Neuropsychological performance in symptomatic and asymptomatic HIV infection

OBJECTIVE

To examine cognitive function in patients at various stages of HIV infection, and to determine the nature and severity associated with stage of illness.

DESIGN

Subjects were administered an extensive battery of neuropsychological tests.

SUBJECTS

Two hundred and thirty-three HIV-1-infected homosexual/bisexual men and 77 HIV-negative control subjects who had been screened for previous neurological illness. All subjects were volunteers in a longitudinal study of neurobehavioral complications of HIV infection.

RESULTS

Patients with symptomatic infection differed from controls on a large number of measures, and asymptomatic patients had a more circumscribed pattern of deficit. On a summary measure of cognitive impairment, there was a twofold increase in the prevalence of impairment in asymptomatic patients relative to controls, and a fourfold increase in symptomatic patients. Memory and dexterity problems appear to be early features of neurobehavioral dysfunction, and frontal lobe deficits were found in patients with symptomatic infection.

CONCLUSION

These data indicate that there is a steady increase in the prevalence of neurobehavioral abnormalities associated with stage of infection. The pattern of abnormality also varies with disease stage.

Depression and neuropsychological performance in asymptomatic HIV infection

OBJECTIVE

The authors examined the effect of depression on neuropsychological performance in HIV-infected men. Previous studies have suggested that depression may account for the neuropsychological abnormalities observed in some patients with HIV infection, but few studies have specifically examined this question.

METHOD

An extensive neuropsychological test battery was administered to 121 HIV-seropositive asymptomatic men and 42 HIV-seronegative comparison subjects. The seropositive subjects were grouped into depressed and non-depressed groups on the basis of scores on the Beck Depression Inventory, Hamilton Rating Scale for Depression, and Structured Clinical Interview for DSM-III-R.

RESULTS

Statistical comparisons revealed very few measures on which the depressed seropositive subjects scored significantly worse than either of the nondepressed comparison groups. The nondepressed seropositive group differed consistently from the seronegative comparison subjects on measures of verbal memory and dexterity.

CONCLUSIONS

These data indicate that the subtle neuropsychological abnormalities observed in some asymptomatic HIV-seropositive subjects cannot be attributed to depression. These data also indicate the advantages of a multifaceted approach to assessment of depression.

Neuropsychological performance in asymptomatic HIV infection

This study compared 74 human immunodeficiency virus (HIV)-negative and 131 HIV-positive asymptomatic homosexual or bisexual men on an extensive neuropsychological test battery. HIV-positive subjects' performance was significantly worse on verbal memory and psychomotor skills. The prevalence of mild but persistent neurobehavioral impairment in the HIV-positive group was approximately twice that in HIV-negative patients, consistently across several criteria for impairment. There was evidence that degree of neuropsychological impairment was related to patients' perceptions of dysfunction in daily life. Findings were not related to degree of depression or to medication effects. These data suggest that approximately 10% to 20% of HIV-positive asymptomatic men suffer mild neuropsychological impairment that influences their daily lives.

Comparison of opiate addicts' reports of psychiatric history with reports of significant-other informants

This study compares self-reports by a sample of 50 opiate addicts with reports of 50 "significant other" informants, on past and current functioning. Moderate to high levels of agreement are found using the Intraclass Correlation Coefficient (ICC) in reporting current opiate use, current employment, and current legal pressures. This finding is consistent with previous studies which found good agreement between addicts and informants in these areas. However, much poorer agreement between addicts and informants is found in assessing the severity of addict's social, employment, and psychological problems, and in assessing the more detailed aspects of drug use. A comparison of the percent agreement data with ICC data used in this study provides empirical support for the argument that percent agreement data represents an inflated estimate of concordance between raters. These findings suggest that addicts and their families have rather divergent perceptions of the addict's problems and, in addition, indicate the value of including family members or significant others in the process of evaluating and treating opiate addicts. The results of the statistical analysis underscore the need in reliability studies of rigorous statistics that take into account chance agreement.

Depletion of cutaneous peptidergic innervation in HIV-associated xerosis

Severe xerosis occurs in approximately 20% of human immunodeficiency virus seropositive patients. Changes in cutaneous innervation have been found in various inflammatory skin diseases and in xerotic skin in familial amyloid. We have therefore carried out a quantitative examination of the cutaneous peptidergic innervation in human immunodeficiency virus-associated xerosis. Immunohistochemistry and image analysis quantitation were used to compare total cutaneous innervation (protein gene product 9.5), calcitonin gene-related peptide, substance P, and vasoactive intestinal peptide peptidergic fibers, at two sites in the skin of human immunodeficiency virus-associated xerosis patients (upper arm, n = 12; upper leg, n = 11) and site-matched seronegative controls (upper arm, n = 10; upper leg, n = 10). Measurement of lengths of fibers of each type was carried out for each subject in the epidermis and papillary dermis, and around the sweat glands. Immunostained mast cells in these areas were counted. Epidermal integrity and maturation were assessed by immunostaining for involucrin. There were significant (Mann-Whitney U test; p < 0.02) decreases in total lengths of protein gene product 9.5 fibers in both epidermis/papillary dermis and sweat gland fields; of calcitonin gene-related peptide innervation in the epidermis/papillary dermis; and of substance P innervation of the sweat glands. There were no differences in the distribution of mast cells, or in the epidermal expression of involucrin. Depletion of the calcitonin gene-related peptide innervation may affect the nutrient blood supply of the upper dermis, and the integrity and function of basal epidermis and Langerhans cells. Diminished substance P innervation of the sweat glands may affect their secretory activity. Both of these changes may be implicated in the development of xerosis.

Drug and alcohol use and neuropsychological performance in asymptomatic HIV infection

The effect of drug and alcohol abuse on neuropsychological performance was examined in 132 human immunodeficiency virus-seropositive gay or bisexual men. Syndromal (diagnostic) criteria of alcohol/drug abuse based on DSM-III-R were used, and quantitative estimates of alcohol consumption were obtained. Very few differences appeared between substance abuse subgroups formed on the basis of recency or severity of drug use. There were some correlations with the quantitative estimate of alcohol use, but not on the measures previously found to differentiate seronegative and asymptomatic seropositive gay men. These data indicate that alcohol use does affect neuropsychological performance but does not account for the differences observed in studies of seronegative and seropositive subjects.

Crucial role of Plexin C1 for pulmonary inflammation and survival during lung injury

Acute pulmonary inflammation during lung injury is initiated by the migration of neutrophils into the alveolar space. The severity of these inflammatory changes within the pulmonary tissue determines the severity of lung injury and ultimately patient outcome. Recent work has demonstrated that the guidance protein Semaphorin 7A propagates the infiltration of neutrophils into an hypoxic tissue site, yet the role of its target receptor Plexin C1 (PLXNC1) during lung injury is to date unknown. We demonstrate here that PLXNC1(+) neutrophils are present within the alveolar space and that PLXNC1 is induced in vitro and in vivo during lung injury. In a model of high-pressure ventilation PLXNC1(-/-) animals show decreased signs of alveolar inflammation and improved survival compared with wild-type controls. Studies employing chimeric animals identified the hematopoietic expression of PLXNC1 to be of crucial importance for the observed results. Functional inhibition of PLXNC1 resulted in improved survival and ameliorated the signs of inflammation within the lung. Furthermore, the injection of a peptide binding to PLXNC1 resulted in improved survival and attenuated pulmonary inflammation. As such we demonstrate here, that previously unknown PLXNC1 holds significant importance for degree of pulmonary inflammation and determines outcome during experimental lung injury.

Perioperative Echokardiographie

Over 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.

Epikardiale Echokardiographie

Epicardial echocardiography has been available since the early 1970s as an intraoperative diagnostic modality to assess ventricular and valvular function. With this technique, an ultrasonic transducer is placed directly on the epicardial surface of the heart, following sternotomy and pericardiotomy. Under the guidance of the cardiac anesthesiologist, the surgeon places the transducer so that the desired views of cardiac structures and great vessels can be obtained. The anesthesiologist performs the acquisition, analysis and interpretation of the echocardiographic images. Despite the feasibility of epicardial echocardiography, transesophageal echocardiography (TEE) has emerged over the last two decades as the main form of intraoperative echocardiography. Although TEE allows continuous monitoring of cardiac and valvular function without interruption of the surgical procedure, placement of a TEE probe may be difficult or contraindicated in some patients. In such cases, epicardial echocardiography may be the optimal ultrasonographic imaging modality to assess ventricular and valvular function during cardiac surgery. We describe the use of epicardial echocardiography for intraoperative assessment of valvular function in two patients where TEE was either contraindicated or probe placement could not be performed safely. The first patient underwent surgical repair of the mitral valve for severe mitral regurgitation. After weaning the patient from cardiopulmonary bypass (CPB), epicardial echocardiography was used to confirm successful reconstruction of the valve and to exclude residual mitral regurgitation. The second patient was scheduled for coronary artery bypass grafting (CABG). Prior to the initiation of CPB, the presence of moderate aortic stenosis was confirmed using Doppler echocardiography via an epicardial approach.

[A new working shift model for anesthesiologists: an analysis 3 years after implementation]

OBJECTIVE

The aim of this study was to assess the efficacy, appropriateness and cost-effectiveness of a new working shift model for anesthesiologists complying with the European working time directive (EWTD) at the University Hospital of Tübingen (UKT), Germany 3 years after implementation

BACKGROUND

Applying the standards of the EWTD is challenging for university hospitals as doctors must comply with the challenge of combining patient care, research and teaching. So far there have been no data available for German university hospitals on how these requirements can be met. As the department of anesthesiology is also a service-providing department it is essential not to increase staffing costs with a new shift model.

METHODS

In 2007 a new working shift model for the department of anesthesiology was designed and introduced in 2008. Shift planning and documentation of working hours were implemented electronically. The calculated number of doctors to run this model was 87.6 full time equivalents (FTE). For 2009 and 2010 the compliance with the EWTD parameters was checked for 1) average weekly working time limit (AWWTL) and 2) compliance to the maximum daily working time limit of 10 h (10 h DWTL). Furthermore, staffing costs for doctors in 2010 were compared to 2007. To check for the time spent in patient care the period of anesthetic attendance (PAA) was chosen, i.e. the total time of patient contact by anesthesiology staff. Data were analyzed descriptively for AWWTL and for 10 h DWTL. FTE, staff costs and PAA were evaluated by one-way ANOVA.

RESULTS

The new shift model allowed 84.4 % of all doctors to comply with the individual AWWT limits of 54 h and 48 h in 2009 (81/96) and 76.0 % in 2010 (79/104). In 2009 61.5 % of anesthesiologists voted for opt-out (59/96) and 53.8 % did so in 2010 (56/104). The 10 h DWTL was respected by 84.0 % in 2009 and by 85.9 % in 2010. The mean number of anesthesiologists rose significantly from 78.4 FTE in 2007 to 82.5 FTE in 2009 and 84.6 FTE in 2010 (p < 0.001 for 2010 vs. 2007, p = 0.004 for 2009 vs. 2007 and was not significant for 2010 vs. 2009). Staff costs per FTE increased from 7,524.79 <euro>/month to 7,800.66 <euro>/month and 7,966.11 <euro>/month in 2007, 2009 and 2010, respectively with the differences being non-significant. The PAA increased significantly from a mean of 6,124 h/month in 2007 to 6,581 h/month in 2009 and 6,872 h/month in 2010 (p < 0.001 for 2010 vs. 2007, whereas 2009 vs. 2007 and 2010 vs. 2009 were not significant). Thus, labour costs increased from 96.59 <euro>/h PAA in 2007 to 98.53 <euro>/h in both 2009 and 2010, the differences being not significant.

CONCLUSIONS

The newly designed shift model allowed a fair compliance with the EWTD in respect to AWTL and 10 h DWTL, although the calculated number of doctors to run the shift model could not be met in 2009 and 2010. Violations of the 10 h DWT limits were stable in 2009 and 2010; however the number of doctors exceeding the AWWT limits appeared to increase. The compliance with opt-out decreased from 2009 to 2010 and a high proportion of AWWTL violations resulted from the group of non-opt-out voters. The staff costs per hour PAA after implementation of the new shift model did not differ significantly from the year before although staffing costs increased by 7.2 % between 2007 and 2010. Costs increased by 162,454 <euro>/year for all PAA hours in 2010. Further evaluation of staff satisfaction with the new shift models is needed and already under way.

[Application fields of intraoperative transesophageal 3D echocardiography]

Intraoperative transesophageal echocardiography (TEE) is an established diagnostic tool and has to be regarded as the standard of care for intraoperative monitoring and cardiac surgical decision-making. Furthermore, intraoperative TEE is also used for monitoring and assessment of hemodynamic changes and the detection of previously unknown pathologies. In the past few years 3D-TEE has extended the spectrum of 2D-TEE by allowing pathomorphological features to be more easily and intuitively linked to the anatomy of the heart and the great vessels. Thus, a comprehensive 2D-TEE examination is favorably complemented by focused 3D-TEE. Especially during mitral valve surgery, 3D-TEE has proven its superiority in the diagnosis of the underlying pathology as demonstrated by a large number of studies in this field. This review presents the available data about the role of intraoperative 3D-TEE echocardiography and introduces practical fields of application.

Content bias of the MacAndrew's Alcoholism Scale in seizure disorder patients

The possibility of content bias in the MacAndrew's Alcoholism Scale (MAC) from the MMPI was examined in groups of seizure disorder (n = 35), general medical (n = 25), and psychiatric patients (n = 20). Scores above criteria on the MAC were associated with reported alcohol problems only for the psychiatric patients. Almost 50% of the seizure patients with no such history had scores above criteria on the MAC. This classification inaccuracy is even greater than that reported recently in contemporary normal samples. The results suggest that caution should be used when one is administering the MAC to seizure disorder patients and that further investigation of possible content bias in other MMPI scales or subscales should be pursued.

[Preoperative evaluation and perioperative management of patients with increased cardiovascular risk]

Due to the increasing age in western countries, combined with high rates of major surgical interventions in high-risk patients, perioperative reduction of cardiovascular complications becomes increasingly more important for perioperative physicians. After identifying patients with increased perioperative risk, specific interventions need to be considered to reduce their risk for cardiovascular complications, either by perioperative medical therapy or specific treatment options (e.g. coronary intervention). Several trials have demonstrated an effect of perioperative beta-blocker-therapy in reducing cardiovascular complications among high-risk patients. Additionally, several monitoring techniques are effective in detecting cardiovascular complications. Nevertheless, it remains unclear whether they are associated with a measurable improvement of outcome. Based on the ACC/AHA-guidelines, the present review describes a stepwise approach to surgical patients to identify perioperative risks, based on specific patient related risk factors, the kind of surgery and on the specific setting (emergency versus elective surgery). In addition, strategies to reduce perioperative cardiovascular complications are discussed.

Time-resolved nuclear dynamics in bound and dissociating acetylene

We have investigated nuclear dynamics in bound and dissociating acetylene molecular ions in a time-resolved reaction microscopy experiment with a pair of few-cycle pulses. Vibrating bound acetylene cations or dissociating dications are produced by the first pulse. The second pulse probes the nuclear dynamics by ionization to higher charge states and Coulomb explosion of the molecule. For the bound cations, we observed vibrations in acetylene (HCCH) and its isomer vinylidene (CCHH) along the CC-bond with a periodicity of around 26 fs. For dissociating dication molecules, a clear indication of enhanced ionization is found to occur along the CH- and CC-bonds after 10 fs to 40 fs. The time-dependent ionization processes are simulated using semi-classical on-the-fly dynamics revealing the underling mechanisms.

Allogeneic Blood Product Usage in Coronary Artery Bypass Grafting (CABG) with minimalized Extracorporeal Circulation System (MECC) Versus Standard On-Pump Coronary Artery Bypass Grafting

Aim:

Intraoperative allogeneic blood product transfusion (ABPT) in cardiac surgery is associated with worse overall outcome, including mortality. The objective of this study was to evaluate the ABPTs in minimalized extracorporeal cardiopulmonary (MECC^TM) compared with standard open system on-pump coronary revascularization.

Methods:

Data of 156 patients undergoing myocardial revascularization between September 2008 and September 2010 were reviewed. 83 patients were operated by the MECC technique and 73 were treated by standard extracorporeal circulation (sECC). ABPT and overall early postoperative complications were analyzed.

Results:

Operative mortality and morbidity were similar in both groups. ABPT in the MECC group was significantly lower than in the sECC group both intraoperatively (7.2 vs. 60.3% of patients p<0.001) and during the first five postoperative days (19.3 vs. 57.5%; p<0.001). “Skin to skin”- (214 ± 45 vs. 232 ± 45 min; p=0.012), cardiopulmonary bypass (CPB) - (82 ± 25 vs. 95 ± 26 min; p=0.014), and X-clamp- times (50 ± 16 vs. 56 ± 17 min; p=0.024) were significantly lower in the MECC group than in the sECC group. Length of ICU (intensive care unit) - and hospital stay were also significantly lower in the MECC group vs. the sECC group (26.7 ± 20.2 vs. 54.5 ± 68.9 h; p<0.001, and 12.0 ± 4.1 vs. 14.5 ± 4.6 days; p<0.001).

Conclusion:

Application of MECC as on-pump coronary artery bypass graft (CABG) results in significantly lower ABPT as well as shorter ICU and in-hospital stay. In order to achieve these benefits of MECC autologous retrograde priming, Bispectral index (BIS) monitoring, intraoperative cell salvage, meticulous hemostasis and strict peri- and postoperative volume management are crucial.

[Scope and limitations of the median nerve mouse model in research on peripheral nerve regeneration]

INTRODUCTION

Peripheral nerve regeneration is usually studied in rat animal models (N. medianus or N. ischiadicus). In this article, we further evaluate the mouse median nerve model with its advantages and possible pitfalls.

MATERIALS AND METHODS

24 mice (C57BL/6) were operated. The median nerve was exposed in the left axilla. After transection, immediate microsurgical repair followed using 11/0 sutures. In the contralateral axilla, 1 cm of median nerve was resected. After the operation, functional regeneration of the median nerve was assessed using the grasping test. Histological analysis was performed after staining with toluidine blue.

RESULTS

All animals survived the procedure. Grip strength increased starting at day 10 and reached its maximum at day 35. Myelinated fibres in the regenerated nerves showed a smaller diameter and a thinner myelin sheath and the typical microfasciculation of regenerated nerve fibres in comparison to the uninjured nerve.

CONCLUSION

The mouse median nerve model is technically demanding but opens a wide field of possible research options using genetically modified mice.

[S3 guidelines on volume therapy: Comments on publication 2014]

Intravascular volume therapy represents one of the pillars of medical actions during inpatient treatment and is dealt with in the S3 guidelines on "intravascular volume therapy in adults". The target group of the guidelines are physicians who must carry out intravascular volume therapy as a component of patient treatment. This article critically reviews and summarizes the essential recommendations.