Noninvasive Assessment of Arterial Pulse-Pressure Variation During General Anesthesia: Clinical Evaluation of a New High-Fidelity Upper Arm Cuff.

OBJECTIVES: To compare noninvasive pulse-pressure variation (PPV) measurements obtained from a new high-fidelity upper arm cuff using a hydraulic coupling technique to corresponding intraarterial PPV measurements. DESIGN: The authors used prospective multicenter comparison and development studies for the new high-fidelity upper arm cuff. SETTING: The study was performed in the departments of Anesthesiology at the Ludwig-Maximilians-Universität München Hospital, the University Hospital of Bonn, and the RoMed Hospital in Rosenheim (all Germany). PARTICIPANTS: A total of 153 patients were enrolled, undergoing major abdominal surgery or neurosurgery with mechanical ventilation. For the evaluation of PPV, 1,467 paired measurements in 107 patients were available after exclusion due to predefined quality criteria. INTERVENTIONS: Simultaneous measurements of PPV were performed from a reference femoral arterial catheter (PPVref) and the high-fidelity upper arm cuff (PPVcuff). The new device uses a semirigid conical shell. It incorporates a hydraulic sensor pad with a pressure transducer, leading to a tissue pressure-pulse contour with all characteristics of an arterial- pulse contour. MEASUREMENTS AND MAIN RESULTS: The comparative analysis of the included measurements showed that PPVref and PPVcuff were closely correlated (r = 0.92). The mean of the differences between PPVref and PPVcuff was 0.1 ± 2.0%, with 95% limits of agreement between -4.1% and 3.9%. To track absolute changes in PPV >2%, the concordance rate between the 2 methods was 93%. CONCLUSIONS: The new high-fidelity upper arm cuff method provided a clinically reliable estimate of PPV.

Clinical Evaluation of a High-fidelity Upper Arm Cuff to Measure Arterial Blood Pressure during Noncardiac Surgery.

BACKGROUND: In most patients having noncardiac surgery, blood pressure is measured with the oscillometric upper arm cuff method. Although the method is noninvasive and practical, it is known to overestimate intraarterial pressure in hypotension and to underestimate it in hypertension. A high-fidelity upper arm cuff incorporating a hydraulic sensor pad was recently developed. The aim of the present study was to investigate whether noninvasive blood pressure measurements with the new high-fidelity cuff correspond to invasive measurements with a femoral artery catheter, especially at low blood pressure. METHODS: Simultaneous measurements of blood pressure recorded from a femoral arterial catheter and from the high-fidelity upper arm cuff were compared in 110 patients having major abdominal surgery or neurosurgery. RESULTS: 550 pairs of blood pressure measurements (5 pairs per patient) were considered for analysis. For mean arterial pressure measurements, the average bias was 0 mmHg, and the precision was 3 mmHg. The Pearson correlation coefficient was 0.96 (P < 0.0001; 95% CI, 0.96 to 0.97), and the percentage error was 9%. Error grid analysis showed that the proportions of mean arterial pressure measurements done with the high-fidelity cuff method were 98.4% in zone A (no risk), 1.6% in zone B (low risk) and 0% in zones C, D, and E (moderate, significant, and dangerous risk, respectively). The high-fidelity cuff method detected mean arterial pressure values less than 65 mmHg with a sensitivity of 84% (95% CI, 74 to 92%) and a specificity of 97% (95% CI, 95% to 98%). To detect changes in mean arterial pressure of more than 5 mmHg, the concordance rate between the two methods was 99.7%. Comparable accuracy and precision were observed for systolic and diastolic blood pressure measurements. CONCLUSIONS: The new high-fidelity upper arm cuff method met the current international standards in terms of accuracy and precision. It was also very accurate to track changes in blood pressure and reliably detect severe hypotension during noncardiac surgery.

Atypical processing of uncertainty in individuals at risk for psychosis.

Current theories of psychosis highlight the role of abnormal learning signals, i.e., prediction errors (PEs) and uncertainty, in the formation of delusional beliefs. We employed computational analyses of behaviour and functional magnetic resonance imaging (fMRI) to examine whether such abnormalities are evident in clinical high risk (CHR) individuals. Non-medicated CHR individuals (n = 13) and control participants (n = 13) performed a probabilistic learning paradigm during fMRI data acquisition. We used a hierarchical Bayesian model to infer subject-specific computations from behaviour - with a focus on PEs and uncertainty (or its inverse, precision) at different levels, including environmental 'volatility' - and used these computational quantities for analyses of fMRI data. Computational modelling of CHR individuals' behaviour indicated volatility estimates converged to significantly higher levels than in controls. Model-based fMRI demonstrated increased activity in prefrontal and insular regions of CHR individuals in response to precision-weighted low-level outcome PEs, while activations of prefrontal, orbitofrontal and anterior insula cortex by higher-level PEs (that serve to update volatility estimates) were reduced. Additionally, prefrontal cortical activity in response to outcome PEs in CHR was negatively associated with clinical measures of global functioning. Our results suggest a multi-faceted learning abnormality in CHR individuals under conditions of environmental uncertainty, comprising higher levels of volatility estimates combined with reduced cortical activation, and abnormally high activations in prefrontal and insular areas by precision-weighted outcome PEs. This atypical representation of high- and low-level learning signals might reflect a predisposition to delusion formation.

Why we interact: on the functional role of the striatum in the subjective experience of social interaction.

There is ample evidence that human primates strive for social contact and experience interactions with conspecifics as intrinsically rewarding. Focusing on gaze behavior as a crucial means of human interaction, this study employed a unique combination of neuroimaging, eye-tracking, and computer-animated virtual agents to assess the neural mechanisms underlying this component of behavior. In the interaction task, participants believed that during each interaction the agent's gaze behavior could either be controlled by another participant or by a computer program. Their task was to indicate whether they experienced a given interaction as an interaction with another human participant or the computer program based on the agent's reaction. Unbeknownst to them, the agent was always controlled by a computer to enable a systematic manipulation of gaze reactions by varying the degree to which the agent engaged in joint attention. This allowed creating a tool to distinguish neural activity underlying the subjective experience of being engaged in social and non-social interaction. In contrast to previous research, this allows measuring neural activity while participants experience active engagement in real-time social interactions. Results demonstrate that gaze-based interactions with a perceived human partner are associated with activity in the ventral striatum, a core component of reward-related neurocircuitry. In contrast, interactions with a computer-driven agent activate attention networks. Comparisons of neural activity during interaction with behaviorally naïve and explicitly cooperative partners demonstrate different temporal dynamics of the reward system and indicate that the mere experience of engagement in social interaction is sufficient to recruit this system.

From gaze cueing to dual eye-tracking: novel approaches to investigate the neural correlates of gaze in social interaction.

Tracking eye-movements provides easy access to cognitive processes involved in visual and sensorimotor processing. More recently, the underlying neural mechanisms have been examined by combining eye-tracking and functional neuroimaging methods. Apart from extracting visual information, gaze also serves important functions in social interactions. As a deictic cue, gaze can be used to direct the attention of another person to an object. Conversely, by following other persons' gaze we gain access to their attentional focus, which is essential for understanding their mental states. Social gaze has therefore been studied extensively to understand the social brain. In this endeavor, gaze has mostly been investigated from an observational perspective using static displays of faces and eyes. However, there is growing consent that observational paradigms are insufficient for an understanding of the neural mechanisms of social gaze behavior, which typically involve active engagement in social interactions. Recent methodological advances have allowed increasing ecological validity by studying gaze in face-to-face encounters in real-time. Such improvements include interactions using virtual agents in gaze-contingent eye-tracking paradigms, live interactions via video feeds, and dual eye-tracking in two-person setups. These novel approaches can be used to analyze brain activity related to social gaze behavior. This review introduces these methodologies and discusses recent findings on the behavioral functions and neural mechanisms of gaze processing in social interaction.

Influence of ethnic group-membership and gaze direction on the perception of emotions. A cross-cultural study between Germany and China.

Emotional facial expressions provide important nonverbal cues in human interactions. The perception of emotions is not only influenced by a person's ethnic background but also depends on whether a person is engaged with the emotion-encoder. Although these factors are known to affect emotion perception, their impact has only been studied in isolation before. The aim of the present study was to investigate their combined influence. Thus, in order to study the influence of engagement on emotion perception between persons from different ethnicities, we compared participants from China and Germany. Asian-looking and European-looking virtual agents expressed anger and happiness while gazing at the participant or at another person. Participants had to assess the perceived valence of the emotional expressions. Results indicate that indeed two factors that are known to have a considerable influence on emotion perception interacted in their combined influence: We found that the perceived intensity of an emotion expressed by ethnic in-group members was in most cases independent of gaze direction, whereas gaze direction had an influence on the emotion perception of ethnic out-group members. Additionally, participants from the ethnic out-group tended to perceive emotions as more pronounced than participants from the ethnic in-group when they were directly gazed at. These findings suggest that gaze direction has a differential influence on ethnic in-group and ethnic out-group dynamics during emotion perception.

Eyes on the mind: investigating the influence of gaze dynamics on the perception of others in real-time social interaction.

Social gaze provides a window into the interests and intentions of others and allows us to actively point out our own. It enables us to engage in triadic interactions involving human actors and physical objects and to build an indispensable basis for coordinated action and collaborative efforts. The object-related aspect of gaze in combination with the fact that any motor act of looking encompasses both input and output of the minds involved makes this non-verbal cue system particularly interesting for research in embodied social cognition. Social gaze comprises several core components, such as gaze-following or gaze aversion. Gaze-following can result in situations of either "joint attention" or "shared attention." The former describes situations in which the gaze-follower is aware of sharing a joint visual focus with the gazer. The latter refers to a situation in which gazer and gaze-follower focus on the same object and both are aware of their reciprocal awareness of this joint focus. Here, a novel interactive eye-tracking paradigm suited for studying triadic interactions was used to explore two aspects of social gaze. Experiments 1a and 1b assessed how the latency of another person's gaze reactions (i.e., gaze-following or gaze version) affected participants' sense of agency, which was measured by their experience of relatedness of these reactions. Results demonstrate that both timing and congruency of a gaze reaction as well as the other's action options influence the sense of agency. Experiment 2 explored differences in gaze dynamics when participants were asked to establish either joint or shared attention. Findings indicate that establishing shared attention takes longer and requires a larger number of gaze shifts as compared to joint attention, which more closely seems to resemble simple visual detection. Taken together, novel insights into the sense of agency and the awareness of others in gaze-based interaction are provided.

A non-verbal Turing test: differentiating mind from machine in gaze-based social interaction.

In social interaction, gaze behavior provides important signals that have a significant impact on our perception of others. Previous investigations, however, have relied on paradigms in which participants are passive observers of other persons' gazes and do not adjust their gaze behavior as is the case in real-life social encounters. We used an interactive eye-tracking paradigm that allows participants to interact with an anthropomorphic virtual character whose gaze behavior is responsive to where the participant looks on the stimulus screen in real time. The character's gaze reactions were systematically varied along a continuum from a maximal probability of gaze aversion to a maximal probability of gaze-following during brief interactions, thereby varying contingency and congruency of the reactions. We investigated how these variations influenced whether participants believed that the character was controlled by another person (i.e., a confederate) or a computer program. In a series of experiments, the human confederate was either introduced as naïve to the task, cooperative, or competitive. Results demonstrate that the ascription of humanness increases with higher congruency of gaze reactions when participants are interacting with a naïve partner. In contrast, humanness ascription is driven by the degree of contingency irrespective of congruency when the confederate was introduced as cooperative. Conversely, during interaction with a competitive confederate, judgments were neither based on congruency nor on contingency. These results offer important insights into what renders the experience of an interaction truly social: Humans appear to have a default expectation of reciprocation that can be influenced drastically by the presumed disposition of the interactor to either cooperate or compete.

Prefrontal dopamine D4 receptors are involved in encoding fear extinction.

The medial prefrontal cortex is known to be crucially involved in the memory for fear extinction. It has been shown that the dopamine D4 receptor is abundantly localized in the medial prefrontal cortex of rodents and that this receptor subtype is involved in the mediation of fear-related behaviour. In the present study, we tested whether dopamine D4 receptors within the medial prefrontal cortex are involved in the learning and encoding of fear extinction. Infusions of the specific dopamine D4 receptor antagonist L-741,741 into the medial prefrontal cortex immediately before fear extinction did not affect fear extinction learning but attenuated the memory on fear extinction on the following day. These results suggest that medial prefrontal cortex dopamine D4 receptors are involved in the consolidation of fear extinction memory.

Reproducibility of transpulmonary thermodilution measurements in patients with burn shock and hypothermia.

Thermal noise, including hypothermia and short-term variations in body temperature, has been reported to influence the accuracy and reproducibility of thermodilution measurements. This variation might theoretically limit the usefulness of this technique in patients with acute burns. We therefore sought to determine the reproducibility of hemodynamic parameters derived from arterial thermal dilution in patients with acute burns and hypothermia. This was a prospective, clinical study of 50 mechanically ventilated patients with burns involving more than 25% of the body surface area that were treated at an eight-bed intensive care burn unit in a university-affiliated hospital. A total of 750 arterial thermodilution measurements were analyzed using the COLD system. Triplicate measurements of the intrathoracic blood volume, cardiac output, total blood volume, and extravascular lung water were performed at regular intervals during the first 48 hours after the thermal injury. Reproducibility was assessed by the coefficient of variation of the triplicate measurements. The correlation of variation was less than 10% at all measurement times for cardiac output, intrathoracic blood volume, and total blood volume. For the extravascular lung water, the coefficient of variation ranged from 9.5% to 12.9%. A maximum of 12.9% was found at 48 hours after burn. No correlation was found between body core temperature and the reproducibility of intrathoracic blood volume index (r = 0.145), cardiac index (r = 0.217), or extravascular lung water index (r = 0.167). The parameters derived from arterial thermodilution show a clinically sufficient reproducibility in patients with acute burns associated with thermal instability.

Clinical review: complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine.

In order to evaluate the complications and risk factors associated with peripheral arterial catheters used for haemodynamic monitoring, we reviewed the literature published from 1978 to 2001. We closely examined the three most commonly used arterial cannulation sites. The reviewed papers included a total of 19,617 radial, 3899 femoral and 1989 axillary artery catheterizations. Factors that contribute to higher complication rates were investigated. Major complications occurred in fewer than 1% of the cases, and rates were similar for the radial, femoral and axillary arteries. We conclude that arterial cannulation is a safe procedure.