Correction: Antidepressant and Neurocognitive Effects of Isoflurane Anesthesia versus Electroconvulsive Therapy in Refractory Depression.

[This corrects the article DOI: 10.1371/journal.pone.0069809.].

Antidepressant and neurocognitive effects of isoflurane anesthesia versus electroconvulsive therapy in refractory depression.

BACKGROUND: Many patients have serious depression that is nonresponsive to medications, but refuse electroconvulsive therapy (ECT). Early research suggested that isoflurane anesthesia may be an effective alternative to ECT. Subsequent studies altered drug, dose or number of treatments, and failed to replicate this success, halting research on isoflurane's antidepressant effects for a decade. Our aim was to re-examine whether isoflurane has antidepressant effects comparable to ECT, with less adverse effects on cognition. METHOD: Patients with medication-refractory depression received an average of 10 treatments of bifrontal ECT (n = 20) or isoflurane (n = 8) over 3 weeks. Depression severity (Hamilton Rating Scale for Depression-24) and neurocognitive responses (anterograde and retrograde memory, processing speed and verbal fluency) were assessed at Pretreatment, Post all treatments and 4-week Follow-up. RESULTS: Both treatments produced significant reductions in depression scores at Post-treatment and 4-week Follow-up; however, ECT had modestly better antidepressant effect at follow-up in severity-matched patients. Immediately Post-treatment, ECT (but not isoflurane) patients showed declines in memory, fluency, and processing speed. At Follow-up, only autobiographical memory remained below Pretreatment level for ECT patients, but isoflurane patients had greater test-retest neurocognitive score improvement. CONCLUSIONS: Our data reconfirm that isoflurane has an antidepressant effect approaching ECT with less adverse neurocognitive effects, and reinforce the need for a larger clinical trial.

Perioperative echocardiography: two-dimensional and three-dimensional applications.

Perioperative echocardiography is an essential skill for today's cardiac anesthesiologist and a driving force for innovation and accomplishment for the future of the subspecialty. Real-time three-dimensional transesophageal echocardiography (RT3-D TEE) will dominate the future practice of perioperative echocardiography, but transthoracic echocardiography (TTE) will grow in application, as will contrast echocardiography. Hand-held ultrasonongraphs will rival current machines in capabilities and make it possible for TTE to become the stethoscope of the future for cardiac anesthesiologists.

Subspecialty accreditation: is being special good?

PURPOSE OF REVIEW: We examined the advantages and disadvantages of certifying additional subspecialties in anesthesiology from five vantage points - patients, generalist anesthesiologists, subspecialist anesthesiologists, departments of anesthesiology, and society as a whole - in order to recommend a course of action. RECENT FINDINGS: The published literature does not provide conclusive data on the relative benefits or costs of subspecialization in anesthesiology. Currently, only critical care medicine and pain medicine are recognized officially as subspecialties of anesthesiology. Pediatric anesthesia and cardiothoracic anesthesia have accredited fellowships, and a fellowship accreditation application is under review for obstetric anesthesia. SUMMARY: Based on our examination, from the five perspectives given above, we recommend that training in all subspecialties of anesthesiology be encouraged. Official fellowship accreditation and subspecialty certification, however, should be reserved for subspecialties in which anesthesiologists provide services comparable to those provided by nonanesthesiologist subspecialists, such as critical care medicine and pain medicine.

Segmental wall-motion abnormalities after an arterial switch operation indicate ischemia.

We prospectively studied 29 consecutive neonates undergoing an arterial switch operation to determine if segmental wall motion abnormalities (SWMA) represented myocardial ischemia. Intraoperative transesophageal echocardiogram was recorded at baseline and twice after cardiopulmonary bypass. Cardiac troponin I (cTnI) levels were measured before sternal incision and 3, 6, 12, 24, 48, and 72 h after removal of the aortic cross-clamp. Immediate postoperative Holter and 15-lead electrocardiograms (ECG) were evaluated for ischemia. Transthoracic echocardiograms were obtained before hospital discharge. At bypass termination, immediately after protamine administration, segmental wall motion was normal in nine neonates and abnormal in 20. SWMA were transient in five and present at the time of chest closure in 15 neonates. Neonates in whom SWMA were present at chest closure had more segments involved than those in whom SWMA were transient (P > 0.001). Neonates with SWMA at chest closure had higher cTnI levels postoperatively versus neonates with normal wall motion (P = 0.02). Postoperative ECG data were available in 26 neonates. There was ECG evidence of myocardial ischemia in two of eight neonates with normal wall motion, one of five with transient SWMA, and nine of 13 with SWMA at chest closure. CTnI levels at 12, 24, and 48 h and intraoperative SWMA were predictive of postoperative SWMA. We believe these data indicate that SWMA, which persist at the completion of an arterial switch operation, and which are present in multiple myocardial segments, correlate with myocardial ischemia. Further follow-up of these patients is needed to determine if increased intraoperative myocardial ischemia correlates with long-term outcomes.

Assessment of left ventricular global and segmental systolic function with transesophageal echocardiography.

The evaluation of LV global and segmental systolic function is a primary application for perioperative TEE. Although the practical techniques customarily used for these applications have limitations, they afford direct measures of function not otherwise available to the clinician in the operating room or intensive care setting.

Gatifloxacin as a possible cause of serious postoperative hypoglycemia.

The case we present describes an episode of serious postoperative hypoglycemia after cardiopulmonary bypass for a relatively minor cardiac procedure. A fluoroquinolone antibiotic had been administered, and we believe that this strongly contributed to this event. Fluoroquinolone antibiotics have a recognized propensity to alter glucose homeostasis.

Is PA-PWRmax truly a preload-independent index of myocardial contractility in anesthetized humans?

This study tested the hypothesis that the preload-adjusted maximal power index (PA-PWRmax) is a load-independent index of human myocardial contractility. Based on the ventricular pressure-volume relationship and derived from stroke work, the index is the product of instantaneous ventricular pressure and volume changes, divided by a correction term of end-diastolic volume (EDV2) or end-diastolic area (EDA3/2) to adjust for preload effects. Echocardiographic measures of instantaneous ventricular area change may be used to obtain PA-PWRmax noninvasively. We prospectively evaluated 28 human subjects undergoing cardiac evacuation before cardiopulmonary bypass procedures. Continuous peripheral arterial pressure, pulmonary arterial pressure, and echocardiographic views of the left ventricle in the transgastric short-axis view were recorded. Simultaneously gated instantaneous fractional shortening (FS) and PA-PWRmax indices were calculated, with FS = (EDA - ESA)/EDA and PA-PWRmax = [MAP (EDA - ESA)]/ EDA3/2, where ESA = end-systolic area and MAP = instantaneous mean arterial pressure. FS decreased uniformly with cardiac evacuation and decreasing pulmonary artery diastolic pressure (t = -5.4; 95% confidence interval, -10 to -0.046; p < 0.001), as did PA-PWRmax (t = -5.8; 95% confidence interval, -2.25 to -1.08; p < 0.001). FS and PA-PWRmax showed a strong downward correlation (r = 0.81). Unlike previous studies of autonomically denervated animals, our study did not find PA-PWRmax to be preload independent, perhaps because of the instantaneous homeostatic mechanisms of the human autonomic nervous system linking contractility to loading conditions.

Development and analysis of a new certifying examination in perioperative transesophageal echocardiography.

UNLABELLED: A key element in developing a process to determine knowledge and ability in applying perioperative echocardiography has included an examination. We report on the development of a certifying examination in perioperative echocardiography. In addition, we tested the hypothesis that examination performance is related to clinical experience in echocardiography. Since 1995, more than 1200 participants have taken the examination, and more than 70% have passed. Overall examination performance was related positively to longer than 3 mo of training (or equivalent) in echocardiography and performance and interpretation of at least six examinations a week. We concluded that the certifying examination in perioperative echocardiography is a valid tool to help determine individual knowledge in perioperative echocardiography application. IMPLICATIONS: This report describes the process involved in developing the certifying transesophageal echocardiography examination and identifies correlates with examination performance.