Ultra-fast recovery from right neglect after 'awake surgery' for slow-growing tumor invading the left parietal area

It is now possible to perform resections of slow-growing tumors in awake patients. Using direct electrical stimulation, real-time functional mapping of the brain can be used to prevent the resection of essential areas near the tumor. Simple clinical observations of patients with a resection of slow-growing tumors have demonstrated substantial recovery within a few days of such 'awake surgery'. The aim of this study was to investigate the kinetics of recovery following the resection of slow-growing tumors invading the left parietal area and to focus mainly on its rapidity. Two patients were assessed by standard line bisection tests and compared with eight healthy individuals. Independently of the pure nature of the symptoms, we report that the patients rapidly and substantially recovered from pronounced right neglect. They were tested 48 hours after the surgery and the recovery was significant for both patients after less than 4 hours. Strikingly, for one patient, recovery was ultra fast and substantial in the first practice session within less than 7 minutes: it occurred without verbal feedback and was substantially retained during the following testing session. Its rapidity suggests a process of unmasking redundant networks. With the slow growth of the lesion, the contralesional hemisphere is probably progressively prepared for rapid unmasking of homologue networks. These results have major clinical implications. For patients with an invading left-side tumor, it is now clear that line bisections are required before, during, and after awake surgery to: plan the surgery, control the quality of the resection, and also optimize the rehabilitation of the patient

Role of the gene Miniature in Drosophila wing maturation.

Miniature is an extracellular zona pellucida domain-containing protein, required for flattening of pupal wing epithelia in Drosophila. Here, we show that Miniature also plays an important role in the post-eclosion wing maturation processes triggered by the neurohormone bursicon. Wing expansion and epithelial apoptosis are drastically delayed in miniature loss-of-function mutants, and sped up upon overexpression of the protein in wings. Miniature acts upstream from the heterotrimeric Gs protein transducing the bursicon signal in wing epithelia. We propose that Miniature interacts with bursicon and regulates its diffusion through or stability within the wing tissue.

Bi-ventricular axial micropump: impact on blood cell integrity.

BACKGROUND AND OBJECTIVE: Off-pump coronary artery bypass grafting has stimulated the development of micro-pumps designed to prevent the hemodynamic instability induced by heart luxation for the exposure of target vessels of the posterior wall. Impella (Aachen, Germany) developed micro-pumps with a miniaturized propeller system for both sides of the heart. The aim of this study was to analyze the impact of both pumps working together on blood cell integrity. MATERIALS AND METHODS: Both right and left-sided micro-pumps were implanted in 5 calves (body weight, 72_4 Kg) during 3 h. Blood samples for hematology and hemolysis parameters were drawn hourly. RESULTS: Both pumps performed well with a flow of 3.6 L +/- 0.3 L during the 3 h of the experiment with stable hemodynamic conditions. Mixed venous oxygen saturation was 63.4 +/- 15.2% at baseline and 63.8 +/- 16.3% at the end of the experiment (P = ns). Red cell count, LDH and free plasma hemoglobin were 6.7 +/- 2.1 x 10(12)/L, 1807 +/- 437 IU/L, and 32 +/- 9 mg/L at baseline vs. 6.1 +/- 2.1 x 10(12)/L, 1871 +/- 410 IU/L, and 52 +/- 9 mg/L at the end of the experiment (P = ns for all comparisons). Platelet count exhibited a non-significant drop (872 +/- 126 vs. 715 +/- 22 x 10(9)/L). CONCLUSIONS: This double pump system based on the Archimed screw principle is hematologically well tolerated under conditions of prolonged cardiac assist.

Assessing the prevalence of hypertension in populations: are we doing it right?

BACKGROUND: Although it is well recognized that the diagnosis of hypertension should be based on blood pressure (BP) measurements taken on several occasions, notably to account for a transient elevation of BP on the first readings, the prevalence of hypertension in populations has often relied on measurements at a single visit. OBJECTIVE: To identify an efficient strategy for assessing reliably the prevalence of hypertension in the population with regards to the number of BP readings required. DESIGN: Population-based survey of BP and follow-up information. SETTING AND PARTICIPANTS: All residents aged 25-64 years in an area of Dar es Salaam (Tanzania). MAIN OUTCOME MEASURES: Three BP readings at four successive visits in all participants with high BP (n = 653) and in 662 participants without high BP, measured with an automated BP device.RESULTS BP decreased substantially from the first to third readings at each of the four visits. BP decreased substantially between the first two visits but only a little between the next visits. Consequently, the prevalence of high BP based on the third reading--or the average of the second and third readings--at the second visit was not largely different compared to estimates based on readings at the fourth visit. BP decreased similarly when the first three visits were separated by 3-day or 14-day intervals. CONCLUSIONS: Taking triplicate readings on two visits, possibly separated by just a few days, could be a minimal strategy for assessing adequately the mean BP and the prevalence of hypertension at the population level. A sound strategy is important for assessing reliably the burden of hypertension in populations.

Temporal variation of wing geometry in Aedes albopictus

Although native to the tropical and subtropical areas of Southeast Asia, Aedes albopictus is now found on five continents, primarily due to its great capacity to adapt to different environments. This species is considered a secondary vector of dengue virus in several countries. Wing geometric morphometrics is widely used to furnish morphological markers for the characterisation and identification of species of medical importance and for the assessment of population dynamics. In this work, we investigated the metric differentiation of the wings of Ae. albopictus samples collected over a four-year period (2007-2010) in São Paulo, Brazil. Wing size significantly decreased during this period for both sexes and the wing shape also changed over time, with the wing shapes of males showing greater differences after 2008 and those of females differing more after 2009. Given that the wings play sex-specific roles, these findings suggest that the males and females could be affected by differential evolutionary pressures. Consistent with this hypothesis, a sexually dimorphic pattern was detected and quantified: the females were larger than the males (with respect to the mean) and had a distinct wing shape, regardless of allometric effects. In conclusion, wing alterations, particularly those involving shape, are a sensitive indicator of microevolutionary processes in this species.

The right to appeal in cases of forensic autopsies. [Le droit de recours en matière d'autopsies médico-légales.]

The decision to carry out forensic autopsies is frequently made to determine the reasons of the death, especially in cases of non-natural death. In Switzerland, the judge strictly controls the authorisation to conduct forensic autopsies and the possibility to appeal against such a decision remains limited. This article aims to analyse the legal framework that enables appeals against a decision to conduct a forensic autopsy, taking into account the jurisprudence from the High Court of Switzerland (Tribunal Fédéral) and the European Court of Human Rights. La décision de pratiquer des autopsies médico-légales est très fréquente pour déterminer les causes de décès, notamment lorsque ceux-ci semblent avoir des causes non naturelles. En Suisse, l'autorisation de procéder à des autopsies médico-légales est strictement encadrée sur le plan légal et la faculté de s'opposer à une telle autorisation reste très limitée. L'article s'attache à analyser les conditions qui permettent de recourir contre une décision d'autopsie médico-légale, à la lumière notamment des décisions du Tribunal Fédéral et de la Cour européenne des droits de l'homme.

Finding the right interactional temperature: do colder patients need more warmth in physician communication style?

Being aware of which communication style should be adopted when facing more difficult patients is important for physicians; it can help prevent patient reactions of dissatisfaction, mistrust, or non-adherence that can be detrimental to the process of care. Past research suggests that less agreeable patients are especially critical towards, and reactive to, their physician's communication style, compared to more agreeable patients. On the basis of the literature, we hypothesized that less agreeable patients would react more negatively than agreeable patients to lower levels of affiliativeness (i.e., warmth, friendliness) in the physicians, in terms of satisfaction with the physician, trust in the physician, and determination to adhere to the treatment. Thirty-six general practitioners (20 men/16 women) working in their own practice in Switzerland were filmed while interacting with 69 patients (36 men/33 women) of different ages (M = 50.7; SD = 18.19; range: 18-84) and presenting different medical problems (e.g., back pain, asthma, hypertension, diabetes). After the medical interview, patients filled in questionnaires measuring their satisfaction with the physician, their trust in the physician, their determination to adhere to the treatment, and their trait of agreeableness. Physician affiliativeness was coded on the basis of the video recordings. Physician gender and dominance, patient gender and age, as well as the gravity of the patient's medical condition were introduced as control variables in the analysis. Results confirmed our hypothesis for satisfaction and trust, but not for adherence; less agreeable patients reacted more negatively (in terms of satisfaction and trust) than agreeable patients to lower levels of affiliativeness in their physicians. This study suggests that physicians should be especially attentive to stay warm and friendly with people low in agreeableness because those patients' satisfaction and trust might be more easily lowered by a cold or distant physician communication style.

Repeating with the right hemisphere: reduced interactions between phonological and lexical-semantic systems in crossed aphasia?

Knowledge on the patterns of repetition amongst individuals who develop language deficits in association with right hemisphere lesions (crossed aphasia) is very limited. Available data indicate that repetition in some crossed aphasics experiencing phonological processing deficits is not heavily influenced by lexical-semantic variables (lexicality, imageability, and frequency) as is regularly reported in phonologically-impaired cases with left hemisphere damage. Moreover, in view of the fact that crossed aphasia is rare, information on the role of right cortical areas and white matter tracts underpinning language repetition deficits is scarce. In this study, repetition performance was assessed in two patients with crossed conduction aphasia and striatal/capsular vascular lesions encompassing the right arcuate fasciculus (AF) and inferior frontal-occipital fasciculus (IFOF), the temporal stem and the white matter underneath the supramarginal gyrus. Both patients showed lexicality effects repeating better words than non-words, but manipulation of other lexical-semantic variables exerted less influence on repetition performance. Imageability and frequency effects, production of meaning-based paraphrases during sentence repetition, or better performance on repeating novel sentences than overlearned clichés were hardly ever observed in these two patients. In one patient, diffusion tensor imaging disclosed damage to the right long direct segment of the AF and IFOF with relative sparing of the anterior indirect and posterior segments of the AF, together with fully developed left perisylvian white matter pathways. These findings suggest that striatal/capsular lesions extending into the right AF and IFOF in some individuals with right hemisphere language dominance are associated with atypical repetition patterns which might reflect reduced interactions between phonological and lexical-semantic processes.

New electrocardiographic criteria for discriminating between Brugada types 2 and 3 patterns and incomplete right bundle branch block.

OBJECTIVES: The aim of this study was to evaluate new electrocardiographic (ECG) criteria for discriminating between incomplete right bundle branch block (RBBB) and the Brugada types 2 and 3 ECG patterns. BACKGROUND: Brugada syndrome can manifest as either type 2 or type 3 pattern. The latter should be distinguished from incomplete RBBB, present in 3% of the population. METHODS: Thirty-eight patients with either type 2 or type 3 Brugada pattern that were referred for an antiarrhythmic drug challenge (AAD) were included. Before AAD, 2 angles were measured from ECG leads V(1) and/or V(2) showing incomplete RBBB: 1) α, the angle between a vertical line and the downslope of the r'-wave, and 2) β, the angle between the upslope of the S-wave and the downslope of the r'-wave. Baseline angle values, alone or combined with QRS duration, were compared between patients with negative and positive results on AAD. Receiver-operating characteristic curves were constructed to identify optimal discriminative cutoff values. RESULTS: The mean β angle was significantly smaller in the 14 patients with negative results on AAD compared to the 24 patients with positive results on AAD (36 ± 20° vs. 62 ± 20°, p < 0.01). Its optimal cutoff value was 58°, which yielded a positive predictive value of 73% and a negative predictive value of 87% for conversion to type 1 pattern on AAD; α was slightly less sensitive and specific compared with β. When the angles were combined with QRS duration, it tended to improve discrimination. CONCLUSIONS: In patients with suspected Brugada syndrome, simple ECG criteria can enable discrimination between incomplete RBBB and types 2 and 3 Brugada patterns.

Experience and intermediate-term results using the Contegra heterograft for right ventricular outflow reconstruction in adults.

OBJECTIVES: The Contegra bioprosthesis (valved heterologous bovine jugular vein) is used for reconstruction of the right ventricular outflow tract (RVOT) in congenital heart malformations and pulmonary valve replacement in different settings. Compared to pulmonary homografts, the Contegra conduit is readily available 'on the shelf'. So far, its use was mainly described in children. The aim of this study is to evaluate the feasibility and the outcome of Contegra graft implantation in the adult. METHODS: Between November 1999 and December 2007, a total of 32 Contegra grafts were implanted in 31 patients (24 men and 7 women), with a mean age of 35.7+/-10.5 years (range 18-54 years). All operations have been completed through median sternotomy with cardiopulmonary bypass. Indications included: Ross procedure for aortic valve disease (n=22); re-operation of corrected Fallot-tetralogy (n=5); isolated pulmonary valve disease (n=2); re-operation of double outlet right ventricle (DORV) (n=1); pulmonary stenosis in congenital dilated cardiomyopathy (DCM) (n=1). Conduit sizes included 22 mm (n=31), 20 mm (n=1). RESULTS: There was no hospital mortality and no valved conduit related early morbidity. In the median follow-up of 38 months (range 1-99 months) of 28 patients there was one late death, not conduit related (total mortality 3.6%). Re-operation for symptomatic graft stenosis was realised in two patients, 7 and 16 months after primo-implantation, corresponding to graft related late morbidity of 7.1%. CONCLUSIONS: In this small review of 32 operations using the Contegra graft for RVOT reconstruction in adult cardiac surgery for different indications, we observed good postoperative mid-term results concerning conduit function. Mean transpulmonary pressure gradients remain low (13.3+/-6.6 mmHg postoperative, 14.5+/-7.9 mmHg at follow-up). The use of the Contegra graft seems to be a good alternative to the homograft with low operative mortality and morbidity. Long-term outcome data are not available and further investigations must be performed to evaluate results.

Importance of the right ventricle in valvular heart disease.

The importance of the right ventricle as a determinant of clinical symptoms, exercise capacity, peri-operative survival and postoperative outcome has been underestimated for a long time. Right ventricular ejection fraction has been used as a measure of right ventricular function but has been found to be dependent on loading conditions, ventricular interaction as well as on myocardial structure. Altered left ventricular function in patients with valvular disease influences right ventricular performance mainly by changes in afterload but also by ventricular interaction. Right ventricular function and regional wall motion can be determined with right ventricular angiography, radionuclide ventriculography, two-dimensional echocardiography or magnetic resonance imaging. However, the complex structure of the right ventricle and its pronounced translational movements render quantification difficult. True regional wall motion analysis is, however, possible with myocardial tagging based on magnetic resonance techniques. With this technique a baso-apical shear motion of the right ventricle was observed which was enhanced in patients with aortic stenosis.

Increased cardiac angiotensin II levels induce right and left ventricular hypertrophy in normotensive mice.

Angiotensin II is a potent arterial vasoconstrictor and induces hypertension. Angiotensin II also exerts a trophic effect on cardiomyocytes in vitro. The goals of the present study were to document an in vivo increase in cardiac angiotensins in the absence of elevated plasma levels or hypertension and to investigate prevention or regression of ventricular hypertrophy by renin-angiotensin system blockade. We demonstrate that high cardiac angiotensin II is directly responsible for right and left ventricular hypertrophy. We used transgenic mice overexpressing angiotensinogen in cardiomyocytes characterized by cardiac hypertrophy without fibrosis and normal blood pressure. Angiotensin-converting enzyme inhibition and angiotensin II type 1 receptor blockade prevent or normalize ventricular hypertrophy. Surprisingly, in control mice, receptor blockade decreases tissue angiotensin II despite increased plasma levels. This suggests that angiotensin II may be protected from metabolization by binding to its receptor. Blocking of the angiotensin II type 1 receptor rather than enhanced stimulation of the angiotensin II type 2 receptor may prevent remodeling and account for the beneficial effects of angiotensin antagonists.