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Concept: Thoracic diaphragm

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BACKGROUND: Among a variety of more common differential diagnoses, the aetiology of acute respiratory failure includes Lyme neuroborreliosis. CASE PRESENTATION: We report an 87-years old huntsman with unilateral phrenic nerve palsy as a consequence of Lyme neuroborreliosis. CONCLUSION: Although Lyme neuroborreliosis is a rare cause of diaphragmatic weakness, it should be considered in the differential workup because of its potentially treatable nature.

Concepts: Medical terms, Lyme disease, Respiratory system, Thoracic diaphragm, Differential diagnosis, Phrenic nerve, Respiratory failure, Neuroborreliosis

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This paper reviews the literature relating to the biofeedback used in physical rehabilitation. The biofeedback methods used in rehabilitation are based on biomechanical measurements and measurements of the physiological systems of the body. The physiological systems of the body which can be measured to provide biofeedback are the neuromuscular system, the respiratory system and the cardiovascular system. Neuromuscular biofeedback methods include electromyography (EMG) biofeedback and real-time ultrasound imaging (RTUS) biofeedback. EMG biofeedback is the most widely investigated method of biofeedback and appears to be an effective in the treatment of many musculoskeletal conditions and in post cardiovascular accident (CVA) rehabilitation. RTUS biofeedback has been demonstrated effective in the treatment of low back pain (LBP) and pelvic floor muscle dysfunction. Cardiovascular biofeedback methods have been shown to be effective in the treatment of a number of health conditions such as hypertension, heart failure, asthma, fibromyalgia and even psychological disorders however a systematic review in this field has yet to be conducted. Similarly, the number of large scale studies examining the use of respiratory biofeedback in rehabilitation is limited. Measurements of movement, postural control and force output can be made using a number of different devices and used to deliver biomechanical biofeedback. Inertial based sensing biofeedback is the most widely researched biomechanical biofeedback method, with a number of studies showing it to be effective in improving measures of balance in a number of populations. Other types of biomechanical biofeedback include force plate systems, electrogoniometry, pressure biofeedback and camera based systems however the evidence for these is limited. Biofeedback is generally delivered using visual displays, acoustic or haptic signals, however more recently virtual reality (VR) or exergaming technology have been used as biofeedback signals. VR and exergaming technology have been primarily investigated in post-CVA rehabilitation, however, more recent work has shown this type of biofeedback to be effective in improving exercise technique in musculoskeletal populations. While a number of studies in this area have been conducted, further large scale studies and reviews investigating different biofeedback applications in different clinical populations are required.

Concepts: Blood, Hypertension, Heart, Respiratory system, Thoracic diaphragm, Mucus, Respiration, Ibn al-Nafis

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Interscalene brachial plexus block (ISBPB) provides excellent analgesia after rotator cuff surgery but is associated with diaphragm dysfunction. In this study, ISBPB with 20 mL of 0.125% or 0.25% bupivacaine were compared to assess the effect on diaphragm function, oxygen saturation, pain control, opioid requirements, and patient satisfaction.

Concepts: Anesthesia, Opioid, Pain, Thoracic diaphragm, Pain management, Rotator cuff, Brachial plexus, Plexus

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We describe in this paper a rare case of a 45-year-old male with a common stem origin of the left gastric artery (LGA), right inferior phrenic artery (RIPA), and left inferior phrenic artery (LIPA), in association with the presence of a hepatosplenomesenteric trunk (HSMT) arising from the abdominal aorta (AA), as revealed by routine multidetector computed tomography (MDCT) angiography. The common stem origin of the LGA, RIPA, and LIPA had an endoluminal diameter of 3.3 mm, the LGA of 2.8 mm. The endoluminal diameter of the RIPA and LIPA was at the origin of approximately 1 mm, complicating selective chemoembolization of the liver parenchyma. Clin. Anat., 2012. © 2012 Wiley Periodicals, Inc.

Concepts: Stomach, Thoracic diaphragm, Arteries of the abdomen, Left gastric artery, Right gastric artery, Celiac artery, Inferior phrenic arteries, Inferior phrenic vein

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Abstract Objective: The aim of the study is to evaluate the application of Neurally Adjusted Ventilatory Assist (NAVA) in the respiratory weaning of patients affected by congenital diaphragmatic hernia (CDH). Methods: We analyzed the NAVA weaning in 12 neonates affected by CDH, relating the effectiveness of the electrical activation of the diaphragm (EAdi) signal to the type of CDH repair (with or without patch), the size of the patch, the stomach and His angle position, and the trend evaluation of some cardio-respiratory parameters with NAVA compared to pressure-support-ventilation (PSV). Results: 5 neonates submitted to primary repair showed a regular EAdi signal and were successfully weaned with NAVA. Of the 7 patients submitted to patch repair, 5 operated with patch limited to the diaphragmatic postero-lateral area had an active EAdi signal that permitted weaning with NAVA. Only in 2 neonates with hemidiaphragm agenesis was NAVA not feasible due to the impossibility to capture the EAdi signal. Compared to PSV, NAVA allows a significant improvement of oxygenation-linked indexes and paCO(2), while PIP is reduced. Conclusion: Neonatal CDH with a postero-lateral diaphragmatic defect allows the NAVA catheter to obtain a correct EAdi signal and develop a viable NAVA ventilation. The lower risk of lung injury in NAVA appears compatible with current ventilatory strategies considered useful in CDH.

Concepts: Milk, Breastfeeding, Respiratory system, Thoracic diaphragm, Diaphragm, Respiration, Congenital diaphragmatic hernia, Weaning

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OBJECTIVES: Phrenic nerve injury after paediatric heart surgery is associated with significant morbidity. Surgical plication of the diaphragm is believed to be beneficial to the patient, with difficult weaning from ventilation; however, the optimal timing remains unclear. We aimed to compare the outcome after two different strategies for treating hemidiaphragmatic paresis. METHODS: A retrospective analysis of all patients with paresis of the diaphragm between 2000 and 2010 was performed, with special attention to the rate of reintubations, ventilation and intensive care unit (ICU) stay and the rate of plication. In 2005, the strategy for treating diaphragmatic paresis in our institution changed from conservative treatment with plication after multiple extubation efforts towards an aggressive one with plication after a single unsuccessful extubation. We compared the outcome of all patients and that of the newborns separately from the two periods. RESULTS: During the study period, 148 patients with diaphragmatic paresis were diagnosed and included. Median age at the cardiac operation was 7 months (1 day-18 years), ventilation time ranged from 4 h to 41 days (median 7 days), 42 (28.4%) of the patients required at least one reintubation and ICU stay ranged from 2 to 63 days (median 11 days). A total of 63 plications were performed-5 (9%) before 2004 and 58 (62%) after 2005, P < 0.001. There were no significant differences in the ventilation time-6 (1-40) vs 8 (0-41) days, P = 0.36, reintubation rate-28 vs 29%, P = 0.85 and ICU stay-10 (3-63) vs 12 (2-55) days, P = 0.41 between both groups. The newborn patients, treated with the different strategies, also did not differ significantly in their outcome: ventilation time-12 (2-40) vs 11.5 (3-34) days, P = 0.38; reintubation rate-43 vs 41%, P = 0.62; ICU stay-16 (6-63) vs 15 (7-55) days, P = 0.55. CONCLUSIONS: Changing the strategy for phrenic nerve injury after paediatric heart surgery towards a more aggressive one with early plication of the diaphragm was not associated with the better outcome. Prospective randomized studies are needed to determine the optimal management of this complication.

Concepts: Infant, Physician, Thoracic diaphragm, Phrenic nerve, Inferior phrenic arteries

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BACKGROUND: Stability of threshold currents during long-term use of phrenic nerve stimulation has been questioned. METHODS AND RESULTS: Between January 5, 1988, and March 5, 2008, 49 patients with functional C2-tetraplegia received an Atrostim PNS (Atrotech Ltd., Tampere, Finland) as treatment of their respiratory insufficiency; a follow-up of 35 of such patients was carried out exclusively in our institution for 6.3 (4.44) 0.04-15.75 years (mean [standard deviation (SD)] range). The device employed four-pole sequential nerve stimulation, which provided four threshold currents subsequently evaluated for each phrenic nerve. Stimulation data were prospectively recorded. The differences between threshold currents recorded 1 year after implantation and the last recorded values were 0.33-0.43 (0.44-0.63) 0-2.9 mA. After having excluded the data of eight patients with values >1 mA (= mean + SD), we registered the differences for the remaining patients of 0.15-0.24 (0.14-0.24) 0-0.95 mA, which is just twice the adjustment accuracy of the device. Out of the eight problem cases one had, and two were suspected to have, surgical trauma; all three nerves recovered. In two cases the values steadily increasing over years might have been caused by unspecific foreign body reaction. Two cases with values >1mA for different durations at different electrodes might be caused by biofilm, and one patient displaying steadily increasing values lived, unwilling to live, only 2 years after the implantation. CONCLUSION: Thus, there was no permanent nerve injury and in 77% of the presented cases threshold currents remained stable.

Concepts: Action potential, Mean, Thoracic diaphragm, Standard deviation, Nerve, Phrenic nerve, Nerves of the head and neck, Kehr's sign

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Robotic-assisted laparoscopic prostatectomy requires patients to be secured in a steep Trendelenburg position for several hours. Added to the CO2 pneumoperitoneum that is created, this positioning invariably restricts diaphragmatic and chest wall excursion, which can adversely affect respiratory gas exchange. This study sought to measure the extent of respiratory gas change during this procedure.

Concepts: Surgery, Respiratory system, Thoracic diaphragm, Respiration, Positioning, Trendelenburg position

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This paper presents an ultra-wideband (UWB) impulse-radio radar signal processing platform used to analyze human respiratory features. Conventional radar systems used in human detection only analyze human respiration rates or the response of a target. However, additional respiratory signal information is available that has not been explored using radar detection. The authors previously proposed a modified raised cosine waveform (MRCW) respiration model and an iterative correlation search algorithm that could acquire additional respiratory features such as the inspiration and expiration speeds, respiration intensity, and respiration holding ratio. To realize real-time respiratory feature extraction by using the proposed UWB signal processing platform, this paper proposes a new four-segment linear waveform (FSLW) respiration model. This model offers a superior fit to the measured respiration signal compared with the MRCW model and decreases the computational complexity of feature extraction. In addition, an early-terminated iterative correlation search algorithm is presented, substantially decreasing the computational complexity and yielding negligible performance degradation. These extracted features can be considered the compressed signals used to decrease the amount of data storage required for use in long-term medical monitoring systems and can also be used in clinical diagnosis. The proposed respiratory feature extraction algorithm was designed and implemented using the proposed UWB radar signal processing platform including a radar front-end chip and an FPGA chip. The proposed radar system can detect human respiration rates at 0.1 to 1 Hz and facilitates the real-time analysis of the respiratory features of each respiration period.

Concepts: Algorithm, Respiratory system, Thoracic diaphragm, Computational complexity theory, Digital signal processing, Respiration, Radar, Ultra-wideband

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Respiratory muscle weakness contributes to respiratory failure in ICU patients. Unfortunately, assessment of weakness is difficult since the most objective test, transdiaphragmatic pressure in response to phrenic nerve stimulation (PdiTw), is difficult to perform. While most clinicians utilize maximum inspiratory pressure (Pimax) to assess strength, the relationship of this index to PdiTw has not been evaluated in a large ICU population. The purpose of the present study was to assess both PdiTw and Pimax in ICU patients to determine how these indices correlate with each other, what factors influence these indices, and how well these indices predict outcomes.

Concepts: Intensive care medicine, Future, Assessment, Psychometrics, Muscular system, Thoracic diaphragm, Muscle weakness, Test