术后认知功能障碍危险因素概述

术后认知功能障碍(POCD)最早发现于老年患者心脏手术后,近年来有研究报道非心脏手术患者也有较高的发生率。患者的基本认知功能出现不同程度的损害,而早期术后认知功能及精神障碍更多见于老年患者。除此之外,全麻的实施及麻醉药物的应用等也与POCD的发生有一定相关性。本文就影响术后认知功能的因素予以综述。     

术前应用丙盐酸戊乙奎醚对老年患者全麻下非心脏手术后早期认知功能的影响

目的探讨全麻下非心脏手术前应用丙盐酸戊乙奎醚0.02mg/kg对老年患者术后早期认知功能的影响.方法抽取全麻下行择期非心脏手术的65岁以上老年患者40例,在手术麻醉诱导前十分钟静脉注射丙盐酸戊乙奎醚0.02mg/kg,麻醉诱导后持续微量泵注射丙泊酚及瑞芬太尼、间断注射阿曲库铵维持麻醉.分别在麻醉前和术后3天内间断采用简易智力量表进行认知功能评估.结果有35例患者完成全部测试,术后认知功能障碍(POCD)发生率为12.5%.结论术前静脉注射0.02mg/kg丙盐酸戊乙奎醚对老年患者非心脏手术认知功能障碍(POCD)的发生无明显影响.     

非心脏手术后认知功能障碍危险因素分析

目的 探讨非心脏手术患者术后认知功能障碍(POCD)患病率及其危险因素.方法 选择45岁以上各类手术患者175例,行全身麻醉或蛛网膜下腔麻醉.所有患者术前1 d 用简易智能状态检查法测试,术后1 d 再次测试,并记录每项测试结果.如果患者术后认知功能评分较术前低2分或以上,则认为发生POCD.分析年龄、性别、手术方式、麻醉方式、术前患高血压或(和)糖尿病等基础疾病、术后拔管时间、受教育时间及苯二氮卓类药物的应用等因素与POCD之间的关系.结果 175例患者中,29例发生POCD,患病率为16.6%.Rank sum及Logistic回归分析表明,年龄及手术方式是POCD的主要相关因素.结论 中老年患者胸腹部及骨科复杂手术POCD的患病率为16.6%,且与年龄及手术方式有关.     

体外循环心脏手术中脑组织氧饱和度最低值与术后认知功能障碍相关性分析

目的分析体外循环心脏手术中脑组织氧饱和度(rScO_2)最低值与术后认知功能障碍(POCD)的相关性,并观察POCD的相关危险因素。方法 109例心脏手术患者术中维持rScO_2在80%基础值且绝对值55%以上。观察术中的rScO_2最低值,并记录体外循环时间、主动脉阻断时间、术中血红蛋白最低值、术中悬浮红细胞输入量、术后机械通气时间、ICU停留时间、术后住院天数、是否接收肾脏替代治疗及重要并发症。于术前1天及术后第4天做认知功能评估两项测试,其中任何一项术前减术后之差≥4分定义为POCD。结果 88例患者完成了术后评估测试,其中25例(28.4%)发生POCD。术中的rScO_2最低值与POCD相关。受教育程度是影响术后认知功能评估完成的危险因素。结论术中rScO_2最低值与POCD相关,rScO_2的最佳范围仍需进一步研究以明确。     

老年患者非心脏手术术后认知功能障碍与围术期血清兴奋性氨基酸含量的关系

目的探讨老年患者非心脏手术围术期血清兴奋性氨基酸（EAA）在术后认知功能障碍（POCD）发病中的意义。方法选取60例65~80岁接受全身麻醉非心脏手术的患者（剔除术前已患阿尔茨海默病及精神疾患的患者）,于麻醉前,术毕,术后24、48、72 h采用反相高效液相色谱荧光法检测血清谷氨酸（Glu）、天冬氨酸（Asp）、甘氨酸（Gly）的浓度,并于术前,术后24、48、72h采用简易智力状态检查法（MMSE）评估患者的认知功能。结果4例患者术后病情危重入住重症监护病房排除在研究范围,15例发生了术后POCD并发症。发生POCD的患者于术毕,术后24、48、72 h的血清Glu、Asp、Gly浓度均高于非POCD患者（均P〈0.05）。结论老年患者血清EAA含量与术后POCD发生有一定相关性,EAA可能参与POCD的病理生理过程。     

血小板-淋巴细胞比联合中性粒细胞-淋巴细胞比预测体外循环支持心脏手术后早期急性肾损伤的风险

目的：探究实验室指标与体外循环支持心脏手术后早期急性肾损伤（AKI）发生之间的相关性,从而预测其发生的风险。方法：纳入2020年1月至2021年12月于武汉大学中南医院心血管外科接受体外循环支持心脏手术的841例患者作为研究对象,回顾性分析所有纳入对象的术前、术中、术后等临床资料。根据患者术后48 h内是否发生AKI将所有患者分为AKI组和Non-AKI组。比较两组患者的基线资料和临床特征,采用单因素及多因素分析影响体外循环支持心脏手术后早期AKI发生的独立危险因素。根据多因素Logistic回归分析结果建立列线图预测模型。结果：319例患者在手术后48 h内被诊断为AKI,AKI发生率为37.9%。单因素及多因素Logistic回归分析显示：术前肌酐升高、体外循环时间延长、术后血小板-淋巴细胞比降低和术后中性粒细胞-淋巴细胞比升高是体外循环支持心脏手术后早期AKI的独立危险因素。列线图模型可以预测早期AKI的风险,敏感性为79.6%,特异性为75.1%。结论：血小板-淋巴细胞比（P/LR）联合中性粒细胞-淋巴细胞比（N/LR）可预测体外循环支持心脏手术后早期急性肾损伤的风险。     

术后认知功能障碍炎症相关机制及其防治

术后认知功能障碍(postoperative cognitive dysfunction，POCD)是一种轻度的认知功能紊乱，是指术前无认知 障碍的患者在麻醉手术后出现精神活动、人格、社交活动及认知能力的改变。记忆减退是认知功能障碍患者的核心 症状及表现，年龄是术后长期认知功能损害的主要危险因素。POCD的发生将延长患者的住院时间，降低患者的生存 质量，增加术后死亡率，给个人和社会造成严重负担。如何有效地预防、干预POCD的发生发展，减少不良后果，是 手术患者(尤其是老年患者)围手术期亟需解决的问题。虽然POCD的病理生理机制仍然不明，但目前倾向于认为炎症 在POCD中扮演重要作用。无菌手术诱导外周炎症反应，通过相关途径传入中枢，因个体差异，导致了不同严重程度 的中枢炎症反应，进而引起POCD。因此，针对POCD的防治方法也应着重围绕减轻炎症反应展开。     

老年患者全髋关节置换术后认知功能障碍与围术期炎性反应的相关性

目的 观察老年患者全髋关节置换术后早期术后认知功能障碍(POCD)的发生及其与围术期炎性反应的关系.方法 选择接受择期单侧全髋关节置换术的老年(年龄≥60岁)患者,应用简易精神状态量表(MMsE)对患者的认知功能进行评定,根据是否发生POCD分为POCD组(17例)和非POCD组(20例),检测术前及术后1、6 h外周血白细胞介素(IL)-1β、IL-6、肿瘤坏死因子(TNF)-α和C反应蛋白(CRP)水平.结果 术后1 d的POCD发生率为45.9%.POCD组患者术后IL-1β及IL-6水平均较术前显著升高(P值均＜0.05);非POCD组患者术后仅IL-6水平较术前显著升高(P值均＜0.05),IL-1β水平无明显变化(P值均＞0.05);POCD组术后1 h的IL-1β及术后6 h的IL-6水平显著高于非POCD组(P值均＜0.05).两组患者手术前后TNF-α水平的差异无统计学意义(P值均＞0.05).两组患者术后6 h的CRP水平较术前显著升高(P值均＜0.05),但两组间的差异均无统计学意义(P值均＞0.05).结论 老年患者全髋关节置换术后早期的POCD发生率较高,术后早期的炎性反应可能与POCD的发生有关.     

老年患者术后谵妄与术后认知功能障碍的相关性研究

目的分析老年非心脏手术患者术后谵妄（POD）与术后早期认知功能障碍（POCD）之间的关系,探讨POD发病的围术期危险因素。方法对2008年9～12月182例行择期非心脏手术的老年患者（≥60岁,除外老年痴呆、严重肝肾功能不全、严重中枢神经系统疾病的患者）进行术前精神心理量表测验。POD采用《精神疾病诊断与统计手册》的标准进行诊断,POCD以国际术后认知功能障碍研究协作组（ISPOCD）推荐的标准进行诊断。术前及术后第1、3天对患者进行POD评估,术前及术后7d对患者进行POCD的神经心理测验。结果172例患者最终完成了术后第3天的谵妄评估,其中有26例发生POD（谵妄组）,发生率为15.1%。138例患者完成了术后第7天的神经心理测验,28例发生POCD,发生率为20.3%。谵妄组中23例完成第7天心理测验,其POCD的发生率（10/23,43.5%）明显高于非谵妄组（18/115,15.7%）。多因素Logistic逐步回归分析结果显示,高血压病史、受教育年数、入室血压、插管后呼气末二氧化碳分压（PetCO2）、术中最低红细胞压积（Hct）、麻醉时间和术后血糖等为术后谵妄的危险因素。结论发生POD的老年患者更易出现早期POCD;高血压病史、受教育年数、麻醉时间及术中最低Hct等因素与老年患者POD的发生有关。     

单肺通气手术患者POCD危险因素分析

目的探讨单肺通气手术患者发生术后认知功能障碍（POCD）的患病率及其危险因素。方法选取60例42～83岁需单肺通气手术患者,于术前1 d和术后7 d分别接受简易智能状态检测,记录手术前后认知功能的改变,并分析围术期因素与患者发生POCD的关系。结果 14例患者发生POCD,患病率为23.3%。年龄增长与POCD的发生呈正相关,单肺通气后脑氧饱和度较基础值下降和乳酸升高值与患者POCD的发生呈正相关。结论单肺通气POCD的患病率为23.3%,年龄增长、乳酸值升高和脑氧饱和度较基础值下降是单肺通气的胸外科手术患者发生POCD的危险因素。     

Value of D-Dimers in patients with acute aortic dissection

Objective: To evaluatel the value of D-dimers in patients with acute aortic dissection (AAD). Methods: This study consisted of 16 patients with AAD and 27 non-AAD patients. Serum D-dimets were measured by Sta-Liatest D-DI immunoturbidimetric assay. Results: D-dimer level was higher (P ＜ 0.001) in patients with AAD(7.91 ± 5.52 μg/ml) than that in non- AAD group(1.57±1.24 μg/ml). D-dimer was positive (＞0.4 μg/ml) in all patients with AAD and in 10 control group patients (37%). Among patients with acute AAD, D-dimers tended to be higher in Stanford A than in Stanford B (8.67 ± 4.31 μg/ml vs. 3.24±1.27 μg/ml, P ＜0.01). D-dimer values tended to be higher in more extended disease(3.84 ± 1.65 μg/ml, 8.57 ± 3.58 μg/ml and 11.87 ± 5.69 μg/ml in thoracic aorta, thoracic and abdominal aorta, thoracic and abdominal aorta and iliacal arteries, respectively, P ＜ 0.05 for both 8.57 ± 3.58 and 11.87 ± 5.69 vs. 3.84 ± 1.65 ). Including the control group into the analysis, we found a sensitivity of 100%, a negative predictive value of 100%, and a specificity of 66% and a positive predictive value of 64% for D-dimer in diagnosis of AAD in our patients with suspected AAD. Conclusion: D-dimer was elevated in patients with AAD. A negative D-dimer test result could be useful in excluding AAD.     

Research of combined liver-kidney transplantation model in rats

Objective： To set up a simple and reliable rat model of combined liver-kidney transplantation. Methods： SD rats served as both donors and recipients. 4℃ sodium lactate Ringer＇s was infused from portal veins to donated livers,and from abdominal aorta to donated kidneys, respectively. Anastomosis of the portal vein and the inferior vena cava （IVC） inferior to the right kidney between the graft and the recipient was performed by a double cuff method, then the superior hepatic vena cava with suture. A patch of donated renal artery was anastomosed to the recipient abdominal aorta. The urethra and bile duct were reconstructed with a simple inside bracket. Results： Among 65 cases of combined liver-kidney transplantation, the success rate in the late 40 cases was 77.5%. The function of the grafted liver and kidney remained normal. Conclusion： This rat model of combined liver-kidney transplantation can be established in common laboratory conditions with high success rate and meet the needs of renal transplantation experiment.     

BLOOD PRESSURE CHANGE WITH AGE IN SALT-SENSITIVE TEENAGERS

Objective To observe blood pressure change with age in salt-sensitive teenagers whose salt sensitivity were determined by repeated testing.Methods Salt sensitivity was determined through intravenous infusion of normal saline combined with volume-depletion by oral diuretic furosemide in 55 teenagers. After five years, salt sensitivity was re-examined and subject blood pressure was followed up. Blood pressure changes in salt-sensitive teenagers were compared to that of non-salt sensitive teenagers over five years.Results After 5 years, the repetition rate of salt sensitivity determined by intravenous saline loading is 92.7%. In teenagers with salt sensitivity on the baseline, both the systolic blood pressure increments and increment rates were much higher than non-salt sensitive teenagers (12.7±12.1 mmHg vs. 2.8±5.2 mmHg, P＜ 0.01; 12.2%± 12.0% vs. 2.5% ±4.4%, P＜ 0.001,respectively). There was a similar trend for diastolic blood pressure (8.4 ± 6.4 mmHg vs. 3.7 ± 6.4 mmHg, P = 0.052; 13.2% ±10.6 % vs. 6.8%± 10.1%, P = 0.053, respectively).Conclusions Salt sensitivity determined by intravenous saline loading showed good reproducibility. Blood pressure increments with age were much higher in salt-sensitive teenagers than non-salt sensitive teenagers, especially in terms of systolic blood pressure.     

安心颗粒对急诊经皮冠状动脉介入术后生活质量影响的研究

目的：评价使用安心颗粒对急诊经皮冠状动脉介入术（PPCI）术后生活质量的影响.方法：将160例接受PPCI的急性ST段抬高型心肌梗死患者随机分为安心颗粒组（术前顿服安心颗粒8.8g,术后安心颗粒4.4 g/次,每日2次）和对照组（仅接受基础药物治疗）.所有患者均服用阿司匹林、氯吡格雷和阿托伐他汀.分别在入院时、出院前1d、出院后180 d时,应用心肌梗死多维度量表（MIDAS）、中文版SF-36评价量表对患者生活质量评分.并观察术后30 d以内的出血并发症、血小板减少症发生情况.结果：入院时和出院前1d,两组患者的心肌梗死MIDAS、SF-36量表评分比较无差异（P＞0.05）;出院后180 d时,与对照组比较,安心颗粒组MIDAS、SF-36评分明显减低（P＜0.05）;组内与入院时比较,两组出院前1d、出院后180 d时,MIDAS、SF-36评分均降低（P＜0.05）.两组患者在随访期间均无大量出血、少量出血、重度和极重度血小板减少症发生,安心颗粒组有4例、对照组有7例发生不明显出血（P＞0.05）.两组发生轻度血小板减少症的患者数比较无差异（P＞0.05）.结论：PPCI使用安心颗粒,能改善急性ST段抬高型心肌梗死患者的生活质量,且不增加出血风险.     

The comparative studies of the influences of Urapidil and Nicardipine on sino-atrial node function, atrio-ventricular node function and hemodynamics

Objective:To investigate the influences of urapidil and nicardipine on rabbit sinus function,atrio-ventricular node function and hemodynamics.Methods:Thirty-two Angora's rabbits were selected and randomly divided into four groups.U1 group:urapidil 0.25 mg/kg;U2 group:urapidil 0.5 mg/kg;N1 group:nicardipine 10 μg/kg;N2 group:nicardipine 20 μg/kg.All these medicine were administrated within 30 seconds.Measurements were taken before and after the administration of urapidil or nicardipine for the following data:mean blood pressure(MAP),heart rate(HR),sino-atrial conduction time(SACT),maximal sinoatrial recovery time(SNRTmax)corrected sinus node recovery time(CSNRT),index of sinus node recovery time(SNRTI),Wenckebach A-V conduction frequency (WB),and P-R interval.Results:Significant MAP and HR changes were identified in all of the four groups before and after administration of both urapidil and nicardipine.No significant changes could be found in the rest of the parameters.Intergroup analysis showed that SACT and CSNRT of N1 and N2 groups were shorter than those of the U2 group(P＜0.01);the MAP decreased(P＜0.01)and the HR increased drastically(P＜0.01).Conclusions:Neither urapidil(0.25 mg/kg,0.5 mg/kg)nor nicardipine(10μg/kg,20μg/kg)has any significant influence on rabbit sinus function or rabbit atrio-ventricular node function.Nicardipine could be a better choice than urapidil for parafunctional sinus node patients.     

Expression of OPGmRNA and ODFmRNA in the patients of hip fracture due to osteoporosis

Objective：To investigate the gene expression of osteoprotegerin（OPG） and osteoclast differentiation factor（ODF） in the bone tissue of patients with hip fracture due to osteoporosis. Methods：OPGmRNA and ODFmRNA in the bone tissue in 50 cases of osteoporosis sufferers（over 50 years old） with hip fracture（Observer Group） and 30 cases of hip facture sufferers with no osteoporosis（Control group） were analyzed with the Semi-Quantitative RT-PCR method. Results：The mRNA expressed of ODF, OPG were both high in the patients with hip fracture. In the control group, the expression of OPG mRNA was observed, while the expression of ODF mRNA was very slight. Conclusion：Aged patients contained all signals including OPG, ODF that are essential for inducing osteoclastogenesis and promoting bone resorption.     

The clinicopathological and immuohistochemical analysis of solid-pseudopapillary tumor of the pancreas： report of 9 cases

Objective：To investigate the clinical features, pathological characteristics and immunophenotype of solid-pseudopapillary tumor of the pancreas（SPTP）. Methods：Nine surgically treated cases of SPTP were retrospectively reviewed. Hematoxylin and Eosin（HE） staining and immunohistochemical staining were used to analyze all cases, and the general clinical data was collected. Results：Six patients were asymptomatic except for a palpable mass. Two patients complained of vague-epigastric pain. One patient appeared jaundice. The tumor was encapsulated and solid tissues alternately with cystic tissues. Histologically, the histological structure of solid portion was pseudopapillary with a fibrovascular core. Tumor cells were uniform and medium-sized which were arranged in sheets ets or nests or pseudopapillary patterns. Immunohistochemical studies demonstrated that SPTP proved positive in vimentin（9/9 cases）, AAT（9/9 cases）, NSE（9/9 cases）, ACT（7/9 cases）, CK20（2/9 cases）, CgA（1/9 cases）, S-100（3/gcases）, PR（4/gcases）, Syn（3/9 cases） and CD56（5/9cases）, negative in CEA and ER. Conclusion：SPTP is a tumor predominantly occurring in young women frequently without special symptoms. This tumor has various characteristical histological patterns with different immunophenotype.     

Dynamic Changes in Serum Estradiol and Progesterone levels in Patients of Premenstrual Syndrome with Adverse Flow of Liver-qi

Objective:To probe into the influence of changes of ovarian hormones on the pathogenesis of the specific sub-type premenstrual syndrome(PMS)and reveal partial microcosmic mechanisms of adverse flow of liver-qi.Methods:Estradiol(E2)and progesterone(P)levels in serum were determined at different phases of menstrual cycle by radioimmunoassay.Results:In the group of PMS with adverse flow of liver-qi.the secretive peak value Of E2 and P at the follicular phase significantly decreased,and the secretive peak value at the luteal phase did not come into being.Conclusions:Low E2 and P secretive peak at the follicular phase and absence of secretive peak at the luteal phase is one of the microcosmic mechanisms of PMS with adverse flow of liver-qi.One of the pathophysiologic mechanisms of specific sub-type PMS is probably the continuous low level of E2and P.     

Real-time Three-dimensional Echocardiography in Assessment of Left Ventricular and Right Ventricular Volumes

Real-time three-dimensional echocardiography (RT3DE)is a new ultrasound technique that enables dynamic threedimensional visualization and quantification of the heart in real time. Investigation of feasibility and methodology of RT3DE in determining left ventricular (LV) and right ventricular (RV) volumes, RT3DE was performed in 35 normal adults using Philips SONOS 7500 system with a 2-4 MHz matrix array transducer. The 60°×60° "pyramid" volume database was obtained and analyzed on a TomTec echo workstation. Both LV and RV volumes were calculated with four 3DE methods (i.e. apical 2, 4, 8, and 16-plane) through manually tracing ventricular endocardial borders in end diastole and end systole. Stroke volumes were then calculated. LV volume was also measured by 2DE Simpson's rule using GE VIVID 7 ultrasound machine.     

SCREENING FOR A 21-CHROMOSOME ABNORMALITY IN PREIMPLANTED EMBRYOS OF ELDERLY WOMEN

Increasing maternal age is the only etiological factor unequivocally linked to Down's syndrome in humans. The occurrence rate of newborns with Down's syndrome is about 1/220 in women over 35 years old. However, the occurrence rate in embryos fertilized in vitro, of the elder woman is unclear. Using FISH we screened the number of chromosome 21 in preimplanted embryos of 5 elderly women (average age, 38.4 years) to study the feasibility and necessity of screening trisomy 21 in embryos in patients over 35 years old at the in vitro fertilization (IVF) center.