Journal of Neurosurgical Anesthesiology, Oct 1, 1994
delayed serum sodium decrease. Septic animals treated with 7-NI showed decrease of osmolality 4 h... more delayed serum sodium decrease. Septic animals treated with 7-NI showed decrease of osmolality 4 h after CLP. Nitric oxide synthase activity in hypothalamus increased at 4 and 24 h after CLP and was reduced with 7-NI. Neurohypophysis content of AVP diminished after CLP and 7-NI did not alter this parameter. Plasma AVP levels increased at 6 h and decreased 18 and 24 h after CLP. Treatment with 7-NI did not alter plasma vasopressin levels. Conclusion We concluded that nNOS does not have a substantial role in vasopressin secretion during experimental sepsis.
Hypothermia in a trauma patient has been associated with increased morbidity and mortality and is... more Hypothermia in a trauma patient has been associated with increased morbidity and mortality and is more frequently seen in those sustaining traumatic brain injuries (TBIs). Acidosis is an important consequence of hypothermia that leads to derangements across the spectrum of the coagulation cascade. Here, we present a case of a 31-year-old male presented after suffering a right parietal penetrating ballistic injury with an associated subdural hematoma and 7 mm midline shift requiring decompressive craniectomy and external ventricular drain (EVD) placement in the setting of severe hypothermia (28°C) and acidosis (pH 7.12). With aggressive rewarming intraoperatively, the use of full-body forced-air warming, warmed IV fluids, and increasing the ambient room temperature, the patient's acidosis and hypothermia improved to pH 7.20 and 34°C. Despite these aggressive attempts to rewarm the patient, he developed coagulopathy in the setting of concurrent hypothermia and acidosis. This case highlights the importance of prompt reversal of hypothermia due to its potentially fatal effects, particularly in the setting of severe TBIs. We discuss the critical aspects of surgical management of the injury and anesthetic management of hypothermia, acidosis, and coagulopathy perioperatively.
We present two cases of unanticipated difficult airway in patients requiring reoperation after ce... more We present two cases of unanticipated difficult airway in patients requiring reoperation after cervical spine instrumentation. In both cases, the upper airway examination was normal, and fiberoptic-guided intubation proceeded with the patient sedated and breathing spontaneously. Cord visualization was difficult, but the scope was eventually advanced into the trachea and the endotracheal tube placed safely. Later review of radiographs showed the previously unrecognized protrusion of cervical hardware into the meso-and hypopharynx. We recommend that anesthesiologists review recent radiographic studies for potential airway compromise before approaching the airway of patients presenting for revision of cervical instrumentation.
This article reports the consensus recommendations of a working group that was convened at the en... more This article reports the consensus recommendations of a working group that was convened at the end of a four-year research project funded by the National Institutes of Health that examined 280 cases of egregious ethical violations in medical practice. The group reviewed data from the parent project, as well as other research on sexual abuse of patients, criminal prescribing of controlled substances, and unnecessary invasive procedures that were prosecuted as fraud. The working group embraced the goals of making such violations significantly less frequent and, when they do occur, identifying them sooner and taking necessary steps to ensure they are not repeated. Following review of data and previously published recommendations, the working group developed 10 recommendations that provide a starting point to meet these goals. Recommendations address leadership, oversight, tracking, disciplinary actions, education of patients, partnerships with law enforcement, further research and rela...
Nitric oxide (NO) is a free radical gas synthesised from arginine and oxygen by enzymes of the fa... more Nitric oxide (NO) is a free radical gas synthesised from arginine and oxygen by enzymes of the family of the nitric oxide synthase. In particular, the neuronal nitric oxide synthase (nNOS) is highly expressed by cells of the hypothalamic paraventricular nucleus, where the sympatho-adrenal system, the hypothalamic-pituitary-adrenal axis and the hypothalamic-neurohypophyseal system originate. These structures are deputed to regulate the neuroendocrine stress response. In the past years, evidence has been accumulated to suggest that NO of nNOS origin plays a significant role in modulating the activity of the above mentioned systems under acute stressor exposure. The availability of nNOS knock-out mice allowed to investigate not only the physiological consequences of a constitutive lack of NO of nNOS origin at the hormonal and molecular level, but also to examine possible behavioural alterations. In this review, we shall discuss and confront the current trends of research in this area, especially focusing on the latest findings gained from genetically modified mice.
Recidivism is a fundamental concept in the U.S. justice system-defined, simply, as the tendency f... more Recidivism is a fundamental concept in the U.S. justice system-defined, simply, as the tendency for a person convicted of wrongdoing to re-offend. Common sense tells us that by finding ways to reduce recidivism, we should also be able to reduce the incidence of misbehavior. But accomplishing that goal is no easy task: Just ask the generations of law enforcement officials, policy makers, judges and others, who for years have grappled with finding the balance between punishment and rehabilitation for those convicted of crimes in the United States.
Since the death of George Floyd in May 2020, the United States has experienced a tumultuous, and ... more Since the death of George Floyd in May 2020, the United States has experienced a tumultuous, and often painful, reckoning with issues of racial justice and inequity. An intense national dialogue has ensued, bringing with it a rising awareness of the corrosive effects of systemic racism.
The protective effects of 17&bgr;-estradiol in cerebral ischemia may be partially due to the bloc... more The protective effects of 17&bgr;-estradiol in cerebral ischemia may be partially due to the blockade of leukocyte adhesion in cerebral endothelial cells, although the molecular mechanisms are not well understood. We report that 17&bgr;-estradiol (E2), but not the &agr;-enantiomer, inhibited the basal and interleukin-1&bgr; (IL-1&bgr;)-mediated expression of the intercellular adhesion molecule type 1 (ICAM1) and NF&kgr;B activation, in cultured brain endothelial cells. However, the degradation of I&kgr;B-&agr;, which is an essential requirement for the translocation of NF&kgr;B to the nucleus, and a common biological target to suppress NF&kgr;B activation, was not halted by E2. These findings indicate that decreased expression of adhesion molecules may account for the capacity E2 to reduce adhesion of leukocytes in cerebral endothelium in vivo, and suggest the existence of brain-specific, estrogen-sensitive pathways, other than I&kgr;B-&agr;_-regulation, to modulate NF&kgr;B. The st...
The protective e¡ects of 17b-estradiol in cerebral ischemia may bepartially due to theblockade of... more The protective e¡ects of 17b-estradiol in cerebral ischemia may bepartially due to theblockade of leukocyte adhesion in cerebral endothelial cells, although the molecular mechanisms are not well understood.We report that 17b-estradiol (E2), but not the a-enantiomer, inhibited the basal and interleukin-1b (IL-1b)mediated expression of the intercellular adhesion molecule type 1 (ICAM1) and NFkB activation, in cultured brain endothelial cells.However, the degradation of IkB-a, which is an essential requirement for the translocation of NFkB to the nucleus, and a common biological target to suppress NFkB activation, was not haltedby E2.These ¢ndings indicate thatdecreased expression of adhesionmoleculesmay account for the capacity E2 to reduce adhesion of leukocytes in cerebral endothelium in vivo, and suggest the existence of brain-speci¢c, estrogen-sensitive pathways, other than IkB-a_-regulation, to modulate NFkB.The stereoselectivity of the E2 e¡ect is consistent with an estrogen rec...
Journal of Cardiothoracic and Vascular Anesthesia, 2020
OBJECTIVES To compare the performance of a novel NeurOs cerebral oximetry monitor against the INV... more OBJECTIVES To compare the performance of a novel NeurOs cerebral oximetry monitor against the INVOS monitor during the entire intraoperative phase of cardiac surgery, including periods of known fluctuation in brain oxygenation, such as preoxygenation, induction, cannulation, and cardiopulmonary bypass. DESIGN This study was a prospective, nonrandomized, healthcare-provider and outcome-assessor blinded study. SETTING Tertiary care university hospital; single institutional study. PARTICIPANTS Twenty-three patients who underwent cardiac surgery with cardiopulmonary bypass. INTERVENTIONS Both self-adhesive INVOS sensors and the assembled NeurOs sensors were placed accordingly when the patient arrived in the operating room. MEASUREMENTS AND MAIN RESULTS Ten out of 13 cases under the normal mode and eight out of the 10 cases under the high- sensitivity mode showed significant correlations between the NeurOs and INVOS groups (p < 0.05, r value from 0.24-0.88). When all cases were combined, NeurOs demonstrated significant correlation with INVOS (r = 0.5, 95% confidence interval [CI] 0.44-0.56, p < 0.01 for normal mode; r = 0.69, 95% CI 0.64 to 0.74, p < 0.01 for high-sensitivity mode) in both modes. To evaluate the data diversity, the authors performed a cluster analysis and found much less variation existed in the NeurOs normal mode when compared with INVOS (standard deviation [SD] 16.6% in INVOS, 4% in NeurOs normal mode) but similar patterns in the high-sensitivity mode (SD 17.6% in INVOS, 15.2% in NeurOs high-sensitivity mode). Bland-Altman plot analysis showed that most of the data fell between ± 1.96 SD lines, which demonstrated good consistency between these two methods under both modes of NeurOs (-28.8 to 30.8 in the normal mode; -36.6 to 32.7 in high-sensitivity mode). In the normal mode of NeurOs monitoring, receiver operating characteristic analysis suggested a 2% cutoff point was most optimal from the baseline for detecting hyperoxia (sensitivity 73%; specificity 66%) and minus 1% (sensitivity 66%; specificity 67%) for detecting hypoxia. Whereas in the high-sensitivity mode, the optimal cutoff point was 3% from baseline for detecting hyperoxia (sensitivity 75%; specificity 68%), and minus 3% for detecting hypoxia (sensitivity 90%; specificity 45%). CONCLUSIONS In conclusion, the novel NeurOs system was found to correlate with INVOS cerebral oximetry measurements during cardiac surgery.
Abstract: Vasospasm that occurs after subarachnoid hemorrhage (SAH), despite successful surgical ... more Abstract: Vasospasm that occurs after subarachnoid hemorrhage (SAH), despite successful surgical or radiological intervention remains with an ominous prognostic recovery period. 1 We investigated the correlation of S100B protein in CSF and serum with incident of ...
Journal of Neurosurgical Anesthesiology, Oct 1, 1994
delayed serum sodium decrease. Septic animals treated with 7-NI showed decrease of osmolality 4 h... more delayed serum sodium decrease. Septic animals treated with 7-NI showed decrease of osmolality 4 h after CLP. Nitric oxide synthase activity in hypothalamus increased at 4 and 24 h after CLP and was reduced with 7-NI. Neurohypophysis content of AVP diminished after CLP and 7-NI did not alter this parameter. Plasma AVP levels increased at 6 h and decreased 18 and 24 h after CLP. Treatment with 7-NI did not alter plasma vasopressin levels. Conclusion We concluded that nNOS does not have a substantial role in vasopressin secretion during experimental sepsis.
Hypothermia in a trauma patient has been associated with increased morbidity and mortality and is... more Hypothermia in a trauma patient has been associated with increased morbidity and mortality and is more frequently seen in those sustaining traumatic brain injuries (TBIs). Acidosis is an important consequence of hypothermia that leads to derangements across the spectrum of the coagulation cascade. Here, we present a case of a 31-year-old male presented after suffering a right parietal penetrating ballistic injury with an associated subdural hematoma and 7 mm midline shift requiring decompressive craniectomy and external ventricular drain (EVD) placement in the setting of severe hypothermia (28°C) and acidosis (pH 7.12). With aggressive rewarming intraoperatively, the use of full-body forced-air warming, warmed IV fluids, and increasing the ambient room temperature, the patient's acidosis and hypothermia improved to pH 7.20 and 34°C. Despite these aggressive attempts to rewarm the patient, he developed coagulopathy in the setting of concurrent hypothermia and acidosis. This case highlights the importance of prompt reversal of hypothermia due to its potentially fatal effects, particularly in the setting of severe TBIs. We discuss the critical aspects of surgical management of the injury and anesthetic management of hypothermia, acidosis, and coagulopathy perioperatively.
We present two cases of unanticipated difficult airway in patients requiring reoperation after ce... more We present two cases of unanticipated difficult airway in patients requiring reoperation after cervical spine instrumentation. In both cases, the upper airway examination was normal, and fiberoptic-guided intubation proceeded with the patient sedated and breathing spontaneously. Cord visualization was difficult, but the scope was eventually advanced into the trachea and the endotracheal tube placed safely. Later review of radiographs showed the previously unrecognized protrusion of cervical hardware into the meso-and hypopharynx. We recommend that anesthesiologists review recent radiographic studies for potential airway compromise before approaching the airway of patients presenting for revision of cervical instrumentation.
This article reports the consensus recommendations of a working group that was convened at the en... more This article reports the consensus recommendations of a working group that was convened at the end of a four-year research project funded by the National Institutes of Health that examined 280 cases of egregious ethical violations in medical practice. The group reviewed data from the parent project, as well as other research on sexual abuse of patients, criminal prescribing of controlled substances, and unnecessary invasive procedures that were prosecuted as fraud. The working group embraced the goals of making such violations significantly less frequent and, when they do occur, identifying them sooner and taking necessary steps to ensure they are not repeated. Following review of data and previously published recommendations, the working group developed 10 recommendations that provide a starting point to meet these goals. Recommendations address leadership, oversight, tracking, disciplinary actions, education of patients, partnerships with law enforcement, further research and rela...
Nitric oxide (NO) is a free radical gas synthesised from arginine and oxygen by enzymes of the fa... more Nitric oxide (NO) is a free radical gas synthesised from arginine and oxygen by enzymes of the family of the nitric oxide synthase. In particular, the neuronal nitric oxide synthase (nNOS) is highly expressed by cells of the hypothalamic paraventricular nucleus, where the sympatho-adrenal system, the hypothalamic-pituitary-adrenal axis and the hypothalamic-neurohypophyseal system originate. These structures are deputed to regulate the neuroendocrine stress response. In the past years, evidence has been accumulated to suggest that NO of nNOS origin plays a significant role in modulating the activity of the above mentioned systems under acute stressor exposure. The availability of nNOS knock-out mice allowed to investigate not only the physiological consequences of a constitutive lack of NO of nNOS origin at the hormonal and molecular level, but also to examine possible behavioural alterations. In this review, we shall discuss and confront the current trends of research in this area, especially focusing on the latest findings gained from genetically modified mice.
Recidivism is a fundamental concept in the U.S. justice system-defined, simply, as the tendency f... more Recidivism is a fundamental concept in the U.S. justice system-defined, simply, as the tendency for a person convicted of wrongdoing to re-offend. Common sense tells us that by finding ways to reduce recidivism, we should also be able to reduce the incidence of misbehavior. But accomplishing that goal is no easy task: Just ask the generations of law enforcement officials, policy makers, judges and others, who for years have grappled with finding the balance between punishment and rehabilitation for those convicted of crimes in the United States.
Since the death of George Floyd in May 2020, the United States has experienced a tumultuous, and ... more Since the death of George Floyd in May 2020, the United States has experienced a tumultuous, and often painful, reckoning with issues of racial justice and inequity. An intense national dialogue has ensued, bringing with it a rising awareness of the corrosive effects of systemic racism.
The protective effects of 17&bgr;-estradiol in cerebral ischemia may be partially due to the bloc... more The protective effects of 17&bgr;-estradiol in cerebral ischemia may be partially due to the blockade of leukocyte adhesion in cerebral endothelial cells, although the molecular mechanisms are not well understood. We report that 17&bgr;-estradiol (E2), but not the &agr;-enantiomer, inhibited the basal and interleukin-1&bgr; (IL-1&bgr;)-mediated expression of the intercellular adhesion molecule type 1 (ICAM1) and NF&kgr;B activation, in cultured brain endothelial cells. However, the degradation of I&kgr;B-&agr;, which is an essential requirement for the translocation of NF&kgr;B to the nucleus, and a common biological target to suppress NF&kgr;B activation, was not halted by E2. These findings indicate that decreased expression of adhesion molecules may account for the capacity E2 to reduce adhesion of leukocytes in cerebral endothelium in vivo, and suggest the existence of brain-specific, estrogen-sensitive pathways, other than I&kgr;B-&agr;_-regulation, to modulate NF&kgr;B. The st...
The protective e¡ects of 17b-estradiol in cerebral ischemia may bepartially due to theblockade of... more The protective e¡ects of 17b-estradiol in cerebral ischemia may bepartially due to theblockade of leukocyte adhesion in cerebral endothelial cells, although the molecular mechanisms are not well understood.We report that 17b-estradiol (E2), but not the a-enantiomer, inhibited the basal and interleukin-1b (IL-1b)mediated expression of the intercellular adhesion molecule type 1 (ICAM1) and NFkB activation, in cultured brain endothelial cells.However, the degradation of IkB-a, which is an essential requirement for the translocation of NFkB to the nucleus, and a common biological target to suppress NFkB activation, was not haltedby E2.These ¢ndings indicate thatdecreased expression of adhesionmoleculesmay account for the capacity E2 to reduce adhesion of leukocytes in cerebral endothelium in vivo, and suggest the existence of brain-speci¢c, estrogen-sensitive pathways, other than IkB-a_-regulation, to modulate NFkB.The stereoselectivity of the E2 e¡ect is consistent with an estrogen rec...
Journal of Cardiothoracic and Vascular Anesthesia, 2020
OBJECTIVES To compare the performance of a novel NeurOs cerebral oximetry monitor against the INV... more OBJECTIVES To compare the performance of a novel NeurOs cerebral oximetry monitor against the INVOS monitor during the entire intraoperative phase of cardiac surgery, including periods of known fluctuation in brain oxygenation, such as preoxygenation, induction, cannulation, and cardiopulmonary bypass. DESIGN This study was a prospective, nonrandomized, healthcare-provider and outcome-assessor blinded study. SETTING Tertiary care university hospital; single institutional study. PARTICIPANTS Twenty-three patients who underwent cardiac surgery with cardiopulmonary bypass. INTERVENTIONS Both self-adhesive INVOS sensors and the assembled NeurOs sensors were placed accordingly when the patient arrived in the operating room. MEASUREMENTS AND MAIN RESULTS Ten out of 13 cases under the normal mode and eight out of the 10 cases under the high- sensitivity mode showed significant correlations between the NeurOs and INVOS groups (p < 0.05, r value from 0.24-0.88). When all cases were combined, NeurOs demonstrated significant correlation with INVOS (r = 0.5, 95% confidence interval [CI] 0.44-0.56, p < 0.01 for normal mode; r = 0.69, 95% CI 0.64 to 0.74, p < 0.01 for high-sensitivity mode) in both modes. To evaluate the data diversity, the authors performed a cluster analysis and found much less variation existed in the NeurOs normal mode when compared with INVOS (standard deviation [SD] 16.6% in INVOS, 4% in NeurOs normal mode) but similar patterns in the high-sensitivity mode (SD 17.6% in INVOS, 15.2% in NeurOs high-sensitivity mode). Bland-Altman plot analysis showed that most of the data fell between ± 1.96 SD lines, which demonstrated good consistency between these two methods under both modes of NeurOs (-28.8 to 30.8 in the normal mode; -36.6 to 32.7 in high-sensitivity mode). In the normal mode of NeurOs monitoring, receiver operating characteristic analysis suggested a 2% cutoff point was most optimal from the baseline for detecting hyperoxia (sensitivity 73%; specificity 66%) and minus 1% (sensitivity 66%; specificity 67%) for detecting hypoxia. Whereas in the high-sensitivity mode, the optimal cutoff point was 3% from baseline for detecting hyperoxia (sensitivity 75%; specificity 68%), and minus 3% for detecting hypoxia (sensitivity 90%; specificity 45%). CONCLUSIONS In conclusion, the novel NeurOs system was found to correlate with INVOS cerebral oximetry measurements during cardiac surgery.
Abstract: Vasospasm that occurs after subarachnoid hemorrhage (SAH), despite successful surgical ... more Abstract: Vasospasm that occurs after subarachnoid hemorrhage (SAH), despite successful surgical or radiological intervention remains with an ominous prognostic recovery period. 1 We investigated the correlation of S100B protein in CSF and serum with incident of ...
Uploads
Papers by Heidi Koenig