冠状动脉搭桥术病人围术期皮质醇分泌的昼夜节律性

观察冠状动脉搭桥术病人围术期皮质醇昼夜分泌节律性的变化。选择在低温体外循环或非体外循环下行冠脉搭桥术的男性病人40例，分为体外循环组和非体外循环组，每组20例。所有病人均在麻醉诱导前(基础值)、气管插管后。10min、肝素化后10min、转机后30min(或切皮后2h)、中和肝素前和术终各时点及术后每3h抽血1次持续到术后24h。采用放射免疫方法检测血浆皮质醇的浓度。两组病人术中各时点血浆皮质醇浓度显著低于麻醉诱导前，而在术后24h明显升高；非体外循环组病人在诱导后和术终时点皮质醇水平高于体外循环组。在术后24h体外循环组与非体外循环组分别有3例和7例病人的皮质醇分泌表现为昼夜节律性，其余病人则无昼夜节律性分泌。体外循环与非体外循环冠状动脉搭桥术后多数病人皮质醇昼夜节律性分泌紊乱，但非体外循环冠脉搭桥术病人术后早期有皮质醇昼夜分泌节律性的病例数多于体外循环组，提示体外循环有可能干扰了围术期皮质醇的分泌节律。     

常规与微创冠脉搭桥术围手术期血浆S100-B蛋白水平的相关研究

目的: 通过测定体外循环和非体外循环条件下冠脉搭桥术患者血浆S100-B蛋白水平的变化，比较2种手术方式对脑损伤程度有无不同，探讨术中影响血浆S100-B蛋白水平变化的相关因素。方法: 30例择期行冠脉搭桥术的患者，分为体外循环组（CPB group，A组）和微创非体外循环组（non-CPB group，B组）,每组均为15例。于术前、麻醉后、主动脉侧壁钳开放时、术毕时、术后2 h、6 h、12 h和24 h采血测血浆S100-B蛋白浓度。结果： （1） 两组患者血浆S100-B蛋白浓度均在升主动脉侧壁钳开放时显著高于术前，且A组患者血浆S100-B蛋白浓度峰值是B组的3倍多（2.32±0.26 μg/L和0.71±0.14 μg/L）,之后逐渐降低，到术后24 h基本接近正常。（2） 术中患者血浆S100-B蛋白升高水平与体外循环转机时间或心表手术操作时间呈正相关（A组：r＝0.659，P＜0.05;B组：r＝0.584, P＜0.05）。结论： 血浆S100-B蛋白水平可以用来评价2种冠脉搭桥术对脑的损伤程度，术后连续检测对于诊断脑损伤并及时采取相应预防措施具有重要价值;非体外循环微创冠脉搭桥术较常规体外循环下手术更能够有效降低对脑损伤的程度和术后出现神经功能障碍的风险。     

星状神经节阻滞对双侧局部脑氧饱和度及对术后认知功能的影响

本研究旨在观察星状神经节阻滞对冠状动脉旁路移植术老年患者术中双侧局部脑氧饱和度(rSO2)及术后认知功能的影响。研究纳入体外循环下冠状动脉旁路移植术患者80例,随机分为超声引导星状神经节阻滞组和生理盐水对照组,比较术中双侧rSO2,采用简易精神量表(MMSE)、视觉语言学习测试(VVLT)、数字广度测试(DST)评估认知功能。结果发现:1术后第7天星状神经节阻滞组术后认知功能障碍发生率明显低于对照组(P0.05);2阻滞组阻滞侧rSO2在体外循环复温前显著高于星状神经节阻滞前(P0.05),体外循环开始前显著高于非阻滞侧(P0.05),体外循环开始前和体外循环停机后显著高于对照组(P0.05);阻滞组非阻滞侧rSO2在麻醉诱导前显著低于阻滞前和对照组(P0.05)。研究显示超声引导星状神经节阻滞可明显增加术中阻滞侧rSO2,明显减少术后认知功能障碍的发生。     

超声引导星状神经节阻滞对老年患者术中脑氧代谢及术后认知功能的影响

观察术前超声引导星状神经节阻滞对老年患者术中脑氧代谢及术后认知功能的影响。我们纳入80名择期行体外循环下冠状动脉旁路移植术的老年患者,采用简易精神状况量表(MMSE)测验认知功能,采用桡动脉-颈内静脉球部血氧含量差、脑氧摄取率评价脑氧代谢水平。结果发现老年患者术中存在脑氧代谢失衡,对术后认知功能有一定损害,术前行超声引导星状神经节阻滞可减少老年患者术后认知功能障碍的发生,其机制可能与改善脑氧代谢有关。     

氯胺酮依赖者(吸食“K”粉者)的认知功能损害

目的:了解氯胺酮依赖者认知功能损害情况。方法:采用认知功能测试量表(包括:数字符号测验、连线测试A和stroop色词测验)对氯胺酮依赖者和相匹配的健康对照者进行测试。结果:氯胺酮依赖者在数字符号测验和stroop色词测验方面得分都明显较正常对照者低。但是两组之间的连线测试A得分没有统计学差异。结论:本研究结果显示氯胺酮依赖者存在某些认知功能损害。     

食道超声和漂浮导管对不同冠脉搭桥术中心脏功能状况和肺动脉压的评价

目的使用食道超声和漂浮导管比较非体外循环不停跳冠状动脉搭桥术(off-pump-CABG)和体外循环下冠状动脉搭桥术(on-pump-CABG)患者的心脏功能状况和肺动脉压,以探知何种冠脉搭桥术式术中的心脏功能状况更优。方法采用完全随机方法将36例患者按照计算器随机数字法随机分为2组,A组为off-pump-CABG术组(n=18),B组为on-pump-CABG术组(n=18)。检测时间点设定为全部手术操作完成后、患者出手术室前,使用食道超声和漂浮导管测量肺动脉收缩压、右心室舒张末期容积、右心室射血分数和左室舒张末压。结果 2组超声心动图与漂浮导管的测量结果差异无统计学意义(P0.05);超声心动图与漂浮导管的测量结果均显示A组的肺动脉舒张压低于B组(P0.05),A组的冠脉搭桥术中心脏功能状况诸指标优于B组(P0.05)。结论 off-pump-CABG和on-pump-CABG术中施行超声心动图与漂浮导管的监测,其效果基本一致;off-pump-CABG术的冠脉搭桥术中心脏功能状况诸指标优于on-pump-CABG术,其原因可能与off-pump-CABG更少的血流动力学扰动和没有血液直接接触非生理管道诱发的细胞因子瀑布有关。     

非体外循环冠状动脉搭桥术临床分析——附21例报告

目的评价非体外循环心脏不停跳冠状动脉搭桥术的临床价值及意义。方法回顾分析21例非体外循环冠状动脉搭桥术的临床资料,对手术方法及围手术期治疗进行分析总结。结果全组无术中需转体外循环,无围手术期急性心肌梗死,无死亡病例。术后心绞痛全部缓解,住院天数12~21d,平均14.53d。结论非体外循环冠状动脉搭桥术安全可行,且可减少输血,减轻手术创伤与并发症。远期效果有待观察。     

金纳多对体外循环脑损伤的保护作用

目的观察金纳多对体外循环脑损伤的保护作用。方法择期行风湿性心脏病二尖瓣置换术患者40例，美国麻醉医师协会分级Ⅱ～Ⅲ级，按随机数字表法随机分为银杏叶提取物组（EGB组）和对照组各20例。银杏叶提取物组（20例）：体外循环管道预充乳酸林格氏液中加入银杏叶提取物注射液1mg／kg；对照组（20例）：体外循环预充乳酸林格氏液。分别于体外循环开始前（T1）、体外循环开始后30min（T2）、体外循环结束时（L）、体外循环结束后2h（T4）、体外循环结束后6h（T5）、体外循环结束后12h（T6）、体外循环结束后24h（T7）7个时间点同步采集桡动脉及颈内静脉血，动脉血进行血气分析，静脉血测定血清S-100β蛋白、神经元特异性烯醇化酶（neuron specific enolase，NSE）浓度。结果CPB开始后即有血清S-100β蛋白和NSE浓度升高，EGB组S-100β蛋白和NSE浓度明显低于对照组，且其达峰时间提前。结论银杏叶提取物能改善脑氧供需平衡，明显减少血清脑损伤标志物S-100β蛋白和NSE的浓度升高，有明确的脑保护作用。     

血液回收对非体外循环冠状动脉旁路移植患者红细胞和血液粘度的影响

目的观察血液回收技术对非体外循环冠状动脉旁路移植患者红细胞、血小板和血液粘度的影响。方法2005年8月~2007年10月间,共完成46例非体外循环冠状动脉旁路移植术,随机分为实验组(血液回收组)和对照组(不使用血液回收机组),每组23例。观察两组用血液制品的数量和术后24h的引流量,比较两组术前和术后24h的红细胞计数、血红蛋白、红细胞压积、血小板计数、低切全血粘度和高切全血粘度。结果实验组用浓缩红细胞和血浆的量明显少于对照组,两组术后24h引流量、术前和术后24h的红细胞计数、血红蛋白、红细胞压积、血小板计数、低切全血粘度和高切全血粘度之间的差异无显著性意义。结论血液回收技术在非体外循环冠状动脉旁路移植患者中能减少输血,对红细胞、血小板和血液粘度无不利影响。     

急性冠状动脉综合征介入治疗前后脑钠肽变化及对临床预后的判断

目的通过测定急性冠状动脉综合征患者介入治疗前后血浆脑钠肽（BNP）水平的变化,探讨急性冠状动脉综合征介入治疗（PCI）对急性冠状动脉综合征患者血浆BNP变化及对临床病情和预后的判断。方法冠心病介入治疗（PCI）168例,分为存活组（143例）和死亡组（25例）;对存活组患者随访至6个月分别测定血浆BNP及死亡、再入院率,超声心动图检查（UCG）左室射血分数（LVEF）。结果PCI术后血浆BNP水平比术前明显降低,从术前的血BNP浓度在（176±27）ng／L逐渐升高,至术后6个月降低到（98±6）ng／L,与术前相比差异具有统计学意义（P〈0．05）。死亡组患者术前血BNP浓度水平比存活组明显升高（P〈0．05）。存活组和死亡组LVEF[（57．0±14．1）％比（31．0±15．0）％,P〈0．01]有统计学意义,Logistic多变量逐步回归分析显示,BNP是预测ACS患者PCI治疗预后的独立预测因子,且与LVEF呈负相关。结论PCI可降低ACS患者血液BNP水平,但术前BNP水平,常提示预后不良     

Attentional problems in children born very preterm or with extremely low birth weight at 7-9 years.

Behavioral rating scales and tests of attention were used to study attentional problems in children born very preterm (< or =27 weeks gestation) or with extremely low birth weight (ELBW; < or =1000 g). Psychological tests of attention (viz., Digits and Spatial Span Forward, Visual Attention from the NEPSY, Trail Making Test B, and Stroop Color and Word Test) were administered to 45 children born very preterm/ELBW and 49 full-term controls, aged 7-9 years of age. Behavioral ratings on an ADHD scale were provided by parents and teachers on inattentive and hyperactive-impulsive symptoms. Children born very preterm/ELBW were found to perform significantly more poorly on Spatial Span Forward, Visual Attention, and Trail Making B than controls. Group differences were also found on parents' ratings on inattentive and total symptoms. Finally, measures of psychological tests of attention were found to be significant predictors of parents' and teachers' ratings of symptoms.     

Effects of diffuse axonal injury on speed of information processing following severe traumatic brain injury

To test the hypothesis that slowed information processing in traumatic brain injury is related to diffuse axonal injury (DAI), the authors compared 10 patients with predominant DAI (diffuse group) and minimal DAI (mixed injury group) on the Symbol Digit Modalities Test, simple and choice reaction time, Trail Making Tests A and B, and the Stroop Neuropsychological Screening Test. The diffuse group was slower than the mixed injury and control groups on basic speed of processing tasks. This difference was not apparent on complex speeded tasks once basic speed of processing was controlled for. The diffuse group's slower speed of processing was not accounted for by differences in injury severity, age, or time postinjury. The diffuse group showed greater recovery over time.     

Short-term response of metabolic hormones to coronary artery bypass surgery

PurposeTo explore the response pattern of plasma adipokine and ghrelin levels to coronary artery bypass graft (CABG) surgery in patients with (on-pump) and without (off-pump) cardiopulmonary bypass (CPB).Material/methodsSixteen consecutive patients (age: 62 ± 10 years, male: 10) with obstructive coronary artery disease (CAD) who underwent elective CABG surgery with CPB and intraoperative GIK infusion were selected for on-pump group and 19 CAD patients (age: 63 ± 10 years, male: 16) were included in the off-pump group. Blood samples were taken before, during and after surgery. Intraoperative samples were withdrawn simultaneously for peripheral vein and sinus coronarius (SC). Plasma adipokine concentrations were measured by ELISA, those of ghrelin by RIA kits.ResultsIn response to surgical intervention there was an early, transient fall in plasma levels of adiponectin (p < 0.0001) and resistin (p = 0.002) followed by an increase to approach their initial values. Plasma ghrelin also increased (p = 0.045), this increase, however, was confined to the period of GIK supported CPB. Plasma insulin (p = 0.003) and resistin (p = 0.009) was significantly higher in the peripheral vein than in SC. The perioperative hormone profile of patients without CPB (off-pump) proved to be comparable to that of on-pump patients in spite of the insulin administration and greater oxidative and inflammatory stress.ConclusionsAdipose tissue-derived factors appear to mediate the metabolic and vascular changes that occur in patients with CABG surgery. Epicardial adipose tissue is unlikely to have major contribution to the development of CAD as adipokines are not elevated in SC independent of the mode of intervention.     

Cortisol differentially affects memory in young and elderly men

Nine young and 11 elderly men participated in this placebo-controlled, double-blind, crossover study (0.5 mg/kg cortisol or intravenous placebo). Participants learned a word list before cortisol administration, and delayed recall was then tested. A 2nd word list was learned and recalled after drug administration. In addition, the Paragraph Recall Test and tests measuring working memory (Digit Span), attention (timed cancellation), and response inhibition (Stroop Color and Word Test) were administered at 2 time points after drug administration. Cortisol reduced recall from the word list learned before treatment in both groups but did not influence recall of the list learned after treatment. In contrast, Digit Span performance was decreased by cortisol in young but not elderly participants. The possibility that differential age-associated brain changes might underlie the present results is discussed.     

Off-pump coronary artery bypass surgery in selected patients is superior to the conventional approach for patients with severely depressed left ventricular function

OBJECTIVES:

Patients with coronary artery disease and left ventricular dysfunction have high mortality when kept in clinical treatment. Coronary artery bypass grafting can improve survival and the quality of life. Recently, revascularization without cardiopulmonary bypass has been presented as a viable alternative. The aim of this study is to compare patients with left ventricular ejection fractions of less than 20% who underwent coronary artery bypass graft with or without cardiopulmonary bypass.

METHODS:

From January 2001 to December 2005, 217 nonrandomized, consecutive, and nonselected patients with an ejection fraction less than or equal to 20% underwent coronary artery bypass graft surgery with (112) or without (off-pump) (105) the use of cardiopulmonary bypass. We studied demographic, operative, and postoperative data.

RESULTS:

There were no demographic differences between groups. The outcome variables showed similar graft numbers in both groups. Mortality was 12.5% in the cardiopulmonary bypass group and 3.8% in the off-pump group. Postoperative complications were statistically different (cardiopulmonary bypass versus off-pump): total length of hospital stay (days)—11.3 vs. 7.2, length of ICU stay (days)—3.7 vs. 2.1, pulmonary complications—10.7% vs. 2.8%, intubation time (hours)—22 vs. 10, postoperative bleeding (mL)—654 vs. 440, acute renal failure—8.9% vs. 1.9% and left-ventricle ejection fraction before discharge—22% vs. 29%.

CONCLUSION:

Coronary artery bypass grafting without cardiopulmonary bypass in selected patients with severe left ventricular dysfunction is valid and safe and promotes less mortality and morbidity compared with conventional operations.     

Neuropsychological test performance in a cognitively intact sample of older Japanese American adults.

The purpose of this paper was to present population-based data showing the effects of age on cognitive test performance in a sample of older Japanese American adults. In addition, the relative effects of education, gender, and primary spoken language were compared to effects that have been reported in the literature for majority culture older adults. Subjects included 201 non-demented Japanese American adults age 70 and older currently enrolled in the Kame Project, a prospective study of aging and dementia in King County, WA. Cognitive tests included the Consortium to Establish a Registry for Alzheimer's Disease (CERAD) neuropsychological assessment battery, WAIS-R Digit Span and Digit Symbol subtests, Trail Making Test, Purdue Pegboard, and Finger Tapping. Older age was associated with significantly (p<0.05) lower scores on all tests; less than high school education was associated with lower scores on all tests except Digit Span, Finger Tapping, and the Purdue Pegboard. Women and English-speaking participants scored higher than men and Japanese speakers on various tests of memory, attention, and visuomotor ability. These data reinforce the importance of using appropriately corrected norms when interpreting results of cognitive screening tests with minority culture older adults.     

California neuropsychological screening battery (CNS/B I & II)

Neuropsychological assessment of individuals exposed to workplace or environmental neurotoxins is a lengthy, highly specialized, and costly endeavor. Literature that documents the central nervous effects of neurotoxins is reviewed, and neuropsychological tests currently used in this type of assessment are discussed. The California Neuropsychological Screening Battery (CNS/B I & II) was designed to afford rapid and broad assessment of the variety of brain functions typically affected by toxic brain injuries. The CNS/B I & II is comprised of: (1) Wechsler Memory Scale; (2) Visual Information Processing; (3) WAIS-R subtests of: Digit Span, Vocabulary, Block Design, Arithmetic, and Digit Symbol; (4) Trail Making Test A and B; (5) Dynamometer; (6) Finger Tapping Test; (7) Purdue Pegboard; (8) Benton Visual Retention Test; and (9) Neurotoxic Anxiety Scale (Bowler, Becker, & Harrison, 1985). Administration time is 50 to 60 minutes. The CNS B/ I & II facilitates intraindividual and intergroup comparisons through examination of subtest scores within the battery.     

Cognitive inhibition in patients with medial orbitofrontal damage

Inhibition underlies cognitive processes such as overcoming habitual responses, suppressing of goal-irrelevant information, and switching of attention between stimuli or task rules. These processes are thought to depend on the frontal lobes. However, the precise role of the ventral frontal regions (orbitofrontal cortex) in these processes remains elusive. In the present study, our goal was to clarify the role of the orbitofrontal cortex in cognitive inhibition by examining the effects of focal lesions to the medial orbitofrontal cortex (posterior part of the gyrus rectus) on performance in tasks that required inhibitory control. Patients who had undergone surgery for an anterior communicating artery aneurysm and normal control subjects (C) participated in the study. The patients were subdivided into three groups: those with resection of the left (LGR+) or right (RGR+) gyrus rectus, and without such a resection (GR-). The Stroop Color-Word test, Trail Making B test, and the Category test were used as instruments for assessing response inhibition, switching between concrete stimuli, and switching between abstract task rules, respectively. In addition, the Digit Symbol test was used to examine sustained attention and processing speed. In the Stroop Color-Word test, the RGR+ group performed worse than all other groups. In the Trail Making B test, the RGR+ and LGR+ groups performed worse than both the GR- and C groups. In the Category test and Digit Symbol test, the groups did not differ significantly from each other. Our study indicates a specific contribution of the medial orbitofrontal cortex to response inhibition and stimulus-based switching of attention.