Moral considerability of brain organoids from the perspective of computational architecture

Human brain organoids equipped with complex cytoarchitecture and closed-loop feedback from virtual environments could provide insights into neural mechanisms underlying cognition. Yet organoids with certain cognitive capacities might also merit moral consideration. A precautionary approach has been proposed to address these ethical concerns by focusing on the epistemological question of whether organoids possess neural structures for morally-relevant capacities that bear resemblance to those found in human brains. Critics challenge this similarity approach on philosophical, scientific, and practical grounds but do so without a suitable alternative. Here, I introduce an architectural approach that infers the potential for cognitive-like processing in brain organoids based on the pattern of information flow through the system. The kind of computational architecture acquired by an organoid then informs the kind of cognitive capacities that could, theoretically, be supported and empirically investigated. The implications of this approach for the moral considerability of brain organoids are discussed.

Ethical, legal and social aspects of human cerebral organoids and their governance in Germany, the United Kingdom and the United States

Human cerebral organoids (HCOs) are model systems that enable researchers to investigate the human brain in ways that had previously been impossible. The emergence of HCOs was accompanied by both expert and layperson discussions concerning the possibility of these novel entities developing sentience or consciousness. Such concerns are reflected in deliberations about how to handle and regulate their use. This perspective article resulted from an international and interdisciplinary research retreat "Ethical, Legal and Social Aspects of Human Cerebral Organoids and their Governance in Germany, the United Kingdom and the United States", which took place in Tübingen, Germany, in August 2022. The retreat focused on whether HCO research requires new ethical and regulatory approaches. It addressed epistemic issues around the detection and theorisation of consciousness, ethical concerns around moral status and research conduct, difficulties for legislation and guidelines managing these entities, and public engagement.

First Organoid Intelligence (OI) workshop to form an OI community

The brain is arguably the most powerful computation system known. It is extremely efficient in processing large amounts of information and can discern signals from noise, adapt, and filter faulty information all while running on only 20 watts of power. The human brain's processing efficiency, progressive learning, and plasticity are unmatched by any computer system. Recent advances in stem cell technology have elevated the field of cell culture to higher levels of complexity, such as the development of three-dimensional (3D) brain organoids that recapitulate human brain functionality better than traditional monolayer cell systems. Organoid Intelligence (OI) aims to harness the innate biological capabilities of brain organoids for biocomputing and synthetic intelligence by interfacing them with computer technology. With the latest strides in stem cell technology, bioengineering, and machine learning, we can explore the ability of brain organoids to compute, and store given information (input), execute a task (output), and study how this affects the structural and functional connections in the organoids themselves. Furthermore, understanding how learning generates and changes patterns of connectivity in organoids can shed light on the early stages of cognition in the human brain. Investigating and understanding these concepts is an enormous, multidisciplinary endeavor that necessitates the engagement of both the scientific community and the public. Thus, on Feb 22-24 of 2022, the Johns Hopkins University held the first Organoid Intelligence Workshop to form an OI Community and to lay out the groundwork for the establishment of OI as a new scientific discipline. The potential of OI to revolutionize computing, neurological research, and drug development was discussed, along with a vision and roadmap for its development over the coming decade.

Human-chimpanzee differences in a FZD8 enhancer alter cell-cycle dynamics in the developing neocortex

The human neocortex differs from that of other great apes in several notable regards, including altered cell cycle, prolonged corticogenesis, and increased size [1-5]. Although these evolutionary changes most likely contributed to the origin of distinctively human cognitive faculties, their genetic basis remains almost entirely unknown. Highly conserved non-coding regions showing rapid sequence changes along the human lineage are candidate loci for the development and evolution of uniquely human traits. Several studies have identified human-accelerated enhancers [6-14], but none have linked an expression difference to a specific organismal trait. Here we report the discovery of a human-accelerated regulatory enhancer (HARE5) of FZD8, a receptor of the Wnt pathway implicated in brain development and size [15, 16]. Using transgenic mice, we demonstrate dramatic differences in human and chimpanzee HARE5 activity, with human HARE5 driving early and robust expression at the onset of corticogenesis. Similar to HARE5 activity, FZD8 is expressed in neural progenitors of the developing neocortex [17-19]. Chromosome conformation capture assays reveal that HARE5 physically and specifically contacts the core Fzd8 promoter in the mouse embryonic neocortex. To assess the phenotypic consequences of HARE5 activity, we generated transgenic mice in which Fzd8 expression is under control of orthologous enhancers (Pt-HARE5::Fzd8 and Hs-HARE5::Fzd8). In comparison to Pt-HARE5::Fzd8, Hs-HARE5::Fzd8 mice showed marked acceleration of neural progenitor cell cycle and increased brain size. Changes in HARE5 function unique to humans thus alter the cell-cycle dynamics of a critical population of stem cells during corticogenesis and may underlie some distinctive anatomical features of the human brain.

The RosR transcription factor is required for gene expression dynamics in response to extreme oxidative stress in a hypersaline-adapted archaeon

Background

Previous work has shown that the hypersaline-adapted archaeon, Halobacterium salinarum NRC-1, is highly resistant to oxidative stress caused by exposure to hydrogen peroxide, UV, and gamma radiation. Dynamic alteration of the gene regulatory network (GRN) has been implicated in such resistance. However, the molecular functions of transcription regulatory proteins involved in this response remain unknown.

Results

Here we have reanalyzed several existing GRN and systems biology datasets for H. salinarum to identify and characterize a novel winged helix-turn-helix transcription factor, VNG0258H, as a regulator required for reactive oxygen species resistance in this organism. This protein appears to be unique to the haloarchaea at the primary sequence level. High throughput quantitative growth assays in a deletion mutant strain implicate VNG0258H in extreme oxidative stress resistance. According to time course gene expression analyses, this transcription factor is required for the appropriate dynamic response of nearly 300 genes to reactive oxygen species damage from paraquat and hydrogen peroxide. These genes are predicted to function in repair of oxidative damage to proteins and DNA. In vivo DNA binding assays demonstrate that VNG0258H binds DNA to mediate gene regulation.

Conclusions

Together these results suggest that VNG0258H is a novel archaeal transcription factor that regulates gene expression to enable adaptation to the extremely oxidative, hypersaline niche of H. salinarum. We have therefore renamed VNG0258H as RosR, for reactive oxygen species regulator.

Lumbosacral nerve root avulsions: MR imaging demonstration of acute abnormalities

Most of the previously reported lumbosacral nerve root avulsions presented with pseudomeningoceles at the time of delayed initial imaging. We report a case of traumatic lumbosacral nerve root injury associated with an isolated femur fracture and demonstrate the evolution of pseudomeningoceles following nerve root avulsions and edema in the perineural fat identified on the initial MR imaging.

Quantitative ultrasound of the calcaneus as a screening tool to detect osteoporosis: different reference ranges for caucasian women, african american women, and caucasian men

The interpretation of results measured by quantitative ultrasound (QUS) of the heel depends on the population studied. We measured estimated bone mineral density (BMD) of the heel using the Hologic Sahara sonometer. People were studied at county fairs, health fairs, and churches. Subjects were not on treatments that would affect bone density, other than calcium supplementation. This included 823 Caucasian women, 131 African American women, and 301 Caucasian men. In contrast to women, for Caucasian men the squared term for age was not significant, and a straight line of decline was the best fit for estimated BMD. African American women had a standard deviation larger than that reported by Hologic for Caucasian women. We compared a history of self-reported fractures with a subject's estimated BMD. An estimated BMD of 0.57 gm/cm2 included 75% of all fractures. This cutoff point was associated with increased fracture prevalence in subjects over age 50, relative risk of 1.4. This result corresponds to the Hologic data T-score of -0.2. When used as a screening tool for osteoporosis fracture risk, an estimated BMD of 0.57 gm/cm2 seems reasonable in those subjects over age 50.

Local nitric oxide release does not affect tachyphylaxis to angiotensin II in dorsal hand veins in man in the presence of prostaglandin synthesis inhibition

AIMS

Local prostaglandin (PG) production contributes to tachyphylaxis to angiotensin II (ANGII) in veins. Our aim was to assess the hypothesis that local nitric oxide (NO) generation is also, in part, responsible for tachyphylaxis to ANGII in veins, using the Aellig dorsal hand vein technique.

METHODS

Eight healthy male volunteers received 600 mg of aspirin (orally) to inhibit PG production. The venoconstrictor effects of ANGII and noradrenaline (NA) were then compared in dorsal hand veins during co-infusion of the NO synthase inhibitor L-NMMA or saline, on separate occasions.

RESULTS

ANGII and NA produced a similar degree of initial venoconstriction. However, the response to ANGII was significantly attenuated by 12 min compared with NA (AUC 147 +/- 38 vs 196 +/- 40, respectively; [95% confidence interval for difference: 7, 92], P = 0.02). Infusion of L-NMMA did not influence the response to ANGII or NA (P = 0.2 and P = 0.3, respectively).

CONCLUSIONS

Tachyphylaxis to ANGII in dorsal hand veins is not dependent on local NO release.

Identification of new triarylethylene oxyalkanoic acid analogues as bone selective estrogen mimetics

Previously, the estrogen receptor (ER) ligand 4-[1-(p-hydroxyphenyl)-2-phenylethyl]phenoxyacetic acid (5) was found to have differential bone loss suppressive effects in the ovariectomized (OVX) rat approaching those of selective ER modulators (SERMs) such as tamoxifen. In an effort to improve efficacy, analogues of this compound were prepared which incorporated features designed to reduce polarity/ionizability. Thus, the acetic acid side chain of 5 was replaced by n-butanoic acid and 1H-tetrazol-4-ylmethyl moieties, to give 8 and 10, respectively. Also, the phenolic hydroxyl of 5 was replaced, giving deoxy analogue 9. We also developed new methods for the synthesis of triarylethylene variants of 5 and 9, namely 4-([1-(p-hydroxyphenyl)-2-phenyl-1-butenyl]phenoxy)-n-butanoic acid (6) and its des-hydroxy counterpart (7), because the former of these had in vitro antiestrogenic effects characteristic of known SERMs. In the OVX rat, 6 and 7 were as effective as 17 beta-estradiol in suppressing serum markers of bone resorption/turnover, namely osteocalcin and deoxypyridinoline, but had only 30% of the uterotrophic efficacy of 17 beta-estradiol. This study has thus identified two triarylethylene oxybutyric acids, 6 and 7, that have differential bone/uterus effects like those of known SERMs.

Acute methionine loading does not alter arterial stiffness in humans

Hyperhomocystinemia is a risk factor for cardiovascular disease, and acute elevation of plasma homocysteine after methionine loading impairs endothelial function in healthy subjects. Interestingly, pretreatment with vitamin C can ameliorate this effect. We have already shown that acute oral vitamin C administration reduces arterial stiffness in healthy subjects, and the aim of the present study was to investigate the effect of methionine loading on arterial stiffness with and without concomitant vitamin C using the noninvasive technique of pulse wave analysis. Eight healthy male subjects (mean age, 29 years; range, 20-42 years) were studied on three occasions at weekly intervals. In a double-blind, double-dummy, randomized order they received orally either 100 mg/kg methionine, 100 mg/kg methionine plus 2 g of vitamin C, or matching placebos. Peripheral and central blood pressure, heart rate, cardiac index, arterial stiffness, and plasma homocysteine levels were assessed at baseline and 6 hours after dosing. Compared with placebo, there was no significant change in any of the hemodynamic parameters, including arterial stiffness, after oral methionine, although plasma homocysteine did increase from 11.5 +/- 1.6 to 28.7 +/- 4.4 microM (mean +/- SEM; p < 0.001). Combined methionine and vitamin C led to a similar increase in plasma homocysteine but significantly reduced augmentation index by 10.5 +/- 3.2% (p = 0.02). Acute hyperhomocystinemia does not significantly alter arterial stiffness, as assessed by pulse wave analysis, whereas a combination of methionine and vitamin C leads to a similar reduction in augmentation index to that previously described after vitamin C alone. These data reinforce evidence that vitamin C reduces arterial stiffness but do not indicate any important interaction with oral methionine.

Promatrilysin expression is induced by fibroblast growth factors in the prostatic carcinoma cell line LNCaP but not in normal primary prostate epithelial cells

BACKGROUND

It has been determined that prostate cancer cells overexpress the matrix metalloprotease matrilysin (MMP-7), but the factors regulating this expression have not been identified. Fibroblast growth factors (FGF), which are expressed in the prostate, might participate in paracrine regulation of matrilysin expression by prostate cancer cells.

METHODS

We tested the ability of recombinant FGF proteins and prostate fibroblast-conditioned media (PFCM) to induce promatrilysin expression in the prostate carcinoma cell line, LNCaP, and in normal prostate epithelial (PrEC) cells. We also characterized prostate fibroblast FGF expression by reverse transcriptase-polymerase chain reaction (RT-PCR). An inhibitor of FGF receptor activation (SU5402) was used to determine the role of FGF proteins in the induction of promatrilysin expression by PFCM.

RESULTS

Recombinant FGF-1, FGF-2, FGF-9, FGF-10, and PFCM significantly induced promatrilysin expression in LNCaP cells but not in PrEC cells. Prostate fibroblasts express mRNAs for these FGF proteins, and inhibition of LNCaP cell FGF receptors with SU5402 substantially reduced the induction of promatrilysin expression by PFCM.

CONCLUSIONS

Stromally expressed FGF proteins induce promatrilysin expression in a prostate carcinoma cell, and may provide a mechanism for the overexpression of promatrilysin observed in prostate cancer.

Cost-benefit comparison: holmium laser versus electrocautery in arthroscopic acromioplasty

This prospective study was designed to measure the costs and benefits of using a laser rather than electrocautery for soft tissue resection during arthroscopic shoulder decompression. Forty-nine shoulders with refractory Neer stage II impingement (persistent fibrosis and tendinitis) were divided into 2 groups. The composition of the 2 groups was similar with regard to sex, worker's compensation status, dominant arm involvement, duration of symptoms, and length of conservative treatment. In one group, electrocautery was used to ablate the bursa and periosteum, release the coracoacromial ligament, and maintain hemostasis. In the other group, a laser was used in place of electrocautery. Patients had been evaluated preoperatively with 2 functional scoring systems. The patients were reexamined at 1 week and at 1, 2, 3, 6, and 12 months after surgery. There were no differences between the groups with regard to functional outcome or satisfaction. There was also no difference in terms of estimated blood loss or operative time. However, there was a statistically significant difference in total hospital charges between groups, with the laser group having a 23% higher hospital bill. On the basis of these results, it is concluded that there was no medical benefit to laser-assisted arthroscopic subacromial decompression but there was an increased monetary cost.

Calcium, phosphorus, and alkaline phosphatase values of elderly subjects

OBJECTIVE

To determine if significant gender differences existed between subjects 65 years of age and older, with regard to calcium, phosphorus, and alkaline phosphatase levels.

DESIGN

A retrospective chart review of laboratory procedures performed in six different physician practices. The data consisted of 178 subjects representing 92 males and 86 females over the age of 65.

DATA SOURCES

Patient data were obtained from the charts housed in a cardiac care center. Subjects, with charts preceding them, were referred by a physician to the cardiac center. The laboratory procedures had been performed previously in the laboratories of the referring physicians.

MAIN OUTCOME MEASURES

After accounting for variation between laboratories, mean values of calcium, phosphorus, and alkaline phosphatase were examined to establish if a gender difference existed in patients over the age of 65. A blocked analysis of variance (ANOVA) was conducted at the 0.05 significance level.

RESULTS

ANOVA analysis yielded significant gender differences for calcium, phosphorus, and alkaline phosphatase (p < 0.05). Females over the age of 65 consistently showed higher levels than males over the age of 65 for all three variables in five of the six laboratories studied.

CONCLUSION

A statistically significant difference was found between the mean levels of men and women 65 years of age and older for calcium, inorganic phosphorus, and alkaline phosphatase. Gender and age are important variables to consider when analyzing and interpreting calcium, phosphorus, and acid phosphatase levels.

Home based rehabilitation for anterior cruciate ligament reconstruction

Fifty-four patients who underwent arthroscopically assisted anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft or allograft were studied prospectively to compare a postoperative home based rehabilitation program with a clinic based program. Fifty-four patients (mean age, 30 years) were assigned randomly to the home based program (27 patients) or the clinic based program (27 patients). The home based schedule featured six physical therapy visits during a 6-month postoperative study period, whereas the clinic based schedule specified 24 physical therapy visits during those 6 months. All patients entered in the study met strict selection criteria: age older than 15 years, no previous ligament repair or reconstruction, no complicating medical conditions, no collegiate or professional athletes, reconstruction at least 6 weeks after injury, and informed consent. At the 6-month followup, no significant statistical differences were found between the two groups in range of motion, thigh atrophy, anterior drawer compliance, hopping tests, Lysholm scores, or subjective health status scores. Thus, the authors conclude that in a selected group of patients who have undergone anterior cruciate ligament reconstruction, a home based postoperative rehabilitation program is feasible, safe, and effective.

A parasomnia overlap disorder involving sleepwalking, sleep terrors, and REM sleep behavior disorder in 33 polysomnographically confirmed cases

A series of 33 patients with combined (injurious) sleepwalking, sleep terrors, and rapid eye movement (REM) sleep behavior disorder (viz. "parasomnia overlap disorder") was gathered over an 8-year period. Patients underwent clinical and polysomnographic evaluations. Mean age was 34 +/- 14 (SD) years; mean age of parasomnia onset was 15 +/- 16 years (range 1-66); 70% (n = 23) were males. An idiopathic subgroup (n = 22) had a significantly earlier mean age of parasomnia onset (9 +/- 7 years) than a symptomatic subgroup (n = 11) (27 +/- 23 years, p = 0.002), whose parasomnia began with either of the following: neurologic disorders, n = 6 [congenital Mobius syndrome, narcolepsy, multiple sclerosis, brain tumor (and treatment), brain trauma, indeterminate disorder (exaggerated startle response/atypical cataplexy)]; nocturnal paroxysmal atrial fibrillation, n = 1; posttraumatic stress disorder/major depression, n = 1; chronic ethanol/amphetamine abuse and withdrawal, n = 1; or mixed disorders (schizophrenia, brain trauma, substance abuse), n = 2. The rate of DSM-III-R (Diagnostic and Statistical Manual, 3rd edition, revised) Axis 1 psychiatric disorders was not elevated; group scores on various psychometric tests were not elevated. Forty-five percent (n = 15) had previously received psychologic or psychiatric therapy for their parasomnia, without benefit. Treatment outcome was available for n = 20 patients; 90% (n = 18) had substantial parasomnia control with bedtime clonazepam (n = 13), alprazolam and/or carbamazepine (n = 4), or self-hypnosis (n = 1). Thus, "parasomnia overlap disorder" is a treatable condition that emerges in various clinical settings and can be understood within the context of current knowledge on parasomnias and motor control/dyscontrol during sleep.

A controlled, longitudinal study of dementia in Parkinson's disease

Serial assessments of cognition, mood, and disability were carried out at nine month intervals over a 54 month period on a cohort of 87 patients with Parkinson's disease (PD) and a matched cohort of 50 control subjects. Dementia was diagnosed from data by rigorously applying DSM-III-R criteria. Initially, 6% (5/87) PD patients were demented, compared with none of the 50 control subjects. A further 10 PD patients met the dementia criteria during the follow up period; this was equivalent, with survival analysis, to a cumulative incidence of 19%. With the number of person years of observation as the denominator, the incidence was 47.6/1000 person years of observation. None of the control subjects fulfilled dementia criteria during the follow up period. The patients with PD who became demented during follow up were older at onset of Parkinson's disease than patients who did not become demented, had a longer duration of Parkinson's disease, and were older at inclusion to the study.

Cognitive impairment and dementia in Parkinson's disease: a controlled study

The performance of 47 patients with Parkinson's disease on a battery of tests of cognition, motor function, disability and mood was compared with the performance of 47 healthy control subjects who were matched to the patients on the basis of age, sex and pre-morbid IQ. An increased prevalence of impairment over a range of cognitive functions was observed in the Parkinson's disease patients as compared with their matched controls. The differences between the Parkinson's disease patients and controls could not be accounted for by factors such as depressed mood, effects of medication or motor impairment. Our findings are discussed in relation to the methodology of previous studies in this area and to the need for a comprehensive clinico-pathological longitudinal study.

Recovery of cerebral metabolism and mitochondrial oxidation state is delayed after hypothermic circulatory arrest

To study the effect of deep hypothermic cardiopulmonary bypass and total circulatory arrest on cerebral metabolism and oxygenation, we measured the cerebral metabolic rate for oxygen (CMRO2) and assessed brain oxygenation by near infrared spectroscopy before, during, and after hypothermic bypass in 15 pediatric patients. One group underwent repair during deep hypothermic bypass (18 degrees C) with continuous flow (n = 9); the second group underwent deep hypothermic bypass with total circulatory arrest (n = 6). In the continuous-flow group, CMRO2 returned to control during rewarming and after cardiopulmonary bypass, as did oxyhemoglobin and deoxyhemoglobin in brain tissue. In the total circulatory arrest group, the oxyhemoglobin and the oxidation state of cytochrome aa3 oxidase decreased significantly during circulatory arrest. After cardiopulmonary bypass, the cytochrome oxidation state and the CMRO2 were significantly lower than control measurements, and brain tissue deoxyhemoglobin was elevated. Results of this study indicate that intracellular brain oxygenation decreases significantly during circulatory arrest and remains impaired after rewarming and cardiopulmonary bypass despite normalization of oxygen availability.

Hypomagnesemia is common following cardiac surgery

Hypomagnesemia is a common disorder in noncardiac surgical patients in the postoperative period, but the effect of cardiac surgery on serum magnesium concentrations remains unclear. The authors hypothesized that cardiac surgery is associated with hypomagnesemia, and prospectively studied 101 subjects (60 +/- 13.1 years of age) undergoing coronary artery revascularization (n = 70), valve replacement (n = 24), or both simultaneously (n = 7). Blood samples and clinical biochemical data were collected before induction of anesthesia, prior to cardiopulmonary bypass (CPB), immediately after CPB, and on postoperative day 1. Blood samples were analyzed for ultrafilterable magnesium, total magnesium, ionized calcium, parathyroid hormone, and free fatty acid concentrations. Outcome variables were also determined. Eighteen of 99 (18.2%) subjects had hypomagnesemia preinduction and this number increased to 71 of 100 (71.0%) following cessation of CPB (P less than 0.05). Patients with postoperative hypomagnesemia had a higher frequency of atrial dysrhythmias (22 of 71 [31.0%] v 3 of 29 [10.3%], P less than 0.05) and required prolonged mechanical ventilatory support (22 of 63 [34.9%] v 4 of 33 [12.1%], P less than 0.05). Hypomagnesemia is common following cardiac surgical procedures with CPB and is associated with clinically important postoperative morbidity.

The effect of hypothermic cardiopulmonary bypass and total circulatory arrest on cerebral metabolism in neonates, infants, and children

Cardiopulmonary bypass management in neonates, infants, and children often requires the use of deep hypothermia at 18 degrees C with occasional periods of circulatory arrest and represents marked physiologic extremes of temperature and perfusion. The safety of these techniques is largely dependent on the reduction of metabolism, particularly cerebral metabolism. We studied the effect of hypothermia on cerebral metabolism during cardiac surgery and quantified the changes. Cerebral metabolism was measured before, during, and after hypothermic cardiopulmonary bypass in 46 pediatric patients, aged 1 day to 14 years. Patients were grouped on the basis of the different bypass techniques commonly used in children: group A--moderate hypothermic bypass at 28 degrees C; group B--deep hypothermic bypass at 18 degrees to 20 degrees C with maintenance of continuous flow; and group C--deep hypothermic circulatory arrest at 18 degrees C. Cerebral metabolism significantly decreased under hypothermic conditions in all groups compared with control levels at normothermia, the data demonstrating an exponential relationship between temperature and cerebral metabolism and an average temperature coefficient of 3.65. There was no significant difference in the rate of metabolism reduction (temperature coefficient) in patients cooled to 28 degrees and 18 degrees C. From these data we were able to derive an equation that numerically expresses a hypothermic metabolic index, which quantitates duration of brain protection provided by reduction of cerebral metabolism owing to hypothermic bypass over any temperature range. Based on this index, patients cooled to 28 degrees C have a predicted ischemic tolerance of 11 to 19 minutes. The predicted duration that the brain can tolerate ischemia ("safe" period of deep hypothermic circulatory arrest) in patients cooled to 18 degrees C, based on our metabolic index, is 39 to 65 minutes, similar to the safe period of deep hypothermic circulatory arrest known to be tolerated clinically. In groups A and B (no circulatory arrest), cerebral metabolism returned to control in the rewarming phase of bypass and after bypass. In group C (circulatory arrest), cerebral metabolism and oxygen extraction remained significantly reduced during rewarming and after bypass, suggesting disordered cerebral metabolism and oxygen utilization after deep hypothermic circulatory arrest. The results of this study suggest that cerebral metabolism is exponentially related to temperature during hypothermic bypass with a temperature coefficient of 3.65 in neonates infants and children. Deep hypothermic circulatory arrest changes cerebral metabolism and blood flow after the arrest period despite adequate hypothermic suppression of metabolism.

Computerized continuous infusion of intravenous anesthetic drugs during pediatric cardiac surgery

We evaluated the efficacy of a computer-assisted continuous infusion device (CACI) using a two-drug infusion of midazolam and sufentanil as an anesthetic technique during pediatric cardiac surgery. Seventeen pediatric patients were anesthetized with CACI using age-appropriate pharmacokinetic models for administering sufentanil and midazolam. Predicted CACI plasma concentrations were correlated with assayed plasma drug concentrations at eight predefined intervals. The accuracy was assessed using median absolute prediction error. We found that plasma levels predicted by CACI provided a reasonable approximation of measured plasma concentrations for both drugs. The median absolute prediction error for sufentanil during cardiopulmonary bypass was compared with measurements made off of cardiopulmonary bypass (both pre and post cardiopulmonary bypass) and were 49% and 32%, respectively, and for midazolam 44% and 32%, respectively. We conclude that (a) current kinetic models provide a reasonable estimate of plasma drug concentrations, and (b) the ease of administration and targeted plasma level provided by the CACI system is an alternative to inhalation anesthesia using calibrated vaporizers.

The pharmacotherapy of septic shock

Septic shock is a common clinical problem in the intensive care setting. The high mortality rate associated with septic shock, regardless of age, reflects the inadequacy of available therapeutic approaches. The purpose of this article is to review the current pharmacologic approaches to the treatment of septic shock with an emphasis on the pathophysiologic correlations of these treatments.

Family management in the prevention of morbidity of schizophrenia: social outcome of a two-year longitudinal study

Effective community treatment of schizophrenia involves not merely the removal of florid symptoms, but restoration of effective social role functioning. The efficacy of a family management approach is compared with an individual approach of similar intensity in terms of its impact on the patient's social adjustment after a florid episode of schizophrenia. Clinical reports, patient self-reports, and interviews with the family members of 36 patients, who were randomly assigned to family or individual management, demonstrated a consistent superiority for family management. The advantages for the family approach were sustained over a two-year period. The potential mechanisms through which the family approach may have achieved its greater efficacy are discussed from a multi-determined perspective.

Family management in the prevention of morbidity of schizophrenia. Clinical outcome of a two-year longitudinal study

Environmental stress may contribute to the clinical morbidity of established cases of schizophrenia treated with optimal neuroleptic drugs. A family-based approach that aimed to enhance the problem-solving capacity of the index patient and his family caregivers was compared with a patient-oriented approach of similar intensity over a two-year period. Thirty-six patients who returned to stressful parental households after florid episodes of schizophrenia (CATEGO and DSM-III) were stabilized with optimal neuroleptics before being randomly assigned to family or individual therapy in a comprehensive community management program. After nine months, family-managed patients had fewer exacerbations of schizophrenia, lower ratings of schizophrenic psychopathology, fewer hospital admissions, and a trend toward lower deficit symptoms and reduced neuroleptic dosage. This reduced clinical morbidity was sustained throughout the second year of less intensive follow-up. The relative efficacy of the family approach in this clinical management study did not appear to be due to prognostic factors, rater bias, stressful life events, or the effectiveness of pharmacotherapy. Definitive tests of these findings with respect to efficacy require further well-designed studies.

Family educational intervention in the treatment of schizophrenia

In the aftermath of deinstitutionalization, when current public policy dictates greater community management of schizophrenia, patients and their families play an increasing role in the treatment of the illness. Since mental health professionals often neglect to educate them on the causes, symptoms, and treatment of schizophrenia, patients and their families are often misinformed, fearful, and ill-equipped to aid in treatment. The authors describe a brief family educational intervention and the questionnaire that was used to compare the knowledge of patients and their families who received the intervention with the knowledge of those who did not. The findings suggest that patients and their families in family treatment programs can acquire and retain information about schizophrenia more readily than patients and families involved in individual treatment. This knowledge enables them to become more effective participants in aftercare and helps surmount the problems associated with posthospital adjustment.

Consecutive-night reliability of portable nocturnal penile tumescence monitor

Consecutive-night reliability of nocturnal penile tumescence (NPT) was determined in 77 patients, including 47 normal controls (NC), 16 patients with end stage renal disease on maintenance hemodialysis (ESRD), and 14 patients with chronic illnesses but normal renal functioning (CI). A portable NPT monitor was used in a clinical research ward setting. Since there is not yet widespread agreement as to the clinically most relevant NPT response criteria, three were examined: the proportion of sleep time during which an erection of a given penile circumference change was maintained, the maximum penile circumference change obtained, and the number of erections per night of a given penile circumference change. For all three response criteria in each of the three populations the consecutive-night correlation of results was statistically significant, suggesting that portable NPT has consecutive-night reliability.

Relationship between plasma desipramine levels and clinical outcome for RDC major depressive inpatients

Depressed patients (N = 31), who met Research Diagnostic Criteria for major affective disorder-depressed, were severely ill and maintained drug-free for a 1-week period on inpatient status. They received a fixed dose (150 mg/day) of desipramine for a 4-week period with drug plasma level determination and clinical ratings performed at fixed time intervals throughout the study. Despite these rigid criteria for entrance and clinical outcome measures, no obvious relationship between plasma desipramine level and clinical outcome was found. The clinical implications of this finding are discussed.

Family management in the prevention of exacerbations of schizophrenia: a controlled study

Environmental stress has been implicated as an important factor in the relapse of schizophrenic patients receiving optimal drug therapy. In a randomized controlled study, we compared at-home family therapy with clinic-based individual supportive care in the community management of schizophrenia in 36 patients taking neuroleptic maintenance medications. The family-treatment approach sought to enhance the stress-reducing capacity of the patient and his or her family through improved understanding of the illness and training in behavioral methods of problem solving. The results at the end of nine months revealed the superiority of this approach in preventing major symptomatic exacerbations. Only one family-treated patient (6 per cent of all patients) was judged to have had a clinical relapse, as compared with eight patients (44 per cent) treated individually. Family-treated patients averaged 0.83 days in the hospital, as compared with 8.39 days for the comparison group. Significantly lower levels of schizophrenic symptomatology on blind rating-scale assessments supported these clinical observations of the superiority of family management.

Family participation in the community rehabilitation of schizophrenics

Families of schizophrenic patients frequently are ill equipped to handle the primary caretaking responsibilities that have fallen to them due to deinstitutionalization. The authors describe a program begun at a medical center in Southern California in 1978 to assist schizophrenic patients living at home and their families. The program, which consists of family therapy sessions in the home, focuses on education about schizophrenia, development of communication skills, and acquisition of structured problem-solving and other behavioral strategies. Preliminary findings of a controlled study of program participants suggest that the family interventions are both cost-effective and highly successful in reducing the incidence of relapse and hospitalization.

Combined monoamine oxidase inhibitor-tricyclic antidepressant treatment: a pilot study

Thirty newly hospitalized patients with RDC major or minor depressive disorder were randomly assigned to open treatment according to fixed dosage steps with 1) amitriptyline alone, up to a maximum dose of 300 mg/day; 2) tranylcypromine alone, up to a maximum dose of 40 mg/day; or 3) the combination of amitriptyline, up to 150 mg/day, and tranylcypromine, up to 20 mg/day. For 28 patients this protocol continued for 4 weeks or until discharge. As measured by the Hamilton and Zung depression scales, patients in all three treatment groups improved equally. The combination treatment produced a nonsignificantly higher frequency of minor side effects, none of which required discontinuation of treatment. The results indicate the feasibility and safety of further controlled clinical research with combined treatment, although caution is advised.

Breast-feeding reduces incidence of hospital admissions for infection in infants

The prevalence of exclusive breast-feeding among infants 0 to 3 months of age in a community was contrasted with the prevalence of breast-feeding among infants hospitalized for the presence of presumed or established infections. During a one-year period, 136 infants, 0 to 3 months of age, were admitted to the hospital. Among the hospitalized group, only 11.0% were being exclusively breast-fed as contrasted with an expected frequency of 25.2% based on community feeding patterns. No bacterial infections were documented among the breast-fed group while 27 bacterial infections were documented among 121 non-breast-fed infants. This survey indicates that exclusively breast-feeding during the first three months of life significantly reduces the incidence of infections that ultimately require hospitalization of infants.