Rapid Drop-Volume Electrochemical Detection of the "Date Rape" Drug Flunitrazepam in Spirits Using a Screen-Printed Sensor in a Dry-Reagent Format

Flunitrazepam is an extremely potent benzodiazepine sedative which is associated with "drug-facilitated sexual assault" when administered within an alcoholic drink. This work describes a simple electrochemical method for on-site rapid detection of flunitrazepam in untreated spirits (whiskey, vodka and gin) using a single-use screen-printed sensor (featuring graphite working and auxiliary electrodes and an Ag/AgCl reference electrode) in a dry reagent format. Analysis was performed by placing a drop of sample on the sensor, which was previously coated with dry KCl, and recording selected reduction/oxidation peaks of the target compound in a cyclic voltammetry scan. The limit of quantification of flunitrazepam was at the sub-mg L^-1 range. The between-sensor % relative standard deviation of the analytically useful reduction peak in a solution containing 11.4 mg L^-1 flunitrazepam was 9.8% (n = 5). Quantification was performed using calibration curves constructed from pooled samples spiked with flunitrazepam with relative errors <15%. The main advantages of the methodology are that it involves no sample pretreatment (such as deoxygenation, extraction or reagent(s) addition) and requires only drop-sized volumes of the sample, thus facilitating rapid on-site screening using portable equipment.

Flavonoids isolated from Tibetan medicines, binding to GABAA receptor and the anticonvulsant activity

BACKGROUND

Our previous studies on Asterothamnus centrali-asiaticus Novopokr. (ACN) and Arenaria kansuensis Maxim. (AKM) had led to the isolation of some phytochemical constituents and evaluation of anticonvulsant effect based on their extracts. ACN and AKM have been widely used in traditional Tibetan herbs for neuropsychiatric diseases and cardiopulmonary disorders.

PURPOSE

The purpose is to investigate structure-activity relationships of flavonoids isolated from ACN and AKM, for binding to the benzodiazepine site (BZ-S) of γ-aminobutyric acid type A (GABA_A) receptor complex, and to search for anticonvulsant compounds without undesirable effects such as myorelaxation and sedation.

STUDY DESIGN AND METHODS

The affinities of these flavonoids for the BZ-S of GABA_A receptors were determined by [³H]flunitrazepam binding to mouse cerebellum membranes in vitro. And the anticonvulsant, myorelaxant and sedative effects were determined by pentylenetetrazol (PTZ)-induced seizure and electrogenic seizure protection, rotarod test and locomotor activity test, respectively.

RESULTS

Fifteen and thirteen flavonoids were isolated from ACN and AKM, respectively. Structure-activity relationships analysis indicated that 6-and/or 8-OMe flavones exhibited the most potent binding affinity to GABA_A receptors. Furthermore, 2',4',5,7-tetrahydroxy-5',6-dimethoxyflavone (DMF, IC₅₀ value of 0.10 μM), a flavone isolated from ACN, presented high anticonvulsant activity against chemical-induced seizures and electrogenic seizures, without myorelaxation and sedation.

CONCLUSION

This study suggested that these flavones, especially DMF, are new BZ receptor ligands and prospective therapeutic candidates for seizures.

[Compartment syndrome of the forearm after intra-arterial self-injection : With a mixture of methadone, flunitrazepam, saliva and water]

A drug-addicted patient injected himself intra-arterially with a mixture of methadone, flunitrazepam, saliva and water. The resulting compartment syndrome could be treated by fasciotomy and multiple debridement, with which a major amputation could be prevented. The course of the treatment and the resulting functional results are described, as well as a brief overview of the literature and a treatment proposal for similar cases.

The effects of sevoflurane on cerebral blood flow autoregulation and flow-metabolism coupling during cardiopulmonary bypass

BACKGROUND

previous studies on non-cardiac surgical patients have shown that cerebral pressure-flow autoregulation and cerebral flow-metabolism coupling are maintained with sevoflurane. The effects of sevoflurane on cerebral blood flow (CBF) autoregulation and flow-metabolism coupling during cardiopulmonary bypass (CPB) have not been studied previously.

METHODS

the effects of sevoflurane-induced burst suppression, monitored with electroencephalography (EEG), on cerebral blood flow velocity (CBFV), cerebral oxygen extraction (COE) and flow autoregulation, were studied in 16 patients undergoing cardiac surgery. The experimental procedure was performed during non-pulsatile CPB with mild hypothermia (34 degreesC) in fentanyl/droperidol-anesthetized patients. Middle cerebral artery transcranial Doppler flow velocity, right jugular vein bulb oxygen saturation and jugular venous pressure were measured continuously. Autoregulation was tested during changes in the mean arterial pressure (40-90 mmHg), induced by sodium nitroprusside and norepinephrine before (control), and during additional sevoflurane administration, in a dose that resulted in an EEG burst-suppression level of 4-6/min.

RESULTS

sevoflurane, at an inspired concentration of 3.36 ± 0.03%, induced a 17% decrease in CBFV (P<0.05) and a 22% decrease in COE (P<0.05) compared with the control. The slope of the positive relationship between CBFV and cerebral perfusion pressure was steeper with sevoflurane (p<0.01) compared with control measurements, as was the slope of the negative relationship between cpp and coe (p<0.01).

CONCLUSION

burst-suppression doses of sevoflurane exert an intrinsic cerebral vasodilatory effect, which impairs CBF autoregulation during mildly hypothermic CPB. Furthermore, during sevoflurane administration, CBF is in excess relative to oxygen demand, indicating a partial loss of the cerebral flow-metabolism coupling.

Long-term ethanol self-administration by the nonhuman primate, Macaca fascicularis, decreases the benzodiazepine sensitivity of amygdala GABA(A) receptors

BACKGROUND

Rodent models of chronic alcohol exposure are typically constrained to relatively short periods of forced ethanol due to the lifespan of these animals. Nonhuman primate models, particularly those employing long-term self-administration, are conceptually more similar to human alcoholic individuals.

METHODS

We performed whole-cell patch clamp recordings on acutely dissociated amygdala neurons isolated from cynomolgus macaque coronal temporal lobe slices. Slices were prepared from control monkeys or monkeys allowed to self-administer oral ethanol for 18 months. Flunitrazepam and acute ethanol modulation of currents gated by exogenous gamma-aminobutyric acid (GABA) application was assessed in these isolated neurons. Complementary experiments were performed on amygdala total RNA using quantitative real-time reverse transcription/polymerase chain reaction to understand potential ethanol-dependent adaptations to subunit composition.

RESULTS

Gamma-aminobutyric acid-gated currents from ethanol-exposed macaque amygdala neurons exhibited reduced modulation by flunitrazepam compared with control neurons. However, this was specific for benzodiazepines as the modest inhibition of GABA-gated currents by acute ethanol was not affected by the chronic ethanol consumption. We also measured mRNA expression levels for the beta, gamma, and delta subunits in total amygdala RNA isolated from control and ethanol-drinking animals. beta1 and gamma2 expression was significantly reduced in samples from ethanol-exposed amygdala.

CONCLUSIONS

Our findings demonstrate that chronic ethanol self-administration reduces the benzodiazepine sensitivity of amygdala GABA(A) receptors. This reduced sensitivity may be the result of decreased expression of an amygdala gamma subunit. These findings suggest that, while rodent and nonhuman primate models of chronic ethanol exposure share many characteristics, the specific molecular adaptations associated with the amygdala GABAergic system may not be identical.

[Drug facilitated sexual assault]

In line with the fact that there is little information regarding drug facilitated sexual assault in national medical literature, the authors aimed to prepare a review of the phenomenon based on available international references. Therefore we offered a definition of the concept of sexual assault, and rape in particular. Consent and ability for valid consent for sexual intercourse were defined as well. A review contains discussion about the basic elements of a concept of drug-facilitated sexual assault. There is also available information in regard to pharmacology of common data rape drugs, i.e. flunitrazepam, gamma-hydroxybutyrate (GHB), and ketamine. We indicate the utmost importance of prompt collecting of biological samples for toxicological screening in patients who are suspected victims of drug facilitated sexual assault.

Dysfunction of GABAA receptor glycolysis-dependent modulation in human partial epilepsy

A reduction in GABAergic neurotransmission has been put forward as a pathophysiological mechanism for human epilepsy. However, in slices of human epileptogenic neocortex, GABAergic inhibition can be clearly demonstrated. In this article we present data showing an increase in the functional lability of GABAergic inhibition in epileptogenic tissue compared with nonepileptogenic human tissue. We have previously shown that the glycolytic enzyme GAPDH is the kinase involved in the glycolysis-dependent endogenous phosphorylation of the alpha1-subunit of GABA(A) receptor, a mechanism necessary for maintaining GABA(A) function. In human epileptogenic cortex obtained during curative surgery of patients with partial seizures, we demonstrate an intrinsic deficiency of GABA(A) receptor endogenous phosphorylation resulting in an increased lability of GABAergic currents in neurons isolated from this tissue when compared with neurons from nonepileptogenic human tissue. This feature was not related to a reduction in the number of GABA(A) receptor alpha1-subunits in the epileptogenic tissue as measured by [(3)H]flunitrazepam photoaffinity labeling. Maintaining the receptor in a phosphorylated state either by favoring the endogenous phosphorylation or by inhibiting a membrane-associated phosphatase is needed to sustain GABA(A) receptor responses in epileptogenic cortex. The increased functional lability induced by the deficiency in phosphorylation can account for transient GABAergic disinhibition favoring seizure initiation and propagation. These findings imply new therapeutic approaches and suggest a functional link to the regional cerebral glucose hypometabolism observed in patients with partial epilepsy, because the dysfunctional GABAergic mechanism depends on the locally produced glycolytic ATP.

Evaluation of the influence of protein precipitation prior to on-line SPE–LC–API/MS procedures using multivariate data analysis☆

Matrix effects on mass spectrometry (MS) response were investigated with three atmospheric pressure ionization (API) sources after on-line solid-phase extraction (SPE) of human plasma. On-line SPE was evaluated with one restricted access material (RAM), two large particle supports (LPS) and one monolith. A sample protein precipitation (PP) with acetonitrile (2:1) and a direct injection were tested. Principal component analysis (PCA) was performed to simplify data presentation and interpretation. Protein precipitation was found to be mandatory for reducing signal modification. Regarding sensitivity towards matrix effects after PP, atmospheric pressure photoionization (APPI) was globally the least sensitive ionization mode while electrospray ionization ESI was the most sensitive.

Commercial valerian interactions with [3H]Flunitrazepam and [3H]MK-801 binding to rat synaptic membranes

Valeriana officinalis extracts are used in folkloric medicine for their sedative, hypnotic and tranquilizer effects. Using [3H]flunitrazepam binding as an indicator, the interactions of commercial Valerian extracts with GABA(A) receptors were examined. There was considerable fluctuation among the different extracts, some mildly enhanced [3H]flunitrazepam binding, others had no effect and others had inhibitory effects, independent of standardization by valerenic acid. Central depression can also be accomplished by a reduction of excitatory transmission. Valerian extracts had modest inhibitory effects on [3H]MK-801 binding, an indicator of NMDA-Valerian interactions. Spectral analyses (UV region) did not show marked differences among the different extracts. The inhibitory effects of one of the extracts on [3H]flunitrazepam binding was somewhat stable, while on [3H]MK-801 binding the inhibitory effects were lost within months. These results suggest that particular care should be taken in analysing and interpreting results from commercial Valerian preparations.

Concurrent use of methamphetamine, MDMA, LSD, ketamine, GHB, and flunitrazepam among American youths

BACKGROUND

The magnitude and the characteristics of the use of methamphetamine, MDMA (Ecstasy), LSD (d-lysergic acid diethylamide), ketamine, GHB (gamma-hydroxybutyrate), and flunitrazepam (Rohypnol) were examined in a probability sample of the U.S. civilian population that included multiethnic urban, suburban, and rural youths aged 16-23 (N=19,084).

METHODS

Data were drawn from the National Survey on Drug Use and Health (NSDUH). Logistic regression analyses were conducted to identify the characteristics associated with the use of each of these drugs and of multiple drugs.

RESULTS

Approximately 20% of youths aged 16-23 reported having ever used one or more of these drugs. Less than 1% of club drug users used club drugs only, and 82% of them had ever used three or more drug classes. Females were more likely than males to report using multiple club drugs. Recent users of methamphetamine were most likely to be females and adolescents aged 16 or 17. Recent users of MDMA tended to be young adults aged 18-21 and residents of metropolitan areas. Most recent users of LSD were adolescents aged 16-19 and those in low-income families. Ketamine users were primarily employed youths. Staying in school and getting married were associated with decreased odds of club drug use. Club drug use was highly associated with the presence of criminal behaviors and recent alcohol abuse or dependence.

CONCLUSIONS

Adolescents are more likely than young adults to use multiple drugs. The clustering of multidrug use and alcohol use disorder is a cause of concern.

GABARAP is not essential for GABA receptor targeting to the synapse

GABA(A) receptors (GABA(A)Rs) containing the gamma2 subunit are thought to require the interacting protein GABARAP (GABA(A)R associated protein) for trafficking to the neuronal plasma membrane. In order to assess whether GABARAP is required for GABA(A) receptor accumulation at synaptic sites, we analysed a GABARAP knockout mouse. GABARAP deficient mice are phenotypically normal and do not show up-regulation of other GABARAP homologues. Also, the total number of GABA(A)Rs, as assessed by benzodiazepine binding, is unaffected by the loss of GABARAP. Immunocytochemistry of cortical sections showed no differences in the expression and punctate distribution of the gamma2 subunit and the receptor anchoring protein gephyrin between GABARAP deficient and wild-type mice. Thus, GABARAP is not essential for trafficking gamma2 subunit containing GABA(A)Rs to the neuronal plasma membrane or targeting them to inhibitory synapses.

Flunitrazepam abuse and malicious use in Texas, 1998-2003

Flunitrazepam is a potent benzodiazepine that is subject to abuse and malicious use. This study describes the patterns of flunitrazepam abuse and malicious use calls received by Texas poison centers during 1998-2003. The distribution of calls by year of call, geographic location of caller, patient gender and age, exposure site, and medical outcome were determined. There was no clear annual trend for abuse calls, but there was a consistent decline in the number of malicious use calls. A significantly higher percentage of abuse calls originated in south and west Texas and of malicious use calls in west Texas. Most abuse patients were males (55%) and adolescents (76%), and most of the exposures occurred in patient's own residence (68%), followed by school (16%). Most of the malicious use patients were females (93%) and adults (74%), and the greatest proportion of the exposures occurred in public areas (47%), followed by the patient's own residence (26%). The highest percentage of both abuse (48%) and malicious use (55%) involved minor effects. However, malicious use calls were significantly less likely to involve no effect (2% vs. 21%) and more likely to involve moderate effects (36% vs. 23%). Reported flunitrazepam abuse and malicious use calls in Texas differed with respect to geographic location of the caller, patient gender and age, exposure site, and medical outcome. Poison centers and health care providers might want to consider these differences when targeting populations for education and prevention efforts.

An abuse liability comparison of flunitrazepam and triazolam in sedative drug abusers

The present double-blind, placebo-controlled study compared the acute effects of oral administration of the benzodiazepine hypnotics flunitrazepam (6 mg/70 kg) and triazolam (1 and 2 mg/70 kg) on measures relevant to abuse liability as well as on psychomotor performance and observer- and participant-rated measures of drug effects in nine sedative drug abusers. Analysis of participant-rated measures collected 24 h after drug administration (next-day; assessing the overall effects of the drug received 24 h earlier) indicated that flunitrazepam, but neither triazolam dose, produced significant increases relative to placebo in next-day ratings of drug liking, the amount of money the drug would be worth on the street, and the amount of money the participant would be willing to pay for the drug on the street. Importantly, these abuse liability differences between flunitrazepam and triazolam were present at a dose of flunitrazepam (6 mg/70 kg) that produced overall drug effects that were comparable to, or significantly less than, those of a high triazolam dose (2 mg/70 kg). Consistent with results of a previous study in our laboratory, these results suggest that flunitrazepam may have a greater abuse liability than triazolam, and that this abuse liability difference emerges on measures taken 24 h after drug administration but not on same-day measures.

[Use of the health insurance database by the centres for evaluation and information on pharmacodependance: examples, interests and future prospects]

In France, the observation and evaluation of drug abuse and dependence associated with pychoactive medications are the responsibility of the National Commission for Narcotics and Psychotropic Drugs. In order to assist this commission, several centres for evaluation and information on pharmacodependence (CEIP) were created throughout in France. Recently, in order to complete their epidemiological tools, several centres have developed another pharmacoepidemiological approach using data for refunded prescriptions obtained from the local and regional French Health Insurance database. This article underlines the potential contribution of the Health Insurance database to improving knowledge of drug use in the real-life conditions based on studies performed by the CEIP. Several examples are given showing the extent of the possibilities (population-based studies, cohort studies, development of misuse indicators). In spite of their limitations (e.g. the difference between consumption and delivery), these examples confirm that these database may be a novel tool for CEIP to assess a potential abuse of a medication.

A brief overview of the clinical pharmacology of "club drugs"

Four different "club drugs" are reviewed: MDMA (methylenedioxymethamphetamine, "Ecstasy"), GHB (gamma-hydroxybutyrate), ketamine, and Rohypnol (flunitrazepam). The neurobiology, clinical pharmacology, and treatment issues for each are discussed.

Measurement of Adolescent Drug Use

There is widespread agreement that estimates of adolescent drug use prevalence from the National Household Survey of Drug Abuse (NHSDA) and Monitoring the Future (MTF) are subject to considerable measurement error. Nevertheless, some have suggested that trends over time in these prevalence estimates probably reflect true trends in drug use, since underreporting may be assumed to be constant over time. A recent National Research Council report criticizes this assumption on logical grounds. The present study examines adolescent drug use responses on the NHSDA and MTF for evidence of "drug omission," "jargon confusion" and "conceptual confusion," three types of misreporting expected to vary in magnitude with changes in drug use practices and changes in survey items. Results demonstrate that adolescent drug users are significantly more likely than adults to report use of drugs not listed in the NHSDA. Among adolescents who wrote in the "other" drugs they used, 66% and 86% of hallucinogen and inhalant responses showed confusion over the meaning of the pharmacological terms used in the NHSDA. Almost 20% of MTF respondents who report lifetime use of Rohypnol or ecstasy, when specifically queried about these drugs, deny lifetime use of any substances in the drug classes intended to assess use of Rohypnol and ecstasy. MTF respondents reporting lifetime use of PCP underreport use of hallucinogens at rates that vary substantially over time, from a high of 45% (in 1986), to a low of just 8% (in 1998). The implications of these findings for adolescent drug use prevalence estimation and survey design are discussed.

Effects of etifoxine on ligand binding to GABA(A) receptors in rodents

The GABA(A) receptor/chloride ionophore is allosterically modulated by several classes of anxiolytic and anticonvulsant agents, including benzodiazepines, barbiturates and neurosteroids. Etifoxine, an anxiolytic and anticonvulsant compound competitively inhibited the binding of [(35)S]t-butylbicyclophosphoro-thionate (TBPS), a specific ligand of the GABA(A) receptor chloride channel site. To investigate the etifoxine modulatory effects on the different binding sites of the GABA(A) receptor complex, we have examined the effects of etifoxine on binding of the receptor agonist [(3)H]muscimol and the benzodiazepine modulator [(3)H]flunitrazepam in rat brain membrane preparations. The anticonvulsant properties of etifoxine combined with muscimol and flunitrazepam were performed in mice with picrotoxin-induced clonic seizures. Etifoxine modestly enhanced binding of [(3)H]muscimol and of [(3)H]flunitrazepam by increasing the number of binding sites without changing the binding affinity of [(3)H]flunitrazepam. In contrast, the compound decreased the affinity of muscimol for its binding site. In vivo, the combination of subactive doses of etifoxine with muscimol or flunitrazepam produced an anticonvulsant additive effect against the picrotoxin-induced clonic seizures in mice. These results suggest that the interaction of etifoxine on the GABA(A) receptor complex would allosterically modify different binding sites due to conformational changes. Functionally, the resulting facilitation of GABA transmission underlies the pharmacological properties of etifoxine.

Plasticity of GABA(a) system during ageing: focus on vestibular compensation and possible pharmacological intervention

The lesion of the vestibular end organ evokes static and dynamic symptoms, which spontaneously regress during a complex process known as 'vestibular compensation'. Vestibular compensation is age-dependent and involves several transmitter-identified pathways in the central nervous system. In this paper we studied the time course of vestibular compensation in adult (3 months) and old (24 months) rats and correlated behavioral recovery with modifications of glutamic acid decarboxylase (GAD) mRNA expression and benzodiazepine receptor density in different brain areas. Compensation in adult rats was complete 28 days after hemilabyrinthectomy, whereas old rats still showed significant behavioral impairment. A higher GABAergic tone was found in old rats, as indicated by higher benzodiazepine receptor density in lateral vestibular nucleus and higher mRNA level for glutamic acid decarboxylase in cerebral cortex and medial vestibular nucleus. In adult, compensated rats, benzodiazepine receptor density in the vestibular nuclei was normal 28 days after lesion, whereas GAD mRNA level was higher in anterior cingulate cortex, only. On the contrary, these parameters were still altered in anterior cingulate and somatosensory cortex, basal ganglia, vestibular nuclei and cerebellum in old rats 28 days after vestibular lesion. We also evaluated the effect of the ergoline derivative nicergoline on behavioral and neurochemical correlates of vestibular compensation in old rats. Nicergoline treatment attenuated the severity of oculomotor and postural symptoms after vestibular lesion and reversed most of these age- and lesion-induced alterations in GAD mRNA expression. Thus, lesion-related alterations of the GABAergic transmission and behavioral profile after vestibular lesion are age-dependent.

Gamma-aminobutyric acidA and benzodiazepine receptor alterations in the rat brain after unilateral 6-hydroxydopamine lesions of the medial forebrain bundle

Gamma-aminobutyric acidA (GABA(A)) and benzodiazepine (BZ) receptors and dopamine uptake sites in 6-hydroxydopamine-treated rat brains were studied by receptor autoradiography using [3H]muscimol, [3H]flunitrazepam and [3H]mazindol binding, respectively. The rats were unilaterally lesioned in the medial forebrain bundle and the brains were analyzed at 1, 2, 4 and 8 weeks post-lesion. Degeneration of the nigrostriatal pathway after 6-hydroxydopamine treatment caused a significant loss of dopamine uptake sites in the ipsilateral striatum and substantia nigra (SN) in the lesioned animals. In the contralateral side, however, dopamine uptake sites showed no significant changes in the brain throughout the experiments. On the other hand, no significant changes in GABA(A) receptors were observed in the brain of both the ipsilateral and contralateral sides during post-lesion. In contrast, BZ receptors were observed significantly increased in the ventromedial part of striatum of the ipsilateral side from 2 to 4 weeks post-lesion. Furthermore, a transient increase in BZ receptors was found in the ipsilateral SN only at 2 weeks post-lesion. In contralateral side, most regions examined showed no significant changes in BZ receptors throughout the experiments except for a transient increase in the SN at 1 week post-lesion. These results demonstrate that 6-hydroxydopamine can cause severe functional damage in dopamine uptake sites in the nigrostriatal pathway. Our results also suggest that the change in BZ receptors is more pronounced than that in GABA(A) receptors in the brain after 6-hydroxydopamine treatment. Furthermore, our findings suggest that the increase in BZ receptors in the brain of 6-hydroxydopamine-treated model may be due to the additional disruption of the nigrostriatal dopamine system. Thus, investigations into possible changes in neurotransmitter receptors other than dopaminergic receptors appear to be important for the elucidation of pathogenesis of Parkinsons disease.

[Clonidine combined with flunitrazepam before carotid endarterectomy decreases cerebrovascular CO2 reactivity]

OBJECTIVE

Assess cerebrovascular CO2 reactivity changes using transcranial Doppler sonography (TCD) after oral premedication associating clonidine (2 micrograms.kg-1) and flunitrazepam (70 micrograms.kg-1) in patients scheduled for carotid stenosis surgery.

STUDY DESIGN

Prospective study, not randomized, the patient being his own "control".

PATIENTS AND METHODS

Thirteen patients undergoing carotid endarterectomy under cervical plexus block were included. The monitoring included: automated arterial pressure cuff, ECG, radial artery catheter, TCD with probe secured in temporal window. The study of the cerebrovascular CO2 reactivity was performed with TCD recording on the side of operation, on the day before, and on the day of carotid endarterectomy, 90 min after the premedication, immediately before surgery. To change PaCO2, four ventilatory states were successively performed: (1) normoventilation, (2) hyperventilation, (3) hypoventilation, (4) "breath-holding test". At each state, it was noted: HR, MAP, PaCO2, mean blood flow velocity in the middle cerebral artery (Vm-MCA), resistance index of Pourcelot (RI), cerebrovascular reactivity (slope Vm-MCA/PaCO2). The results (+/- SEM) were analyzed by Wilcoxon test or t test.

RESULTS

After premedication, cerebrovascular CO2 reactivity decreased (0.043 +/- 0.019 vs 0.034 +/- 0.013; p < 0.05) without modification of RI (0.578 +/- 0.291 vs 0.612 +/- 0.025; NS). No complication during carotid clamping was reported.

CONCLUSION

Inclusion of clonidine in premedication before carotid stenosis surgery must be questioned because a decrease of cerebrovascular CO2 reactivity could be deleterious in case of intraoperative stroke.

Characterization of benzodiazepine receptor binding in immature rat brain after kainic acid administration

PURPOSE

To evaluate the effects of status epilepticus on benzodiazepine (BDZ) receptor binding in immature rat brain.

METHODS

Twenty-four immature (15 days old) and six adult (90 days old) rats were used in this study. Status epilepticus was induced in immature animals by administration of kainic acid (7 mg/kg intraperitoneal), whereas adults rats received saline. Animals were killed 72 hours or 35 days after treatment, and their brains were used for in vitro autoradiography experiments to determine BDZ binding.

RESULTS

In basal conditions and compared with the adult group, immature animals presented reduced BDZ binding in the entorhinal cortex, substantia nigra pars reticulata, and periaqueductal gray. Seventy-two hours after kainic acid-induced status epilepticus, immature rats showed significantly increased BDZ in the frontal (48%), cingulate (39%), sensorimotor (39%), piriform (57%), and entorhinal (59%) cortices, the medial (84%) and basolateral (27%) amygdaloid nuclei, the dentate gyrus (51%), and the substantia nigra pars reticulata (43%). Thirty-five days after status epilepticus, immature rats displayed decreased BDZ binding in the entorhinal cortex (48%), dentate gyrus (36%), and fields CA1, CA2, and CA3 of Ammon's horn (30%).

CONCLUSIONS

The present study demonstrates that status epilepticus and temporal lobe epilepsy produce a characteristic pattern of BDZ binding changes in the immature rat brain that differs from the one previously seen in adults.

Distribution of the gamma-aminobutyric acid(A) receptor complex alpha 5 subunit in chick brain. An immunocytochemical and autoradiographic study

This work reports the distribution of the gamma-aminobutyric acid(A) (GABA(A)) receptor complex alpha5 subunit in the chick using an antibody raised against this subunit in the rat, an immunoprecipitation study and a comparative autoradiographic study using [(3)H]flunitrazepam in the presence of 1 microM zolpidem, which is considered to bind only to those areas presenting the alpha5 subunit. The specificity of the antibody for the chick GABA(A) receptor complex alpha5 subunit is supported by the similar bands obtained by Western blotting from rat and chick, the immunoprecipitation study and the general agreement in the distribution and pattern of labelling of this antibody in both species. The immunocytochemical and autoradiographic distributions in both the chick and rat are compared and some areas with disagreement between these distributions are discussed. The general conclusion is that the alpha5 subunit of the GABA(A) complex receptor seems to have been conserved along evolution.

Identification of benzodiazepine binding site residues in the gamma2 subunit of the gamma-aminobutyric acid(A) receptor

gamma-Aminobutyric acid(A) receptor gamma-subunits are important for benzodiazepine (BZD) binding and modulation of the gamma-aminobutyric acid-mediated Cl(-) current. Previously, by using gamma2/alpha1 chimeric subunits, we identified two domains of the gamma2-subunit, Lys-41-Trp-82 and Arg-114-Asp-161, that are, in conjunction, necessary and sufficient for high-affinity BZD binding. In this study, we generated additional gamma2/alpha1 chimeric subunits and gamma2 point mutants to identify specific residues within the gamma2 Lys-41-Trp-82 region that contribute to BZD binding. Mutant gamma2 and gamma2/alpha1 chimeric subunits were expressed with wild-type alpha1 and beta2 subunits in HEK 293 cells, and the binding of several BZDs was measured. We present evidence that the gamma2 region Met-57-Ile-62 is important for flunitrazepam binding and that, in particular, gamma2 Met-57 and gamma2 Tyr-58 are essential determinants for conferring high-affinity binding. Furthermore, we identify an additional residue, gamma2 Ala-79, that not only is important for high-affinity binding by flunitrazepam (a strong positive modulator) but also plays a crucial role in the binding of the imidazobenzodiazepines Ro15-1788 (a zero modulator) and Ro15-4513 (a weak negative modulator) in the BZD binding pocket. Results from site-directed mutagenesis of gamma2 Ala-79 suggest that this residue may be part of a microdomain within the BZD binding site that is important for binding imidazobenzodiazepines. This separation of drug-specific microdomains for competitive BZD ligands lends insight into the structural determinants governing the divergent effects of these compounds.

[Dependence on psychotropic drugs and substitution treatment: recent trends. The OPPIDUM study of the Centers for Evaluation and Information on Drug Dependence (CEIP), October 1997]

The aim of this study was to identify the latest trends in psychotropic drug use and the effect of the increase of maintenance treatments for serious opioid addiction. The results are based on data from OPPIDUM, an annual survey primarily concerned with the consumption of licit and illicit drugs. The study involved 1066 drug addicts recruited during the month of October 1997 from 38 French health centres connected with the Centres for Evaluation and Information on Drug Addiction (CEIP). The most frequently reported drugs were benzodiazepines (n = 323), some of which, especially flunitrazepam (Rohypnol, n = 123), are extremely addictive. The data showed a slight decrease in heroin consumption as well as a marked increase in the use of maintenance treatments. The association between benzodiazepines and buprenorphine (Subutex) should consequently be studied, whether buprenorphine is being used illicitly or prescribed as a maintenance treatment.

Prevalence, patterns, and correlates of voluntary flunitrazepam Use

OBJECTIVE

To determine prevalence, patterns, and correlates of voluntary flunitrazepam use in a sample of sexually active adolescent and young adult women 14 to 26 years of age.

DESIGN

Cross-sectional survey.

SETTING

University-based ambulatory reproductive health clinics.

PATIENTS OR OTHER PARTICIPANTS

There were 904 women self-identified as white, African-American, or Mexican-American.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

Lifetime, frequency, patterns, and physical effects of flunitrazepam use.

RESULTS

Lifetime use was reported by 5.9% (n = 53) of subjects, with frequency of use ranging from 1 to 40 times. Flunitrazepam was taken most often with alcohol (74%), and 49% took this substance with other illicit drugs. Logistic regression analyses controlling for age and race/ethnicity found that users were significantly more likely than were nonusers to report lifetime use of marijuana (odds ratio [OR] = 3.6) or LSD (OR = 5.2), having a peer or partner who used flunitrazepam (OR = 21.7), pressure to use flunitrazepam when out with friends (OR = 2.7), and a mother who had at least a high school education (OR = 2.6). Finally, 10% of voluntary users reported experiencing subsequent physical or sexual victimization.

CONCLUSIONS

Voluntary use of flunitrazepam is becoming a health concern to sexually active young women who reside in the southwestern United States. Young women who have used LSD or marijuana in the past or who have a peer or partner who used this drug appear to be at the greatest risk.

Abuse liability of flunitrazepam among methadone-maintained patients

Abuse liability and acute subjective and psychomotor effects of flunitrazepam were assessed in ten methadone-maintained males with history of benzodiazepine and alcohol use, who voluntarily participated in a double-blind, controlled, cross-over, randomized clinical trial. There were six experimental sessions in which a single oral dose of flunitrazepam 1, 2, and 4 mg; triazolam 0.5 and 0.75 mg; and placebo was given. Evaluations included physiological measures; psychomotor performance tasks (simple reaction time, Digit Symbol Substitution Test, balance task, Maddox-wing device); and self-administered subjective effects questionnaires [Addiction Research Center Inventory (ARCI), Profile of Mood States (POMS), a series of visual analog scales (VAS)]. All drugs but flunitrazepam 1 mg caused an impairment of psychomotor tasks. Effects were more evident with the highest doses of both drugs. Only flunitrazepam 4 mg produced a significant decrease in balance time. Triazolam 0.75 mg induced increases in sedation measured by ARCI-PCAG, depression in POMS, and VAS-drowsiness scores. Flunitrazepam 4mg caused euphoria-related effects as measured by increases in ARCI-MBG and "high" scores in the VAS. Our findings of flunitrazepam-induced euphoria in methadone-maintained subjects together with epidemiological evidence of flunitrazepam abuse by opioid dependents, suggest that it may be included in the group of benzodiazepines with a relatively high abuse potential.

Flunitrazepam and triazolam: a comparison of behavioral effects and abuse liability

The performance, observer-rated, and participant-rated effects of orally administered placebo, and two benzodiazepines, flunitrazepam (2, 4 and 8 mg/70 kg) and triazolam (0.25, 0.5 and 1 mg/70 kg), were compared in 14 sedative drug abusers using a double-blind crossover design. Both flunitrazepam and triazolam produced dose-related decrements in memory and psychomotor/cognitive performance, and increases in many participant- and observer-rated measures. Effects of flunitrazepam had an earlier onset and a longer duration than those of triazolam. Although there was evidence that the flunitrazepam doses selected for study were somewhat higher overall relative to the selected triazolam doses, analysis of the participant-rated measures collected 24 h after drug administration (next-day) suggests that flunitrazepam may have a greater abuse liability than triazolam when abuse liability is assessed 24 h after drug administration. The highest flunitrazepam dose produced effects that were significantly greater than those of the highest triazolam dose on next-day ratings of good effects, take again, and worth; all tested flunitrazepam doses produced effects greater than any triazolam dose on next-day ratings of liking and take again. The highest flunitrazepam dose, but no triazolam dose, significantly increased the maximum dollar value at which participants chose drug over money in a Drug versus Money Choice Procedure.

Rohypnol misuse in the United States

Rohypnol, a potent sedative-hypnotic drug prescribed extensively throughout the world, is illicit in the United States. Recently, this drug has gained popularity among United States youths as a cheap means of intoxication and subsequently has become the focus of numerous criminal investigations. College men are alleged to slip Rohypnol tablets into unsuspecting women's drinks and then sexually abuse their sedated victims. Although law enforcement agencies and drug policy groups consider Rohypnol to be an "imminent problem," little is actually known about patterns of misuse. Presented here is a brief overview of Rohypnol's contemporary appearance in the United States.

Determination of omeprazole in human plasma by high-performance liquid chromatography

A new method for the determination of omeprazole in human plasma was developed. Omeprazole was extracted from plasma with toluene-isoamylalcohol (95:5, v/v), the organic phase was evaporated, dissolved in the mobile phase and injected into a reversed-phase C18 column. Flunitrazepam was used as an internal standard. The mobile phase consisted of 47% methanol and 53% of 0.1 M dipotassium hydrogenphosphate, pH 7.8. The spectrophotometric detection was performed at 302 nm. Limit of quantitation was 9.7 ng/ml and the calibration curve was linear up to 1240 ng/ml.

Photoaffinity labeling of peripheral benzodiazepine receptors in R-3327 Dunning prostatic tumors

Photoaffinity labeling of peripheral benzodiazepine receptors (PBZr) in mitochondrial and microsomal fractions from AT-1, H, and G Dunning R-3327 tumor sublines was performed using the photoaffinity ligand 3H-PK 14105. Subsequent sodium dodecyl sulphate (SDS)-polyacrylamide gel electrophoresis (PAGE) revealed specific labeling of a 17 kDa protein in the microsomal fractions from these tumors. In the mitochondrial fractions, however, two bands with the apparent molecular mass of 17 and 18 kDa in AT-1 and H tumors were identified, whereas only the 17 kDa band was present in G tumors. Using another ligand, 3H-flunitrazepam, to photoaffinity label PBZr, proteins with molecular masses of 17, 30, 42, and 48 kDa were identified. These data suggest the possibility of different subclasses of PBZrs in Dunning prostatic tumors.

Abuse of flunitrazepam (Rohypnol) and other benzodiazepines in Austin and south Texas

Flunitrazepam (Rohypnol) is a benzodiazepine sedative-hypnotic that has generated significant media attention in the United States because of its abuse and its association with "date rape." A field investigation was conducted in south Texas to ascertain the nature and consequences of the abuse of flunitrazepam. In semistructured interviews, 66 subjects identified as flunitrazepam users were asked about their use of alcohol and other drugs and their sexual behaviors. Many subjects identified the drugs they had used as "roches" and gave descriptions of tablets of other benzodiazepines that were not consistent with flunitrazepam. Almost all subjects used other drugs, primarily alcohol and marijuana. Adverse consequences included amnesia, discoordination, automobile accidents, sexual assault, and respiratory depression or arrest. A significant proportion of the subjects reported that continued use was unappealing to them. The abuse of sedative-hypnotics in southeast Texas involves several benzodiazepines and is not limited to flunitrazepam.

Mapping of GABAA receptor sites that are photoaffinity-labelled by [3H]flunitrazepam and [3H]Ro 15-4513

The GABAA receptor in brain membranes prepared from bovine cerebral cortex and cerebellum has been photoaffinity-labelled by the classical benzodiazepine agonist, [3H]flunitrazepam, or by the partial inverse agonist [3H]Ro 15-4513. Following solubilization and precipitation with trichloroacetic acid, the photoaffinity-labelled receptor preparations were subjected to specific chemical cleavage using hydroxylamine, a reagent which cleaves specifically at a relatively rare Asn-Gly bond. The resulting peptides were resolved by denaturing polyacrylamide gel electrophoresis and mapping of these peptides to the known amino acid sequences of the GABAA receptor subunits has localized the photoaffinity-labelling sites for these two ligands to distinct portions of the alpha subunits. It is shown that the site for [3H]flunitrazepam photoaffinity-labelling in the receptor populations of both the cerebral cortex and cerebellum occurs within residues 1-103 of the bovine alpha 1 subunit sequence (or within analogous segments of homologous alpha subunits). In contrast, the site of photoaffinity-labelling by [3H]Ro 15-4513 in the cerebral cortex and in the diazepam-sensitive GABAA receptor population of the cerebellum lies between residues 104 and the carboxy-terminus of the bovine alpha 1 or homologous alpha subunits. However, the [3H]Ro 15-4513 photoaffinity-labelling site for the diazepam-insensitive receptors of the cerebellum is shown to occur within residues 1-101 (alpha 6 subunit numbering). These results demonstrate that the photoaffinity-labelling sites for [3H]flunitrazepam and [3H]Ro 15-4513 on the GABAA receptor are localized to distinct domains of the alpha 1 subunit and that [3H]Ro 15-4513 photoaffinity labels a site on the alpha 6 subunit that is unique from its site of labelling on the alpha 1 subunit.

Temporal lobe central benzodiazepine binding in unilateral mesial temporal lobe epilepsy

PET-demonstrated decreases in [11C]flumazenil binding occur in anterior mesial temporal structures on the side of epileptogenesis in unilateral mesial temporal lobe epilepsy. We performed quantitative autoradiography on anterior mesial and lateral temporal specimens from 11 subjects with unilateral mesial temporal lobe epilepsy and six neurologically normal controls to identify the predominant in vitro correlates of the decreased [11C]flumazenil binding. In anterior mesial temporal regions exhibiting the greatest neuronal cell loss, decreases in agonist and antagonist binding to type 1 and 2 (central) benzodiazepine binding sites were highly correlated with neuronal cell counts. Cell loss and decreased binding were particularly prominent in the lateral portion of hippocampal region CA1, adjacent to CA2. Lateral temporal central benzodiazepine binding was diffusely increased, achieving statistical significance in cortical laminae V and VI. These findings suggest that the predominant source of PET-demonstrated decreases in [11C]flumazenil binding in mesial temporal epilepsy is hippocampal sclerosis, rather than down-regulation of central benzodiazepine binding sites on surviving hippocampal neurons.

Comparison of two regional anesthetic techniques for knee arthroscopy

This study compares the efficacy of "3-in-1 block" versus femoral nerve block for knee arthroscopy. One-hundred patients had a 3-in-1 block; 180 patients had a femoral nerve block. The 3-in-1 block provided anesthesia in 75 patients; 20 patients needed supplementary local anesthesia. Five patients required a general anesthesia to complete the operation. The femoral nerve block was effective in 88 patients; 90 patients needed intravenous flunitrazepam and/or fentanyl; 2 patients needed general anesthesia. The 3-in-1 block provided more satisfactory muscle relaxation and a longer postoperative analgesia than femoral nerve block. No side effects were recorded in either group. Our results suggest that the 3-in-1 block is the most effective technique of regional anesthesia for knee arthroscopy.

Alterations in the brain GABAA/benzodiazepine receptor-chloride ionophore complex in a genetic model of paroxysmal dystonia: a quantitative autoradiographic analysis

Dystonia is a relatively common syndrome of sustained muscle contractions, frequently causing twisting and repetitive movements or abnormal postures. The most frequent type of dystonia is idiopathic generalized dystonia, whose pathophysiology is largely unknown. In this respect, mutant animal strains with inborn dystonia may be helpful to elucidate the pathophysiological defects involved in idiopathic dystonia. The genetically dystonic (dtsz) hamster is an animal model of paroxysmal dystonia that displays attacks of generalized dystonia either spontaneously or in response to mild environmental stimuli. In the present study, a quantitative autoradiographic analysis of ligand binding to different sites of the GABAA/benzodiazepine receptor-chloride ionophore complex was carried out in 123 brain areas from genetically dystonic mutant hamsters and age-matched control hamsters. Animals were killed 2 weeks after their last dystonic attack. Analysis of the GABA-binding site of the receptor complex, using the ligand [3H]muscimol, and the benzodiazepine site labelled with [3H]flunitrazepam revealed no significant alterations in the binding of either ligand in any of the brain regions examined. In contrast, widespread changes were observed in binding densities of [35S]t-butylbicyclophosphorothionate ([35S]t-butylbicyclophosphorothionate), which labels the picrotoxinin site of the GABAA receptor-chloride ionophore complex. Significantly increased [35S]t-butylbicyclophosphorothionate binding was found in several parts of the thalamus, cortex, and hippocampus as well as in the red nucleus, the subthalamic nucleus, and the granular layer of the cerebellum. Since high-affinity [35S]TBPS binding is thought to represent the closed conformation of the GABA-gated chloride ionophore, increased TBPS binding would indicate an impaired GABAergic function. The study is consistent with the concept that dystonia is caused by impaired connections between the basal ganglia, the thalamus, and frontal association areas. The data on increased [35S]TBPS binding are the first evidence implicating alterations in the GABA-gated chloride ion channel function in a movement disorder, i.e. idiopathic generalized dystonia.

Ibotenic acid lesion of nucleus basalis magnocellularis differentially affects cholinergic, glutamatergic and GABAergic markers in cortical rat brain regions

The present study was undertaken to study the effect of reduced cortical cholinergic activity on gamma-aminobutyric acid (GABA)ergic and glutamatergic mechanisms in cholinoceptive cortical target regions which are assumed to play an important role for realizing cognitive functions. The densities of cortical muscarinic cholinergic receptor subtypes and corresponding receptor genes m1 through m4, N-methyl-D-aspartate (NMDA), alpha-amino-3-hydroxy-5-methyl-isoxazole-4-propionic acid (AMPA) and kainate glutamate receptor subtypes as well as GABAA and benzodiazepine receptors were measured in rats 1 week after unilateral ibotenic acid lesion of the nucleus basalis magnocellularis (Nbm) applying quantitative receptor autoradiography and in situ hybridization. Ibotenic acid lesion resulted in a striking loss of acetylcholinesterase (AChE) staining in the lesioned Nbm which is associated with a 60% decrease in AChE staining and a 30% reduction in [3H]hemicholinium-3 binding in frontal and parietal cortical regions as well fore- and hindlimb areas ipsilateral to the lesion, being more prominent in the more rostral cortical regions. M1-muscarinic cholinergic receptor binding was not changed in any of the cortical regions studied 1 week after lesion. M2-muscarinic receptor binding levels are slightly increased in the parietal cortex only. The lesion-induced increase in parietal cortical M2-muscarinic receptor binding is complemented by an increase in the hybridization signal for the corresponding m4-mRNA transcript. In cortical regions displaying a reduced activity of AChE and decreased levels of high-affinity choline uptake sites due to forebrain cholinergic lesion, NMDA receptor binding was markedly reduced in comparison to the unlesioned brain side whereas AMPA and kainate binding has been significantly increased in these regions. Muscimol binding to GABAA receptors was increased in the rostral portions of frontal and parietal cortices as compared with the unlesioned brain side. Binding levels of benzodiazepine receptors were not affected by the lesion in any of the cortical regions studied. The differential changes in glutamate and GABA receptor subtypes following lesion might be regarded as the consequence of a cortical reorganization compensating for the reduced cholinergic presynaptic input. The data further suggest that presynaptic cortical cholinergic deficits might affect both glutamatergic and GABAergic functions with different intensity and different directions.

[Topographic changes in cerebral electric activity after premedication with flunitrazepam]

AIM

The effects on cerebral function of premedication with the benzodiazepine flunitrazepam and with morphine were studied on the evening of the preoperative day (2 mg flunitrazepam p.o.) and 90 minutes before induction of anaesthesia (2 mg flunitrazepam plus 15 mg morphine i.m.).

DESIGN

The EEG was analysed topographically (17 electrodes) and quantitatively.

RESULTS

As a typical effect of benzodiazepines, increases in electrical activity in the frequency band beta-1 of the power spectrum were observed, and could be demonstrated 10 minutes after oral application, mainly in the frontal and central parts of the cortex. Increases in the powerbands delta and theta indicated induction of sleep approximately 15-20 minutes after application and were not looked upon as an effect of the benzodiazepine exclusively. These increases were noticed first in the central, occipital and temporal areas and after 30 minutes in the frontal parts of the cortex. Flunitrazepam plus morphine showed qualitatively similar but quantitatively less pronounced results. Topographical differences were similar to the results of an application of flunitrazepam alone.

DISCUSSION

The results demonstrate the importance of a topographical as well as quantitative evaluation in studies on complex interactions of sedative or narcotic drugs and their clinical effects on cerebral function.

Motor signs of wakefulness during general anaesthesia with propofol, isoflurane and flunitrazepam/fentanyl and midlatency auditory evoked potentials

Auditory evoked potentials have been used as an indicator of awareness. In the present study we combined epidural analgesia with three techniques of general anaesthesia. Motor signs of intra-operative wakefulness were documented and assessed along with cardiovascular changes and with midlatency auditory evoked potentials. Thirty patients undergoing elective laparotomy were studied as follows: first continuous epidural analgesia was used in all patients to block painful sensation to the level of T5. Intravenous general anaesthesia was induced with propofol (2.5 mg.kg-1 b.w., group 1, n = 10), thiopentone (5 mg.kg-1 b.w., group 2, n = 10) or etomidate (0.2 mg.kg-1 b.w., group 3, n = 10) and maintained with a propofol (3-5 mg.kg-1, group 1), isoflurane (0.4-0.8 Vol%, group 2), flunitrazepam and fentanyl (0.005 mg.kg-1 b.w.) bolus injection every 20 to 30 s (group 3). Heart rate and arterial pressure were recorded continuously. Purposeful movements of the limbs, eye-opening or other movements as well as coughing were documented as motor signs of intra-operative wakefulness. Auditory evoked potentials were recorded in the awake state, after induction and during maintenance of general anaesthesia. Motor signs of intra-operative wakefulness occurred statistically significantly more often in the patients of the flunitrazepam/fentanyl group than in those of the propofol and isoflurane group. There was no correlation between wakefulness and cardiocirculatory parameters. In the awake patients midlatency auditory evoked potentials had high peak to peak amplitudes and a periodic waveform.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of sedation on otoacoustic emissions]

Even though the measurement of transitory evoked otoacoustic emissions (TEOAE) is easy and without problems in babies, sedation might be necessary in children aged between 1 and 4 years. As only very little information is available on the influence of a sedation on the TEOAE, the present study was performed. 35 normal hearing patients who were treated with benzodiazepines as a premedication for an operation were included in the investigation. 15 patients received diazepam and 20 were given flunitrazepam in a dosage of 10 and 1 mg respectively. The TEOAE were measured using the ILO 88 system by Bray and Kemp 1 day before, 1 hour after and 3 days after drug intake. 10 additional subjects of whom measurements were taken at the same time intervals served as controls. No statistically significant changes could be detected before and after drug treatment in respect of amplitudes of the TEOAE and frequency of maximum amplitudes. Hence, we conclude that sedation as used in this study must be considered negligible when measuring TEOAE.

Unconscious perception and mid-latency auditory evoked potentials]

There is a high incidence of intraoperative awareness during cardiac surgery. Mid-latency auditory evoked potentials (MLAEP) reflect the primary cortical processing of auditory stimuli. In the present study, we investigated MLAEP and explicit and implicit memory for information presented during cardiac anaesthesia. PATIENTS AND METHODS. Institutional approval and informed consent was obtained in 30 patients scheduled for elective cardiac surgery. Anaesthesia was induced in group I (n = 10) with flunitrazepam/fentanyl (0.01 mg/kg) and maintained with flunitrazepam/fentanyl (1.2 mg/h). The patients in group II (n = 10) received etomidate (0.25 mg/kg) and fentanyl (0.005 mg/kg) for induction and isoflurane (0.6-1.2 vol%)/fentanyl (1.2 mg/h) for maintenance of general anaesthesia. Group III (n = 10) served as a control and patients were anaesthetized as in I or II. After sternotomy an audiotape that included an implicit memory task was presented to the patients in groups I and II. The story of Robinson Crusoe was told, and it was suggested to the patients that they remember Robinson Crusoe when asked what they associated with the word Friday 3-5 days postoperatively. Auditory evoked potentials were recorded awake and during general anaesthesia before and after the audiotape presentation on vertex (positive) and mastoids on both sides (negative). Auditory clicks were presented binaurally at 70 dBnHL at a rate of 9.3 Hz. Using the electrodiagnostic system Pathfinder I (Nicolet), 1000 successive stimulus responses were averaged over a 100 ms poststimulus interval and analyzed off-line. Latencies of the peak V, Na, Pa were measured. V belongs to the brainstem-generated potentials, which demonstrates that auditory stimuli were correctly transduced. Na, Pa are generated in the primary auditory cortex of the temporal lobe and are the electrophysiological correlate of the primary cortical processing of the auditory stimuli. RESULTS. None of the patients had an explicit memory of intraoperative events. Five patients in group I, one patient in group II, and no patients in group III showed implicit memory of the intraoperative tape message. They remembered Robinson Crusoe spontaneously when they were asked their associations with Friday. In the awake state AEP peak latencies were in the normal range. During general anaesthesia in group I, the peaks Na, Pa did not increase in latency or decrease in amplitude before and after the audiotape presentation. The primary cortical complex Na/Pa could be identified as in the awake state. In contrast, in group II Na, Pa showed a marked increase in latency and a decrease in amplitude or were completely suppressed. CONCLUSIONS. During general anaesthesia auditory information can be processed and remembered postoperatively by an implicit memory function, when the electrophysiological conditions of primary cortical stimuli processing is preserved. Implicit memory can be observed more often when high-dose opioid analgesia is combined with receptor-binding agents like the benzodiazepines than under non-specific anaesthetics like isoflurane. Non-specific anaesthetics seem to provide a more effective suppression of auditory stimuli processing than receptor-specific agents.

[Changes in the cerebral hemodynamics during Rohypnol anesthesia in neurosurgical patients]

Intracranial pressure, cerebral perfusion pressure, and intracerebral blood volume changes were observed in 43 patients with volumetric intracranial processes (intracranial hematomas, tumors) during general rohypnol anesthesia. Intracranial and cerebral perfusion pressures were found to correlate with intracerebral blood volume. Rohypnol anesthesia decreased intracranial pressure by 25% due to reduced arterial blood influx into the head, mechanisms responsible for autoregulation of cerebral circulation being intact.

Midlatency auditory evoked potentials and explicit and implicit memory in patients undergoing cardiac surgery

BACKGROUND

A high incidence of intraoperative awareness during cardiac surgery has been reported. Midlatency auditory evoked potentials (MLAEP) have been used recently as an indicator of awareness. In the current study, memory for information presented during anesthesia was investigated using MLAEP as one experimental indicator in 45 patients scheduled for elective cardiac surgery.

METHODS

In all patients general anesthesia was maintained using high-dosage fentanyl (1.2 mg.h-1). In addition, the patients of group 1 (n = 10) received flunitrazepam (1.2 mg.h-1), the patients of group 2 (n = 10) isoflurane (0.6-1.2 vol%), and the patients of group 3 (n = 10) propofol (4-8 mg.kg-1.h-1). Group 4 (n = 15) served as a control, and those patients were assigned randomly to one of the anesthetic regimes. After sternotomy and before cardiopulmonary bypass, an audiotape, which included an implicit memory task, was presented to the patients of groups 1-3. Auditory evoked potentials were recorded while the patients were awake and during general anesthesia immediately before and after the audiotape presentation. Latencies of the brain stem peak V and the early cortical potentials Na and Pa were measured.

RESULTS

Three to 5 days postoperatively no patient had a clear explicit memory of intraoperative events. However, there were statistically significant differences in the incidence of implicit recall among the groups. Five patients in the flunitrazepam-fentanyl group, 1 patient in the isoflurane-fentanyl group, 1 patient in the propofol-fentanyl group, and no patient in the control group showed an implicit memory of the intraoperative tape message. In the awake state, MLAEP showed high peak-to-peak amplitudes and a periodic waveform. In the patients with implicit memory postoperatively, MLAEP continued to show this pattern during general anesthesia. The early cortical potentials Na and Pa did not increase in latency or decrease in amplitude before or after the audiotape presentation. In contrast, in the patients without implicit memory, MLAEP waveform was severely attenuated or abolished. Na and Pa showed marked increases in latencies and decreases in amplitudes or were completely suppressed. In 9 patients, including all patients (7 of 9) with implicit memory, Pa latency increased less than 12 ms, and 21 of 23 patients without implicit memory showed a Pa latency increase of greater than 12 ms during anesthesia and the audiotape presentation. Therefore, the Pa latency increase of greater or less than 12 ms may provide sensitivity of 100% and specificity of 77% in distinguishing patients with implicit memory from patients without implicit memory postoperatively.

CONCLUSIONS

When the early cortical potentials of MLAEP are preserved during general anesthesia, auditory information may be processed and remembered postoperatively by an implicit memory task.

Mid-latency auditory evoked potentials and circulatory response to loud sounds

We investigated in 60 patients scheduled for elective aorto-coronary bypass grafting if loud sounds by themselves can induce cardiovascular responses and if these could be related to mid-latency auditory evoked potentials (MLAEP). Anaesthesia was induced in group I (n = 20) with flunitrazepam-fentanyl 0.01 mg kg-1 and maintained with flunitrazepam-fentanyl 1.2 mg h-1. Patients in groups II (n = 20) and III (n = 20) received etomidate 0.25 mg kg-1 and fentanyl 0.005 mg kg-1 for induction and 0.6-1.2 vol% isoflurane and fentanyl 1.2 mg h-1, or propofol 4-8 mg kg-1 h-1 and fentanyl 1.2 mg h-1 for maintenance of general anaesthesia. After preparation of the sternum the operation was stopped for several minutes. Then, as a loud auditory stimulus, the sound of the running sternotomy saw was presented to the patients by putting the saw inverted on the sternum for several seconds. Heart rate (HR), arterial pressure (SAP), pulmonary capillary wedge pressure (PCWP), cardiac index, systemic vascular resistance and MLAEP were measured in the awake state, before and after presentation of the sound. Latencies of the peak V, Na, Pa, Nb and P1 were measured. In group I there were statistically significant increases in HR (63.5-70.2 beat min-1), SAP (123.9-146-5 mm Hg) and PCWP (9.2-11.7 mm Hg) after presentation of the sound. These haemodynamic changes were not observed in patients in groups II and III. In the awake state, AEP had high peak -to-peak amplitudes and a periodic waveform.(ABSTRACT TRUNCATED AT 250 WORDS)