A randomised double-blind trial of phenylephrine and metaraminol infusions for prevention of hypotension during spinal and combined spinal-epidural anaesthesia for elective caesarean section.

Prophylactic vasopressor administration is commonly recommended to reduce maternal hypotension during spinal anaesthesia for caesarean section. Metaraminol has undergone limited investigation in obstetric anaesthesia for this purpose, particularly in comparison with phenylephrine. In this multicentre, randomised, double-blind, non-inferiority study, we compared prophylactic phenylephrine or metaraminol infusions, started immediately after spinal anaesthesia, in 185 women who underwent elective caesarean section. Phenylephrine was initially infused at 50 µg.min-1 , and metaraminol at 250 µg.min-1 . The primary outcome was the difference in umbilical arterial pH between groups; secondary outcomes included other neonatal acid-base measures, and maternal haemodynamic changes. The mean (SD) umbilical arterial pH was 7.28 (0.06) in the phenylephrine group vs. 7.31 (0.04) in the metaraminol group (p = 0.0002). The estimated mean (95%CI) pH difference of 0.03 (0.01-0.04) was above the pre-determined lower boundary of clinical non-inferiority, and also met the criterion for superiority. Umbilical artery lactate concentration was 2.8 (1.2) mmol.l-1 in the phenylephrine group vs. 2.3 (0.7) mmol.l-1 in the metaraminol group (p = 0.0018). Apgar scores did not significantly differ between groups. There was a higher incidence of hypotension, defined as systolic arterial pressure < 90% baseline, in the phenylephrine group; there was a higher incidence of hypertension and severe hypertension (systolic arterial pressure > 110% and > 120% baseline, respectively) in the metaraminol group. There was no significant difference between groups in the incidence of nausea, vomiting or maternal bradycardia. We conclude that, when used as an infusion to prevent hypotension after spinal anaesthesia for elective caesarean section, metaraminol is at least non-inferior to phenylephrine with respect to neonatal acid-base outcomes.

Does adding milk to tea delay gastric emptying?

BACKGROUND: Many preoperative fasting guidelines suggest that hot tea or coffee with milk added should be considered similar to solid food, allowing an interval of 6 h before commencing anaesthesia. There is little evidence to support these instructions, with recent guidelines undecided on the issue. This study aimed to establish whether there was a clinically significant delay in gastric emptying associated with adding a modest amount of milk to tea. METHODS: This randomized controlled crossover study was conducted in 10 healthy volunteers. The paracetamol absorption technique and real-time ultrasound measurement of the cross-sectional area of the gastric antrum were used to assess gastric emptying after ingestion of 300 ml of black tea or 300 ml of tea with milk (250 ml black tea plus 50 ml of full fat milk). RESULTS: The mean difference in the time to reach the peak paracetamol concentration (tmax) was -8 min [95% confidence interval (CI) -23.1 to 7] in favour of tea with milk. Ultrasound assessment indicated that the geometric mean of the half-time to gastric emptying (T1/2) after tea without milk was 22.7 (95% CI 12.7-40.9) min and after tea with milk 23.6 (95% CI 13.5-41.0) min (ratio 1.04) (95% CI 0.47-2.29). CONCLUSIONS: This study demonstrated no difference in gastric emptying times when a modest amount of milk was added to tea. These findings suggest that it may be acceptable to allow patients to add a small quantity of milk to their tea or coffee and follow the same fasting restrictions applied to clear fluids.

Parkinson's disease patients show impaired corrective grasp control and eye-hand coupling when reaching to grasp virtual objects.

The effect of Parkinson's disease (PD) on hand-eye coordination and corrective response control during reach-to-grasp tasks remains unclear. Moderately impaired PD patients (n=9) and age-matched controls (n=12) reached to and grasped a virtual rectangular object, with haptic feedback provided to the thumb and index fingertip by two 3-degree of freedom manipulanda. The object rotated unexpectedly on a minority of trials, requiring subjects to adjust their grasp aperture. On half the trials, visual feedback of finger positions disappeared during the initial phase of the reach, when feedforward mechanisms are known to guide movement. PD patients were tested without (OFF) and with (ON) medication to investigate the effects of dopamine depletion and repletion on eye-hand coordination online corrective response control. We quantified eye-hand coordination by monitoring hand kinematics and eye position during the reach. We hypothesized that if the basal ganglia are important for eye-hand coordination and online corrections to object perturbations, then PD patients tested OFF medication would show reduced eye-hand spans and impoverished arm-hand coordination responses to the perturbation, which would be further exasperated when visual feedback of the hand was removed. Strikingly, PD patients tracked their hands with their gaze, and their movements became destabilized when having to make online corrective responses to object perturbations exhibiting pauses and changes in movement direction. These impairments largely remained even when tested in the ON state, despite significant improvement on the Unified Parkinson's Disease Rating Scale. Our findings suggest that basal ganglia-cortical loops are essential for mediating eye-hand coordination and adaptive online responses for reach-to-grasp movements, and that restoration of tonic levels of dopamine may not be adequate to remediate this coordinative nature of basal ganglia-modulated function.

Unrestricted access to sugammadex: impact on neuromuscular blocking agent choice, reversal practice and associated healthcare costs.

Sugammadex is known to rapidly and completely reverse the effects of amino-steroidal neuromuscular blocking agents. However, the high costs of sugammadex have so far prevented its introduction as the standard reversal agent in most healthcare systems. At the Royal Perth Hospital, sugammadex was recently introduced as an unrestricted alternative to neostigmine for the reversal of amino-steroidal neuromuscular blocking agents. The aim of this retrospective observational audit was to investigate the impact of this change on clinical practice and associated healthcare costs. Data from all patients intubated during a one-month period in April to May 2010 and for a similar period in 2011 were retrospectively collected and the use of neuromuscular blocking agents and reversal agents were identified and the associated costs were calculated. More steroidal neuromuscular blocking agents and sugammadex (+743%), but less glycopyrrolate and neostigmine (-48%) were used in 2011. Using the manufacturer's list price, muscle relaxation and reversal costs increased from about A$42 per case to about A$127 per case. Between the investigated time periods no differences were found for anaesthesia time, operating time or time spent in the post anaesthesia care unit. However, there was a statistically significant decrease in the time between surgery and discharge (median 2.0 vs 2.2 days). While the design of the audit was such that no inferences can be made about the cause of this change, this is an interesting observation worthy of further investigation.

Extending epidural analgesia for emergency Caesarean section: a meta-analysis.

There is no high-level evidence supporting an optimal top-up solution to convert labour epidural analgesia to surgical anaesthesia for Caesarean section. The aim of this meta-analysis was to identify the best epidural solutions for emergency Caesarean section anaesthesia, with respect to rapid onset and low supplementation of intraoperative block. Eleven randomized controlled trials, involving 779 parturients, were identified for inclusion after a systematic literature search and risk of bias assessment. 'Top-up' boluses were classified into three groups: 0.5% bupivacaine or levobupivacaine (Bup/Levo); lidocaine and epinephrine, with or without fentanyl (LE ± F); and 0.75% ropivacaine (Ropi). Pooled analysis using the fixed-effects method was used to calculate the mean difference (MD) for continuous outcomes and risk ratio (RR) for dichotomous outcomes. Lidocaine and epinephrine, with or without fentanyl, resulted in a significantly faster onset of sensory block [MD -4.51 min, 95% confidence interval (CI) -5.89 to -3.13 min, P < 0.00001]. Bup/Levo was associated with a significantly increased risk of intraoperative supplementation compared with the other groups (RR 2.03; 95% CI 1.22-3.39; P = 0.007), especially compared with Ropi (RR 3.24, 95% CI 1.26-8.33, P=0.01). Adding fentanyl to a local anaesthetic resulted in a significantly faster onset but did not affect the need for intraoperative supplementation. Bupivacaine or levobupivacaine 0.5% was the least effective solution. If the speed of onset is important, then a lidocaine and epinephrine solution, with or without fentanyl, appears optimal. If the quality of epidural block is paramount, then 0.75% ropivacaine is suggested.

Intraoperative thrombolysis in a patient with cardiopulmonary arrest undergoing caesarean delivery.

Thromboembolic events during pregnancy remain a major cause of morbidity and mortality with possible catastrophic sequelae for the patient. The decision whether to use high-risk therapeutic thrombolytics during pregnancy or perinatally is complicated and many considerations pertain. We report on the thrombolytic management of a 34-year-old woman who had an asystolic cardiac arrest secondary to massive pulmonary embolism while undergoing emergency caesarean delivery. The patient was thrombolysed during successful cardiopulmonary resuscitation. Return of spontaneous circulation was accompanied by massive uterine bleeding. Instead of performing a postpartum hysterectomy, the uterus was preserved through continuous manual pressure and packing for four hours by the obstetric team until haemostasis was achieved. The patient survived and was later discharged without any major neurological deficit.

Chemosensory function of amphibian skin: integrating epithelial transport, capillary blood flow and behaviour.

Terrestrial anuran amphibians absorb water across specialized regions of skin on the posterioventral region of their bodies. Rapid water absorption is mediated by the insertion of aquaporins into the apical membrane of the outermost cell layer. Water moves out of the epithelium via aquaglyceroporins in the basolateral membrane and into the circulation in conjunction with increased capillary blood flow to the skin and aquaporins in the capillary endothelial cells. These physiological responses are activated by intrinsic stimuli relating to the animals' hydration status and extrinsic stimuli relating to the detection of osmotically available water. The integration of these processes has been studied using behavioural observations in conjunction with neurophysiological recordings and studies of epithelial transport. These studies have identified plasma volume and urinary bladder stores as intrinsic stimuli that activate the formation of angiotensin II (AII) to stimulate water absorption behaviour. The coordinated increase in water permeability and capillary blood flow appears to be mediated primarily by sympathetic stimulation of beta adrenergic receptors, although the neurohypopyseal hormone arginine vasotocin (AVT) may also play a role. Extrinsic stimuli relate primarily to the ionic and osmotic properties of hydration sources. Toads avoid NaCl solutions that have been shown to be harmful in acute exposure, approx. 200-250 mm. The avoidance is partially attenuated by amiloride raising the hypothesis that the mechanism for salt detection by toads resembles that for salt taste in mammals that take in water by mouth. In this model, depolarization of the basolateral membrane of taste cells is coupled to afferent neural stimulation. In toad skin we have identified innervation of skin epithelial cells by branches of spinal nerves and measured neural responses to NaCl solutions that elicit behavioural avoidance. These same concentrations produce depolarization of the basolateral membrane in isolated epithelial preparations. As with salt taste in mammals, the neural responses and depolarization of basolateral membrane potential are partially inhibited by amiloride. In addition, toads are more tolerant of sodium gluconate solution which is consistent with the phenomenon in mammalian taste physiology termed the anion paradox in which sodium salts with larger molecular weight anions produce a reduced intensity of salt taste. Finally, toads also avoid concentrated solutions of a non-electrolyte, mannitol, which differs from NaCl solutions in not affecting transepithelial conductance and requires a longer time to depolarize the basolateral membrane. Osmotic stimuli may mediate sensory processes for longer term detection of conditions with low water potential while ionic stimuli are more important for shorter term analysis of rehydration sources.

Quantitative lipid analysis and life span of the fat-3 mutant of Caenorhabditis elegans.

The long-chain polyunsaturated fatty acids (LC PUFAs) docosahexaenoic acid (DHA, 22:6n3) and eicosapentaenoic acid (EPA, 20:5n3) are important for health and development of organisms, but the precise biological function of these molecules is not known. It has been suggested that they may play a part in aging, as they are highly susceptible to oxidation. A genetic mutant of Caenorhabditis elegans (fat-3), which lacks a functional delta-6 desaturase, and thus LC PUFAs including EPA, allows dietary manipulation of long-chain n3 fatty acids in this nematode. The life span of C. elegans strains N2 (wild-type) and BX30 [fat-3(wa22)] with and without supplemental EPA and DHA was analyzed. In addition, quantitative analysis was performed on total lipids, phospholipids, and triglycerides, as it is important to understand where fatty acids are being partitioned among the various lipid classes. The results show a beneficial effect of these molecules on the life span of C. elegans and will aid in the elucidation of the underlying causes of PUFA deficiency in the simple animal C. elegans as well as in humans.

Spatio-temporal analysis of feature-based attention.

The cortical mechanisms of feature-selective attention to color and motion cues were studied in humans using combined electrophysiological, magnetoencephalographic, and hemodynamic (functional magnetic resonance imaging) measures of brain activity. Subjects viewed a display of random dots that periodically either changed color or moved coherently. When attention was directed to the color change it elicited enhanced neural activity in visual area V4v, previously shown to be specialized for processing color information. In contrast, when dot movement was attended it produced enhanced activity in the motion-specialized area human MT. Parallel recordings of event-related electrophysiological and magnetoencephalographic responses indicated that the attention-related facilitation of neural activity in these specialized cortical areas occurred rapidly, beginning as early as 90-120 ms after stimulus onset. We conclude that selection of an entire feature dimension (motion or color) boosts neural activity in its specialized cortical module much more rapidly than does selection of one feature value from another (e.g., one color from another), as reported in previous electrophysiological studies. By combining methods with high spatial and temporal resolution it is possible to analyze the precise time course of feature-selective processing in specialized cortical areas.

Feature-selective attention enhances color signals in early visual areas of the human brain.

We used an electrophysiological measure of selective stimulus processing (the steady-state visual evoked potential, SSVEP) to investigate feature-specific attention to color cues. Subjects viewed a display consisting of spatially intermingled red and blue dots that continually shifted their positions at random. The red and blue dots flickered at different frequencies and thereby elicited distinguishable SSVEP signals in the visual cortex. Paying attention selectively to either the red or blue dot population produced an enhanced amplitude of its frequency-tagged SSVEP, which was localized by source modeling to early levels of the visual cortex. A control experiment showed that this selection was based on color rather than flicker frequency cues. This signal amplification of attended color items provides an empirical basis for the rapid identification of feature conjunctions during visual search, as proposed by "guided search" models.

Objects are highlighted by spatial attention.

Selective attention may be focused upon a region of interest within the visual surroundings, thereby improving the perceptual quality of stimuli at that location. It has been debated whether this spatially selective mechanism plays a role in the attentive selection of whole objects in a visual scene. The relationship between spatial and object-selective attention was investigated here through recordings of event-related brain potentials (ERPs) supplemented with functional magnetic brain imaging (fMRI). Subjects viewed a display consisting of two bar-shaped objects and directed attention to sequences of stimuli (brief corner offsets) at one end of one of the bars. Unattended stimuli belonging to the same object as the attended stimuli elicited spatiotemporal patterns of neural activity in the visual cortex closely resembling those elicited by the attended stimuli themselves, albeit smaller in amplitude. This enhanced neural activity associated with object-selective attention was localized by use of ERP dipole modeling and fMRI to the lateral occipital extrastriate cortex. We conclude that object-selective attention shares a common neural mechanism with spatial attention that entails the facilitation of sensory processing of stimuli within the boundaries of an attended object.

Effects of spatial congruity on audio-visual multimodal integration.

Spatial constraints on multisensory integration of auditory (A) and visual (V) stimuli were investigated in humans using behavioral and electrophysiological measures. The aim was to find out whether cross-modal interactions between A and V stimuli depend on their spatial congruity, as has been found for multisensory neurons in animal studies (Stein & Meredith, 1993). Randomized sequences of unimodal (A or V) and simultaneous bimodal (AV) stimuli were presented to right- or left-field locations while subjects made speeded responses to infrequent targets of greater intensity that occurred in either or both modalities. Behavioral responses to the bimodal stimuli were faster and more accurate than to the unimodal stimuli for both same-location and different-location AV pairings. The neural basis of this cross-modal facilitation was studied by comparing event-related potentials (ERPs) to the bimodal AV stimuli with the summed ERPs to the unimodal A and V stimuli. These comparisons revealed neural interactions localized to the ventral occipito-temporal cortex (at 190 msec) and to the superior temporal cortical areas (at 260 msec) for both same- and different-location AV pairings. In contrast, ERP interactions that differed according to spatial congruity included a phase and amplitude modulation of visual-evoked activity localized to the ventral occipito-temporal cortex at 100-400 msec and an amplitude modulation of activity localized to the superior temporal region at 260-280 msec. These results demonstrate overlapping but distinctive patterns of multisensory integration for spatially congruent and incongruent AV stimuli.

Exogenous attentional selection of transparent superimposed surfaces modulates early event-related potentials.

Using a transparent motion paradigm, [Valdes-Sosa, M., Bobes, M. A., Rodriguez, V., & Pinilla, T. (1998). Switching attention without shifting the spotlight object-based attentional modulation of brain potentials, Journal of Cognitive Neuroscience, 10, 137-151; Valdes-Sosa, M., Cobo, A., & Pinilla, T. (2000). Attention to object files defined by transparent motion, Journal of Experimental Psychological: Human Perception and Performance, 26, 488-505] found that when attention is endogenously directed to one surface, observers can more reliably report the direction of a brief translation of the cued than the uncued surface. Using a similar design [Reynolds, J. H., Alborzian, S., & Stoner, G. R. (2003). Exogenously cued attention triggers competitive selection of surfaces, Vision Research, 43, 59-66] found that even in the absence of an endogenous cue, the first translation acted as a potent exogenous cue that impaired the observer's ability to discriminate a subsequent translation of the other surface. We investigated the neural basis of this exogenous cueing effect by recording visual event-related potentials (ERPs) elicited by translations of the cued and uncued surfaces. Subjects were given the task of judging whether or not the first and second translations were identical in direction, and their performance was impaired when the second translation occurred on the uncued, as compared to the cued surface. The posterior C1 (75-110 ms) and N1 (160-210 ms) components of the ERP elicited by the second translation of the cued surface were larger than those elicited by translation of the uncued surface. These behavioral and ERP cueing effects were present even when the two surfaces were identical in color and thus could not be attributed to attention-related modulations of the gain of color channels. These findings provide evidence that exogenous cueing results in preferential selection of the cued surface at both early and intermediate stages of visual-cortical processing.

Cutaneous blood flow and water absorption by dehydrated toads.

Blood cell flux (BCF) in ventral pelvic skin capillaries was measured in toads, Bufo woodhouseii and Bufo punctatus, using a chamber that allowed hydration behavior and water absorption to be observed concurrently in unrestrained animals. Dehydrated B. woodhouseii and B. punctatus placed on a rehydration solution significantly increased BCF relative to that on a dry surface in less than 2 min. Skin contact with a rehydration solution rather than dehydration alone is the primary stimulus for increased seat patch blood flow. In B. woodhouseii, the water absorption response was initiated after the increase in BCF had started but before maximum BCF was reached. BCF and water uptake across the ventral skin of both species placed on deionized water were not different from those of toads placed on 50 mM NaCl. Similarly, no significant correlation between BCF and rate of water uptake could be observed in dehydrated toads of either species. Angiotensin II (AII) injection in hydrated B. punctatus had no effect on BCF, suggesting that factors other than AII are responsible for the increase in blood flow upon water contact in dehydrated toads.

Dynamics of feature binding during object-selective attention.

Objects in the environment may be attended selectively and perceived as unified ensembles of their constituent features. To investigate the timing and cortical localization of feature-integration mechanisms in object-based attention, recordings of event-related potentials and magnetic fields were combined with functional MRI while subjects attended to one of two superimposed transparent surfaces formed by arrays of dots moving in opposite directions. A spatiotemporal analysis revealed evidence for a rapid increase in neural activity localized to a color-selective region of the fusiform gyrus when the surface moving in the attended direction displayed an irrelevant color feature. These data provide support for the "integrated-competition" model of object-selective attention and point to a dynamic neural substrate for the rapid binding process that links relevant and irrelevant features to form a unified perceptual object.

Sustained division of the attentional spotlight.

By voluntarily directing attention to a specific region of a visual scene, we can improve our perception of stimuli at that location. This ability to focus attention upon specific zones of the visual field has been described metaphorically as a moveable spotlight or zoom lens that facilitates the processing of stimuli within its 'beam'. A long-standing controversy has centred on the question of whether the spotlight of spatial attention has a unitary beam or whether it can be divided flexibly to disparate locations. Evidence supporting the unitary spotlight view has come from numerous behavioural and electrophysiological studies. Recent experiments, however, indicate that the spotlight of spatial attention may be divided between non-contiguous zones of the visual field for very brief stimulus exposures (&<100 ms). Here we use an electrophysiological measure of attentional allocation (the steady-state visual evoked potential) to show that the spotlight may be divided between spatially separated locations (excluding interposed locations) over more extended time periods. This spotlight division appears to be accomplished at an early stage of visual-cortical processing.

An analysis of audio-visual crossmodal integration by means of event-related potential (ERP) recordings.

Crossmodal integration was studied in humans by presenting random sequences of auditory (brief noise bursts), visual (flashes), and audiovisual (simultaneous noise bursts and flashes) stimuli from a central location at irregular intervals between 600 and 800 ms. The subjects' task was to press a button to infrequent and unpredictable (P=0.15) target stimuli that could be either a more intense noise burst, a brighter flash, or a combination of the two. In accordance with previous studies, behavioral data showed that bimodal target stimuli were responded to much faster and were identified more accurately than the unimodal target stimuli. The neural basis of this crossmodal interaction was investigated by subtracting the ERPs to the auditory (A) and the visual (V) stimuli alone from the ERP to the combined audiovisual (AV) stimuli (i.e. interaction=AV-(A+V)). Using this approach, we replicated previous reports of both early (at around 40 ms) and late (after 100 ms) ERP interaction effects. However, it appears that the very early interaction effects can be largely accounted for by an anticipatory ERP that precedes both the unimodal and bimodal stimuli. In calculating the ERP interaction this slow shift is subtracted twice, resulting in an apparent shift of the opposite polarity that may be confounded with actual crossmodal interactions.