Chest wall kinematics and respiratory muscle action in ankylosing spondylitis patients.

No direct measurements of the pressures produced by the ribcage muscles, the diaphragm and the abdominal muscles during hyperventilation have been reported in patients with ankylosing spondylitis. Based on recent evidence indicating that abdominal muscles are important contributors to stimulation of ventilation, it was hypothesised that, in ankylosing spondylitis patients with limited ribcage expansion, a respiratory centre strategy to help the diaphragm function may involve coordinated action of this muscle with abdominal muscles. In order to validate this hypothesis, the chest wall response to a hypercapnic/hyperoxic rebreathing test was assessed in six ankylosing spondylitis patients and seven controls by combined analysis of: 1) chest wall kinematics, using optoelectronic plethysmography, this system is accurate in partitioning chest wall expansion into the contributions of the ribcage and the abdomen; and 2) respiratory muscle pressures, oesophageal, gastric and transdiaphragmatic (Pdi); the pressure/volume relaxation characteristics of both the ribcage and the abdomen allowed assessment of the peak pressure of both inspiratory and expiratory ribcage muscles, and of the abdominal muscles. During rebreathing, chest wall expansion increased to a similar extent in patients to that in controls; however, the abdominal component increased more and the ribcage component less in patients. Peak inspiratory ribcage, but not abdominal, muscle pressure was significantly lower in patients than in controls. End-inspiratory Pdi increased similarly in both groups, whereas inspiratory swings in Pdi increased significantly only in patients. No pressure or volume signals correlated with disease severity. The diaphragm and abdominal muscles help to expand the chest wall in ankylosing spondylitis patients, regardless of the severity of their disease. This finding supports the starting hypothesis that a coordinated response of respiratory muscle activity optimises the efficiency of the thoracoabdominal compartment in conditions of limited ribcage expansion.     

Effects of expiratory threshold loading on thoracoabdominal motion in cats

Expiratory muscle activity may alter rib cage and abdominal configuration at end-expiration and thereby affect the pattern of thoracoabdominal motion during subsequent inspiration. In this study, expiratory muscles were stimulated by the application of a series of expiratory threshold loads (ETL) (range: 0 to + 10 cm H2O) in 10 cats lightly anaesthetized with pentobarbitone. Thoracoabdominal motion was monitored by inductance plethysmography. Peak internal intercostal and abdominal muscle electrical activity increased proportionately with the magnitude of the ETL, suggesting comparable activation of both expiratory muscle groups. Increases in end-expiratory abdominal volume, however, were greater than increases in end-expiratory rib cage volume, during ETL. This resulted in a shift of the end-expiratory thoracoabdominal position to the right of the relaxation characteristic. During ETL, there was inward movement of the abdomen in early inspiration and this decrease in abdominal volume correlated closely with the change in end-expiratory abdominal volume and the magnitude of the ETL (mean r = 0.95, P less than 0.01). In three animals, sectioning the abdominal muscles resulted in a further increase in end-expiratory abdominal volume for a given ETL. Deepening anesthesia progressively reduced and eventually abolished expiratory muscle activation and under these conditions, ETL increased end-expiratory rib cage and abdominal volume along the thoracoabdominal relaxation characteristic. The results of this study indicate that while abdominal muscle activation acts to decrease abdominal volume at end-expiration, the action of the expiratory intercostal muscles predominates during ETL to produce a smaller rib cage volume at the expense of an enlargement of abdominal volume.     

Respiratory muscle strength for discriminating frailty in community-dwelling elderly: a cross-sectional study

ObjectivesTo compare obtained and predicted inspiratory and expiratory muscle strength between frail, pre-frail, and non-frail older people; to examine the association between inspiratory and expiratory muscle strength and frailty in older people; and to determine cut-off points for inspiratory and expiratory muscle strength for discriminating frailty in older people.MethodsA cross-sectional study was conducted with 379 community-dwelling older adults. Frailty was assessed using Fried’s phenotype, while inspiratory and expiratory muscle strength were measured with maximum inspiratory and maximum expiratory pressures. Inferential analyses were performed using paired Student t-tests, one-way analysis of variance (ANOVA) tests, and a multinomial logistic regression model. ROC curves were constructed to establish cut-off points of maximum inspiratory and expiratory pressures for discriminating frailty and pre-frailty.ResultsFrail and pre-frail participants presented significantly lower mean inspiratory and expiratory pressures compared to non-frail participants; values were significantly lower than predicted. Inspiratory and expiratory muscle strength were inversely associated with frailty and pre-frailty. Cut-off points ≥-50cmH₂O and ≤60cmH₂O for maximum inspiratory and expiratory pressures, respectively, were established as optimal discriminators of frailty. The cut-off point ≤65cmH₂O for maximum expiratory pressure was established as a discriminant for the presence of pre-frailty.ConclusionsInspiratory and expiratory muscle strength were lower in frail than in pre-frail older adults, and lower in pre-frail than in non-frail peers. Frailty and pre-frailty were inversely associated with inspiratory and expiratory muscle strength. Cut-off points for inspiratory and expiratory muscle strength may be useful in clinical practice for discriminating frailty and pre-frailty in older adults.     

Respiratory changes in abdominal configuration in supine dogs

In an attempt to understand the respiratory changes in abdominal muscle length in supine dogs (Ninane et al., 1988), we have recorded the electromyographic (EMG) activity of the transversus abdominis, external oblique, and rectus abdominis in eight supine, lightly anesthetized animals, and we have measured the respiratory changes in anteroposterior (AP) and transverse (T) diameters of the abdomen. Five animals had phasic expiratory EMG activity in the transversus during room air breathing, while only two animals had expiratory activity in the external oblique; no animal had phasic expiratory activity in the rectus. Activation of the transversus during expiration was invariably associated with a decrease in the abdominal T diameter and a rise in gastric pressure. In contrast, the abdominal AP diameter tended to increase. These alterations in abdominal configuration remained unchanged after denervation of the triangularis sterni, but decreased in magnitude when activation of the transversus was reduced by supplemental anesthesia. Conversely, these alterations in abdominal configuration increased in magnitude when expiratory activation of the transversus was increased by hyperoxic hypercapnia. These observations indicate that in supine dogs: (1) Expiratory contraction of the transversus acts primarily to reduce the transverse diameter of the abdomen; (2) This reduction, in turn, promotes an increase in abdominal pressure which results secondarily in an outward motion of the ventral abdominal wall; and (3) The latter may explain why the rectus abdominis, although electrically silent, shortens during expiration below its in situ relaxation length. The present observations also establish that in supine dogs breathing at rest, the abdomen does not move with a single degree of freedom.     

A mathematical and graphical analysis of inspiratory muscle action

In this paper a mathematical and graphical analysis is presented for the action of the diaphragm and the intercostal/accessory muscles of inspiration, in terms of the pressure developed, the volumes displaced and the work performed by each set of muscles. An analogous model is described which behaves according to the analysis. The critical variable by which the action of the diaphragm and intercostal/accessory muscles can be measured is the change in abdominal pressure Pab. When delta Pab = 0 it is assumed that the diaphragm has contracted isometrically and is acting as a fixator preventing an expiratory displacement of the abdomen. When delta Pab greater than 0 the diaphragm shortens and acts as an agonist. When delta Pab less than 0 the diaphragm lengthens as it contracts, performs negative work and the abdomen is displaced in an expiratory direction. For a given change in lung volume, as delta Pab diminishes, there is progressive recruitment of intercostal/accessory muscles and a progressive increase in the work of breathing over and above that required to produce the same change in lung volume by contraction of the diaphragm alone. For values of delta Pab greater than 0 the sum of diaphragm and intercostal/accessory muscle work is less than the total work, because of an increase in the elastic energy stored in the rib cage. For Pab less than 0 there is a decrease in the elastic energy stored in the rib cage leading to a marked increase in work performed and pressures developed by the intercostal/accessory muscles.     

Multimodal ultrasound imaging of primary thyroid schwannoma: A case report

Rationale:Primary schwannoma of the thyroid gland is very rare, and its preoperative diagnosis is difficult.Patient concerns:We report the case of a thyroid nodule in an 18-year-old woman, who presented with a mass in her left neck with stiffness and normal thyroid function. However, the patient complained of numbness in her left upper extremity, and ultrasound (US) features were suspicious of malignancy.Diagnoses:Multimodal US imaging was performed using B-mode, color doppler, ultrasonic elastography (UE), and contrast-enhanced ultrasound (CEUS). CEUS revealed heterogeneous enhancement and “target sign” within the tumor. The nodule was suspicious for malignancy and classified as TI-RADS 4b, while the elasticity values measured by UE indicated a benign lesion. Fine needle aspiration (FNA) was subsequently performed in the markedly contrast-enhanced area for biopsy. Cytological results revealed a benign schwannoma.Intervention:The patient underwent left lobe resection. Postoperative pathology confirmed it to be a primary benign schwannoma of the thyroid.Outcomes:After thyroidectomy, the patient was followed-up with US. At present, all laboratory tests and thyroid imaging are normal, and the numbness of the left upper limb has disappeared.Lessons:The combination of different US modalities is useful for the diagnosis of thyroid lesions. FNA performed under CEUS guidance improves the accuracy of biopsy sampling.     

Contrast-enhanced ultrasonographic imaging of hepatic splenosis: A case report

Rationale:Hepatic splenosis or heterotopic auto-transplantation of spleen in the liver usually occurs after either spleen trauma or surgery. It is of great importance for the differential diagnosis of hepatic splenosis and other liver tumors because surgery is usually not needed if a diagnosis of splenosis is confirmed.Patient concerns:Multiple hepatic masses were revealed by grayscale ultrasound in a 55-year-old man complaining of persistent colic in the upper abdomen after greasy food.Diagnosis:Benign neoplasm with enlarged lymph node in the gastro-hepatic ligament was suspected by contrast enhanced US. The nature of the hepatic mass was undetermined by CECT.Interventions:The lesions were surgically removed.Outcomes:Multiple splenic tissue implants in the liver and peritoneum were confirmed by pathology after surgery. The patient recovered well and was followed up for more than 1 year without recurrence.Lessons:Splenosis should be included in the differential diagnosis of focal liver lesion in patients with a history of spleen trauma or surgery. In spite of nonspecific findings on pre-contrast ultrasound, splenosis shows characteristic homogeneous hyperenhancement in arterial and portal phases, as well as prolonged hyperenhancement in the late phase for more than 5 minutes. Furthermore, the confidence of the diagnosis of splenosis may be enhanced by identifying multiple masses with similar enhancing patterns in other regions of the abdominal cavity.     

Effects of aminophylline on respiratory muscle interaction

We studied the effects of aminophylline on respiratory muscle interaction during quiet breathing by measuring (1) changes in rib cage and abdominal cross-sectional area, (2) tidal volume, (3) abdominal and esophageal pressure, (4) diaphragm and parasternal intercostal electromyogram (EMG) and parasternal intercostal intramuscular pressure, and (5) triangularis sternl and transversus abdominis EMG, in 14 supine anesthetized dogs. Measurements were done before and 5 and 10 min after administration of progressively increasing doses of aminophylline, reaching a total dose of 5, 10, 20, 40, and 80 mg/kg. In 12 of 14 dogs after aminophylline administration, quiet inspiration became biphasic, or if inspiration was already biphasic under control conditions, the first phase was clearly enhanced after aminophylline administration. Biphasic inspiration was defined as an inspiratory pattern in which rib cage and abdominal expansion showed two distinct phases. First, the onset of inspiration was characterized by a sudden increase in rib cage cross-sectional area often associated with a decrease in abdominal dimensions. During this initial part the parasternals and the diaphragm were electrically silent, confirming that it was achieved by relaxation of expiratory muscles. Further inspiration occurred predominantly through expansion of the abdomen. In the first phase, a pressure drop in the parasternal intercostals was present, presumably due to passive shortening of these muscles caused by expiratory muscle relaxation. On the average, 42 +/- 28% of the rib cage expansion was due to expiratory muscle relaxation at a dose of 80 mg/kg versus 17 +/- 21% under control conditions (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Expiratory muscle activity during song production in the canary

Elaborate respiratory patterns accompany song production in male canaries (Serinus canaria). To learn how such patterns arise, electromyographic activity was measured in the expiratory muscles in the abdomen. Most song phrases are accompanied either by mini-breaths (when syllable repetition rates are 2 to 27/sec) or by pulsatile expiration (when syllable repetition rates are 30 to 38/sec). In both cases there is a one-to-one correspondence between bursts of expiratory muscle electrical activity and song syllables. Phrases with syllable repetition rates of 62-70/sec, which are rare, are accompanied by expiratory airflow that may be either pulsatile or continuous. The expiratory muscles are active throughout such phrases, suggesting that the muscles of the vocal organ, the syrinx, are responsible for producing separate notes. Thus, at rates up to 38/sec, the abdominal muscles of canaries contract briefly for the production of each song syllable.     

Expiratory muscle recruitment during inspiratory flow-resistive loading and exercise

Both exercise and inspiratory flow-resistive loading may cause recruitment of expiratory muscles. To evaluate the extent of recruitment in combined exercise and flow-resistive loading, and to estimate the effect on inspiratory muscle work, we studied five men, 26 to 39 yr of age, during mild exercise with different degrees of inspiratory flow-resistive loading. Each subject performed four 1-h exercise runs at 30% of their maximal oxygen consumption on different days while inspiring through an external resistor of either 1.4, 14.5, 19.9, or 30.6 cm H2O/s/L. Mouth and esophageal pressure, inspiratory flow rate, and abdominal and rib cage motion were recorded continuously. Abdominal expansion tended to lead and rib cage expansion tended to lag the start of inspiration as judged from the beginning of negative pressure development at the mouth. These time differences increased as resistive load increased. Plots of abdominal versus rib cage motion also showed increase in phase shift, with the abdomen leading the rib cage on inspiration. For all subjects, the esophageal pressure at the end of expiration became less negative as the resistive load increased, indicating that the end-expiratory volume decreased with increasing resistive load. We conclude that there was increasing use of expiratory muscles as the resistive load increased, and that the initial expansion of the abdomen at high resistive loads represented elastic recoil of structures that had been compressed below the volume at FRC by the expiratory muscles.(ABSTRACT TRUNCATED AT 250 WORDS)     

Ultrasound,electromyography, and balloon guidance for injecting botulinum toxin for cricopharyngeal achalasia: A case report

Introduction:Botulinum toxin (BTX) injection is a widely used treatment option for dysphagia associated with cricopharyngeal (CP) muscle achalasia, but uniform standards and protocols for administration techniques and injection sites are still lacking. This case study suggests that a unique administration technique involving a combination of ultrasound, electromyography, and balloon guidance for injecting the CP muscle can reduce inadvertent migration of BTX to non-injected tissues and increase the effectiveness and safety of BTX treatment.Patient concerns:We describe the case of a 74-year-old man who could not swallow food or saliva for 8 months.Diagnosis:The patient showed signs of true bulbar paralysis, including dizziness, hoarseness, and dysphagia. The fiberoptic endoscopic evaluation of swallowing showed massive mucilage secretion and residual materials in the postcricoid region and aspiration when swallowing 1 ml of yogurt. The video fluoroscopic swallowing study showed profoundly limited epiglottic folding and CP muscle non-relaxation, despite several unsuccessful swallow attempts.Interventions:To manage insufficient relaxation opening of the CP muscle, BTX injection was performed using ultrasound, electromyography, and balloon catheter guidance. The narrow CP muscle situated above the balloon was identified as the target of injection by ultrasound.Outcomes:The patient was able to eat a soft diet. The follow-up fibrotic endoscopic swallowing study demonstrated a reduction in the amount of pharyngeal residue. The video fluoroscopic swallowing study showed that CP muscle relaxation was significantly enhanced and no penetration was shown.Conclusion:The unique administration technique with triple guidance holds several advantages, suggesting that it may be a promising treatment for CP muscle achalasia.     

Ultrasonographic features of eccrine spiradenoma: A case report

Rationale:Eccrine spiradenoma (ES) is a rare benign skin adnexal tumor originating from eccrine sweat glands. The features of ES on ultrasonography (US) have received little attention. Therefore, we report the sonographic findings in a case of an ES that originated from the abdominal wall and discuss the previously reported cases.Patient concerns:A 53-year-old woman was admitted to our hospital with a complaint of a painful nodule on the right side of her abdominal wall of 1-year duration.Diagnoses:The mass on the right side of abdominal wall was diagnosed as ES by histopathological examination.Interventions:The patient subsequently underwent total excision of the mass.Outcomes:The patient recovered well and had no complications during the 1-year follow-up.Lessons:As eccrine spiradenoma (ES) is rare and most of the tumors are excised without prior imaging studies. Little is known regarding the features of ES on ultrasonography (US). Familiarizing with the clinical and US features of this rare tumor may increase awareness of the disease among sonographers and clinicians.     

Relationship between swallowing muscles and trunk muscle mass in healthy elderly individuals: A cross-sectional study

Background and objectiveA decrease of swallowing muscle strength causes dysphagia, and a relationship between swallowing muscle strength and appendicular muscle mass has been reported. Moreover, the effect of trunk retention function on swallowing function has been clinically recognized. However, the relationship between trunk muscle mass and swallowing muscle strength is unclear. We aimed to clarify the association between these variables in elderly individuals.MethodsSubjects were 118 healthy community-dwelling individuals aged ≥65 years (men: 37, women: 81). We measured total muscle mass, grip strength, jaw-opening force, tongue pressure, cross-sectional area (CSA) of the geniohyoid muscle, and tongue muscle thickness. The appendicular skeletal muscle mass index (ASMI) and trunk muscle mass index (TMI) were calculated based on the appendicular skeletal muscle mass and trunk muscle mass, and corrected by height squared. Multiple regression analysis was performed with jaw-opening force and tongue pressure as dependent variables and with age, sex, grip strength, ASMI, TMI, CSA of the geniohyoid muscle, and tongue muscle thickness as independent variables.ResultsSignificant explanatory factors for jaw-opening force were sex (p = 0.002) and TMI (p = 0.003). Significant explanatory factors for tongue pressure were aging (p = 0.001), tongue muscle thickness (p = 0.027), and TMI (p = 0.033).ConclusionsUntil now, the relationship between swallowing muscles and whole body muscle mass has been reported using ASMI as the indicator of whole body muscle mass. This study suggests that TMI may be used as a highly relevant indicator of swallowing muscles rather than ASMI.     

Iliopsoas hematoma presenting with sudden knee extensor weakness: A case report

Rationale:Hematoma of the iliopsoas muscle is a rare condition. Prolonged pressure conditions due to hematoma of the femoral nerve can cause severe pain in the affected groin, hip, and thigh, and quadriceps weakness. We report a rare case of a spontaneous iliopsoas muscle hematoma that caused sudden femoral neuropathy.Patient concerns:A 71-year-old woman presented sudden left hip pain and knee extensor weakness. The pain was aggravated with left hip extension. She had a bilateral total hip replacement surgery due to avascular necrosis. She was diagnosed as mild stenosis of the cerebral artery and took aspirin to prevent cerebral artery atherosclerosis.Diagnosis:A hip computed tomography scan demonstrated a suspicious fluid collection at the left iliopsoas bursa. We considered the possibility of lower limb weakness due to neuralgic amyotrophy and performed electromyography and enhanced lumbosacral magnetic resonance imaging (MRI). Electromyography finding showed left femoral neuropathy of moderate severity around the inguinal area was diagnosed. On MRI, left iliopsoas bursitis or hematoma, and displacement of the left femoral nerve due to the iliopsoas bursitis/hematoma were observed.Intervention:Ultrasonography (US)-guided aspiration of the left iliopsoas hematoma was performed. We started steroid pulse therapy for 8 days.Outcomes:After US-guided aspiration and steroid pulse therapy, the patient''s knee extension motor grade improved from grade 1 to 2, and the pain was slightly reduced. At 3 weeks after the aspiration procedure, her hip flexion motor grade had improved from grade 3+ to 4 at follow-up.Lessons:Imaging studies are fundamental to diagnose of iliopsoas hematoma. Electromyography examination plays an important role in determining the prognosis of patients and lesion site. Despite the negligible change in sitting position, hematoma can develop. Physicians should consider hematoma that cause femoral neuropathy.     

Involuntary movement in stiff-person syndrome with amphiphysin antibodies: A case report

Rationale:Stiff-person syndrome (SPS) is a rare neurological immune disorder characterized by progressive axial and proximal limb muscle rigidity, stiffness, and painful muscle spasms. Amphiphysin antibodies are positive in approximately 5% of SPS patients. To date, there have been no relevant reports on involuntary movement in cases of SPS with amphiphysin antibodies.Patient concerns:We describe the case of a 69-year-old man with a 2-year history of progressive stiffness in the neck, bilateral shoulders, and chest muscles, and a more-than-a-year history of dyspnea accompanied by mandibular involuntary movement. The patient was a vegetarian and had good health in the past. The family''s medical history was unremarkable.Diagnoses:He was diagnosed with SPS based on the progressive muscle stiffness, the amphiphysin antibody seropositivity, the continuous motor activity on electromyography, and the effective treatment with benzodiazepines.Interventions:The patient was orally administered clonazepam and baclofen, and corticosteroid IV followed by prednisone orally.Outcomes:In the hospital, after treatment with methylprednisolone, clonazepam, and baclofen, the patient''s rigidity, stiffness, and dyspnea significantly improved. The involuntary movement of the mandible persisted throughout the treatment process. Currently, under oral treatment with baclofen and clonazepam, the patient''s symptoms of muscle stiffness and dyspnea exist, and follow-up is continued.Lessons:We report a rare and novel case of involuntary movement in SPS with amphiphysin antibodies. The present report explores the relationship between SPS and involuntary movement and expands the spectrum of clinical manifestations of SPS.     

Expiratory muscle activity in anesthetized children: effect on the single breath technique

Phasic expiratory activity of the abdominal muscles occurs in adults during halothane anesthesia, but has not been demonstrated in children. If present, abdominal muscle activity would preclude the use of recently developed tests of respiratory mechanics in children during anesthesia. We therefore measured abdominal muscle activity throughout induction of anesthesia with halothane in 10 patients between 1.5 and 9.5 years of age, seven with normal respiratory function and three with chronic airway obstruction. During induction of anesthesia with halothane in N2O and oxygen, the abdominal wall electromyograph (a-EMG) was continuously recorded from surface electrodes. At the same time, the expiratory time constant (tau a) was measured using the single breath test (SBT). The patients were then paralyzed with succinyl choline, and the a-EMG signal and expiratory time constant during paralysis (tau p) were recorded. The raw a-EMG signal and its moving time average were compared with the phase of respiration and with the end-tidal fraction of halothane (Fehalo), and the effect of abdominal muscle activity on tau a was noted. Of the 10 patients, 2 had no abdominal muscle activity at any time during induction. Of the remaining 8 patients, 3 had continuous abdominal muscle activity throughout induction, including one patient with asthma. In the remaining five patients, abdominal muscle activity was present during light halothane anesthesia and disappeared at increased Fehalo. When abdominal muscle activity was present, tau a was significantly less than tau p. It is concluded that abdominal muscle activity in expiration is undetectable during deep halothane anesthesia in most children.(ABSTRACT TRUNCATED AT 250 WORDS)     

Respiratory muscle dysfunction after herpes zoster

We report an unusual neurologic complication of herpes zoster. After thoracic herpes zoster, our patient complained of severe shortness of breath as a result of myoclonus of the abdominal muscles as documented by electromyography. The myoclonus resulted in repetitive interruption of expiratory air flow, resulting in shortness of breath and a staccato speech. This case demonstrates the need to evaluate the function of all the respiratory muscles in a patient complaining of dyspnea.     

Weakness of expiratory muscles and pulmonary complications in malnourished patients undergoing upper abdominal surgery

Background and objective: Malnutrition is prevalent in hospitalized patients and causes systemic damage including effects on the respiratory and immune systems, as well as predisposing to infection and increasing postoperative complications and mortality. This study aimed to assess the impact of malnutrition on the rate of postoperative pulmonary complications, respiratory muscle strength and chest wall expansion in patients undergoing elective upper abdominal surgery. Methods: Seventy‐five consecutive candidates for upper abdominal surgery (39 in the malnourished group (MNG) and 36 in the control group (CG)) were enrolled in this prospective controlled cohort study. All patients were evaluated for nutritional status, respiratory muscle strength, chest wall expansion and lung function before surgery. Postoperative pulmonary complications (pneumonia, tracheobronchitis, atelectasis and acute respiratory failure) before discharge from hospital were also evaluated. Results: The MNG showed expiratory muscle weakness (MNG 65 ± 24 vs CG 82 ± 22 cm H₂O; P < 0.001) and decreased chest wall expansion (P < 0.001), whereas inspiratory muscle strength and lung function were preserved (P > 0.05). The MNG also had a higher incidence of postoperative pulmonary complications compared with the CG (31% and 11%, respectively; P = 0.05). In addition, expiratory muscle weakness was correlated with BMI in the MNG (r = 0.43; P < 0.01). The association between malnutrition and expiratory muscle weakness increased the likelihood of postoperative pulmonary complications after upper abdominal surgery (P = 0.02). Conclusions: These results show that malnutrition is associated with weakness of the expiratory muscles, decreased chest wall expansion and increased incidence of pulmonary complications in patients undergoing elective upper abdominal surgery.     

Ventilatory and respiratory muscle responses to hypercapnia in patients with paraplegia

To evaluate ventilatory and respiratory muscle responses to hypercapnia in patients with paraplegia with paralysis of abdominal muscles, we studied seven patients with complete transection of the midthoracic cord (Th6-Th7) and six normal subjects. Minute ventilation (V E) and mean inspiratory flow responses to hypercapnia were similar in normal subjects and patients with paraplegia, but in the latter, at any given level of end-tidal CO(2) partial pressure (PET(CO(2))), tidal volume (VT) was reduced and frequency was increased. In normal subjects during hypercapnia, end-expiratory transpulmonary pressure (PL) and abdominal volume at end expiration decreased markedly, whereas end-expiratory volume of the rib cage (Vrc,E) remained constant, suggesting progressive recruitment of abdominal muscles. In patients with paraplegia compared to normal subjects the decrease in end-expiratory PL was reduced, and it was associated with a decrease in Vrc,E, suggesting recruitment of rib cage expiratory muscles. For a PET(CO(2)) of 70 mm Hg the estimated expiratory muscle contribution to VT was 10.3 and 28.4% (p < 0.02) in patients with paraplegia and normal subjects, respectively. We conclude that the V E-CO(2) relationship is preserved in patients with paraplegia with the development of a rapid and shallow pattern of breathing. This suggests that expiratory muscle paralysis elicits adaptation of the ventilatory control system similar to that observed in patients with generalized respiratory muscle weakness.     

Physiotherapeutic assessment and management of chronic pelvic pain syndrome: A case report

Introduction:Chronic pelvic pain syndrome is difficult for the diagnosis and therapy and that means the patient attending the physician or physiotherapist may present various symptoms. There are no guidelines concern physiotherapy diagnosis and treatment of chronic pelvic pain syndrome. This study presents the physiotherapeutic assessment and management in men with pelvic pain symptoms.Patient concerns:Forty-six-year-old man attended the physiotherapy consulting room due to symptoms of pain in the perineum, lower abdomen, urethra, and scrotum for a year. Earlier, the patient had consulted a urologist who made a diagnosis of cystitis and prescribed medications that did not get results.Diagnosis:Ultrasound imaging and manual inspection (per rectum) of the pelvic floor was conducted by physiotherapist. Also, the abdominal and lower extremities muscles were assessed. Patient reported pain symptoms during examination of the musculus ischiocavernosus, puboanalis, pubococcygeus, iliococcygeus, coccygeus, and canalis pudentalis seu Alcocki.Interventions:The patient was given physiotherapeutic interventions consisting in the manual therapy of the lumbopelvic hip complex and the manual therapy per rectum.Outcomes:During 10th session of the physiotherapeutic treatment, patient reported improvement in pain symptoms. A month later, patient reported total alleviation of the pain symptoms during control visit.Conclusion:Therapy of chronic pelvic pain syndrome is a process that involves application of different therapies and different approaches. Functional and structural assessment and also therapy conducted by physiotherapist is becoming an integral part of urology and represents 1 possible conservative treatment form.