Intraoperative mapping of language functions: a longitudinal neurolinguistic analysis

OBJECT: This prospective longitudinally designed study was conducted to evaluate language functions pre- and postoperatively in patients who underwent microsurgical treatment of tumors in close proximity to or within language areas and to detect those patients at risk for a postoperative aphasic disturbance. METHODS: Between 1991 and 2005, 153 awake craniotomies with subsequent cortical mapping of language functions were performed in 149 patients. Language functions were assessed using a standardized test battery. Risk factors were obtained from multivariate logistic regression models. RESULTS: Language mapping was able to be performed in all patients, and complete tumor resection was achieved in 48.4%. Within 21 days after surgery a new language deficit (aphasic disturbance) was observed in 41 (32%) of the 128 cases without preoperative deficits. There were a total of 60 cases involving postoperative aphasic disturbances, including cases both with and without preoperative disturbances. Risk factors for postoperative aphasic disturbance were preoperative aphasia (p<0.0002), intraoperative complications (p<0.02), language-positive sites within the tumor (p<0.001), and nonfrontal lesion location (p<0.001). In patients without a preoperative deficit, a normal (yet submaximal) naming performance was a powerful predictor for an early postoperative aphasic disturbance (p<0.0003). Seven months after treatment 10.9% of the 128 cases without preoperative aphasic disturbances continued to demonstrate new postoperative language disturbances. A total of 17.6% of all cases demonstrated new postoperative language disturbances after 7 months. Risk factors for persistent aphasic disturbance were increased age (>40 years, p<0.02) and preoperative aphasia (p<0.001). CONCLUSIONS: Every attempt should be undertaken to preserve language-relevant areas intraoperatively, even when they are located within the tumor. New postoperative deficits resolve in the majority of patients, which may be a result of cortical mapping as well as functional reorganization.     

Concordance between functional magnetic resonance imaging and intraoperative language mapping

Although the correspondence between functional-magnetic resonance imaging (fMRI) representations of the sensorimotor cortex and intraoperative electrophysiology (including somatosensory evoked potential, SSEP, recordings and direct cortical stimulation) has been reported, a similar correspondence between fMRI and intraoperative localization of the language-sensitive cortex is not as well established. The aim of the present study was to evaluate the concordance between fMRI and intraoperative electrophysiology with respect to the localization of the language-sensitive and sensorimotor cortices. We present the results of 21 patients who underwent language and sensorimotor mapping by fMRI and intraoperative electrophysiology including SSEP recordings (n = 21), direct cortical stimulation of motor cortex (n = 15) and direct cortical stimulation of Broca's and Wernicke's area (n = 5). When responses were obtained with both methods, localization of function concurred in all cases. These observations suggest that fMRI represents a reliable preoperative tool for the identification of language-sensitive areas.     

Current state of three-dimensional characterisation of antifungal targets and its use for molecular modelling in drug design

The alarming rise in life-threatening systemic fungal infections due to the emergence of drug-resistant fungal strains had produced an increased demand for new antimycotics, especially those targeting novel antifungal structures. Drug discovery has developed from screening natural products and chemical synthesis to a modern approach, namely structure-based drug design. Whilst many antifungal agents currently in use were discovered more than 30 years ago, characterisation of various drug targets has only been achieved recently, contributing immensely to understanding the structure–activity relationships of antifungals and their targets. Three-dimensional characterisation has become a well established tool for modern antifungal drug research and should play an important role in investigations for new antifungal agents.     

Kunstfehler. Ärzterecht

Ohne Zusammenfassung     

Phenolsäuren- und Indolausscheidung im Urin bei Gabe von α-Methyldopa

Zusammenfassung Bei Ratten und bei hypertoniekranken Menschen wurden das Phenolsäure- und Indolsäuremuster des Urins vor und nach Gabe von -Methyldopa papierchromatographisch untersucht. Vanillinmandelsäure und 5-Hydroxyindolessigsäureausscheidung wurden beim Menschen quantitativ bestimmt.Bei den Ratten waren unter -Methyldopagabe die Katecholaminabbauprodukte Vanillinsäure, p-Hy droxybenzoesäure, ferner die o-Hydroxyphenylbrenztraubensäure und die o-Hydroxyhippursäure vermehrt. Dihydroxyferulasäure, Indolessigsäure, Indolmilchsäure und 5-Hydroxyindolessigsäure waren vermindert. Es traten verschiedene neue unbekannte Flecken auf. Beim hypertoniekranken Menschen war die Ausscheidung der Katecholaminabbauprodukte bei Gabe von -Methyldopa zunächst vermindert, stieg dann wieder an, und es wurden vermehrt m- und p-Hydroxybenzoesäure und Vanillinsäure ausgeschieden. 5-Hydroxyindolessigsäure war vermehrt, Indolessigsäure, Indolmilchsäure vermindert.Als Erklärung für die verminderte Ausscheidung verschiedener Phenol- und Indolsäuren ist die Decarboxylasehemmung durch -Methyldopa anzunehmen. Die erhöhte Ausscheidung mehrerer Phenolsäuren des Katecholaminabbaues spricht für eine Enzymadaptation oder für eine Umgehung des durch -Methyldopa gehemmten Stoffwechselweges. Außerdem ist an die Möglichkeit einer sekundären Freisetzung biogener Amine durch -Methyldopa zu denken.Die Arbeit wurde mit Unterstützung der Deutschen Forschungsgemeinschaft durchgeführt.FräuleinSigrid Klein danken wir für sorgfältige technische Mitarbeit.Wir danken der Firma Merck, Sharp und Dohme, USA, für die Überlassung von Versuchsmengen von Aldomet (-Methyldopa).     

Kathetergestützter Aortenklappenersatz: Alternative zur offenen Chirurgie bei Hochrisikopatienten

Prosthetic aortic valve replacement with extracorporeal circulation is the therapy of choice for high-grade symptomatic aortic stenosis; the mean risk of the procedure is 2–5 %. Due to age and comorbidities, a number of patients can be at a far higher risk. Meanwhile, catheter-based valve replacement procedures constitute an alternative for these patients by minimizing the operative risk. Between 7/2007 and 11/2008 a total of 182 patients with a mean age of 81.1 years were treated. According to the logistic Euroscore the predicted operative risk was at a mean of 22.5 % and according to STS score at 23.5 %. A total of 145 CoreValve and 37 Edwards-Sapien prostheses were implanted; transarterial access was preferred in 79 % of the patients. The 30-day mortality in the total collective was 10.9 %. After one year, over 78 % of patients with transarterial access and 56 % of patients with transapical access were still alive. Substantial complications were AV block requiring pacemaker implantation (21 %) and peripheral vascular complications (20 %). Catheter-based aortic valve replacement could be established as a routine alternative procedure for patients with increased operative risk. Mortality is satisfactory, given the score-predicted risk. Further improvement of results can be expected through optimization of procedural management and technical modifications of valves and catheters.