The effect of propofol on patient reaction time and its relationship with loss of verbal contact before induction of anaesthesia.

Increasing the calculated plasma concentration of propofol has been shown to increase choice reaction time and visual and auditory response times. We studied the relationship of reaction to a vibrating handset as the effect-site target-controlled propofol concentration was incrementally increased in 20 patients during sedation, before induction of general anaesthesia. The reaction time increased, initially slowly and then more rapidly, as the calculated effect-site concentration of propofol increased, until the reaction to the vibrating handset was lost at a mean (SD) propofol effect-site concentration of 2.0 (0.6) µg.ml(-1) . The loss of response to verbal contact occurred at a propofol effect-site concentration of 2.4 (0.5) µg.ml(-1) . Reaction time may be of use clinically to warn of impending loss of verbal contact.

Reaction time-monitored patient-maintained propofol sedation: a pilot study in oral surgery patients.

Previous volunteer studies of an effect-site controlled patient-maintained sedation system using propofol have demonstrated a risk of oversedation. We have incorporated a reaction time monitor into the handset to add an individualised patient-feedback mechanism. This pilot study assessed if the reaction time-feedback modification would prove safe and effective in 20 healthy patients receiving sedation while undergoing oral surgery. All patients successfully sedated themselves without reaching any unsafe endpoints. All 20 maintained verbal contact throughout. The mean (SD) lowest peripheral blood oxygen saturation was 98.0 (2.1)% breathing room air. No patient required supplementary oxygen. The mean (SD) maximum effect-site propofol concentration reached was 1.6 (0.5) µg.ml(-1). The present system was found to be safe and effective, allowing oral surgery treatment under conscious sedation, but preventing oversedation.

Patient-maintained propofol sedation using reaction time monitoring: a volunteer safety study.

Previous volunteer studies of an effect-site controlled, patient-maintained sedation system using propofol have demonstrated a risk of over-sedation. We have incorporated a reaction-time monitor into the handset of the patient-maintained sedation system to add an individualised patient-feedback mechanism. This study assessed if such reaction-time feedback modification would reduce the risk of over-sedation in 20 healthy volunteers deliberately attempting to over-administer themselves propofol. All the volunteers successfully sedated themselves without reaching any unsafe endpoints. All volunteers maintained verbal contact throughout, in accordance with the definition of conscious sedation. The mean (SD) lowest S(p) O(2) was 97 (1.7) % when breathing room air and no volunteer required supplementary oxygen. The mean (SD) maximum effect-site propofol concentration reached was 1.7 (0.4) µg.ml(-1) . The present system was found to be safer than its predecessors, allowing conscious sedation, but preventing over-sedation.

A qualitative evaluation of internet information on hip and knee osteoarthritis.

BACKGROUND: Hip and knee arthritis are two of the most common conditions that result in referral to orthopaedic outpatient clinics. Many patients now use the internet to research their condition and to inform their decision about treatment options. This has implications for the process of informed consent. AIM: To assess the quality of patient information on the internet regarding hip and knee arthritis. METHODS: 'Hip arthritis' and 'Knee arthritis' were entered as search terms into a popular search engine. To adjust for temporal variation, the process was repeated one month and one year later. Of the 200 results analysed, 83 websites met the inclusion criteria. The quality of patient information presented on these websites was assessed using a validated scoring instrument by two independent observers. RESULTS: Most websites assessed were of poor quality; nearly half of all websites did not mention any risks or complications associated with surgical intervention for these conditions. CONCLUSIONS: As part of their professional obligation to provide a robust process of informed consent, clinicians should be aware of the variable quality of patient information available on the internet. As such, they should be prepared to advise their patients about quality websites where reliable information can be sought.

The cardiovascular effects of normobaric hyperoxia in patients with heart rate fixed by permanent pacemaker.

To investigate whether the established reductions in heart rate and cardiac output with hyperoxia in humans are primary effects or secondary to increases in systemic vascular resistance, we paced the hearts of nine patients with permanent pacemakers at a fixed rate when breathing either medical air (inspired O(2) fraction 0.21) or oxygen (inspired O(2) fraction 0.80) in a randomised, double-blind fashion. A thoracic bio-impedance machine was used to measure heart rate, stroke volume and blood pressure and calculate cardiac index and systemic vascular resistance index. Oxygen caused no change in cardiac index (p = 0.18), stroke index (p = 0.44) or blood pressure (p = 0.52) but caused a small (5.5%) increase in systemic vascular resistance index (p = 0.03). This suggests that hyperoxia has no direct myocardial depressant effects, but that the changes in cardiac output reported in previous studies are secondary to changes in systemic vascular resistance.

Rapid aneuploidy screening with fluorescence in-situ hybridisation: is it a sufficiently robust stand-alone test for prenatal diagnosis?

OBJECTIVES: To assess the clinical utility of fluorescence in-situ hybridisation with chromosomes 13, 18, 21, X and Y as a stand-alone test in detecting chromosomal abnormalities, and the types of chromosomal abnormalities missed. DESIGN: Retrospective analysis. SETTING: A restructured Government hospital in Singapore and an academic hospital in the United States. PARTICIPANTS: Cytogenetic data of prenatal specimens and results of fluorescence in-situ hybridisation of 5883 patients performed between January 2000 and August 2007 were reviewed. RESULTS: Fluorescence in-situ hybridisation detected 558 (9.5%) patients with chromosomal abnormalities. Abnormal ultrasounds (70%) and maternal serum screens (21%) were the most indicative of chromosomal abnormalities. When comparing fluorescence in-situ hybridisation data with karyotype results for the five chromosomes of interest, the sensitivity and specificity were 99.3% and 99.9%, respectively. When comparing fluorescence in-situ hybridisation data with karyotype results for all chromosomes, the sensitivity decreased to 86.8%, whereas the specificity remained at 99.9%. Of 643 cases with karyotype abnormalities, 85 were fluorescence in-situ hybridisation-negative (false negative rate, 13.2%), which included structural rearrangements, chromosome mosaicism, and other trisomies. Despite abnormal ultrasound indications, fluorescence in-situ hybridisation missed 32 cases which included structural rearrangements, mosaicisms, and other trisomies. CONCLUSION: This study does not support fluorescence in-situ hybridisation as a stand-alone test. Institutions supporting fluorescence in-situ hybridisation as a stand-alone test must seriously consider the risks of a missed diagnosis.

Numerical Simulations of Realistic Lead Trajectories and an Experimental Verification Support the Efficacy of Parallel Radiofrequency Transmission to Reduce Heating of Deep Brain Stimulation Implants during MRI.

Patients with deep brain stimulation (DBS) implants may be subject to heating during MRI due to interaction with excitatory radiofrequency (RF) fields. Parallel RF transmit (pTx) has been proposed to minimize such RF-induced heating in preliminary proof-of-concept studies. The present work evaluates the efficacy of pTx technique on realistic lead trajectories obtained from nine DBS patients. Electromagnetic simulations were performed using 4- and 8-element pTx coils compared with a standard birdcage coil excitation using patient models and lead trajectories obtained by segmentation of computed tomography data. Numerical optimization was performed to minimize local specific absorption rate (SAR) surrounding the implant tip while maintaining spatial homogeneity of the transmitted RF magnetic field (B1+), by varying the input amplitude and phase for each coil element. Local SAR was significantly reduced at the lead tip with both 4-element and 8-element pTx (median decrease of 94% and 97%, respectively), whereas the median coefficient of spatial variation of B1+ inhomogeneity was moderately increased (30% for 4-element pTx and 20% for 8-element pTx) compared to that of the birdcage coil (17%). Furthermore, the efficacy of optimized 4-element pTx was verified experimentally by imaging a head phantom that included a wire implanted to approximate the worst-case lead trajectory for localized heating, based on the simulations. Negligible temperature elevation was observed at the lead tip, with reasonable image uniformity in the surrounding region. From this experiment and the simulations based on nine DBS patient models, optimized pTx provides a robust approach to minimizing local SAR with respect to lead trajectory.

Distribution of heterotopic neurons in normal hemispheric white matter: a morphometric analysis.

One of the frequent abnormalities described in the context of surgically resected temporal lobe (TL) specimens is the presence of heterotopic neurons within white matter (WM). We have attempted to morphometrically define the distribution of the heterotopic neurons in normal subjects, comparing the incidence of heterotopic neurons in TL WM with that in occipital (OL) and frontal lobe (FL) sections. Using a a combination of routine and special stains combined with immunohistochemical confirmation 20 adult autopsy cases were examined. WM from TL, FL, and Ol sections was outlined and the area measured by image analysis. Using defined criteria, heterotopic neurons within these areas were counted. Results confirm our hypothesis that normal adult TL WM contains a significantly higher population of residual/heterotopic neurons than OL and FL WM groups. It is felt that these neurons represent interstitial remnants of the subplate which have failed to undergo programmed cell death. The significance of these findings with regard to assessment of similar findings in temporal lobectomy specimens is addressed. A second intriguing association of this TL WM heterotopia concerns its possible relationship to the more frequent occurrence of ¿malformative neoplasms¿ with neuronal elements (such as ganglioglioma and dysembryoplastic neuroepithelial tumor) in the temporal lobe.

Age-related changes in [3H]MK-801 binding in the Fischer 344 rat brain.

In this study we tested the hypothesis that the efficacy of L-glutamate to stimulate [3H]MK-801 binding to the NMDA receptor/channel complex is altered as a function of aging. L-Glutamate, or related excitatory amino acid (EAA), is the endogenous neurotransmitter of the NMDA receptor/channel complex. These studies examined the efficacy and potency with which L-glutamate produces receptor activation, channel opening and subsequent MK-801 binding as a function of increasing age by comparing dose-response curves (EC50 and Emax) from 6-, 12-, and 24-month-old F-344 rats. The number of NMDA receptors, as determined by [3H]MK-801 binding in the presence of a saturating concentration of L-glutamate, was reduced in the inner frontal cortex, entorhinal cortex and the lateral striatum in aged rats when compared with young adults. When a range of L-glutamate concentrations were used, differences in Emax were noted in the same brain regions in addition to several others in aged and middle-aged animals when compared with young-adult animals. No changes in EC50 values were noted in any of the brain regions at either age when compared with young-adults.

Strain comparison of synaptic density in hippocampal CA1 of aged rats.

Synaptic density in hippocampal CA1 stratum radiatum was studied in two different strains of rat at 3 and 24-28 months of age. Neither Fischer 344 nor Sprague-Dawley rodents showed any age-related loss of synapses. These data support the contention that synapse loss with age is not a generalized phenomenon in the mammalian CNS.

Reactive synaptogenesis in hippocampal area CA1 of aged and young adult rats.

Selective lesions that result in a partial loss of neuronal input appear to signal residual, undamaged inputs to sprout and replace synaptic connections that have been lost. Previous investigations have compared this process of reactive synaptogenesis in young and old animals in the hippocampal dentate gyrus and have demonstrated that the aged brain has a diminished capacity for reinnervation following massive denervation of a target area. This investigation has focused on the lesion-induced plasticity of an adjacent area of the hippocampal formation, area CA1 of regio superior, in young adult and aged rats. Young adult aged Fischer 344 rates were subjected to a unilateral, intraventricular injection of kainic acid that selectively destroyed the CA3-CA4 hippocampal pyramidal neurons. Following a 2-day interoperative interval, the rats sustained an ipsilateral transection of the fimbria-fornix. Animals were killed at 4, 10, 30, and 60 days following the second transection and processed for electron microscopic analysis. Photographic montages were constructed of area CA1 extending from the alveus to the hippocampal fissure. The density of synapses, both intact and degenerating, was determined and analyzed as a function of age, days postlesion, and zone of analysis. Synaptic density decreased 30-40% contralaterally and 60-70% ipsilaterally in both aged and young adult rats. While both age groups restored synaptic density to preoperative levels, aged subjects required significantly more time. Aged rats appeared to be retarded in the initial phases of synaptic replacement. The delay in the aged animals' reactive response was not due to any differences in degeneration clearance between the age groups.

GABA as a potential transmitter in lizard photoreceptors: immunocytochemical and biochemical evidence.

The retina of the desert night lizard, Xantusia vigilis, was examined for immunoreactivity to antibodies against gamma-aminobutyric acid and L-glutamate decarboxylase. At the electron microscopic level it was found that a distinct population of the photoreceptor cells was immunoreactive to both antibodies. Computer-assisted reconstruction of serial sections positively identified the immunoreactive receptors as cones. These cones constituted 15% of the photoreceptors in the retinal sections, and they were morphologically distinct. The mean diameter of the labeled cone synaptic pedicles was 5.8 micron whereas that of the unlabeled pedicles was 7.9 micron, a statistically significant difference. L-glutamate decarboxylase was extracted from the lizard brain, positively identified radiometrically, and shown by immunodiffusion to crossreact with the antibody used for localization. The authors suggest that the immunoreactive cones synthesize and accumulate gamma-aminobutyric acid. Whether or not it is used by those cones as a neurotransmitter should be tested directly.

Ultrastructural characterization of identified cholinergic neurons transplanted to the hippocampal formation of the rat.

The ultrastructural features of cholinergic neurons transplanted to the rat hippocampal formation were studied by using a monoclonal antibody to choline acetyltransferase (ChAT). Septal cell suspensions were prepared from E-18 rat embryos and injected into the hippocampus of host rats that had been previously subjected to a bilateral transection of the fimbria-fornix. Rats with fimbria-fornix lesions alone and unoperated rats served as controls and were examined to characterize the native hippocampal cholinergic system. Both unoperated controls and rats with fimbria-fornix lesions showed a sparse population of intrinsic ChAT-immunoreactive neurons that were most numerous in the subgranular zone, the hilus fascia dentata, and near the hippocampal fissure. ChAT-positive terminals from controls formed synapses on dendritic structures that were primarily symmetrical. ChAT-positive dendrites in controls received synaptic input from nonimmunoreactive axon terminals. In rats with septal transplants, ChAT-immunoreactive transplant neurons were found that were either bipolar or multipolar. Axons of transplanted neurons were unmyelinated and arose either from the cell body or a primary dendritic process where they gave off numerous collaterals. Terminals from transplant neurons formed synapses with many nonimmunoreactive neurons. In transplant animals, two main targets of ChAT-immunoreactive terminals were identified: The great majority of synapses were symmetrical junctions with dendritic spines and shafts. A number of terminals were found that appeared to be juxtaposed to nonimmunoreactive axon terminals, possibly forming symmetrical axo-axonic connections. In contrast, such axo-axonic contacts were not observed in the controls. It is concluded that transplanted cholinergic neurons may reinnervate the host hippocampus; however, this reinnervation is different from what is seen in the intact hippocampal formation.

Neurochemical basis of disruption of hippocampal long term potentiation by chronic alcohol exposure.

The aim of this review is to summarize the possible mechanisms underlying the long-term impairment of learning and memory resulting from chronic ethanol treatment (CET) especially that involving decrements in long-term potentiation (LTP) in hippocampus. CET for a 28-week duration affects the rat hippocampal formation in such a way as to decrease the magnitude of LTP; an effect that can last as long as 7 months after ethanol withdrawal. It appears that NMDA receptor number in hippocampus is unchanged after CET whereas the data suggest a more pronounced role for changes in GABAergic and cholinergic synaptic transmission in determining how CET influences the induction of LTP in hippocampus. In particular, changes in presynaptic modulation of neurotransmitter release in hippocampus may be one mechanism by which CET inhibits LTP. Thus, the mechanisms underlying the effect of CET on LTP are a result of changes in a number of neurotransmitter systems in hippocampus (GABAergic and cholinergic) rather than based solely on changes in glutamate transmission.

Transmitter phenotype is a major determinant in the specificity of synapses formed by cholinergic neurons transplanted to the hippocampus.

Embryonic habenular or striatal cholinergic tissues were transplanted to the hippocampal formation of adult rats. The connectivity of these grafts with the host hippocampal formation was analysed using acetylcholinesterase histochemistry and immunocytochemistry with a monoclonal antibody to choline acetyltransferase. Both graft types produced laminar arrangements of acetylcholinesterase-positive fibers in the hippocampal formation that closely resembled the native pattern of cholinergic innervation. In addition, graft-derived choline acetyltransferase-immunoreactive synapses were found in the host hippocampal formation. These synapses were formed on non-immunoreactive dendritic structures and were similar to the types of cholinergic synapses found in the hippocampal formation of normal animals. These data indicate that the cholinergic transmitter phenotype is a major determinant of whether a neuron will form typical cholinergic synapses with hippocampal targets.

Autoradiographic characterization of putative excitatory amino acid transport sites.

Removal of excitatory amino acids from the extracellular space is now postulated to occur through at least two distinct transport systems that are distinguished by their ionic dependency. Thus, both sodium-dependent and chloride-dependent systems have been described in the mammalian central nervous system. In this report we attempt to characterize these sites by autoradiography, using D-[3H]aspartate and L-[3H]glutamate as ligands. Previous studies have shown that sequestration of radioligand into membrane vesicles can be a potential artifact when examining transport sites. We have found that sequestration can be alleviated by incubation of tissue sections in xylenes prior to incubation with radioligand. Using in vitro autoradiography we have characterized the two binding sites with respect to their distribution, kinetics and pharmacology. Both appeared to have a single, saturable binding site with Kds in the low micromolar range. Sodium-dependent D-aspartate binding predominated, having a Bmax that was five times greater than chloride-dependent L-glutamate binding in whole brain. The levels of binding to the two sites varied between brain regions. Sodium-dependent D-aspartate binding was highest in the cerebellar molecular layer greater than dentate gyrus molecular layer greater than entorhinal cortex. Chloride-dependent L-glutamate binding was highest in the outer layers of cerebral cortex greater than dentate gyrus molecular layer greater than entorhinal cortex greater than striatum. Pharmacological characterization of these sites also showed major differences. Sodium-dependent D-aspartate binding was most potently inhibited by L-aspartate greater than threo-beta-hydroxyaspartate greater than L-cysteine sulfinic acid greater than L-cysteic acid. Chloride-dependent glutamate binding was most potently inhibited by L-glutamate greater than L-alpha-amino adipic acid greater than quisqualate greater than L-serine-o-sulfate. The differences in distribution, ligand binding properties and pharmacology of these sites suggest that a significant variable in excitatory amino acid circuitry may include heterogeneity in transporters associated with excitatory pathways.

Regulation of ciliary neurotrophic factor receptor alpha in sciatic motor neurons following axotomy.

Spinal motor neurons are one of the few classes of neurons capable of regenerating axons following axotomy. Injury-induced expression of neurotrophic factors and corresponding receptors may play an important role in this rare ability. A wide variety of indirect data suggests that ciliary neurotrophic factor receptor alpha may critically contribute to the regeneration of injured spinal motor neurons. We used immunohistochemistry, in situ hybridization and retrograde tracing techniques to study the regulation of ciliary neurotrophic factor receptor alpha in axotomized sciatic motor neurons. Ciliary neurotrophic factor receptor alpha immunoreactivity, detected with two independent antisera, is increased in a subpopulation of caudal sciatic motor neuron soma one, two and six weeks after sciatic nerve transection and reattachment, while no changes are detected at one day and 15 weeks post-lesion. Ciliary neurotrophic factor receptor alpha messenger RNA levels are augmented in the same classes of neurons following an identical lesion, suggesting that increased synthesis contributes, at least in part, to the additional ciliary neurotrophic factor receptor alpha protein. Separating the proximal and distal nerve stumps with a plastic barrier does not noticeably affect the injury-induced change in ciliary neurotrophic factor receptor alpha regulation, thereby indicating that this injury response is not dependent on signals distal to the lesion traveling retrogradely through the nerve or signals generated by axonal growth through the distal nerve. The prolonged increases in ciliary neurotrophic factor receptor alpha protein and messenger RNA found in regenerating sciatic motor neurons contrast with the responses of non-regenerating central neurons, which are reported to display, at most, a short-lived increase in ciliary neurotrophic factor receptor alpha messenger RNA expression following injury. The present data are the first to demonstrate, in vivo, neuronal regulation of ciliary neurotrophic factor receptor alpha protein in response to injury. Moreover, they suggest that the ability of a subpopulation of spinal motor neurons to regulate ciliary neurotrophic factor receptor alpha levels in response to injury may play a role in their survival and axonal regeneration. Consistent with such a role, we also find relatively high, and probably elevated, levels of ciliary neurotrophic factor receptor alpha immunoreactivity in regenerating axons.

Isolation and curing of the Klebsiella pneumoniae large indigenous plasmid using sodium dodecyl sulphate.

The ability of Klebsiella pneumoniae (NCTC, CL687/80) to produce and, in turn, excrete glutamate has been equated with the presence of a large indigenous plasmid with an apparent molecular mass in the region of 96 +/- 2 kbp (n = 6). Unlike mitomycin C, novobiocine and ethidium bromide (curing agents), the use of sodium dodecyl sulphate (SDS) proved very effective in curing the plasmid with a relatively high frequency (6.25 x 10(-4)). Furthermore, the absence of isocitrate dehydrogenase (ICDH) activity in the cured strain strongly suggests that the structural gene encoding ICDH in this organism, in sharp contrast to all known ICDHs, is plasmid-encoded. Moreover, the SDS-based protocol reported for the isolation of the K. pneumoniae indigenous plasmid has proven successful with other organisms including Pseudomonad and Corynebacteria, as well as in recombinant strains of Escherichia coli.

Elimination of cocaine by pregnant sheep following single or multiple exposures.

To test the hypothesis that chronic exposure to cocaine would alter drug elimination in pregnant and fetal sheep compared to a single exposure, we administered intravenous cocaine HCl to 8 pregnant sheep daily as a bolus, followed by a 2-h infusion beginning at gestational age 75 days. Eight additional animals received an equivalent volume of saline. Three days after maternal and fetal catheter placement on day 125, ewes in both groups received cocaine HCl, 2 mg/kg, as a bolus. Maternal and fetal plasma samples were serially obtained and analyzed for cocaine and benzoylecognine. Cocaine half-life in the ewes and fetuses exposed to cocaine was no different from that in animals exposed to saline. We conclude that cocaine is rapidly metabolized in pregnant sheep and that chronic administration does not alter drug clearance.