Rewarming of healthy volunteers after induced mild hypothermia: a healthy volunteer study

OBJECTIVES

The study compares the efficacy of two active and one passive warming interventions in healthy volunteers with induced mild hypothermia.

METHODS

Eight volunteers were studied in a random order crossover design. Each volunteer was studied during re-warming from a core temperature of 35 degrees C with each of: a radiant warmer (Fisher & Paykel); a forced air warmer (Augustine Medical), and a polyester filled blanket, to re-warm.

RESULTS

No significant differences in re-warming rates were observed between the three warming devices. It was found that the subject's endogenous heat production was the major contributor to the re-warming of these volunteers. Metabolic rates of over 350 W were seen during the study.

CONCLUSIONS

For patients with mild hypothermia and in whom shivering is not contraindicated our data would indicate that the rate of re-warming would be little different whether a blanket or one of the two active devices were used. In the field, this may provide the caregiver a useful choice.

Potential clinical implications of direction of a trans-sphincteric anal fistula track

Background

The longitudinal direction of a trans-sphincteric anal fistula track through the anal sphincter complex may have implications regarding fistulotomy.

Methods

The angle of the track of trans-sphincteric fistulas relative to the longitudinal axis of the anal canal was measured before operation by means of magnetic resonance imaging (MRI) in 46 patients. This was compared with the findings at operation.

Results

The track passed cranially as well as laterally at an acute angle (less than 90°) in 23 patients while it passed either transversely or caudally at an obtuse angle (90° or more) in the remaining 23. The internal opening was significantly higher in relation to the dentate line (above in eight patients, at the dentate line in 14 and below in one patient) when the track was acute than when it was obtuse (above in one, at the dentate line in 17 and below in five patients) (P = 0·004). The fistula track crossed the sphincter at a median angle of 35°, 95° and 132° from internal openings sited above, at and below dentate line level respectively (P = 0·002).

Conclusion

Fistula tracks passed cranially and laterally through the sphincter complex in half of these patients, and were most acutely angled on MRI when internal openings were situated above the dentate line. Preoperative MRI might alert surgeons to the potential hazard of fistulotomy being more extensive than anticipated from simple palpation of the level of the internal opening.

Magnetic resonance imaging for primary fistula in ano

BACKGROUND

This was a prospective study designed to determine the therapeutic impact of magnetic resonance imaging (MRI) in primary fistula in ano, and to assess its effect on outcome.

METHODS

Thirty patients with suspected primary fistula in ano underwent preoperative MRI, and the findings were revealed during surgery following examination under anaesthesia (EUA). Any effect on operative approach was noted. Outcome was assessed at a median of 12 months.

RESULTS

Two patients had sinuses, one had no sepsis and 27 had fistulas: five superficial, seven intersphincteric, 14 trans-sphincteric and one suprasphincteric. MRI and EUA agreed in 15 patients and MRI findings altered the surgical approach in a further three (10 per cent); two of the latter patients were believed to have a sinus at EUA, which MRI correctly identified as a fistula, allowing definitive treatment. The therapeutic impact of MRI was therefore 10 per cent. Persisting disagreement between MRI and EUA in 12 patients mostly related to minor discrepancies in classification. Only one patient required further unplanned surgery, which was for skin-bridging rather than any new sepsis.

CONCLUSION

In experienced hands, MRI has a therapeutic impact of 10 per cent for primary fistula in ano, precipitating surgery that is likely to reduce recurrence in a small, but important, proportion of patients.

The clinical course of fistulating Crohn's disease

AIM

To determine the clinical characteristics, management and outcome of Crohn's fistulas from the time of first presentation.

METHODS

Patients treated for fistulas 6 years previously were assessed for disease demographics, fistula characteristics and treatment from first presentation to final follow-up.

RESULTS

Eighty-seven patients with active Crohn's fistulas were evaluated. The median age was 35 years and the median duration of Crohn's disease was 8 years at study entry. Disease was ileo-colonic or colonic in 85%, and 65% had rectal involvement. A single fistula was present in one-third and multiple fistulas in two-thirds; 65% of fistulas were perianal; 80% of fistulas were complex. After a median follow-up from the last treatment of 5.9 years, 68% of patients showed healing of all fistulas, 18% showed healing of some fistulas and 14% showed no healing of fistulas. The fistula site did not influence healing. Perianal and recto-vaginal fistulas took a median of 2.6 years to heal. Half of the complex fistulas required a stoma, resection or proctectomy.

CONCLUSIONS

Healing is usually achieved. However, morbidity is great and healing is slow. Proctectomy is required in one-fifth of patients, and perineal healing is often slow. Defining the perianal fistula anatomy as complex or simple determines the likelihood of healing and the type of surgical approach required.

The clinical course of fistulating Crohn's disease

AIM

To determine the clinical characteristics, management and outcome of Crohn's fistulas from the time of first presentation.

METHODS

Patients treated for fistulas 6 years previously were assessed for disease demographics, fistula characteristics and treatment from first presentation to final follow-up.

RESULTS

Eighty-seven patients with active Crohn's fistulas were evaluated. The median age was 35 years and the median duration of Crohn's disease was 8 years at study entry. Disease was ileo-colonic or colonic in 85%, and 65% had rectal involvement. A single fistula was present in one-third and multiple fistulas in two-thirds; 65% of fistulas were perianal; 80% of fistulas were complex. After a median follow-up from the last treatment of 5.9 years, 68% of patients showed healing of all fistulas, 18% showed healing of some fistulas and 14% showed no healing of fistulas. The fistula site did not influence healing. Perianal and recto-vaginal fistulas took a median of 2.6 years to heal. Half of the complex fistulas required a stoma, resection or proctectomy.

CONCLUSIONS

Healing is usually achieved. However, morbidity is great and healing is slow. Proctectomy is required in one-fifth of patients, and perineal healing is often slow. Defining the perianal fistula anatomy as complex or simple determines the likelihood of healing and the type of surgical approach required.

Response of fistulating Crohn's disease to infliximab treatment assessed by magnetic resonance imaging

AIMS

To assess fistula track healing after infliximab treatment using magnetic resonance imaging.

METHODS

Magnetic resonance imaging and clinical evaluation were performed before and after three infliximab infusions given over a 6-week period. Magnetic resonance images were evaluated for abscesses and fistula tracks. Paired magnetic resonance image examinations were rated 'better', 'unchanged' or 'worse'. Magnetic resonance imaging and clinical outcomes were then compared.

RESULTS

Of the 12 referred patients, pre-treatment magnetic resonance imaging detected abscesses in three (two not treated). Of the 10 treated patients, seven had peri-anal fistulas, two of whom also had recto-vaginal fistulas, and three had abdominal wall entero-cutaneous fistulas. After infliximab, four were in remission, one had a response and five were non-responders. One developed a peri-anal abscess. Magnetic resonance imaging improved in six, was unchanged in two and was worse in two. In four of the six with improvement in magnetic resonance imaging, the fistula track resolved, but two of these had clinically persistent entero-cutaneous fistulas. The clinical outcome and magnetic resonance imaging correlated in seven of the 10 patients; in three (two entero-cutaneous and one peri-anal), there was discordance.

CONCLUSIONS

Magnetic resonance imaging identifies clinically silent sepsis. Fistulas may persist despite clinical remission. Clinical response to infliximab and clinical correlation with magnetic resonance imaging were poor in patients with abdominal entero-cutaneous fistulas.

Home-based study of anti-HIV drug regimen adherence among HIV-infected women: feasibility and preliminary results

Collection of antiretroviral medication adherence data in the homes of HIV-infected people may have methodological advantages that can improve data quality. However, the feasibility of this approach has not been established. In addition, data on adherence, and its predictors, among HIV-infected women have been limited. Sixty-three HIV-positive women who were prescribed at least one antiretroviral drug in the last month were interviewed in their homes. A standard instrument was used to collect data on all antiretroviral medications prescribed and taken in the three days prior to the interview. Data were also collected on factors thought potentially to affect the ability to be adherent. The results of this study suggest that it is feasible to conduct home-based adherence research. Sixty-seven per cent reported taking all prescribed antiretroviral medication doses. One-third took a sub-optimal dose putting themselves at increased risk of treatment failure and the selection of resistant HIV strains. Unintentional reasons for missing doses were most commonly reported. An ability to describe the intended effect of antiretroviral therapy on HIV viral load was the best predictor of adherence. This finding is consistent with other research suggesting that adherence is associated with an understanding and belief in the effectiveness of antiretroviral therapy.

Alteration of anal sphincter morphology following vaginal delivery revealed by multiplanar anal endosonography

OBJECTIVE

To assess morphologic change in the anal sphincters in the absence of endosonographic evidence of trauma after vaginal delivery.

DESIGN

Prospective observational study.

SETTING

District general hospital.

POPULATION

Consecutively booked nulliparous pregnant women attending antenatal clinic.

METHODS

All women were examined using three-dimensional anal endosonography, simple manometry and had questionnaire assessment of incontinence before and after delivery.

MAIN OUTCOME MEASURES

Components of the anal canal were measured in the axial, sagittal and coronal planes and paired pre- and post-delivery examinations were compared. Any changes were related to changes in continence and anal canal manometry.

RESULTS

Twenty-two women had a vaginal delivery and no endosonographic evidence of perineal trauma after delivery. After delivery, there was significant shortening of the length of the anterior external anal sphincter [EAS] (mean 21.7 vs 20.5 mm, P = 0.02) when measured in the sagittal plane, which increased in anterior angulation with respect to the axis of the anal canal (10 degrees vs 13.8 degrees, P = 0.03). In the axial plane, no change was seen in the thickness of any of the sphincter components after delivery. None of these morphologic changes correlated with changes in manometry or continence score.

CONCLUSIONS

Anal sphincter morphology changes after an otherwise atraumatic vaginal delivery. This change does not correlate with any functional symptoms.

Assessment of third degree tears using three-dimensional anal endosonography with combined anal manometry: a novel technique

Three-dimensional anal endosonography has enabled sagittal and coronal reconstructions of the anal canal to be matched with longitudinal pressure data, to present a combined picture of structure and function. This novel technique has been applied to a group of women with a clinical diagnosis of a third degree tear. Endosonography showed that only 68% of women had ultrasound evidence of sphincter damage. Anal canal anatomy and pressure profile did not differ significantly between those with and those without sphincter damage, but the anterior external anal sphincter and the puborectalis tended to be shorter and the pressures were lower in those with sphincter disruption.

Endoanal ultrasound

This pictorial review demonstrates the normal anatomy and abnormalities that are readily demonstrated with endoanal ultrasound of the anal sphincters.

Endosonographic anatomy of the normal anal canal compared with endocoil magnetic resonance imaging

PURPOSE

This study was designed to clarify the sonographic anatomy of the normal anal canal by comparison with endoanal magnetic resonance imaging, to determine agreement between these imaging modalities and interobserver error in measuring layer thickness.

METHODS

Three-dimensional endosonographic and endocoil magnetic resonance images of the anal canal were obtained in four males and five nulliparous females aged 22 to 34 years. Images were analyzed at similar levels throughout the canal using a graphics-overlay technique to compare sonographic with magnetic resonance images. Measurements were taken at one level for agreement analysis between modalities and for interobserver variability in the measurement of the thickness of the main anal canal layers.

RESULTS

The muscularis submucosae ani, muscle bundles in the longitudinal muscle layer, and puboanalis were identified on sonography. The outer border of the external sphincter was demarcated by an interface reflection with ischioanal fat. Clarification of the external sphincter anatomy allowed excellent correlation (Ri = 0.96) for the assessment of thickness. There was excellent correlation for the interobserver measurement of the external and internal sphincters and the submucosal width on endosonography, but there was poor correlation for the longitudinal muscle (0.12).

CONCLUSION

The overlay technique has improved endosonographic interpretation, and measurement of external sphincter thickness has been validated both by comparison with magnetic resonance and on interobserver agreement.

HIV in China

A team of American nurse and physician educators collaborated with the Nursing Department of the Hunan Medical University, Changsha, Hunan Province, People's Republic of China, to develop a "train-the-trainer" program for Chinese nurses. The program included didactic and experiential learning activities intended to increase Chinese nurses' level of comfort when discussing culturally sensitive issues such as sexual behavior and drug use. The program emphasized collaborative development of educational materials that reflected the local cultural content. Chinese nurses responded enthusiastically but remained uncomfortable with sexual information after an initial workshop. Follow-up training programs are essential. Successful HIV/AIDS education requires teachers and students to examine personal and cultural values to address the affective learning domain.

Evaluation of two self-care treatments for prevention of vaginal candidiasis in women with HIV

Vaginal candidiasis (VC) is a common concern for women living with HIV infection. The authors evaluated the effectiveness of two self-care approaches to prophylaxis of VC among HIV-infected women, weekly intravaginal application of Lactobacillus acidophilus or weekly intravaginal application of clotrimazole tablets, in a randomized, double-blind, placebo-controlled trial. VC was defined as a vaginal swab positive for Candida species in the presence of signs/symptoms of vaginitis and the absence of a diagnosis of Trichomonas vaginalis or bacterial vaginosis. Thirty-four episodes of VC occurred among 164 women followed for a median of 21 months. The relative risk of experiencing an episode of VC was 0.4 (95% CI = 0.2, 0.9) in the clotrimazole arm and 0.5 (95% CI = 0.2, 1.1) in the Lactobacillus acidophilus arm. The estimated median time to first episode VC was longer for clotrimazole (p = .03, log rank test) and Lactobacillus acidophilus (p = .09, log rank test) compared with placebo. Vaginal yeast infections can be prevented with local therapy. Education about self-care for prophylaxis of VC should be offered to HIV-infected women.

Assessment of external anal sphincter morphology in idiopathic fecal incontinence with endocoil magnetic resonance imaging

The failure of external anal sphincter repair may relate to sphincter atrophy where muscle fibers are replaced by fat, seen on MRI due to the differing signals returned by fat and muscle tissue. Manometry, electrophysiology, and MRI with an endocoil were performed on 34 fecally incontinent patients with intact sphincters on endosonography. The area of the external sphincter was measured in the midcoronal plane, and the percentage fat content calculated. Sphincter muscle area correlated strongly with squeeze pressure (P < 0.001) but not with percentage fat content. There was no relationship between percentage fat and age, weight, anal sensation, squeeze pressure, sphincter length or width, or pudendal nerve terminal motor latency. There was a trend for smaller sphincters to contain a higher percentage fat content (P = 0.059). MRI has established a relationship between function and external sphincter bulk, but not fat content, although smaller muscles may contain more fat.

Endocoil magnetic resonance imaging quantification of external anal sphincter atrophy

BACKGROUND

Anal function depends on the integrity and quality of the sphincter muscles. The diagnosis of external anal sphincter atrophy on endocoil magnetic resonography has been associated with poor outcome from sphincter repair, although the imaging criteria for atrophy remain unclear.

METHODS

Women with intact sphincters on endosonography and either normal (more than 60 cm H(2)O) (n = 9) or low (n = 16) squeeze pressures had endocoil magnetic resonography and electromyography. The area and fat content of the external anal sphincter and puborectalis were measured on mid-coronal magnetic resonography and images were graded as showing normal, intermediate or advanced atrophy. The definition of the external anal sphincter on endosonography and the thickness of the internal anal sphincter were also assessed.

RESULTS

Women with a normal anal squeeze pressure had a larger external anal sphincter cross-sectional area (mean(s.d.) 240(56) versus 193(62) mm(2); P = 0.01) with a lower mean fat content (mean(s.d.) 23(4) versus 30(6) per cent; P < 0.001) than those with low squeeze pressures. There was an overall correlation between squeeze pressure, cross-sectional area (r = 0.32, P = 0.02) and fat content (r = - 0.51, P < 0.001). Patients with a thin (less than 2 mm) internal anal sphincter and/or a poorly defined external sphincter on endosonography were more likely to have atrophy (positive predictive value 74 per cent).

CONCLUSION

: Potential endosonographic markers for external anal sphincter atrophy are suggested, and a visual scale for endocoil magnetic resonographic assessment has been validated.

Anal sphincter damage after vaginal delivery using three-dimensional endosonography

OBJECTIVE

To determine the incidence and functional consequences of external sphincter trauma compared with other perineal structures using a novel imaging technique, three-dimensional endosonography.

METHODS

Fifty-five nulliparous women (mean age 30 years, range 18--47 years) had three-dimensional anal endosonography, anal manometry, and questionnaire assessment of continence at a median gestation of 33 weeks (23--42 weeks) and 10 weeks (7--22 weeks) after delivery.

RESULTS

There was ultrasound evidence of postpartum trauma in 13 of 45 women who had a vaginal delivery (29%, confidence interval [CI] 16%, 44%), involving the external sphincter in five (11%, CI 4%, 24%), the puboanalis in nine (20%, CI 10%, 35%), and the transverse perineii in three (7%, CI 1%, 18%). In four, more than one structure was damaged. External sphincter trauma was associated with a significant decrease in squeeze pressure (P =.035) and an increase in incontinence score (P =.02) compared with those without trauma. Tears to the puboanalis or transverse perineii only did not affect pressure or incontinence scores. Coronal imaging of the external anal sphincter was a useful adjunct to the assessment of trauma.

CONCLUSION

The overall incidence of trauma to the sphincter complex was similar to that of previous reports, although actual damage to the external sphincter was less common and represented the only functionally significant component.

Multiplanar anal endosonography--normal anal canal anatomy

INTRODUCTION

Volume acquisition during anal ultrasound enables multiplanar imaging of the anal canal. The normal ultrasonic multiplanar appearance of the anal canal is described and gender differences in canal anatomy are highlighted.

METHODS

Ten male and 12 female normal volunteers (mean ages 31.5 years (s.d. 5.9) and 31.2 (s.d. 6.7)) had three-dimensional anal endosonography (3-D AES). Each volume dataset was seeded in the axial plane facilitating multiplanar identification of known anatomical structures.

RESULTS

The anterior external anal sphincter (EAS) was significantly longer in men than women 30.1 mm (3.9) vs 16.9 mm (7.4) (P < 0.001). There was no difference in the length of the puborectalis 24.7 mm (6.4) vs 24 mm (5) (P=0.78) in men compared with women. The cranial extent of the anterior EAS was tilted forward in both sexes. The angle formed by the anterior EAS and the longitudinal axis of the anal canal was more acute in men than in women (11.1 degrees vs 18.6 degrees; P=0.007). Dataset volume seeding of familiar structures in the axial plane allowed the multiplanar endosonographic anatomy to be described.

CONCLUSIONS

Multiplanar AES has enabled detailed longitudinal measurement of the components of the anal canal and has revealed important gender differences. The multiplanar ultrasonic appearance of the normal anal canal has been described for the first time.

Dantrolene reduces serum TNFalpha and corticosterone levels and muscle calcium, calpain gene expression, and protein breakdown in septic rats

The effects of dantrolene on serum TNFalpha and corticosterone levels and on muscle calcium, calpain gene expression, and protein breakdown were studied in rats with abdominal sepsis induced by cecal ligation and puncture. Treatment of rats with 10 mg/kg of dantrolene 2 h before and 8 h after induction of sepsis reduced serum TNFalpha and corticosterone, muscle calcium levels, mRNA levels for m- and mu-calpain, and the muscle specific calpain p94, as well as total and myofibrillar protein breakdown rates, determined as release of tyrosine and 3-methylhistidine, respectively, from incubated extensor digitorum longus muscles. The results support the concept that increased calcium concentrations may be an important mechanism of sepsis-induced muscle protein breakdown. The data also indicate that other mechanisms, in addition to reduced muscle calcium concentrations such as decreased levels of TNFalpha and glucocorticoids, may contribute to the anti-catabolic effects of dantrolene during sepsis. The observations are important from a clinical standpoint because they suggest that the catabolic response in skeletal muscle during sepsis may be prevented by treatment with a calcium antagonist.

Prospective assessment of interobserver agreement for endoanal MRI in fecal incontinence

BACKGROUND

Endoanal magnetic resonance (MR) imaging is a new technique for the assessment of anal sphincter integrity in fecal incontinence and an alternative to anal endosonography. The present study aimed to determine interobserver variation for assessment of anal sphincter integrity using endoanal MR imaging.

METHODS

Fifty-two consecutive anally incontinent patients underwent MR imaging by using a purpose-built endoanal receiver coil and static 1.0-T magnet. T2-weighted axial, coronal, and sagittal scans were independently assessed by two radiologists who noted external and internal sphincter integrity. Findings were compared and agreement was assessed with the kappa statistic.

RESULTS

There was disagreement in 18 of 49 technically adequate studies (37%; kappa = 0.46), indicating "moderate" agreement. Agreement was strongest if the sphincters were either both intact or both disrupted. Observers agreed in only one diagnosis of an isolated internal sphincter defect and in no diagnosis of an isolated external sphincter defect.

CONCLUSION

The overall interobserver agreement for assessment of sphincter integrity using endoanal MR imaging is "moderate." Interobserver agreement using endoanal MR imaging is less than that reported for anal endosonography.

Gender differences in the longitudinal pressure profile of the anal canal related to anatomical structure as demonstrated on three-dimensional anal endosonography

BACKGROUND

Anal canal squeeze pressure is assumed to be due to external sphincter contraction, but the contribution of other muscles has not been explored.

METHODS

Ten male and ten nulliparous female asymptomatic subjects had three-dimensional anal endosonography and manometry. Incremental squeeze pressures at 0. 5-cm intervals, expressed as a percentage of the maximum pressure recorded anywhere in the canal, were related to the following anatomical levels: puborectalis, overlap between external anal sphincter (EAS) and puborectalis, external and internal anal sphincters, and external anal sphincter only. Levels were determined by coronal and sagittal endosonographic reconstructions.

RESULTS

Puborectalis was the same length in men and women (median 23.9 versus 27.1 mm) but represented a greater proportion of the anal canal in women (45 versus 61 per cent; P = 0.02). At the level of puborectalis alone, the pressure generated as a proportion of maximum anal canal pressure was 71 (range 32-100) per cent in men and 62 (range 32-100) per cent in women. At the level of the EAS alone, the pressure was 60 (4-98) per cent in men and 82 (41-100) per cent in women; where the external sphincter was overlapped by puborectalis, the pressure was 98 (60-100) per cent in men and 75 (47-100) per cent in women.

CONCLUSION

Maximal anal canal squeeze pressure is found where the puborectalis overlaps the EAS. This segment represents a significant proportion of anal canal length in women.

Prospective assessment of accuracy of endoanal MR imaging and endosonography in patients with fecal incontinence

OBJECTIVE

Endoanal MR imaging was prospectively compared with anal endosonography to determine any superiority in the characterization of sphincter morphology in fecal incontinence.

SUBJECTS AND METHODS

Fifty-two consecutive patients with fecal incontinence were examined with anal endosonography and endoanal MR imaging after a detailed bowel history, clinical examination, and complete anorectal physiologic testing. External and internal anal sphincter integrity was noted on both endosonograms and MR images by two radiologists in consensus, who read individual scans in a random order to avoid recall bias. Imaging findings were subsequently compared, and arbitration of any disagreement between endosonography and MR imaging was made in consensus by a surgeon and a gastroenterologist who also had access to the patient's history, clinical examination, and anorectal physiologic testing results.

RESULTS

Complete agreement was found between anal endosonographic and MR imaging interpretations in 32 patients (62%): 10 with combined external and internal sphincter injuries, two with isolated internal sphincter injury, and 20 with intact sphincters. Of 20 patients in whom results of the scans were disparate, incorrect interpretation was found on endosonography in six patients, on MR imaging in 15. Overall, one error relating to the internal sphincter was made on endosonography versus 12 on MR imaging (p = 0.002), and five errors relating to the external sphincter were made on endosonography versus six on MR imaging (p = 1.0).

CONCLUSION

This study suggests that endoanal sonography and endoanal MR imaging are equivalent in diagnosing external anal sphincter injury, but MR imaging is inferior in diagnosing internal anal sphincter injury.

Sepsis stimulates release of myofilaments in skeletal muscle by a calcium-dependent mechanism

Sepsis is associated with a pronounced catabolic response in skeletal muscle, mainly reflecting degradation of the myofibrillar proteins actin and myosin. Recent studies suggest that sepsis-induced muscle proteolysis may reflect ubiquitin-proteasome-dependent protein breakdown. An apparently conflicting observation is that the ubiquitin-proteasome pathway does not degrade intact myofibrils. Thus, it is possible that actin and myosin need to be released from the myofibrils before they can be ubiquitinated and degraded by the proteasome. We tested the hypothesis that sepsis results in disruption of Z-bands, increased expression of calpains, and calcium-dependent release of myofilaments in skeletal muscle. Sepsis induced in rats by cecal ligation and puncture resulted in increased gene expression of micro-calpain, m-calpain, and p94 and in Z-band disintegration in the extensor digitorum longus muscle. The release of myofilaments from myofibrillar proteins was increased in septic muscle. This response to sepsis was blocked by treating the rats with dantrolene, a substance that inhibits the release of calcium from intracellular stores to the cytoplasm. The present results provide evidence that sepsis is associated with Z-band disintegration and a calcium-dependent release of myofilaments in skeletal muscle. Release of myofilaments may be an initial and perhaps rate-limiting component of sepsis-induced muscle breakdown.