Intraoperative Electroencephalography Alpha-Band Power Is a Better Proxy for Preoperative Low MoCA Under Propofol Compared With Sevoflurane.

BACKGROUND: Preoperative abnormal cognitive status is a risk factor for postoperative complications yet remains underdiagnosed. During propofol general anesthesia, intraoperative electroencephalography (EEG) variables, such as alpha band power (α-BP), correlate with cognitive status. This relationship under sevoflurane is unclear. We investigated whether EEG biomarkers of poor cognitive status found under propofol could be extended to sevoflurane. METHODS: In this monocentric prospective observational study, 106 patients with intraoperative EEG monitoring were included (propofol/sevoflurane = 55/51). We administered the Montreal Cognitive Assessment (MoCA) scale to identify abnormal cognition (low MoCA) 1 day before intervention. EEG variables included delta to beta frequency band powers. Results were adjusted to age and drug dosage. We assessed depth of anesthesia (DoA) using the spectral edge frequency (SEF 95 ) and maintained it within (8-13) Hz. RESULTS: The difference in α-BP between low and normal MoCA patients was significantly larger among propofol patients (propofol: 4.3 ± 4.8 dB versus sevoflurane: 1.5 ± 3.4 dB, P = .022). SEF 95 and age were not statistically different between sevoflurane and propofol groups. After adjusting to age and dose, low α-BP was significantly associated with low MoCA under propofol (odds ratio [OR] [confidence interval {CI}] = 0.39 [0.16-0.94], P = .034), but not under sevoflurane, where theta-band power was significantly associated with low MoCA (OR [CI] = 0.31 [0.13-0.73], P = .007). CONCLUSIONS: We suggest that intraoperative EEG biomarkers of abnormal cognition differ between propofol and sevoflurane under general anesthesia.

Using velocity-pressure loops in the operating room: a new approach of arterial mechanics for cardiac afterload monitoring under general anesthesia.

Cardiac afterload is usually assessed in the ascending aorta and can be defined by the association of peripheral vascular resistance (PVR), total arterial compliance (Ctot), and aortic wave reflection (WR). We recently proposed the global afterload angle (GALA) and ß-angle derived from the aortic velocity-pressure (VP) loop as continuous cardiac afterload monitoring in the descending thoracic aorta. The aim of this study was to 1) describe the arterial mechanic properties by studying the velocity-pressure relations according to cardiovascular risk (low-risk and high-risk patients) in the ascending and descending thoracic aorta and 2) analyze the association between the VP loop (GALA and ß-angle) and cardiac afterload parameters (PVR, Ctot, and WR). PVR, Ctot, WR, and VP loop parameters were measured in the ascending and descending thoracic aorta in 50 anesthetized patients. At each aortic level, the mean arterial pressure (MAP), cardiac output (CO), and PVR were similar between low-risk and high-risk patients. In contrast, Ctot, WR, GALA, and ß-angle were strongly influenced by cardiovascular risk factors regardless of the site of measurement along the aorta. The GALA angle was inversely related to aortic compliance, and the ß-angle reflected the magnitude of wave reflection in both the ascending and descending aortas (P < 0.001). Under general anesthesia, the VP loop can provide new visual insights into arterial mechanical properties compared with the traditional MAP and CO for the assessment of cardiac afterload. Further studies are necessary to demonstrate the clinical utility of the VP loop in the operating room.NEW & NOTEWORTHY Our team recently proposed the global afterload angle (GALA) and ß-angle derived from the aortic velocity-pressure (VP) loop as continuous cardiac afterload monitoring in the descending thoracic aorta under general anesthesia. However, the evaluation of cardiac afterload at this location is unusual. The present study shows that VP loop parameters can describe the components of cardiac afterload both in the ascending and descending thoracic aorta in the operating room. Aging and cardiovascular risk factors strongly influence VP loop parameters. The VP loop could provide continuous visual additional information on the arterial system than the traditional mean arterial pressure and cardiac output during the general anesthesia.

Norepinephrine reduces arterial compliance less than phenylephrine when treating general anesthesia-induced arterial hypotension.

INTRODUCTION: During general anesthesia, arterial hypotension is frequent and may be an important contributor to perioperative morbidity. We assessed the effect of a 5 µg bolus of Norepinephrine (NA) when compared with 50 µg bolus of Phenylephrine (PE) administered to treat hypotension during maintenance anesthesia, on MAP, derived cardiac output and arterial stiffness parameters. METHODS: Patients scheduled for a neurosurgical procedure under general anesthesia were prospectively included. Monitoring included invasive blood pressure, esophageal Doppler, and arterial tonometer used to estimate central aortic pressure with arterial stiffness parameters, such as augmentation index (Aix). After initial resuscitation, hypotensive episodes were corrected by a bolus administration of NA or PE in a peripheral venous line. RESULTS: There were 269 bolus administrations of vasopressors (149 NA, 120 PE) in 47 patients with no adverse effects detected. A decrease in stroke volume (SV) was observed with PE compared with NA (-18 ± 9% vs. -14 ± 7%, P < 0.001). This decrease was associated with an increase in Aix, which was greater for PE than for NA (+10 ± 8% vs. +6 ± 6%, P < 0.0001), and a decrease in total arterial compliance greater for PE compared to NA (Ctot = SV/Central Pulse Pressure) (-35 ± 9% vs. -29 ± 10%, P < 0.001). DISCUSSION: This study suggests that 5 µg of NA administered as a bolus in a peripheral venous line could treat general anesthesia-induced arterial hypotension with a smaller decrease in SV and arterial compliance when compared to PE.

Robust raspberry-like metallo-dielectric nanoclusters of critical sizes as SERS substrates.

Raspberry-like nano-objects made of large plasmonic satellites (>10 nm) covering a central dielectric particle have many potential applications as photonic materials, superlenses and (bio-) sensors, but their synthesis remains challenging. Herein, we show how to build stable and robust raspberry-like nano-systems with close-packed satellites, by combining monodisperse silica particles (80 or 100 nm diameter) and oppositely charged noble metal nanoparticles (Au or Ag) with well-defined sizes (10-50 nm). The spectral characteristics of their associated plasmonic resonances (wavelength, linewidth, extinction cross-section) and the electromagnetic coupling between satellites were observed using the spatial modulation spectroscopy technique and interpreted through a numerical model. The composite nano-objects exhibit numerous hot spots at satellite junctions, resulting in excellent surface-enhanced Raman scattering (SERS) performance. The SERS efficiency of the raspberry-like clusters is highly dependent on their structure.

Comparison of cardiac output measured by oesophageal Doppler ultrasonography or pulse pressure contour wave analysis.

BACKGROUND: Maintaining adequate organ perfusion during high-risk surgery requires continuous monitoring of cardiac output to optimise haemodynamics. Oesophageal Doppler Cardiac Output monitoring (DCO) is commonly used in this context, but has some limitations. Recently, the cardiac output estimated by pulse pressure analysis- (PPCO) was developed. This study evaluated the agreement of cardiac output variations estimated with 9 non-commercial algorithms of PPCO compared with those obtained with DCO. METHODS: High-risk patients undergoing neurosurgery were monitored with invasive blood pressure and DCO. For each patient, 9 PPCO algorithms and DCO were recorded before and at the peak effect for every haemodynamic challenge. RESULTS: Sixty-two subjects were enrolled; 284 events were recorded, including 134 volume expansions and 150 vasopressor boluses. Among the 9 algorithms tested, the Liljestrand-Zander model led to the smallest bias (0.03 litre min(-1) [-1.31, +1.38] (0.21 litre min(-1) [-1.13; 1.54] after volume expansion and -0.13 litre min(-1) [-1.41, 1.15] after vasopressor use). The corresponding percentage of the concordance was 91% (86% after volume expansion and 94% after vasopressor use). The other algorithms, especially those using the Winkessel concept and the area under the pressure wave, were profoundly affected by the vasopressor. CONCLUSIONS: Among the 9 PPCO algorithms examined, the Liljestrand-Zander model demonstrated the least bias and best limits of agreement, especially after vasopressor use. Using this particular algorithm in association with DCO calibration could represent a valuable option for continuous cardiac output monitoring of high risk patients. CLINICAL TRIAL REGISTRATION: Comité d'éthique de la Société de Réanimation de Langue Française No. 11-356.

[Chordoma]. / Les chordomes.

PURPOSES: To review in the literature, all the epidemiological, clinical, radiological, histological and therapeutic data regarding chordomas as well as various notochordal entities: ecchordosis physaliphora, intradural and intraparenchymatous chordomas, benign notochordal cell tumors, parachordomas and extra-axial chordomas. To identify different types of chordomas, including familial forms, associations with tuberous sclerosis, Ollier's disease and Maffucci's syndrome, forms with metastasis and seeding. To assess the recent data regarding molecular biology and progress in targeted therapy. To compare the different types of radiotherapy, especially protontherapy and their therapeutic effects. To review the largest series of chordomas in their different localizations (skull base, sacrum and mobile spine) from the literature. MATERIALS: The series of 136 chordomas treated and followed up over 20 years (1972-2012) in the department of neurosurgery at Lariboisière hospital is reviewed. It includes: 58 chordomas of the skull base, 47 of the craniocervical junction, 23 of the cervical spine and 8 from the lombosacral region. Similarly, 31 chordomas in children (less than 18 years of age), observed in the departments of neurosurgery of les Enfants-Malades and Lariboisière hospitals, are presented. They were observed between 1976 and 2010 and were located intracranially (n=22 including 13 with cervical extension), 4 at the craniocervical junction level and 5 in the cervical spine. METHODS: In the entire Lariboisière series and in the different groups of localization, different parameters were analyzed: the delay of diagnosis, of follow-up, of occurrence of metastasis, recurrence and death, the number of primary patients and patients referred to us after progression or recurrence and the number of deaths, recurrences and metastases. The influence of the quality of resection (total, subtotal and partial) on the prognosis is also presented. Kaplan-Meier actuarial curves of overall survival and disease free survival were performed in the entire series, including the different groups of localization based on the following 4 parameters: age, primary and secondary patients, quality of resection and protontherapy. In the pediatric series, a similar analysis was carried-out but was limited by the small number of patients in the subgroups. RESULTS: In the Lariboisière series, the mean delay of diagnosis is 10 months and the mean follow-up is 80 months in each group. The delay before recurrence, metastasis and death is always better for the skull base chordomas and worse for those of the craniocervical junction, which have similar results to those of the cervical spine. Similar figures were observed as regards the number of deaths, metastases and recurrences. Quality of resection is the major factor of prognosis with 20.5 % of deaths and 28 % of recurrences after total resection as compared to 52.5 % and 47.5 % after subtotal resection. This is still more obvious in the group of skull base chordomas. Adding protontherapy to a total resection can still improve the results but there is no change after subtotal resection. The actuarial curve of overall survival shows a clear cut in the slope with some chordomas having a fast evolution towards recurrence and death in less than 4 years and others having a long survival of sometimes more than 20 years. Also, age has no influence on the prognosis. In primary patients, disease free survival is better than in secondary patients but not in overall survival. Protontherapy only improves the overall survival in the entire series and in the skull base group. Total resection improves both the overall and disease free survival in each group. Finally, the adjunct of protontherapy after total resection is clearly demonstrated. In the pediatric series, the median follow-up is 5.7 years. Overall survival and disease free survival are respectively 63 % and 54.3 %. Factors of prognosis are the histological type (atypical forms), localization (worse for the cervical spine and better for the clivus) and again it will depend on the quality of resection. CONCLUSIONS: Many different pathologies derived from the notochord can be observed: some are remnants, some may be precursors of chordomas and some have similar features but are probably not genuine chordomas. To-day, immuno-histological studies should permit to differentiate them from real chordomas. Improving knowledge of molecular biology raises hopes for complementary treatments but to date the quality of surgical resection is still the main factor of prognosis. Complementary protontherapy seems useful, especially in skull base chordomas, which have better overall results than those of the craniocervical junction and of the cervical spine. However, we are still lacking an intrinsic marker of evolution to differentiate the slow growing chordomas with an indolent evolution from aggressive types leading rapidly to recurrence and death on which more aggressive treatments should be applied.

[The impact of early cranioplasty on cerebral blood flow and its correlation with neurological and cognitive outcome. Prospective multi-centre study on 24 patients]. / Impact de la cranioplastie sur l'hémodynamique cérébrale comme facteur pronostic de l'amélioration clinique chez les patients craniectomisés pour traumatisme crânien grave.

INTRODUCTION: Cranioplasty after decompressive craniectomy in patients suffering from severe head injury often leads to a functional improvement although, to date, the pathophysiology of this phenomenon remains unclear. A few hypotheses have been proposed. The impact of cranioplasty on cerebral perfusion could be one explanation. We have evaluated the impact of cranioplasty on the functional status of patients undergoing decompressive craniectomy for severe head injury with its influence on cerebral perfusion. MATERIALS AND METHODS: Twenty-four patients undergoing craniectomy for severe head injury were included in this multi-centric and prospective study. All of them had a cranioplasty within 12 weeks following decompressive craniectomy. A clinical and radiological evaluation was performed prior to and after cranioplasty. Neurological and cognitive evaluation was performed with the Glasgow Outcome Score (GOS), the Frontal Assessment Battery (FAB) and the Mini Mental State Examination (MMSE). Radiological evaluation was performed by perfusion CT scan and transcranial Doppler. RESULTS: A statistically significant neurological and cognitive improvement was observed in 92% of patients at 6 months follow-up (F-U). Brain perfusion was improved at 6 weeks F-U, predominantly in the affected hemisphere. Systolic and diastolic blood velocity flow were improved in both middle cerebral arteries. CONCLUSION: Cranioplasty after decompressive craniectomy for patients suffering from severe head injury probably improves the functional outcome of these patients, thanks to a global improvement of cerebral perfusion.

Ultrafast nonlinear optical response of a single gold nanorod near its surface plasmon resonance.

The ultrafast optical nonlinearity of an optically characterized single gold nanorod is investigated around its surface plasmon resonance, by combining a far-field spatial modulation technique with a high sensitivity pump-probe setup. The spectrally and temporally dependent response is quantitatively interpreted in terms of the bulklike optical nonlinearity enhanced by the plasmonic effect. The plasmon resonance dynamics is shown to be mostly governed by nonequilibrium electron and phonon processes. Their contributions to the nonlinear optical response of a single metal nano-object are elucidated, and the latter is connected to the nonlinearities of ensembles.

ACoM: A classification method for elementary flux modes based on motif finding.

Elementary flux mode analysis is a powerful tool for the theoretical study of metabolic networks. However, when the networks are complex, the determination of elementary flux modes leads to combinatorial explosion of their number which prevents from drawing simple conclusions from their analysis. To deal with this problem we have developed a method based on the Agglomeration of Common Motifs (ACoM) for classifying elementary flux modes. We applied this algorithm to describe the decomposition into elementary flux modes of the central carbon metabolism in Bacillus subtilis and of the yeast mitochondrial energy metabolism. ACoM helps to give biological meaning to the different elementary flux modes and to the relatedness between reactions. ACoM, which can be viewed as a bi-clustering method, can be of general use for sets of vectors with values 0, +1 or -1.

Dopexamine Test in septic shock with hyperlactatemia.

OBJECTIVE: To evaluate the 6 hours haemodynamic effects of dopexamine (DPX) infusion in septic shock patients with persistent hyperlactatemia treated with high dose of norepinephrine (NE). STUDY DESIGN: Preliminary, prospective, uncontrolled study. PATIENTS: Twenty-one septic shock with NE>0.5 µg/kg/min, venous mixed oxygen saturation (ScvO(2)/SvO(2))>70%, cardiac index (CI)>3.5 l/min/m(2) and lactate>3 mmol/l. INTERVENTIONS: Infusion of DPX at 0.5 µg/kg/min. After 6 hours, patients were classified as DPX-responders or DPX-non-responders according to the presence or not of a decrease ≥20% in lactatemia. MEASUREMENT: DPX-responders and DPX-non-responders were compared with MAP, CI, central venous pressure (CVP), heart rate (HR) before infusion of DPX (h0), 30 minutes (h0.5) and 6 hours later (h6); and with NE infusion rate at h0 and h6. RESULTS: Eleven (52%) patients were DPX-responders and 10 (48%) DPX-non-responders. At H0.5, DPX-responders increased MAP more than DPX-non-responders (+21% versus +7%, P=0.01) with no change in CI, CVP and HR in both groups. At h0.5, an increase in MAP higher than 14%, compared to h0, could predict lactate clearance at h6 (sensitivity 91%, specificity 90%). From h0 to h6, increase in MAP (80±7 versus 70±8 mmHg, P<0.01) in DPX-responders allowed reduction in NE infusion (from 1.6±0.3 to 0.4±0.3 µg/kg/min, P<0.01); 28-day mortality was lower in DPX-responders than in DPX-non-responders (7 versus 90%, P<0.01). CONCLUSION: This study suggests that DPX did induce a decrease in lactatemia in 52% of septic shock, that could be predict by an increase in MAP (>14% within 30 minutes). Controlled studies are needed to confirm those preliminary results.

Uncontrollable high-frequency tachypnea: a rare and nearly fatal complication of endoscopic third ventriculostomy: case report and literature review.

BACKGROUND: Endoscopic third ventriculostomy (ETV) is considered a safe procedure although it carries its rate of risks and complications that may occasionally be life-threatening. CASE REPORT: This is a report about a 48-year-old woman presenting with progressive gait unsteadiness, weakness of the lower extremities and cognitive impairment due to tri-ventricular hydrocephalus. This was treated with standard ETV. In the immediate post-operative period the patient developed a severe and uncontrollable tachypnea requiring sedation, intubation and mechanical ventilation. CONCLUSION: Tachypnea may be an early complication after standard ETV and although its mechanism remains yet unclear, we speculate that it may be related to excessive traction and/or surgical manipulation of the floor of the third ventricle. Supportive care with mechanical ventilation is the mainstay of treatment until spontaneous normalization of the respiratory mechanism occurs.

Structural basis for human monoglyceride lipase inhibition.

Monoglyceride lipase (MGL) is a serine hydrolase that hydrolyses 2-arachidonoylglycerol (2-AG) into arachidonic acid and glycerol. 2-AG is an endogenous ligand of cannabinoid receptors, involved in various physiological processes in the brain. We present here the first crystal structure of human MGL in its apo form and in complex with the covalent inhibitor SAR629. MGL shares the classic fold of the alpha/beta hydrolase family but depicts an unusually large hydrophobic occluded tunnel with a highly flexible lid at its entry and the catalytic triad buried at its end. Structures reveal the configuration of the catalytic triad and the shape and nature of the binding site of 2-AG. The bound structure of SAR629 highlights the key interactions for productive binding with MGL. The shape of the tunnel suggests a high druggability of the protein and provides an attractive template for drug discovery.

Quantitative determination of the size dependence of surface plasmon resonance damping in single Ag@SiO(2) nanoparticles.

The optical extinction spectra of single silver nanoparticles coated with a silica shell were investigated in the size range 10-50 nm. Measurements were performed using the spatial modulation spectroscopy technique which permits independent determination of both the size of the metal nanoparticle under study and the width of its localized surface plasmon resonance (LSPR). These parameters can thus be directly correlated at a single particle level for the first time. The results show a linear increase of the width of the LSPR with the inverse diameter in the small size regime (less than 25 nm). For these nanoparticles of well-controlled environment, this can be ascribed to quantum confinement of electrons or, classically, to increase of the electron surface scattering processes. The impact of this effect was measured quantitatively and compared to the predictions by theoretical models.

[Toxic shock syndrome consecutive to the presence of vaginal tampon for menstruation regressive after early haemodynamic optimization and activated protein C infusion]. / Choc toxique staphylococcique dans un contexte menstruel de port de tampons vaginaux d'évolution favorable après optimisation hémodynamique précoce et administration de protéine C activée.

A 19-year-old woman was admitted in the intensive care unit for a septic shock recognized as a menstrual toxic shock syndrome with a Staphylococcus aureus. An early goal oriented therapy was started in order to correct in particular the venous central O(2) saturation (ScvO(2)) associated to an early empiric anti-infectious treatment. A multi-organ failure appeared in a second time, so that we began a protein C activated infusion. The outcome was also auspicious. Bacteriologic samples and specific samples for the research of Staphylococci toxins confirmed the diagnosis of toxic shock syndrome with Staphylococcus aureus. A genotypic study allowed us to identify many anomalies which could be involved in the incompletely understood physiopathology of this disease.

Fano profiles induced by near-field coupling in heterogeneous dimers of gold and silver nanoparticles.

The near-field coupling between a gold and a silver spherical nanoparticle is investigated theoretically. Fano profiles are observed in the absorption cross section of the gold nanoparticle due to the coupling between the spectrally localized surface plasmon resonance of the silver nanoparticle and the continuum of interband transitions of the gold one. The effect of dimer internal characteristics (particle sizes and distance), surrounding medium (through the refractive index), and external excitation (polarization and propagation directions) are addressed. In particular, it is shown that the near-field coupling can be tuned from the weak to the strong regime by rotating the polarization direction, and that the Fano profiles are sensitive to the shadowing effect even for small particle sizes.

Optical properties and relaxation processes at femtosecond scale of bimetallic clusters.

The optical properties of Au-Ag and Ni-Ag clusters are measured by linear optical absorption spectroscopy and the time-resolved pump-probe femtosecond technique allowing a study of the influence of alloy or core-shell structure.

Acoustic vibration modes and electron-lattice coupling in self-assembled silver nanocolumns.

Using ultrafast spectroscopy, we investigated electron-lattice coupling and acoustic vibrations in self-assembled silver nanocolumns embedded in an amorphous Al2O3 matrix. The measured electron-lattice energy exchange time is smaller in the nanocolumns than in bulk silver, with a value very close to that of isolated nanospheres with comparable surface to volume ratio. Two vibration modes were detected and ascribed to the breathing and extensional mode of the nanocolumns, in agreement with numerical simulations.

Coherent acoustic vibration of metal nanoshells.

Using time-resolved pump-probe spectroscopy, we have performed the first investigation of the vibrational modes of gold nanoshells. The fundamental isotropic mode launched by a femtosecond pump pulse manifests itself in a pronounced time-domain modulation of the differential transmission probed at the frequency of nanoshell surface plasmon resonance. The modulation amplitude is significantly stronger, and the period is longer than that in a gold nanoparticle of the same overall size, in agreement with theoretical calculations. This distinct acoustical signature of nanoshells provides a new and efficient method for identifying these versatile nanostructures and for studying their mechanical and structural properties.

Optical control of the coherent acoustic vibration of metal nanoparticles.

Optical control of the coherent breathing vibrations of silver nanospheres is demonstrated using a high-sensitivity femtosecond pump-probe technique in a double-pump pulse configuration. Oscillation of the fundamental mode that usually dominates the time-domain vibrational response can thus be stopped, permitting observation of the first order radial mode and determination of its properties. These are found to be in agreement with the predictions of the model of an elastic sphere embedded in an elastic matrix.

Direct measurement of the single-metal-cluster optical absorption.

The absorption of a single isolated metal cluster is directly measured using a novel far-field optical technique based on modulation of its position. Single gold nanoparticles with average diameters down to 5 nm, dispersed on a transparent substrate, are optically detected and their absolute absorption cross section determined.