The emergency medicine training needs of rural general practitioners

This study aimed to identify the emergency medicine training needs of rural general practitioners (GPs) in the catchment area of the Hunter Rural Division of General Practice. The GPs were surveyed using a questionnaire in which they were asked about their confidence levels in a number of specific emergency medicine skills, and about the areas of emergency medicine that they saw as priorities for upskilling. More than a third of GPs who were responsible for on-call work at the hospital indicated that they had low levels of confidence in a number of their emergency medicine skills, in particular skills relating to paediatric emergencies, cardiovascular emergencies, and respiratory emergencies. These emergency medicine domains were also seen as high priorities for upskilling by the majority of the respondents. The study shows that rural doctors need the opportunity to access emergency medicine training that provides upskilling not only in the management of clinical problems, but also in practical procedures.     

c-Jun expression after axotomy of corneal trigeminal ganglion neurons is dependent on the site of injury

The proto-oncogene c-Jun has been implicated in the control of neuronal responses to injury and in axonal growth during regenerative processes. We have investigated the expression of c-Jun during normal terminal remodelling in trigeminal ganglion neurons innervating the cornea and after acute injury of epithelial nerve terminals or parent axons. Remodelling and rearrangement, or damage limited to corneal epithelium endings, was not a trigger for activation of c-Jun expression. However, injury of parent axons in the stroma or in the orbital ciliary nerves induced c-Jun expression in 50% of the population of corneal neurons, which included all of the large myelinated and 20% of the small neuropeptide-containing corneal neurons. This suggests that c-Jun expression in trigeminal ganglion neurons is not associated with normal remodelling or regeneration of peripheral nerve terminals, and that it takes place only when parent axons are injured. A substantial number of damaged neurons do not express c-Jun, indicating that in primary sensory neurons, injury and regeneration may not always be coupled to the expression of this proto-oncogene.     

Glial cell line-derived neurotrophic factor-like immunoreactivity in human trigeminal ganglion and nucleus

Glial cell line-derived neurotrophic factor (GDNF) is shown by immunohistochemistry in human trigeminal sensory system from 22 weeks of gestation to adulthood. In the trigeminal ganglion, a distinct subpopulation of GDNF-positive neurones is observed, which amounts to about 15% at early pre-term and adult ages and peaks to around 30% at perinatal ages. Labelled neurones are mostly small- and medium-sized. Occasionally, Schwann and satellite cells are stained. GDNF/substance P (SP) and GDNF/calcitonin gene-related peptide (CGRP) double stained neurones occur at all ages examined, whereas GDNF/trkA coexistence can be observed in pre- and full-term newborns only. Centrally, GDNF-immunostained fibers and terminal-like structures are mainly restricted to the spinal trigeminal nucleus, where they are codistributed with SP and CGRP. In the subnucleus caudalis, positive neurones can also be observed both in the superficial laminae and in the magnocellular part, with higher frequency in adults. These results suggest that GDNF may play a functional role in human trigeminal primary sensory neurones throughout life and provide indication for its possible involvement in the regulation of pain-related neuronal circuits in human trigeminal sensory system.     

Satellite-cell-derived nerve growth factor and neurotrophin-3 are involved in noradrenergic sprouting in the dorsal root ganglia following peripheral nerve injury in the rat

Injury to a peripheral nerve induces in the dorsal root ganglia (DRG) sprouting of sympathetic and peptidergic terminals around large-diameter sensory neurons that project in the damaged nerve. This pathological change may be implicated in the chronic pain syndromes seen in some patients with peripheral nerve injury. The mechanisms underlying the sprouting are not known. Using in situ hybridization and immunohistochemical techniques, we have now found that nerve growth factor (NGF) and neurotrophin-3 (NT3) synthesis is upregulated in satellite cells surrounding neurons in lesioned DRG as early as 48 h after nerve injury. This response lasts for at least 2 months. Quantitative analysis showed that the levels of mRNAs for NT3 and NGF increased in ipsilateral but not contralateral DRG after nerve injury. Noradrenergic sprouting around the axotomized neurons was associated with p75-immunoreactive satellite cells. Further, antibodies specific to NGF or NT3, delivered by an osmotic mini-pump to the DRG via the lesioned L5 spinal nerve, significantly reduced noradrenergic sprouting. These results implicate satellite cell-derived neurotrophins in the induction of sympathetic sprouting following peripheral nerve injury.     

Prevention of anterior cruciate ligament injuries in soccer

Proprioceptive training has been shown to reduce the incidence of ankle sprains in different sports. It can also improve rehabilitation after anterior cruciate ligament (ACL) injuries whether treated operatively or nonoperatively. Since ACL injuries lead to long absence from sports and are one of the main causes of permanent sports disability, it is essential to try to prevent them. In a prospective controlled study of 600 soccer players in 40 semiprofessional or amateur teams, we studied the possible preventive effect of a gradually increasing proprioceptive training on four different types of wobble-boards during three soccer seasons. Three hundred players were instructed to train 20 min per day with 5 different phases of increasing difficulty. The first phase consisted of balance training without any balance board; phase 2 of training on a rectangular balance board; phase 3 of training on a round board; phase 4 of training on a combined round and rectangular board; phase 5 of training on a so-called BABS board. A control group of 300 players from other, comparable teams trained normally and received no special balance training. Both groups were observed for three whole soccer seasons, and possible ACL lesions were diagnosed by clinical examination, KT-1000 measurements, magnetic resonance imaging or computed tomography, and arthroscopy. We found an incidence of 1.15 ACL injuries per team per year in the control group and 0.15 injuries per team per year in the proprioceptively trained group (P<0.001). Proprioceptive training can thus significantly reduce the incidence of ACL injuries in soccer players.     

Pertussis toxin does not affect the adenosine-induced inhibition of the efferent function of cardiac capsaicin-sensitive nerves

Summary The negative inotropic effect of adenosine (1–100 M) was abolished in isolated guinea-pig atria obtained from pertussis toxin-pretreated guinea pigs electrically driven at 4 Hz. However, the inhibitory effect of the same concentrations of adenosine on the cardiac response to stimulation of non-adrenergic non-cholinergic (NANC), capsaicin-sensitive sensory nerves, was not modified by the toxin.These results suggest that, while pertussis toxin-sensitive G proteins are involved in the negative inotropic effect of adenosine, they do not mediate the inhibitory effect of adenosine on cardiac NANC neurotransmission.     

Renal nerve and blood pressure responses to stimulation of cardiac receptors in dogs and cats by bradykinin

Summary It has been recently demonstrated in anesthetized, sinoaortic denervated-vagotomized (SAD+V_x) cats that epicardial or intracoronary (IC) bradykinin (BK) evokes an increase in efferent renal nerve activity (RNA) and a pressor response which is mediated by the cardiac sympathetic afferent nerves. The purpose of this study was to compare the effect of epicardial, IC, and left atrial (LA) administration of BK on arterial blood pressure (ABP) and RNA in intact and SAD+V_x cats and dogs. A total of seven cats and eight dogs anesthetized with chloralose were prepared with a left circumflex coronary arterial catheter (dogs) or a LA catheter (cats). Changes in ABP and RNA were determined in both dogs and cats when 1 to 100 g/ml of BK was applied to the anterior surface of the left ventricle or injected IC or LA (0.3 and 3.0 g/kg BK) in the intact and SAD+V_x state. In both the intact and SAD +V_x cat, a pressor response was consistently elicited with epicardial BK. In the SAD+V_x state, epicardial BK increased ABP by 33.4±4.7 mm Hg (p<.001). RNA followed this same trend showing a consistent and significant increase with both LA and epicardial BK (+24.8±8.4% in the SAD+V_x state; P<.05). Changes in RNA in dogs were highly variable with epicardial and IC BK in intact and in SAD V_x dogs, resulting in insignificant changes in this parameter. The results of this study demonstrate that the reflex effects of stimulation of cardiac sympathetic afferents by BK are species specific and need not evoke an increase in peripheral sympathetic outflow.Supported by National Institutes of Health Gran #HL-22594 and American Heart Association Grant # 81672.     

Hemispherectomy — 25 years later — findings and concepts

Summary In the first part the case of a then 27 year old female patient with right-sided infantile spastic hemiplegia after left-sided porencephaly is described, in whom hemispherectomy was performed 25 years ago. The postoperative state and the development are described as well as the social outcome and the present neurological status. A computer-tomogram shows the actual state of the brain.The second part is devoted to a scientific discussion of the supplementary motility after pyramidal lesions which is defined as the action of descending subcortico-spinal pathways starting probably in the mesencephalon, whereas an ipsilateral pathway is unlikely. Comparative neurological experiments serve to support such a concept as well as similar observations in traumatic cerebral lesions in man. In the light of the far more skilled motility in cerebral lesions of the young as well as the possibility of a shift of neuropsychological functions of the dominant to the contralateral hemisphere in children up to the age of 8–10 the possibility is discussed that plasticity — the concept of Albert Bethe — could form the mechanism of auxiliary function.Furthermore the surprising sensory performances in some of the patients with hemispherectomy are emphasized and the possibilities of anipsilateral substratum are discussed; however, this contrasts with the concepts formulated for the auxiliary motility after pyramidal lesions. Clarification of these problems will probably follow only after further experimental work.

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Zusammenfassung Im ersten Teil der Arbeit wird der Fall einer damals 27-jährigen Patientin beschrieben, die eine rechtsseitige infantile spastische Hemiplegie nach linksseitiger Porencephalie hatte. Bei ihr war 25 Jahre zuvor eine Hemisphärektomie durchgeführt worden. Der postoperative klinische Status und die Entwicklung der Syndrome wird beschrieben und über die soziale Situation berichtet. Schließlich wird der derzeitige neurologische Status genau wiedergegeben. Erstmalig zeigt ein Computer-Tomogramm den Zustand des Hirns nach diesem Zeitraum.Im zweiten Teil der Arbeit wird die Entstehung der Ersatz-Motilität diskutiert, die als eine Aktion deszendierender subkortiko-spinaler Bahnen definiert wird, die wahrscheinlich vom Mittelhirn ihren Ausgang nehmen, während die Tätigkeit ipsilateraler Systeme für unwahrscheinlich gehalten wird. Vergleichende Tierexperimente am Hirn unterstützen eine solche Auffassung, ebenso wie auch die Beobachtung bei umschriebenen Hirnverletzungen des Menschen.Dann wird die Möglichkeit von Ersatzfunktionen durch Plastizität diskutiert — ein Begriff von Albert Bethe. Dies erscheint im Lichte vieler Beobachtungen wichtig, da die Ersatz-Motilität bei Hirnläsionen junger Menschen sehr viel höhere Geschicklichkeit ermöglicht als bei Läsionen von Älteren; weiter ist zu beachten, daß neuropsychologische Funktionen bei einer Hirnläsion vor dem 8. bis 10. Lebensjahr von einer dominanten Hemisphäre noch auf die andere Seite verlegt und dort lokalisiert werden können. Schließlich wird bei diesen Patienten auf die erstaunlichen Fähigkeiten der sensiblen Systeme nach Hemisphärektomie hingewiesen und hier die Möglichkeit eines ipsilateralen anatomischen Apparates diskutiert. Jedoch können bei der Sensibilität so genaue funktionell-morphologische Vorstellungen noch nicht formuliert werden, wie sie sich z. Zt. schon für die Ersatz-Motilität nach Pyramidenbahnläsion ergeben. Erst genauere Experimente im Tierversuch können weitere Aufklärung bringen.

     

A reevaluation of the functional organization and cytoarchitecture of the feline lateral posterior complex, with observations on adjoining cell groups

The organization of the cat's lateral posterior complex was reevaluated and its cytoarchitecture described. Analysis of visual representations within the complex confirmed that the pulvinar, lateral zone (LPL), and interjacent zone (LPi) correspond to separate representations of the visual field and established that the zones exhibit heterogeneous connections as a result of retinotopic interconnections with extrastriate areas which represent varying amounts of the visual field. A common system of visual representation extending through layers with differing anatomical connections was identified within zone LPL. The concept of an "isorepresentation cord" was introduced to describe these variable correspondences between sensory representations and connectional relationships. Isorepresentation cords are conceived as holding in common representation of a common locus on a sensory surface without functioning as a unit with respect to connections. Visual representations within the lateral posterior complex consist of many such cords arranged in orderly array. Zone LPm (medial) was also delineated more accurately on the basis of its connections with the ectosylvian visual area. Analysis of termination patterns which occupy boundary regions adjacent to and between the principal zones further established the existence of a collection of cell groups which form a thin, irregular shell investing the principal zones. The identification of these additional cell groups and the recognition of connectional heterogeneity within the principal zones of the complex made it possible to identify and describe the subtle cytoarchitectural differences which characterize the subdivisions of the lateral posterior complex and their boundaries with adjoining nuclear groups. The present findings are discussed with respect to the functions of the lateral posterior complex in interconnecting cortical visual and visuomotor areas, and with respect to the conceptual issues raised by variable correspondences between sensory representations and connectional relationships within thalamus.