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Some conditions that predispose to ventilatory failure increase the work of breathing (chronic obstructive pulmonary disease [COPD], obesity, kyphoscoliosis), whereas others cause severe respiratory muscle weakness. Specific reasons for muscle weakness include critical illness (electrolyte imbalance, acidemia, shock, sepsis), chronic illness (poor nutrition, cachexia), and neuromuscular diseases. Inspiratory muscle weakness from mechanical disadvantage to the diaphragm is characteristic of asthma and COPD. The increased work of breathing combined with muscle weakness increases the pressure needed to inspire a breath and decreases maximal inspiratory pressure. When this pressure exceeds 0.4, dyspnea and inspiratory muscle fatigue ensue. One way to lower this pressure and avert fatigue is to lower the tidal volume. Ventilatory drive is high, not low, in ventilatory failure. Concomitant shortening of inspiration and breath duration cause the small tidal volume and increased respiratory rate. Gas exchange is compromised by ventilation/perfusion imbalance, and the ratio of dead space to tidal volume is also increased by rapid, shallow breathing. Reduction in tidal volume minimizes dyspnea, but the small tidal volume is inadequate for gas exchange. Acute treatment of respiratory muscle failure involves respiratory muscle rest through mechanical ventilation and removal of noxious influences (infection, metabolic disarray), whereas chronic treatment involves rebuilding the contractile apparatus by nutritional repletion and training.
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PMID:Respiratory muscles and ventilatory failure: 1993 perspective. 850 1

Of 114 patients who had TRAM flap breast reconstruction, 46 (40 percent) had preexisting abdominal surgical scars. Sixty-six free TRAM flaps and 9 pedicled TRAM flaps were performed in the 46 patients. The records were analyzed to determine what impact, if any, abdominal scars had on postoperative complications. There were no reconstructive failures or significant (>25 percent) flap losses. Eight minor complications occurred in 7 patients (15 percent). The incidences of abdominal-wall weakness (4.3 percent), partial flap loss (4.3 percent), minor fat necrosis (4.3 percent), and donor-site wound problems (4.3 percent) were acceptable. Subcostal scars and multiple abdominal scars were found to predispose to skin complications. Right lower paramedian scars precluded free TRAM flaps because of damage to the inferior epigastric vessels in three of three patients. Both obesity (p = 0.003) and smoking (p = 0.05) were associated with a greater risk of wound-healing complications. We conclude that with certain technical modifications, TRAM flap reconstruction is a safe and effective procedure in patients with abdominal scars.
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PMID:TRAM flaps in patients with abdominal scars. 981 Oct 38

For many older individuals, impairment of musculoskeletal function, especially weakness, stiffness, and pain, cause progressive disability, thereby limiting mobility and decreasing the quality of life. With advancing age, musculoskeletal soft tissue function declines, susceptibility to degenerative diseases and injuries increases, and the ability to recover from disease or injury declines; these changes increase the probability of impairment (Fig. 1). However, the function of individual cells, tissues, or organ systems may remain stable or even improve temporarily with age, and a number of interventions have the potential to maintain or improve musculoskeletal function. Age-related changes in cells, tissues, and musculoskeletal function are not necessarily unidirectional or uniform among individuals, organ systems, tissues, or cells, nor are they necessarily irreversible. Surgical procedures can restore mobility for many patients with age-related musculoskeletal injuries or degenerative diseases. Regular resistance and range-of-motion exercises can decrease the age-related loss of strength and help maintain or restore flexibility. However, exercise programs can also cause injury. Older individuals should have a careful medical evaluation before starting an exercise program, and the program should be selected based on this evaluation. This is especially important for individuals with systemic illness and for individuals at greater risk of musculoskeletal injury, including people with previous joint injuries, obesity, osteoarthritis, joint deformity, weakness, or restricted joint motion. Trophic hormone replacement or supplementation may also modify age-related changes in the soft tissues, including loss of strength, but these hormones have adverse effects. Systemic or local use of growth factors and cell transplantation after expanding the population of mesenchymal stem cells in culture could improve healing in older people. Other potential methods of slowing or reversing age-related deterioration of the soft tissues include inhibition of posttranslational modification of matrix proteins and alteration of the activity of selected transcription factors. In particular, better understanding of the role of transcription factors in cell sequence may make it possible to devise methods of delaying or reversing age-related loss of cell proliferative and synthetic capacity.
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PMID:Maintaining and restoring mobility in middle and old age: the importance of the soft tissues. 914 88

Sleep is characterized by many changes in the respiratory system, including a reduction in respiratory motor output associated with the loss of wakefulness, increased upper airway resistance, and blunted protective reflexes (such as load compensation), that result in reduced alveolar ventilation. The development of carbon dioxide retention appears to be linked to the exaggeration of sleep-related changes on ventilation by coexistent respiratory system disorders. Sleep-disordered breathing is becoming increasingly recognized in subjects with neuromuscular diseases, who may be prone to nocturnal respiratory events due to diaphragm and bulbar muscle weakness, abnormal central respiratory control, obesity, and sleep position restrictions. Nocturnal gas exchange deterioration may occur in patients with chronic obstructive pulmonary disease, particularly during rapid eye movement sleep when activity of the respiratory muscles other than the diaphragm is inhibited. Concurrent obstructive sleep apnea syndrome may further compromise nocturnal ventilation, thereby contributing to the development of acute or chronic respiratory failure. The use of noninvasive nocturnal ventilation at night has resulted in significant improvements in symptoms of hypoventilation and daytime carbon dioxide retention in various clinical settings, yet important questions remain about implementation of this modality.
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PMID:Sleep-wake cycles and the management of respiratory failure. 936 92

Psychosocial factors may explain some of the variation in pain reporting among individuals with knee OA. This has important potential implications for management; indeed, several studies (reviewed in ref. 56) have demonstrated that interventions may reduce knee pain without apparent halting or reversing of structural damage. Such interventions have included the simple provision of support by monthly telephone calls (57), self-management programs (58), and cognitive-behavioral approaches designed to teach patients ways of coping with their pain (59). These programs are even more effective if the spouse is involved (60). It should be noted that there may be a large placebo effect in these interventions, and the degree to which patients are responding simply to an interest being taken in them and their problems is unclear; at least one study has shown that formal cognitive-behavioral therapy is no better than didactic education at improving pain and function in knee OA (though both are beneficial) (61). Many studies examining the role of psychosocial factors have suffered from poor design; many, for example, fail to control for radiographic severity. Future studies should define how pain is identified (dichotomous, ever/never/current, severity), differentiate community and hospital subjects, and separate patients by type and location of OA. Studies should also control for other factors potentially associated with pain: obesity, comorbidity, muscle weakness, and aerobic fitness. Prospective studies would allow clarification of the cause and effect relationship between anxiety, depression, and pain, both in the community and in patients who have elected to seek medical help. In this way, we may increase our understanding of the complex interaction between mood, social factors, and pain reporting in knee OA and, thus, improve the effectiveness, already equivalent to many pharmacologic interventions, of treatments designed to address psychosocial factors.
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PMID:The relationship between psychosocial variables and pain reporting in osteoarthritis of the knee. 953 95

Endoscopic techniques through umbilical and mons pubis ports have provided a method to plicate rectus muscle diastasis without skin resection. Limited or no skin excision is performed. Major series have included only women. The criteria for patient selection for endoscopic abdominoplasty include a protuberant abdomen caused by rectus muscle diastasis with minimal actual or potential skin laxity. There should not be significant intra-abdominal obesity. Extra-abdominal familial fat deposits may be part of the abdominal aesthetic deformity. In most women, rectus muscle diastasis because of pregnancy, obesity, or aging is associated with actual or potential skin laxity of the abdomen and lateral trunk. Endoscopic abdominoplasty in these women would produce mediocre early results and poor aging potential for the future. There are a limited number of women who are reasonable candidates for the endoscopic approach. In contrast, rectus muscle diastasis without skin laxity is a common finding in men older than 30 to 40 years of age. There may be a history of weight fluctuations, weightlifting, or full-excursion sit-up exercises, which may lead to progressive separation of the rectus muscles over time. Other etiologic factors include chronic or intermittent abdominal distension, advancing age, or familial weakness of the abdominal musculofascial tissues. Endoscopically assisted abdominoplasty was performed in four male patients with good to excellent results at 4 to 18 months. Minor complications occurred in half the patients but were successfully treated without re-operation. Men with prominent abdominal contours who are diet- and exercise-resistant should be examined both for familial fat deposits and for significant rectus muscle diastasis. Contouring of the male abdomen may be the primary indication for endoscopically assisted abdominoplasty.
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PMID:Rectus muscle diastasis in males: primary indication for endoscopically assisted abdominoplasty. 958 6

The paper concerns surgical treatment of rhonchus. 41 patients with rhonchus and sleep apnea were examined and treated. The patients were characterized by obesity, short fat neck, diseases of the upper respiratory tracts (chronic tonsillitis, adenoids, distortion of the nasal septum, deformity of the external nose, weakness of the palatine curtain). After cleansing of the upper respiratory tracts and recovery of nasal breathing all the patients underwent CO2 laser surgery on the soft palate with good effect.
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PMID:[On aspects of surgical treatment of pathological snoring]. 979 29

The patient was a 50-year-old house wife. There were complicated consanguineous marriages in the family tree. Since 30 years of age, she had suffered from progressive limb muscle weakness, but without myalgia and myasthenia. At present, she was wheelchair-bound. Physical examinations showed obesity, congenital livedo racemosa, epicanthus palpebrae and left renal defect. Neurologically, facial, anterior cervical, and iliopsoas muscles were well preserved, but others were severely involved. Laboratory examinations revealed mildly elevated myogenic serum enzymes, and myogenic changes on needle EMG. In her muscle biopsy from the left rectus femoris muscle, there were no inflammatory changes, but marked variations of the fiber size as well as adipose tissue replacement were recognized. Strickingly, basophilic masses located in the center of the sarcoplasm were present in about 10% of the fibers. Histochemically, the masses were present in both type 1 and 2 fibers, and exhibited almost similar stained patterns to the tubular aggregates, but were dystrophin-, GRP78- and clathrin-positive. Under electron microscopy, the masses consisted of aggregates of the vesiculotubular structure, measuring approximately from 60 nm to more than 6 microns in diameter, which were continuous with T system/sarcoplasmic reticulum and were clearly segregated from myofilaments. This is a chronic progressive muscular disorder of adult onset with the peculiar pathological finding of vesiculotubular structure.
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PMID:[Clinico-pathological analysis of vesiculotubular myopathy of adult onset]. 1020 72

A retrospective analysis of Cushing's syndrome from the retrieved records of 24 out of a total of 27 referred cases over a period of 10 years (January 1985-January 1995) showed confirmation in 16 cases. Fourteen (88%) were females, 9 (56%) were in their third decade. Duration of symptoms before admission was one year or less in eleven (69%) patients. Among symptoms weakness, fatigue and weight gain and among signs moon face, truncal obesity and buffalo hump were found in all patients. Amenorrhea occurred in all the women of childbearing age. Basal urinary 17-hydroxycorticoid (17-OHCS) values were elevated in 9/12 patients and low dose dexamethasone suppression test favoured Cushing's syndrome in 8/9 patients. Definitive treatment consisted of bilateral adrenalectomy in 7 and transfrontal pituitary adenomectomy in 3. Two patients declined surgery; 4 patients were lost to follow up before definitive treatment. Two patients who had bilateral adrenalectomy and two who had transfrontal adenomectomy died subsequently while three remained in good health on corticosteroid replacement therapy. Three of the 7 patients who had bilateral adrenalectomy developed Nelson's syndrome. It is concluded that Cushing's disease is the most frequent cause of Cushing's syndrome in our series. The patients presented with the well-known clinical manifestations of hypercortisolism. However, our laboratory facilities require considerable improvement to serve as a reliable adjunct to clinical evaluation. Since Cushing's syndrome, whatever the cause, is eventually fatal if left untreated, surgical intervention is mandatory after confirmation of the cause with appropriate laboratory tests.
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PMID:Cushing's syndrome: a ten year experience at Tikur Anbassa Hospital. 1021 44

This report describes two unrelated patients with obesity, mental retardation, body asymmetry, and muscle weakness. Several obesity syndromes with common characteristics have been described. Findings in our patients, in addition to those of the previously reported cases, include body asymmetry, characteristic physiognomy, lordosis, and typical anomalies of hands and feet. These physical manifestations correspond to the Camera-Marugo-Cohen syndrome. Our patients represent the second and third cases of this condition.
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PMID:The Camera-Marugo-Cohen syndrome: report of two new patients. 1175 73


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