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Denoix N, McCook O, Scheuerle A, Kapapa T, Hoffmann A, Gündel H, Waller C, Szabo C, Radermacher P, Merz T. Brain Histology and Immunohistochemistry After Resuscitation From Hemorrhagic Shock in Swine With Pre-Existing Atherosclerosis and Sodium Thiosulfate (Na2S2O3) Treatment. Front Med (Lausanne) 2022; 9:925433. [PMID: 35847799 PMCID: PMC9279570 DOI: 10.3389/fmed.2022.925433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/09/2022] [Indexed: 11/26/2022] Open
Abstract
Background The hydrogen sulfide (H2S) and the oxytocin/oxytocin receptor (OT/OTR) systems interact in the central nervous and cardiovascular system. As a consequence of osmotic balance stress, H2S stimulates OT release from the paraventricular nuclei (PVN) in the hypothalamic regulation of blood volume and pressure. Hemorrhagic shock (HS) represents one of the most pronounced acute changes in blood volume, which, moreover, may cause at least transient brain tissue hypoxia. Atherosclerosis is associated with reduced vascular expression of the main endogenous H2S producing enzyme cystathionine-γ-lyase (CSE), and, hence, exogenous H2S administration could be beneficial in these patients, in particular after HS. However, so far cerebral effects of systemic H2S administration are poorly understood. Having previously shown lung-protective effects of therapeutic Na2S2O3 administration in a clinically relevant, long-term, porcine model of HS and resuscitation we evaluated if these protective effects were extended to the brain. Methods In this study, available unanalyzed paraffin embedded brain sections (Na2S2O3N = 8 or vehicle N = 5) of our recently published HS study were analyzed via neuro-histopathology and immunohistochemistry for the endogenous H2S producing enzymes, OT, OTR, and markers for brain injury and oxidative stress (glial fibrillary acidic protein (GFAP) and nitrotyrosine). Results Neuro-histopathological analysis revealed uninjured brain tissue with minor white matter edema. Protein quantification in the hypothalamic PVN showed no significant inter-group differences between vehicle or Na2S2O3 treatment. Conclusions The endogenous H2S enzymes, OT/OTR co-localized in magnocellular neurons in the hypothalamus, which may reflect their interaction in response to HS-induced hypovolemia. The preserved blood brain barrier (BBB) may have resulted in impermeability for Na2S2O3 and no inter-group differences in the PVN. Nonetheless, our results do not preclude that Na2S2O3 could have a therapeutic benefit in the brain in an injury that disrupts the BBB, e.g., traumatic brain injury (TBI) or acute subdural hematoma (ASDH).
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Affiliation(s)
- Nicole Denoix
- Clinic for Psychosomatic Medicine and Psychotherapy, Ulm University Medical Center, Ulm, Germany
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Oscar McCook
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Angelika Scheuerle
- Division of Neuropathology, Institute for Pathology, Ulm University Medical Center, Ulm, Germany
| | - Thomas Kapapa
- Clinic for Neurosurgery, Ulm University Medical Center, Ulm, Germany
| | - Andrea Hoffmann
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Harald Gündel
- Clinic for Psychosomatic Medicine and Psychotherapy, Ulm University Medical Center, Ulm, Germany
| | - Christiane Waller
- Department of Psychosomatic Medicine and Psychotherapy, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
| | - Csaba Szabo
- Department of Science and Medicine, University of Fribourg, Fribourg, Switzerland
| | - Peter Radermacher
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Tamara Merz
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
- *Correspondence: Tamara Merz
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Possible oxytocin-related biomarkers in anxiety and mood disorders. Prog Neuropsychopharmacol Biol Psychiatry 2022; 116:110531. [PMID: 35150782 DOI: 10.1016/j.pnpbp.2022.110531] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/30/2021] [Accepted: 02/05/2022] [Indexed: 02/08/2023]
Abstract
Anxiety and mood disorders are prevalent, disabling, and frequently difficult to treat. Such disorders are often comorbid and share similar characteristics. For more accurate diagnosis and improved treatment, a deeper understanding of the pathophysiology of anxiety and mood disorders is important. Oxytocin, a neuropeptide synthesized in the hypothalamus, affects human psychology and behaviors such as social and affiliative behaviors, fear and emotion processing, and stress regulation. Thus, oxytocin is believed to exert anxiolytic and antidepressant-like effects. This review article provides an overview of clinical studies on relationships between the oxytocin system and anxiety and mood disorders, focusing on oxytocin-related biomarker findings. Biomarkers used in such studies include central and peripheral oxytocin levels, analysis of oxytocin-related genes, and expression levels of oxytocin and oxytocin receptor genes in postmortem brains. Although a growing number of studies support the presence of oxytocinergic effects on anxiety and mood disorders, study results are heterogeneous and inconclusive. Moderating factors such as the characteristics of study populations, including sex, age, context, early life adversity, and attachment styles in patient cohorts, might affect the heterogeneity of the study results. Limitations in existing research such as small sample sizes, large dependence on peripheral sources of oxytocin, and inconsistent results between immunoassay methods complicate the interpretation of existing findings.
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H2S in Critical Illness—A New Horizon for Sodium Thiosulfate? Biomolecules 2022; 12:biom12040543. [PMID: 35454132 PMCID: PMC9029606 DOI: 10.3390/biom12040543] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 04/01/2022] [Accepted: 04/02/2022] [Indexed: 12/13/2022] Open
Abstract
Ever since the discovery of endogenous H2S and the identification of its cytoprotective properties, efforts have been made to develop strategies to use H2S as a therapeutic agent. The ability of H2S to regulate vascular tone, inflammation, oxidative stress, and apoptosis might be particularly useful in the therapeutic management of critical illness. However, neither the inhalation of gaseous H2S, nor the administration of inorganic H2S-releasing salts or slow-releasing H2S-donors are feasible for clinical use. Na2S2O3 is a clinically approved compound with a good safety profile and is able to release H2S, in particular under hypoxic conditions. Pre-clinical studies show promise for Na2S2O3 in the acute management of critical illness. A current clinical trial is investigating the therapeutic potential for Na2S2O3 in myocardial infarct. Pre-eclampsia and COVID-19 pneumonia might be relevant targets for future clinical trials.
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McCook O, Scheuerle A, Denoix N, Kapapa T, Radermacher P, Merz T. Localization of the hydrogen sulfide and oxytocin systems at the depth of the sulci in a porcine model of acute subdural hematoma. Neural Regen Res 2021; 16:2376-2382. [PMID: 33907009 PMCID: PMC8374554 DOI: 10.4103/1673-5374.313018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/17/2020] [Accepted: 12/10/2020] [Indexed: 11/24/2022] Open
Abstract
In the porcine model discussed in this review, the acute subdural hematoma was induced by subdural injection of autologous blood over the left parietal cortex, which led to a transient elevation of the intracerebral pressure, measured by bilateral neuromonitoring. The hematoma-induced brain injury was associated with albumin extravasation, oxidative stress, reactive astrogliosis and microglial activation in the ipsilateral hemisphere. Further proteins and injury markers were validated to be used for immunohistochemistry of porcine brain tissue. The cerebral expression patterns of oxytocin, oxytocin receptor, cystathionine-γ-lyase and cystathionine-β-synthase were particularly interesting: these four proteins all co-localized at the base of the sulci, where pressure-induced brain injury elicits maximum stress. In this context, the pig is a very relevant translational model in contrast to the rodent brain. The structure of the porcine brain is very similar to the human: the presence of gyri and sulci (gyrencephalic brain), white matter to grey matter proportion and tentorium cerebelli. Thus, pressure-induced injury in the porcine brain, unlike in the rodent brain, is reflective of the human pathophysiology.
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Affiliation(s)
- Oscar McCook
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Angelika Scheuerle
- Department of Neuropathology, Ulm University Medical Center, Günzburg, Germany
| | - Nicole Denoix
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
- Clinic for Psychosomatic Medicine and Psychotherapy, Ulm University Medical Center, Ulm, Germany
| | - Thomas Kapapa
- Department of Neurosurgery, Ulm University Medical Center, Ulm, Germany
| | - Peter Radermacher
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
| | - Tamara Merz
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, Ulm, Germany
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The Gasotransmitter Hydrogen Sulfide and the Neuropeptide Oxytocin as Potential Mediators of Beneficial Cardiovascular Effects through Meditation after Traumatic Events. TRAUMA CARE 2021. [DOI: 10.3390/traumacare1030016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Trauma and its related psychological and somatic consequences are associated with higher cardiovascular morbidity. The regulation of both the gasotransmitter hydrogen sulfide (H2S) and the neuropeptide oxytocin (OT) have been reported to be affected during physical and psychological trauma. Both mediators are likely molecular correlates of trauma-induced cardiovascular complications, because they share parallel roles and signaling pathways in the cardiovascular system, both locally as well as on the level of central regulation and the vagus nerve. Meditation can alter the structure of specific brain regions and can have beneficial effects on cardiovascular health. This perspective article summarizes the evidence pointing toward the significance of H2S and OT signaling in meditation-mediated cardio-protection.
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Merz T, McCook O, Denoix N, Radermacher P, Waller C, Kapapa T. Biological Connection of Psychological Stress and Polytrauma under Intensive Care: The Role of Oxytocin and Hydrogen Sulfide. Int J Mol Sci 2021; 22:9192. [PMID: 34502097 PMCID: PMC8430789 DOI: 10.3390/ijms22179192] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/06/2021] [Accepted: 08/20/2021] [Indexed: 12/12/2022] Open
Abstract
This paper explored the potential mediating role of hydrogen sulfide (H2S) and the oxytocin (OT) systems in hemorrhagic shock (HS) and/or traumatic brain injury (TBI). Morbidity and mortality after trauma mainly depend on the presence of HS and/or TBI. Rapid "repayment of the O2 debt" and prevention of brain tissue hypoxia are cornerstones of the management of both HS and TBI. Restoring tissue perfusion, however, generates an ischemia/reperfusion (I/R) injury due to the formation of reactive oxygen (ROS) and nitrogen (RNS) species. Moreover, pre-existing-medical-conditions (PEMC's) can aggravate the occurrence and severity of complications after trauma. In addition to the "classic" chronic diseases (of cardiovascular or metabolic origin), there is growing awareness of psychological PEMC's, e.g., early life stress (ELS) increases the predisposition to develop post-traumatic-stress-disorder (PTSD) and trauma patients with TBI show a significantly higher incidence of PTSD than patients without TBI. In fact, ELS is known to contribute to the developmental origins of cardiovascular disease. The neurotransmitter H2S is not only essential for the neuroendocrine stress response, but is also a promising therapeutic target in the prevention of chronic diseases induced by ELS. The neuroendocrine hormone OT has fundamental importance for brain development and social behavior, and, thus, is implicated in resilience or vulnerability to traumatic events. OT and H2S have been shown to interact in physical and psychological trauma and could, thus, be therapeutic targets to mitigate the acute post-traumatic effects of chronic PEMC's. OT and H2S both share anti-inflammatory, anti-oxidant, and vasoactive properties; through the reperfusion injury salvage kinase (RISK) pathway, where their signaling mechanisms converge, they act via the regulation of nitric oxide (NO).
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Affiliation(s)
- Tamara Merz
- Institute for Anesthesiological Pathophysiology and Process Engineering, Medical Center, Ulm University, Helmholtzstraße 8/1, 89081 Ulm, Germany; (T.M.); (N.D.); (P.R.)
| | - Oscar McCook
- Institute for Anesthesiological Pathophysiology and Process Engineering, Medical Center, Ulm University, Helmholtzstraße 8/1, 89081 Ulm, Germany; (T.M.); (N.D.); (P.R.)
| | - Nicole Denoix
- Institute for Anesthesiological Pathophysiology and Process Engineering, Medical Center, Ulm University, Helmholtzstraße 8/1, 89081 Ulm, Germany; (T.M.); (N.D.); (P.R.)
- Clinic for Psychosomatic Medicine and Psychotherapy, Medical Center, Ulm University, 89081 Ulm, Germany
| | - Peter Radermacher
- Institute for Anesthesiological Pathophysiology and Process Engineering, Medical Center, Ulm University, Helmholtzstraße 8/1, 89081 Ulm, Germany; (T.M.); (N.D.); (P.R.)
| | - Christiane Waller
- Department of Psychosomatic Medicine and Psychotherapy, Nuremberg General Hospital, Paracelsus Medical University, 90471 Nuremberg, Germany;
| | - Thomas Kapapa
- Clinic for Neurosurgery, Medical Center, Ulm University, 89081 Ulm, Germany;
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McCook O, Denoix N, Radermacher P, Waller C, Merz T. H 2S and Oxytocin Systems in Early Life Stress and Cardiovascular Disease. J Clin Med 2021; 10:jcm10163484. [PMID: 34441780 PMCID: PMC8397059 DOI: 10.3390/jcm10163484] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 02/07/2023] Open
Abstract
Today it is well established that early life stress leads to cardiovascular programming that manifests in cardiovascular disease, but the mechanisms by which this occurs, are not fully understood. This perspective review examines the relevant literature that implicates the dysregulation of the gasomediator hydrogen sulfide and the neuroendocrine oxytocin systems in heart disease and their putative mechanistic role in the early life stress developmental origins of cardiovascular disease. Furthermore, interesting hints towards the mutual interaction of the hydrogen sulfide and OT systems are identified, especially with regards to the connection between the central nervous and the cardiovascular system, which support the role of the vagus nerve as a communication link between the brain and the heart in stress-mediated cardiovascular disease.
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Affiliation(s)
- Oscar McCook
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89081 Ulm, Germany; (N.D.); (P.R.); (T.M.)
- Correspondence: ; Tel.: +49-731-500-60185; Fax: +49-731-500-60162
| | - Nicole Denoix
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89081 Ulm, Germany; (N.D.); (P.R.); (T.M.)
- Clinic for Psychosomatic Medicine and Psychotherapy, Ulm University Medical Center, 89081 Ulm, Germany
| | - Peter Radermacher
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89081 Ulm, Germany; (N.D.); (P.R.); (T.M.)
| | - Christiane Waller
- Department of Psychosomatic Medicine and Psychotherapy, Nuremberg General Hospital, Paracelsus Medical University, 90471 Nuremberg, Germany;
| | - Tamara Merz
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89081 Ulm, Germany; (N.D.); (P.R.); (T.M.)
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Schulz J, Kramer S, Kanatli Y, Kuebart A, Bauer I, Picker O, Vollmer C, Truse R, Herminghaus A. Sodium Thiosulfate Improves Intestinal and Hepatic Microcirculation Without Affecting Mitochondrial Function in Experimental Sepsis. Front Immunol 2021; 12:671935. [PMID: 34163476 PMCID: PMC8215355 DOI: 10.3389/fimmu.2021.671935] [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: 02/24/2021] [Accepted: 05/18/2021] [Indexed: 11/25/2022] Open
Abstract
Introduction In the immunology of sepsis microcirculatory and mitochondrial dysfunction in the gastrointestinal system are important contributors to mortality. Hydrogen sulfide (H2S) optimizes gastrointestinal oxygen supply and mitochondrial respiration predominantly via K(ATP)-channels. Therefore, we tested the hypothesis that sodium thiosulfate (STS), an inducer of endogenous H2S, improves intestinal and hepatic microcirculation and mitochondrial function via K(ATP)-channels in sepsis. Methods In 40 male Wistar rats colon ascendens stent peritonitis (CASP) surgery was performed to establish sepsis. Animals were randomized into 4 groups (1: STS 1 g • kg-1 i.p., 2: glibenclamide (GL) 5 mg • kg-1 i.p., 3: STS + GL, 4: vehicle (VE) i.p.). Treatment was given directly after CASP-surgery and 24 hours later. Microcirculatory oxygenation (µHBO2) and flow (µflow) of the colon and the liver were continuously recorded over 90 min using tissue reflectance spectrophotometry. Mitochondrial oxygen consumption in tissue homogenates was determined with respirometry. Statistic: two-way ANOVA + Dunnett´s and Tukey post - hoc test (microcirculation) and Kruskal-Wallis test + Dunn’s multiple comparison test (mitochondria). p < 0.05 was considered significant. Results STS increased µHbO2 (colon: 90 min: + 10.4 ± 18.3%; liver: 90 min: + 5.8 ± 9.1%; p < 0.05 vs. baseline). Furthermore, STS ameliorated µflow (colon: 60 min: + 51.9 ± 71.1 aU; liver: 90 min: + 22.5 ± 20.0 aU; p < 0.05 vs. baseline). In both organs, µHbO2 and µflow were significantly higher after STS compared to VE. The combination of STS and GL increased colonic µHbO2 and µflow (µHbO2 90 min: + 8.7 ± 11.5%; µflow: 90 min: + 41.8 ± 63.3 aU; p < 0.05 vs. baseline), with significantly higher values compared to VE. Liver µHbO2 and µflow did not change after STS and GL. GL alone did not change colonic or hepatic µHbO2 or µflow. Mitochondrial oxygen consumption and macrohemodynamic remained unaltered. Conclusion The beneficial effect of STS on intestinal and hepatic microcirculatory oxygenation in sepsis seems to be mediated by an increased microcirculatory perfusion and not by mitochondrial respiratory or macrohemodynamic changes. Furthermore, the effect of STS on hepatic but not on intestinal microcirculation seems to be K(ATP)-channel-dependent.
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Affiliation(s)
- Jan Schulz
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Sandra Kramer
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Yasin Kanatli
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Anne Kuebart
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Inge Bauer
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Olaf Picker
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Christian Vollmer
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Richard Truse
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Anna Herminghaus
- Department of Anesthesiology, University Hospital Duesseldorf, Duesseldorf, Germany
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Trautwein B, Merz T, Denoix N, Szabo C, Calzia E, Radermacher P, McCook O. ΔMST and the Regulation of Cardiac CSE and OTR Expression in Trauma and Hemorrhage. Antioxidants (Basel) 2021; 10:233. [PMID: 33546491 PMCID: PMC7913715 DOI: 10.3390/antiox10020233] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/01/2021] [Accepted: 02/01/2021] [Indexed: 12/19/2022] Open
Abstract
Genetic deletion of 3-mercaptopyruvate sulfurtransferase (MST) is known to result in hypertension and cardiac hypertrophy in older mice, and is associated with increased anxiety-like behaviors. Endogenous hydrogen sulfide (H2S) produced by MST in the mitochondria is also known to be involved in physiological and cellular bioenergetics, and its dysfunction associated with depressive behavior and increased cardiovascular morbidity. Interestingly, early life stress has been shown to lead to a significant loss of cystathionine-γ-lyase (CSE) and oxytocin receptor (OTR) expression in the heart. Thus, we were interested in testing the hypothesis of whether genetic MST mutation (ΔMST) would affect cardiac CSE and OTR expression and affect the mitochondrial respiration in a clinically relevant, resuscitated, mouse model of trauma and hemorrhagic shock. In ΔMST mice, we found a reduction of CSE and OTR in both the naive as well as injured state, in contrast to the wild type (wt) controls. Interestingly, the ΔMST showed a different complex IV response to injury than the wt controls, although our claims are based on the non-demonstrated assumption that naive wt and naive ΔMST mice have comparable complex IV activity. Finally, hemorrhagic shock led to a reduction of CSE and OTR, confirming previous results in the injured mouse heart. To date, the exact mechanisms of the cardiac interaction between H2S and OT are not clear, but they point the way to potential cardioprotective therapies.
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Affiliation(s)
- Britta Trautwein
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89081 Um, Germany; (B.T.); (T.M.); (N.D.); (E.C.); (P.R.)
| | - Tamara Merz
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89081 Um, Germany; (B.T.); (T.M.); (N.D.); (E.C.); (P.R.)
| | - Nicole Denoix
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89081 Um, Germany; (B.T.); (T.M.); (N.D.); (E.C.); (P.R.)
- Clinic for Psychosomatic Medicine and Psychotherapy, Ulm University Medical Center, 89070 Ulm, Germany
| | - Csaba Szabo
- Department of Science and Medicine, University of Fribourg, 1700 Fribourg, Switzerland;
| | - Enrico Calzia
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89081 Um, Germany; (B.T.); (T.M.); (N.D.); (E.C.); (P.R.)
| | - Peter Radermacher
- Institute for Anesthesiological Pathophysiology and Process Engineering, Ulm University Medical Center, 89081 Um, Germany; (B.T.); (T.M.); (N.D.); (E.C.); (P.R.)
| | - Oscar McCook
- Clinic for Psychosomatic Medicine and Psychotherapy, Ulm University Medical Center, 89070 Ulm, Germany
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