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Heiderich S, Bastian B, Johannsen S, Klingler W, Rüffert H, Schuster F. [Trigger-free anesthesia : Indications and safe application]. Anaesthesiologie 2023:10.1007/s00101-023-01311-2. [PMID: 37382624 DOI: 10.1007/s00101-023-01311-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 06/07/2023] [Indexed: 06/30/2023]
Abstract
The safe anesthesiological care of patients with neuromuscular diseases poses a particular challenge for anesthetists. Only a small group of muscle diseases and syndromes are associated with an increased risk of malignant hyperthermia and therefore require trigger-free anesthetic procedures avoiding volatile anesthetics and succinylcholine. These diseases are frequently associated with mutations in the RYR1, CACNA1S or STAC-3 genes. In other neuromuscular diseases, anesthetic-induced rhabdomyolysis can occur. Therefore, volatile anesthetics should be avoided in these patients in addition to the contraindication for succinylcholine. In other neuromuscular diseases the risk of a propofol infusion syndrome or myotonic crises can be elevated or the duration of the effect of non-depolarizing muscle relaxants can be changed in an incalculable way. In every case an individual anesthetic aproach including the avoidance of potential pharmacological or non-pharmacological triggers is essential for the safety of the patients.
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Affiliation(s)
- Sebastian Heiderich
- Klinik für Anästhesiologie und Intensivmedizin, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| | - Börge Bastian
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Stephan Johannsen
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Werner Klingler
- Fachabteilung für Anästhesie, Intensivmedizin und Schmerztherapie, SRH Kliniken Landkreis Sigmaringen, Sigmaringen, Deutschland
| | - Henrik Rüffert
- Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Helios Klinikum Schkeuditz, Schkeuditz, Deutschland
| | - Frank Schuster
- Institut für Anästhesiologie, Intensivmedizin und Notfallmedizin, Donau-Isar-Klinikum Deggendorf-Dingolfing-Landau, Deggendorf, Deutschland
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Weber P, Klingler W, Schleip R, Weber N, Joisten C. The Influence of a Single Instrument-Assisted Manual Therapy (IAMT) for the Lower Back on the Structural and Functional Properties of the Dorsal Myofascial Chain in Female Soccer Players: A Randomised, Placebo-Controlled Trial. J Clin Med 2022; 11:jcm11237110. [PMID: 36498690 PMCID: PMC9736370 DOI: 10.3390/jcm11237110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/26/2022] [Accepted: 11/26/2022] [Indexed: 12/05/2022] Open
Abstract
Background: Instrument-assisted manual therapy (IAMT) is indicated to improve flexibility, reduce pain, and induce hyperaemia locally and along myofascial chains. The underlying effects are largely unclear. This randomised, placebo-controlled pilot study aimed to gain first insights into these effects, primarily on the structural level, through ultrasonography. Methods: 67 healthy female soccer players aged 20.9 (±3.9) years were examined after right lumbar intervention (IAMT: intervention group (IG), heat application: comparison group (CG), pressure-less placebo: placebo group (PG)). Ultrasonography (absolute movement and shear motion), flexibility tests (passive straight leg raise test (PSLR), lumbar and thoracic double inclinometry), and superficial skin temperature were recorded before (t0), immediately (t1) and 45 min after the intervention (t2). Results: IAMT decreased the absolute mobility of the superficial lamina and its shear motion to the superficial fascia compared with the PG (t1; p < 0.05). PSLR improved in the IG compared with the CG (t2) and PG (t1, t2; p < 0.05). The temperature increased in the IG and CG compared with the PG (t1, t2) and in the CG compared with the IG (t1; p < 0.05). Conclusion: IAMT of the lumbar back briefly reduces absolute mobility of the superficial lamina and its shear motion to the superficial fascia, improves flexibility, and increases the temperature.
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Affiliation(s)
- Patrick Weber
- Department for Physical Activity in Public Health, Institute of Movement and Neurosciences, German Sport University Cologne, 50933 Cologne, Germany
- PANOVIA Medical Cooperative Society, 50354 Hürth, Germany
- Correspondence:
| | - Werner Klingler
- Anaesthesiology, SRH Hospitals Sigmaringen, 72488 Sigmaringen, Germany
- Experimental Anaesthesiology, Ulm University, 89081 Ulm, Germany
- Clinical Sciences, Queensland University of Technology, Brisbane, QLD 4000, Australia
| | - Robert Schleip
- Conservative and Rehabilitative Orthopaedics, Department of Sport and Health Sciences, Technical University of Munich, 80809 Munich, Germany
- Department for Medical Professions, Diploma University of Applied Sciences, 37242 Bad Sooden-Allendorf, Germany
| | - Nadine Weber
- PANOVIA Medical Cooperative Society, 50354 Hürth, Germany
| | - Christine Joisten
- Department for Physical Activity in Public Health, Institute of Movement and Neurosciences, German Sport University Cologne, 50933 Cologne, Germany
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Stark PC, Kalkbrenner C, Klingler W, Brucher R. Characterization and comparison of a 2-, 4- and 8-MHz central venous catheter ultrasound probe for venous air emboli detection. GMS Health Innov Technol 2022; 16:Doc03. [PMID: 35910412 PMCID: PMC9290754 DOI: 10.3205/hta000135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
This paper presents a concept for detection of venous air emboli inside the superior vena cava using a central venous catheter with integrated Doppler ultrasound transducer installed on the tip. Several Doppler probes each with a single insonation frequencies of 2 MHz, 4 MHz or 8 MHz are characterized and compared for usefulness in this scenario. During in vitro experiments using an artificial blood circulatory with blood mimicking fluid bubbles with defined volumes were injected and recorded as gaseous embolic events. The in vitro results of measured embolus-blood-ratio values (EBR) in respect to the air bubbles volumes and its echogenicity showed a good correlation with the simulation model of spherical cross section scattering of such air bubbles. It is shown that the probe design still needs some improvements using a 4 MHz insonation frequency to get a useable detection sensitivity in such scenario within vena cava superior. The results suggest that it is possible to estimate the air bubble volume corresponding to the EBR using such a catheter probe.
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Affiliation(s)
- Philipp Ch. Stark
- Department of Mechatronics and Medical Engineering, University of Applied Science, Ulm, Germany,*To whom correspondence should be addressed: Philipp Ch. Stark, Department of Mechatronics and Medical Engineering, University of Applied Science, Ulm, Germany, E-mail:
| | - Christoph Kalkbrenner
- Department of Mechatronics and Medical Engineering, University of Applied Science, Ulm, Germany
| | - Werner Klingler
- Anaesthesiology, SRH Kliniken, Sigmaringen, Germany,Ulm University, Experimental Anesthesiology, Ulm, Germany
| | - Rainer Brucher
- Department of Mechatronics and Medical Engineering, University of Applied Science, Ulm, Germany
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Pfenninger EG, Faust JO, Klingler W, Fessel W, Schindler S, Kaisers UX. [Escalation and de-escalation concept for intensive care beds in hospitals reserved for COVID-19]. Anaesthesist 2022; 71:12-20. [PMID: 34104980 PMCID: PMC8186355 DOI: 10.1007/s00101-021-00982-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 04/09/2021] [Accepted: 04/16/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Since the spread of Severe Acute Respiratory Syndrom Corona Virus 2 (SARS-CoV‑2) in Germany, intensive care beds have been kept free for patients suffering from Corona Virus Disease (COVID-19). Also, after the number of infections had declined, intensive care beds were kept free prophylactically; however, the percentage of beds reserved for COVID-19 differ in the individual federal states in Germany. The aim of this article is to define a necessary clearance quota of intensive beds for COVID-19 patients in Germany. An escalation and de-escalation scheme was created for rising and falling numbers of infected patients. METHODS Data from the COVID-19 resource board of the state of Baden-Württemberg, the daily situation report of the Robert Koch Institute (RKI), the register of COVID-19 intensive care beds of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) as well as the daily report of COVID-19 Baden-Württemberg from April to November 2020 were used for the calculation. RESULTS At the end of November 2020 approximately 13.5% of intensive care beds in Germany were used by COVID-19 patients. Of all persons tested positive for SARS-CoV‑2, 1.5% were admitted to an intensive care unit. The hospitalization rate was 6% and the mean age of infected persons was 43 years. Based on these numbers hospitals are recommended to keep 10% of intensive care beds available for COVID-19 patients in the case of less than 35 new infections/100,000 in the catchment area, 20% should be kept free in case of an advanced warning level of 35 new infections/100,000 inhabitants and 30% for a critical limit of 50 new infections/100,000 inhabitants. Further internal hospital triggers, such as the occupancy of the intensive care beds with COVID-19 patients, should be considered. CONCLUSION If the number of infections is low a general nationwide retention rate of more than 10% of intensive care beds for COVID-19 patients is not justified. Locally increasing numbers of infections require a local dynamic approach. If the number of infections increases, the free holding capacity should be increased according to a step by step concept in close coordination with the local health authorities and other internal hospital triggers. In order not to overwhelm hospital capacities in the event of local outbreaks, a corresponding relocation concept should be considered at an early stage.
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Affiliation(s)
- E G Pfenninger
- Stabsstelle Katastrophenschutz, Universitätsklinikum Ulm, Albert-Einstein-Allee 29, 89081, Ulm, Deutschland.
- UAG Notfall, Ministerium für Soziales und Integration Baden-Württemberg, Stuttgart, Deutschland.
| | - J-O Faust
- UAG Notfall, Ministerium für Soziales und Integration Baden-Württemberg, Stuttgart, Deutschland
- Geschäftsführung, SRH Kliniken Landkreis Sigmaringen, Sigmaringen, Deutschland
| | - W Klingler
- Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, SRH Kliniken Sigmaringen, Sigmaringen, Deutschland
| | - W Fessel
- UAG Notfall, Ministerium für Soziales und Integration Baden-Württemberg, Stuttgart, Deutschland
- Ministerium für Soziales und Integration Baden-Württemberg, Stuttgart, Deutschland
| | - S Schindler
- UAG Notfall, Ministerium für Soziales und Integration Baden-Württemberg, Stuttgart, Deutschland
- Ministerium für Soziales und Integration Baden-Württemberg, Stuttgart, Deutschland
| | - U X Kaisers
- Klinikumvorstand, Universitätsklinikum Ulm, Ulm, Deutschland
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Zullo A, Mancini FP, Schleip R, Wearing S, Klingler W. Fibrosis: Sirtuins at the checkpoints of myofibroblast differentiation and profibrotic activity. Wound Repair Regen 2021; 29:650-666. [PMID: 34077595 DOI: 10.1111/wrr.12943] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 05/04/2021] [Accepted: 05/06/2021] [Indexed: 12/11/2022]
Abstract
Fibrotic diseases are still a serious concern for public health, due to their high prevalence, complex etiology and lack of successful treatments. Fibrosis consists of excessive accumulation of extracellular matrix components. As a result, the structure and function of tissues are impaired, thus potentially leading to organ failure and death in several chronic diseases. Myofibroblasts represent the principal cellular mediators of fibrosis, due to their extracellular matrix producing activity, and originate from different types of precursor cells, such as mesenchymal cells, epithelial cells and fibroblasts. Profibrotic activation of myofibroblasts can be triggered by a variety of mechanisms, including the transforming growth factor-β signalling pathway, which is a major factor driving fibrosis. Interestingly, preclinical and clinical studies showed that fibrotic degeneration can stop and even reverse by using specific antifibrotic treatments. Increasing scientific evidence is being accumulated about the role of sirtuins in modulating the molecular pathways responsible for the onset and development of fibrotic diseases. Sirtuins are NAD+ -dependent protein deacetylases that play a crucial role in several molecular pathways within the cells, many of which at the crossroad between health and disease. In this context, we will report the current knowledge supporting the role of sirtuins in the balance between healthy and diseased myofibroblast activity. In particular, we will address the signalling pathways and the molecular targets that trigger the differentiation and profibrotic activation of myofibroblasts and can be modulated by sirtuins.
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Affiliation(s)
- Alberto Zullo
- Department of Sciences and Technologies, Benevento, Italy.,CEINGE Advanced Biotechnologies s.c.a.r.l. Naples, Italy
| | | | - Robert Schleip
- Department of Sport and Health Sciences, Technical University Munich, Germany.,Fascia Research Group, Department of Neurosurgery, Ulm University, Germany.,Diploma University of Applied Sciences, Bad Sooden-Allendorf, Germany
| | - Scott Wearing
- Department of Sport and Health Sciences, Technical University Munich, Germany.,Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Werner Klingler
- Department of Sport and Health Sciences, Technical University Munich, Germany.,Fascia Research Group, Department of Neurosurgery, Ulm University, Germany.,Faculty of Health, Queensland University of Technology, Brisbane, Queensland, Australia.,Department of Anaesthesiology, SRH Hospital Sigmaringen, Germany
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6
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Klingler W. [Electroconvulsive therapy-effective treatment or not?]. Anaesthesist 2021; 70:269-270. [PMID: 33825939 DOI: 10.1007/s00101-021-00925-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Werner Klingler
- Abteilung Anästhesie, SRH Kliniken Landkreis Sigmaringen, Hohenzollernstr. 40, 72488, Sigmaringen, Deutschland.
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Heiderich S, Bastian B, Johannsen S, Klingler W, Rüffert H, Schuster F. [The European Malignant Hyperthermia Group consensus guidelines on perioperative management of malignant hyperthermia suspected or susceptible patients]. Anaesthesist 2020; 70:155-157. [PMID: 33269407 DOI: 10.1007/s00101-020-00893-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Sebastian Heiderich
- Klinik für Anästhesiologie und Intensivmedizin, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30659, Hannover, Deutschland.
| | - Börge Bastian
- Zentrum für Maligne Hyperthermie, Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Stephan Johannsen
- Zentrum für Maligne Hyperthermie, Klinik und Poliklinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Werner Klingler
- Klinik für Anästhesie und Intensivmedizin, SRH Kliniken Landkreis Sigmaringen, Sigmaringen, Deutschland
| | - Henrik Rüffert
- Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, Helios Klinik Schkeuditz, Schkeuditz, Deutschland
| | - Frank Schuster
- Zentrum für Maligne Hyperthermie, Klinik und Poliklinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
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8
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Hoppe K, Sartorius T, Chaiklieng S, Wietzorrek G, Ruth P, Jurkat-Rott K, Wearing S, Lehmann-Horn F, Klingler W. Paxilline Prevents the Onset of Myotonic Stiffness in Pharmacologically Induced Myotonia: A Preclinical Investigation. Front Physiol 2020; 11:533946. [PMID: 33329012 PMCID: PMC7719791 DOI: 10.3389/fphys.2020.533946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 10/12/2020] [Indexed: 11/13/2022] Open
Abstract
Reduced Cl− conductance causes inhibited muscle relaxation after forceful voluntary contraction due to muscle membrane hyperexcitability. This represents the pathomechanism of myotonia congenita. Due to the prevailing data suggesting that an increased potassium level is a main contributor, we studied the effect of a modulator of a big conductance Ca2+- and voltage-activated K+ channels (BK) modulator on contraction and relaxation of slow- and high-twitch muscle specimen before and after the pharmacological induction of myotonia. Human and murine muscle specimens (wild-type and BK−/−) were exposed to anthracene-9-carboxylic acid (9-AC) to inhibit CLC-1 chloride channels and to induce myotonia in-vitro. Functional effects of BK-channel activation and blockade were investigated by exposing slow-twitch (soleus) and fast-twitch (extensor digitorum longus) murine muscle specimens or human musculus vastus lateralis to an activator (NS1608) and a blocker (Paxilline), respectively. Muscle-twitch force and relaxation times (T90/10) were monitored. Compared to wild type, fast-twitch muscle specimen of BK−/− mice resulted in a significantly decreased T90/10 in presence of 9-AC. Paxilline significantly shortened T90/10 of murine slow- and fast-twitch muscles as well as human vastus lateralis muscle. Moreover, twitch force was significantly reduced after application of Paxilline in myotonic muscle. NS1608 had opposite effects to Paxilline and aggravated the onset of myotonic activity by prolongation of T90/10. The currently used standard therapy for myotonia is, in some individuals, not very effective. This in vitro study demonstrated that a BK channel blocker lowers myotonic stiffness and thus highlights its potential therapeutic option in myotonia congenital (MC).
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Affiliation(s)
- Kerstin Hoppe
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Goethe University, Frankfurt University Hospital, Frankfurt, Germany.,Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Wuerzburg University Hospital, Wuerzburg, Germany
| | - Tina Sartorius
- Department of Pharmacology, Toxicology and Clinical Pharmacy, Institute of Pharmacy, University of Tuebingen, Tuebingen, Germany
| | - Sunisa Chaiklieng
- Division of Neurophysiology in the Center of Rare Diseases, Ulm University, Ulm, Germany.,Faculty of Public Health, Khon Kaen University, Muang Khon Kaen, Thailand
| | - Georg Wietzorrek
- Institute for Molecular and Cellular Pharmacology, Innsbruck Medical University, Innsbruck, Austria
| | - Peter Ruth
- Department of Pharmacology, Toxicology and Clinical Pharmacy, Institute of Pharmacy, University of Tuebingen, Tuebingen, Germany
| | - Karin Jurkat-Rott
- Division of Experimental Anesthesiology, University Medical Center Ulm, Ulm, Germany
| | - Scott Wearing
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia.,Department of Conservative and Rehabilitation Orthopedics, Faculty of Sport and Health Science, Technical University of Munich, Munich, Germany
| | - Frank Lehmann-Horn
- Division of Neurophysiology in the Center of Rare Diseases, Ulm University, Ulm, Germany
| | - Werner Klingler
- Division of Neurophysiology in the Center of Rare Diseases, Ulm University, Ulm, Germany.,Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia.,Department of Conservative and Rehabilitation Orthopedics, Faculty of Sport and Health Science, Technical University of Munich, Munich, Germany.,Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, SRH Clinincs, Sigmaringen, Germany
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Bastian B, Heiderich S, Schuster F, Johannsen S, Klingler W, Rüffert H. Kommentar zur Leitlinie der European Malignant Hyperthermia Group zur Verfügbarkeit von Dantrolen für die Behandlung der Malignen Hyperthermie. Anaesthesist 2020; 69:751-752. [DOI: 10.1007/s00101-020-00839-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hoppe K, Chaiklieng S, Lehmann-Horn F, Jurkat-Rott K, Wearing S, Klingler W. Preclinical pharmacological in vitro investigations on low chloride conductance myotonia: effects of potassium regulation. Pflugers Arch 2020; 472:1481-1494. [PMID: 32748018 DOI: 10.1007/s00424-020-02410-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 05/24/2020] [Accepted: 05/26/2020] [Indexed: 12/20/2022]
Abstract
In myotonia, reduced Cl- conductance of the mutated ClC-1 channels causes hindered muscle relaxation after forceful voluntary contraction due to muscle membrane hyperexcitability. Repetitive contraction temporarily decreases myotonia, a phenomena called "warm up." The underlying mechanism for the reduction of hyperexcitability in warm-up is currently unknown. Since potassium displacement is known to reduce excitability in, for example, muscle fatigue, we characterized the role of potassium in native myotonia congenita (MC) muscle. Muscle specimens of ADR mice (an animal model for low gCl- conductance myotonia) were exposed to increasing K+ concentrations. To characterize functional effects of potassium ion current, the muscle of ADR mice was exposed to agonists and antagonists of the big conductance Ca2+-activated K+ channel (BK) and the voltage-gated Kv7 channel. Effects were monitored by functional force and membrane potential measurements. By increasing [K+]0 to 5 mM, the warm-up phenomena started earlier and at [K+]0 7 mM only weak myotonia was detected. The increase of [K+]0 caused a sustained membrane depolarization accompanied with a reduction of myotonic bursts in ADR mice. Retigabine, a Kv7.2-Kv7.5 activator, dose-dependently reduced relaxation deficit of ADR myotonic muscle contraction and promoted the warm-up phenomena. In vitro results of this study suggest that increasing potassium conductivity via activation of voltage-gated potassium channels enhanced the warm-up phenomena, thereby offering a potential therapeutic treatment option for myotonia congenita.
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Affiliation(s)
- Kerstin Hoppe
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany.
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital of Wuerzburg, Oberduerrbacher Str. 6, 97080, Wuerzburg, Germany.
| | - Sunisa Chaiklieng
- Division of Neurophysiology in the Center of Rare Diseases, Ulm University, Albert Einstein Allee 23, 89081, Ulm, Germany
- Faculty of Public Health, Khon Kaen University, Muang Khon Kaen, Thailand
| | - Frank Lehmann-Horn
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital of Wuerzburg, Oberduerrbacher Str. 6, 97080, Wuerzburg, Germany
| | - Karin Jurkat-Rott
- Universtiy Medical Center Ulm, Division of Experimental Anesthesiology, Albert-Einstein-Allee 23, 89081, Ullm, Germany
| | - Scott Wearing
- Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, 4059, Australia
- Department of Conservative and Rehabilitation Orthopedics, Faculty of Sport and Health Science, Technical University of Munich, Gerog-Brauchle-Ring 60/62, Munich, Germany
| | - Werner Klingler
- Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, 4059, Australia
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, SRH Clinincs, Hohenzollernstraße 40, 72488, Sigmaringen, Germany
- Department of Conservative and Rehabilitation Orthopedics, Faculty of Sport and Health Science, Technical University of Munich, Gerog-Brauchle-Ring 60/62, Munich, Germany
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Bartsch KM, Schleip R, Zullo A, Hoppe K, Klingler W. The Stiffness Comparison Test: A pilot study to determine inter-individual differences in palpatory skill related to gender, age, and occupation-related experience. J Bodyw Mov Ther 2020; 24:1-6. [PMID: 33218495 DOI: 10.1016/j.jbmt.2020.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 06/05/2020] [Accepted: 06/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Manual palpation is a core skill in physical examination. Assessing elastic properties such as tissue stiffness has the potential for being an important diagnostics tool in the detection of cancer and other diseases. OBJECTIVE The study describes the newly developed Stiffness Comparison Test (SCT). The aim of our study was to test the SCT as a tool to detect interindividual differences in palpation skill related to gender, age and occupational experience. METHODS We used eight pairs of polyuterhane gel pads with the stiffness difference decreasing from the first to the last pair. Test subjects were asked to palpate each pair and determine stiffness differences. PARTICIPANTS We recruited 25 osteopaths, 48 other manual therapists and 50 participants from other non-manual professions. RESULTS As hypothesized there was no significant difference in SCT performance between the sexes (t(121) = 0.288, p = .774). To investigate if an age-related decline would have an effect on palpation skill, we carried out a linear regression. As hypothesized, the model did not predict any significant associations (F(1, 121) = 2.733, b = -0.149, p = .101, R2 = 0.022). To compare the effect of occupational groups on SCT performance a one-way ANOVA was conducted. There were no statistically significant differences between group means (F(2, 120) = 0.598, p = .552). CONCLUSIONS The SCT can be used as simple and affordable tool for assessment, teaching and training in all disciplines of manual medicine. Further refinements of the tool are suggested to advance its discrimination power.
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Affiliation(s)
- Katja Martina Bartsch
- Verein zur Förderung der Faszienforschung e.V., Munich, Germany; Department of Sport Science and Sports, Friedrich-Alexander University Erlangen-Nürnberg, Germany.
| | - Robert Schleip
- Experimental Anaesthesiology, Ulm University, Ulm, Germany; Department of Sports Medicine and Health Promotion, Friedrich Schiller University Jena, Jena, Germany; Fascia Research Group, Experimental Anesthesiology, Ulm University, Ulm, Germany; Diploma University of Applied Sciences, Bad Sooden-Allendorf, Germany; Conservative and Rehabilitative Orthopedics, Department of Sport and Health Sciences, Technical University of Munich, Germany.
| | - Alberto Zullo
- Department of Sciences and Technologies, University of Sannio, Benevento, Italy.
| | - Kerstin Hoppe
- Department of Anaesthesia, Critical Care Medicine and Pain Therapy, University of Frankfurt, Frankfurt, Germany.
| | - Werner Klingler
- Experimental Anaesthesiology, Ulm University, Ulm, Germany; SRH Hospital, Sigmaringen, Germany; Queensland University of Technology, Brisbane, Australia; Conservative and Rehabilitative Orthopedics, Department of Sport and Health Sciences, Technical University of Munich, Germany.
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Zullo A, Fleckenstein J, Schleip R, Hoppe K, Wearing S, Klingler W. Structural and Functional Changes in the Coupling of Fascial Tissue, Skeletal Muscle, and Nerves During Aging. Front Physiol 2020; 11:592. [PMID: 32670080 PMCID: PMC7327116 DOI: 10.3389/fphys.2020.00592] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/11/2020] [Indexed: 12/18/2022] Open
Abstract
Aging is a one-way process associated with profound structural and functional changes in the organism. Indeed, the neuromuscular system undergoes a wide remodeling, which involves muscles, fascia, and the central and peripheral nervous systems. As a result, intrinsic features of tissues, as well as their functional and structural coupling, are affected and a decline in overall physical performance occurs. Evidence from the scientific literature demonstrates that senescence is associated with increased stiffness and reduced elasticity of fascia, as well as loss of skeletal muscle mass, strength, and regenerative potential. The interaction between muscular and fascial structures is also weakened. As for the nervous system, aging leads to motor cortex atrophy, reduced motor cortical excitability, and plasticity, thus leading to accumulation of denervated muscle fibers. As a result, the magnitude of force generated by the neuromuscular apparatus, its transmission along the myofascial chain, joint mobility, and movement coordination are impaired. In this review, we summarize the evidence about the deleterious effect of aging on skeletal muscle, fascial tissue, and the nervous system. In particular, we address the structural and functional changes occurring within and between these tissues and discuss the effect of inflammation in aging. From the clinical perspective, this article outlines promising approaches for analyzing the composition and the viscoelastic properties of skeletal muscle, such as ultrasonography and elastography, which could be applied for a better understanding of musculoskeletal modifications occurring with aging. Moreover, we describe the use of tissue manipulation techniques, such as massage, traction, mobilization as well as acupuncture, dry needling, and nerve block, to enhance fascial repair.
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Affiliation(s)
- Alberto Zullo
- Department of Sciences and Technologies, University of Sannio, Benevento, Italy
- CEINGE Advanced Biotechnologies, Naples, Italy
| | - Johannes Fleckenstein
- Department of Sports Medicine, Institute of Sports Sciences, Goethe-University Frankfurt, Frankfurt, Germany
| | - Robert Schleip
- Department of Sport and Health Sciences, Technical University Munich, Munich, Germany
- Department of Sports Medicine and Health Promotion, Friedrich-Schiller University Jena, Jena, Germany
| | - Kerstin Hoppe
- Department of Anaesthesiology, Würzburg University, Würzburg, Germany
| | - Scott Wearing
- Department of Sport and Health Sciences, Technical University Munich, Munich, Germany
- Faculty of Health School, Queensland University of Technology, Brisbane, QLD, Australia
| | - Werner Klingler
- Department of Sport and Health Sciences, Technical University Munich, Munich, Germany
- Faculty of Health School, Queensland University of Technology, Brisbane, QLD, Australia
- Fascia Research Group, Department of Experimental Anaesthesiology, Ulm University, Ulm, Germany
- Department of Anaesthesiology, SRH Hospital Sigmaringen, Sigmaringen, Germany
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Pfenninger EG, Klingler W, Keiloweit T, Eble M, Wenzel V, Krüger WA. [Terrorist attack training exercise-What can be learned? : Baden-Württemberg counterterrorism exercise (BWTEX)]. Anaesthesist 2020; 69:477-486. [PMID: 32488534 DOI: 10.1007/s00101-020-00797-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND There is a risk of terror attacks in the Federal Republic of Germany, which might increase in the future. A timely comprehensive strategy for treatment and care of a large number of casualties helps minimize chaos and improve the outcome of patients. Adequate training is vital for successful implementation of an emergency plan. Therefore, the effectiveness of training should be assessed and evaluated; however, data collection capabilities for training events are extremely limited, so that publications on the topic are almost impossible to find. OBJECTIVE This study aimed to collect data from a simulated terrorist attack in order to draw conclusions from a clinical point of view concerning the improvement of preclinical and clinical management, taking interface problems into consideration. MATERIAL AND METHODS On 19 October 2019 the Ministry of the Interior, Digitalization and Migration of Baden-Württemberg conducted a large-scale simulation of a terrorist attack in the city center of Constance, called the Baden-Württemberg counterterrorism exercise (BWTEX). The simulation included an explosion of a car bomb as well as the use of firearms by terrorists. The large scale of the simulation with the high number of participants in combination with close cooperation between military and civil forces was unprecedented. The police force, the armed forces, civil protection forces, air rescue teams and staff from Constance, Friedrichshafen and Sigmaringen regional hospitals in southwest Germany worked together to treat simulated injuries to victims of the attack. The following parameters were recorded when the injured patients arrived at the hospital: prehospital triage time, prehospital triage score, initial treatment and quality of documentation on site as well as triage time, triage score, injury severity scale (ISS) score based on the specified injury pattern, treatment, and quality of documentation on hospital arrival. RESULTS Out of a total of 84 "injured patients" 55 were admitted to hospital and 80% were triaged at the scene. Injured patients of triage category 1 (TK1 red: life-threatening injury, immediate treatment) arrived at the hospital 198 ± 50 min after the attack, injured patients of triage category 2 (TK2 yellow: severely injured, urgent treatment) after 131 ± 44 min and injured patients of triage category 3 (TK3 green: slightly injured, non-urgent treatment) arrived after 157 ± 46 min. There was no significant difference in terms of arrival time at the hospital between the triage scores (r = 0.2) or between the ISS scores (r = 0.43). The authors assume that approximately 44% of TK1 patients would have died due to avoidable time delays. Prehospital medical documentation was insufficient in 78% and insufficient in 65% in the hospitals. CONCLUSION A mass casualty incident resulting from a terrorist attack differs greatly from a conventional mass casualty incident. The scene of the attack has to be evacuated as quickly as possible, which means that a large number of patients arrive untreated at the nearest hospitals. The setting up of treatment facilities in city centers and areas close to the city seems to be counterproductive because the time delay may result in higher mortality rates of victims. The particularities of mass casualties caused by a terrorist attack have to be incorporated into terrorist attack training.
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Affiliation(s)
- E G Pfenninger
- Stabsstelle Katastrophenschutz, Universitätsklinikum Ulm, Albert-Einstein-Allee 29, 89081, Ulm, Deutschland. .,Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, SRH Kliniken Sigmaringen, Sigmaringen, Deutschland.
| | - W Klingler
- Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, SRH Kliniken Sigmaringen, Sigmaringen, Deutschland
| | - Th Keiloweit
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Konstanz, Konstanz, Deutschland
| | - M Eble
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Medizin Campus Bodensee, Klinikum Friedrichshafen, Friedrichshafen, Deutschland
| | - V Wenzel
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Medizin Campus Bodensee, Klinikum Friedrichshafen, Friedrichshafen, Deutschland
| | - W A Krüger
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Klinikum Konstanz, Konstanz, Deutschland
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Weber P, Graf C, Klingler W, Weber N, Schleip R. The feasibility and impact of instrument-assisted manual therapy (IAMT) for the lower back on the structural and functional properties of the lumbar area in female soccer players: a randomised, placebo-controlled pilot study design. Pilot Feasibility Stud 2020; 6:47. [PMID: 32322406 PMCID: PMC7164264 DOI: 10.1186/s40814-020-00592-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 04/02/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Myofascial (self-)treatments, such as foam rollers to therapeutic instruments in manual therapy, are utilized increasingly in prevention and therapy in healthy people, athletes, and patients suffering from chronic back pain. However, there is limited knowledge about the effectiveness of treatment and the underlying mechanisms of myofascial therapies, especially for instrument-assisted manual therapy (IAMT). Therefore, this pilot study will investigate the feasibility and impact of IAMT for the lumbar area compared with heat application and placebo treatment as a basis for calculating the sample size for further full studies. The primary outcomes will be a critical analysis of the feasibility of the measurement protocol in terms of time economy and expressiveness and of the short- and long-term effects on shear motion of the single tissue layers of the lower back obtained through ultrasound imaging. Secondary outcomes will include thickness and compressibility of the lumbar structures and flexibility of the dorsal structures, indentometry, and superficial skin temperature. METHODS A minimum of 60 healthy, competitive 15-35-year-old female soccer players will be recruited and randomised into three groups. Short-term effects of IAMT on thoracolumbar structures will be compared with heat application and pressure-less placebo treatment. Long-term effects in the IAMT group will be tested after nine further interventions over a 5-week period (2×/week) and compared with the placebo group, which will not receive further treatments but will serve as a control. Intermediate and final testing of both groups will occur in weeks three and five. DISCUSSION This pilot study will assess the feasibility and the impact of IAMT for the lower back particularly by examining the structural and functional properties of myofascial tissue using diagnostic ultrasound. These outcomes could evaluate the feasibility of the measurements used, shall build a basis for sample size calculation of further full studies, and might generate a greater understanding of myofascial therapies, especially IAMT, for the lower back and its benefits. If this approach proves to be practicable, next steps will be further full studies with soccer players, other sports, and patients with low back pain. TRIAL REGISTRATION German Clinical Trials Register (DRKS00012252) 20.06.2018; retrospectively registered.
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Affiliation(s)
- Patrick Weber
- Department Movement and Health Promotion, German Sport University Cologne, Cologne, Germany
| | - Christine Graf
- Department Movement and Health Promotion, German Sport University Cologne, Cologne, Germany
| | - Werner Klingler
- Anaesthesiology, SRH Hospitals Sigmaringen, Sigmaringen, Germany
- Experimental Anaesthesiology, Ulm University, Germany, Ulm, Germany
- Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Nadine Weber
- Department Cardiology, Aachen University, Aachen, Germany
| | - Robert Schleip
- Conservative and Rehabilitative Orthopaedics, Department of Sport and Health Sciences, Technical University of Munich, Munich, Germany
- Sports Medicine and Health Promotion, Friedrich-Schiller University Jena, Jena, Germany
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Abstract
The ubiquitous network of fascial tissues in the human body is usually regarded as a passive contributor to musculoskeletal dynamics. This review aims to highlight the current understanding of fascial stiffness regulation. Notably the ability for active cellular contraction which may augment the stiffness of fascial tissues and thereby contribute to musculoskeletal dynamics. A related narrative literature search via PubMed and Google Scholar reveals a multitude of studies indicating that the intrafascial presence of myofibroblasts may enable these tissues to alter their stiffness. This contractile tissue behavior occurs not only in several pathological fibrotic contractures but has also been documented in normal fasciae. When viewed at time frames of seconds and minutes the force of such tissue contractions is not sufficient for exerting a significant effect on mechanical joint stability. However, when viewed in a time-window of several minutes and longer, such cellular contractions can impact motoneuronal coordination. In addition, over a time frame of days to months, this cellular activity can induce long-term and severe tissue contractures. These findings tend to question the common clear distinction between active tissues and passive tissues in musculoskeletal dynamics. Clin. Anat. 32:891-895, 2019. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Robert Schleip
- Department of Neuroanesthesiology, Neurosurgical Clinic, Ulm University, Guenzburg, Germany.,Department of Sports Medicine and Health Promotion, Friedrich Schiller University Jena, Jena, Germany.,Fascia Research Group, Experimental Anesthesiology, Ulm University, Ulm, Germany
| | - Werner Klingler
- Fascia Research Group, Experimental Anesthesiology, Ulm University, Ulm, Germany.,Faculty of Health School - Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
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16
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Schleip R, Gabbiani G, Wilke J, Naylor I, Hinz B, Zorn A, Jäger H, Breul R, Schreiner S, Klingler W. Fascia Is Able to Actively Contract and May Thereby Influence Musculoskeletal Dynamics: A Histochemical and Mechanographic Investigation. Front Physiol 2019; 10:336. [PMID: 31001134 PMCID: PMC6455047 DOI: 10.3389/fphys.2019.00336] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 03/13/2019] [Indexed: 11/19/2022] Open
Abstract
Fascial tissues form a ubiquitous network throughout the whole body, which is usually regarded as a passive contributor to biomechanical behavior. We aimed to answer the question, whether fascia may possess the capacity for cellular contraction which, in turn, could play an active role in musculoskeletal mechanics. Human and rat fascial specimens from different body sites were investigated for the presence of myofibroblasts using immunohistochemical staining for α-smooth muscle actin (n = 31 donors, n = 20 animals). In addition, mechanographic force registrations were performed on isolated rat fascial tissues (n = 8 to n = 18), which had been exposed to pharmacological stimulants. The density of myofibroblasts was increased in the human lumbar fascia in comparison to fasciae from the two other regions examined in this study: fascia lata and plantar fascia [H(2) = 14.0, p < 0.01]. Mechanographic force measurements revealed contractions in response to stimulation by fetal bovine serum, the thromboxane A2 analog U46619, TGF-β1, and mepyramine, while challenge by botulinum toxin type C3–used as a Rho kinase inhibitor– provoked relaxation (p < 0.05). In contrast, fascial tissues were insensitive to angiotensin II and caffeine (p < 0.05). A positive correlation between myofibroblast density and contractile response was found (rs = 0.83, p < 0.001). The hypothetical application of the registered forces to human lumbar tissues predicts a potential impact below the threshold for mechanical spinal stability but strong enough to possibly alter motoneuronal coordination in the lumbar region. It is concluded that tension of myofascial tissue is actively regulated by myofibroblasts with the potential to impact active musculoskeletal dynamics.
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Affiliation(s)
- Robert Schleip
- Department of Neuroanesthesiology, Neurosurgical Clinic, Ulm University, Günzburg, Germany.,Department of Sports Medicine and Health Promotion, Friedrich Schiller University Jena, Jena, Germany.,Fascia Research Group, Experimental Anesthesiology, Ulm University, Ulm, Germany
| | - Giulio Gabbiani
- Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Jan Wilke
- Department of Sports Medicine, Institute of Sport Science, Goethe University Frankfurt, Frankfurt, Germany
| | - Ian Naylor
- School of Pharmacy, University of Bradford, Bradford, United Kingdom
| | - Boris Hinz
- Laboratory of Tissue Repair and Regeneration, Matrix Dynamics Group, University of Toronto, Toronto, ON, Canada
| | - Adjo Zorn
- Fascia Research Group, Experimental Anesthesiology, Ulm University, Ulm, Germany
| | - Heike Jäger
- Division of Neurophysiology, Ulm University, Ulm, Germany
| | - Rainer Breul
- Anatomische Anstalt, Ludwig-Maximilians-Universität, München, Germany
| | | | - Werner Klingler
- Fascia Research Group, Experimental Anesthesiology, Ulm University, Ulm, Germany.,Faculty of Health School - Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
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17
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Hoppe K, Chaiklieng S, Lehmann‐Horn F, Jurkat‐Rott K, Wearing S, Klingler W. Elevation of extracellular osmolarity improves signs of myotonia congenita in vitro: a preclinical animal study. J Physiol 2019; 597:225-235. [PMID: 30284249 PMCID: PMC6312412 DOI: 10.1113/jp276528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 10/01/2018] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS During myotonia congenita, reduced chloride (Cl- ) conductance results in impaired muscle relaxation and increased muscle stiffness after forceful voluntary contraction. Repetitive contraction of myotonic muscle decreases or even abolishes myotonic muscle stiffness, a phenomenon called 'warm up'. Pharmacological inhibition of low Cl- channels by anthracene-9-carboxylic acid in muscle from mice and ADR ('arrested development of righting response') muscle from mice showed a relaxation deficit under physiological conditions compared to wild-type muscle. At increased osmolarity up to 400 mosmol L-1 , the relaxation deficit of myotonic muscle almost reached that of control muscle. These effects were mediated by the cation and anion cotransporter, NKCC1, and anti-myotonic effects of hypertonicity were at least partly antagonized by the application of bumetanide. ABSTRACT Low chloride-conductance myotonia is caused by mutations in the skeletal muscle chloride (Cl- ) channel gene type 1 (CLCN1). Reduced Cl- conductance of the mutated channels results in impaired muscle relaxation and increased muscle stiffness after forceful voluntary contraction. Exercise decreases muscle stiffness, a phenomena called 'warm up'. To gain further insight into the patho-mechanism of impaired muscle stiffness and the warm-up phenomenon, we characterized the effects of increased osmolarity on myotonic function. Functional force and membrane potential measurements were performed on muscle specimens of ADR ('arrested development of righting response') mice (an animal model for low gCl- conductance myotonia) and pharmacologically-induced myotonia. Specimens were exposed to solutions of increasing osmolarity at the same time as force and membrane potentials were monitored. In the second set of experiments, ADR muscle and pharmacologically-induced myotonic muscle were exposed to an antagonist of NKCC1. Upon osmotic stress, ADR muscle was depolarized to a lesser extent than control wild-type muscle. High osmolarity diminished myotonia and facilitated the warm-up phenomenon as depicted by a faster muscle relaxation time (T90/10 ). Osmotic stress primarily resulted in the activation of the NKCC1. The inhibition of NKCC1 with bumetanide prevented the depolarization and reversed the anti-myotonic effect of high osmolarity. Increased osmolarity decreased signs of myotonia and facilitated the warm-up phenomenon in different in vitro models of myotonia. Activation of NKCC1 activity promotes warm-up and reduces the number of contractions required to achieve normal relaxation kinetics.
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Affiliation(s)
- Kerstin Hoppe
- Department of AnaesthesiaCritical Care Medicine and Pain TherapyUniversity of FrankfurtFrankfurtGermany
| | - Sunisa Chaiklieng
- Division of Neurophysiology in the Center of Rare DiseasesUlm UniversityUlmGermany
- Faculty of Public HealthKhon Knen UniversityMuang Khon KaenThailand
| | - Frank Lehmann‐Horn
- Division of Neurophysiology in the Center of Rare DiseasesUlm UniversityUlmGermany
| | - Karin Jurkat‐Rott
- Department of NeuroanaesthesiologyNeurosurgical UniversityGuenzburgGermany
| | - Scott Wearing
- Institute of Health and Biomedical InnovationQueensland University of TechnologyKelvin GroveQLDAustralia
| | - Werner Klingler
- Institute of Health and Biomedical InnovationQueensland University of TechnologyKelvin GroveQLDAustralia
- Department of NeuroanaesthesiologyNeurosurgical UniversityGuenzburgGermany
- Department of AnaesthesiologyIntensive Care Medicine and Pain TherapySRH KlinikumSigmarringenGermany
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18
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Zügel M, Maganaris CN, Wilke J, Jurkat-Rott K, Klingler W, Wearing SC, Findley T, Barbe MF, Steinacker JM, Vleeming A, Bloch W, Schleip R, Hodges PW. Fascial tissue research in sports medicine: from molecules to tissue adaptation, injury and diagnostics: consensus statement. Br J Sports Med 2018; 52:1497. [PMID: 30072398 PMCID: PMC6241620 DOI: 10.1136/bjsports-2018-099308] [Citation(s) in RCA: 110] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2018] [Indexed: 01/10/2023]
Abstract
The fascial system builds a three-dimensional continuum of soft, collagen-containing, loose and dense fibrous connective tissue that permeates the body and enables all body systems to operate in an integrated manner. Injuries to the fascial system cause a significant loss of performance in recreational exercise as well as high-performance sports, and could have a potential role in the development and perpetuation of musculoskeletal disorders, including lower back pain. Fascial tissues deserve more detailed attention in the field of sports medicine. A better understanding of their adaptation dynamics to mechanical loading as well as to biochemical conditions promises valuable improvements in terms of injury prevention, athletic performance and sports-related rehabilitation. This consensus statement reflects the state of knowledge regarding the role of fascial tissues in the discipline of sports medicine. It aims to (1) provide an overview of the contemporary state of knowledge regarding the fascial system from the microlevel (molecular and cellular responses) to the macrolevel (mechanical properties), (2) summarise the responses of the fascial system to altered loading (physical exercise), to injury and other physiological challenges including ageing, (3) outline the methods available to study the fascial system, and (4) highlight the contemporary view of interventions that target fascial tissue in sport and exercise medicine. Advancing this field will require a coordinated effort of researchers and clinicians combining mechanobiology, exercise physiology and improved assessment technologies.
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Affiliation(s)
- Martina Zügel
- Division of Sports Medicine, Ulm University, Ulm, Germany
| | - Constantinos N Maganaris
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Jan Wilke
- Department of Sports Medicine, Goethe University, Frankfurt, Germany
| | | | - Werner Klingler
- Department of Anesthesiology, BKH Günzburg, Günzburg, Germany
| | - Scott C Wearing
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Thomas Findley
- Department of Physical Medicine, New Jersey Medical School, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, USA
| | - Mary F Barbe
- Department of Anatomy and Cell Biology, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Andry Vleeming
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, Medical University Ghent, Ghent, Belgium
| | - Wilhelm Bloch
- Department of Molecular and Cellular Sport Medicine, Institute of Cardiovascular Research and Sport Medicine, German Sport University Cologne, Cologne, Germany
| | - Robert Schleip
- Fascia Research Group, Experimental Anesthesiology, Ulm University, Ulm, Germany
| | - Paul William Hodges
- Centre of Clinical Research Excellence in Spinal Pain, Injury and Health, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
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19
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Fleckenstein J, Schleip R, Sachs C, Driscoll M, Shockett S, Findley T, Klingler W. Faszienforschung: Quo vadis? Manuelle Medizin 2018. [DOI: 10.1007/s00337-018-0475-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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20
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Klingler W, Driscoll M. Revolution in fascia research. J Bodyw Mov Ther 2018; 22:844. [PMID: 30368328 DOI: 10.1016/j.jbmt.2018.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Werner Klingler
- Experimental Anesthesiology, Ulm University, Germany; Academic SRH Hospital Sigmaringen, Germany; Queensland University of Technology, Brisbane, Australia.
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21
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Schleip R, Zorn A, Wilke J, Klingler W. Contractility of human and rat lumbar fascia. J Bodyw Mov Ther 2018. [DOI: 10.1016/j.jbmt.2018.09.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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22
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Avila Gonzalez CA, Driscoll M, Schleip R, Wearing S, Jacobson E, Findley T, Klingler W. Frontiers in fascia research. J Bodyw Mov Ther 2018; 22:873-880. [PMID: 30368329 DOI: 10.1016/j.jbmt.2018.09.077] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 09/06/2018] [Indexed: 01/07/2023]
Abstract
Basic sciences are the backbone of every clear understanding of how the body is composed and how different structures and functions are connected with each other. It is obvious that there is a huge variability in human beings - not only in terms of the outer appearance such as measurements of height, weight, muscle mass and other physical properties, but also with respect to metabolic and functional parameters. This article highlights recent developments of research activities in the field of fascia sciences with a special emphasis on assessment strategies as the basis of further studies. Anatomical and histological studies show that fascial tissue is highly variable in terms of density, stiffness, and other parameters such as metabolic and humoral activity. Moreover, it encompasses nerves and harbours a system of micro-channels, also known as the primo vascular system. As ultrasound is a widely available method, its use is appealing not only for imaging of fascial structures, but also for thorough scientific analysis. Unlike most other imaging technologies, US has the advantage of real-time analysis of active or passive movements. In addition, other assessment methods for fascial tissue are discussed. In conclusion, fascial tissue plays an important role not only in functional anatomy, but also in evolutionary and molecular biology, sport, and exercise science as well as in numerous therapeutic approaches. A high density of nerves is found in fascial tissue. Knowledge of individual characteristics, especially by visualizing with ultrasound, leads to personalized therapeutic approaches, such as in pain therapy.
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Affiliation(s)
- Carla Alessandra Avila Gonzalez
- Department of Anaesthesiology, Intensive Care, Palliative Care, and Pain Medicine, BG University Hospital Bergmannsheil, Ruhr University Bochum, Germany; Department of Anaesthesiology and Intensive Care Medicine, Hessing Foundation, Augsburg, Germany.
| | - Mark Driscoll
- Department of Mechanical Engineering, McGill University, Canada
| | - Robert Schleip
- Fascia Research Group, Department of Experimental Anaesthesiology, Ulm University, Germany
| | - Scott Wearing
- Faculty of Health School - Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Eric Jacobson
- Department of Global Health & Social Medicine, Harvard Medical School, Boston, USA; Motion Analysis Laboratory, Department of Physical Medicine & Rehabilitation, Spaulding Rehabilitation Hospital, USA
| | - Tom Findley
- Rutgers New Jersey Medical School, State University of New Jersey, USA
| | - Werner Klingler
- Fascia Research Group, Department of Experimental Anaesthesiology, Ulm University, Germany; Faculty of Health School - Clinical Sciences, Queensland University of Technology, Brisbane, Australia
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Mall S, Elischer P, Zullo A, Textor M, Alt A, Klingler W, Melzer W. Cross-Influence of Halothane and Voltage on Intracellular Ca2+ in Isolated Muscle Fibers of Mice Expressing Human RyR1 Mutation Y522S. Biophys J 2018. [DOI: 10.1016/j.bpj.2017.11.2590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Schleip R, Wilke J, Schreiner S, Wetterslev M, Klingler W. Needle biopsy-derived myofascial tissue samples are sufficient for quantification of myofibroblast density. Clin Anat 2018; 31:368-372. [PMID: 29314236 DOI: 10.1002/ca.23040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 12/19/2017] [Accepted: 12/27/2017] [Indexed: 01/02/2023]
Abstract
Quantification of myofibroblasts is a promising method for assessing tissue properties in the field of fascia research. This is commonly performed by immunohistochemistry for α-smooth muscle actin. However, usually larger tissue samples sizes are required for quantification. The aim of this investigation was to explore whether a microscopic quantification of myofibroblasts can be conducted with fascial tissue samples derived via percutaneous needle biopsy. Fascial tissues were derived via percutaneous needle biopsy from the fascia lata of 11 persons (aged 19-40 years). Following immunohistochemistry, selected fields for photomicroscopic analysis were chosen by a Monte Carlo method based randomization procedure. On these fields, a digital quantification for the relative density of α-smooth muscle actin was attempted. The newly developed quantification method could successfully be applied in all tissue samples. The median α-smooth muscle actin density in the selected tissue samples ranged between 0% and 1.7% (median 0%, IQR 0%-0.001%). The applied protocol proved to be workable for the purpose of an estimation of the α-smooth muscle actin density in fascial tissue samples derived via percutaneous needle biopsy. Since this type of biopsy is less invasive than the commonly performed open muscle biopsy, this offers a new and useful perspective for future histological investigations of fascial tissue properties in living patients. Clin. Anat. 31:368-372, 2018. © 2018 Wiley Periodicals, Inc.
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Affiliation(s)
- R Schleip
- Department of Neuroanesthesiology, Neurosurgical Clinic, Ulm University, Guenzburg, Germany
| | - J Wilke
- Department of Sports Medicine, Institute of Sport Science, Goethe University Frankfurt, Germany
| | - S Schreiner
- Division of Neurophysiology, Ulm University, Ulm, Germany
| | - M Wetterslev
- Department of Rheumatology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - W Klingler
- Department of Neuroanesthesiology, Neurosurgical Clinic, Ulm University, Guenzburg, Germany
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Abstract
Sechs Testbestecke zur direkten Bestimmung des freien Thyroxins wurden überprüft. In mehreren Versuchsreihen wurde untersucht, welche klinische Relevanz diese Methoden haben. Präzisions- und Verdünnungsstudien wurden durchgeführt. Vom analytischen Standpunkt sind drei der Tests zu bemängeln. Bei fünf der Methoden kann aber eine dem T4/TBG-Quotienten entsprechende klinische Relevanz bestätigt werden. Drei der Methoden hatten Schwierigkeiten bei der Abgrenzung Hypothyreose/Euthyreose, ein Test bei der Abgrenzung Euthyreose/Hyperthyreose.
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Abstract
Bedingt durch die immer größer werdende Anzahl von radioimmunologischen Bestimmungen steigen auch die Probleme, die mit dem Umgang radioaktiver Substanzen verbunden sind. Verschiedene nicht-radioaktive Verfahren sind in jüngster Zeit entwickelt worden, wobei der Enzymimmunoassay (EIA) in der Routineanwendung bereits eine gewisse Bedeutung erlangt hat. Homogener und heterogener Enzymimmunoassay werden beschrieben. Die Forderungen, die an Enyzme, Substrate und an Enzym-Substrat-Reaktionen im Enzymimmunoassay zu stellen sind, werden aufgeführt.
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Zullo A, Textor M, Elischer P, Mall S, Alt A, Klingler W, Melzer W. Voltage modulates halothane-triggered Ca 2+ release in malignant hyperthermia-susceptible muscle. J Gen Physiol 2017; 150:111-125. [PMID: 29247050 PMCID: PMC5749113 DOI: 10.1085/jgp.201711864] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 11/16/2017] [Indexed: 12/20/2022] Open
Abstract
Malignant hyperthermia can result from mutations in the ryanodine receptor that favor anesthetic-induced Ca2+ release. Zullo et al. find that membrane potential modulates the effect of the volatile anesthetic halothane on skeletal muscle ryanodine receptors possessing the Y524S mutation. Malignant hyperthermia (MH) is a fatal hypermetabolic state that may occur during general anesthesia in susceptible individuals. It is often caused by mutations in the ryanodine receptor RyR1 that favor drug-induced release of Ca2+ from the sarcoplasmic reticulum. Here, knowing that membrane depolarization triggers Ca2+ release in normal muscle function, we study the cross-influence of membrane potential and anesthetic drugs on Ca2+ release. We used short single muscle fibers of knock-in mice heterozygous for the RyR1 mutation Y524S combined with microfluorimetry to measure intracellular Ca2+ signals. Halothane, a volatile anesthetic used in contracture testing for MH susceptibility, was equilibrated with the solution superfusing the cells by means of a vaporizer system. In the range 0.2 to 3%, the drug causes significantly larger elevations of free myoplasmic [Ca2+] in mutant (YS) compared with wild-type (WT) fibers. Action potential–induced Ca2+ signals exhibit a slowing of their time course of relaxation that can be attributed to a component of delayed Ca2+ release turnoff. In further experiments, we applied halothane to single fibers that were voltage-clamped using two intracellular microelectrodes and studied the effect of small (10-mV) deviations from the holding potential (−80 mV). Untreated WT fibers show essentially no changes in [Ca2+], whereas the Ca2+ level of YS fibers increases and decreases on depolarization and hyperpolarization, respectively. The drug causes a significant enhancement of this response. Depolarizing pulses reveal a substantial negative shift in the voltage dependence of activation of Ca2+ release. This behavior likely results from the allosteric coupling between RyR1 and its transverse tubular voltage sensor. We conclude that the binding of halothane to RyR1 alters the voltage dependence of Ca2+ release in MH-susceptible muscle fibers such that the resting membrane potential becomes a decisive factor for the efficiency of the drug to trigger Ca2+ release.
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Affiliation(s)
- Alberto Zullo
- Institute of Applied Physiology, Ulm University, Ulm, Germany.,CEINGE - Biotecnologie Avanzate, Napoli, Italy.,Department of Sciences and Technologies, University of Sannio, Benevento, Italy
| | - Martin Textor
- Institute of Applied Physiology, Ulm University, Ulm, Germany
| | | | - Stefan Mall
- Institute of Applied Physiology, Ulm University, Ulm, Germany
| | - Andreas Alt
- Institute of Legal Medicine, Ulm University, Ulm, Germany
| | - Werner Klingler
- Department of Neuroanaesthesiology, Ulm University, Günzburg, Germany.,Queensland University of Technology, Brisbane, Australia
| | - Werner Melzer
- Institute of Applied Physiology, Ulm University, Ulm, Germany
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Coburger J, Kapapa T, Wirtz CR, Jurkat-Rott K, Klingler W. High prevalence of rare ryanodine receptor type 1 variants in patients suffering from aneurysmatic subarachnoid hemorrhage: A pilot study. J Clin Neurosci 2017; 45:209-213. [PMID: 28750945 DOI: 10.1016/j.jocn.2017.06.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 06/15/2017] [Indexed: 10/19/2022]
Abstract
Subarachnoid hemorrhage (SAH) remains a challenging neurosurgical disease. The ryanodine receptor type 1 Ca2+ channel (RyR1) plays a crucial role in vasoconstriction and hemostasis. Mutations of the encoding gene, RYR1, are known to cause susceptibility to malignant hyperthermia (MH). Recently, a RYR1 mutation was found to be associated with abnormal bleeding times. Therefore, an assessment of the RYR1 gene might be of high relevance in patients with aneurysmatic SAH. In the presented pilot study, we screened 10 patients suffering from SAH for RYR1 variants and, for the first time in SAH, performed an assessment of pathogenicity of these variants using protein prediction software. Four of the patients showed a RYR1 variant. For three of the variants, p.Glu79Lys, p.Arg885C, p.Glu2635 Val, all three programs predicted pathogenicity. Their prevalence in the general population is very low i.e. under 0.005%. For the fourth variant, p.Pro4501Leu (RS73933023), the results of the prediction programs were discrepant and the prevalence in the general population was high, i.e. almost 0.5%, which is too frequent to be associated with the rare SAH phenotype. Clinical evaluation revealed that no differences concerning neurological outcome, presence of vasospasm, ischemic deficits and mean hospital stay between patients with and without variants were found. However, in our series SAH patients have an increased frequency of rare RYR1 variants. Hence, potentially contributing to the pathogenesis of SAH. Further data is needed to confirm this preliminary result.
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Affiliation(s)
- Jan Coburger
- Department of Neurosurgery, Ulm University, Germany.
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Wilke J, Schleip R, Klingler W, Stecco C. The Lumbodorsal Fascia as a Potential Source of Low Back Pain: A Narrative Review. Biomed Res Int 2017; 2017:5349620. [PMID: 28584816 PMCID: PMC5444000 DOI: 10.1155/2017/5349620] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 04/24/2017] [Indexed: 12/19/2022]
Abstract
The lumbodorsal fascia (LF) has been proposed to represent a possible source of idiopathic low back pain. In fact, histological studies have demonstrated the presence of nociceptive free nerve endings within the LF, which, furthermore, appear to exhibit morphological changes in patients with chronic low back pain. However, it is unclear how these characteristics relate to the aetiology of the pain. In vivo elicitation of back pain via experimental stimulation of the LF suggests that dorsal horn neurons react by increasing their excitability. Such sensitization of fascia-related dorsal horn neurons, in turn, could be related to microinjuries and/or inflammation in the LF. Despite available data point towards a significant role of the LF in low back pain, further studies are needed to better understand the involved neurophysiological dynamics.
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Affiliation(s)
- Jan Wilke
- Department of Sports Medicine, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Robert Schleip
- Fascia Research Group, Neurosurgical Clinic Guenzburg, Ulm University, Ulm, Germany
| | - Werner Klingler
- Fascia Research Group, Neurosurgical Clinic Guenzburg, Ulm University, Ulm, Germany
| | - Carla Stecco
- Department of Molecular Medicine, Institute of Human Anatomy, University of Padova, Padova, Italy
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Klingler W, Pfenninger E. [Pharmacogenetics in anesthesia and intensive care medicine : Clinical and legal challenges exemplified by malignant hyperthermia]. Anaesthesist 2017; 65:380-90. [PMID: 27142362 DOI: 10.1007/s00101-016-0167-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Pharmacotherapy is a key component of anesthesiology and intensive care medicine. The individual genetic profile influences not only the effect of pharmaceuticals but can also completely alter the mode of action. New technologies for genetic screening (e.g. next generation sequencing) and increasing knowledge of molecular pathways foster the disclosure of pharmacogenetic syndromes, which are classified as rare diseases. Taking into account the high genetic variability in humans and over 8000 known rare diseases, up to 20 % of the population may be affected. In summary, rare diseases are not rare. Most pharmacogenetic syndromes lead to a weakening or loss of pharmacological action. In contrast, malignant hyperthermia (MH), which is the most relevant pharmacogenetic syndrome for anesthesia, is characterized by a pharmacologically induced overactivation of calcium metabolism in skeletal muscle. Volatile anesthetic agents and succinylcholine trigger life-threatening hypermetabolic crises. Emergency treatment is based on inhibition of the calcium release channel of the sarcoplasmic reticulum by dantrolene. After an adverse pharmacological event patients must be informed and a clarification consultation must be carried out during which the hereditory character of MH is explained. The patient should be referred to a specialist MH center where a predisposition can be diagnosed by the functional in vitro contracture test from a muscle biopsy. Additional molecular genetic investigations can yield mutations in the genes for calcium-regulating proteins in skeletal muscle, e.g. ryanodine receptor 1 (RyR1) and calcium voltage-gated channel subunit alpha 1S (CACNA1S). Currently, an association to MH has only been shown for 35 mutations out of more than 400 known and probably hundreds of unknown genetic variations. Furthermore, MH predisposition is not excluded by negative mutation screening. For anesthesiological patient safety it is crucial to identify individuals at risk and warn genetic relatives; however, the legal requirements of the Patients Rights Act and the Human Genetic Examination Act must be strictly adhered to. Specific features of insurance and employment law must be respected under consideration of the Human Genetic Examination Act.
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Affiliation(s)
- W Klingler
- Abteilung Neuroanästhesie, Universität Ulm im Bezirkskrankenhaus Günzburg, Ludwig-Heilmeyer-Str. 2, 89312, Günzburg, Deutschland.
| | - E Pfenninger
- Abteilung Neuroanästhesie, Universität Ulm im Bezirkskrankenhaus Günzburg, Ludwig-Heilmeyer-Str. 2, 89312, Günzburg, Deutschland
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31
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Hoppe K, Hack G, Lehmann-Horn F, Jurkat-Rott K, Wearing S, Zullo A, Carsana A, Klingler W. Hypermetabolism in B-lymphocytes from malignant hyperthermia susceptible individuals. Sci Rep 2016; 6:33372. [PMID: 27646467 PMCID: PMC5028841 DOI: 10.1038/srep33372] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 08/24/2016] [Indexed: 01/20/2023] Open
Abstract
Malignant hyperthermia (MH) is a pharmacogenetic disorder of skeletal muscle metabolism which is characterized by generalized muscle rigidity, increased body temperature, rhabdomyolysis, and severe metabolic acidosis. The underlying mechanism of MH involves excessive Ca(2+) release in myotubes via the ryanodine receptor type 1 (RyR1). As RyR1 is also expressed in B-lymphocytes, this study investigated whether cellular metabolism of native B-lymphocytes was also altered in MH susceptible (MHS) individuals. A potent activator of RyR1, 4-chloro-m-cresol (4-CmC) was used to challenge native B-lymphocytes in a real-time, metabolic assay based on a pH-sensitive silicon biosensor chip. At the cellular level, a dose-dependent, phasic acidification occurred with 4-CmC. The acidification rate, an indicator of metabolic activation, was significantly higher in B-lymphocytes from MHS patients and required 3 to 5 fold lower concentrations of 4-CmC to evoke similar acidification rates to MHN. Native B-lymphocytes from MHS individuals are more sensitive to 4-CmC than those from MHN, reflecting a greater Ca(2+) turnover. The acidification response, however, was less pronounced than in muscle cells, presumably reflecting the lower expression of RyR1 in B-lymphocytes.
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Affiliation(s)
- Kerstin Hoppe
- Department of Anaesthesia, Intensive Care Medicine and Pain Therapy, Frankfurt University, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Guido Hack
- Division of Neurophysiology in the Center of Rare Diseases, Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Frank Lehmann-Horn
- Division of Neurophysiology in the Center of Rare Diseases, Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Karin Jurkat-Rott
- Division of Neurophysiology in the Center of Rare Diseases, Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany
| | - Scott Wearing
- Institute of Health and Biomedical Innovation, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove 4059, Australia
| | - Alberto Zullo
- Department of Science and Technologies, University of Sannio, Benevento, Italy and CEINGE Advanced Biotechnologies s.c.ar.l, Naples, Italy.,Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy
| | - Antonella Carsana
- Department of Molecular Medicine and Medical Biotechnology, University of Naples Federico II, Naples, Italy
| | - Werner Klingler
- Division of Neurophysiology in the Center of Rare Diseases, Ulm University, Albert-Einstein-Allee 23, 89081 Ulm, Germany.,Department of Neuroanaesthesiology, Neurosurgical University, Ludwig-Heilmeyerstr. 2, 89312 Guenzburg, Germany
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Dennenmoser S, Schleip R, Klingler W. Clinical mechanistic research: Manual and movement therapy directed at fascia electrical impedance and Sonoelastography as a tool for the examination of changes in lumbar fascia after tissue manipulation. J Bodyw Mov Ther 2016. [DOI: 10.1016/j.jbmt.2015.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Fascia is composed of collagenous connective tissue surrounding and interpenetrating skeletal muscle, joints, organs, nerves, and vascular beds. Fascial tissue forms a whole-body, continuous three-dimensional viscoelastic matrix of structural support. The classical concept of its mere passive role in force transmission has recently been disproven. Fascial tissue contains contractile elements enabling a modulating role in force generation and also mechanosensory fine-tuning. This hypothesis is supported by in vitro studies demonstrating an autonomous contraction of human lumbar fascia and a pharmacological induction of temporary contraction in rat fascial tissue. The ability of spontaneous regulation of fascial stiffness over a time period ranging from minutes to hours contributes more actively to musculoskeletal dynamics. Imbalance of this regulatory mechanism results in increased or decreased myofascial tonus, or diminished neuromuscular coordination, which are key contributors to the pathomechanisms of several musculoskeletal pathologies and pain syndromes. Here, we summarize anatomical and biomechanical properties of fascial tissue with a special focus on fascial dysfunctions and resulting clinical manifestations. Finally, we discuss current and future potential treatment options that can influence clinical manifestations of pain syndromes associated with fascial tissues.
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Affiliation(s)
- W Klingler
- Fascia Research Group, Division of Neurophysiology, Ulm University, Albert-Einstein-Allee 11, 89081, Ulm, Germany
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Affiliation(s)
- Robert Schleip
- a Fascia Research Group, Division of Neurophysiology , Ulm University , Germany
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35
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Hoppner A, Klingler W. Erratum zu: Erkennen und behandeln des Status epilepticus. Notf Rett Med 2014. [DOI: 10.1007/s10049-014-1908-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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36
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Hoppe K, Schleip R, Lehmann-Horn F, Jäger H, Klingler W. Contractile elements in muscular fascial tissue - implications for in-vitro contracture testing for malignant hyperthermia. Anaesthesia 2014; 69:1002-8. [DOI: 10.1111/anae.12752] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2014] [Indexed: 01/11/2023]
Affiliation(s)
- K. Hoppe
- Department of Anaesthesiology; Ulm University; Ulm Germany
- Department of Anaesthesia; Intensive Care Medicine and Pain Therapy; Frankfurt University; Frankfurt am Main Germany
| | - R. Schleip
- Division of Neurophysiology; Ulm University; Ulm Germany
| | | | - H. Jäger
- Division of Neurophysiology; Ulm University; Ulm Germany
| | - W. Klingler
- Division of Neurophysiology; Ulm University; Ulm Germany
- Department of Neuroanaesthesiology; Neurosurgical University; Guenzburg Germany
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38
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Hoppner A, Klingler W. Erkennen und behandeln des Status epilepticus. Notf Rett Med 2014. [DOI: 10.1007/s10049-013-1765-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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39
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Klingler W, Heiderich S, Girard T, Gravino E, Heffron JJA, Johannsen S, Jurkat-Rott K, Rüffert H, Schuster F, Snoeck M, Sorrentino V, Tegazzin V, Lehmann-Horn F. Functional and genetic characterization of clinical malignant hyperthermia crises: a multi-centre study. Orphanet J Rare Dis 2014; 9:8. [PMID: 24433488 PMCID: PMC3896768 DOI: 10.1186/1750-1172-9-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Accepted: 01/08/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Malignant hyperthermia (MH) is a rare pharmacogenetic disorder which is characterized by life-threatening metabolic crises during general anesthesia. Classical triggering substances are volatile anesthetics and succinylcholine (SCh). The molecular basis of MH is excessive release of Ca2+ in skeletal muscle principally by a mutated ryanodine receptor type 1 (RyR1). To identify factors explaining the variable phenotypic presentation and complex pathomechanism, we analyzed proven MH events in terms of clinical course, muscle contracture, genetic factors and pharmocological triggers. METHODS In a multi-centre study including seven European MH units, patients with a history of a clinical MH episode confirmed by susceptible (MHS) or equivocal (MHE) in vitro contracture tests (IVCT) were investigated. A test result is considered to be MHE if the muscle specimens develop pathological contractures in response to only one of the two test substances, halothane or caffeine. Crises were evaluated using a clinical grading scale (CGS), results of IVCT and genetic screening. The effects of SCh and volatile anesthetics on Ca2+ release from sarcoplasmic reticulum (SR) were studied in vitro. RESULTS A total of 200 patients met the inclusion criteria. Two MH crises (1%) were triggered by SCh (1 MHS, 1 MHE), 18% by volatile anesthetics and 81% by a combination of both. Patients were 70% male and 50% were younger than 12 years old. Overall, CGS was in accord with IVCT results. Crises triggered by enflurane had a significantly higher CGS compared to halothane, isoflurane and sevoflurane. Of the 200 patients, 103 carried RyR1 variants, of which 14 were novel. CGS varied depending on the location of the mutation within the RyR1 gene. In contrast to volatile anesthetics, SCh did not evoke Ca2+ release from isolated rat SR vesicles. CONCLUSIONS An MH event could depend on patient-related risk factors such as male gender, young age and causative RyR1 mutations as well as on the use of drugs lowering the threshold of myoplasmic Ca2+ release. SCh might act as an accelerant by promoting unspecific Ca2+ influx via the sarcolemma and indirect RyR1 activation. Most MH crises develop in response to the combined administration of SCh and volatile anesthetics.
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Affiliation(s)
- Werner Klingler
- Department of Neuroanesthesiology, Ulm University, Ludwig-Heilmeyer-Str. 2, Günzburg 89312, Germany
- Division of Neurophysiology, Ulm University, Albert-Einstein Allee 11, Ulm 89081, Germany
- Rare Disease Center, University Hospital Ulm, Ulm 89081, Germany
| | - Sebastian Heiderich
- Department of Neuroanesthesiology, Ulm University, Ludwig-Heilmeyer-Str. 2, Günzburg 89312, Germany
- Division of Neurophysiology, Ulm University, Albert-Einstein Allee 11, Ulm 89081, Germany
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, Hannover 30625, Germany
| | | | | | | | - Stephan Johannsen
- Department of Anesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - Karin Jurkat-Rott
- Division of Neurophysiology, Ulm University, Albert-Einstein Allee 11, Ulm 89081, Germany
- Rare Disease Center, University Hospital Ulm, Ulm 89081, Germany
| | - Henrik Rüffert
- University of Leipzig, Helios Kliniken Leipziger Land Leipzig, Germany
| | - Frank Schuster
- Department of Anesthesia and Critical Care, University of Würzburg, Würzburg, Germany
| | - Marc Snoeck
- Department of Anesthesia, Canisius-Wilhelmina Hospital, University of Nijmegen, Nijmegen, The Netherlands
| | - Vincenzo Sorrentino
- Molecular Medicine Section, Department of Molecular and Developmental Medicine, University of Siena, via A. Moro 2, Siena 53100, Italy
| | | | - Frank Lehmann-Horn
- Division of Neurophysiology, Ulm University, Albert-Einstein Allee 11, Ulm 89081, Germany
- Rare Disease Center, University Hospital Ulm, Ulm 89081, Germany
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Jäger H, Klingler W, Lehmann-Horn F, Schleip R. Do Calcium Activated Potassium Channels Control Proliferation of Myofibroblasts? Implications for Fibroproliferative Diseases. J Bodyw Mov Ther 2012. [DOI: 10.1016/j.jbmt.2012.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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41
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Hafner S, Ehrmann U, Jentzmik F, Klingler W, Georgieff M, Froeba G. Fulminant rhabdomyolysis after prolonged radical prostatectomy managed with continuous veno-venous haemodialysis, regional citrate anticoagulation, and a polysulphone high-flux filter. Br J Anaesth 2012; 108:702-3. [DOI: 10.1093/bja/aes086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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42
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Schleip R, Duerselen L, Vleeming A, Naylor IL, Lehmann-Horn F, Zorn A, Jaeger H, Klingler W. Strain hardening of fascia: Static stretching of dense fibrous connective tissues can induce a temporary stiffness increase accompanied by enhanced matrix hydration. J Bodyw Mov Ther 2012; 16:94-100. [PMID: 22196433 DOI: 10.1016/j.jbmt.2011.09.003] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 09/11/2011] [Accepted: 09/12/2011] [Indexed: 11/18/2022]
Affiliation(s)
- Robert Schleip
- Fascia Research Group, Division of Neurophysiology, Ulm University, Albert-Einstein-Allee 11, 89081 Ulm, Germany.
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Klingler W, Lehmann-Horn F, Schulte-Sasse U. [Hotline for malignant hyperthermia. New telephone number for the German nationwide 24 h service center: 08221/9600]. Anaesthesist 2011; 60:172-4. [PMID: 21308355 DOI: 10.1007/s00101-011-1851-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- W Klingler
- Neuroanästhesie, Neurochirurgische Universitätsklinik Ulm, BKH Günzburg, Ludwig Heilmeyer Strasse 2, Günzburg, Germany.
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44
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45
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Schorl M, Dirks B, Klingler W. Hirnstammblutungen. Notf Rett Med 2010. [DOI: 10.1007/s10049-009-1237-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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46
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Zullo A, Klingler W, De Sarno C, Ferrara M, Fortunato G, Perrotta G, Gravino E, Di Noto R, Lehmann-Horn F, Melzer W, Salvatore F, Carsana A. Functional characterization of ryanodine receptor (RYR1) sequence variants using a metabolic assay in immortalized B-lymphocytes. Hum Mutat 2009; 30:E575-90. [PMID: 19191333 DOI: 10.1002/humu.20991] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Mutations in the RYR1 gene are linked to malignant hyperthermia (MH), central core disease and multi-minicore disease. We screened by DHPLC the RYR1 gene in 24 subjects for mutations, and characterized functional alterations caused by some RYR1 variants. Three novel sequence variants and twenty novel polymorphisms were identified. Immortalized lymphoblastoid cell lines from patients with RYR1 variants and from controls were stimulated with 4-chloro-m-cresol (4-CmC) and the rate of extracellular acidification was recorded. We demonstrate that the increased acidification rate of lymphoblastoid cells in response to 4-CmC is mainly due to RYR1 activation. Cells expressing RYR1 variants in the N-terminal and in the central region of the protein (p.Arg530His, p.Arg2163Pro, p.Asn2342Ser, p.Glu2371Gly and p.Arg2454His) displayed higher activity compared with controls; this could account for the MH-susceptible phenotype. Cell lines harboring RYR1(Cys4664Arg) were significantly less activated by 4-CmC. This result indicates that the p.Cys4664Arg variant causes a leaky channel and depletion of intracellular stores. The functional changes detected corroborate the variants analyzed as disease-causing alterations and the acidification rate measurements as a means to monitor Ca(2+)-induced metabolic changes in cells harboring mutant RYR1 channels.
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Hoppe K, Dirks B, Stahl W, Muth CM, Klingler W. Images in resuscitation: ECG misinterpretion underneath high-voltage power lines. Resuscitation 2009; 80:973-4. [PMID: 19581041 DOI: 10.1016/j.resuscitation.2009.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Revised: 05/06/2009] [Accepted: 06/08/2009] [Indexed: 11/17/2022]
Affiliation(s)
- Kerstin Hoppe
- Department of Anaesthesiology, University of Ulm, 89073 Ulm, Germany.
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Pawlik MT, Seyfried TF, Riegger C, Klingler W, Selig C. Bispectral index monitoring during cardiopulmonary resuscitation repeated twice within 8 days in the same patient: a case report. Int J Emerg Med 2008; 1:209-12. [PMID: 19384519 PMCID: PMC2657270 DOI: 10.1007/s12245-008-0037-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2008] [Accepted: 05/12/2008] [Indexed: 10/27/2022] Open
Abstract
Research on cardiac resuscitation has led to various changes in the techniques and drug administration involved in modern advanced life support. Besides improving primary cardiac survival, interest is increasingly focused on a favourable neurological outcome. However, until now there has been no on-site equipment to support the clinical observations of the cardiopulmonary resuscitation (CPR) team. Bispectral index (BIS) monitoring has been used for avoiding awareness during anaesthesia for many years. We report a case of a 68-year-old patient suffering twice from cardiac arrest due to thromboembolism within a few days. While the first cardiac resuscitation was survived without neurological consequences, the patient died after the second event. Both resuscitation events were monitored using the BIS. We discuss the course of BIS values and their possible contribution to the prediction of outcome.
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Affiliation(s)
- Michael T Pawlik
- Department of Anaesthesiology, University of Regensburg, 93042, Regensburg, Germany.
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Klingler W, Dirks B. Untersuchung des Bewusstlosen. Notf Rett Med 2007. [DOI: 10.1007/s10049-007-0906-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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