Protective Reflexes Research Articles

Factors To Be Evaluated in Children Undergoing Dental Treatment Under General Anaesthesia - A Retrospective Study

Introduction: General anaesthesia is the reversible state of unconsciousness that results in coma with loss of protective reflexes. GA in dentistry is the most cost effective and practiced mode of treatment. A definite group of patients who are not cooperative to the normal treatment will be treated only by giving general anesthesia. The potential risk factors for the usage of GA are emergency surgery, anaesthesiologist error, fluctuations in Blood pressure and Heart rate, Palor, Jaundice, Cyanosis and cardiovascular and pulmonary problems. Aim: The aim was to examine factors evaluated among children undergoing general anaesthesia for dental rehabilitation. Materials and methods: The study was implemented in a private dental institution, Chennai, India. Ethical approval was obtained from the Institutional review board prior to the start of the study. Total 140 children treated under GA were included in the study. Data was collected with following parameters like age, Gender, pallor, Jaundice, cyanosis, Blood pressure, Respiratory system examination, Cardiovascular system examination. The collected data was divided into 3 groups 0-5, 6-10 and 11-15 years and was analysed using SPSS statistical software. Data analysis done using chi square test and pearson correlation was done. p value < 0.005 was considered statistically significant. Results and Discussion: In a total of 140 patients, different factors such as pallor. jaundice were taken in consideration and the analysis was done with comparison of ages. It is seen that most of the children who are accepted for the procedure are children in the age group of 0-5 years, followed by 6-10 years and the least percentage of acceptance is 11-15 years. Conclusion: Within the limits of the study, some factors have been examined by the dental practitioner before General Anesthesia. Majority of the children show the absence of the pallor, jaundice and cyanosis.

A Retrospective Analysis of Foreign Body Ingestions Among the Pediatric Age Group in a Tertiary Care Hospital in Jeddah, Saudi Arabia.

Foreign body ingestion (FBI) among the pediatric age group is considered a major clinical problem that can cause life-threatening complications, as it can obstruct the airway due to poor/immature airway protection reflexes. In this study, we aimed to retrospectively describe the epidemiology, clinical characteristics, and outcomes of FBI among the pediatric age group in Dr. Soliman Fakeeh Hospital, Jeddah, Saudi Arabia. We conducted a retrospective study of pediatric patients (0-14 years) presenting to a tertiary care hospital in Jeddah, Saudi Arabia, from January 2019 to October 2022. The study reviewed records of patients with FBI in the emergency department. Data collection included age, gender, comorbidities, foreign body (FB) type, anatomical location, presenting symptoms, time to emergency room (ER) presentation, need for endoscopy, and complications. We performed a statistical analysis using the Statistical Package for Social Sciences (SPSS) 25 (IBM SPSS Statistics, Armonk, NY), where p<0.05 was considered statistically significant. We identified 244 FBI cases, with most cases being male (62.7%). The most common site of FB impaction was the stomach (38.9%), followed by the upper esophagus (29.1%). Clinical presentation was variable, with 20.5% of cases experiencing vomiting, 13.5% experiencing drooling, and 9.4% experiencing dysphagia. Out of 244 cases, 132 (54.1%) were referred to gastroenterology for urgent FB removal by endoscopy. A total of 186 cases (76.2%) did not have complications, whereas 3.6% had serious sequela. The association between age and FBI was statistically significant (p=0.00), whereas there was no association between gender and FBI. Our results showed that FB ingestion was prevalent among children at our tertiary care hospital, with urgent endoscopy being the most common removal procedure. Early detection and immediate presentation to the emergency room are crucial for preventing complications. Common FBI included coins and batteries, with most incidents in 1-3-year-old males. Parents should be aware of the dangers of FBI and implement preventive measures to reduce its incidence.

Phytotherapy of respiratory infections in children: Iceland moss syrup as a new treatment for dry cough. A review

Regardless of the season, cough is one of the most common reasons for visiting a doctor, especially during the period of a high incidence of acute respiratory infections and other diseases manifested by cough, including long-term cough (laryngitis, tracheitis, bronchitis, pneumonia, tuberculosis, asthma, and other diseases). Patients often seek medical advice at a pharmacy without first seeing a doctor. In most cases, the cough is a protective reflex that helps to clear the accumulated bronchial secretion; however, it can significantly worsen the patient's condition and quality of life in adults and children. It negatively impacts the quality of life when the cough is still dry and unproductive, or the sputum is very thick. The article addresses various aspects of using herbal medicinal products of the Herbion series for various cough types, including post-infectious cough. Evidence supports using herbal medicinal products for dry and productive cough and a novel product from the Herbion series, Iceland moss syrup, for treating dry cough, including in children from 1 year.

Safety of removal of ProSeal laryngeal mask airway in children in the supine versus lateral position in a deep plane of anesthesia: A randomized controlled trial.

When a ProSeal laryngeal mask airway (PLMA) is removed with the child in a deep plane of anesthesia, the upper airway muscle tone and protective upper airway reflexes may be obtunded. To determine whether the supine or lateral position is safer for the removal of a PLMA in deeply anesthetized children by comparing the incidence of upper airway complications. This randomized single-blind comparative trial was conducted at a tertiary care hospital between January 2020 and September 2020. Forty children of the American Society of Anesthesiologists class I/II of ages 1-12 years age undergoing surgery under general anesthesia with PLMA used as the definitive airway device were recruited. Patients were randomly allocated to lateral group or supine group for PLMA removal in a deep plane of anesthesia in the lateral or supine position. The primary outcome was the number of patients experiencing one or more upper airway complications and the secondary outcomes were incidence of individual respiratory adverse effects and of severe airway complications. The incidence of airway complications was 30% in the supine group and 20% in the lateral group (P = 0.6641). Incidence of laryngospasm, immediate stridor, and excessive secretions were similar. Early stridor and oxygen desaturation were higher in the supine group (P = 0.0374, P = 0.0183 respectively). The overall incidence of upper airway complications was similar with the removal of a PLMA in the supine or lateral position in deeply anesthetized children. The incidence of oxygen desaturation and stridor were higher with PLMA removal in the supine as compared to the lateral position.

Sharbat Zoofa Murakkab, A Promising Unani Formulation for Sual (Cough)

It has been described that Sual (cough) is the movement of lungs to remove or reduce the painful stress on the lungs). Cough is a physiologically useful protective reflex that clears the respiratory tract. It occurs due to stimulation of chemo receptors in throat, respiratory passages or stretch receptors in the lungs. According to Unani scholars, Sual (cough) is an act by which Tabiyat removes Aziyat (irritating substances) from the lungs, cough with mucus and sputum. It affects mainly quality of life, works productivity and public health resources etc. The drugs available in the modern medicine produce more or less side effects in the human body. The Unani classical formulation is traditionally used for the treatment of cough, early stages of asthma and useful in bronchial Asthma, phlegmatic cough. Expel phlegm from the chest. It is used to clear mucus from the chest and clear chest congestion. It is 100% natural and vegetarian product. No side effects of Sharbat Zoofa Murakkab mentioned and reported in Unani classical literature and a clinical study was conducted by the Central Council for Research in Unani Medicine under Ministry of AYUSH, Government of India, more studies are required to validate the Pharmacopeial formulation on large scale.

Anodal transcranial direct current stimulation over the right primary somatosensory cortex increases cough reflex sensitivity: a pilot randomised controlled crossover trial.

The cough reflex is a protective reflex of the human body. Increases or decreases in cough reflex sensitivity may be related to chronic cough, aspiration pneumonia and other diseases. The right primary somatosensory cortex (RS1) is the main activation centre for the urge to cough. Here, we discuss the effects of transcranial direct current stimulation (tDCS) of RS1 on the cough reflex and urge to cough. In addition, we explored the role of the left dorsolateral prefrontal cortex (lDLPFC) in cough using tDCS. 24 healthy young adults completed this pilot randomised controlled crossover experiment. Each person was tested three times, receiving, in random order, anodal tDCS of RS1 or lDLPFC or sham stimulation. The current intensity was set to 2 mA, the stimulation time was 30 min and the interval between any two stimuli was ≥1 week. After each intervention, the citric acid cough challenge test was used immediately to assess the urge to cough and cough reflex sensitivity. The cough reflex thresholds, expressed as LogC2 and LogC5, were significantly reduced after RS1 anodal stimulation compared to sham stimulation, accompanied by increased urge-to-cough sensitivity (urge-to-cough log-log slope 1.19±0.40 point·L·g-1 versus 0.92±0.33 point·L·g-1, p=0.001), but the threshold for the urge to cough did not change significantly. There were no significant changes in the urge to cough and cough reflex sensitivity after tDCS anodal lDLPFC stimulation. Anodal tDCS stimulation of the RS1 can increase urge-to-cough sensitivity and reduce cough reflex threshold. The effects of tDCS on cough reflex, as well as the underlying mechanisms driving those effects, should be explored further.

Effect of compound chamomile and lidocaine hydrochloride gel on oropharyngeal complications after the use of laryngeal mask airway with positive pressure ventilation

Objective: To evaluate the effect of compound chamomile and lidocaine hydrochloride gel on oropharyngeal complications after the use of laryngeal mask airway with positive pressure ventilation. Methods: A total of 64 patients undergoing elective surgery under general anesthesia using laryngeal mask airway (LMA) with positive pressure ventilation in Beijing Tongren Hospital Affiliated to Capital Medical University From January to March 2023 were prospectively selected and divided into two groups by the random number table method: normal saline group (n=32), with 18 males and 14 females, aged 28-64 (48.4±10.6) years, and the compound chamomile and lidocaine hydrochloride gel group (chamomile gel group, n=32), with 18 males and 14 females, aged 24-64 (46.3±10.8) years. Patients in both groups received total intravenous anesthesia. Before LMA placement, the front, shoulder and back of LMA were lubricated with normal saline and compound chamomile and lidocaine hydrochloride gel in the normal saline group and the chamomile gel group, respectively. The main outcome measure was the incidence of postoperative oropharyngeal mucosal inflammation at different time points after the removal of the laryngeal mask. Secondary outcome measures included oropharyngeal mucositis score, sore throat score, hoarse voice score, cough score and throat dryness score at different time points after LMA removal, the number of LMA insertion times, time of successful insertion and leakage pressure, as well as stress reactions such as cough and agitation before and after LMA removal, and adverse reactions such as tongue numbness and protective pharyngeal reflex limitation during recovery. Results: The incidence of oropharyngeal mucositis in the chamomile gel group was 25.0% (8/32), 31.3% (10/32), 28.1% (9/32) and 3.1% (1/32) at 0.5, 3, 6 and 24 h after LMA removal, respectively, which were lower than those of normal saline group [53.1% (17/32), 59.4% (19/32), 59.4% (19/32) and 21.9% (7/32)] (all P<0.05). The oropharyngeal mucositis scores of patients in the chamomile gel group were 0 (0, 0.8), 0 (0, 1.0), 0 (0, 1.0) and 0 (0, 0) respectively at 0.5, 3, 6 and 24 h after LMA removal, which were lower than those in the saline group [1.0 (1.0, 1.8), 1.0 (0, 2.0), 1.0 (0, 2.0) and 0 (0, 0)] (all P<0.05). The cough score of the patients in the chamomile gel group was 0 (0, 0) and 0 (0, 0) at 3, 6 h after LMA removal, which were lower than those of the normal saline group [(0, 0) and 0 (0, 0)] (both P<0.05). The throat dryness score of the patients in the chamomile gel group was 0 (0, 1.0) at 3 h after LMA removal, which was lower than that of the normal saline group [1.0 (0.3, 1.0)] (P=0.019). The time of successful LMA insertion in the chamomile gel group was 25.0 (20.3, 29.8) s, which was shorter than that in the saline group [29.0 (25.0, 32.0) s] (P=0.016). There were no significant differences in the number of LMA insertion, leakage pressure, postoperative sore throat and hoarse voice scores between the two groups (all P>0.05). Likewise, there were no stress reactions such as cough and agitation before and after LMA removal, and no adverse reactions such as tongue numbness and limited protective pharyngeal reflex during recovery. Conclusion: Compound chamomile and hydrochloride lidocaine gel can reduce the incidence of postoperative oropharyngeal mucositis, relieve the symptoms of postoperative oropharyngeal mucositis, pharyngeal dryness and cough, and improve the postoperative comfort of patients using the laryngeal mask airway with positive pressure ventilation.

Procedural (Conscious) Sedation and Analgesia in Emergency Setting: How to Choose Agents?

Pain has long been defined as an unpleasant sensory and emotional experience originating from any region of the body in the presence or absence of tissue injury. Physicians involved in acute medicine commonly undertake a variety of invasive and painful procedures that prompt procedural sedation and analgesia (PSA), which is a condition sparing the protective airway reflexes while depressing the patient's awareness of external stimuli. This state is achieved following obtaining the patient's informed consent, necessary point-ofcare monitoring, and complete recording of the procedures. The most commonly employed combination for PSA mostly comprises short-acting benzodiazepine (midazolam) and a potent opioid, such as fentanyl. The biggest advantage of opioids is that despite all the powerful effects, upper airway reflexes are preserved and often do not require intervention. Choices of analgesic and sedative agents should be strictly individualized and determined for the specific condition. The objective of this review article was to underline the characteristics, effectiveness, adverse effects, and pitfalls of the relevant drugs employed in adults to facilitate PSA in emergency procedures.

Dysphagia

Swallowing is a complex interplay of nerves, muscles and protective reflexes which involves both involuntary and voluntary phases. Difficulty swallowing can occur due to a variety of underlying pathologies, but can broadly be differentiated into high (oropharyngeal) and low (oesophageal) dysphagia. Using case scenarios this article will highlight common dysphagia presentations encountered in general practice and their appropriate history, examination, investigation and management.

Concurrent, dual perturbations of the 5-HT and NA systems reveal dynamic interplay in regulating the neonate autoresuscitation reflex

Sudden Infant Death Syndrome (SIDS) is a leading cause of infant mortality worldwide. Postmortem studies indicate abnormalities in the serotonergic (5-HT) and noradrenergic (NA) systems of the respiratory network. To better understand the relative and potential combined contributions and interactions of these two neurotransmitter systems to SIDS pathology, we developed a novel series of conditionally expressed inhibitory (hM4De) and excitatory (hM3D) DREADD models that allows for singular excitation or inhibition of either the whole 5-HT or whole NA systems as defined by cre- and FLPo- drivers. These models were then uniquely combined to further enable 1) concurrent stimulation or inhibition of both the NA and 5-HT systems in the same animal or 2) inhibition of one system while exciting the other system in the same animal. In total, after two years of complex breeding combining 3 loci and 6 alleles, we developed 8 distinct sets of conditional genetic mouse models for various singular and combined 5-HT and NA system perturbation paradigms.Failure of the neonate auto-resuscitation reflex is hypothesized to be a common endpoint in many SIDS cases. The autoresuscitation reflex can be readily assayed in neonate mice by repeated bouts of exposure to an anoxic gas to induce bradycardia and apnea followed by restoration of room air to observe successful or failed autoresuscitation. The 8 experimental groups and 2 control groups were repeatedly assayed for the autoresuscitation reflex using a new closed loop robotic neonate cardiorespiratory assessment platform and outcomes were analyzed with our recently developed comprehensive respiratory analysis platform, Breathe Easy, to calculate operant outcomes. In &gt;170 mouse pups (≈17 pups per group) assayed over three months, we found that singular DREADD-mediated activation or inhibition of the NA system results in decreased survival. Interestingly, we found that DREADD-mediated 5-HT activation decreases survival. In contrast to previous studies, we found that DREADD-mediated 5-HT inhibition does not impact survival, particularly when all neonates are challenged to autoresuscitation failure. Furthermore, we show survival is restored to control levels when NA inhibition is combined with 5-HT inhibition; however, failure via NA activation is not rescued by 5-HT inhibition. Controls used for comparison were CNO-injected controls as we also show an effect of CNO on survival that cannot be attributed to time of day, rig, experimenter, weight, background genotype, etc. As the underlying genetic and environmental mechanisms driving SIDS are likely to have pleiotropic effects across multiple neural systems, our first-of-its-kind dual 5-HT and NA system modulations sets the stage to more comprehensively model key aspects of SIDS neuropathology that reveal a previously uncharacterized dynamic functional interplay between the NA and 5-HT systems in protective respiratory reflexes. NIH: 1F32HL160073-01A1, R01HL130249 44617-S4. BCM McNair Scholar Program, March of Dimes Basil O'Connor Research Award, Parker B. Francis Fellowship, CJ Foundation for SIDS. This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

The Nasal Solitary Chemosensory Cell Signaling Pathway Triggers Mouse Avoidance Behavior to Inhaled Nebulized Irritants.

The nasal epithelium houses a population of solitary chemosensory cells (SCCs). SCCs express bitter taste receptors and taste transduction signaling components and are innervated by peptidergic trigeminal polymodal nociceptive nerve fibers. Thus, nasal SCCs respond to bitter compounds, including bacterial metabolites, and these reactions evoke protective respiratory reflexes and innate immune and inflammatory responses. We tested whether SCCs are implicated in aversive behavior to specific inhaled nebulized irritants using a custom-built dual-chamber forced-choice device. The behavior of mice was recorded and analyzed for the time spent in each chamber. Wild-type (WT) mice exhibited an aversion to 10 mm denatonium benzoate (Den) or cycloheximide and spent more time in the control (saline) chamber. The SCC-pathway knock-out (KO) mice did not exhibit such an aversion response. The bitter avoidance behavior of WT mice was positively correlated with the concentration increase of Den and the number of exposures. Bitter-ageusic P2X2/3 double KO mice similarly showed an avoidance response to nebulized Den, excluding the taste system's involvement and pointing to an SCC-mediated major contributor to the aversive response. Interestingly, SCC-pathway KO mice showed an attraction to higher Den concentrations; however, chemical ablation of the olfactory epithelium eliminated this attraction attributed to the smell of Den. These results demonstrate that activation of SCCs leads to a rapid aversive response to certain classes of irritants with olfaction, but not gustation, contributing to the avoidance behavior during subsequent irritant exposures. This SCC-mediated avoidance behavior represents an important defense mechanism against the inhalation of noxious chemicals.

Practical guide for safe sedation.

This practical guide has been developed to ensure safe and effective sedation performed in adult patients outside of the operating room, for instance in intensive care units and dental treatment rooms and in the field of palliative care. Sedation levels are classified based on level of consciousness, airway reflex, spontaneous ventilation, and cardiovascular function. Deep sedation induces loss of consciousness and protective reflexes, and can cause respiratory depression and pulmonary aspiration. Invasive medical procedures necessitating deep sedation include cardiac ablation, endoscopic submucosal dissection, and internal radiation therapy. Appropriate analgesia is necessary for procedures that require deep sedation. The sedationist should evaluate the risks of the planned procedure, explain the sedation process to the patient, and obtain the patient's informed consent. Major parameters to be evaluated preoperatively are the patient's airway and general condition. Equipment, instruments, and drugs necessary for emergency situations should be defined and routinely maintained. To prevent aspiration, patients scheduled for moderate or deep sedation should fast preoperatively. In both inpatients and outpatients, biological monitoring should be continued until the discharge criteria are met. Anesthesiologists should be involved in management systems that ensure safe and effective sedation even if they do not personally perform all sedation procedures.

The superior cervical ganglion is involved in chronic chemoreflex sensitization during recovery from acute lung injury.

Introduction: Acute lung injury (ALI) initiates an inflammatory cascade that impairs gas exchange, induces hypoxemia, and causes an increase in respiratory rate (fR). This stimulates the carotid body (CB) chemoreflex, a fundamental protective reflex that maintains oxygen homeostasis. Our previous study indicated that the chemoreflex is sensitized during the recovery from ALI. The superior cervical ganglion (SCG) is known to innervate the CB, and its electrical stimulation has been shown to significantly sensitize the chemoreflex in hypertensive and normotensive rats. We hypothesized that the SCG is involved in the chemoreflex sensitization post-ALI. Methods: We performed a bilateral SCG ganglionectomy (SCGx) or sham-SCGx (Sx) in male Sprague Dawley rats 2weeks before inducing ALI (Week -2 i.e., W-2). ALI was induced using a single intra-tracheal instillation of bleomycin (bleo) (day 1). Resting-fR, Vt (Tidal Volume), and V̇ E (Minute Ventilation) were measured. The chemoreflex response to hypoxia (10% O2, 0% CO2) and normoxic-hypercapnia (21% O2, 5% CO2) were measured before surgery on W (-3), before bleo administration on W0 and on W4 post-bleo using whole-body plethysmography (WBP). Results: SCGx did not affect resting fR, Vt and V̇E as well as the chemoreflex responses to hypoxia and normoxic hypercapnia in either group prior to bleo. There was no significant difference in ALI-induced increase in resting fR between Sx and SCGx rats at W1 post-bleo. At W4 post-bleo, there were no significant differences in resting fR, Vt, and V̇E between Sx and SCGx rats. Consistent with our previous study, we observed a sensitized chemoreflex (delta fR) in response to hypoxia and normoxic hypercapnia in Sx rats at W4 post-bleo. However, at the same time, compared to Sx rats, the chemoreflex sensitivity was significantly less in SCGx rats in response to either hypoxia or normoxic hypercapnia. Discussion: These data suggest that SCG is involved in the chemoreflex sensitization during ALI recovery. Further understanding of the underlying mechanism will provide important information for the long-term goal of developing novel targeted therapeutic approaches to pulmonary diseases to improve clinical outcomes.

Invasive Mechanical Ventilation in Traumatic Brain Injured Patients with Acute Respiratory Failure.

Patients with severe traumatic brain injury (TBI) need to be admitted to intensive care (ICU) because they require invasive mechanical ventilation (IMV) due to reduced consciousness resulting in loss of protective airway reflexes, reduced ability to cough and altered breathing control. In addition, these patients can be complicated by pneumonia and acute distress syndrome (ARDS). IMV allows these patients to be sedated, decreasing intracranial pressure and ensuring an adequate oxygen delivery and tight control of arterial carbon dioxide tension. However, IMV can also cause dangerous effects on the brain due to its interaction with intrathoracic and intracranial compartments. Moreover, when TBI is complicated by ARDS, the setting of mechanical ventilation can be very difficult as ventilator goals are often different and in conflict with each other. Consequently, close brain and respiratory monitoring is essential to reduce morbidity and mortality in mechanically ventilated patients with severe TBI and ARDS. Recently, recommendations for the setting of mechanical ventilation in patients with acute brain injury (ABI) were issued by the European Society of Intensive Care Medicine (ESICM). However, there is insufficient evidence regarding ventilation strategies for patients with ARDS associated with ABI. The purpose of this paper is to analyze in detail respiratory strategies and targets in patients with TBI associated with ARDS.

Silica nanoparticles inhibit responses to ATP in human airway epithelial 16HBE cells.

Besides its role in gas exchange, the airway epithelium exerts protective responses against environmental insults. Epithelial cells and sensory neurons lining up the airway epithelium can sense the presence of and the damage induced by various foreign substances and react by triggering protective reflexes, such as enhanced mucociliary clearance, initiation of cough and induction of inflammation. As a result of nano-technological development, the exposure of the general population to airborne nanomaterials has increased in the past decades, raising concerns about the toxicity of such particulates. Because of their low cost, easy production and versatility, silica nanoparticles (SiNPs) are widely used in multiple manufacturing applications as anti-caking, densifying and hydrophobic agents and are among the most highly produced nanomaterials worldwide. SiNPs affect the function of the airway epithelium, but the biochemical pathways targeted by these particles remain largely unknown. SiNPs have been repeatedly shown to induce release of damage-associated molecular pattern ATP in exposed cells. We have investigated the effects of SiNPs on the responses of 16HBE14o- cultured human bronchial epithelial (16HBE) cells to extracellular ATP, using measurements of intracellular Ca2+ concentration. Upon stimulation with extracellular ATP, these cells displayed a concentration-dependent increase in intracellular Ca2+, which was mediated by release from intracellular stores. SiNPs induced a dose-dependent Ca2+ increase and inhibited the Ca2+ responses to ATP. The latter effect occurred within minutes of application and at low µg/ml concentrations, which are significantly faster and more potent than those previously reported for the induction of cellular toxicity and pro-inflammatory responses. SiNPs-induced inhibition is independent from the increase in intracellular Ca2+ they produce, is largely irreversible and occurs via a non-competitive mechanism. These findings suggest that SiNPs reduce the ability of epithelial cells to support defensive responses via ATP-dependent signaling.

Alterations in Pulmonary Physiology with Lung Transplantation.

Lung transplant is a treatment option for patients with end-stage lung diseases; however, survival outcomes continue to be inferior when compared to other solid organs. We review the several anatomic and physiologic changes that result from lung transplantation surgery, and their role in the pathophysiology of common complications encountered by lung recipients. The loss of bronchial circulation into the allograft after transplant surgery results in ischemia-related changes in the bronchial artery territory of the allograft. We discuss the role of bronchopulmonary anastomosis in blood circulation in the allograft posttransplant. We review commonly encountered complications related to loss of bronchial circulation such as allograft airway ischemia, necrosis, anastomotic dehiscence, mucociliary dysfunction, and bronchial stenosis. Loss of dual circulation to the lung also increases the risk of pulmonary infarction with acute pulmonary embolism. The loss of lymphatic drainage during transplant surgery also impairs the management of allograft interstitial fluid, resulting in pulmonary edema and early pleural effusion. We discuss the role of lymphatic drainage in primary graft dysfunction. Besides, we review the association of late posttransplant pleural effusion with complications such as acute rejection. We then review the impact of loss of afferent and efferent innervation from the allograft on control of breathing, as well as lung protective reflexes. We conclude with discussion about pulmonary function testing, allograft monitoring with spirometry, and classification of chronic lung allograft dysfunction phenotypes based on total lung capacity measurements. We also review factors limiting physical exercise capacity after lung transplantation, especially impairment of muscle metabolism. © 2023 American Physiological Society. Compr Physiol 13:4269-4293, 2023.

Chronic cough

Coughing is an important protective reflex of the respiratory tract and primarily serves clearance of the bronchial system. It is also an exceptionally common symptom in outpatient care that can be an expression of avariety of diseases. Coughing duration of longer than 8weeks is referred to as chronic cough. Astructured, often interdisciplinary diagnostic process is essential. The aim here is to identify causal treatment options, avoiding overdiagnosis and simultaneously not overlooking severe illness. This article discusses current diagnostic procedures, important differential diagnoses and possible treatment options.

Molecular taxonomy of nociceptors and pruriceptors.

Molecular taxonomy of nociceptors and pruriceptors.

Traumatic Amourosis in the Management of Panfacial Traum: A Case Report

Traumatic orbital injuries following maxillofacial trauma occur significantly with the most common etiology being road traffic accidents. Despite natural protective anatomy and reflexes of the eye the injuries to the orbital following facial fractures have a higher degree of vulnerability. The injury so sustained leads to greater morbidity, which may be due to loss of vision. Cases of traumatic amaurosis is seldom reported in the literature. The present article presents a case of closed head injury with pan-facial trauma associated with symptomatic traumatic amaurosis of the left orbit which was managed by conventional open reduction and internal fixation followed by orbital evisceration.

Circumferential upper extremities burn, bilateral Dupuytren's disease and COVID-19 disease – an unfavorable triad: a case report

Upper extremities are frequently involved in fire burns due to the natural protective reflexes. The presence of bilateral Dupuytrenʼs disease and COVID-19 disease in patients with circumferential upper extremity burns can negatively impact the outcome, through severe contracture and a tendency to hypoxia or infections, which affects normal wound healing. Enzymatic debridement with a concentrate of proteolytic enzymes enriched in bromelain prevents compartment syndrome development in such patients, reduces blood loss, surgery duration, and appears to favor a more rapid recovery.