Glycated hemoglobin A1c level on the day of emergency surgery is a marker of premorbid glycemic control: a retrospective observational study

Sugammadex, a γ-cyclodextrin derivative, belongs to a new class of selective relaxant binding agents. Sugammadex was approved 10-years ago by the European medicines agency and today is used in clinical anesthesia and emergency medicine globally. In this review, indications for neuromuscular block, the challenge of neuromuscular monitoring and the practice of under-dosing of sugammadex as a potential cost-saving strategy are discussed. Reversal of neuromuscular block is important to accelerate the spontaneous recovery of neuromuscular function. Sugammadex is able to reverse a rocuronium- or vecuronium-induced neuromuscular block rapidly and efficiently from every depth of neuromuscular block. However, since sugammadex was introduced in clinical anesthesia, several studies have reported administration of a lower-than-recommended dose of sugammadex. The decision to under-dose sugammadex is often motivated by cost reduction concerns, as the price of sugammadex is much higher than that of neostigmine outside the United States. However, under-dosing of sugammadex leads to an increased risk of recurrence of neuromuscular block after an initial successful (but transient) reversal. Similarly, when not using objective neuromuscular monitoring, under-dosing of sugammadex may result in residual neuromuscular block in the postoperative care unit, with its attendant negative pulmonary outcomes. Therefore, an appropriate dose of sugammadex, based on objective determination of the depth of neuromuscular block, should be administered to avoid residual or recurrent neuromuscular block and attendant postoperative complications. Whether the reduction in perioperative recovery time of the patient can be translated into additional procedural cases performed, faster operative turnover times, or improved organizational resource utilization, has yet to be determined in actual clinical practice that includes verification of neuromuscular recovery prior to tracheal extubation. The current review addresses the indications for neuromuscular block, the challenge of neuromuscular monitoring, the practice of under-dosing of sugammadex as a potential cost-saving strategy in reversal of deep neuromuscular block, the economics of sugammadex administration and the potential healthcare cost-saving strategies.     

Activation of Matrix Metalloproteinase-3 is altered at the frog neuromuscular junction following changes in synaptic activity

The extracellular matrix surrounding the neuromuscular junction is a highly specialized and dynamic structure. Matrix Metalloproteinases are enzymes that sculpt the extracellular matrix. Since synaptic activity is critical to the structure and function of this synapse, we investigated whether changes in synaptic activity levels could alter the activity of Matrix Metalloproteinases at the neuromuscular junction. In particular, we focused on Matrix Metalloproteinase 3 (MMP3), since antibodies to MMP3 recognize molecules at the frog neuromuscular junction, and MMP3 cleaves a number of synaptic basal lamina molecules, including agrin. Here we show that the fluorogenic compound (M2300) can be used to perform in vivo proteolytic imaging of the frog neuromuscular junction to directly measure the activity state of MMP3. Application of this compound reveals that active MMP3 is concentrated at the normal frog neuromuscular junction, and is tightly associated with the terminal Schwann cell. Blocking presynaptic activity via denervation, or TTX nerve blockade, results in a decreased level of active MMP3 at the neuromuscular junction. The loss of active MMP3 at the neuromuscular junction in denervated muscles can result from decreased activation of pro-MMP3, or it could result from increased inhibition of MMP3. These results support the hypothesis that changes in synaptic activity can alter the level of active MMP3 at the neuromuscular junction.     

Extreme Levels of Noise Constitute a Key Neuromuscular Deficit in the Elderly

Fluctuations during isometric force production tasks occur due to the inability of musculature to generate purely constant submaximal forces and are considered to be an estimation of neuromuscular noise. The human sensori-motor system regulates complex interactions between multiple afferent and efferent systems, which results in variability during functional task performance. Since muscles are the only active component of the motor system, it therefore seems reasonable that neuromuscular noise plays a key role in governing variability during both standing and walking. Seventy elderly women (including 34 fallers) performed multiple repetitions of isometric force production, quiet standing and walking tasks. No relationship between neuromuscular noise and functional task performance was observed in either the faller or the non-faller cohorts. When classified into groups with either nominal (group NOM, 25^th –75^th percentile) or extreme (either too high or too low, group EXT) levels of neuromuscular noise, group NOM demonstrated a clear association (r²>0.23, p<0.05) between neuromuscular noise and variability during task performance. On the other hand, group EXT demonstrated no such relationship, but also tended to walk slower, and had lower stride lengths, as well as lower isometric strength. These results suggest that neuromuscular noise is related to the quality of both static and dynamic functional task performance, but also that extreme levels of neuromuscular noise constitute a key neuromuscular deficit in the elderly.     

Presynaptic effect of the aziridinium ion of acetylcholine mustard (methyl-2-acetoxyethyl-2'-chloroethylamine) on the phrenic nerve--rat diaphragm preparation.

The rat diaphragm has been used to investigate the neuromuscular blocking action of acetylcholine mustard which yields a potent nicotinic agonist, an aziridinium ion, in aqueous medium. Evidence was obtained that the acetylcholine mustard aziridinium ion impaired neuromuscular activity when the phrenic nerve was stimulated and that the ion did not directly inhibit muscle contraction. Impairment of neuromuscular activity was characterized by a latent period and depended both on the concentration of aziridinium ion and the frequency of stimulation of the phrenic nerve. Elevated concentrations of Ca-2+ and choline changed the response of the rat diaphragm to the aziridinium ion, the former increasing the rate of development of neuromuscular block and the latter protecting against neuromuscular block. These results indicated that the aziridinium ion may act either at the site of choline uptake or have an effect on acetylcholine synthesis in the nerve ending and that impairment of neuromuscular transmission in the rat diaphragm involved the availability of acetylcholine. Similar results were obtained with acetylcholine mustard aziridinium ion subjected to alkaline hydrolysis. This substance is thought to be choline mustard aziridinium ion. Although difficult to prove with the rat diaphragm it is possible that acetylcholinesterase of this preparation could hydrolyze acetylcholine mustard aziridinium ion at the neurotransmitter site and the resultant choline mustard aziridinium ion would interfere with the uptake of choline and eventually prevent neuromuscular transmission. This hemicholinium-like hypothesis for the mechanism of action of choline mustard aziridinium ion is compatible with reported date for toxicity of acetylcholine mustard aziridinium ion in the mouse.     

Cell death of motoneurons in the chick embryo spinal cord. VIII. Motoneurons prevented from dying in the embryo persist after hatching

A chronic neuromuscular blockade during those embryonic stages when naturally occurring spinal motoneuron death occurs, results in the prevention of this cell loss. The excess motoneurons are maintained as long as the neuromuscular blockade is continued; once embryonic neuromuscular activity resumes, however, the excess motoneurons undergo a delayed period of cell death. By contrast, the resumption of neuromuscular activity in these same preparations after hatching did not result in a delayed cell death. The excess motoneurons, prevented from dying in the embryo, persisted for as long as 4 days postnatally despite the presence of considerable limb motility. The maintenance of motoneurons may be regulated differently before and after hatching.     

Development of neuromuscular junctions on small mesenteric arteries of the rat

This ultrastructural study has investigated the development of the innervation of second order mesenteric arteries from the ileum region of the rat intestine, particularly, the time course of the formation of the plexus of varicose axons around the arteries, and the formation of autonomic neuromuscular junctions. The time points studied were postnatal days-2, -4, -8 and -13. This study has revealed that the formation of neuromuscular junctions with mature structural characteristics occurred at ~2 weeks postnatal. The plexus of varicose axons developed predominantly between day-4 and day-13, which agrees with previous light microscopy studies of catecholamne containing nerves around similar vessels. At day-2 and day-4, the axons lacked varicosities and were mainly contained in large bundles located in the outer region of the adventitia. The medio-adventitial border consisted of a dense layer of extracellular matrix and fibroblasts. By day-8, there were more axons and most were distributed in smaller bundles. Some had grown through the adventitia to lie at the medio-adventitial border and axon varicosities were also observed. Some varicosities had formed rudimentary neuromuscular contacts. By day-13, there were significantly more contacting varicosities compared to day-8. They were structurally more mature, being twice the size with three times the number of synaptic vesicles and consistently contained a mitochondrion. Conversely, the neuromuscular contact areas were similar at both time points. Some organisation of the synaptic vesicles associated with the prejunctional membrane, was evident in varicosities at day-8 but there were no presynaptic membrane specialisations similar to the putative neurotransmitter release sites found at mature skeletal neuromuscular junctions. The aggregation of small vesicles at the prejunctional membrane was more pronounced in neuromuscular junctions at day-13 with some having presynaptic membrane specialisations. Comparison of the structure of developing autonomic neuromuscular junctions with that of skeletal neuromuscular junctions has revealed a number of similarities.     

The role of synapse elimination in the establishment of neuromuscular compartments

To investigate the specificity of development of initial neuromuscular connections, we examined the compartmental distribution of synapses in neonatal rat lateral gastrocnemius (LG) muscle. Initial neuromuscular connections might be restricted to the compartmental territories present in adults; alternatively, synapse elimination could establish the compartments from a less precise pattern of innervation. We examined 46 pups of ages 0 to 14 postnatal days using a variety of techniques. The principle method was evoked electromyographic (EMG) activity in response to nerve stimulation. The nerve branch to one neuromuscular compartment was cut and the remainder of the nerve was stimulated. The presence of EMG activity was used to identify the areas of muscle contracting in response to nerve stimulation. After cutting a particular branch, EMG activity generally could not be recorded from the denervated compartment. These results indicate that the pattern of innervation at birth is essentially compartment-specific, and that neuromuscular compartments are not shaped from some less precise pattern by postnatal synapse elimination. The factors which operate prenatally to determine this high degree of specificity in neuromuscular connectivity seen at the time of birth, however, remain unknown.     

Cytoplasmic actin in postsynaptic structures at the neuromuscular junction

We used an antibody prepared against Aplysia (mollusc) body-wall actin that specifically reacts with certain forms of cytoplasmic actin in mammalian cells to probe for the presence of actin at the neuromuscular junction. Immunocytochemical studies showed that actin or an actinlike molecule is concentrated at neuromuscular junctions of normal and denervated adult rat muscle fibers. Actin is present at the neuromuscular junctions of fibers of developing diaphragm muscles as early as embryonic day 18, well before postsynaptic folds are formed. These results suggest that cytoplasmic actin may play a role in the clustering or stabilization of acetylcholine receptors at the neuromuscular junction.     

Influence of immobilisation of limbs in kittens on the morphology of the developing neuromuscular junctions

Immobilisation of limbs in kittens, in which the neuromuscular apparatus is in active growing phase, affects the maturation of the end-plates, which appear smaller and pointed. Longer periods of immobilisation lead to a significant reduction in the surface area of the neuromuscular junctions which were seen to be "V" or "W" shaped.     

Mechanisms controlling axonal sprouting at the neuromuscular junction

This review considers the relative roles of sprouting stimuli, perisynaptic Schwann cells and neuromuscular activity in axonal sprouting at the neuromuscular junction in partially denervated muscles. A number of sprouting stimuli, including insulin-like growth factor II, which are generated from inactive muscle fibers in partially denervated and paralyzed skeletal muscles, has been considered. There is also evidence that perisynaptic Schwann cells induce and guide axonal sprouting in adult partially denervated muscles. Excessive neuromuscular activity significantly reduces bridging of perisynaptic Schwann cell processes between innervated and denervated endplates and thereby inhibits axonal sprouting in partially denervated adult muscles. Elimination of neuromuscular activity is also detrimental to sprouting in these muscles, suggesting that calcium influx into the nerve is crucial for axonal sprouting. The role of neuromuscular activity in axonal sprouting will be considered critically in the context of the roles of sprouting stimuli and perisynaptic Schwann cells in the process of axonal sprouting.     

Relationship between the in vivo and in vitro activity of some naturally occurring glutamate analogues on the somatic neuromuscular junction of Lucilia sericata

ABSTRACT. A preparation of Lucilia sericata flight motor system was arranged so that ganglionic and neuromuscular function could be monitored while experimental compounds were injected into the intact insect. Injections of l -glutamate, the putative excitatory transmitter at the insect neuromuscular junction, caused a reversible paralysis of the flight muscles. A number of structural analogues of l -glutamic acid, found in various seed plants, were injected and the results compared. The salts of several of these compounds were as active or more active in causing the paralysis than glutamate itself. Two of the most toxic compounds, salts of 4-methylene glutamic acid and quisqualic acid were further tested in vitro by iontophoretically applying them directly to exposed insect neuromuscular junctions. Both compounds showed glutamate-agonistic activity when applied directly to the neuromuscular junction but were less active than glutamate. This difference between in vivo and in vitro effects is caused by removal mechanisms which protect the muscle membranes from the effects of glutamate. These mechanisms do not so readily remove or inactivate 4-methylene glutamate or quisqualate. Consequently, for a given dose, the concentration of the analogues at the neuromuscular junction remains longer above the critical level which causes paralysis.     

Effect of an alternating magnetic field on the working capacity of human muscles under the conditions of local or general fatigue

The effect of a magnetic field on changes in working capacity at different stages of fatigue during cyclic exercises was studied. The data obtained indicated that the magnetic field affected the neuromuscular system, increasing working capacity under the conditions of considerable local or general fatigue without causing pathological changes in neuromuscular regulation.     

Quantitative investigation of the neuromuscular junction of rat skeletal muscle fibres after double innervation

Summary In normal (untreated) rats the mean length ratio of postsynaptic to presynaptic membrane was 2.7±0.8 for neuromuscular junctions of slow-twitch soleus muscle fibres and 4.2±1.0 for neuromuscular junctions of fast-twitch extensor digitorum longus muscle fibres; this difference was significant (P<0.001). After experimental double innervation by fast and slow muscle nerves for four months, the ratio was (1) 2.9±0.8 for the original slow-twitch fibre end-plate and 2.8±0.8 for the newly established one, both not significantly different from that of the normal slow-twitch fibres; and (2) 2.2±0.5 for the original fast-twitch fibre end-plate and 2.2±0.7 for the newly established one, both significantly smaller than that of the normal fast-twitch fibres (P<0.001). This means that the double innervated slow-twitch muscle fibres retained their original neuromuscular junction type, whereas the doubly-innervated fast-twitch muscle fibres underwent a dramatic transformation of their neuromuscular junction from the fast-muscle to the slow-muscle type. In both doubly innervated fibres, the ultrastructural characteristics of neuromuscular junctions, whether altered or not, were identical at both end-plate regions.     

The formation of the microcirculatory bed of the neuromuscular systems of the tongue in human prenatal ontogeny]

A complex of adequate neurohistological and injection methods with use of mathematical analysis of the data obtained has been performed to study prenatal and early postnatal periods of ontogenesis of the microcirculatory bed of the human tongue neuromuscular systems. Certain changes of the degree in organization and structural-functional integration have been revealed; they demonstrate periodicity of the morphological changes of the vasculo-neural complex of the extra- and intrafusal part of the muscular tissue. In the neuromuscular spindles the microvascular network of capillaries is formed, their volumetric part changes in the process of development in greater degree than the microvascular bed of the extrafusal muscular fibers. In formation of the microcirculatory vascular bed of the neuromuscular spindles not only capillaries, getting into them together with nervous fibers, but also microvessels of the surrounding muscle tissue participate. This determines a higher level of the vascularization degree of the intrafusal muscle fibers.     

Formation of Neuromuscular Junctions and Synthesis of Sensory Neuropeptides in the Co-cultures of Dorsal Root Ganglion and Cardiac Myocytes

Aim The interactions between primary sensory neurons and cardiac myocytes are still unclear. In the present study, the co-culture model of dorsal root ganglion (DRG) explant and cardiac myocytes was used to characterize the morphological relationship between primary sensory nerve endings and cardiac myocytes and to investigate whether cardiac myocytes could induce substance P (SP) and calcitonin gene-related peptide (CGRP) synthesis in DRG neurons and release from DRG neurons in the neuromuscular co-cultures. Methods The formation of neuromuscular junctions was observed with scanning electron microscopy (SEM). SP and CGRP expression were detected by immunocytochemistry. Basal SP and CGRP release and capsaicin-evoked SP and CGRP release were analyzed by radioimmunoassay (RIA). Results In this study, neuromuscular junctions were observed in the co-cultures of DRG explant and cardiac myocytes. SP-immunoreactive (IR) and CGRP-IR neurons were detected in both neuromuscular co-cultures and DRG explant cultures, but the number of SP-IR and CGRP-IR neurons migrating from DRG explant was significantly increased in neuromuscular co-cultures. Capsaicin-evoked SP and CGRP release but not basal SP and CGRP release in neuromuscular co-cultures increased significantly as compared with that in the cultures of DRG explant alone. Conclusions The results implicated that the morphological relationship between sensory nerve terminal and cardiac myocyte is much more close in vitro than it is in vivo. Cardiac myocytes may induce sensory neuropeptide synthesis and capsaicin-evoked neuropeptide release in neuromuscular co-cultures. Further experiment needs to be performed about the significance of neuropeptide synthesis and capsaicin-evoked neuropeptide release induced by target cardiac myocytes. Zhen Liu and Huaxiang Liu contributed equally to this article.     

Further observations concerning the motor innervation of the tensor tympani muscle of the cat

The cat tensor tympani muscle presented an uncommon ultrastructural organization of neuromuscular junctions compared with those in the other striated muscles. In cross sections, individual neuromuscular junctions had very extended contact area of the nerve terminal and muscle fiber, the terminal bouton was covering as a "calyx" the postjunctional muscle fiber. Long basal lamina was interposed between them. The sarcolemma at the level of the nerve terminal had multiple infoldings along its length, or smooth postjunctional muscle membrane was found beneath endings on both fiber types.     

Structural alterations at the neuromuscular junctions of matrix metalloproteinase 3 null mutant mice

Matrix metalloproteinases are important regulators of extracellular matrix molecules and cell-cell signaling. Antibodies to matrix metalloproteinase 3 (MMP3) recognize molecules at the frog neuromuscular junction, and MMP3 can remove agrin from synaptic basal lamina (VanSaun & Werle, 2000). To gain insight into the possible roles of MMP3 at the neuromuscular junction, detailed observations were made on the structure and function of the neuromuscular junctions in MMP3 null mutant mice. Striking differences were found in the appearance of the postsynaptic apparatus of MMP3 null mutant mice. Endplates had an increased volume of AChR stained regions within the endplate structure, leaving only small regions devoid of AChRs. Individual postsynaptic gutters were wider, containing prominent lines that represent the AChRs concentrated at the tops of the junctional folds. Electron microscopy revealed a dramatic increase in the number and size of the junctional folds, in addition to ectopically located junctional folds. Electrophysiological recordings revealed no change in quantal content or MEPP frequency, but there was an increase in MEPP rise time in a subset of endplates. No differences were observed in the rate or extent of developmental synapse elimination. In vitro cleavage experiments revealed that MMP3 directly cleaves agrin. Increased agrin immunofluorescence was observed at the neuromuscular junctions of MMP3 null mutant mice. These results provide strong evidence that MMP3 is involved in the control of synaptic structure at the neuromuscular junction and they support the hypothesis that MMP3 is involved in the regulation of agrin at the neuromuscular junction.     

Development of neuromuscular spindles in the muscles of the floor of the human oral cavity during intrauterine development]

By means of histological, neurohistological, histochemical and morphometrical techniques the development, number and histotopography of neuromuscular spindles have been studied in 860 muscles of the mouth cavity fundus obtained from 108 human embryos, fetuses and newborns. In genioglossal and in geniohyoid muscles, the spindles are layed down at the 7th week of gestation. Their differentiation starts at the 9th week -- with forming the first sensitive endings, nuclear bursa and cellular elements of the spindle capsule. By the 14th week, the subcapsular space becomes evident, and by the 20th week of embryogenesis neuromuscular spindles resemble definitive structures. In the anterior belly of the digastric muscle, the foundation and initial differentiation of the spindles is retarded. The mylohyoid muscle has no spindles. Morphogenesis of neuromuscular spindles has been studied with special reference to the beginning of functional activity of the fundal muscles in the mouth cavity during embryogenesis in view of the theory of systemogenesis.