[Fluid therapy--introduction].
Explore the source record for details and available documents.
Blood Volume↗
Biomedical subjects
Claudia D Spies
Publications and source records attributed to Claudia D Spies.
[Fluid therapy--pathophysiological principles as well as intra- and perioperative monitoring].
Explore the source record for details and available documents.
Blood Pressure↗
[Fluid therapy--volume therapy in fast-track colon surgery].
Explore the source record for details and available documents.
Colon↗
The effect of computerized tailored brief advice on at-risk drinking in subcritically injured trauma patients.
BACKGROUND: One-third of injured patients treated in the emergency department (ED) have an alcohol use disorder (AUD). Few are screened and receive counseling because ED staff have little time for additional tasks. We hypothesized that computer technology can screen and provide an intervention that reduces at-risk drinking (British Medical Association criteria) in injured ED patients. METHODS: In all, 3,026 subcritically injured patients admitted to an ED were screened for an AUD using a laptop computer that administered the AUD Identification Test (AUDIT) and assessed motivation to reduce drinking. Patients with a positive AUDIT (n = 1,139) were randomized to an intervention (n = 563) or control (n = 576) condition. The computer generated a customized printout based on the patient's own alcohol use pattern, level of motivation, and personal factors, which was provided in the form of feedback and advice. RESULTS: Most patients (85%) used the computer with minimal assistance. At study entry, a similar proportion in each group met criteria for at-risk drinking (49.6% versus 46.8%, p = 0.355). At 6 months, 21.7% of intervention and 30.4% of control patients met criteria for at-risk drinking (p = 0.008). Intervention patients also had a 35.7% decrease in alcohol intake, compared with a 20.5% decrease in controls (p = 0.006). At 12 months, alcohol intake decreased by 22.8% in the intervention group versus 10.9% in controls (p = 0.023), but the proportion of at-risk drinkers did not significantly differ (37.3% versus 42.6%, p = 0.168). CONCLUSIONS: The computer-generated intervention was associated with a significant decrease in alcohol use and at-risk drinking. Research is needed to further evaluate and adapt information technology to provide preventive clinical services in the ED.
Adult↗
Immune reactivity is more suppressed in patients with alcoholic liver disease than in patients with virus-induced cirrhosis after CRH stimulation.
BACKGROUND: The most frequent diagnoses for liver transplantation are virus-induced cirrhosis (VIC) and alcoholic liver disease (ALD), after an abstinence period of at least 6 months. Chronic ethanol consumption has been linked to an abnormal neuroendocrine-immune axis and to an altered surgical stress response inducing an increased infection rate. Preoperative stress testing might be relevant to detect stress-induced immune alteration. The aim of this study was to investigate the preoperative stress-like response to corticotrophin-releasing-hormone challenge (CRH) of patients with ALD compared with patients with VIC and their immune sequelae. METHODS: Nine patients with ALD and 8 patients with VIC were included in this clinical study prior to transplantation. All patients received CRH in the morning. Blood samples were drawn before and after stress testing. RESULTS: In response to CRH, the ALD patients showed a significant decrease in the plasma interleukin (IL)-6/IL-10 ratio. After lipopolysaccharide stimulation of whole blood from CRH-challenged ALD patients, IL-10 increased significantly. The cytotoxic T1-(Tc1) to cytotoxic T2 (Tc2) ratio was significantly decreased in ALD patients after the stress test. Infections occurred significantly more often in ALD patients within the past year before study inclusion. CONCLUSIONS: ALD patients showed a stronger anti-inflammatory immune status and response than VIC patients. This difference was associated with a higher infection rate despite a median alcohol abstinence time of 3.5 years. Although an altered immune response is well known among patients with actual alcohol-use disorders, to the best of our knowledge, it is not described in patients after such a long abstinence time.
Adrenocorticotropic Hormone↗
Nicotine stimulation on extracellular glutamate levels in the nucleus accumbens of ethanol-withdrawn rats in vivo.
BACKGROUND: Nicotine can release glutamate in the limbic system. Presynaptic activation of glutamate receptors might be relevant for the subsequent firing of excitatory postsynaptic potentials. This might be relevant in early ethanol withdrawal. The effects and differences of nicotine stimulation on glutamate response measured by microdialysis in the nucleus accumbens (NAC) between ethanol-withdrawn rats (EW group) and ethanol-naïve rats (control group) were investigated. METHODS: Rats were ethanol-intoxicated according to a binge-drinking model: recurrent cycle of 4 days of intoxication (EW group) or 5% sucrose (control group), followed by a 3-day recovery. This was followed by a 2-day intoxication period and subsequent abstinence. After the last oral intake, microdialysis was performed in the left NAC for a 16-hour withdrawal period. At the end of the withdrawal period, a rated withdrawal score (RWS) was documented. Then, nicotine was given subcutaneously at a dose of 0.5 mg/kg and amino acid levels determined by microdialysis were followed for an additional 3 hours. RESULTS: The RWS was not correlated to the last amount of ethanol received, but was correlated to the total amount of ethanol administered during the pretreatment period: the basal values of extracellular glutamate were found to be decreased in the EW group before withdrawal. Cessation of ethanol significantly increased glutamate levels with a peak between 4 and 10 hours after the last oral intake. Sixteen hours after ethanol withdrawal, the same level as in the control group was achieved. Nicotine significantly increased glutamate levels in the NAC of the EW group but not in ethanol-naïve rats. CONCLUSIONS: This study showed that withdrawal of ethanol was associated with an increase in extracellular glutamate levels. Systemic administration of nicotine in vivo produced an increase in extracellular levels of glutamate in the core region of the NAC during ethanol withdrawal. This might be a relevant pathomechanism for increased craving either for alcohol or for nicotine after ethanol withdrawal.
Alcoholic Intoxication↗
Effects of dopexamine on the intestinal microvascular blood flow and leukocyte activation in a sepsis model in rats.
INTRODUCTION: The administration of dopexamine may constitute a therapeutical option to improve hepatosplanchnic perfusion in sepsis. In order to verify this hypothesis, we administered dopexamine in an experimental sepsis model in rats. METHODS: This prospective, randomized, controlled laboratory study was conducted in 42 Wistar rats. The animals were divided into 3 groups. Group 1 (CON group) served as control group. The Animals of groups 2 (LPS Group) and 3 received an endotoxin infusion (20 mg/kgfor 15 min). In addition, in group 3 (DPX group) dopexamine was administered 0.5 microg/kg/minover 4 hours. One half of the animals of each group underwent studies of intestinal microvascular blood flow (IMBF) using laser Doppler fluxmetry. In the other half an intravital microscopic evaluation of the leukocyte endothelium cell interaction in the intestinal microcirculation was performed. Functional capillary denstity (FCD) in the intestinal mucosaand the circular as well as the longitudinal muscle layer was estimated. RESULTS: One hour after endotoxin challenge IMBF decreased significantly in the untreated LPS group to 51% compared to baseline (p<0.05). In DPX treated endotoxin animals we found significantly higher values at the level of CON group. The after endotoxin challenge impaired FCD was improved by dopexamine in the longitudinal (DPX + 33% vs. LPS; p <0.05) and in the circular muscle layer (DPX + 48% vs. LPS; p < 0.05) as a result of dopexamine administration. The administration of dopexamine reduced the count of firmly adherent leukocytes when compared to the untreated LPS group (-31%, p<0.05). TNF-alpha plasma levels were reduced by dopexamine infusion (LPS group 3637 +/- 553 pg/mL; DPXgroup 1933 +/- 201 pg/mL) one hour after endotoxin challenge. CONCLUSIONS: The administration of dopexamine improved IMBF and FCD as parameters of intestinal microcirculation and reduced leukocyte activation as a parameter of inflammation in experimental sepsis.
Animals↗
Comparison of uncalibrated arterial waveform analysis in cardiac surgery patients with thermodilution cardiac output measurements.
INTRODUCTION: Cardiac output (CO) monitoring is indicated only in selected patients. In cardiac surgical patients, perioperative haemodynamic management is often guided by CO measurement by pulmonary artery catheterisation (COPAC). Alternative strategies of CO determination have become increasingly accepted in clinical practice because the benefit of guiding therapy by data derived from the PAC remains to be proven and less invasive alternatives are available. Recently, a device offering uncalibrated CO measurement by arterial waveform analysis (COWave) was introduced. As far as this approach is concerned, however, the validity of the CO measurements obtained is utterly unclear. Therefore, the aim of this study was to compare the bias and the limits of agreement (LOAs) (two standard deviations) of COWave at four specified time points prior, during, and after coronary artery bypass graft (CABG) surgery with a simultaneous measurement of the gold standard COPAC and aortic transpulmonary thermodilution CO (COTranspulm). METHODS: Data from 30 patients were analysed during this prospective study. COPAC, COTranspulm, and COWave were determined in all patients at four different time points prior, during, and after CABG surgery. The COPAC and the COTranspulm were measured by triple injection of 10 ml of iced isotone sodium chloride solution into the central venous line of the PAC. Measurements of COWave were simultaneously taken at these time points. RESULTS: The overall correlation showed a Spearman correlation coefficient between COPAC and COWave of 0.53 (p < 0.01) and 0.84 (p < 0.01) for COPAC and COTranspulm. Bland-Altman analysis showed a mean bias and LOAs of 0.6 litres per minute and -2.2 to +3.4 litres per minute for COPAC versus COWave and -0.1 litres per minute and -1.8 to +1.6 litres per minute for COPAC versus COTranspulm. CONCLUSION: Arterial waveform analysis with an uncalibrated algorithm COWave underestimated COPAC to a clinically relevant extent. The wide range of LOAs requires further evaluation. Better results might be achieved with an improved new algorithm. In contrast to this, we observed a better correlation of thermodilution COTranspulm and thermodilution COPAC measurements prior, during, and after CABG surgery.
Aged↗
Increased interleukin-6 after cardiac surgery predicts infection.
Early diagnosis and treatment of infection after cardiac surgery with cardiopulmonary bypass (CPB) improves outcome. Conventional laboratory tests, such as C-reactive protein and white blood cell count can not distinguish patients with early infection from those with systemic inflammatory response syndrome but without infection. After CPB, there is a systemic release of proinflammatory and antiinflammatory cytokines, including tumor necrosis factor-alpha, interleukin (IL)-6, and IL-10. We investigated the predictive ability of these variables for infection after cardiac surgery. Forty-six patients with impaired left ventricular ejection fraction (<60%), scheduled for cardiac surgery, were included. Plasma samples were drawn 1 day before and immediately before surgery, on admission to the intensive care unit, and on days 1, 3, and 7 after surgery. Infection was identified according to the criteria of the Centers for Disease Control and Prevention. After surgery 13 patients developed an infection. In patients with infection, confirmed a median of 4 days after surgery, all measurements of IL-6, and IL-10 on postoperative day 3 were significantly increased. Tumor necrosis factor-alpha, leukocytes, and C-reactive protein were not increased in these patients. Immediately after surgery blood glucose was significantly increased in patients with infection. Increased IL-6 after CPB is predictive of infection after cardiac surgery in patients with impaired left ventricular function.
Aged↗
Clonidine attenuated early proinflammatory response in T-cell subsets after cardiac surgery.
T-cells play a central role in the immune response to injury. Cardiac surgery is associated with significant risk of systemic inflammatory response syndrome and subsequent unbalanced induction of proinflammatory cytokines. As clonidine has immunomodulating properties via reducing sympathetic activity, this study involved the analysis of T-cell function in the early postoperative period in patients undergoing coronary artery bypass graft surgery. Forty patients undergoing cardiac surgery were randomly allocated to one of the following groups: clonidine group (n = 20) [clonidine 1 microg kg(-1) h(-1)] and placebo group (n = 20). Study medication was started after induction of anesthesia and maintained until 6 h after surgery. Blood samples to determine Th1 and Th2 cells and cytotoxic lymphocytes (Tc1 and Tc2 cells) were drawn preoperatively, on admission to the intensive care unit, 6 and 12 h postoperatively as well as on the morning of days 1 and 2 after surgery. In the clonidine group significantly lower levels of Th1/Th2 ratios as well as Tc1/Tc2 ratios were found 6 h postoperatively compared to the placebo group (P < 0.05). Clonidine changed the ratio of T-lymphocyte subpopulations in peripheral blood in favor of a proinflammatory response, which might be favorable for maintaining immune balance after surgery.
Adrenergic alpha-Agonists↗
Preoperative oral carbohydrate administration to ASA III-IV patients undergoing elective cardiac surgery.
In this study we investigated the effects of preoperative oral carbohydrate administration on postoperative insulin resistance (PIR), gastric fluid volume, preoperative discomfort, and variables of organ dysfunction in ASA physical status III-IV patients undergoing elective cardiac surgery, including those with noninsulin-dependent Type-2 diabetes mellitus. Before surgery, 188 patients were randomized to receive a clear 12.5% carbohydrate drink (CHO), flavored water (placebo), or to fast overnight (control). CHO and placebo were treated in double-blind format and received 800 mL of the corresponding beverage in the evening and 400 mL 2 h before surgery. Patients were monitored from induction of general anesthesia until 24 h postoperatively. Exogenous insulin requirements to control blood glucose levels <or=10.0 mmol/L were used as a marker for PIR. Gastric fluid volume was measured by passive gastric reflux and preoperative discomfort using visual analog scales. Postoperative clinical and surgical data were recorded. Blood glucose levels and insulin requirements did not differ between groups. Patients receiving CHO and placebo were less thirsty compared with controls (P < 0.01 and P = 0.06, respectively). Ingested liquids did not cause increased gastric fluid volume or other adverse events. The CHO group required less intraoperative inotropic support after initiation of cardiopulmonary bypass weaning (P < 0.05). In conclusion, preoperative CHO administration before cardiac surgery does not affect PIR. Clear fluids reduce thirst and may be recommended as a safe procedure in ASA III-IV patients. Further research is indicated to investigate possible cardioprotective effects of preoperative CHO intake.
Administration, Oral↗
Pulse contour analysis after normothermic cardiopulmonary bypass in cardiac surgery patients.
INTRODUCTION: Monitoring of the cardiac output by continuous arterial pulse contour (COPiCCOpulse) analysis is a clinically validated procedure proved to be an alternative to the pulmonary artery catheter thermodilution cardiac output (COPACtherm) in cardiac surgical patients. There is ongoing debate, however, of whether the COPiCCOpulse is accurate after profound hemodynamic changes. The aim of this study was therefore to compare the COPiCCOpulse after cardiopulmonary bypass (CPB) with a simultaneous measurement of the COPACtherm. METHODS: After ethical approval and written informed consent, data of 45 patients were analyzed during this prospective study. During coronary artery bypass graft surgery, the aortic transpulmonary thermodilution cardiac output (COPiCCOtherm) and the COPACtherm were determined in all patients. Prior to surgery, the COPiCCOpulse was calibrated by triple transpulmonary thermodilution measurement of the COPiCCOtherm. After termination of CPB, the COPiCCOpulse was documented. Both COPACtherm and COPiCCOtherm were also simultaneously determined and documented. RESULTS: Regression analysis between COPACtherm and COPiCCOtherm prior to CPB showed a correlation coefficient of 0.95 (P < 0.001), and after CPB showed a correlation coefficient of 0.82 (P < 0.001). Bland-Altman analysis showed a mean bias and limits of agreement of 0.0 l/minute and -1.4 to +1.4 l/minute prior to CPB and of 0.3 l/minute and -1.9 to +2.5 l/minute after CPB, respectively. Regression analysis of COPiCCOpulse versus COPiCCOtherm and of COPiCCOpulse versus COPACtherm after CPB showed a correlation coefficient of 0.67 (P < 0.001) and 0.63 (P < 0.001), respectively. Bland-Altman analysis showed a mean bias and limits of agreement of -1.1 l/minute and -1.9 to +4.1 l/minute versus -1.4 l/minute and -4.8 to +2.0 l/minute, respectively. CONCLUSION: We observed an excellent correlation of COPiCCOtherm and COPACtherm measurement prior to CPB. Pulse contour analysis did not yield reliable results with acceptable accuracy and limits of agreement under difficult conditions after weaning from CPB in cardiac surgical patients. The pulse contour analysis thus should be re-calibrated as soon as possible, to prevent false therapeutic consequences.
Cardiac Output↗
Circulating immune parameters predicting the progression from hospital-acquired pneumonia to septic shock in surgical patients.
INTRODUCTION: Hospital-acquired pneumonia after surgery is one of the major causes of septic shock. The excessive inflammatory response appears to be responsible for the increased susceptibility to infections and subsequent sepsis. The primary aim of this study was to investigate immune parameters at the onset of pneumonia, before the development of subsequent septic shock. The secondary aim was to investigate the usefulness of these immune parameters in predicting progression from hospital-acquired pneumonia to septic shock. METHODS: This prospective clinical study included 76 patients with the diagnosis of hospital-acquired pneumonia. Approval was obtained from the local institutional ethics committee and relatives of the patients gave informed consent. Of the 76 patients, 29 subsequently developed septic shock. All patients were included within 4 h of establishing the diagnosis of hospital-acquired pneumonia (first collection of blood samples and the analysis of immune mediators). In addition, we defined early (within 12 h of onset of septic shock) and late (within 72 to 96 h of onset) stages of septic shock for the collection of blood samples and the analysis of immune mediators. The immune parameters tumor necrosis factor-alpha, IL-1beta, IL-6, IL-8 and IL-10 as well as the endothelial leucocyte adhesion molecule were analyzed. RESULTS: In the pneumonia group with subsequent septic shock, levels of IL-1beta, IL-6, IL-8 and IL-10 were significantly increased before the onset of septic shock compared to patients without subsequent septic shock. This progression was best predicted by IL-1beta, IL-6, IL-8 and IL-10 (area under the curve > or = 0.8). CONCLUSION: At the onset of hospital-acquired pneumonia, a significant relevant systemic cytokine mediated response had already been initiated. It might, therefore, be possible to identify patients at risk for septic shock with these predictive markers during early pneumonia. In addition, immune modulating therapy might be considered as adjuvant therapy.
Adult↗
Increased interleukin-10 and cortisol in long-term alcoholics after cardiopulmonary bypass: a hint to the increased postoperative infection rate?
BACKGROUND: Previous studies have shown that 20% of all patients admitted to the hospital abuse alcohol and have increased morbidity after surgery. Long-term alcoholic patients are shown to suffer from immune alterations, which might be critical for adequate postoperative performance. Cardiac surgery with cardiopulmonary bypass (CPB) also leads to pronounced immune alteration, which might be linked with patients' ability to combat infections. Therefore, the aim of our study was to investigate the perioperative levels of TNF-alpha, interleukin-6, interleukin-10, and cortisol in long-term alcoholic and nonalcoholic patients undergoing cardiac surgery to elucidate a possible association with postoperative infections. METHODS: Forty-four patients undergoing elective cardiac surgery were included in this prospective study. Long-term alcoholic patients (n=10) were defined as having a daily ethanol consumption of at least 60 g and fulfilling the Diagnostic and Statistical Manual of Mental Disorders for alcohol abuse. The nonalcoholic patients (n=34) were defined as drinking less than 20 g ethanol per day. Blood samples were obtained to analyze the immune status upon admission to hospital, the morning before surgery and on admission to the ICU, the morning of days one and three after surgery. RESULTS: Basic characteristics of patients did not differ between groups. Long-term alcoholics had a fourfold increase in postsurgery infection rate and prolonged need for ICU treatment and mechanical ventilation. Postoperative levels of interleukin-10 and cortisol were significantly increased in long-term alcoholic patients compared with nonalcoholic patients. These observations were in line with postoperative interleukin-10 being predictive for postoperative infectious complications. CONCLUSIONS: The increased infection rate in long-term alcoholics strengthens the urgent need for interventional approaches providing modulation of the perioperative immune and HPA response in these high-risk patients to counteract their postoperative immune suppression.
Aged↗
Bispectral index versus COMFORT score to determine the level of sedation in paediatric intensive care unit patients: a prospective study.
INTRODUCTION: Most clinicians give sedatives and analgesics according to their professional experience and the patient's estimated need for sedation. However, this approach is prone to error. Inadequate monitoring of sedation and analgesia may contribute to adverse outcomes and complications. With this in mind, data obtained continuously using nonstimulating methods such as bispectral index (BIS) may have benefits in comparison with clinical monitoring of sedation. The aim of this prospective observational trial was to evaluate the use of electroencephalographic (EEG) BIS for monitoring sedation in paediatric intensive care unit (PICU) patients. METHODS: Forty paediatric patients (<18 years) were sedated for mechanical ventilation in a cardiac surgical and general PICU. In each paediatric patient BIS and COMFORT score were obtained. The study protocol did not influence ongoing PICU therapy. BIS and corresponding COMFORT score were collected three times for each patient. Measurements with the best starting EEG impedances were analyzed further. Deep sedation was defined as a COMFORT score between 8 and 16, and light sedation as a score between 17 and 26. Biometric and physiological data, and Pediatric Risk of Mortality III scores were also recorded. RESULTS: There was a good correlation (Spearman's rho 0.651; P = 0.001) between BIS and COMFORT score in the presence of deep sedation and low starting impedance. Receiver operating characteristic (ROC) analysis revealed best discrimination between deep and light sedation at a BIS level of 83. CONCLUSION: In the presence of deep sedation, BIS correlated satisfactorily with COMFORT score results if low EEG impedances were guaranteed.
Adolescent↗
Altered immune parameters in chronic alcoholic patients at the onset of infection and of septic shock.
INTRODUCTION: Chronic alcoholic patients have a threefold to fourfold increased risk for developing a severe infection or septic shock after surgery, which might be due to altered immune response. The aim of this outcome matched study was to investigate proinflammatory and anti-inflammatory immune parameters during the course of infection and subsequent septic shock in chronic alcoholic patients, and to compare these parameters with those in nonalcoholic patients. METHODS: Twenty-eight patients from a cohort of fifty-six with either pneumonia or peritonitis and subsequent septic shock were selected. Fourteen patients were chronic alcoholics whereas fourteen were nonalcoholic patients. Chronic alcoholic patients met criteria (Diagnostic and Statistical Manual of Mental Disorders IV, of the American Psychiatric Association) for alcohol abuse or dependence. Measurements were performed during the onset of infection (within 24 hours after the onset of infection), in early septic shock (within 12 hours after onset of septic shock) and in late septic shock (72 hours after the onset). Blood measurements included proinflammatory and anti-inflammatory cytokines. RESULTS: Chronic alcoholic patients exhibited significantly lower plasma levels of IL-8 (P < 0.010) during the onset of infection than did matched nonalcoholic patients. In early septic shock, chronic alcoholic patients had significantly decreased levels of IL-1beta (P < 0.015), IL-6 (P < 0.016) and IL-8 (P < 0.010). The anti-inflammatory parameters IL-10 and tumour necrosis factor receptors I and II did not differ between alcoholic and nonalcoholic patients. CONCLUSION: At the onset of infection and during early septic shock, chronic alcoholic patients had lower levels of proinflammatory immune parameters than did nonalcoholic patients. Therefore, immunomodulatory therapy administered early may be considered in chronic alcoholic patients at the onset of an infection because of their altered proinflammatory immune response.
Adult↗
Recombinant factor VIIa for excessive bleeding after thrombectomy prior to kidney transplantation.
Explore the source record for details and available documents.
Aged↗
Antibiotic-mediated release of tumour necrosis factor alpha and norharman in patients with hospital-acquired pneumonia and septic encephalopathy.
OBJECTIVE: To investigate antibiotic-mediated release of tumour necrosis factor (TNF)-alpha and norharman in patients with hospital-acquired pneumonia with and without additional septic encephalopathy. DESIGN: Prospective observational study with a retrospective post hoc analysis. SETTING: Surgical intensive care unit (ICU) at a university hospital. PATIENTS: Thirty-seven patients were consecutively included (9 patients with hospital-acquired pneumonia, 11 patients with hospital-acquired pneumonia and septic encephalopathy, 17 control patients) in the study. Pneumonia was defined according to the criteria of the American Thoracic Society. INTERVENTIONS: Patients received cephalosporins for antibiotic treatment of hospital-acquired pneumonia. Blood samples were taken before, immediately after and 4 h after application of cephalosporins. MEASUREMENTS AND RESULTS: Of the pneumonia patients, 55% developed septic encephalopathy. ICU stay, complications and mortality were significantly increased. An increased release of TNF-alpha was immediately seen in all pneumonia patients after antibiotics compared to controls, whereas the level did not differ between patients with and without septic encephalopathy. Norharman was significantly increased in pneumonia patients 4 h after antibiotic treatment, in tendency more enhanced in the pneumonia patients without encephalopathy. CONCLUSIONS: Patients with hospital-acquired pneumonia and septic encephalopathy had a significantly longer ICU stay with higher mortality rate compared to patients with hospital-acquired pneumonia alone. Antibiotic-mediated TNF-alpha release may induce the kynurenine pathway. TNF-alpha activates indolamine-2,3-dioxygenase with neurotoxic quinolinic acid as the end product. Norharman seems to counteract this mechanism and seems to play a role in neuroprotection. The worse outcome of patients with encephalopathy expresses the need to investigate protective factors and mechanisms.
Adult↗