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Sher Y, Desai N, Sole J, D'souza MP. Dyspnea and Dyspnea-Associated Anxiety in the ICU Patient Population: A Narrative Review for CL Psychiatrists. J Acad Consult Liaison Psychiatry 2024; 65:54-65. [PMID: 37952697 DOI: 10.1016/j.jaclp.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 10/31/2023] [Accepted: 11/06/2023] [Indexed: 11/14/2023]
Abstract
BACKGROUND Consultation-liaison psychiatrists frequently address dyspnea in intensive care unit (ICU) patients. Dyspnea is common in this patient population, but is frequently misunderstood and underappreciated in noncommunicative ICU patients. OBJECTIVE This paper provides an updated review on dyspnea specifically in the ICU population, including its pathophysiology and management, pharmacological and nonpharmacological, aimed at consultation-liaison psychiatrists consulting in ICU. METHODS A literature review was conducted with PubMed, querying published articles for topics associated with dyspnea and dyspnea-associated anxiety in ICU patient populations. When literature in ICU populations was limited, information was deduced from dyspnea and anxiety management from non-ICU populations. Articles discussing the definition of dyspnea, mechanistic pathways, screening tools, and pharmacologic and nonpharmacologic management were included. RESULTS A reference guide was created to help consultation-liaison psychiatrists and intensivists in the screening and treatment of dyspnea and dyspnea-associated anxiety in critically ill patients. CONCLUSIONS Dyspnea is frequently associated with anxiety, prolonged days on mechanical ventilation, and worse quality of life after discharge. It can also increase the risk of posttraumatic stress disorder post-ICU discharge. However, it is not routinely screened for, identified, or addressed in the ICU. This manuscript provides an updated review on dyspnea and dyspnea-associated anxietyin the ICU population, including its pathophysiology and management, and offers a useful reference for consultation-liaison psychiatrists to provide treatment recommendations.
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Affiliation(s)
- Yelizaveta Sher
- Division of Medical Psychiatry, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine.
| | - Nikita Desai
- Division of Critical Care Medicine, Department of Medicine, Stanford University School of Medicine
| | - Jon Sole
- Division of Medical Psychiatry, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine
| | - Melissa Patricia D'souza
- Division of Critical Care Medicine, Department of Medicine, Stanford University School of Medicine
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Rajan S, Alchoubassi J, Bharadwaj MS, Kofke WA. Evolving horizon of global neuroanesthesia education, pathway to standardization, and accreditation. Int Anesthesiol Clin 2023; 61:1-7. [PMID: 37232674 DOI: 10.1097/aia.0000000000000406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Shobana Rajan
- Department of Anesthesiology, Critical Care and Pain Medicine, UT McGovern Medical School, Houston, TX
| | | | | | - W Andrew Kofke
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
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Iggena D, Maier PM, Häußler SM, Menk M, Olze H, Larkum ME, Finke C, Ploner CJ. Post-encoding modulation of spatial memory consolidation by propofol. Cortex 2022; 156:1-12. [DOI: 10.1016/j.cortex.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 05/09/2022] [Accepted: 08/10/2022] [Indexed: 11/03/2022]
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Vogt KM, Pryor KO. Anesthesia and the neurobiology of fear and posttraumatic stress disorder. Curr Opin Anaesthesiol 2022; 35:593-599. [PMID: 35993581 PMCID: PMC9469898 DOI: 10.1097/aco.0000000000001176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW Dysfunction of fear memory systems underlie a cluster of clinically important and highly prevalent psychological morbidities seen in perioperative and critical care patients, most archetypally posttraumatic stress disorder (PTSD). Several sedative-hypnotics and analgesics are known to modulate fear systems, and it is theoretically plausible that clinical decisions of the anesthesiologist could impact psychological outcomes. This review aims to provide a focused synthesis of relevant literature from multiple fields of research. RECENT FINDINGS There is evidence in some contexts that unconscious fear memory systems are less sensitive to anesthetics than are conscious memory systems. Opiates may suppress the activation of fear systems and have benefit in the prevention of PTSD following trauma. There is inconsistent evidence that the use of propofol and benzodiazepines for sedation following trauma may potentiate the development of PTSD relative to other drugs. The benefits of ketamine seen in the treatment of major depression are not clearly replicated in PTSD-cluster psychopathologies, and its effects on fear processes are complex. SUMMARY There are multiple theoretical mechanisms by which anesthetic drugs can modulate fear systems and clinically important fear-based psychopathologies. The current state of research provides some evidence to support further hypothesis investigation. However, the absence of effectiveness studies and the inconsistent signals from smaller studies provide insufficient evidence to currently offer firm clinical guidance.
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Affiliation(s)
- Keith M. Vogt
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, School of Medicine
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh
- Center for the Neural Basis of Cognition
- Clinical and Translational Science Institute, University of Pittsburgh
| | - Kane O. Pryor
- Department of Anesthesiology, Weill Cornell Medicine
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Zhong J, Li Y, Fang L, Han D, Gong C, Hu S, Wang R, Wang L, Yao R, Li B, Zhu Y, Yu Y. Effects of Sevoflurane and Propofol on Posttraumatic Stress Disorder After Emergency Trauma: A Double-Blind Randomized Controlled Trial. Front Psychiatry 2022; 13:853795. [PMID: 35280171 PMCID: PMC8914077 DOI: 10.3389/fpsyt.2022.853795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/28/2022] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE Posttraumatic stress disorder (PTSD) is a frequent and disabling consequence of traumatic events. A previous study found that early use of propofol was a potential risk factor for PTSD. This prospective study aimed to investigate the effect of propofol and sevoflurane on PTSD after emergency surgery in trauma patients. METHODS A total of 300 trauma patients undergoing emergency surgery were randomly divided into two groups and anesthetized with propofol and/or sevoflurane. Perioperative clinical data were collected. The incidence of PTSD was evaluated with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) in the two groups 1 month after the operation. The relevance of the injury time and CAPS-5 scores was assessed by Spearman correlation analysis. Logistic regression analysis was used to analyze the risk factors for PTSD. RESULTS The incidence of PTSD in the propofol group was higher than that in the sevoflurane group 1 month postoperatively (23.2 vs. 12.2%, P = 0.014). The injury time was negatively correlated with the CAPS-5 score in the propofol group (r = -0.226, P < 0.001). In the logistic regression analysis, the utilization of propofol was an independent risk factor for PTSD (P = 0.017). CONCLUSION Early use of propofol general anesthesia in emergency surgery for trauma patients may increase the risk of PTSD. CLINICAL TRIAL REGISTRATION www.chictr.org.cn, identifier: ChiCTR2100050202.
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Affiliation(s)
- Junfeng Zhong
- Department of Pain, Shaoxing People's Hospital, Shaoxing, China
| | - Yan Li
- Department of Anesthesiology, Suzhou Xiangcheng People's Hospital, Suzhou, China
| | - Lichao Fang
- Emergency and Critical Department, Suzhou Xiangcheng People's Hospital, Suzhou, China
| | - Dan Han
- Department of Anesthesiology, Xuzhou Renci Hospital, Xuzhou, China
| | - Chuhao Gong
- Department of Anesthesiology, Xuzhou Renci Hospital, Xuzhou, China
| | - Shuangyan Hu
- Department of Anesthesiology, Shaoxing People's Hospital, Shaoxing, China
| | - Rongguo Wang
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China
| | - Liwei Wang
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China
| | - Rui Yao
- Department of Anesthesiology, The First People's Hospital of Xuzhou, Xuzhou, China
| | - Beiping Li
- Department of Anesthesiology, The First People's Hospital of Xuzhou, Xuzhou, China
| | - Yangzi Zhu
- Department of Anesthesiology, Xuzhou Central Hospital, Xuzhou, China
| | - Youjia Yu
- Department of Anesthesiology, Suzhou Xiangcheng People's Hospital, Suzhou, China
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Pradier B, Wachsmuth L, Nagelmann N, Segelcke D, Kreitz S, Hess A, Pogatzki-Zahn EM, Faber C. Combined resting state-fMRI and calcium recordings show stable brain states for task-induced fMRI in mice under combined ISO/MED anesthesia. Neuroimage 2021; 245:118626. [PMID: 34637903 DOI: 10.1016/j.neuroimage.2021.118626] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 09/27/2021] [Indexed: 11/28/2022] Open
Abstract
For fMRI in animal models, the combination of low-dose anesthetic, isoflurane (ISO), and the sedative medetomidine (MED) has recently become an advocated regimen to achieve stable neuronal states and brain networks in rats that are required for reliable task-induced BOLD fMRI. However, in mice the temporal stability of neuronal states and networks in resting-state (rs)-fMRI experiments during the combined ISO/MED regimen has not been systematically investigated. Using a multimodal approach with optical calcium (Ca2+) recordings and rs-fMRI, we investigated cortical neuronal/astrocytic Ca2+activity states and brain networks at multiple time points while switching from anesthesia with 1% ISO to a combined ISO/MED regimen. We found that cortical activity states reached a steady-state 45 min following start of MED infusion as indicated by stable Ca2+ transients. Similarly, rs-networks were not statistically different between anesthesia with ISO and the combined ISO/MED regimen 45 and 100 min after start of MED. Importantly, during the transition time we identified changed rs-network signatures that likely reflect the different mode of action of the respective anesthetic; these included a dose-dependent increase in cortico-cortical functional connectivity (FC) presumably caused by reduction of ISO concentration and decreased FC in subcortical arousal nuclei due to MED infusion. Furthermore, we report detection of visual stimulation-induced BOLD fMRI during the stable ISO/MED neuronal state 45 min after induction. Based on our findings, we recommend a 45-minute waiting period after switching from ISO anesthesia to the combined ISO/MED regimen before performing rs- or task-induced fMRI experiments.
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Affiliation(s)
- Bruno Pradier
- Department of Clinical Radiology, Translational Research Imaging Center, University Hospital Münster, Münster 48149, Germany; Department of Anesthesiology Intensive Care and Pain Medicine, University Hospital Münster, Germany
| | - Lydia Wachsmuth
- Department of Clinical Radiology, Translational Research Imaging Center, University Hospital Münster, Münster 48149, Germany
| | - Nina Nagelmann
- Department of Clinical Radiology, Translational Research Imaging Center, University Hospital Münster, Münster 48149, Germany
| | - Daniel Segelcke
- Department of Anesthesiology Intensive Care and Pain Medicine, University Hospital Münster, Germany
| | - Silke Kreitz
- Institute of Experimental and Clinical Pharmacology and Toxicology, Emil Fischer Center, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Andreas Hess
- Institute of Experimental and Clinical Pharmacology and Toxicology, Emil Fischer Center, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Esther M Pogatzki-Zahn
- Department of Anesthesiology Intensive Care and Pain Medicine, University Hospital Münster, Germany
| | - Cornelius Faber
- Department of Clinical Radiology, Translational Research Imaging Center, University Hospital Münster, Münster 48149, Germany.
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Linassi F, Obert DP, Maran E, Tellaroli P, Kreuzer M, Sanders RD, Carron M. Implicit Memory and Anesthesia: A Systematic Review and Meta-Analysis. Life (Basel) 2021; 11:850. [PMID: 34440594 PMCID: PMC8400596 DOI: 10.3390/life11080850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/14/2021] [Accepted: 08/15/2021] [Indexed: 12/01/2022] Open
Abstract
General anesthesia should induce unconsciousness and provide amnesia. Amnesia refers to the absence of explicit and implicit memories. Unlike explicit memory, implicit memory is not consciously recalled, and it can affect behavior/performance at a later time. The impact of general anesthesia in preventing implicit memory formation is not well-established. We performed a systematic review with meta-analysis of studies reporting implicit memory occurrence in adult patients after deep sedation (Observer's Assessment of Alertness/Sedation of 0-1 with spontaneous breathing) or general anesthesia. We also evaluated the impact of different anesthetic/analgesic regimens and the time point of auditory task delivery on implicit memory formation. The meta-analysis included the estimation of odds ratios (ORs) and 95% confidence intervals (CIs). We included a total of 61 studies with 3906 patients and 119 different cohorts. For 43 cohorts (36.1%), implicit memory events were reported. The American Society of Anesthesiologists (ASA) physical status III-IV was associated with a higher likelihood of implicit memory formation (OR:3.48; 95%CI:1.18-10.25, p < 0.05) than ASA physical status I-II. Further, there was a lower likelihood of implicit memory formation for deep sedation cases, compared to general anesthesia (OR:0.10; 95%CI:0.01-0.76, p < 0.05) and for patients receiving premedication with benzodiazepines compared to not premedicated patients before general anesthesia (OR:0.35; 95%CI:0.13-0.93, p = 0.05).
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Affiliation(s)
- Federico Linassi
- Department of Anaesthesia and Intensive Care, Ca’ Foncello Treviso Regional Hospital, Piazzale Ospedale 1, 31100 Treviso, Italy;
| | - David Peter Obert
- Department of Anaesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Muenchen, Germany; (D.P.O.); (M.K.)
| | - Eleonora Maran
- Department of Anaesthesia and Intensive Care, Ca’ Foncello Treviso Regional Hospital, Piazzale Ospedale 1, 31100 Treviso, Italy;
| | - Paola Tellaroli
- Department of Developmental Psychology and Socialisation, University of Padova, Via Venezia 8, 35121 Padova, Italy;
| | - Matthias Kreuzer
- Department of Anaesthesiology and Intensive Care, School of Medicine, Technical University of Munich, Ismaninger Str. 22, 81675 Muenchen, Germany; (D.P.O.); (M.K.)
| | - Robert David Sanders
- Department of Anaesthetics, Royal Prince Alfred Hospital, Camperdown, NSW 2050, Australia;
| | - Michele Carron
- Department of Medicine, Anaesthesiology and Intensive Care, University of Padova, Via C. Battisti 267, 35121 Padova, Italy;
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Midazolam and Ketamine Produce Distinct Neural Changes in Memory, Pain, and Fear Networks during Pain. Anesthesiology 2021; 135:69-82. [PMID: 33872345 DOI: 10.1097/aln.0000000000003774] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Despite the well-known clinical effects of midazolam and ketamine, including sedation and memory impairment, the neural mechanisms of these distinct drugs in humans are incompletely understood. The authors hypothesized that both drugs would decrease recollection memory, task-related brain activity, and long-range connectivity between components of the brain systems for memory encoding, pain processing, and fear learning. METHODS In this randomized within-subject crossover study of 26 healthy adults, the authors used behavioral measures and functional magnetic resonance imaging to study these two anesthetics, at sedative doses, in an experimental memory paradigm using periodic pain. The primary outcome, recollection memory performance, was quantified with d' (a difference of z scores between successful recognition versus false identifications). Secondary outcomes were familiarity memory performance, serial task response times, task-related brain responses, and underlying brain connectivity from 17 preselected anatomical seed regions. All measures were determined under saline and steady-state concentrations of the drugs. RESULTS Recollection memory was reduced under midazolam (median [95% CI], d' = 0.73 [0.43 to 1.02]) compared with saline (d' = 1.78 [1.61 to 1.96]) and ketamine (d' = 1.55 [1.12 to 1.97]; P < 0.0001). Task-related brain activity was detected under saline in areas involved in memory, pain, and fear, particularly the hippocampus, insula, and amygdala. Compared with saline, midazolam increased functional connectivity to 20 brain areas and decreased to 8, from seed regions in the precuneus, posterior cingulate, and left insula. Compared with saline, ketamine decreased connectivity to 17 brain areas and increased to 2, from 8 seed regions including the hippocampus, parahippocampus, amygdala, and anterior and primary somatosensory cortex. CONCLUSIONS Painful stimulation during light sedation with midazolam, but not ketamine, can be accompanied by increased coherence in brain connectivity, even though details are less likely to be recollected as explicit memories. EDITOR’S PERSPECTIVE
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Neurons in the Nonhuman Primate Amygdala and Dorsal Anterior Cingulate Cortex Signal Aversive Memory Formation under Sedation. Anesthesiology 2021; 134:734-747. [PMID: 33684203 DOI: 10.1097/aln.0000000000003732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Anesthetics aim to prevent memory of unpleasant experiences. The amygdala and dorsal anterior cingulate cortex participate in forging emotional and valence-driven memory formation. It was hypothesized that this circuitry maintains its role under sedation. METHODS Two nonhuman primates underwent aversive tone-odor conditioning under sedative states induced by ketamine or midazolam (1 to 8 and 0.1 to 0.8 mg/kg, respectively). The primary outcome was behavioral and neural evidence suggesting memory formation. This study simultaneously measured conditioned inspiratory changes and changes in firing rate of single neurons in the amygdala and the dorsal anterior cingulate cortex in response to an expected aversive olfactory stimulus appearing during acquisition and tested their retention after recovery. RESULTS Aversive memory formation occurred in 26 of 59 sessions under anesthetics (16 of 29 and 10 of 30, 5 of 30 and 21 of 29 for midazolam and ketamine at low and high doses, respectively). Single-neuron responses in the amygdala and dorsal anterior cingulate cortex were positively correlated between acquisition and retention (amygdala, n = 101, r = 0.51, P < 0.001; dorsal anterior cingulate cortex, n = 121, r = 0.32, P < 0.001). Neural responses during acquisition under anesthetics were stronger in sessions exhibiting memory formation than those that did not (amygdala median response ratio, 0.52 versus 0.33, n = 101, P = 0.021; dorsal anterior cingulate cortex median response ratio, 0.48 versus 0.32, n = 121, P = 0.012). The change in firing rate of amygdala neurons during acquisition was correlated with the size of stimuli-conditioned inspiratory response during retention (n = 101, r = 0.22 P = 0.026). Thus, amygdala and dorsal anterior cingulate cortex responses during acquisition under anesthetics predicted retention. Respiratory unconditioned responses to the aversive odor anesthetics did not differ from saline controls. CONCLUSIONS These results suggest that the amygdala-dorsal anterior cingulate cortex circuit maintains its role in acquisition and maintenance of aversive memories in nonhuman primates under sedation with ketamine and midazolam and that the stimulus valence is sufficient to drive memory formation. EDITOR’S PERSPECTIVE
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10
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Zisopoulos G, Roussi P, Mouloudi E. Psychological morbidity a year after treatment in intensive care unit. Health Psychol Res 2020; 8:8852. [PMID: 33553785 PMCID: PMC7859955 DOI: 10.4081/hpr.2020.8852] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 10/21/2020] [Indexed: 11/23/2022] Open
Abstract
Several studies have linked treatment in the Intensive Care Unit (ICU) with negative psychological outcomes. This study explores the prevalence of negative psychological outcomes in Greek patients (N=29), a year after treatment in ICU. Percentages of participants with anxiety [41%, 95% CI (22%, 60%)] and Post- Traumatic Stress Disorder (PTSD) [34%, 95% CI (16%, 53%)] symptoms were similar to the related literature. Percentages of participants with depressive [17%, 95% CI (3%, 32%)] symptoms were rather low. Only 10% of participants reported absence of quality of live issues. Anxiety symptoms were related to desire to talk about the ICU experience (p=0.010), duration of propofol administration (p=0.018) and loss of employment (p=0.019) and negatively related to duration of stay in the ICU (p=0.025). PTSD symptoms were related to experiencing other stressors during the year after the ICU stay (p=0.001), social constraint (p=0.003), duration of propofol administration (p=0.004), loss of employment (p=0.020), low income (p=0.022) and negative ICU memories (p=0.029). Depressive symptoms were related to loss of employment (p=0.003), low income (p=0.029) and social constraint (p=0.033). Patients experience elevated levels of psychological symptoms long after they are discharged from the hospital. Several psychosocial factors emerged as important factors to consider for predicting levels of distress.
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Affiliation(s)
- George Zisopoulos
- Applied Psychology Laboratory, Department of Social and Clinical Psychology, Aristotle University of Thessaloniki
| | - Pagona Roussi
- Applied Psychology Laboratory, Department of Social and Clinical Psychology, Aristotle University of Thessaloniki
| | - Eleni Mouloudi
- Intensive Care Unit, Ippokrateio General Hospital of Thessaloniki, Greece
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11
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Worsham CM, Banzett RB, Schwartzstein RM. Dyspnea, Acute Respiratory Failure, Psychological Trauma, and Post-ICU Mental Health: A Caution and a Call for Research. Chest 2020; 159:749-756. [PMID: 33011205 PMCID: PMC7528739 DOI: 10.1016/j.chest.2020.09.251] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 09/24/2020] [Accepted: 09/25/2020] [Indexed: 11/01/2022] Open
Abstract
Dyspnea is an uncomfortable sensation with the potential to cause psychological trauma. Patients presenting with acute respiratory failure, particularly when tidal volume is restricted during mechanical ventilation, may experience the most distressing form of dyspnea known as air hunger. Air hunger activates brain pathways known to be involved in posttraumatic stress disorder (PTSD), anxiety, and depression. These conditions are considered part of the post-intensive care syndrome. These sequelae may be even more prevalent among patients with ARDS. Low tidal volume, a mainstay of modern therapy for ARDS, is difficult to avoid and is likely to cause air hunger despite sedation. Adjunctive neuromuscular blockade does not prevent or relieve air hunger, but it does prevent the patient from communicating discomfort to caregivers. Consequently, paralysis may also contribute to the development of PTSD. Although research has identified post-ARDS PTSD as a cause for concern, and investigators have taken steps to quantify the burden of disease, there is little information to guide mechanical ventilation strategies designed to reduce its occurrence. We suggest such efforts will be more successful if they are directed at the known mechanisms of air hunger. Investigation of the antidyspnea effects of sedative and analgesic drugs commonly used in the ICU and their impact on post-ARDS PTSD symptoms is a logical next step. Although in practice we often accept negative consequences of life-saving therapies as unavoidable, we must understand the negative sequelae of our therapies and work to minimize them under our primary directive to "first, do no harm" to patients.
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Affiliation(s)
- Christopher M Worsham
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA; Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Robert B Banzett
- Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA
| | - Richard M Schwartzstein
- Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA.
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12
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Madsen SS, Møller K, Olsen KS, Vestergaard MB, Lindberg U, Larsson HBW, Mårtensson J, Werner MU, Santos SAG, Asghar MS. Neuroplasticity induced by general anaesthesia: study protocol for a randomised cross-over clinical trial exploring the effects of sevoflurane and propofol on the brain - A 3-T magnetic resonance imaging study of healthy volunteers. Trials 2020; 21:805. [PMID: 32962743 PMCID: PMC7506820 DOI: 10.1186/s13063-020-04468-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 05/30/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Although used extensively worldwide, the effects of general anaesthesia on the human brain remain largely elusive. Moreover, general anaesthesia may contribute to serious conditions or adverse events such as postoperative cognitive dysfunction and delirium. To understand the basic mechanisms of general anaesthesia, this project aims to study and compare possible de novo neuroplastic changes induced by two commonly used types of general anaesthesia, i.e. inhalation anaesthesia by sevoflurane and intravenously administered anaesthesia by propofol. In addition, we wish to to explore possible associations between neuroplastic changes, neuropsychological adverse effects and subjective changes in fatigue and well-being. METHODS This is a randomised, participant- and assessor-blinded, cross-over clinical trial. Thirty healthy volunteers (male:female ratio 1:1) will be randomised to general anaesthesia by either sevoflurane or propofol. Multimodal magnetic resonance imaging (MRI) of the brain will be performed before and after general anaesthesia and repeated after 1 and 8 days. Each magnetic resonance imaging session will be accompanied by cognitive testing and questionnaires on fatigue and well-being. After a wash-out period of 4 weeks, the volunteers will receive the other type of anaesthetic (sevoflurane or propofol), followed by the same series of tests. Primary outcomes: changes in T1-weighted 3D anatomy and diffusion tensor imaging. SECONDARY OUTCOMES changes in resting-state functional magnetic resonance imaging, fatigue, well-being, cognitive function, correlations between magnetic resonance imaging findings and the clinical outcomes (questionnaires and cognitive function). Exploratory outcomes: changes in cerebral perfusion and oxygen metabolism, lactate, and response to visual stimuli. DISCUSSION To the best of our knowledge, this is the most extensive and advanced series of studies with head-to-head comparison of two widely used methods for general anaesthesia. Recruitment was initiated in September 2019. TRIAL REGISTRATION Approved by the Research Ethics Committee in the Capital Region of Denmark, ref. H-18028925 (6 September 2018). EudraCT and Danish Medicines Agency: 2018-001252-35 (23 March 2018). www.clinicaltrials.gov , ID: NCT04125121 . Retrospectively registered on 10 October 2019.
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Affiliation(s)
- Signe Sloth Madsen
- Department of Neuroanaesthesiology, The Neuroscience Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Neuroanaesthesiology, Rigshospitalet Glostrup, University of Copenhagen, Valdemar Hansens Vej 15, 2600 Glostrup, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, The Neuroscience Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Karsten Skovgaard Olsen
- Department of Neuroanaesthesiology, The Neuroscience Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Mark Bitsch Vestergaard
- Functional Imaging Unit, Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Valdemar Hansens Vej 1-23, entrance 5, 2600 Glostrup, Denmark
| | - Ulrich Lindberg
- Functional Imaging Unit, Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Valdemar Hansens Vej 1-23, entrance 5, 2600 Glostrup, Denmark
| | - Henrik Bo Wiberg Larsson
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Functional Imaging Unit, Department of Clinical Physiology, Nuclear Medicine and PET, Rigshospitalet, University of Copenhagen, Valdemar Hansens Vej 1-23, entrance 5, 2600 Glostrup, Denmark
| | - Johan Mårtensson
- Faculty of Medicine, Department of Clinical Sciences Lund, Logopedics, Phoniatrics and Audiology, Lund University, 22100 Lund, Sweden
| | - Mads U. Werner
- Multidisciplinary Pain Center, The Neuroscience Center, Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Sofia Alexandra Gaspar Santos
- Department of Neuroanaesthesiology, The Neuroscience Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Mohammad Sohail Asghar
- Department of Neuroanaesthesiology, The Neuroscience Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
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Propofol Modulates Early Memory Consolidation in Humans. eNeuro 2020; 7:ENEURO.0537-19.2020. [PMID: 32295771 PMCID: PMC7307630 DOI: 10.1523/eneuro.0537-19.2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/21/2020] [Accepted: 03/23/2020] [Indexed: 02/06/2023] Open
Abstract
Maintenance of memory across time is crucial for adaptive behavior. Current theories posit that the underlying consolidation process depends on stabilization of synapses and reorganization of interactions between hippocampus and neocortex. However, the temporal properties of hippocampal-neocortical network reconfiguration during consolidation are still a matter of debate. Translational research on this issue is challenged by the paucity of techniques to transiently interfere with memory in the healthy human brain. Here, we report a neuro-pharmacological approach with the GABAAergic anesthetic propofol and a memory task sensitive to hippocampal dysfunction. Patients undergoing minor surgery learned word lists before injection of an anesthetic dose of propofol. Results show that administration of the drug shortly after learning (∼13 min) impairs recall after awakening but spares recognition. By contrast, later administration (∼105 min) has no effect. These findings suggest significant changes in memory networks very early after learning that are decisive for later recall. Propofol general anesthesia provides an experimental tool to modulate the first steps of hippocampus-mediated memory consolidation in humans.
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Galarza Vallejo A, Kroes MCW, Rey E, Acedo MV, Moratti S, Fernández G, Strange BA. Propofol-induced deep sedation reduces emotional episodic memory reconsolidation in humans. SCIENCE ADVANCES 2019; 5:eaav3801. [PMID: 30906867 PMCID: PMC6426467 DOI: 10.1126/sciadv.aav3801] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 01/31/2019] [Indexed: 05/29/2023]
Abstract
The adjustment of maladaptive thoughts and behaviors associated with emotional memories is central to treating psychiatric disorders. Recent research, predominantly with laboratory animals, indicates that memories can become temporarily sensitive to modification following reactivation, before undergoing reconsolidation. A method to selectively impair reconsolidation of specific emotional or traumatic memories in humans could translate to an effective treatment for conditions such as posttraumatic stress disorder. We tested whether deep sedation could impair emotional memory reconsolidation in 50 human participants. Administering the intravenous anesthetic propofol following memory reactivation disrupted memory for the reactivated, but not for a non-reactivated, slideshow story. Propofol impaired memory for the reactivated story after 24 hours, but not immediately after propofol recovery. Critically, memory impairment occurred selectively for the emotionally negative phase of the reactivated story. One dose of propofol following memory reactivation selectively impaired subsequent emotional episodic memory retrieval in a time-dependent manner, consistent with reconsolidation impairment.
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Affiliation(s)
- Ana Galarza Vallejo
- Laboratory for Clinical Neuroscience, Centre for Biomedical Technology, Universidad Politécnica de Madrid, Spain
| | - Marijn C. W. Kroes
- Laboratory for Clinical Neuroscience, Centre for Biomedical Technology, Universidad Politécnica de Madrid, Spain
- Department of Psychology and Center for Neural Science, New York University, New York, NY, USA
- Donders Institute for Brain, Cognition, and Behaviour, Donders Institute, Radboud University Medical Centre, Nijmegen 6525 EZ, Netherlands
| | - Enrique Rey
- Department of Gastroenterology, Hospital Clínico San Carlos and Instituto de Investigación Sanitaria San Carlos, Universidad Complutense de Madrid, Spain
| | - Maria Victoria Acedo
- Department of Anesthesia, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos, Universidad Complutense de Madrid, Spain
| | - Stephan Moratti
- Laboratory for Clinical Neuroscience, Centre for Biomedical Technology, Universidad Politécnica de Madrid, Spain
- Department of Basic Psychology I, Complutense University of Madrid, Spain
| | - Guillén Fernández
- Donders Institute for Brain, Cognition, and Behaviour, Donders Institute, Radboud University Medical Centre, Nijmegen 6525 EZ, Netherlands
| | - Bryan A. Strange
- Laboratory for Clinical Neuroscience, Centre for Biomedical Technology, Universidad Politécnica de Madrid, Spain
- Department of Neuroimaging, Alzheimer’s Disease Research Centre, Reina Sofia–CIEN Foundation, Madrid, Spain
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15
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Veselis RA. Complexities of human memory: relevance to anaesthetic practice. Br J Anaesth 2019; 121:210-218. [PMID: 29935575 DOI: 10.1016/j.bja.2018.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 02/09/2018] [Accepted: 03/16/2018] [Indexed: 01/19/2023] Open
Abstract
Mechanisms of anaesthetic actions on memory have largely focused on easily definable aspects of episodic memory, with emphasis on particular drug interactions on specific memory processes. However, the memory landscape of the perioperative experience includes many facets that lie outside these conceptualisations. These include patient recall of preoperative conversations, patient beliefs regarding allergies and unusual/uncommon anaesthetic events, memories of awareness, and particularly vivid dreams during anaesthesia. In no small part, memories are influenced by a patient's interpretations of events in light of their own belief systems. From the practitioner's point of view, relating fully to the patient's experience requires some framework of understanding. The purpose of this review is to highlight research over the previous decades on belief systems and their interactions with autobiographical memory, which organises episodic memories into a personally relevant narrative. As a result, memory is a set of continuously malleable processes, and is best described as a (re)constructive rather than photographic instantiation. Belief systems are separate but closely interacting processes with autobiographical memory. The interaction of a constantly evolving set of memories with belief systems can explain phenomena such as illusions, distortions, and (re)constructions of factitious events. How anaesthetics and our patient interactions influence these behaviours, and vice versa, will be important questions to explore and define with future research.
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Affiliation(s)
- R A Veselis
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA; Department of Anesthesiology, Weill Cornell Medical College, New York, NY, USA.
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Radek L, Kallionpää R, Karvonen M, Scheinin A, Maksimow A, Långsjö J, Kaisti K, Vahlberg T, Revonsuo A, Scheinin H, Valli K. Dreaming and awareness during dexmedetomidine- and propofol-induced unresponsiveness. Br J Anaesth 2018; 121:260-269. [DOI: 10.1016/j.bja.2018.03.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 03/01/2018] [Accepted: 03/27/2018] [Indexed: 11/26/2022] Open
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Samuel N, Taub A, Paz R, Raz A. Implicit aversive memory under anaesthesia in animal models: a narrative review. Br J Anaesth 2018; 121:219-232. [DOI: 10.1016/j.bja.2018.05.046] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 05/15/2018] [Accepted: 05/15/2018] [Indexed: 12/23/2022] Open
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Circulating Endocannabinoids: From Whence Do They Come and Where are They Going? Neuropsychopharmacology 2018; 43:155-172. [PMID: 28653665 PMCID: PMC5719092 DOI: 10.1038/npp.2017.130] [Citation(s) in RCA: 239] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 05/29/2017] [Accepted: 06/09/2017] [Indexed: 12/15/2022]
Abstract
The goal of this review is to summarize studies in which concentrations of circulating endocannabinoids in humans have been examined in relationship to physiological measurements and pathological status. The roles of endocannabinoids in the regulation of energy intake and storage have been well studied and the data obtained consistently support the hypothesis that endocannabinoid signaling is associated with increased consumption and storage of energy. Physical exercise mobilizes endocannabinoids, which could contribute to refilling of energy stores and also to the analgesic and mood-elevating effects of exercise. Circulating concentrations of 2-arachidonoylglycerol are very significantly circadian and dysregulated when sleep is disrupted. Other conditions under which circulating endocannabinoids are altered include inflammation and pain. A second important role for endocannabinoid signaling is to restore homeostasis following stress. Circulating endocannabinoids are stress-responsive and there is evidence that their concentrations are altered in disorders associated with excessive stress, including post-traumatic stress disorder. Although determination of circulating endocannabinoids can provide important information about the state of endocannabinoid signaling and thus allow for hypotheses to be defined and tested, the large number of physiological factors that contribute to their circulating concentrations makes it difficult to use them in isolation as a biomarker for a specific disorder.
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19
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Electroconvulsive therapy regulates emotional memory bias of depressed patients. Psychiatry Res 2017; 257:296-302. [PMID: 28787655 DOI: 10.1016/j.psychres.2017.07.069] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 06/20/2017] [Accepted: 07/29/2017] [Indexed: 12/17/2022]
Abstract
Emotional memory bias is considered to be an important base of the etiology of depression and can be reversed by antidepressants via enhancing the memory for positive stimuli. Another antidepressant treatment, electroconvulsive therapy (ECT), has rapid antidepressant effect and frequently causes short-term memory impairment. However, it is unclear about the short-term effect of ECT on memory bias. In this study, the incidental memory task with emotional pictures were applied to evaluate the emotional memory of twenty depressed patients at pre- and post-ECT (three days after ECT) compared to twenty healthy controls. The depressive symptoms were evaluated using the Hamilton rating scale of depression (HRSD). Before ECT, patients showed decreased recognition memory for positive pictures compared to controls and remembered negative pictures more easily than positive pictures in the recognition task. In patients, the main effect of session (pre-ECT and post-ECT) was significant for both recognition and recall memory with reduced memory performance. The interaction between valence (positive, neutral and negative) and session was significant for recognition memory, indicating that negative memory was impaired more severely than positive memory. Our study indicates that ECT relieves depressive symptoms and regulates emotional memory through more severe impairment on memory for negative stimuli.
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Kang H, Nakae A, Ito H, Vitayaburananont P, Minamoto T, Ikeda T, Osaka M, Mashimo T, Fujino Y, Hagihira S. Effects of sedation on subjective perception of pain intensity and autonomic nervous responses to pain: A preliminary study. PLoS One 2017; 12:e0183635. [PMID: 28880899 PMCID: PMC5589124 DOI: 10.1371/journal.pone.0183635] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 07/26/2017] [Indexed: 11/21/2022] Open
Abstract
Rather than relying solely on subjective pain evaluation using means such as the visual analogue scale (VAS), in clinical situations it is possible to observe evoked responses of the autonomic nervous system (ANS) as objective indicators. Few studies, however, have reported these relationships under finely controlled sedation. 16 healthy male participants were administrated in intravenous sedation with either propofol or midazolam randomly. We initially determined, using pharmacokinetic simulation, the effect-site concentration (Ce) of anaesthetic at loss of response to verbal command and eyelash reflex (Ce-LOR). Then subsequently adjusted Ce to 75%, 50%, and 25% of Ce-LOR to achieve deep, moderate, and light sedation. At awake control state and each sedation level, a noxious electrical stimulation was applied three times at the right forearm, an average pain intensity of the three stimuli was rated on a VAS (0–10). Changes in the peripheral perfusion index measured by oximetry were used as an indicator of ANS response. We analyzed the influence of sedation level on VAS and ANS responses compared to the awake control state. While ANS responses were similar in all conditions, VAS was statistically significantly lower in moderate (5.6±0.6, p <0.005) or deep (5.3±0.6, p <0.001) sedation than in the awake state (7.2±0.4). This study revealed that even when the ANS responds similarly to the same stimulation, subjective pain perception is attenuated by sedation. A cerebral mechanism other than that of the brainstem might determine subjective pain intensity.
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Affiliation(s)
- Hongling Kang
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Aya Nakae
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Hiroshi Ito
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Piyasak Vitayaburananont
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takehiro Minamoto
- Graduate School of Human Sciences, Osaka University, Suita, Osaka, Japan
| | - Takashi Ikeda
- Graduate School of Human Sciences, Osaka University, Suita, Osaka, Japan
| | - Mariko Osaka
- Graduate School of Human Sciences, Osaka University, Suita, Osaka, Japan
| | - Takashi Mashimo
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Satoshi Hagihira
- Department of Anesthesiology and Intensive Care, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
- * E-mail:
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Haiying G, Mingjie H, Lingyu Z, Qingxiang W, Haisong W, Bingxi Z. Anesthetics inhibit extracellular signal-regulated Kinase1/2 phosphorylation via NMDA receptor, phospholipase C and protein kinase C in mouse hippocampal slices. Neurochem Int 2017; 103:36-44. [DOI: 10.1016/j.neuint.2016.12.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 12/25/2016] [Accepted: 12/29/2016] [Indexed: 11/16/2022]
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22
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Frequency Specificity of fMRI in Mesial Temporal Lobe Epilepsy. PLoS One 2016; 11:e0157342. [PMID: 27314671 PMCID: PMC4912074 DOI: 10.1371/journal.pone.0157342] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 05/29/2016] [Indexed: 11/25/2022] Open
Abstract
Medial temporal lobe epilepsy (mTLE) is a system-level disease characterized by aberrant neuronal synchronization and widespread alterations in function. Previous studies have focused on the amplitude analysis of the blood oxygenation level-dependent (BOLD) signals to reveal the aberrant alterations in mTLE. However, these methods did not work well in the cases where the amplitudes of two oscillations are correlated but the underlying oscillations are neither phase coherent nor frequency consistent. To address this problem, we investigated the differences of frequency specificity between patients with mTLE and healthy controls using the extreme-point symmetric mode decomposition (ESMD) method. In this method, the BOLD signals were decomposed into a set of intrinsic mode functions (IMFs) and the instantaneous frequency of each IMF was calculated using the direct interpolation strategy. The intrinsic frequency (denoted as Freq) for every voxel was obtained by the weighted sum of the instantaneous frequencies of all the IMFs. The Freq was used as an index to evaluate the altered frequency specificity of 41 patients with mTLE (17 right-side, 24 left-side) and 24 healthy control subjects. The results show that the peak of frequency distribution curve for the patients moves towards the higher frequency than that for the healthy controls. Compared with the healthy control group, the patients with left mTLE demonstrate higher Freq in the default mode network, middle frontal gyrus, insula, middle temporal gyrus and calcarine gyrus; the patients with right mTLE demonstrate higher Freq in the precuneus and occipital lobe. For the three groups, the distinct frequency distribution appears in the left and right hippocampus due to the hippocampal structural and functional asymmetries. The preliminary results imply that the frequency-specific correlated oscillations in the distributed brain regions can provide information about the nature of diseases affecting the brain and the alterations of frequency specificity are associated with the pathological characteristics of mTLE.
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Affiliation(s)
- J Kurata
- Department of Anesthesiology and Pain Clinic, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo City, Tokyo 113-8519, Japan
| | - H C Hemmings
- Departments of Anesthesiology and Pharmacology, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
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