体外循环诱发炎性反应与患者术后认知功能障碍的关系

目的 探讨体外循环(CPB)诱发炎性反应与患者术后认知功能障碍(POCD)的关系.方法 择期CPB下心脏瓣膜置换手术的患者25例,随机分为2组:对照组(C组,n=12)和乌司他丁组(U组,n=13).两组麻醉诱导、麻醉维持及体外循环方法相同.U组麻醉诱导后立即静脉注射乌司他丁1.2万U/kg,CPB预充液中加入乌司他丁0.6万U/kg,主动脉开放前5 min体外循环中加入乌司他丁0.6万U/kg,C组给予等容量生理盐水.分别于麻醉诱导后切皮前、CPB结束时、术后24 h时采 集外周静脉血样,测定血浆IL-6浓度及外周血中性粒细胞NF-kB表达水平.分别于术前、术后3、7 d时测试认知功能,记录POCD发生情况.结果 与C组比较,U组血浆IL-6浓度和中性粒细胞NF-kB表达降低(P<0.05或0.01),POCD发生率差异无统计学意义(P>0.05).结论 CPB诱发炎性反应与患者POCD发生无关.     

全麻患者麻醉恢复期躁动与术后认知功能障碍的关系

目的 评价全麻患者麻醉恢复期躁动与术后认知功能障碍(POCD)的关系.方法 择期全麻手术患者280例,性别不限,年龄18～70岁,体重52 ～ 80 kg,ASA分级Ⅰ或Ⅱ级.于拔除气管导管后15～40 min时采用术后恢复质量评估量表评估麻醉恢复期躁动的发生情况,于术前1d、术后1～7d评估认知功能.根据是否出现POCD将患者分为POCD组和非POCD组.记录患者一般情况、术前合并症及手术类型,将组间差异有统计学意义的因素进行多因素logistic回归分析.结果 术后POCD发生率40.7％.logistic回归分析结果显示:与POCD发生明显相关因素的危险程度从高至低:麻醉恢复期躁动、麻醉时间、年龄.结论 全麻患者麻醉恢复期躁动是POCD发生的独立危险因素之一.     

老年病人冠状动脉搭桥术后神经功能障碍的初步探讨

目的：通过对冠状动脉搭桥（CABG）术中进行经颅脑氧饱和度（TCCO）和经颅多谱勒（TCD）监测，探讨老年病人CABG术中局部脑氧饱和度（rSO2)和大脑中动脉微栓数量（HITS）的变化与术后神经功能障碍的关系。方法：择期CABG手术358例，根据年龄为Ⅰ组（年龄≥60岁）和Ⅱ组（年龄＜60岁，术中使用TCCO和TCD持续监测rSO2和HITS，术后随访进行神经功能的检查和评估。结果：本组病人术后神经功能障碍发病率14％，其中I组为18．7％，Ⅱ组为6％，I组明显高于Ⅱ组（P＜0．05），同时I组的术后清醒时间，气管拔管时间，ICU时间，住院时间和住院死亡率也明显高于Ⅱ组，低rSO2的发病率为25．4％，其中I组为30．2％，Ⅱ组为17．3％，I组明显高于Ⅱ组（P＜0．05），而术中I组和Ⅱ组的HITS无明显差别（P＞0．05）。结论：老年病人术后神经功能障碍发病率高，与术前合并并脑血管病等危险因素和术中低rSO2发生率高有关，而与HITS的绝大数量无关。引起低rSO2的原因可能与低灌注，脑氧供／氧耗失衡，或低灌注和栓塞多种因素共同作用所致。     

非心脏大手术老年患者术后认知功能障碍与术中脑氧代谢的关系

目的 探讨非心脏大手术老年患者术后认知功能的改变及与术中脑氧代谢的关系.方法 择期非心脏大手术老年患者64例,年龄65～85岁,于术前2～3 d和术后第7天时,分别由心理医师进行一次神经心理测验.在单项测验中术前与术后分值之差≥1个术前分值标准差定为认知功能受损,一个患者在2项或2项以上测验中出现认知功能受损则定为认知功能障碍.于麻醉诱导后即刻、2 h、离开麻醉恢复室时分别同步采集桡动脉和颈内静脉球部血样进行血气分析,计算脑血流量/脑氧代谢率比值(CBF/CMRO2＞20为异常).结果 61例患者完成术后神经心理测验,有10例(16.4%)发生术后认知功能障碍(POCD).logistic回归分析显示麻醉诱导后2h时CBF/CMRO2的异常与POCD发生有关.结论 非心脏手术老年患者术后POCD的发生与术中脑氧代谢异常有关.     

全麻老年患者术后认知功能障碍的危险因素

目的 筛选全麻老年患者术后认知功能障碍(POCD)的危险因素.方法 择期全麻下行胸部或腹部手术的老年患者300例,年龄65～80岁,采用全凭静脉麻醉.根据术后3d是否发生认知功能障碍,将患者分为非POCD组和POCD组.记录患者一般资料及术前空腹血糖、糖化血红蛋白、血脂及血压.将组间差异有统计学意义的因素进行logistic回归分析,筛选POCD的危险因素.结果 98例患者发生POCD,发生率为32.7％.logistic回归分析结果显示:高龄、糖尿病和高血压是POCD的独立危险因素(P＜0.05).结论 高龄、糖尿病和高血压是全麻老年患者POCD的独立危险因素.     

MRI测定海马体积预测老年患者发生术后认知功能障碍的准确性

目的 评价术前MRI测定海马体积预测老年患者发生术后认知功能障碍(POCD)的准确性.方法 拟行胃肠道手术的患者41例,年龄≥65岁,分别于术前和术后4d采用韦氏成人记忆、智力量表中的敏感项目、联线和钉板测试进行神经心理学测试.术后4d借鉴国际术后认知功能障碍研究组织推荐的Z分法评价认知功能,根据是否发生POCD分为POCD组和非POCD组.术前采用MRI测定海马体积,海马体积与Z分间进行直线相关分析,分析海马体积对POED的预测价值.结果 36例老年患者完成本试验,其中13例患者发生了POCD,发生率为36%.POCD组海马体积(4.75 4±0.23)小于非POCD组(5.06±0.31)(P<0.01).海马体积与Z分间呈负相关(r=-0.324,P<0.05).以海马体积预测发生POCD的准确率为77.8%,灵敏度为92.3%,特异度为70.0%,约登指数为0.623.结论 术前采用MRI测定的海马体积可准确地预测老年患者是否发生POCD.     

载脂蛋白E基因多态性与认知损害

研究发现载脂蛋白E基因多态性与认知损害有良好的相关性，可能成为认知损害发生的预测或诊断指标，与术后认知功能障碍的关系值得进二步探讨。     

MRI测定海马体积预测老年患者发生术后认知功能障碍的准确性

Objective To assess the accuracy of MRI measurement of hippocampal formation in predicting postoperative cognitive dysfunction (POCD) in elderly patients.Methods Forty-one ASA Ⅱor Ⅲ patients aged≥65 yr undergoing gastrointestinal tract surgery were enrolled in this study.MRI was performed to measure the volume of hippocampal formation before surgery and the results were standardized according to the individual intracranial volume.All patients underwent a battery of neuropsychological tests including sensitive tests on the Wechsler adult memory scale and Wechsler adult intelligence scale,trail making test and the grooved pegboard test.We used the Z score to identify POCD as recommended by Moiler.All patients were then divided into POCD group and non-POCD group according to the results of the neuropsychological tests.The results of the tests were correlated with the volume of hippocampal formation measured by MRI.The value of MPI measurement of hippocampal volume in predicting POCD was analyzed.Results Thirty-six patients completed the whole battery of neuropsychological tests after surgery.Thirteen of the 36 patients were found to have COPD (36%) on the 4th postoperative day.The hippocampal volume was significandy smaller in POCD group (4.75±0.23) than in non-POCD group(5.06±0.31).Hippocampal volume was found to be effective in predicting POCD.The overall accuracy of prediction was 77.8%(28/36 patients) with 92.3% sensitivity (12/13 patients),70.0% specificity (16/23 patients) and 0.623 Youden index.Conclusion The MRI measurement of hippocampal volume is valuable as a predictor of POCD in the elderly.     

MRI测定海马体积预测老年患者发生术后认知功能障碍的准确性

Objective To assess the accuracy of MRI measurement of hippocampal formation in predicting postoperative cognitive dysfunction (POCD) in elderly patients.Methods Forty-one ASA Ⅱor Ⅲ patients aged≥65 yr undergoing gastrointestinal tract surgery were enrolled in this study.MRI was performed to measure the volume of hippocampal formation before surgery and the results were standardized according to the individual intracranial volume.All patients underwent a battery of neuropsychological tests including sensitive tests on the Wechsler adult memory scale and Wechsler adult intelligence scale,trail making test and the grooved pegboard test.We used the Z score to identify POCD as recommended by Moiler.All patients were then divided into POCD group and non-POCD group according to the results of the neuropsychological tests.The results of the tests were correlated with the volume of hippocampal formation measured by MRI.The value of MPI measurement of hippocampal volume in predicting POCD was analyzed.Results Thirty-six patients completed the whole battery of neuropsychological tests after surgery.Thirteen of the 36 patients were found to have COPD (36%) on the 4th postoperative day.The hippocampal volume was significandy smaller in POCD group (4.75±0.23) than in non-POCD group(5.06±0.31).Hippocampal volume was found to be effective in predicting POCD.The overall accuracy of prediction was 77.8%(28/36 patients) with 92.3% sensitivity (12/13 patients),70.0% specificity (16/23 patients) and 0.623 Youden index.Conclusion The MRI measurement of hippocampal volume is valuable as a predictor of POCD in the elderly.     

脊柱手术患者术后谵妄和术后认知功能障碍的危险因素

目的 筛选脊柱手术患者术后谵妄(POD)和术后认知功能障碍(POCD)的危险因素.方法 择期全麻下行脊柱手术的患者120例,性别不限,年龄50～76岁.根据术后2d是否发生POD,将患者分为非POD组和POD组,根据术后3d是否发生POCD,将患者分为非POCD组和POCD组.术前1d分别采用Stroop色词测验和Beck抑郁自评量表评估执行功能和抑郁状态,记录年龄、性别、受教育程度、每周饮酒量、精神病史、ASA分级和Charlson合并症指数、麻醉方法和术中抗胆碱能药物使用情况、术后1d时VAS评分,将组间差异有统计学意义的因素进行多因素logistic回归分析,筛选POD和POCD的危险因素.结果 11例患者发生POD,发生率9.2％;30例患者发生POCD,发生率25.0％.logistic同归分析结果显示:Stroop评分低、Beck抑郁评分高、Charlson合并症指数高和精神病史是POD的危险因素;Stroop评分低、Beck抑郁评分高、Charlson合并症指数高和每周饮酒量多是POCD的危险因素(p＜0.05或0.01).结论 术前执行功能降低、抑郁状态和合并症多是脊柱手术患者POD和POCD共同的危险因素,精神病史是POD的危险因素,饮酒量多是POCD的危险因素.     

载脂蛋白E基因多态性与认知损害

研究发现载脂蛋白E基因多态性与认知损害有良好的相关性,可能成为认知损害发生的预测或诊断指标,与术后认知功能障碍的关系值得进一步探讨。     

老年病人全麻术后颅内兴奋性氨基酸水平与术后认知功能障碍的关系

目的 探讨老年病人全麻术后颅内兴奋性氨基酸(EAA)水平的变化与术后认知功能障碍(POCD)发生的关系.方法 40例择期老年病人行全麻手术,年龄65～79岁,ASA Ⅰ～Ⅲ级.于麻醉前、术毕、术后24、48和72h时取颈内静脉球部血样,采用反相高效液相色谱荧光法(RP-HPLC)检测血浆EAA浓度.所有患者均实施有效的术后镇痛,采用简易智力状态检查法(MMSE)分别评估麻醉前、术后3d认知功能.结果 术后3d期间,11例病人发生POCD(28%).与麻醉前比较,术后24、48h POCD病人血浆谷氨酸(Glu)、天冬氨酸(Asp)、甘氨酸(Gly)浓度升高(P<0.05或0.01),术后72h恢复.与非POCD病人比较,术后24、48h POCD病人血浆Glu、Asp、Gly浓度升高(P<0.05).POCD病人Glu和Asp浓度与MMSE评分呈显著负相关(Glu:r=-0.86,P<0.01;Asp:r=-0.99,P<0.01).结论 老年病人全麻术后颅内EAA水平的升高可能参与了POCD发生的病理生理过程.     

老年病人全麻术后颅内兴奋性氨基酸水平与术后认知功能障碍的关系

Objective To investigate the relationship between the changes in intracranial excitatory amino acid(EAA) levels and the incidence of postoperative cognitive dysfunction (POCD) in eldedy patients after general anesthesia. Methods Forty ASA Ⅰ-Ⅲ patients of both sexes aged 65-79 yr weighing 48-76 kg undergoing elective non-cardiac surgery under general anesthesia were studied.Anesthesia was induced with midazolam,fentanyl,etomidate and succinylcholine and maintained with continuous iv infusion of propofol,remifentanil,isoflurane inhalation and intermittent iv boluses of vecuronium.The right internal jugular vein was cannulated with a catheter which was advanced cephalad until jugular bulb.The jugular bulb venous blood samples were taken before (T0,baseline),at the end of (T1) and at 24,48 and 72h(T2-4) after operation for measurement of plasma concentrations of glutamate (Glu),aspartate (Asp) and glycine (Gly) by RP-HPLC.The cognitive function was evaluated by mini-mental state examination (MMSE) at T0 and T4.Results Eleven of the 40 patients developed POCD (28%).The plasma Gh,Asp and Gly concentrations were significantly increased after operation as compared with the baseline values in POCD patients and were significantly higher than in non-POCD patients.The plasma concentrations of Glu and Asp were negatively correlated with MMSE score(Glu:r=-0.86.P<0.01;Asp:r=-0.99,P<0.01).Conclusion Elderly patients may develop POCD after operation performed under general anesthesia through increase in intracranial EAA levels.     

老年病人全麻术后颅内兴奋性氨基酸水平与术后认知功能障碍的关系

Objective To investigate the relationship between the changes in intracranial excitatory amino acid(EAA) levels and the incidence of postoperative cognitive dysfunction (POCD) in eldedy patients after general anesthesia. Methods Forty ASA Ⅰ-Ⅲ patients of both sexes aged 65-79 yr weighing 48-76 kg undergoing elective non-cardiac surgery under general anesthesia were studied.Anesthesia was induced with midazolam,fentanyl,etomidate and succinylcholine and maintained with continuous iv infusion of propofol,remifentanil,isoflurane inhalation and intermittent iv boluses of vecuronium.The right internal jugular vein was cannulated with a catheter which was advanced cephalad until jugular bulb.The jugular bulb venous blood samples were taken before (T0,baseline),at the end of (T1) and at 24,48 and 72h(T2-4) after operation for measurement of plasma concentrations of glutamate (Glu),aspartate (Asp) and glycine (Gly) by RP-HPLC.The cognitive function was evaluated by mini-mental state examination (MMSE) at T0 and T4.Results Eleven of the 40 patients developed POCD (28%).The plasma Gh,Asp and Gly concentrations were significantly increased after operation as compared with the baseline values in POCD patients and were significantly higher than in non-POCD patients.The plasma concentrations of Glu and Asp were negatively correlated with MMSE score(Glu:r=-0.86.P<0.01;Asp:r=-0.99,P<0.01).Conclusion Elderly patients may develop POCD after operation performed under general anesthesia through increase in intracranial EAA levels.     

乌司他丁对老年髋关节置换患者术后认知功能障碍的影响

目的:评价乌司他丁对老年髋关节置换术患者术后认知功能障碍的影响.方法:择期行髋关节置换术的老年患者80例,年龄≥65岁,ASAⅠ或Ⅱ级,随机分为两组,对照组和乌司他丁组,每组40例.乌司他丁组男21例,女19例,平均年龄(75.00±7.81)岁,体重(58.20±11.21) kg,在手术切皮前(1万 U/kg)、术后第l、2、3 天 5 000 U/kg 缓慢静脉注射乌司他丁;对照组男20例,女20例,平均年龄(72.80±7.25)岁,体重(55.60±7.50) kg,只给予等量生理盐水.术前1 d和术后3 d用简易智能状态检查法(MMSE)进行认知功能测试,以术后MMSE评分下降大于或等于术前1个标准差评定为术后认知障碍.于术前(To)、术毕(T1)、术后3 h(T2)、1 d(T3)、 3 d(T4)测定血清S100β蛋白含量.结果:对照组 10例发生认知障碍(25%),乌司他丁组 1例发生(2.5%),较对照组降低(P<0.05).对照组手术前后MMSE评分分别为(25.2±2.1)、(22.6±2.5)分,T0～4 时S100β蛋白浓度分别为(0.041±0.012)、(0.125±0.031)、(0.178±0.036)、(0.142±0.038)、(0.048±0.015) μg/L;乌司他丁组手术前后MMSE评分分别为(25.9±2.4)、(24.8±2.1)分,T0～4 时S100蛋白浓度分别为(0.040±0.013)、(0.095±0.021)、(0.116±0.017)(0.087±0.019)、(0.043±0.012) μg/L.与术前比较,对照组术后3 d MMSE评分降低(P<0.05),T1～3时S100β蛋白浓度升高(P<0.05);与对照组比较,乌司他丁组术后3 d MMSE评分增加(P<0.05),T1～3时S100β蛋白浓度降低(P<0.05 ).结论:老年髋关节置换术患者围术期应用乌司他丁,能一定程度的预防患者术后认知障碍的发生.     

地塞米松对老龄大鼠术后认知功能的影响

目的 评价地塞米松对老龄大鼠术后认知功能的影响.方法 雄性SD大鼠180只,18 ～ 20月龄,体重400 ～ 600 g,采用随机数字表法,将大鼠随机分为3组(n=60)∶对照组(C组)、手术组(S组)和地塞米松组(D组).采用大鼠剖腹探查手术模型.D组于麻醉开始时腹腔注射地塞米松10 mg/kg.C组不进行手术,腹腔注射生理盐水2 ml/kg.于术后3h、7d时测定海马OX42(小胶质细胞激活特异性标志物)的表达水平;于术后3h、1d、3d和7d时测定海马IL-1β mRNA和TNF-α mRNA的表达水平.采用Morris水迷宫实验和条件恐怖适应实验检测大鼠术后认知功能.结果 与C组比较,S组和D组逃逸潜伏期延长,穿越原平台次数减少,术后僵直时间缩短,海马OX42表达、IL-1β mR-NA和TNF-α mRNA表达上调(P＜0.05或0.01);与S组比较,D组逃逸潜伏期缩短,穿越原平台次数增多,术后僵直时间延长,海马OX42、IL-1β mRNA和TNF-α mRNA表达下调(P＜0.05或0.01).结论 地塞米松可抑制海马小胶质细胞过度激活,减轻炎性反应,从而改善老龄大鼠术后认知功能.     

胆囊胆固醇结石形成与载脂蛋白E基因多态性的关系

载脂蛋白Ｅ(ＡｐｏＥ)由 3个等位基因 (ε2 、ε3、ε4)分别编码 3种异构体(ＡｐｏＥ2 、Ｅ3、Ｅ4) ,组成 6种表型 (Ｅ2 /2、Ｅ2 /3、Ｅ2 /4、Ｅ3/3、Ｅ3/4、Ｅ4/4)。本研究旨在探讨胆固醇结石形成与ＡｐｏＥ基因多态性的关系 ,现报道如下。一、材料与方法1 .标本来源 :本院胆囊胆固醇结石患者 40例 ,其中男 1 1例 ,女 2 9例 ,平均年龄 ( 52± 4)岁。正常对照组为门诊体检者 ,共 60例 ,其中男 1 6例 ,女44例 ,平均年龄 ( 50± 4)岁。2 .方法 :( 1 )ＡｐｏＥ基因多态性检测 :基因组ＤＮＡ提出 :取外周静脉血5ｍｌ,乙二胺四乙酸 (ＥＤＴＡ)抗…     

载脂蛋白E基因多态性与胆石病关系的Meta分析

目的 探讨载脂蛋白E(apoE)基因多态性与胆石病的关系.方法 全面检索和筛选相关文献,通过Meta分析的方法对各研究结果进行数据合并,并评价其发表偏倚,运用敏感性分析评价结果的可靠性.结果 检索到相关文献11篇,包括1248例胆石病患者,1660例对照组.Meta分析研究发现,apoE等位基因ε4 以及基因型E3/E4在胆石病患者中的分布频率明显高于对照组.其合并0R值及95%的CJ(可信区间)分别是1.32(1.01～1.71)、1.60(1.04～2.46),P<0.05.发表性偏倚和敏感性分析显示部分存在发表偏倚,但稳定性较好.结论 胆石病与apoE基因的多态性密切相关,等位基因ε4以及基因型E3/E4是胆石病的危险因子.

Abstract：

Objective To evaluate the relationship between apoE gene polymorphisms and gallstone. Methods We included all the published studies on the association between apoE gene polymorphisms and gall-stone. A meta-analysis was employed to summarize all these studies, calculate the pooled OR and its 95% confidence interval (95% CI) , and test the overall effects. The Egger's publication bias analysis and sensitivity analysis were carried out to evaluate the reliability and stability of the meta-analysis. Results Eleven association studies between the apoE gene polymorphisms and gallstone fulfilled our inclusion criteria. There were 1248 patients with gallstones and 1660 controls. Remarkable heterogeneities were discovered in the allele ε4 and genotype E3/E4 of apoE between gallstone and control subjects in these studies (P<0. 05). Their ORs and 95%CIs were 1.32 (1.01, 1. 71), 1. 60 (1. 04, 2. 46), respectively (P<0. 05). The results of sensitivity analysis and publication bias analysis showed the reliability and stability of this meta-analysis. Conclusion apoE gene polymorphisms are associated with gallstone. Those with the alleleε4 or genotype E3 /E4 had a higher risk of suffering from gallstone.     

参麦注射液对体外循环心脏瓣膜置换术患者术后认知功能的影响

目的 参麦注射液对体外循环心脏瓣膜置换术患者术后认知功能的影响.方法 择期CPB下心脏瓣膜置换术患者40例,年龄40 ～ 70岁,体重指数18 ～ 28 kg/m2,ASA分级Ⅱ或Ⅲ级,NYHA分级Ⅱ或Ⅲ级,蒙特利尔认知评估(MoCA)评分≥26分.采用随机数字表法,将患者分为2组(n=20):对照组(C组)和参麦注射液组(S组).麻醉诱导后S组静脉输注参麦注射液0.6 ml/kg(加入250ml生理盐水),C组给予等容量生理盐水,于转机前输注完毕.记录主动脉阻断时间、CPB时间、麻醉时间、麻醉药用量.于术前3d、术后3、7、14 d进行MoCA评分(＜26分为发生POCD),记录术后14 d内POCD的发生情况.结果 2组患者主动脉阻断时间、CPB时间、麻醉时间、麻醉药用量比较差异无统计学意义(P＞0.05);与术前3d比较,C组术后3、7d、S组术后3d时MoCA评分降低(P＜0.01);与C组比较,S组术后3、7d时MoCA评分升高,POCD发生率降低(P＜0.05或0.01).结论 参麦注射液可改善CPB下心脏瓣膜置换术患者术后认知功能.     

肝脏缺血再灌注对患者术后短期认知功能的影响

目的 评价肝脏缺血再灌注对患者术后短期认知功能的影响.方法 拟在全麻下行肝脏部分切除术患者30例,性别不限,年龄18～60岁,心功能分级Ⅰ或Ⅱ级,肝功能分级A级,ASA分级Ⅰ或Ⅱ级.采用随机数字表法,将患者随机分为2组(n=15):未阻断肝门组(C组)和阻断肝门组(I/R组).术中采取全凭静脉麻醉,维持脑电双频谱指数值40～ 60.分别于术前1 d(基础状态)、术后7d进行神经心理学测试,计算基础值与术后成绩的差值,记录认知功能障碍的发生情况.结果 与C组比较,I/R组累加测试、数字符号测试、循迹连线测试B与倒背数字广度测试成绩的基础值与术后成绩差值升高(P＜0.05或0.01),其他神经心理学测试成绩的基础值与术后成绩差值差异无统计学意义(P＞0.05).C组和I/R组术后认知功能障碍的发生率分别为20％和87％,I/R组高于C组(P＜0.05).肝门阻断时间与认知功能障碍的发生无相关性(P＞0.05).结论 肝脏缺血再灌注可增加术后短期认知功能障碍的发生,但缺血时间与POCD的发生无关.