Peter B. Rosenberger

Autism and Unfavorable Left-Right Asymmetries of the Brain.

Utilizing computerized brain tomography, left-right morphologic asymmetries of the parietooccipital region were judged in 16 autistic patients, 44 mentally retarded patients, and 100 miscellaneous neurological patients. In 57% of the autistic patients the right parietooccipital region was wider than the left, while this pattern of cerebral asymmetry was found in only 23% of the mentally retarded patients and 25% of the neurological patients. It is suggested that unfavorable morphologic asymmetries of the brain near the posterior language zone may contribute to the difficulties autistic children experience in acquiring language.

Impact of Intraoperative Transesophageal Echocardiography on Surgical Decisions in 12,566 Patients Undergoing Cardiac Surgery

BACKGROUNDnThe utility of intraoperative transesophageal echocardiography (TEE) for different types of cardiac surgical procedures has not been thoroughly investigated despite its increasing popularity. Therefore, we retrospectively evaluated the impact of before and after cardiopulmonary bypass (CPB) TEE on surgical decisions in 12,566 consecutive patients undergoing cardiac surgery at a single institution.nnnMETHODSnWe analyzed all patients undergoing cardiac surgical procedures who had an intraoperative TEE examination between 1990 and 2005 at the Brigham and Womens Hospital. Results of the TEE examinations were entered into a database. Previously undiagnosed TEE findings from the pre- and post-CPB examinations that directly impacted surgical decisions were evaluated.nnnRESULTSnBefore and after CPB TEE examinations influenced surgical decision making in 7.0% and 2.2%, respectively, of all evaluated patients (n = 12,566). In patients undergoing only coronary artery bypass graft surgery (CABG [n = 3,835]), surgical decisions were influenced by 5.4% of the pre-CPB and 1.5% of the post-CPB TEE examinations, and in 6.3% and 3.3%, respectively, of those patients undergoing isolated valve procedures (n = 3,840). In combined CABG and valve procedures (n = 2,944), surgical decisions were influenced by 12.3% of the pre-CPB and 2.2% of the post-CPB TEE examinations.nnnCONCLUSIONSnIntraoperative TEE influences cardiac surgical decisions in more than 9% of all patients in the presented study population, with the greatest observed impact in patients undergoing combined CABG and valve procedures.

Intelligence and physical features of children of women with epilepsy

The teratogenicity of maternal epilepsy has been attributed to several factors, including the antiepileptic drugs taken to prevent seizures during pregnancy, the occurrence of seizures during pregnancy, and the factors in the mother that caused her to have epilepsy. We have addressed the hypothesis that the children of women who have a history of epilepsy (seizure history), but who took no antiepileptic drugs (AED) and had no tonic-clonic seizures in pregnancy, have an increased risk of malformations and diminished intelligence. The frequency of cognitive dysfunction was determined in 57 seizure history and 57 matched control children aged 6-l6 years. The masked evaluation of the children included a physical and neurologic examination and testing with the Wechsler Intelligence Scale for Children-Revised (WISC-R) and a systematic physical examination for the features of the fetal AED syndrome. The evaluation of both parents of each child included a test of reasoning (Ravens Progressive Matrix) and a physical examination. There were no differences between the two groups of children in either IQ scores or physical features; none of the seizure history children was judged to have the anticonvulsant face or digit hypoplasia. This study had 80% power to rule out a difference of seven or more IQ points between the two groups, based on a two-sided test at a 5% level of significance. Our confidence in concluding that there was no difference between seizure history and control infants was strengthened by the fact that no statistically significant differences were observed with respect to multiple outcomes, including eight related measures of intelligence. Thirty (53%) of the seizure history mothers resumed taking AED after the birth of the child we evaluated. Additional studies are needed to address the teratogenicity of the antiepileptic drugs as monotherapy.

Identification of vasodilator-stimulated phosphoprotein (VASP) as an HIF-regulated tissue permeability factor during hypoxia

Increased tissue permeability is commonly associated with hypoxia of many origins. Since hypoxia‐inducible factor (HIF) represents a predominant hypoxia signaling mechanism, we compared hyp‐oxia‐elicited changes in tissue barrier function in mice conditionally lacking intestinal epithelial hypoxia‐inducible factor‐1α (hifla). Somewhat surprisingly, these studies revealed that mutant hifla mice were protected from hypoxia‐induced increases in intestinal permeability in vivo. Guided by microarray analysis of tissues derived from these mutant hifla mice, we identified HIF‐1‐dependent repression of vasodilator‐stimulated phosphoprotein (VASP), a molecule known to be important in the control of cytoskeletal dynamics, including barrier function. Studies at the mRNA and protein level confirmed hypoxia‐elicited repression of VASP in murine tissue, cultured epithelia and endothelia, as well as human saphenous vein ex vivo. Targeted repression of VASP by siRNA recapitulated our findings with hypoxia and directed overexpression of VASP abolished hypoxia‐induced barrier dysfunction. Studies in the cloned human VASP promoter revealed hypoxia‐dependent transcriptional repression, and functional studies by chromatin immunoprecipitation (ChIP) and site‐directed mutagenesis revealed hypoxia‐dependent binding of HIF‐1α to the human VASP promoter. These studies identify HIF‐1‐dependent repression of VASP as a control point for hypoxia‐regulated barrier dysfunction.—Rosenberger, P., Khoury, J., Kong, T., Weissmuller, T., Robinson, A. M., Colgan, S. P. Identification of vasodilator‐stimulated phosphoprotein (VASP) as an HIF‐regulated tissue permeability factor during hypoxia. FASEB J. 21, 2613–2621 (2007)

Critical Care Issues in the Patient After Major Joint Replacement

Admission rates of orthopedic patients to intensive care units are increasing. Thus, an intensivists familiarity with specific problems associated with major joint replacement surgery is of utmost importance in order to meet the needs of this particular patient population. In this article, the authors review the most commonly encountered complications after major hip and knee arthroplasty. Perioperative risk factors for morbidity and mortality and the epidemiology, diagnosis, and treatment of cardiopulmonary complications in this patient population are discussed. Procedure-specific complications such as fat embolism and acrylic bone cement—related issues are reviewed.

Attention deficits and hyperactivity

SummaryThe precise nature of the relationship among attention deficit, hyperkinesis, and specific learning disabilities remains a mystery. They are encountered in one another’s company with far greater than chance frequency. It is clear, on the one hand, that attention deficit and learning disability aggravate one another; that is, that what is difficult to learn is difficult to attend to, and vice versa. Furthermore, in children at least, attending ability and activity level have a reciprocal relationship; that is, improvement of attention tends to reduce activity level, and vice versa. On the other hand, each of these disorders is seen in isolation with sufficient frequency to assure us that none of the three is simply a by-product of one or both of the other two.

[Intraoperative echocardiography: impact on surgical decision-making].

ZusammenfassungSeit der Einführung der intraoperativen Echokardiographie in die Klinik Mitte der 1970er Jahre sind deren Anwendung und Nutzen im perioperativen Bereich stetig gewachsen. Die intraoperative Echokardiographie spielt vor allem bei herzchirurgischen Patienten eine bedeutende Rolle. Hier stehen dem Untersucher mit der transösophagealen Echokardiographie (TEE) und der epiaortalen Sonographie (EUS) zwei wichtige diagnostische Untersuchungstechniken zur Verfügung. Mit der intraoperativen TEE können Befunde erhobenen werden, die Einfluss auf das chirurgische Management haben und somit das Outcome eines Patienten beeinflussen können. Aber auch bei nichtkardiochirurgischen Patienten kann der Einsatz der TEE sinnvoll sein und zu einer Verbesserung des intraoperativen Managements bei Hochrisikopatienten beitragen. Zudem kann die TEE bei Patienten, die intraoperativ hämodynamisch instabil werden oder kardiopulmonal reanimiert werden müssen, zur Klärung der Ursache beitragen. Durch den in der TEE erhobenen Befund kann so möglicherweise eine weiterführende Therapie veranlasst werden. Ein Vorteil der TEE ist hierbei, dass diese ohne Unterbrechung der chirurgischen Versorgung des Patienten durchgeführt werden kann.AbstractSince the introduction of intraoperative echocardiography into clinical practice in the 1970’s its use and utility in the perioperative period has become increasingly more evident. Especially in patients undergoing cardiac surgical procedures intraoperative echocardiography has gained great diagnostic importance. Intraoperative transesophageal echocardiography (TEE) and epiaortic ultrasound are two important and complementing diagnostic modalities in this patient population. The clinical information obtained with intraoperative TEE in certain cases might have a direct impact on surgical decision-making and therefore may positively influence patient outcome. In patients undergoing non-cardiac surgical procedures, TEE can be a valuable tool in high-risk patients, in patients experiencing hemodynamic instability or in those suffering intraoperative cardiac arrest. Intraoperative TEE might allow a primary diagnosis of the underlying etiology and facilitate the institution of further therapeutic interventions. In addition TEE can be performed during ongoing cardiopulmonary resuscitation and does not interfere with patient management. This review introduces the clinician to the current evidence of the impact of intraoperative echocardiography on intraoperative surgical decisions during surgical procedures. It helps the clinician to identify indications and realize the potential applications of intraoperative echocardiography.Since the introduction of intraoperative echocardiography into clinical practice in the 1970s its use and utility in the perioperative period has become increasingly more evident. Especially in patients undergoing cardiac surgical procedures intraoperative echocardiography has gained great diagnostic importance. Intraoperative transesophageal echocardiography (TEE) and epiaortic ultrasound are two important and complementing diagnostic modalities in this patient population. The clinical information obtained with intraoperative TEE in certain cases might have a direct impact on surgical decision-making and therefore may positively influence patient outcome. In patients undergoing non-cardiac surgical procedures, TEE can be a valuable tool in high-risk patients, in patients experiencing hemodynamic instability or in those suffering intraoperative cardiac arrest. Intraoperative TEE might allow a primary diagnosis of the underlying etiology and facilitate the institution of further therapeutic interventions. In addition TEE can be performed during ongoing cardiopulmonary resuscitation and does not interfere with patient management. This review introduces the clinician to the current evidence of the impact of intraoperative echocardiography on intraoperative surgical decisions during surgical procedures. It helps the clinician to identify indications and realize the potential applications of intraoperative echocardiography.

[Perioperative echocardiography: basic principles].

ZusammenfassungDie intraoperative Echokardiographie hat sich innerhalb der Anästhesiologie und Intensivmedizin während der letzten Jahre zu einem modernen Verfahren der perioperativen kardialen Diagnostik und Patientenüberwachung entwickelt. Fortschritte in der Bildaufbereitung und die Entwicklung neuer Schallwandlertechniken für die transösophageale Echokardiographie (TEE) haben hierzu in besonderem Maß beigetragen. Durch die Einführung multiplaner TEE-Sonden mit integrierter Doppler-Echokardiographiekapazität steht dem klinisch tätigen Anästhesisten eine neue Technik zur Verfügung, um Herzkammern, Herzklappen sowie die großen Gefäße qualitativ und quantitativ zu beurteilen. Die Kenntnis der physikalisch-technischen Grundlagen der Echokardiographie ist eine wichtige Voraussetzung, um diese Technologie erfolgreich am Patienten einzusetzen. Der vorliegende Übersichtsbeitrag beschreibt die verschiedenen Formen der Echokardiographie (M-mode, 2D- und Doppler-Echokardiographie) und deren spezifische Anwendungsmöglichkeiten. Zusätzlich werden die typischen Artefakte, die bei der Anwendung von Echokardiographieverfahren auftreten können, dargestellt und deren Beurteilung, Erkennung und Vermeidung erläutert.AbstractOver the past decades, echocardiography has undergone a continuous evolution in technology that has promoted its clinical application and acceptance throughout perioperative medicine. These technological advances include improvements in transducer development that permit superior imaging quality and a wider selection of probes for epicardial, epiaortic, and surface echocardiography which can also be used in conjunction with multiplane transesophageal echocardiography. Moreover, the addition of Doppler technology and digital acquisition has secured the role of echocardiography as a valuable and relatively noninvasive diagnostic tool for the assessment of cardiovascular disease and hemodynamic monitoring throughout the perioperative period. Therefore, it has become increasingly important for perioperative physicians to understand the basic principles and underlying fundamental concepts pertaining to the technology and physics of echocardiography, as well as its inherent limitations. The current review outlines the modes and applications of different echocardiographic techniques used in perioperative echocardiography including M-mode, two-dimensional echocardiography, and Doppler assessment of blood flow. In addition, the limitations of these techniques and typical artifacts associated with the perioperative use of echocardiography are described.

Decreased Proopiomelanocortin mRNA in Lymphocytes of Chronic Alcoholics After Intravenous Human Corticotropin Releasing Factor Injection

BACKGROUNDnAlcohol abuse may involve an altered neuroendocrine response that mediates lymphocyte-derived proopiomelanocortin (POMC) production and inflammation. We investigated POMC messenger RNA (mRNA) expression in human lymphocytes ex vivo and their relation to plasma ACTH and immunoreactive beta-endorphin (IR-beta-EP) after intravenous injection of human corticotropin releasing factor (hCRF) in chronic alcoholics (n = 12) and nonalcoholics (n = 12) before surgery. Lipopolysaccharide-stimulated interleukin (IL)-1 receptor antagonist (IL-1 Ra) as a marker for chronic inflammation was determined.nnnMETHODSnChronic alcohol abuse was diagnosed according to DSM-IV criteria and alcohol consumption >60 g/day. A reverse transcription-polymerase chain reaction method with total RNA and subsequent solid phase minisequencing was used to quantify lymphocytic POMC mRNA after intravenous hCRF injection. Plasma ACTH, cortisol, and lipopolysaccharide-stimulated IL-1 Ra of monocytes were measured by enzyme-linked immunosorbent assay, and plasma IR-beta-EP was measured by using radioimmunoassay.nnnRESULTSnBaseline values of POMC mRNA content in lymphocytes and IL-1 Ra of chronic alcoholics were significantly increased compared with nonalcoholics (p < 0.01). Thirty minutes after intravenous hCRF injection, a significant increase of lymphocytic POMC mRNA was measured (p < 0.05) in nonalcoholics, whereas in chronic alcoholics a significant decrease was observed (p < 0.05).nnnCONCLUSIONSnChronic alcoholic patients had an altered neuroendocrine immune axis before intravenous hCRF administration and were not able to adjust to intravenous CRF injection by increasing lymphocytic POMC mRNA expression.

Focal left temporal lobe lesions and delayed speech acquisition.

The prevalence of focal cerebral injury in children with delayed speech acquisition is unknown. Among 30 children with a delay in speech acquisition, computerized brain tomography revealed focal left temporal lesions in two of the children. Unilateral temporal lobe damage may account for a small proportion of children with delayed speech acquisition.