The clinical importance of the anastomoses between median and ulnar nerves in the forearm

The aim of this study was to investigate the appearance of anastomosis between median and ulnar nerve in people of different sex and the specification of the clinical importance. Especially, findings were about: 1. Frequency of appearance. 2. Distribution according to the sex. 3. Research of bilateral or unilateral appearance of anastomosis. 4. Co-existence with other anastomoses. 5. Length of anastomosis, height at which anastomosis joins median and ulnar nerves using the medial epicondyle as point of reference. Material - Method: A research was made on 100 cadavers (total 163 forearms) in detailed exploration in the morgue of Athens. The anatomic study was carried out with the use of magnifying glasses (4x). We used approach shape ‘S’ in all the flexion surface of the forearm (Mc Connell, 1927). Results: The results of this study are summarised as follows: 1. Anastomoses between median and ulnar nerves were found in 14 out 163 samples of forearms, which were studied. These anastomoses were classified into three types: Type I(n:12, 87%): Anastomosis between anterior interosseous nerve and ulnar nerve. Type II(n:1, 7%): Anastomosis between muscular branches of the flexor digitorum superficialis muscles and the ulnar nerve. Type IΙΙ(n:1, 7%): Anastomosis between median and ulnar nerve. 2. The average length of anastomosis was about 6,4 cm. Respectively the average height of origin from the medial epicondyle was about 6,8 cm, while the average height at which the connection joined the ulnar nerve was 11cm. 3. Anastomoses between ulnar nerve proximally to the median nerve distally weren’t found out, neither were anastomoses between these nerves and the radial nerve. 4. With regard to the analysis of frequency the following were found: a) By the cross - correlation between sex and presence or not anastomosis in the right forearm according to the Pearson test we received the following data: Χ²:0,11 and P:0,73. b) Respectively by the same cross - correlation for the left forearm we received the following data: Χ²:4,27 and P:0,038.Σκοπός της εργασίας ήταν η διερεύνηση του ποσοστού εμφάνισης και της μορφής των αναστομώσεων μέσου και ωλένιου νεύρου σε άτομα διαφορετικού φύλου καθώς και ο καθορισμός της κλινικής σημασίας αυτών. Ειδικότερα ερευνήθησαν: 1. Συχνότητα εμφάνισης. 2. Κατανομή ως προς το φύλο. 3. Έρευνα για αμφοτερόπλευρη ή ετερόπλευρη εμφάνιση της αναστόμωσης. 4. Συνύπαρξη με άλλες αναστομώσεις. 5. Μήκος αναστόμωσης, ύψος της έκφυσης και κατάφυσης της ανα-στόμωσης από τον έσω επικόνδυλο. Υλικό - Μέθοδος: Ερευνήθησαν 100 ανθρώπινα πτώματα (σύνολο 163 αντιβράχια) με λεπτομερή παρασκευή στο νεκροτομείο Αθηνών. Η χειρουργική μελέτη έγινε με την χρήση μεγεθυντικών γυαλιών (4x). Χρη-σιμοποιήθηκε προσπέλαση σχήματος ‘S’ σε όλη την καμπτική επιφάνεια του αντιβραχίου (Mc Connell,1927). Αποτελέσματα: Τα αποτελέσματα της μελέτης συνοψίζονται στα παρακάτω. 1. Αναστομώσεις μέσου και ωλένιου νεύρου παρατηρήθηκαν σε 14 από τα 163 αντιβράχια που ελέγχθηκαν (9%). Οι αναστομώσεις αυτές κατατάσσονται σε τρείς τύπους όπως φαίνεται παρακάτω: Τύπος Ι (n:12, 86%): Αναστόμωση μεταξύ προσθίου μεσοστέου νεύρου και ωλένιου νεύρου. Τύπος ΙΙ (n:1, 7%): Αναστόμωση μεταξύ μυϊκών κλάδων για τους επιπολής καμπτήρες μύες του αντιβραχίου και το ωλένιο νεύρο. Τύπος ΙΙΙ (n:1, 7%): Αναστόμωση απευθείας μεταξύ μέσου και ωλένιου νεύρου. 2. Το μέσο μήκος της αναστόμωσης ήταν 6,4 εκ. Αντίστοιχα το μέσο ύψος έκφυσης από τον έσω επικόνδυλο ήταν 6,8 εκ. , ενώ το μέσο ύψος κατάφυσης ήταν 11εκ. 3. Δεν διαπιστώθηκαν αναστομώσεις μεταξύ του ωλένιου νεύρου κεντρικά και του μέσου νεύρου περιφερικά, ούτε και αναστομώσεις μεταξύ των παραπάνω νεύρων και του αντίστοιχου κερκιδικού νεύρου. 4. Όσον αφορά την ανάλυση συχνοτήτων βρέθηκαν τα εξής: α) Από την συσχέτιση φύλου και παρουσία ή μη αναστόμωσης στο δεξιό αντιβράχιο σύμφωνα με το Pearson test ελήφθησαν τα δεδομένα: Χ²: 0,11 και P: 0,73. β) Αντίστοιχα από την ίδια συσχέτιση για το αριστερό αντιβράχιο ελήφθησαν τα δεδομένα: Χ²: 4,27 και P: 0,038

Dyspnea and respiratory muscle strength in end-stage liver disease

AIM: To investigate the prevalence of chronic dyspnea and its relationship to respiratory muscle function in end-stage liver disease. METHODS: Sixty-eight consecutive, ambulatory, Caucasian patients with end-stage liver disease, candidates for liver transplantation, were referred for preoperative respiratory function assessment. Forty of these (29 men) were included in this preliminary study after applying strict inclusion and exclusion criteria. Seventeen of 40 patients (42%) had ascites, but none of them was cachectic. Fifteen of 40 patients (38%) had a history of hepatic encephalopathy, though none of them was symptomatic at study time. All patients with a known history and/or presence of co-morbidities were excluded. Chronic dyspnea was rated according to the modified medical research council (mMRC) 6-point scale. Liver disease severity was assessed according to the Model for end-stage liver disease (MELD). Routine lung function tests, maximum static expiratory (Pemax) and inspiratory (Pimax) mouth pressures were measured. Respiratory muscle strength (RMS) was calculated from Pimax and Pemax values. In addition, arterial blood gases and pattern of breathing (V(E): minute ventilation; V(T): tidal volume; V(T)/T(I): mean inspiratory flow; T(I): duration of inspiration) were measured. RESULTS: Thirty-five (88%) of 40 patients aged (mean ± SD) 52 ± 10 years reported various degrees of chronic dyspnea (mMRC), ranging from 0 to 4, with a mean value of 2.0 ± 1.2. MELD score was 14 ± 6. Pemax, percent of predicted (%pred) was 105 ± 35, Pimax, %pred was 90 ± 29, and RMS, %pred was 97 ± 30. These pressures were below the normal limits in 12 (30%), 15 (38%), and 14 (35%) patients, respectively. Furthermore, comparing the subgroups of ascites to non-ascites patients, all respiratory muscle indices measured were found significantly decreased in ascites patients. Patients with ascites also had a significantly worse MELD score compared to non-ascites ones (P = 0.006). Significant correlations were found between chronic dyspnea and respiratory muscle function indices in all patients. Specifically, mMRC score was significantly correlated with Pemax, Pimax, and RMS (r = -0.53, P < 0.001; r = -0.42, P < 0.01; r = -0.51, P < 0.001, respectively). These correlations were substantially closer in the non-ascites subgroup (r = -0.82, P < 0.0001; r = -0.61, P < 0.01; r = -0.79, P < 0.0001, respectively) compared to all patients. Similar results were found for the relationship between mMRC vs MELD score, and MELD score vs respiratory muscle strength indices. In all patients the sole predictor of mMRC score was RMS (r = -0.51, P < 0.001). In the subgroup of patients without ascites this relationship becomes closer (r = -0.79, P < 0.001), whilst this relationship breaks down in the subgroup of patients with ascites. The disappearance of such a correlation may be due to the fact that ascites acts as a “confounding” factor. PaCO(2) (4.4 ± 0.5 kPa) was increased, whereas pH (7.49 ± 0.04) was decreased in 26 (65%) and 34 (85%) patients, respectively. PaO(2) (12.3 ± 0.04 kPa) was within normal limits. V(E) (11.5 ± 3.5 L/min), V(T) (0.735 ± 0.287 L), and V(T)/T(I) (0.449±0.129 L/s) were increased signifying hyperventilation in both subgroups of patients. V(T)/T(I) was significantly higher in patients with ascites than without ascites. Significant correlations, albeit weak, were found for PaCO(2) with V(E) and V(T)/T(I) (r = -0.44, P < 0.01; r = -0.41, P < 0.01, respectively). CONCLUSION: The prevalence of chronic dyspnea is 88% in end-stage liver disease. The mMRC score closely correlates with respiratory muscle strength