Quantification of exhaled propofol is not feasible during single-lung ventilation using double-lumen tubes: A multicenter prospective observational trial

Background

Volatile propofol can be measured in exhaled air and correlates to plasma concentrations with a time delay. However, the effect of single-lung ventilation on exhaled propofol is unclear. Therefore, our goal was to evaluate exhaled propofol concentrations during single-lung compared to double-lung ventilation using double-lumen tubes.

Methods

In a first step, we quantified adhesion of volatile propofol to the inner surface of double-lumen tubes during double- and single-lumen ventilation in vitro. In a second step, we enrolled 30 patients scheduled for lung surgery in two study centers. Anesthesia was provided with propofol and remifentanil. We utilized left-sided double-lumen tubes to separately ventilate each lung. Exhaled propofol concentrations were measured at 1-min intervals and plasma for propofol analyses was sampled every 20 min. To eliminate the influence of dosing on volatile propofol concentration, exhalation rate was normalized to plasma concentration.

Results

In-vitro ventilation of double-lumen tubes resulted in increasing propofol concentrations at the distal end of the tube over time. In vitro clamping the bronchial lumen led to an even more pronounced increase (Δ AUC +62%) in propofol gas concentration over time. Normalized propofol exhalation during lung surgery was 31% higher during single-lung compared to double-lung ventilation.

Conclusion

During single-lung ventilation, propofol concentration in exhaled air, in contrast to our expectations, increased by approximately one third. However, this observation might not be affected by change in perfusion-ventilation during single-lung ventilation but rather arises from reduced propofol absorption on the inner surface area of the double-lumen tube. Thus, it is only possible to utilize exhaled propofol concentration to a limited extent during single-lung ventilation.

Registration of Clinical Trial

DRKS-ID DRKS00014788 ( www.drks.de ).     

Feeling addressed! The neural processing of social communicative cues in patients with major depression

The feeling of being addressed is the first step in a complex processing stream enabling successful social communication. Social impairments are a relevant characteristic of patients with major depressive disorder (MDD). Here, we investigated a mechanism which—if impaired—might contribute to withdrawal or isolation in MDD, namely, the neural processing of social cues such as body orientation and gesture. During funtional magnetic resonance imaging (fMRI) data acquisition, 33 patients with MDD and 43 healthy control subjects watched video clips of a speaking actor: one version with a gesture accompanying the speech and one without gesture. Videos were filmed simultaneously from two different viewpoints: one with the actor facing the viewer head‐on (frontal) and one side‐view (lateral). After every clip, the participants were instructed to evaluate whether they felt addressed or not. Despite overall comparable addressment ratings and a large overlap in activation patterns in MDD and healthy subjects for gesture processing, the anterior cingulate cortex, bilateral superior/middle frontal cortex, and right angular gyrus were more strongly activated in patients than in healthy subjects for the frontal conditions. Our analyses revealed that patients showed specifically higher activation than healthy subjects for the frontal condition without gesture in regions including the posterior cingulate cortex, left prefrontal cortex, and the left hippocampus. We conclude that MDD patients can recognize and interpret social cues such as gesture or body orientation; however, they seem to require more neural resources. This additional effort might affect successful communication and contribute to social isolation in MDD.     

Von Mundschleimhauterkrankungen zum oralen Plattenepithelkarzinom

Der Freie Zahnarzt - Mundschleimhauterkrankungen begegnen der Zahnärztin/dem Zahnarzt in Klinik und Praxis bei der täglichen Arbeit am Patienten und stellen oftmals eine große...     

Superior Temporal Sulcus Disconnectivity During Processing of Metaphoric Gestures in Schizophrenia

The left superior temporal sulcus (STS) plays an important role in integrating audiovisual information and is functionally connected to disparate regions of the brain. For the integration of gesture information in an abstract sentence context (metaphoric gestures), intact connectivity between the left STS and the inferior frontal gyrus (IFG) should be important. Patients with schizophrenia have problems with the processing of metaphors (concretism) and show aberrant structural connectivity of long fiber bundles. Thus, we tested the hypothesis that patients with schizophrenia differ in the functional connectivity of the left STS to the IFG for the processing of metaphoric gestures. During functional magnetic resonance imaging data acquisition, 16 patients with schizophrenia (P) and a healthy control group (C) were shown videos of an actor performing gestures in a concrete (iconic, IC) and abstract (metaphoric, MP) sentence context. A psychophysiological interaction analysis based on the seed region from a previous analysis in the left STS was performed. In both groups we found common positive connectivity for IC and MP of the STS seed region to the left middle temporal gyrus (MTG) and left ventral IFG. The interaction of group (C>P) and gesture condition (MP>IC) revealed effects in the connectivity to the bilateral IFG and the left MTG with patients exhibiting lower connectivity for the MP condition. In schizophrenia the left STS is misconnected to the IFG, particularly during the processing of MP gestures. Dysfunctional integration of gestures in an abstract sentence context might be the basis of certain interpersonal communication problems in the patients.Key words: coverbal gestures, integration, fMRI, psychophysiological interaction, concretism     

Increased neural activity during overt and continuous semantic verbal fluency in major depression: mainly a failure to deactivate

Major depression is associated with impairments in semantic verbal fluency (VF). However, the neural correlates underlying dysfunctional cognitive processing in depressed subjects during the production of semantic category members still remain unclear. In the current study, an overt and continuous semantic VF paradigm was used to examine these mechanisms in a representative sample of 33 patients diagnosed with a current episode of unipolar depression and 33 statistically matched healthy controls. Subjects articulated words in response to semantic category cues while brain activity was measured with functional magnetic resonance imaging (fMRI). Compared to controls, patients showed poorer task performance. On the neural level, a group by condition interaction analysis, corrected for task performance, revealed a reduced task-related deactivation in patients in the right parahippocampal gyrus, the right fusiform gyrus, and the right supplementary motor area. An additional and an increased task-related activation in patients were observed in the right precentral gyrus and the left cerebellum, respectively. These results indicate that a failure to suppress potentially interfering activity from inferior temporal regions involved in default-mode network functions and visual imagery, accompanied by an enhanced recruitment of areas implicated in speech initiation and higher-order language processes, may underlie dysfunctional cognitive processing during semantic VF in depression. The finding that patients with depression demonstrated both decreased performance and aberrant brain activation during the current semantic VF task demonstrates that this paradigm is a sensitive tool for assessing brain dysfunctions in clinical populations.     

In vivo X-ray cine-tomography for tracking morphological dynamics

Scientific cinematography using ultrafast optical imaging is a common tool to study motion. In opaque organisms or structures, X-ray radiography captures sequences of 2D projections to visualize morphological dynamics, but for many applications full four-dimensional (4D) spatiotemporal information is highly desirable. We introduce in vivo X-ray cine-tomography as a 4D imaging technique developed to study real-time dynamics in small living organisms with micrometer spatial resolution and subsecond time resolution. The method enables insights into the physiology of small animals by tracking the 4D morphological dynamics of minute anatomical features as demonstrated in this work by the analysis of fast-moving screw-and-nut–type weevil hip joints. The presented method can be applied to a broad range of biological specimens and biotechnological processes.The best method to study morphological changes of anatomic features and physiological processes is to observe their dynamics in 4D, that is, in real time and in 3D space. To achieve this we have developed in vivo X-ray cine-tomography to gain access to morphological dynamics with unrivaled 4D spatiotemporal resolution. This opens the way to a wide range of hitherto inaccessible, systematic investigations of small animals and biological internal processes such as breathing, circulation, digestion (1), reproduction, and locomotion (2).At the micrometer resolution range, state-of-the-art optical imaging techniques can achieve high magnifications to visualize tissues and even individual cells for 4D studies. These methods however are confined to transparent or fluorescent objects, or are limited either by low penetration depth <1 mm or poor time resolution (3). For optically opaque living organisms X-ray imaging methods are highly appropriate due to the penetrating ability of the radiation. Modern synchrotron radiation facilities provide brilliant and partially coherent radiation suitable for high-resolution volume imaging methods such as X-ray computed microtomography (SR-µCT). For static specimens SR-µCT has proven to be a powerful tool to study small animal morphology in 3D (4–6). The benefits of various physical contrast mechanisms, high spatial resolution, and short measuring times, as well as enormous sample throughput compared with laboratory X-ray setups, have led to its widespread use in life sciences.Real-time in vivo X-ray imaging with micrometer spatial resolution was realized so far by recording time sequences of 2D projection radiographs of different organisms (1, 6, 7), providing time information about functional dynamics but losing any information about the third spatial dimension.Recently, 4D in vivo X-ray experiments have been performed to study cell migration in frog embryos (8, 9) using tomographic sequences of a few seconds exposure time per tomogram interrupted by longer nonexposure time slots. In this way the authors followed relatively slow dynamics and morphological changes during embryonic development with 2-µm resolution over total time intervals of several hours. The fastest 4D time series yet reported were realized with a temporal resolution of 0.5 s and spatial resolution of 25 µm (10), applied to a living caterpillar used as test specimen for imaging, but without any analysis of dynamics.In this paper, we demonstrate the quantitative 4D investigation of morphological dynamics by in vivo X-ray 4D cine-tomography, introduced here as the combination of ultrafast SR-µCT and motion analysis procedures. Using this approach allows us to investigate previously inaccessible 3D morphological dynamics in small animals, presently with feature sizes in the micrometer range and with temporal resolution down to a few tens of milliseconds. In the past, ultrafast in vivo imaging was hardly possible for such applications, due to the strongly competing requirements for simultaneous high contrast, high signal-to-noise ratio (SNR), and concurrent low radiation dose, as well as the need for simultaneous high spatial resolution and maximum temporal resolution.In the following we describe how in vivo X-ray 4D cine-tomography meets the above challenges by optimizing image contrast, SNR, and spatial and temporal resolution in the ultrafast SR-µCT system and by establishing a dedicated data analysis pipeline, all within a unified framework (Fig. S1). We demonstrate the potential of the technique by investigating morphological dynamics in fast-moving weevils, focusing here on the exoskeletal joints.     

Fenestrated-branched endografts and visceral debranching plus stenting (hybrid) for complex aortic aneurysm repair

Objective

The aim of this study was to assess the immediate postoperative and midterm outcome of complex aortic aneurysm treatment necessitating four-vessel revascularization with either a total endovascular approach (fenestrated-branched stent graft [FBSG]) or a hybrid technique of visceral debranching plus stenting.

Subcortical shape alterations in major depressive disorder: Findings from the ENIGMA major depressive disorder working group

Alterations in regional subcortical brain volumes have been investigated as part of the efforts of an international consortium, ENIGMA, to identify reliable neural correlates of major depressive disorder (MDD). Given that subcortical structures are comprised of distinct subfields, we sought to build significantly from prior work by precisely mapping localized MDD-related differences in subcortical regions using shape analysis. In this meta-analysis of subcortical shape from the ENIGMA-MDD working group, we compared 1,781 patients with MDD and 2,953 healthy controls (CTL) on individual measures of shape metrics (thickness and surface area) on the surface of seven bilateral subcortical structures: nucleus accumbens, amygdala, caudate, hippocampus, pallidum, putamen, and thalamus. Harmonized data processing and statistical analyses were conducted locally at each site, and findings were aggregated by meta-analysis. Relative to CTL, patients with adolescent-onset MDD (≤ 21 years) had lower thickness and surface area of the subiculum, cornu ammonis (CA) 1 of the hippocampus and basolateral amygdala (Cohen's d = ?0.164 to ?0.180). Relative to first-episode MDD, recurrent MDD patients had lower thickness and surface area in the CA1 of the hippocampus and the basolateral amygdala (Cohen's d = ?0.173 to ?0.184). Our results suggest that previously reported MDD-associated volumetric differences may be localized to specific subfields of these structures that have been shown to be sensitive to the effects of stress, with important implications for mapping treatments to patients based on specific neural targets and key clinical features.