- 9 min, P < 0.001). The delays of recovery at each site were strongly correlated (r = 0.87; P < 0.001) but the time lag between the responses varied greatly: 1 to 21 min, mean: 8 +/- 5 min, coefficient of variation: 56.6%. CONCLUSION: The orbicularis oculi should not be monitored alone for assessment of recovery from profound neuromuscular blockade by atracurium, as it predicts poorly the time of the recovery of the adductor pollicis.     

Onset of the neuromuscular block simulated in an anatomical model

Radioiodine scintigraphy is the gold standard exploration for imaging metastases of differentiated thyroid cancer and enables the decision of therapy with 131 radioactive iodine to be made. However, other approaches may be of use for diagnosis when there is no visible uptake after the administration of 131I, while elevated thyroblobulin levels suggest the presence of metastatic tissue in one third of metastatic patients. In order to detect recurrences or metastases, in conjunction with conventional imaging techniques (cervical and hepatic ultrasonography, lung CT scan..), other scintigraphic explorations with various radiopharmaceutics may be used, although none of them has any specificity towards thyroid cancer. Tl201 and MIBI which are used as perfusion tracers for myocardial explorations, are also used for detection of various tumors and for metastatic thyroid cancer. The performances of both radiopharmaceutics in imaging metastases are differently evaluated between investigators with a sensitivity ranging from 45 to 94% while the specificity varies less (82-97%). 18-Fluoro-deoxyglucose is retained in malignant tissue depending on the grade of malignancy. It has been shown to accumulate in thyroid cancer and metastases. Its detection by whole body PETscan represents a limitation for use which will be modified by new techniques. 111In-octreotide which binds to somatostatin receptors located on tumor cell membranes is able to show thyroid cancer metastases in some instances. We report on the very preliminary results of these combined scintigraphic approaches, performed in a limited number of patients who had no radioiodine uptake and elevated Tg levels, in order to determine the most appropriate exploration in terms of performance and cost.     

Expression of extraocular-superfast-myosin heavy chain in rat laryngeal muscles

Superfast myosin heavy chain (MHC), which is found in jaw-closing muscle and extraocular muscle (EOM), may also be found in rat laryngeal muscles. Immunostaining and Western blot using anti-EOM antibody were performed to identify and localize EOM MHC in laryngeal muscles. Specific reactivity of laryngeal IIL MHC was confirmed by Western blot and on immunostaining, all fibers in the lateral part of thyroarytenoid muscle reacted with EOM antibody. A scattered pattern of positive fibers was observed in the medial part of the thyroarytenoid, the posterior cricoarytenoid and the lateral cricoarytenoid muscles. EOM MHC was not detected in the cricothyroid muscle. The expression of EOM MHC in rat laryngeal muscle is consistent with the functional demands of the airway protection reflex.     

Sarcomere lesion damage occurs mainly in slow fibers of reloaded rat adductor longus muscles

Sarcomere lesions were previously observed with reloading of rat adductor longus muscles after spaceflight and hindlimb unloading (HU). Spaceflown rats displayed more lesioned fibers in the "slow-fiber" region, suggesting a damage-susceptible fiber type. Unloading induces fast myosin expression in some slow fibers, generating hybrid fibers. We examined whether lesion damage differed among slow-, hybrid-, and fast-fiber types in HU-reloaded adductor longus muscles. Temporal HU for 5, 8, 11, 14, and 17 days revealed that hybrid fiber percent, detected by antimyosin immunostaining, peaked at 29 +/- 12% by 14 days. A 14-day HU followed by 12-14 h of voluntary reloading was performed to induce lesions. chi2 analysis showed that slow fibers were preferentially damaged, accounting for 92 +/- 5% of lesioned fibers; hybrid and fast fibers accounted for 7 +/- 4 and <0.5%, respectively. Atrophy did not explain differential lesion damage across fiber types, as slow and hybrid fibers atrophied to a similar extent. Because active myofiber contractions are requisite for lesion formation, selective recruitment of slow fibers most likely explains their damage susceptibility.     

Dose-response relationships for edrophonium and neostigmine antagonism of rocuronium bromide (ORG 9426)-induced neuromuscular blockade

BACKGROUND: Rocuronium bromide (ORG 9426) is a new nondepolarizing muscle relaxant with a rapid onset but an intermediate duration of action. The dose-response relationships for neostigmine and edrophonium were studied during antagonism of neuromuscular block induced by rocuronium bromide. METHODS: Sixty-four ASA physical status 1 or 2 adults were given 0.6 mg/kg rocuronium bromide during thiopental-fentanyl-nitrous oxide-isoflurane anesthesia. Train-of-four (TOF) stimulation was applied to the ulnar nerve every 10 s, and the force of contraction of the adductor pollicis muscle was recorded. When spontaneous recovery of first twitch height reached 10% of its initial control value, edrophonium (0.1, 0.2, 0.4, or 1 mg/kg) or neostigmine (0.005, 0.01, 0.02, or 0.05 mg/kg) was administered by random allocation. Neuromuscular function in another eight subjects was allowed to recover spontaneously. Assisted recovery was defined as actual recovery minus mean spontaneous recovery in patients who were not given antagonists. RESULTS: The dose-response curves for neostigmine- and edrophonium-assisted antagonism of rocuronium bromide neuromuscular blockade for the single twitch and TOF ratio were not parallel. The doses of neostigmine required to achieve 50% and 80% recovery (ED50 and ED80, respectively) of the first twitch after 10 min were 0.017 (0.001) and 0.033 (0.001) mg/kg (mean (standard error of estimate for the mean)), respectively. Corresponding ED50 and ED80 values for edrophonium were 0.161 (0.001) and 0.690 (0.001) mg/kg, respectively. These values corresponded to neostigmine:edrophonium potency ratios of 9.5 (0.56) and 21 (0.67) for first twitch ED50 and ED80 height, respectively. The calculated doses producing ED50 of the TOF ratio at 10 min were 0.017 (0.001) and 0.469 (0.001) mg/kg for neostigmine and edrophonium, respectively. These values corresponded to a potency ratio of 27.5 (1.66). CONCLUSIONS: Under the conditions described in this study, if reversal was attempted at 10% first twitch recovery, edrophonium was less capable than neostigmine of reversing fade (potency ratio of 19.2 and 27.5 at 5 and 10 min, respectively) than first twitch (potency ratio of 6.7 and 9.5 at 5 and 10 min, respectively) during antagonism of rocuronium bromide-induced blockade. Edrophonium was found to be less effective than neostigmine at reversing rocuronium bromide-induced TOF fade.     

The effect of neostigmine on suxamethonium induced neuromuscular block in the dog

The effects of neostigmine on suxamethonium induced neuromuscular block were investigated in the intact, anaesthetised dog using the train-of-four twitch to record neuromuscular activity. Marked antagonism of the block was observed when the train-of-four ratio was 0.38 and less. To avoid potentiating the block, the use of neostigmine is not recommended without first determining the state of neuromuscular activity with a peripheral nerve stimulator using train-of-four stimulation.     

The relationships between the temporomandibular joint disc and related masticatory muscles in humans

A study of the relationships of the temporomandibular joint disc and the lateral pterygoid, temporalis, and masseter muscles during the human fetal period and in the adult was conducted. The superior head of the lateral pterygoid muscle was seen to insert into the anteromedial two thirds of the temporomandibular joint disc. The fibers of the posterior one third of the temporalis muscle and fibers of the deep bundle of the masseter muscle were attached on the anterolateral one third of the disc. The attachment of these muscles to the disc was through the anterior extension of the disc, also known as the premeniscal or prediscal lamina. The possible functional role of these muscle attachments is discussed.     

Calcitonin gene-related peptide-like immunoreactive motoneurons innervating the canine intrinsic laryngeal muscles

Structural genomics promises to deliver experimentally determined three-dimensional structures for many thousands of protein domains. These domains will be carefully selected, so that the methods of fold assignment and comparative protein structure modeling will result in useful models for most other protein sequences. The impact on biology will be dramatic.     

Recruitment of the bi-articular gastrocnemius muscles during maximal isometric contractions in humans

The main purpose of this study was to investigate the maximal isometric plantarflexion moment as a function of the triceps surae's length. As the gastrocnemius are bi-articular actuators, their respective lengths were modified by variations of the ankle and knee joints angles. The mechanical results agreed ones previously published in the literature. The maximal and minimal isometric moments were attained at maximal lengthening and shortening of the gastrocnemius respectively. The gastrocnemius electromyographic (EMG) activities showed paradoxal results. Their EMG activities decreased with their lengthening when this was induced by ankle joint angle variations. Inversely, their EMG activities increased with their lengthening when this was induced by knee joint angle variations. These results allowed the authors to hypothesize the existence of specific recruitment of neuro-muscular compartments of the gastrocnemius with knee extension.     

Rupture of the flexor pollicis longus tendon at the musculotendinous junction in a bowler

Traumatic rupture of the flexor tendons at the musculotendinous junction is rare. A case of flexor pollicis longus tendon rupture at the musculotendinous junction is described. The mechanism of the tendon injury appears to be longitudinal traction on the contracted muscle during delivery of a bowling ball.     

Synaptic segregation at the developing neuromuscular junction

Throughout the developing nervous system, competition between axons causes the permanent removal of some synaptic connections. In mouse neuromuscular junctions at birth, terminal branches of different axons are intermingled. However, during the several weeks after birth, these branches progressively segregated into nonoverlapping compartments before the complete withdrawal of all but one axon. Segregation was caused by selective branch atrophy, detachment, and withdrawal; the axon branches that were nearest to the competitor's branches were removed before the more distant branches were removed. This progression suggests that the signals that mediate the competitive removal of synapses must decrease in potency over short distances.     

Value of the monitoring of curarisation during prolonged mivacurium induced neuromuscular block

A case of neuromuscular blockade of about 200 min of duration, in a 9-year-old boy from mivacurium 0.15 mg.kg-1 is reported. The diagnosis was delayed, after onset of the first signs of recovery, due to the lack of monitoring of neuromuscular transmission. The neuromuscular blockade was reversed with neostigmine 0.04 mg.kg-1. Complete reversal required fifty minutes. The presence of an abnormal genetic variant of pseudocholinesterases was demonstrated by the measurements of pseudocholinesterase activity and dibucaine number. The importance of monitoring of neuromuscular transmission for diagnosis and treatment of mivacurium-induced neuromuscular blockade is underlined.     

Increased acute and chronic mitotic activity in rat laryngeal muscles after botulinum toxin injection

OBJECTIVES: To characterize the acute and chronic cellular effects of botulinum toxin (BT) injection into rat laryngeal muscles. A complete characterization of these effects is important because patients with focal dystonias of the head and neck are commonly treated with BT injection. Further, potential muscular changes in the larynx must be carefully delineated owing to the critical phonatory and airway protective functions of these muscles. STUDY DESIGN: The acute and chronic cellular effects of BT injection were studied using 5'-bromo 2'-deoxyuridine (BrdU) following single and repeated BT injection into rat laryngeal muscles. BrdU is incorporated into mitotically active nuclei such that changes in cell proliferative behavior following BT injection can be monitored. RESULTS: Increased mitotic activity was detected in the tissue samples studied following BT injection. Differences in the times of the peak distribution of BrdU-labeled cells in each laryngeal muscle were observed. This may be related to the diffusion effects of BT. Prolonged muscle fiber changes, including splitting, were also observed as the result of repeated BT injection. CONCLUSIONS: The results of this study suggest that BT may induce a proliferative response in muscle tissue.     

Morphological study of laryngeal ganglions and associated nerve cells in humans and five mammals

The arrangement and numbers of intralaryngeal ganglia and associated neurons in humans and four mammals (dogs, rabbits, guinea pigs and rats) were investigated morphologically and compared with the results obtained in the cat which have been reported previously. Intralaryngeal ganglia were mostly distributed in branches of the internal branch of superior laryngeal nerve in all species, dorsal and/or dorsolateral to the posterior cricoarytenoid muscle in humans, dogs and cats and around the inferior laryngeal nerve in humans, dogs, cats, guinea pigs and rats. The total number of laryngeal ganglionic neurons was 2,000 to 2,400 in humans, 300-450 in dogs, 600-800 in cats, 250-320 in rats, and 100-150 in rabbits and guinea pigs. More than 80 percent of ganglionic neurons were present in the supraglottis in all species, except the rat, in which about 60 percent were in the subglottis. Each ganglion in all species existed within the nerve bundle, and was chiefly encapsulated with fibrous tissue, many ganglionic cells, glial cells, Schwann cells, vessels and connective tissue. The present morphological study of intralaryngeal ganglia in humans and four mammals suggests that the laryngeal ganglionic neurons have the same arrangement as in cats.