Novel Pulmonary Function Parameter Shifts in High-Grade Upper Airway Stenoses.

Upper airway stenosis (UAS) is a common problem for anesthesiologists in laryngology as well as head and neck surgery, but it may lead to life-threatening situations if it is undetected. This retrospective case series was performed on patients who had UAS and presented with severe dyspnea or encountered difficulties in airway management. To assess the severity of UAS, the degree of stenosis was calculated using computed tomography scans and direct endoscopy. Lung function test was collected, and measured values were extracted as percentage of predicted reference values. Lower and higher grade stenoses were defined by Cotton-Myer classification and median degree of stenosis. Median of detected stenoses was 73% (64%-85%), with 7 of 10 patients classified as Cotton-Myer grade 3. Lung function tests showed typical parameter shifts as known from obstructive pulmonary diseases (OPDs). Furthermore, statistical analyses showed a significant higher value of residual volume (RV)/total lung capacity (TLC) in patients with higher grade stenosis (P < .05), whereas forced expiratory volume in 1 second /vital capacity (FEV1/VC) did not show a significant difference in same subgroups. In conclusion, the elevation of RV/TLC with concomitant normal FEV1/VC in symptomatic patients could be used to demarcate rare UAS from common OPD. Moreover, RV-TLC ratio might be used to distinguish between low- and high-grade UAS. But further epidemiological studies will be necessary to validate these findings. Level of evidence: 4.

State-dependent block of voltage-gated sodium channels by the casein-kinase 1 inhibitor IC261.

Background and Purpose IC261 (3-[(2,4,6-trimethoxyphenyl)methylidenyl]-indolin-2-one) has previously been introduced as an isoform specific inhibitor of casein kinase 1 (CK1) causing cell cycle arrest or cell death of established tumor cell lines. However, it is reasonable to assume that not all antitumor activities of IC261 are mediated by the inhibition of CK1. Meanwhile there is growing evidence that functional voltage-gated sodium channels are also implicated in the progression of tumors as their blockage suppresses tumor migration and invasion of different tumor cell lines. Thus, we asked whether IC261 functionally inhibits voltage-gated sodium channels. Experimental Approach Electrophysiological experiments were performed using the patch-clamp technique at human heart muscle sodium channels heterologously expressed in human TsA cells. Key Results IC261 inhibits sodium channels in a state-dependent manner. IC261 does not interact with the open channel and has only a low affinity for the resting state of the hNav1.5 (human voltage-gated sodium channel; Kr: 120 µM). The efficacy of IC261 strongly increases with membrane depolarisation, indicating that the inactivated state is an important target. The results of different experimental approaches finally revealed an affinity of IC261 to the inactivated state between 1 and 2 µM. Conclusion and Implications IC261 inhibits sodium channels at a similar concentration necessary to reduce CK1δ/ε activity by 50% (IC50 value 1 µM). Thus, inhibition of sodium channels might contribute to the antitumor activity of IC261.

In Vivo Measurement in Pigs of Wash-In Kinetics of Xenon at its Site of Action.

BACKGROUND: Xenon (Xe) in many respects is an ideal anaesthetic agent. Its blood/gas partition coefficient is lower than that of any other anaesthetic, enabling rapid induction of and emergence from anaesthesia. While the whole body kinetics during wash-in of inhalational anaesthesia is well known, data describing the pharmacokinetics of xenon in the cerebral compartment at the site of action are still largely missing. METHODS: In order to illuminate xenon's cerebral pharmacokinetics, we anaesthetised five pigs and measured arterial, mixed- and sagittal sinus-venous blood, as well as end-expiratory gas concentrations of xenon by gas chromatography-mass spectrometry (GCMS) up to 30 minutes after starting the anaesthetic gas mixture. RESULTS: Despite xenon's fast onset of effect the half-time for equilibration between xenon concentration in arterial blood and at the site of action is measured to be 1.49 ± 0.04 minutes versus 3.91 ± 0.1 minutes. Successful loading of xenon in the brain during inhalational anesthesia was accomplished after approximately 15 minutes although the end-expiratory xenon concentration reached a plateau after 7 minutes. Thus cerebral xenon uptake rate is only moderate, xenon fast onset of action being largely due to its extremely fast alveolar uptake. CONCLUSIONS: To ensure safety and precise control during anaesthesia we need a profound knowledge about to what extent the measured end-tidal concentrations reflect the drug concentrations in the target tissue. The results of this study expand our knowledge about the temporal characteristics of xenon´s pharmacokinetics at its site of action and provide the basis for appropriate clinical protocols and experimental designs of future studies.

Glucose modulates food-related salience coding of midbrain neurons in humans.

Although early rat studies demonstrated that administration of glucose diminishes dopaminergic midbrain activity, evidence in humans has been lacking so far. In the present functional magnetic resonance imaging study, glucose was intravenously infused in healthy human male participants while seeing images depicting low-caloric food (LC), high-caloric food (HC), and non-food (NF) during a food/NF discrimination task. Analysis of brain activation focused on the ventral tegmental area (VTA) as the origin of the mesolimbic system involved in salience coding. Under unmodulated fasting baseline conditions, VTA activation was greater during HC compared with LC food cues. Subsequent to infusion of glucose, this difference in VTA activation as a function of caloric load leveled off and even reversed. In a control group not receiving glucose, VTA activation during HC relative to LC cues remained stable throughout the course of the experiment. Similar treatment-specific patterns of brain activation were observed for the hypothalamus. The present findings show for the first time in humans that glucose infusion modulates salience coding mediated by the VTA. Hum Brain Mapp 37:4376-4384, 2016. © 2016 Wiley Periodicals, Inc.

Chirurgische Behandlung von Melanomen in der Schwangerschaft: eine praktische Anleitung.

Als ein Tumor, der primär eine chirurgische Behandlung erfordert, ist ein neu diagnostiziertes oder vorbestehendes Melanom in der Schwangerschaft eine klinische Rarität. In solchen Fällen steht der Chirurg vor der Herausforderung, ein geeignetes therapeutisches Vorgehen festlegen zu müssen. Auf der Grundlage unserer klinischen Erfahrung und einer Übersicht über die Literatur geben wir in der vorliegenden Arbeit eine Anleitung für das praktische Vorgehen bei dieser seltenen klinischen Konstellation. Unserer Erfahrung nach müssen schwangere Melanom-Patientinnen im Hinblick auf ihre therapeutischen Optionen ausführlich beraten werden. Naturgemäß setzen sie ihr ungeborenes Kind an die erste Stelle und zögern, der erforderlichen Operation zuzustimmen, obwohl bei ihnen eine möglicherweise lebensbedrohliche Erkrankung diagnostiziert worden ist. Daher ist es entscheidend, diese Patientinnen klar darüber zu informieren, dass, wie die vorliegenden medizinischen Erfahrungen zeigen, eine Schwangerschaft per se kein Grund ist, eine notwendige Melanom-Operation aufzuschieben. Jedoch müssen bei einigen Parametern wie den präoperativen Bildgebungsverfahren, der Positionierung auf dem Operationstisch, der Überwachung, Anästhesie und der perioperativen Medikation bestimmte Anpassungen vorgenommen werden, um der speziellen Situation Rechnung zu tragen.

Surgical treatment of melanoma in pregnancy: a practical guideline.

A tumor primarily requiring surgical treatment, newly diagnosed or preexisting melanoma during pregnancy is a clinical rarity. In such cases, the surgeon faces the challenge of having to decide on the appropriate therapeutic course of action. Based on our clinical experience and a review of the literature, we herein provide a guideline on how to practically deal with this rare clinical conundrum. In our experience, pregnant melanoma patients require thorough counseling with respect to their therapeutic options. They naturally tend to put their unborn child first, and are hesitant to consent to necessary surgery despite a potentially life-threatening diagnosis. It is therefore crucial to clearly inform these patients that - based on existing medical experience - pregnancy by itself is no reason to hold off on any type of necessary melanoma surgery. However, various parameters such as preoperative imaging procedures, positioning on the operating table, monitoring, anesthesia, and perioperative medication require certain adjustments in order to comply with this special situation.

Evaluation of Homobivalent Carbolines as Designed Multiple Ligands for the Treatment of Neurodegenerative Disorders.

Neurodegenerative diseases represent a challenge for biomedical research due to their high prevalence and lack of mechanism-based treatments. Because of the complex pathology of neurodegenerative disorders, multifunctional drugs have been increasingly recognized as potential treatments. We identified homobivalent γ-carbolinium salts as potent inihitors of both cholinesterases, N-methyl-D-aspartate receptors, and monoamine oxidases. Homobivalent γ-carbolines displayed similar structure-activity relationships on all tested targets and may present promising designed multiple ligands for the treatment of neurodegenerative disorders.

Open channel block of NMDA receptors by diphenhydramine.

BACKGROUND AND PURPOSE: Diphenhydramine is a well known H1-receptor antagonist that plays a major role in clinical practice. Nowadays, diphenhydramine is primarily applied to prevent nausea but also its sedative and analgesic effects are of clinical importance. As other drugs mediating sedative and analgesic properties partly operate via the inhibition of glutamate receptors, we tested the hypothesis that diphenhydramine, as well interacts with excitatory ionotropic glutamate receptors. EXPERIMENTAL APPROACH: Electrophysiological patch-clamp experiments were performed on glutamate receptors which were heterologously expressed in human TsA cells. KEY RESULTS: Diphenhydramine inhibits NMDA-mediated membrane currents in a reversible and concentration-dependent manner at clinically relevant concentrations. The inhibition occurred in a noncompetitive manner. Diphenhydramine did not compete with NMDA or glycine for their binding sites and half-maximal inhibition was obtained around 25 µM diphenhydramine, independent of the subunit composition. The inhibition was caused by a classical open channel blocking mechanism and varied strongly with the membrane potential. Our results suggest that diphenhydramine most probably interacts with the Mg2+ binding site or a very closely related area of the channel pore. CONCLUSION AND IMPLICATIONS: The data presented here provide evidence that the NMDA receptor antagonism of diphenhydramine contribute to its sedative and potentially LTP-related effects like analgesia and amnesia.

Mechanism and functional impact of CD40 ligand-induced von Willebrand factor release from endothelial cells.

Co-stimulation via CD154 binding to CD40, pivotal for both innate and adaptive immunity, may also link haemostasis to vascular remodelling. Here we demonstrate that human platelet-bound or recombinant soluble CD154 (sCD154) elicit the release from and tethering of ultra-large (UL) von Willebrand factor (vWF) multimers to the surface of human cultured endothelial cells (ECs) exposed to shear stress. This CD40-mediated ULVWF multimer release from the Weibel-Palade bodies was triggered by consecutive activation of TRAF6, the tyrosine kinase c-Src and phospholipase Cγ1 followed by inositol-1,4,5 trisphosphate-mediated calcium mobilisation. Subsequent exposure to human washed platelets caused ULVWF multimer-platelet string formation on the EC surface in a shear stress-dependent manner. Platelets tethered to these ULVWF multimers exhibited P-selectin on their surface and captured labelled monocytes from the superfusate. When exposed to shear stress and sCD154, native ECs from wild-type but not CD40 or vWF-deficient mice revealed a comparable release of ULVWF multimers to which murine washed platelets rapidly adhered, turning P-selectin-positive and subsequently capturing monocytes from the perfusate. This novel CD154-provoked ULVWF multimer-platelet string formation at normal to fast flow may contribute to vascular remodelling processes requiring the perivascular or intravascular accumulation of pro-inflammatory macrophages such as arteriogenesis or atherosclerosis.

Promethazine inhibits NMDA-induced currents - new pharmacological aspects of an old drug.

BACKGROUND AND PURPOSE: The phenothiazine derivative promethazine was first introduced into clinical practice as an antiallergic drug owing to its H1-receptor antagonizing properties. Nowadays, promethazine is primarily used as a sedative and/or as an antiemetic. The spectrum of clinically relevant effects is mediated by different molecular targets. Since glutamate is the predominant excitatory transmitter in the vertebrate brain and involved in alertness control, pain processing, and neurotoxicity we tested the hypothesis that promethazine interacts with excitatory ionotropic glutamate receptors. EXPERIMENTAL APPROACH: Electrophysiological experiments were performed by means of the patch-clamp technique at glutamate receptors heterologously expressed in human TsA cells. KEY RESULTS: Promethazine selectively inhibited NMDA receptors whereas AMPA- and kainate receptors were hardly affected. Inhibition of NMDA-induced membrane currents occurred in a reversible manner with a half-maximal effect at around 20 µM promethazine. The inhibition occurred in a non-competitive manner as it did neither vary with the glutamate nor the glycine concentration. Analysis of the underlying mechanism revealed only a weak dependency on receptor usage, pH value (pH 6.8-7.8), and membrane potential (zδ = 0.44 ± 0.04 according to the Woodhull-model). In line with the latter finding, promethazine did not interact with the Mg(2+) binding site. However, the displacement of promethazine by 9-aminoacridine indicates that promethazine may interact with the channel pore more externally in relation to the Mg(2+) binding site. CONCLUSION AND IMPLICATIONS: Promethazine inhibits NMDA-mediated membrane currents in a reversible and concentration-dependent manner. The results presented here provide evidence that the NMDA receptor antagonism may contribute to clinically relevant effects of promethazine like sedation, analgesia or neuroprotection.

Targeting Spinal Long-Term Potentiation as a Basis for Analgesia Recent Developments.

Recent investigations of pain mechanisms leading to the induction and maintenance of long-term potentiation (LTP) in the spinal cord have identified a huge number of molecular targets that might be appropriate for therapeutically intervention. In this short review we summarize recently published studies investigating drugs that affect LTP in the spinal cord. After providing an overview of spinal pain pathways and of the respective methods for their investigation, molecular targets for possible pharmacological interventions are discussed.

Targeting spinal long-term potentiation as a basis for anlagesia: recent developments.

Recent investigations of pain mechanisms leading to the induction and maintenance of long-term potentiation (LTP) in the spinal cord have identified a huge number of molecular targets that might be appropriate for therapeutically intervention. In this short review we summarize recently published studies investigating drugs that affect LTP in the spinal cord. After providing an overview of spinal pain pathways and of the respective methods for their investigation, molecular targets for possible pharmacological interventions are discussed.

Intranasal application of xenon reduces opioid requirement and postoperative pain in patients undergoing major abdominal surgery: a randomized controlled trial.

BACKGROUND: Both central sensitization after peripheral tissue injury and the development of opioid tolerance involve activation of N-methyl-D-aspartate (NMDA) receptors. At subanesthetic doses the NMDA receptor antagonist xenon suppresses pain-evoked sensitization of pain-processing areas in the central nervous system. Although numerous studies describe the effect of NMDA receptor antagonists on postoperative pain, clinical studies elucidating their intraoperative analgesic potency when applied in a low dosage are still largely missing. METHODS: To analyze the analgesic effect of low-dose xenon using new application methods, the authors tested nasally applied xenon as an add-on treatment for analgesia in 40 patients undergoing abdominal hysterectomy. Within a randomized double-blind placebo-controlled study design, intraoperative and postoperative requirement of opioids as well as postoperative subjective experiences of pain were measured as primary outcome variables. RESULTS: Intranasal application of xenon significantly reduced intraoperative opioid requirement (mean difference [MD] -2.0 µg/min; 95% CI [CI95]-0.53 to -3.51, Bonferroni correction adjusted P value [pcorr]= 0.028) without relevant side effects and significantly reduced postoperative pain (MD -1.34 points on an 11-point rating scale; CI95 -0.60 to -2.09, pcorr = 0.002). However, postoperative morphine consumption (MD -8.8 µg/min; CI95 1.2 to -18.8, pcorr = 0.24) was not significantly reduced in this study. CONCLUSIONS: Low-dose xenon significantly reduces intraoperative analgesic use and postoperative pain perception. Because NMDA receptor antagonists suppress central sensitization, prevent the development of opioid tolerance, and reduce postoperative pain, the intraoperative usage of NMDA receptor antagonists such as xenon is suggested to improve effectiveness of pain management within a concept of multimodal analgesia.

Atomoxetine acts as an NMDA receptor blocker in clinically relevant concentrations.

BACKGROUND AND PURPOSE: There is increasing evidence that not only the monoaminergic but also the glutamatergic system is involved in the pathophysiology of attention-deficit hyperactivity disorder (ADHD). Hyperactivity of glutamate metabolism might be causally related to a hypoactive state in the dopaminergic system. Atomoxetine, a selective noradrenaline reuptake inhibitor, is the first non-stimulant approved for the treatment of this disorder. Here we have evaluated the effects of atomoxetine on glutamate receptors in vitro. EXPERIMENTAL APPROACH: The whole-cell configuration of the patch-clamp technique was used to analyse the effect of atomoxetine on N-methyl-d-aspartate (NMDA) receptors in cultured rodent cortical and hippocampal neurons as well as on NMDA receptors heterologously expressed in human TsA cells. KEY RESULTS: Atomoxetine blocked NMDA-induced membrane currents. Half-maximal inhibition emerged at about 3 microM which is in the range of clinically relevant concentrations found in plasma of patients treated with this drug. The inhibition was voltage-dependent, indicating an open-channel blocking mechanism. Furthermore, the inhibitory potency of atomoxetine did not vary when measured on NMDA receptors from different brain regions or with different subunit compositions. CONCLUSIONS AND IMPLICATIONS: The effective NMDA receptor antagonism by atomoxetine at low micromolar concentrations may be relevant to its clinical effects in the treatment of ADHD. Our data provide further evidence that altered glutamatergic transmission might play a role in ADHD pathophysiology.

Xenon-induced changes in CNS sensitization to pain.

Electrophysiological investigations of the spinal cord in animals have shown that pain sensitizes the central nervous system via glutamate receptor dependent long-term potentiation (LTP) related to an enhancement of pain perception. To expand these findings, we used functional magnetic resonance (fMRI), blood oxygen level dependent (BOLD) and perfusion imaging in combination with repeated electrical stimulation in humans. Specifically we monitored modulation of somatosensory processing during inhibition of excitatory transmission by ocular application of the glutamate receptor antagonist xenon. BOLD responses upon secondary stimulation increased in mid insular and in primary/secondary sensory cortices under placebo and decreased under xenon treatments. Xenon-induced decreases in regional perfusion were confined to stimulation responsive brain regions and correlated with time courses of xenon concentrations in the cranial blood. Moreover, effects of xenon on behavioral, fMRI and perfusion data scaled with stimulus intensity. The dependence of pain sensitization on sufficient pre-activation reflects a multistage process which is characteristic for glutamate receptor related processes of LTP. This study demonstrates how LTP related processes known from the cellular level can be investigated at the brain systems level.

In vitro-evaluation of lipid emulsions as vehicles for the administration of xenon: interaction with NMDA receptors.

The noble gas xenon is an antagonist of the NMDA (N-methyl-D-aspartate)-type glutamate receptor which may account for the ideal anesthetic profile and potent neuroprotective properties demonstrated even at subanesthetic concentrations. Because lipid emulsions also promote NMDA antagonistic effects they may serve as ideal carriers for xenon. In this in vitro study, we investigated the efficacy of xenon dissolved in various lipid emulsions (Intralipid, Lipofundin, ClinOleic and Abbolipid on NMDA-evoked currents in cultured cortical neurons. The NMDA receptor blocking property at a clinically relevant concentration seen in the lipid emulsions tested may contribute to the anesthetic, analgetic and neuroprotective effects of xenon administered by way of these lipid carriers. Abbolipid? may serve as the most acceptable carrier since the NMDA antagonistic effect of xenon was enhanced in combination with this emulsion.

Xenon blocks AMPA and NMDA receptor channels by different mechanisms.

The noble gas xenon (Xe) inhibits not only NMDA receptors (NMDARs) but also the two other subtypes of glutamate receptor i.e. AMPA (AMPARs) and kainate receptors. Preliminary studies on AMPARs suggest that Xe sensitivity might be coupled to receptor desensitization. In order to find out if this hypothesis can be applied to all glutamate receptors, we analyzed additional 'non-desensitizing' AMPARs mutants and compared these with homologous mutants of NMDARs. Membrane currents of Neuro2A or SH-SY5Y cells transfected with cDNA encoding AMPA- or NMDA receptors were investigated by whole cell recordings under voltage clamp conditions. Agonists (glutamate, kainate, NMDA) were applied to the cells by means of a rapid perfusion system. Xenon was preincubated for 20 s before testing it in combination with the particular agonist. Xe (3.5 mM) reduced peak and plateau currents of AMPA wild-type receptors [GluR1(i); GluR2(i,Q)] activated for 5 s with 3 mM glutamate, by 45 and 55% respectively. With mutant AMPARs showing greatly diminished or abolished desensitization i.e. GluR1(i)_L497Y, GluR1(i)_A636T(Lc) GluR2(i,Q)_R649E and GluR2(i,Q)_A643T(Lc) the reduction by Xe was significantly smaller and varied by between 4 and 20%. In contrast, no difference in the blocking capacity of Xe was observed comparing wild-type NR1-1a/NR2A receptors with receptors having point mutations within NR2A that substantially slowed (NR2A_A651T(Lc)) or accelerated (NR2A_M823W) receptor desensitization. Thus, our data indicate that in AMPARs channel blockade by Xe is related to desensitization, whereas in NMDARs no evidence for such a relation was found. Thus, Xe seems to exert its inhibiting effect on various ionotropic glutamate receptors by different molecular mechanisms.

Evidence that Xenon does not produce open channel blockade of the NMDA receptor.

Previous studies had not excluded the possibility that the mechanism by which Xenon (Xe) blocks N-methyl-D-aspartate (NMDA) receptors might be that of an open-channel blocker. We tested this possibility on mutant NMDA receptors carrying an alanine (A) to cysteine (C) mutation located within the SYTANLAAF-motif of the third transmembrane region (TM3). This mutation was shown to yield constitutively open ion channels after modification with a thiol-modifying reagent. We expressed such mutant channels in Neuro2A cells and recorded glutamate (50 microM)-induced currents in the whole cell recording mode. Although Xe (3.5 mM) blocked the currents through the wild-type receptor NR1-1a/NR2A and NR1-1a/NR2B by approximately 40% and those through the mutant receptors NR1-1a/NR2A(A650C) or NR1-1a/NR2B(A651C) by approximately 30%, it was unable to block the currents through the methane thiosulfonate etyhlammonium-modified mutant receptors. On the other hand, established open-channel blockers of the NMDA receptor such as MK-801 (1 microM) or Mg ions (Mg(2+); 1 mM) were able to block these permanently open channels. These results suggest that Xe does not act as a classical open-channel blocker at the NMDA receptor.

Rapid increase of glial glutamate uptake via blockade of the protein kinase A pathway.

Glutamate is the main excitatory neurotransmitter in the vertebrate central nervous system. Removal of this transmitter from the synaptic cleft by glial and neuronal transporter systems plays an important role in terminating glutamatergic neurotransmission. The effects of different activators and blockers of PKA and PKC on glutamate uptake were studied in primary glial cells cultivated from the rat cortex using the patch-clamp recording technique and immunocytochemical methods. GF 109203X enhances glutamate-induced membrane currents in a concentration- and time-dependent manner. After pre-application for 40 s the maximal transport capacity was increased by 30-80%. The estimated Km-value of the transport system did not change after drug application and the enhanced glutamate uptake was reversible within a few minutes upon washout. Activators and blockers of the PKC pathway did not affect glutamate uptake, whereas H89, a selective blocker of PKA, mimicked the effects of GF 109203X, indicating involvement of the protein kinase A pathway. The GF 109203X-induced increase in transport capacity is likely to be mediated by GLAST since the GLT-1 selective blocker dihydrokainate was unable to block basal or stimulated glutamate uptake. Furthermore, the increase in transport activity may well be based on an increase in cell surface expression of the transporter protein since preincubation with cytochalasin-B, a protein that blocks actin polymerization, almost completely abolished the effect of GF 109203X and H89. These results indicate that GF 109203X and H89 enhance glial glutamate uptake via blockade of the PKA. The described effect may affect glutamatergic neurotransmission by reducing the glutamate concentration in the synaptic cleft.