The sensory thalamus and cerebral motor cortex are affected concurrently during induction of anesthesia with propofol: a case series with intracranial electroencephalogram recordings

Purpose

Brain imaging studies suggest that loss of consciousness induced by general anesthetics is associated with impairment of thalamic function. There is, however, limited information on the time course of these changes. We recently obtained intracranial electroencephalogram (EEG) recordings from the ventroposterolateral (VPL) nucleus of the thalamus and from the motor cortex during induction of anesthesia in three patients to study the time course of the alterations of cortical and thalamic function.

Clinical features

The patients were American Society of Anesthesiologists physical status I-II males aged 33-57 yr with intractable central pain caused by brachial plexus injury (patient 1 and 2) or insular infarct (patient 3). Anesthesia was induced with propofol (2.5-3.1 mg·kg^?1 over 30-45 sec) followed, after loss of consciousness, by rocuronium for tracheal intubation. The data retained for analysis are from one minute before the start of propofol to 110 sec later during ventilation of the patients’ lungs before tracheal intubation. Spectral analysis was used to measure absolute EEG power. Propofol caused significant increases of cortical and thalamic power in the delta to beta frequency bands (1-30 Hz). These increases of cortical and thalamic power occurred either concomitantly or within seconds of each other. Propofol also caused a decrease in cortical and thalamic high-gamma (62-200 Hz) power that also followed a similar time course.

Conclusion

We conclude that induction of anesthesia with propofol in these patients was associated with concurrent alterations of cortical and sensory thalamic activity.     

The Impact of Body Mass Index on Patient Reported Outcome Measures (PROMs) and Complications Following Primary Hip Arthroplasty

Influence of BMI upon patient outcomes and complications following THA was examined across a national cohort of patients. Outcomes were compared by BMI groups (19.0–29.9 kg/m² [reference], 30.0–34.9 kg/m² [obese class I], 35.0 kg/m²+ [obese class II/III]), adjusted for case-mix differences. Obese class I patients had a significantly smaller improvement in OHS (18.9 versus 20.5, P < 0.001) and a greater risk of wound complications (odds ratio [OR] = 1.57, P = 0.006). For obese class II/III patients, there were significantly smaller improvements in OHS and EQ-5D index (P < 0.001), and greater risk of wound complications (P = 0.006), readmission (P = 0.001) and reoperation (P = 0.003). Large improvements in patient outcomes were seen irrespective of BMI, although improvements were marginally smaller and complication rates higher in obese patients.     

Spatially robust estimates of biological nitrogen (N) fixation imply substantial human alteration of the tropical N cycle

Biological nitrogen fixation (BNF) is the largest natural source of exogenous nitrogen (N) to unmanaged ecosystems and also the primary baseline against which anthropogenic changes to the N cycle are measured. Rates of BNF in tropical rainforest are thought to be among the highest on Earth, but they are notoriously difficult to quantify and are based on little empirical data. We adapted a sampling strategy from community ecology to generate spatial estimates of symbiotic and free-living BNF in secondary and primary forest sites that span a typical range of tropical forest legume abundance. Although total BNF was higher in secondary than primary forest, overall rates were roughly five times lower than previous estimates for the tropical forest biome. We found strong correlations between symbiotic BNF and legume abundance, but we also show that spatially free-living BNF often exceeds symbiotic inputs. Our results suggest that BNF in tropical forest has been overestimated, and our data are consistent with a recent top-down estimate of global BNF that implied but did not measure low tropical BNF rates. Finally, comparing tropical BNF within the historical area of tropical rainforest with current anthropogenic N inputs indicates that humans have already at least doubled reactive N inputs to the tropical forest biome, a far greater change than previously thought. Because N inputs are increasing faster in the tropics than anywhere on Earth, both the proportion and the effects of human N enrichment are likely to grow in the future.Over the last few decades, humans have dramatically altered the global nitrogen (N) cycle (1–3). Three main processes—Haber–Bosch fixation of atmospheric N₂, widespread cultivation of leguminous N-fixing crops, and incidental N fixation during fossil fuel combustion—collectively add more reactive N to the biosphere each year than all natural processes combined (2). Although human perturbation of the N cycle has brought substantial benefits to society (most notably, an increase in crop production) (4), it has also had a number of negative effects on both ecosystems (5, 6) and people (7).Although humanity’s large imprint on the global N cycle is clear, quantifying the extent of anthropogenic changes depends, in large part, on establishing baseline estimates of nonanthropogenic N inputs (1, 8, 9). Before recent human activities, biological N fixation (BNF) was the largest source of new N to the biosphere (9). Terrestrial BNF has been particularly challenging to quantify, because it displays high spatial and temporal heterogeneity at local scales, it arises from both symbiotic associations between bacteria and plants as well as free-living microorganisms (e.g., in leaf litter and soil) (10), and high atmospheric concentrations of N₂ make direct flux measurements unfeasible. Consequently, spatial estimates of BNF have always been highly uncertain (11), and global rate estimates have fallen precipitously in the last 15 y (from 100–290 to ∼44 Tg N y⁻¹) (9). This decline in BNF implies an increase in the relative magnitude of anthropogenic N inputs from 100–150% to 190–470% of BNF (9).Historically, the largest anthropogenic changes to the N cycle have occurred in the northern temperate zone: first throughout the United States and western Europe and more recently, in China (12, 13). Large-scale estimates of BNF in natural ecosystems in these regions are consistently low (11), leading some to conclude that anthropogenic N inputs in the northern temperate zone exceed naturally occurring BNF and preindustrial atmospheric N deposition by an order of magnitude or more (1, 14). By contrast, the highest rates of naturally occurring BNF have been thought to occur in the evergreen lowland tropical rainforest biome (11), implying that, on a regional basis, human alteration of the tropical N cycle has been comparatively modest. However, in recent years, the tropics have seen some of the most dramatic increases in anthropogenic N inputs of any region on Earth—a trend that is likely to continue (2, 6, 13). Anthropogenic N inputs are increasing in tropical regions, primarily because of increasing fossil fuel combustion (13) and expanding high-N-input agriculture for both food and biofuels (6). These anthropogenic N inputs are having a measurable effect on tropical ecosystems (15). However, understanding and forecasting the effects of anthropogenic N depend, in part, on accurate estimates of BNF in lowland tropical rainforest.Unfortunately, the paradigm that the tropics have high rates of BNF is based on a paucity of evidence and several tenuous assumptions. For example, an early global synthesis of terrestrial BNF (11)—which included contributions from both symbiotic and free-living sources—included only one measured estimate of symbiotic BNF from tropical forest (16 kg N ha⁻¹ y⁻¹) (16). That single estimate, scaled over thousands of square kilometers, represented the only direct evidence of high tropical BNF rates available at that time (Fig. 1). Subsequent modeled estimates (17) that indirectly estimated BNF have reinforced the notion that tropical BNF rates are high and dominated by the symbiotic form of fixation (Fig. 1). Such high estimates of symbiotic BNF are consistent with the large number of leguminous trees in tropical forest (18–20). However, many legume species do not form N-fixing nodules (21), and of those species that do, nodulation in individuals varies with soil nutrient status, N demand, and tree age (22). Several recent analyses (10, 22–24) indicate lower tropical forest BNF and suggest that symbiotic BNF may not be as important to total BNF as previously thought (Fig. 1), although few studies have simultaneously measured symbiotic and free-living BNF.Open in a separate windowFig. 1.Previous estimates of BNF in tropical rainforest and BNF measured in this study. Percentages indicate the proportion of total BNF from symbiotic BNF. Cleveland et al. 1999 A (11) is a literature database-derived estimate of tropical forest BNF; Cleveland et al. 1999 B (11) is a modeled estimate of BNF based on the correlation between net primary productivity (NPP) and BNF derived with remotely sensed NPP and evergreen broadleaved forest (EBF) land cover classification. Central estimates and variance for Cleveland et al., 1999 A (11) and Reed et al. 2011 (10) represent the low, central, and high data-based estimates of BNF assuming 5%, 15%, and 15% legume cover, respectively. Central estimates and variance for Wang and Houlton 2009 (17) represent the modeled mean and SD of BNF predicted for the EBF biome. Central estimates and variance for Cleveland et al. 2010 (23) represent the low, central, and high estimates of symbiotic BNF plus free-living BNF or modeled BNF plus free-living BNF. Central estimates and variance for BNF in the four forest ages measured here (primary, 5–15 y, 15–30 y, and 30–50 y) represent means ± 1 SD (n = 3). Our estimate of BNF in a dynamic primary forest (gap dynamics) lacks SD, because it consisted of only two measurements: low and high estimates of forest turnover times equal to 150 and 75 y, respectively.There is also a sound theoretical basis for questioning high estimates of BNF in tropical forest. Namely, high concentrations of soil N in the legume-rich tropics create something of a paradox. Although BNF could create N-rich conditions, the substantial energetic cost of BNF means—and some data show—that BNF should be suppressed under high N availability in primary forests (25). Because of high rates of net primary productivity and high N demand in secondary forests (26, 27), regenerating canopy gaps or abandoned agricultural land may have higher rates of BNF than late-successional forest ecosystems (26).Resolving the uncertainty in the tropical (and global) N cycle requires that we overcome the enduring challenge of quantifying BNF in any ecosystem. How do we estimate large-scale rates of a process that displays extreme spatial heterogeneity at local scales? Whether using acetylene reduction assays, ¹⁵N tracer incubations, or the ¹⁵N natural abundance method, most past approaches to empirically estimate symbiotic BNF have relied on spatial extrapolations of BNF rates measured at the level of individual trees. Typically, such extrapolations are based on legume abundance (e.g., percent cover) and make species- or genera-level assumptions about nodulation status of putative N fixers. Here, we applied a method commonly used by community ecologists to measure rare species abundances—stratified adaptive cluster sampling (SACS) (28)—to measure symbiotic BNF. This approach could be used in any ecosystem, and in contrast to other methods, SACS generates unbiased estimates of mean symbiotic BNF (independent of legume abundance) and can more robustly capture the irregular distribution of nodules on the landscape. We simultaneously measured symbiotic and free-living BNF multiple times over the course of 1 y to generate spatially explicit rates of BNF inputs in primary and secondary (5–50 y old) lowland tropical forest in Costa Rica and then used the understanding gained from those estimates to revisit estimates of BNF and anthropogenic N inputs in the tropical forest biome.     

Airway responses to inhaled ouabain in subjects with and without asthma

Challenges with ouabain and histamine were performed a week apart in 10 patients with asthma and 5 normal subjects. Concentrations were increased cumulatively until specific airway conductance decreased by 30% or the maximal concentration of 1.0% was reached. At low concentrations, ouabain induced bronchodilatation in six patients who had asthma. Bronchodilatation gradually decreased with increasing concentrations and was followed by bronchoconstriction in two patients with asthma who had high airway sensitivity to histamine. Ouabain caused only bronchoconstriction in three patients with severe asthma. The normal subjects showed mild bronchodilatation or no response to ouabain. Several possible biochemical mechanisms may be responsible for the bronchodilatory response to low doses of ouabain, such as stimulation of adenylate cyclase or (Na+,K+)-adenosine triphosphatase. The absence of a bronchodilatory response to ouabain in patients with severe asthma suggests an impairment in the activity of these enzymes.     

Pediatric phyllodes tumors: A review of the National Cancer Data Base and adherence to NCCN guidelines for phyllodes tumor treatment

Background

Phyllodes tumors are fibroepithelial breast lesions that are uncommon in women and rare among children. Due to scarcity, few large pediatric phyllodes tumor series exist. Current guidelines do not differentiate treatment recommendations between children and adults. We examined national guideline adherence for children and adults.