51
|
Cui K, Lyu S, Song X, Liu H, Yuan F, Xu F, Zhang M, Wang W, Zhang M, Zhang D, Tian J. Drug-Eluting Stent Versus Coronary Artery Bypass Grafting for Diabetic Patients With Multivessel and/or Left Main Coronary Artery Disease: A Meta-Analysis. Angiology 2019; 70:765-773. [PMID: 30995117 DOI: 10.1177/0003319719839885] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
With the development of stent design and surgical techniques, the relative benefit of percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) in patients with diabetes and complex coronary artery disease are highly debated. This meta-analysis was conducted to compare the outcomes of drug-eluting stent (DES) implantation and CABG in these cohorts. A comprehensive search of PubMed, Embase, and Cochrane Library up to January 4, 2018, was performed. Only randomized controlled trials (RCTs), subgroup analysis from RCTs, or adjusted observational studies were eligible. Five RCTs and 13 adjusted observational studies involving 17 532 patients were included. Overall, PCI with DES was significantly associated with higher risk of all-cause mortality (hazard ratio [HR]: 1.16, 95% confidence interval [CI]: 1.05-1.29), myocardial infarction (MI; HR: 1.69, 95% CI: 1.43-2.00), and repeat revascularization (HR: 3.77, 95% CI: 2.76-5.16) compared with CABG. Nevertheless, the risk of stroke was significantly lower in the DES group (HR: 0.67, 95% CI: 0.54-0.83). The incidence of the composite end point of death, MI, or stroke was comparable between the 2 groups (HR: 0.99, 95% CI: 0.84-1.17). Despite the higher risk of stroke, CABG was better than PCI with DES for diabetic patients with multivessel and/or left main coronary artery disease.
Collapse
Affiliation(s)
- Kongyong Cui
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Shuzheng Lyu
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Xiantao Song
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Hong Liu
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Fei Yuan
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Feng Xu
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Min Zhang
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Wei Wang
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Mingduo Zhang
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Dongfeng Zhang
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Jinfan Tian
- 1 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University and Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| |
Collapse
|
52
|
Indja B, Fanning JP, Maller JJ, Fraser JF, Bannon PG, Vallely M, Grieve SM. Neural network imaging to characterize brain injury in cardiac procedures: the emerging utility of connectomics. Br J Anaesth 2018; 118:680-688. [PMID: 28510745 DOI: 10.1093/bja/aex088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Cognitive dysfunction is a poorly understood but potentially devastating complication of cardiac surgery. Clinically meaningful assessment of cognitive changes after surgery is problematic because of the absence of a means to obtain reproducible, objective, and quantitative measures of the neural disturbances that cause altered brain function. By using both structural and functional connectivity magnetic resonance imaging data to construct a map of the inter-regional connections within the brain, connectomics has the potential to increase the specificity and sensitivity of perioperative neurological assessment, permitting rational individualized assessment and improvement of surgical techniques.
Collapse
Affiliation(s)
- B Indja
- Sydney Translational Imaging Laboratory, Heart Research Institute, Charles Perkins Centre, The University of Sydney, NSW, Australia.,Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia.,The Baird Institute for Applied Heart and Lung Surgical Research, Newtown, NSW, Australia
| | - J P Fanning
- School of Medicine, The University of Queensland, Herston, Brisbane, Queensland, Australia, General Electric Healthcare, Sydney, NSW, Australia.,Critical Care Research Group, The Prinice Charles Hospital, Brisbane, Queensland, Australia
| | - J J Maller
- Sydney Translational Imaging Laboratory, Heart Research Institute, Charles Perkins Centre, The University of Sydney, NSW, Australia.,General Electric Healthcare, Australia
| | - J F Fraser
- School of Medicine, The University of Queensland, Herston, Brisbane, Queensland, Australia, General Electric Healthcare, Sydney, NSW, Australia.,Critical Care Research Group, The Prinice Charles Hospital, Brisbane, Queensland, Australia
| | - P G Bannon
- Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia.,The Baird Institute for Applied Heart and Lung Surgical Research, Newtown, NSW, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Camperdown, Sydney, NSW, Australia
| | - M Vallely
- Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia.,The Baird Institute for Applied Heart and Lung Surgical Research, Newtown, NSW, Australia.,Institute of Academic Surgery, Royal Prince Alfred Hospital, Camperdown, Sydney, NSW, Australia
| | - S M Grieve
- Sydney Translational Imaging Laboratory, Heart Research Institute, Charles Perkins Centre, The University of Sydney, NSW, Australia.,Sydney Medical School, The University of Sydney, Camperdown, NSW, Australia.,Department of Radiology, Royal Prince Alfred Hospital, Camperdown, Sydney, NSW, Australia
| |
Collapse
|
53
|
Lewis C, Parulkar SD, Bebawy J, Sherwani S, Hogue CW. Cerebral Neuromonitoring During Cardiac Surgery: A Critical Appraisal With an Emphasis on Near-Infrared Spectroscopy. J Cardiothorac Vasc Anesth 2018; 32:2313-2322. [DOI: 10.1053/j.jvca.2018.03.032] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Indexed: 11/11/2022]
|
54
|
Danielson M, Reinsfelt B, Westerlind A, Zetterberg H, Blennow K, Ricksten SE. Effects of methylprednisolone on blood-brain barrier and cerebral inflammation in cardiac surgery-a randomized trial. J Neuroinflammation 2018; 15:283. [PMID: 30261896 PMCID: PMC6158839 DOI: 10.1186/s12974-018-1318-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 09/18/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Cognitive dysfunction is a frequent complication to open-heart surgery. Cerebral inflammation caused by blood-brain barrier (BBB) dysfunction due to a systemic inflammatory response is considered a possible etiology. The effects of the glucocorticoid, methylprednisolone, on cerebrospinal fluid (CSF) markers of BBB function, neuroinflammation, and brain injury in patients undergoing cardiac surgery with cardiopulmonary bypass were studied. METHODS In this prospective, randomized, blinded study, 30 patients scheduled for elective surgical aortic valve replacement were randomized to methylprednisolone 15 mg/kg (n = 15) or placebo (n = 15) as a bolus dose administered after induction of anesthesia. CSF and blood samples were obtained the day before and 24 h after surgery for assessment of systemic and brain inflammation (interleukin-6, interleukin-8, tumor necrosis factor-alpha), axonal injury (total-tau, neurofilament light chain protein), neuronal injury (neuron-specific enolase), astroglial injury (S-100B, glial fibrillary acidic protein), and the BBB integrity (CSF/serum albumin ratio). RESULTS In the control group, there was a 54-fold and 17-fold increase in serum interleukin-6 and interleukin-8, respectively. This systemic activation of the inflammatory cytokines was clearly attenuated by methylprednisolone (p < 0.001). The increase of the CSF levels of the astroglial markers was not affected. A postoperative BBB dysfunction was seen in both groups as the CSF/serum albumin ratio increased from 6.4 ± 8.0 to 8.0 in the placebo group (p < 0.01) and from 5.6 ± 2.3 to 7.2 in the methylprednisolone group (p < 0.01) with no difference between groups (p = 0.98). In the CSF, methylprednisolone attenuated the interleukin-6 release (p < 0.001), which could be explained by the fall in systemic interleukin-6, and the serum to CSF gradient of IL-6 seen both at baseline and after surgery. In the CSF, methylprednisolone enhanced the interleukin-8 release (p < 0.001) but did not affect postoperative changes in CSF levels of tumor necrosis factor alpha. Serum levels of S-100B and neuron-specific enolase increased in both groups with no difference between groups. CSF levels of total tau, neurofilament light chain protein, and neuron-specific enolase were not affected in any of the groups. CONCLUSIONS Preventive treatment with high-dose methylprednisolone attenuated the systemic inflammatory response to open-heart surgery with cardiopulmonary bypass, but did not prevent or attenuate the increase in BBB permeability or the neuroinflammatory response. TRIAL REGISTRATION Clinical Trials, Identifier: NCT01755338 , registered 24 December 2012.
Collapse
Affiliation(s)
- Mattias Danielson
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| | - Björn Reinsfelt
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| | - Anne Westerlind
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, University of Gothenburg, SE-413 45, Gothenburg, Sweden
| | - Henrik Zetterberg
- Deparment of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, SE-41345, Gothenburg, Sweden
| | - Kaj Blennow
- Deparment of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, SE-41345, Gothenburg, Sweden
| | - Sven-Erik Ricksten
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, University of Gothenburg, SE-413 45, Gothenburg, Sweden.
| |
Collapse
|
55
|
Kamenskaya OV, Loginova IY, Klinkova AS, Chernyavskiy AM, Alsov SA, Sirota DA, Lomivorotov VV, Karaskov AM. [Predictors of neurological complications during surgical treatment of the ascending aorta and aortic arch chronic dissection]. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 118:12-17. [PMID: 30132450 DOI: 10.17116/jnevro20181187112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To evaluate the prognostic significance of oxygen supply to the brain in the risk of neurological complications in the early post operative period of surgical treatment of the ascending aorta and aortic arch. MATERIAL AND METHODS The level of oxygenation (rSO2) in the right and left hemispheres was measured in 68 patients with ascending aorta and aortic arch chronic dissection. Before and in the nearest period after surgery, the patients underwent a clinical/instrumental neurological study. RESULTS The incidence of ischemic stroke in the early post operative period was 5.9%, cognitive impairment was recorded in 22% of patients. Among the parameters of oxygen supply to the brain, the dynamics of rSO2 during circulatory arrest had a significant impact on the post operative neurological status. The risk of cognitive impairment, besides the association with the oxygen status of the brain, increased with the age of patients and comorbid pathology. CONCLUSION The decrease in rSO2 by ≥30% during surgical treatment of ascending aorta and aortic arch dissection increases the risk of ischemic stroke and cognitive impairment in the early post operative period.
Collapse
Affiliation(s)
- O V Kamenskaya
- Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - I Yu Loginova
- Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - A S Klinkova
- Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - A M Chernyavskiy
- Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - S A Alsov
- Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - D A Sirota
- Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - V V Lomivorotov
- Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - A M Karaskov
- Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| |
Collapse
|
56
|
Tamura K, Maruyama T, Sakurai S. Preventive Effect of Suvorexant for Postoperative Delirium after Coronary Artery Bypass Grafting. Ann Thorac Cardiovasc Surg 2018; 25:26-31. [PMID: 30089761 PMCID: PMC6388307 DOI: 10.5761/atcs.oa.18-00038] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE Suvorexant is an orexin receptor antagonist and is effective in inducing sleep. We hypothesized that Suvorexant would reduce the incidence of postoperative delirium (POD) after coronary artery bypass grafting (CABG). METHODS We reviewed 88 patients (12 women, mean age: 69.3 ± 2.5 years) who were undergone CABG alone. Patients were divided into two groups; patients received Suvorexant (S group, n = 36), patients not received Suvorexant (N group, n = 52), and the following data were analyzed and compared between two groups. RESULTS Intensive Care Unit Delirium Screening Checklist Score was significantly lower in S group compared with N group (N:S = 2.0 ± 1.7:0.8 ± 1.0, p = 0.0003). Although POD was present in 11 of 52 patients (21.2%) in N group, one patient (2.8%) developed in S group (p = 0.008). In S group, both intensive care unit stay (N:S = median 6:5 days, p = 0.001) and hospital stay (N:S = median 23:20 days, p = 0.035) were significantly shorter than in N group. CONCLUSIONS Suvorexant might reduce incidence of POD in patients undergone CABG.
Collapse
Affiliation(s)
- Kiyoshi Tamura
- Department of Cardiovascular Surgery, Soka Municipal Hospital, Soka, Saitama, Japan
| | - Toshiyuki Maruyama
- Department of Cardiovascular Surgery, Soka Municipal Hospital, Soka, Saitama, Japan
| | - Syogo Sakurai
- Department of Cardiovascular Surgery, Soka Municipal Hospital, Soka, Saitama, Japan
| |
Collapse
|
57
|
Hayashi K, Oshima H, Shimizu M, Kobayashi K, Matsui S, Nishida Y, Usui A. Preoperative 6-Minute Walk Distance Is Associated With Postoperative Cognitive Dysfunction. Ann Thorac Surg 2018; 106:505-512. [DOI: 10.1016/j.athoracsur.2018.03.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 02/18/2018] [Accepted: 03/05/2018] [Indexed: 10/16/2022]
|
58
|
Hong-Qiang H, Mang-Qiao S, Fen X, Shan-Shan L, Hui-Juan C, Wu-Gang H, Wen-Jun Y, Zheng-Wu P. Sirt1 mediates improvement of isoflurane-induced memory impairment following hyperbaric oxygen preconditioning in middle-aged mice. Physiol Behav 2018; 195:1-8. [PMID: 30040951 DOI: 10.1016/j.physbeh.2018.07.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 07/20/2018] [Accepted: 07/20/2018] [Indexed: 01/04/2023]
Abstract
Hyperbaric oxygen (HBO) preconditioning (PC) has been suggested as a feasible method to provide neuroprotection from postoperative cognitive dysfunction (POCD). However, whether HBO-PC can ameliorate cognitive deficits induced by isoflurane, and the possible mechanism by which it may exert its effect, has not yet been clarified. In the present study, middle-aged mice were exposed to isoflurane anesthesia (1.5 minimal alveolar concentration [MAC]) for 2 h to establish a POCD model. After HBO preconditioning, cognitive function and expression of hippocampal sirtuin 1 (Sirt1), nuclear factor erythroid 2-related factor 2 (Nrf2) and heme oxygenase 1 (HO-1) were evaluated 24 h following isoflurane treatment, in the presence or absence of Sirt1 knockdown by short hairpin RNA (shRNA). HBO preconditioning increased the expression of Sirt1, Nrf2, and HO-1 and ameliorated memory dysfunction. Meanwhile, Sirt1 knockdown inhibited the expression of Nrf2 and HO-1 and attenuated the HBO preconditioning-associated memory improvement. Our results suggest that the application of HBO preconditioning is a useful treatment for POCD, and that Sirt1 may be a potential molecular target for POCD therapy.
Collapse
Affiliation(s)
- Hu Hong-Qiang
- Department of Anesthesiology, PLA No. 174 Hospital, Chenggong Hospital Affiliated to Xiamen University, Xiamen, Fujian 361003, China
| | - Shu Mang-Qiao
- Department of Psychiatry, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China; Department of Psychiatry, Changan Hospital, Xi'an 710016, China
| | - Xue Fen
- Department of Psychiatry, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Liu Shan-Shan
- Department of Anesthesiology, PLA No. 174 Hospital, Chenggong Hospital Affiliated to Xiamen University, Xiamen, Fujian 361003, China
| | - Cao Hui-Juan
- Department of Anesthesiology, PLA No. 174 Hospital, Chenggong Hospital Affiliated to Xiamen University, Xiamen, Fujian 361003, China
| | - Hou Wu-Gang
- Department of Anesthesiology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Yan Wen-Jun
- Department of Anesthesiology, Gansu Provincial Hospital, Lanzhou 730000, China.
| | - Peng Zheng-Wu
- Department of Psychiatry, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| |
Collapse
|
59
|
Kofke WA, Ren Y, Augoustides JG, Li H, Nathanson K, Siman R, Meng QC, Bu W, Yandrawatthana S, Kositratna G, Kim C, Bavaria JE. Reframing the Biological Basis of Neuroprotection Using Functional Genomics: Differentially Weighted, Time-Dependent Multifactor Pathogenesis of Human Ischemic Brain Damage. Front Neurol 2018; 9:497. [PMID: 29997569 PMCID: PMC6028620 DOI: 10.3389/fneur.2018.00497] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 06/07/2018] [Indexed: 12/18/2022] Open
Abstract
Background: Neuroprotection studies are generally unable to demonstrate efficacy in humans. Our specific hypothesis is that multiple pathophysiologic pathways, of variable importance, contribute to ischemic brain damage. As a corollary to this, we discuss the broad hypothesis that a multifaceted approach will improve the probability of efficacious neuroprotection. But to properly test this hypothesis the nature and importance of the multiple contributing pathways needs elucidation. Our aim is to demonstrate, using functional genomics, in human cardiac surgery procedures associated with cerebral ischemia, that the pathogenesis of perioperative human ischemic brain damage involves the function of multiple variably weighted proteins involving several pathways. We then use these data and literature to develop a proposal for rational design of human neuroprotection protocols. Methods: Ninety-four patients undergoing deep hypothermic circulatory arrest (DHCA) and/or aortic valve replacement surgery had brain damage biomarkers, S100β and neurofilament H (NFH), assessed at baseline, 1 and 24 h post-cardiopulmonary bypass (CPB) with analysis for association with 92 single nucleotide polymorphisms (SNPs) (selected by co-author WAK) related to important proteins involved in pathogenesis of cerebral ischemia. Results: At the nominal significance level of 0.05, changes in S100β and in NFH at 1 and 24 h post-CPB were associated with multiple SNPs involving several prospectively determined pathophysiologic pathways, but were not individually significant after multiple comparison adjustments. Variable weights for the several evaluated SNPs are apparent on regression analysis and, notably, are dissimilar related to the two biomarkers and over time post CPB. Based on our step-wise regression model, at 1 h post-CPB, SOD2, SUMO4, and GP6 are related to relative change of NFH while TNF, CAPN10, NPPB, and SERPINE1 are related to the relative change of S100B. At 24 h post-CPB, ADRA2A, SELE, and BAX are related to the relative change of NFH while SLC4A7, HSPA1B, and FGA are related to S100B. Conclusions: In support of the proposed hypothesis, association SNP data suggest function of specific disparate proteins, as reflected by genetic variation, may be more important than others with variation at different post-insult times after human brain ischemia. Such information may support rational design of post-insult time-sensitive multifaceted neuroprotective therapies.
Collapse
Affiliation(s)
- William A Kofke
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, United States
| | - Yue Ren
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, United States
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, United States
| | - Hongzhe Li
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, PA, United States
| | - Katherine Nathanson
- Department of Medicine, Division of Translational Medicine and Human Genetics Abramson Cancer Center Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Robert Siman
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Qing Cheng Meng
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, United States
| | - Weiming Bu
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, United States
| | - Sukanya Yandrawatthana
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, United States
| | - Guy Kositratna
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, United States
| | - Cecilia Kim
- The Center for Applied Genomics, Children's Hospital of Philadelphia, Philadelphia, PA, United States
| | - Joseph E Bavaria
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
60
|
High-Target Versus Low-Target Blood Pressure Management During Cardiopulmonary Bypass to Prevent Cerebral Injury in Cardiac Surgery Patients. Circulation 2018; 137:1770-1780. [DOI: 10.1161/circulationaha.117.030308] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 12/12/2017] [Indexed: 12/16/2022]
|
61
|
Long term outcomes of drug-eluting stent versus coronary artery bypass grafting for left main coronary artery disease: a meta-analysis. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2018; 15:162-172. [PMID: 29662510 PMCID: PMC5895956 DOI: 10.11909/j.issn.1671-5411.2018.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background It is still controversial whether percutaneous coronary intervention with drug-eluting stent (DES) is safe and effective compared to coronary artery bypass graft surgery (CABG) for unprotected left main coronary artery (ULMCA) disease at long-term follow up (≥ 3 years). Methods Eligible studies were selected by searching PubMed, EMBASE, and Cochrane Library up to December 6, 2016. The primary endpoint was a composite of death, myocardial infarction (MI) or stroke during the longest follow-up. Death, cardiac death, MI, stroke and repeat revascularization were the secondary outcomes. Results Four randomized controlled trials and twelve adjusted observational studies involving 14,130 patients were included. DES was comparable to CABG regarding the occurrence of the primary endpoint (HR = 0.94, 95% CI: 0.86–1.03). Besides, DES was significantly associated with higher incidence of MI (HR = 1.56, 95% CI: 1.09–2.22) and repeat revascularization (HR = 3.09, 95% CI: 2.33–4.10) compared with CABG, while no difference was found between the two strategies regard as the rate of death, cardiac death and stroke. Furthermore, DES can reduce the risk of the composite endpoint of death, MI or stroke (HR = 0.80, 95% CI: 0.67–0.95) for ULMCA lesions with SYNTAX score ≤ 32. Conclusions Although with higher risk of repeat revascularization, PCI with DES appears to be as safe as CABG for ULMCA disease at long-term follow up. In addition, treatment with DES could be an alternative interventional strategy to CABG for ULMCA lesions with low to intermediate anatomic complexity.
Collapse
|
62
|
Cox RM, Jamgochian GC, Nicholson K, Wong JC, Namdari S, Abboud JA. The effectiveness of cerebral oxygenation monitoring during arthroscopic shoulder surgery in the beach chair position: a randomized blinded study. J Shoulder Elbow Surg 2018; 27:692-700. [PMID: 29396097 DOI: 10.1016/j.jse.2017.11.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 11/01/2017] [Accepted: 11/06/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Beach chair positioning for shoulder surgery is associated with measurable cerebral desaturation events (CDEs) in up to 80% of patients. Near-infrared spectroscopy (NIRS) technology allows real-time measurement of cerebral oxygenation and may minimize the frequency of CDEs. The purpose of this study was to investigate the incidence of CDEs when anesthetists were aware of and blinded to NIRS monitoring and to determine the short-term cognitive effects of surgery in the beach chair position. METHODS NIRS was used to monitor cerebral oxygenation saturation in 41 consecutive patients undergoing arthroscopic shoulder surgery in the beach chair position. Patients were randomized to 2 groups, anesthetists aware of or blinded to NIRS data. The Montreal Cognitive Assessment (MoCA) was used to assess cognitive function preoperatively, immediately postoperatively, and at 2 and 6 weeks postoperatively. RESULTS Overall, 7 (17.5%) patients experienced a CDE, 5 (25%) in the aware group and 2 (10%) in the blinded group. There was no significant difference in MoCA scores between the aware and blinded groups preoperatively (27.9.1 vs. 28.2; P = .436), immediately postoperatively (26.1 vs. 26.2; P = .778), 2 weeks postoperatively (28.0 vs. 28.1; P = .737), or 6 weeks postoperatively (28.5 vs. 28.4; P = .779). There was a correlation of NIRS with systolic blood pressure (r = 0.448), diastolic blood pressure (r = 0.708), and mean arterial pressure (r = 0.608). CONCLUSION In our series, the incidence of CDEs was much lower than previously reported and was not lowered by use of NIRS. Patients did not have significant cognitive deficits after arthroscopic surgery in the beach chair position, and there was a correlation between NIRS and intraoperative brachial blood pressure.
Collapse
Affiliation(s)
- Ryan M Cox
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Grant C Jamgochian
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Kristen Nicholson
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Justin C Wong
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Surena Namdari
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Joseph A Abboud
- Department of Orthopaedic Surgery, The Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA.
| |
Collapse
|
63
|
Huang C, Mårtensson J, Gögenur I, Asghar MS. Exploring Postoperative Cognitive Dysfunction and Delirium in Noncardiac Surgery Using MRI: A Systematic Review. Neural Plast 2018; 2018:1281657. [PMID: 29743884 PMCID: PMC5878869 DOI: 10.1155/2018/1281657] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 01/09/2018] [Indexed: 12/25/2022] Open
Abstract
Surgical patients are at high risk of developing postoperative cognitive dysfunction (POCD) and postoperative delirium (POD). POCD and POD are associated with increased morbidity and mortality and worsening functional outcomes leading to severe socioeconomic consequences for the patient and the society in general. Magnetic resonance imaging (MRI) offers a unique opportunity to study the anatomy and function of the brain. MRI thus plays an important role in elucidating the neuronal component of POCD and POD. Our aim has been to systematically gather MRI findings that are related to POCD and POD. Systematic searches were conducted in PubMed, EMBASE, and PsycINFO: MRI studies investigating patients with POCD as identified by perioperative cognitive testing or patients with delirium identified postoperatively by the Confusion Assessment Method. A total of ten eligible papers were included with a total of 269 surgical patients, 36 patient controls, and 55 healthy controls who all underwent MRI examination. These studies suggested that reduction of thalamic and hippocampal volumes and reduction of cerebral blood flow may be associated with POCD, while presurgery/preexisting and postoperative white matter pathology may be associated with POD. However, the evidence from these studies is rather weak. Future MRI studies are warranted to verify the current findings.
Collapse
Affiliation(s)
- Chenxi Huang
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Copenhagen University Hospital, Køge, Denmark
| | | | - Ismail Gögenur
- Department of Surgery, Center for Surgical Science, Zealand University Hospital, Copenhagen University Hospital, Køge, Denmark
| | - Mohammad Sohail Asghar
- Department of Neuroanaesthesia and Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| |
Collapse
|
64
|
Long-Term Outcomes for Patients With Stroke After Coronary and Valve Surgery. Ann Thorac Surg 2018; 106:85-91. [PMID: 29501638 DOI: 10.1016/j.athoracsur.2018.01.067] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 12/12/2017] [Accepted: 01/22/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Postoperative stroke is one of the most devastating complications of cardiac surgery. When life-threatening situations such as large infarction and hemorrhage occur, neurosurgical procedures may be performed. In this study, we analyzed the long-term medical and surgical outcomes of stroke after cardiac surgery. METHODS We conducted a retrospective, nationwide, population-based study. All enrolled patients underwent first-time cardiac surgery and were further divided into the subgroups of nonstroke, stroke with medical treatment, and stroke with neurosurgical treatment. All-cause mortality, recurrent stroke, and readmission were analyzed. RESULTS We included 67,051 patients in this study. Patients with postoperative stroke (2.6%, n = 1,731) exhibited an in-hospital mortality rate of 12.3% (n = 213) and a 5-year mortality rate of 49.1% (n = 850). Unprecedentedly, the 83 patients who underwent neurosurgical procedures exhibited an in-hospital mortality of 16.9%; this rate increased to 65.1% at the 5-year follow-up. This neurosurgical subgroup exhibited the highest rate of long-term mortality (p < 0.001). In the neurosurgical subgroup, age was the risk factor for all-cause mortality (hazard ratio, 2.60; 95% confidence interval, 1.60-4.24; p < 0.001). CONCLUSIONS Postoperative stroke often leads to high mortality and poor long-term outcomes. Patients who experienced a severe stroke and underwent neurosurgical procedures also exhibited poor outcomes. Patients and their families should be informed of relatively high mortality and poor long-term outcomes before neurosurgical operation.
Collapse
|
65
|
Feinkohl I, Winterer G, Pischon T. Associations of dyslipidaemia and lipid-lowering treatment with risk of postoperative cognitive dysfunction: a systematic review and meta-analysis. J Epidemiol Community Health 2018; 72:499-506. [PMID: 29437865 DOI: 10.1136/jech-2017-210338] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/18/2018] [Accepted: 01/18/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Lipid imbalance is linked to age-related cognitive impairment, but its role in postoperative cognitive dysfunction (POCD) is unknown. Here, we present a systematic review and meta-analysis on dyslipidaemia, lipid-lowering treatment and POCD risk. METHODS PubMed, Ovid SP and Cochrane databases were searched for longitudinal studies that reported on associations of any measure of dyslipidaemia and/or lipid-lowering treatment with POCD as relative risks (RRs) or ORs. Fixed-effects inverse variance models were used to combine effects. RESULTS Of 205 articles identified in the search, 17 studies on 2725 patients (grand mean age 67 years; mean age range 61-71 years) with follow-up periods of 1 day to 4 years (median 7 days; IQR 1-68 days) were included. Studies focused almost exclusively on hypercholesterolaemia as a measure of dyslipidaemia and on statins as lipid-lowering treatment. Across 12 studies on hypercholesterolaemia, we found no association with POCD risk (RR 0.93; 95% CI 0.80 to 1.08; P=0.34). Statin use before surgery was associated with a reduced POCD risk across eight studies (RR 0.81; 95% CI 0.67 to 0.98; P=0.03), but data on treatment duration were lacking. CONCLUSION Statin users appear to be at reduced risk of POCD although hypercholesterolaemia per se may not be associated with POCD risk. Trial studies are needed to evaluate the usefulness of statins in POCD prevention.
Collapse
Affiliation(s)
- Insa Feinkohl
- Molecular Epidemiology Research Group, Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
| | - Georg Winterer
- Department of Anesthesiology and Operative Intensive Care Medicine, Experimental and Clinical Research Center (ECRC), Charité Universitaetsmedizin, Berlin, Germany
| | - Tobias Pischon
- Molecular Epidemiology Research Group, Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany.,Charité Universitaetsmedizin Berlin, Berlin, Germany.,MDC/BIH Biobank, Max-Delbrueck-Center for Molecular Medicine in the Helmholtz Association (MDC) and Berlin Institute of Health (BIH), Berlin, Germany
| |
Collapse
|
66
|
Hood R, Budd A, Sorond FA, Hogue CW. Peri-operative neurological complications. Anaesthesia 2018; 73 Suppl 1:67-75. [DOI: 10.1111/anae.14142] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 11/27/2022]
Affiliation(s)
- R. Hood
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - A. Budd
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - F. A. Sorond
- Department of Neurology; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - C. W. Hogue
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago IL USA
| |
Collapse
|
67
|
Bezerra DM, Bezerra EM, Junior AJS, Amorim MAS, Miranda DBD. Postoperative visual loss due to conversion disorder after spine surgery: a case report. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 26804714 PMCID: PMC9391679 DOI: 10.1016/j.bjane.2015.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Background and objective Case report Conclusions
Collapse
|
68
|
Oh CS, Park S, Wan Hong S, Kang WS, Yoon TG, Kim SH. Postoperative Delirium in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting According to the Anesthetic Agent: A Retrospective Study. J Cardiothorac Vasc Anesth 2017. [DOI: 10.1053/j.jvca.2017.02.047] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
|
69
|
Soundhar A, Udesh R, Mehta A, Schindler J, Jeevanantham V, Gleason T, Thirumala PD. Delirium Following Transcatheter Aortic Valve Replacement: National Inpatient Sample Analysis. J Cardiothorac Vasc Anesth 2017; 31:1977-1984. [DOI: 10.1053/j.jvca.2017.03.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Indexed: 12/14/2022]
|
70
|
Khan MM, Herrmann N, Gallagher D, Gandell D, Fremes SE, Wijeysundera HC, Radhakrishnan S, Sun YR, Lanctôt KL. Cognitive Outcomes After Transcatheter Aortic Valve Implantation: A Metaanalysis. J Am Geriatr Soc 2017; 66:254-262. [PMID: 29159840 DOI: 10.1111/jgs.15123] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES To quantitatively summarize changes in cognitive performance in individuals with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). DESIGN Metaanalysis. PARTICIPANTS Individuals undergoing TAVI (N = 1,065 (48.5% male) from 18 studies, average age ≥80). MEASUREMENTS The MEDLINE, EMBASE, and Cochrane Central databases were searched for original peer-reviewed reports assessing cognitive performance using standardized cognitive tests before and after TAVI. Data were extracted for cognitive scores before TAVI; perioperatively (within 7 days after TAVI); 1, 3, and 6 months after TAVI, and 12 to 34 months after TAVI (over the long term). Standardized mean differences (SMDs) were generated using random-effects models for changes in cognition at each time point. Metaregression analyses were conducted to assess the association between population and procedural characteristics and cognitive outcomes. Risk of bias was assessed. RESULTS There were no significant changes from baseline in perioperative cognitive performance (SMD = 0.05, 95% confidence interval (CI) = -0.08-0.18; z = 0.75, P = .46), although overall cognitive performance had improved significantly 1 month after TAVI (SMD = -0.33, 95% CI = -0.50 to -0.16; z = 3.83, P < .001). There were no differences in cognitive performance 3 and 6 months after TAVI or over the long term. Cognitive outcomes were not associated with any covariates in regression analyses. CONCLUSION Cognitive performance is preserved after TAVI, suggesting TAVI is not detrimental to cognition.
Collapse
Affiliation(s)
- Maisha M Khan
- Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Nathan Herrmann
- Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Psychiatry, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| | - Damien Gallagher
- Department of Psychiatry, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| | - Dov Gandell
- Department of Geriatric Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Sam Radhakrishnan
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Yue Ran Sun
- Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Krista L Lanctôt
- Neuropsychopharmacology Research Group, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.,Department of Psychiatry, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
71
|
Caldas JR, Haunton VJ, Panerai RB, Hajjar LA, Robinson TG. Cerebral autoregulation in cardiopulmonary bypass surgery: a systematic review. Interact Cardiovasc Thorac Surg 2017; 26:494-503. [DOI: 10.1093/icvts/ivx357] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 10/03/2017] [Indexed: 01/06/2023] Open
Affiliation(s)
- Juliana R Caldas
- Department of Anesthesia, Heart Institute, University of São Paulo, São Paulo, Brazil
- Hospital Sao Rafael, Salvador, Bahia, Brazil
| | - Victoria J Haunton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Ludhmila A Hajjar
- Department of Anesthesia, Heart Institute, University of São Paulo, São Paulo, Brazil
- Department of Cardiopneumology, Heart Institute, University of São Paulo, Brazil
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| |
Collapse
|
72
|
TREK-1 pathway mediates isoflurane-induced memory impairment in middle-aged mice. Neurobiol Learn Mem 2017; 145:199-204. [PMID: 29042297 DOI: 10.1016/j.nlm.2017.10.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 04/14/2017] [Accepted: 10/13/2017] [Indexed: 01/08/2023]
Abstract
Post-operative cognitive dysfunction (POCD) has been widely reported, especially in elderly patients. An association between POCD and inhalational anesthetics, such as isoflurane, has been suggested. The TWIK-related K+ channel-1 (TREK-1) controls several major cellular responses involved in memory formation and is believed to participate in the development of depression, cerebral ischemia and blood-brain barrier dysfunction. However, the specific role of TREK-1 in mediating anesthesia-induced POCD remains unknown. In the current study, we determined that exposure to isoflurane affected memory in middle-aged mice and altered TREK-1 expression. In addition, TREK-1 over-expression exacerbated isoflurane-induced memory impairment, while TREK-1 silence attenuated the impairment. Taken together, our data demonstrate that inhibition of TREK-1 protects mice from cognitive impairment induced by anesthesia and TREK-1 is a potential therapeutic target against memory impairment induced by volatile anesthetics.
Collapse
|
73
|
Guarracino F, Baldassarri R, Zanatta P. Current Status of Neuromonitoring in Cardiac Surgery. CURRENT ANESTHESIOLOGY REPORTS 2017. [DOI: 10.1007/s40140-017-0229-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
74
|
Zhang Z, Ma Q, Shah B, Mackensen GB, Lo DC, Mathew JP, Podgoreanu MV, Terrando N. Neuroprotective Effects of Annexin A1 Tripeptide after Deep Hypothermic Circulatory Arrest in Rats. Front Immunol 2017; 8:1050. [PMID: 28912778 PMCID: PMC5582068 DOI: 10.3389/fimmu.2017.01050] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/14/2017] [Indexed: 01/01/2023] Open
Abstract
Resolution agonists, including lipid mediators and peptides such as annexin A1 (ANXA1), are providing novel approaches to treat inflammatory conditions. Surgical trauma exerts a significant burden on the immune system that can affect and impair multiple organs. Perioperative cerebral injury after cardiac surgery is associated with significant adverse neurological outcomes such as delirium and postoperative cognitive dysfunction. Using a clinically relevant rat model of cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA), we tested the pro-resolving effects of a novel bioactive ANXA1 tripeptide (ANXA1sp) on neuroinflammation and cognition. Male rats underwent 2 h CPB with 1 h DHCA at 18°C, and received vehicle or ANXA1sp followed by timed reperfusion up to postoperative day 7. Immortalized murine microglial cell line BV2 were treated with vehicle or ANXA1sp and subjected to 2 h oxygen–glucose deprivation followed by timed reoxygenation. Microglial activation, cell death, neuroinflammation, and NF-κB activation were assessed in tissue samples and cell cultures. Rats exposed to CPB and DHCA had evident neuroinflammation in various brain areas. However, in ANXA1sp-treated rats, microglial activation and cell death (apoptosis and necrosis) were reduced at 24 h and 7 days after surgery. This was associated with a reduction in key pro-inflammatory cytokines due to inhibition of NF-κB activation in the brain and systemically. Treated rats also had improved neurologic scores and shorter latency in the Morris water maze. In BV2 cells treated with ANXA1sp, similar protective effects were observed including decreased pro-inflammatory cytokines and cell death. Notably, we also found increased expression of ANXA1, which binds to NF-κB p65 and thereby inhibits its transcriptional activity. Our findings provide evidence that treatment with a novel pro-resolving ANXA1 tripeptide is neuroprotective after cardiac surgery in rats by attenuating neuroinflammation and may prevent postoperative neurologic complications.
Collapse
Affiliation(s)
- Zhiquan Zhang
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Qing Ma
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Bijal Shah
- Center for Drug Discovery, Department of Neurobiology, Duke University Medical Center, Durham, NC, United States
| | - G Burkhard Mackensen
- Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, WA, United States
| | - Donald C Lo
- Center for Drug Discovery, Department of Neurobiology, Duke University Medical Center, Durham, NC, United States
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Mihai V Podgoreanu
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Niccolò Terrando
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States.,Center for Translational Pain Medicine, Duke University Medical Center, Durham, NC, United States
| |
Collapse
|
75
|
Influence of the postoperative inflammatory response on cognitive decline in elderly patients undergoing on-pump cardiac surgery: a controlled, prospective observational study. BMC Anesthesiol 2017; 17:113. [PMID: 28851286 PMCID: PMC5576316 DOI: 10.1186/s12871-017-0408-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 08/22/2017] [Indexed: 02/03/2023] Open
Abstract
Background The role of non-infective inflammatory response (IR) in the aetiology of postoperative cognitive dysfunction (POCD) is still controversial. The aim of this controlled, prospective observational study was to assess the possible relationship between the grade of IR, defined by procalcitonin (PCT) changes, and development of POCD related to cardiac surgery. Methods Forty-two patients, who were ≥ 60 years of age and scheduled for elective cardiac surgery, were separated into the low inflammatory (LIR) and high inflammatory (HIR) response groups based on their PCT levels measured on the first postoperative day. A matched normative control group of 32 subjects was recruited from primary care practice. The PCT and C-reactive protein (CRP) levels were monitored daily during the first five postoperative days. The cognitive function and mood state were preoperatively tested with a set of five neurocognitive tests and two mood inventories and at the seventh postoperative day. The Reliable Change Index modified for practice (RCIp) using data from normative controls was applied to determine the significant decline in test performance. Results The LIR (n = 20) and HIR (n = 22) groups differed significantly in the PCT (p < 0.001) but not in the CRP time courses. The incidence of POCD at the first postoperative week was 35.7% in the cohort. The LIR and HIR groups did not vary in the RCIp Z scores of neurocognitive tests and frequencies of POCD (7 vs 8 cases, respectively, p > 0.05). Additionally, there was no difference in the mood states, anxiety levels and perioperative parameters known to influence the development of POCD. Conclusions In this study, the magnitude of the non-infective inflammatory response generated by on-pump cardiac surgery did not influence the development of POCD in the early postoperative period in elderly patients.
Collapse
|
76
|
Khalil A, Faisal A, Ng SC, Liew YM, Lai KW. Multimodality registration of two-dimensional echocardiography and cardiac CT for mitral valve diagnosis and surgical planning. J Med Imaging (Bellingham) 2017; 4:037001. [PMID: 28840172 DOI: 10.1117/1.jmi.4.3.037001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 07/27/2017] [Indexed: 11/14/2022] Open
Abstract
A registration method to fuse two-dimensional (2-D) echocardiography images with cardiac computed tomography (CT) volume is presented. The method consists of two major procedures: temporal and spatial registrations. In temporal registration, the echocardiography frames at similar cardiac phases as the CT volume were interpolated based on electrocardiogram signal information, and the noise of the echocardiography image was reduced using the speckle reducing anisotropic diffusion technique. For spatial registration, an intensity-based normalized mutual information method was applied with a pattern search optimization algorithm to produce an interpolated cardiac CT image. The proposed registration framework does not require optical tracking information. Dice coefficient and Hausdorff distance for the left atrium assessments were [Formula: see text] and [Formula: see text], respectively; for left ventricle, they were [Formula: see text] and [Formula: see text], respectively. There was no significant difference in the mitral valve annulus diameter measurement between the manually and automatically registered CT images. The transformation parameters showed small deviations ([Formula: see text] deviation in translation and [Formula: see text] for rotation) between manual and automatic registrations. The proposed method aids the physician in diagnosing mitral valve disease as well as provides surgical guidance during the treatment procedure.
Collapse
Affiliation(s)
- Azira Khalil
- University of Malaya, Department of Biomedical Engineering, Faculty of Engineering, Kuala Lumpur, Malaysia.,Islamic Science University of Malaysia, Faculty of Science and Technology, Nilai, Negeri Sembilan, Malaysia
| | - Amir Faisal
- University of Malaya, Department of Biomedical Engineering, Faculty of Engineering, Kuala Lumpur, Malaysia
| | - Siew-Cheok Ng
- University of Malaya, Department of Biomedical Engineering, Faculty of Engineering, Kuala Lumpur, Malaysia
| | - Yih Miin Liew
- University of Malaya, Department of Biomedical Engineering, Faculty of Engineering, Kuala Lumpur, Malaysia
| | - Khin Wee Lai
- University of Malaya, Department of Biomedical Engineering, Faculty of Engineering, Kuala Lumpur, Malaysia
| |
Collapse
|
77
|
The Risk of Neurological Dysfunctions after Deep Hypothermic Circulatory Arrest with Retrograde Cerebral Perfusion. J Stroke Cerebrovasc Dis 2017; 26:3009-3019. [PMID: 28844545 DOI: 10.1016/j.jstrokecerebrovasdis.2017.07.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 06/10/2017] [Accepted: 07/30/2017] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE Retrograde cerebral perfusion (RCP) is a brain protection technique that is adopted generally for anticipated short periods of deep hypothermic circulatory arrest (DHCA). However, the real impact of this technique on cerebral protection during DHCA remains a controversial issue. METHODS For 344 (59.5%) of 578 consecutive patients (mean age, 66.9 ± 10.9 years) who underwent cardiovascular surgery under DHCA at the present authors' institution (1999-2015), RCP was the sole technique of cerebral protection that was adopted in addition to deep hypothermia. Surgery of the thoracic aorta was performed in 95.9% of these RCP patients; in 92 cases there was an aortic arch involvement. Outcomes were reviewed retrospectively. The focus was on postoperative neurological dysfunctions. RESULTS There were 33 (9.6%) in-hospital deaths. Thirty-one (9%) patients had permanent neurological dysfunctions and 66 (19.1%) transitory neurological dysfunctions alone. Age older than 74 years (odds ratio [OR], 1.88, P = .023), surgery for acute aortic dissection (OR, 2.57; P = .0009), and DHCA time longer than 25 minutes (OR, 2.44; P = .0021) were predictors of neurological dysfunctions. The 10-year nonparametric estimate of freedom from all-cause death was 61.8% (95% confidence interval, 57.8%-65.8%). Permanent postoperative neurological dysfunctions were risk factors for cardiac or cerebrovascular death (hazard ratio, 2.6; P = .039) even after an adjusted survival analysis (P < .04). CONCLUSIONS According to the study findings, RCP, in addition to deep hypothermia, combines with a low risk of neurological dysfunctions provided that DHCA length is 25 minutes or less. Permanent postoperative neurological dysfunctions are predictors of poor late survival.
Collapse
|
78
|
Husebråten IM, Fiane AE, Ringdal MAI, Thiara AP. Measurement of gaseous microemboli in the prime before the initiation of cardiopulmonary bypass. Perfusion 2017; 33:30-35. [DOI: 10.1177/0267659117723454] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: The use of cardiopulmonary bypass is associated with a risk of neurocognitive deficit caused by gaseous microemboli. Flushing the empty bypass circuit with carbon dioxide, which is more soluble than air, may reduce the amount of gaseous microemboli in the priming solution before the initiating of cardiopulmonary bypass. Method: We measured the amount of gaseous microemboli in twenty primed bypass circuits. Ten circuits were flushed with carbon dioxide before being primed and ten circuits were non-flushed. All circuits in both groups were primed with crystalloid priming. An ultrasonic clinical bubble counter was used to count gaseous microemboli in the prime for 20 minutes. Results: The median numbers of gaseous microemboli counts were highest during the first minute in both groups, with a significantly lower median value in the group flushed with carbon dioxide (397.5) versus the non-flushed group (1900). In the 20th minute, the median values of gaseous microemboli were significantly lower (p<0.023) in the flushed (0.5) versus non-flushed (10.75) groups. The gaseous microembolic count in the flushed group remained lower than in the non-flushed group when tested minute by minute throughout the whole 20-minute period. Conclusion: Flushing the bypass circuits with carbon dioxide before priming significantly decreased the number of gaseous microemboli in the priming solution.
Collapse
Affiliation(s)
- Inger M. Husebråten
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| | - Arnt E. Fiane
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| | | | - Amrit P.S. Thiara
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
79
|
Neurocognitive and Psychiatric Issues Post Cardiac Surgery. Heart Lung Circ 2017; 26:779-785. [DOI: 10.1016/j.hlc.2016.12.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 12/14/2016] [Indexed: 12/15/2022]
|
80
|
Abstract
Perioperative care of the patients with neurological diseases can be challenging. Most important consideration is the management and understanding of pathophysiology of these disorders and evaluation of new neurological changes that occur perioperatively. Perioperative generally refers to 3 phases of surgery: preoperative, intraoperative, and postoperative. We have tried to address few commonly encountered neurological conditions in clinical practice, such as delirium, stroke, epilepsy, myasthenia gravis, and Parkinson disease. In this article, we emphasize on early diagnosis and management strategies of neurological disorders in the perioperative period to minimize morbidity and mortality of patients.
Collapse
Affiliation(s)
- Manjeet Singh Dhallu
- Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ahmed Baiomi
- Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Madhavi Biyyam
- Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sridhar Chilimuri
- Department of Medicine, Bronx-Lebanon Hospital Center, Bronx, NY, USA.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
81
|
A clinical review of inhalation anesthesia with sevoflurane: from early research to emerging topics. J Anesth 2017; 31:764-778. [PMID: 28585095 PMCID: PMC5640726 DOI: 10.1007/s00540-017-2375-6] [Citation(s) in RCA: 108] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 05/20/2017] [Indexed: 12/20/2022]
Abstract
A large number of studies during the past two decades have demonstrated the efficacy and safety of sevoflurane across patient populations. Clinical researchers have also investigated the effects of sevoflurane, its hemodynamic characteristics, its potential protective effects on several organ systems, and the incidence of delirium and cognitive deficiency. This review examines the clinical profiles of sevoflurane and other anesthetic agents, and focuses upon emerging topics such as organ protection, postoperative cognitive deficiency and delirium, and novel ways to improve postanesthesia outcomes.
Collapse
|
82
|
Efeito de dois protocolos de controle glicêmico diferentes sobre a disfunção cognitiva após cirurgia de revascularização do miocárdio. Braz J Anesthesiol 2017; 67:258-265. [DOI: 10.1016/j.bjan.2016.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 01/07/2016] [Indexed: 11/17/2022] Open
|
83
|
Dieleman JM, de Wit GA, Nierich AP, Rosseel PM, van der Maaten JM, Hofland J, Diephuis JC, de Lange F, Boer C, Neslo RE, Moons KG, van Herwerden LA, Tijssen JG, Kalkman CJ, van Dijk D. Long-term outcomes and cost effectiveness of high-dose dexamethasone for cardiac surgery: a randomised trial. Anaesthesia 2017; 72:704-713. [PMID: 28317094 DOI: 10.1111/anae.13853] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/26/2017] [Indexed: 11/30/2022]
Abstract
Prophylactic intra-operative administration of dexamethasone may improve short-term clinical outcomes in cardiac surgical patients. The purpose of this study was to evaluate long-term clinical outcomes and cost effectiveness of dexamethasone versus placebo. Patients included in the multicentre, randomised, double-blind, placebo-controlled DExamethasone for Cardiac Surgery (DECS) trial were followed up for 12 months after their cardiac surgical procedure. In the DECS trial, patients received a single intra-operative dose of dexamethasone 1 mg.kg-1 (n = 2239) or placebo (n = 2255). The effects on the incidence of major postoperative events were evaluated. Also, overall costs for the 12-month postoperative period, and cost effectiveness, were compared between groups. Of 4494 randomised patients, 4457 patients (99%) were followed up until 12 months after surgery. There was no difference in the incidence of major postoperative events, the relative risk (95%CI) being 0.86 (0.72-1.03); p = 0.1. Treatment with dexamethasone reduced costs per patient by £921 [€1084] (95%CI £-1672 to -137; p = 0.02), mainly through reduction of postoperative respiratory failure and duration of postoperative hospital stay. The probability of dexamethasone being cost effective compared with placebo was 97% at a threshold value of £17,000 [€20,000] per quality-adjusted life year. We conclude that intra-operative high-dose dexamethasone did not have an effect on major adverse events at 12 months after cardiac surgery, but was associated with a reduction in costs. Routine dexamethasone administration is expected to be cost effective at commonly accepted threshold levels for cost effectiveness.
Collapse
Affiliation(s)
- J M Dieleman
- Department of Anesthesiology and Intensive Care, University Medical Center, Utrecht, the Netherlands
| | - G A de Wit
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, the Netherlands
| | - A P Nierich
- Department of Cardiothoracic Anesthesia, Isala Klinieken, Zwolle, the Netherlands
| | - P M Rosseel
- Department of Cardiothoracic Anesthesia, Amphia Ziekenhuis, Breda, the Netherlands
| | - J M van der Maaten
- Department of Anesthesiology, University Medical Center, Groningen, the Netherlands
| | - J Hofland
- Department of Cardiothoracic Anesthesia, Erasmus Medical Center, Rotterdam, the Netherlands
| | - J C Diephuis
- Department of Cardiothoracic Anesthesia, Medisch Spectrum Twente, Enschede, the Netherlands
| | - F de Lange
- Department of Cardiothoracic Anesthesia, Medical Center, Leeuwarden, the Netherlands
| | - C Boer
- Department of Anesthesiology, Vrije Universiteit University Medical Center, Amsterdam, the Netherlands
| | - R E Neslo
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, the Netherlands
| | - K G Moons
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, the Netherlands
| | - L A van Herwerden
- Department of Cardiothoracic Surgery, University Medical Center, Utrecht, the Netherlands
| | - J G Tijssen
- Department of Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - C J Kalkman
- Department of Anesthesiology and Intensive Care, University Medical Center, Utrecht, the Netherlands
| | - D van Dijk
- Department of Anesthesiology and Intensive Care, University Medical Center, Utrecht, the Netherlands
| | | |
Collapse
|
84
|
Ottens TH, Hendrikse J, Nathoe HM, Biessels GJ, van Dijk D. Brain volume and cognitive function in patients with revascularized coronary artery disease. Int J Cardiol 2017; 230:80-84. [DOI: 10.1016/j.ijcard.2016.12.079] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 11/18/2016] [Accepted: 12/16/2016] [Indexed: 11/26/2022]
|
85
|
De Cosmo G, Sessa F, Fiorini F, Congedo E. Effect of remifentanil and fentanyl on postoperative cognitive function and cytokines level in elderly patients undergoing major abdominal surgery. J Clin Anesth 2016; 35:40-46. [DOI: 10.1016/j.jclinane.2016.07.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 06/19/2016] [Accepted: 07/05/2016] [Indexed: 02/05/2023]
|
86
|
Cole SP. Intensive Care Management of Thoracic Aortic Surgical Patients, Including Thoracic and Infradiaphragmatic Endovascular Repair (EVAR/TEVAR). Semin Cardiothorac Vasc Anesth 2016; 19:331-41. [PMID: 26660057 DOI: 10.1177/1089253215613791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The patient with thoracic aortic disease can present for open or endovascular repair. Thoracic endovascular aortic repair (TEVAR) has emerged as a minimally invasive option for a multitude of aortic pathology, including dissections, aneurysms, traumatic injuries, and ulcers. Postoperative management of these patients depends on the extent of procedure, whether it was open or endovascular, and, finally, on the preoperative comorbidities present. While procedural success has catapulted TEVAR to popularity, midterm results have been mixed. Additionally, periprocedural complications such as paraplegia and renal failure remain a significant morbidity in these patients.
Collapse
|
87
|
Pan K, Li X, Chen Y, Zhu D, Li Y, Tao G, Zuo Z. Deferoxamine pre-treatment protects against postoperative cognitive dysfunction of aged rats by depressing microglial activation via ameliorating iron accumulation in hippocampus. Neuropharmacology 2016; 111:180-194. [PMID: 27608977 DOI: 10.1016/j.neuropharm.2016.09.004] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 08/08/2016] [Accepted: 09/04/2016] [Indexed: 12/31/2022]
Abstract
Postoperative cognitive dysfunction (POCD) is a common complication of elderly patients after surgery. The mechanisms of POCD have not been clarified. Iron accumulation is a feature of neurodegeneration. Recent reports showed that iron content was increased with impaired cognition induced by surgery. We sought to investigate whether iron chelation would attenuate POCD. In this study, male aged (18 months) Sprague-Dawley rats received 100 mg/kg deferoxamine or saline solution (0.9%) for 6 days before exploratory laparotomy. Cognition was evaluated by Morris water maze before and after surgery. Additional rats received deferoxamine or saline were used to determine hippocampal iron content, iron transport-related proteins (transferrin receptor, divalent metal transporter 1, ferroportin 1 and hepcidin), oxidative stress, microglial activation and brain cell apoptosis. It was found that deferoxamine improved postoperative spatial memory in aged rats. Deferoxamine significantly reduced hippocampal iron concentration and ferritin. Surgery increased divalent metal transporter 1 and hepcidin, decreased transferrin receptor and ferroportin 1, and enhanced ferroportin 1 mRNA. However, deferoxamine reversed the changes of these proteins. Furthermore, deferoxamine sharply reduced the hippocampal reactive oxygen species, malondialdehyde concentration and OX-42 that is a marker of microglia, which might reduce postoperative brain cell apoptosis. This study showed that deferoxamine may improve postoperative cognition of aged rats by ameliorating oxidative stress induced by hippocampal iron accumulation, microglial activation and brain cell apoptosis. This study suggests a potential therapeutic method for reducing POCD.
Collapse
Affiliation(s)
- Ke Pan
- Department of Anesthesiology, Southwest Hospital, The Third Military Medical University, Chongqing, China; Department of Anesthesiology, No. 281 Hospital of People's Liberation Army, Hebei, China
| | - Xiaojun Li
- Department of Anesthesiology, Southwest Hospital, The Third Military Medical University, Chongqing, China
| | - Yan Chen
- Department of Anesthesiology, Southwest Hospital, The Third Military Medical University, Chongqing, China
| | - Dan Zhu
- Department of Anesthesiology, Southwest Hospital, The Third Military Medical University, Chongqing, China
| | - Yuping Li
- Department of Anesthesiology, Southwest Hospital, The Third Military Medical University, Chongqing, China
| | - Guocai Tao
- Department of Anesthesiology, Southwest Hospital, The Third Military Medical University, Chongqing, China.
| | - Zhiyi Zuo
- Department of Anesthesiology, University of Virginia, Charlottesville, VA, USA.
| |
Collapse
|
88
|
S100B protein and neuron-specific enolase as predictors of cognitive dysfunction after coronary artery bypass graft surgery. Eur J Anaesthesiol 2016; 33:681-9. [DOI: 10.1097/eja.0000000000000450] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
89
|
Lomivorotov VV, Efremov SM, Kirov MY, Fominskiy EV, Karaskov AM. Low-Cardiac-Output Syndrome After Cardiac Surgery. J Cardiothorac Vasc Anesth 2016; 31:291-308. [PMID: 27671216 DOI: 10.1053/j.jvca.2016.05.029] [Citation(s) in RCA: 156] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia.
| | - Sergey M Efremov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Mikhail Y Kirov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia
| | - Evgeny V Fominskiy
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Alexander M Karaskov
- Department of Cardiac Surgery, Research Institute of Circulation Pathology, Novosibirsk, Russia
| |
Collapse
|
90
|
Abstract
Abstract
Background
Although postoperative cognitive dysfunction (POCD) is well described after coronary artery bypass graft (CABG) surgery, a major concern has been that a progressive decline in cognition will ultimately lead to dementia. Since dementia interferes with the ability to carry out daily functions, the impact has far greater ramifications than cognitive decline defined purely by a decreased ability to perform on a battery of neurocognitive tests. The authors hypothesized that early cognitive impairment measured as baseline cognitive impairment is associated with an increased risk of long-term dementia.
Methods
The authors conducted a prospective longitudinal study on 326 patients aged 55 yr and older at the time of undergoing CABG surgery. Dementia was classified by expert opinion on review of performance on the Clinical Dementia Rating Scale and several other assessment tasks. Patients were also assessed for POCD at 3 and 12 months and at 7.5 yr using a battery of neuropsychologic tests and classified using the reliable change index. Associations were assessed using univariable analysis.
Results
At 7.5 yr after CABG surgery, the prevalence of dementia was 36 of 117 patients (30.8%; 95% CI, 23 to 40). POCD was detected in 62 of 189 patients (32.8%; 95% CI, 26 to 40). Due to incomplete assessments, the majority (113 patients), but not all, were assessed for both dementia and POCD. Fourteen of 32 (44%) patients with dementia were also classified as having POCD. Preexisting cognitive impairment and peripheral vascular disease were both associated with dementia 7.5 yr after CABG surgery. POCD at both 3 (odds ratio, 3.06; 95% CI, 1.39 to 9.30) and 12 months (odds ratio, 4.74; 95% CI, 1.63 to 13.77) was associated with an increased risk of mortality by 7.5 yr.
Conclusions
The prevalence of dementia at 7.5 yr after CABG surgery is greatly increased compared to population prevalence. Impaired cognition before surgery or the presence of cardiovascular disease may contribute to the high prevalence.
Collapse
|
91
|
Basciani R, Kröninger F, Gygax E, Jenni H, Reineke D, Stucki M, Hagenbuch N, Carrel T, Eberle B, Erdoes G. Cerebral Microembolization During Aortic Valve Replacement Using Minimally Invasive or Conventional Extracorporeal Circulation: A Randomized Trial. Artif Organs 2016; 40:E280-E291. [DOI: 10.1111/aor.12744] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Reto Basciani
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
| | - Felix Kröninger
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
| | - Erich Gygax
- Department of Cardiovascular Surgery; Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern; Bern
| | - Hansjörg Jenni
- Department of Cardiovascular Surgery; Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern; Bern
| | - David Reineke
- Department of Cardiovascular Surgery; Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern; Bern
| | - Monika Stucki
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
| | | | - Thierry Carrel
- Department of Cardiovascular Surgery; Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern; Bern
| | - Balthasar Eberle
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
| |
Collapse
|
92
|
Hovens IB, van Leeuwen BL, Mariani MA, Kraneveld AD, Schoemaker RG. Postoperative cognitive dysfunction and neuroinflammation; Cardiac surgery and abdominal surgery are not the same. Brain Behav Immun 2016; 54:178-193. [PMID: 26867718 DOI: 10.1016/j.bbi.2016.02.003] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 01/25/2016] [Accepted: 02/07/2016] [Indexed: 12/21/2022] Open
Abstract
Postoperative cognitive dysfunction (POCD) is a debilitating surgical complication, with cardiac surgery patients at particular risk. To gain insight in the mechanisms underlying the higher incidence of POCD after cardiac versus non-cardiac surgery, systemic and central inflammatory changes, alterations in intraneuronal pathways, and cognitive performance were studied after cardiac and abdominal surgery in rats. Male Wistar rats were subjected to ischemia reperfusion of the upper mesenteric artery (abdominal surgery) or the left coronary artery (cardiac surgery). Control rats remained naïve, received anesthesia only, or received thoracic sham surgery. Rats were subjected to affective and cognitive behavioral tests in postoperative week 2. Plasma concentrations of inflammatory factors, and markers for neuroinflammation (NGAL and microglial activity) and the BDNF pathway (BDNF, p38MAPK and DCX) were determined. Spatial memory was impaired after both abdominal and cardiac surgery, but only cardiac surgery impaired spatial learning and object recognition. While all surgical procedures elicited a pronounced acute systemic inflammatory response, NGAL and TNFα levels were particularly increased after abdominal surgery. Conversely, NGAL in plasma and the paraventricular nucleus of the hypothalamus and microglial activity in hippocampus and prefrontal cortex on postoperative day 14 were increased after cardiac, but not abdominal surgery. Both surgery types induced hippocampal alterations in BDNF signaling. These results suggest that POCD after cardiac surgery, compared to non-cardiac surgery, affects different cognitive domains and hence may be more extended rather than more severe. Moreover, while abdominal surgery effects seem limited to hippocampal brain regions, cardiac surgery seems associated with more wide spread alterations in the brain.
Collapse
Affiliation(s)
- Iris B Hovens
- Department of Molecular Neurobiology, University of Groningen, Nijenborgh 7, 9747 AG Groningen, The Netherlands; Department of Surgery and Surgical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - Barbara L van Leeuwen
- Department of Surgery and Surgical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Massimo A Mariani
- Department of Cardio-Thoracic Surgery, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Aletta D Kraneveld
- Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Faculty of Science, Utrecht University, Universiteitsweg 99, 3584 CG Utrecht, The Netherlands
| | - Regien G Schoemaker
- Department of Molecular Neurobiology, University of Groningen, Nijenborgh 7, 9747 AG Groningen, The Netherlands; Department of Cardiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| |
Collapse
|
93
|
Abstract
PURPOSE OF REVIEW Maintenance of adequate blood flow and oxygen to the brain is one of the principal endpoints of all surgery and anesthesia. During operations in general anesthesia, however, the brain is at particular risk for silent ischemia. Despite this risk, the brain still remains one of the last monitored organs in clincial anesthesiology. RECENT FINDINGS Transcranial Doppler (TCD) sonography and near-infrared spectroscopy (NIRS) experience a revival as these noninvasive technologies help to detect silent cerebral ischemia. TCD allows for quantification of blood flow velocities in basal intracranial arteries. TCD-derived variables such as the pulsatility index might hint toward diminished cognitive reserve or raised intracranial pressure. NIRS allows for assessment of regional cerebral oxygenation. Monitoring should be performed during high-risk surgery for silent cerebral ischemia and special circumstances during critical care medicine. Both techniques allow for the assessment of cerebrovascular autoregulation and individualized management of cerebral hemodynamics. SUMMARY TCD and NIRS are noninvasive monitors that anesthesiologists apply to tailor cerebral oxygen delivery, aiming to safeguard brain function in the perioperative period.
Collapse
|
94
|
Clingan S, Schuldes M, Francis S, Hoerr H, Riley J. In vitro elimination of gaseous microemboli utilizing hypobaric oxygenation in the Terumo® FX15 oxygenator. Perfusion 2016; 31:552-9. [PMID: 26993481 DOI: 10.1177/0267659116638148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND This study examines the efficacy of hypobaric oxygenation as it relates to the elimination of gaseous microemboli (GME) at designated flow, pressure and temperature combinations. METHODS Hypobaric oxygenation was employed for experimental trials (n=60), but not for control trials (n=60), while circuit design, data measurements and testing conditions were maintained for both settings. Hypobaric oxygenation conditions were created by applying 100% oxygen at sub-atmospheric sweep gas pressures of 0.67 atmospheres to the gas phase of an integrated hollow-fiber microporous membrane oxygenator. GME were quantified using an Emboli Detection and Classification system (EDAC), while a continuous air infusion, at a rate of 100 ml/min, was applied to the circuit. Trials were conducted at 37°C, 28°C, and 18°C and at two flow and line pressure combinations of: 3.5 L/min & 150 mmHg and 5 L/min & 200 mmHg. RESULTS Sub-atmospheric sweep gas pressures allowed adequate oxygenation independent of carbon dioxide removal while significantly reducing the potential entrance of nitrogen into the blood. GME was reduced significantly across all temperatures and flows when compared to control trials; GME counts were reduced by 99.7% post-oxygenator and 99.99% at the arterial cannula. CONCLUSION Correlation between the use of hypobaric oxygenation and GME counts suggests hypobaric oxygenation could play a significant role in the reduction of GME.
Collapse
Affiliation(s)
- Sean Clingan
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | | | | | | |
Collapse
|
95
|
Abstract
The initially reported periprocedural neurological events rates associated with transcatheter aortic valve replacement raised concerns that ultimately led to the development and to the clinical research of novel embolic protection devices. Although the reduction of clinical stroke is a desired goal, the current research design of embolic protection devices focuses on surrogate markers of the clinical disease, primarily on silent central nervous system lesions observed in postprocedural diffuse-weighted magnetic resonance imaging and cognitive function testing. As the mere presence of particulate debris in brain matter may not correlate with the extent of brain injury, cognitive function, or quality of life, the clinical significance of embolic protection devices has yet to be determined, and interpretation of study results with regard to real-life clinical use should be viewed accordingly. The purpose of this article is to provide an overview of the updated ongoing clinical research on embolic protection devices and present its major caveats.
Collapse
Affiliation(s)
- Arie Steinvil
- From the Section of Interventional Cardiology, Division of Cardiology (A.S., R.W.) and Department of Neurology (R.T.B.), MedStar Washington Hospital Center, Washington, DC
| | - Richard T. Benson
- From the Section of Interventional Cardiology, Division of Cardiology (A.S., R.W.) and Department of Neurology (R.T.B.), MedStar Washington Hospital Center, Washington, DC
| | - Ron Waksman
- From the Section of Interventional Cardiology, Division of Cardiology (A.S., R.W.) and Department of Neurology (R.T.B.), MedStar Washington Hospital Center, Washington, DC
| |
Collapse
|
96
|
Pawliszak W, Szwed K, Szwed M, Kowalewski M, Bieliński M, Piskunowicz M, Sukiennik A, Zaborowska K, Anisimowicz L, Borkowska A. Predictive value of the SYNTAX score for short-term cognitive outcomes after off-pump coronary artery bypass surgery. Int J Cardiol 2016; 209:9-11. [PMID: 26874452 DOI: 10.1016/j.ijcard.2016.02.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 01/31/2016] [Accepted: 02/01/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Wojciech Pawliszak
- Department of Cardiac Surgery, Nicolaus Copernicus University, Collegium Medicum, M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Krzysztof Szwed
- Department of Clinical Neuropsychology, Nicolaus Copernicus University, Collegium Medicum, M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland.
| | - Magdalena Szwed
- Department of Clinical Neuropsychology, Nicolaus Copernicus University, Collegium Medicum, M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Mariusz Kowalewski
- Department of Cardiac Surgery, Nicolaus Copernicus University, Collegium Medicum, M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Maciej Bieliński
- Department of Clinical Neuropsychology, Nicolaus Copernicus University, Collegium Medicum, M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Małgorzata Piskunowicz
- Department of Clinical Neuropsychology, Nicolaus Copernicus University, Collegium Medicum, M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Adam Sukiennik
- Department of Cardiology and Internal Diseases, Nicolaus Copernicus University, Collegium Medicum, M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Katarzyna Zaborowska
- Department of Clinical Neuropsychology, Nicolaus Copernicus University, Collegium Medicum, M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Lech Anisimowicz
- Department of Cardiac Surgery, Nicolaus Copernicus University, Collegium Medicum, M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Alina Borkowska
- Department of Clinical Neuropsychology, Nicolaus Copernicus University, Collegium Medicum, M. Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| |
Collapse
|
97
|
Bezerra DM, Bezerra EM, Silva Junior AJ, Amorim MAS, Miranda DBD. [Postoperative visual loss due to conversion disorder after spine surgery: a case report]. Rev Bras Anestesiol 2016; 68:91-95. [PMID: 26804714 DOI: 10.1016/j.bjan.2015.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 03/03/2015] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Patients undergoing spinal surgeries may develop postoperative visual loss. We present a case of total bilateral visual loss in a patient who, despite having clinical and surgical risk factors for organic lesion, evolved with visual disturbance due to conversion disorder. CASE REPORT A male patient, 39 years old, 71kg, 1.72 m, ASA I, admitted to undergo fusion and discectomy at L4-L5 and L5-S1. Venoclysis, cardioscopy, oximetry, NIBP; induction with remifentanil, propofol and rocuronium; intubation with ETT (8.0mm) followed by capnography and urinary catheterization for diuresis. Maintenance with full target-controlled intravenous anesthesia. During fixation and laminectomy, the patient developed severe bleeding and hypovolemic shock. After 30minutes, hemostasis and hemodynamic stability was achieved with infusion of norepinephrine, volume expansion, and blood products. In the ICU, the patient developed mental confusion, weakness in the limbs, and bilateral visual loss. It was not possible to identify clinical, laboratory or image findings of organic lesion. He evolved with episodes of anxiety, emotional lability, and language impairment; the hypothesis of conversion syndrome with visual component was raised after psychiatric evaluation. The patient had complete resolution of symptoms after visual education and introduction of low doses of antipsychotic, antidepressant, and benzodiazepine. Other symptoms also regressed, and the patient was discharged 12 days after surgery. After 60 days, the patient had no more symptoms. CONCLUSIONS Conversion disorders may have different signs and symptoms of non-organic origin, including visual component. It is noteworthy that the occurrence of this type of visual dysfunction in the postoperative period of spinal surgery is a rare event and should be remembered as a differential diagnosis.
Collapse
Affiliation(s)
- Dailson Mamede Bezerra
- Centro de Ensino e Treinamento Dr. José Quinan, Goiânia, GO, Brasil; Defesa Profissional da Sociedade de Anestesiologia do Estado de Goiás (2015/2016), Goiânia, GO, Brasil; Universidade Estadual Paulista Júlio de Mesquita Filho (FMB/Unesp), Faculdade de Medicina, Botucatu, SP, Brasil.
| | | | | | | | - Denismar Borges de Miranda
- Pontifícia Universidade Católica de Goiás (PUC/GO), Goiânia, GO, Brasil; Universidade Federal de Goiás (UFG), Goiânia, GO, Brasil
| |
Collapse
|
98
|
Argunova YA, Pomeshkina SA, Trubnikova OA. [Cognitive dysfunction after coronary artery bypass grafting]. Zh Nevrol Psikhiatr Im S S Korsakova 2016. [PMID: 28635728 DOI: 10.17116/jnevro201611691111-115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Despite the advances in surgical and anesthetic techniques for coronary artery bypass grafting (CABG), the incidence of neurological complications, including postoperative cognitive dysfunction (POCD), remains high. CABG is performed more often in elderly patients with severe comorbidities. However, comprehensive prevention measures and POCD rehabilitation have not yet been developed. Physical training is an effective and safe method for correcting endothelial dysfunction, severe systemic inflammatory response syndrome, lipid peroxidation, i.e. mechanisms contributing to the development and severity of POCD.
Collapse
Affiliation(s)
- Yu A Argunova
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - S A Pomeshkina
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| | - O A Trubnikova
- Research Institute for Complex Issues of Cardiovascular Diseases, Kemerovo, Russia
| |
Collapse
|
99
|
Maslov LN, Tsibulnikov SY, Tsepokina AV, Khutornaya MV, Kutikhin AG, Tsibulnikova MR, Basalay MV, Mrochek AG. [Neuroprotective and nephroprotective effects of remote postconditioning: Prospects for clinical use]. TERAPEVT ARKH 2016. [PMID: 28635945 DOI: 10.17116/terarkh2016888121-126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The results of experimental and clinical studies strongly suggest that remote ischemic preconditioning (RIP) has no neuroprotective effect during cardiac surgery performed under extracorporeal circulation. Remote preconditioning (RP) has no neuroprotective effect in hemorrhagic stroke. A randomized multicenter study is needed to evaluate the efficiency RIP in patients with ischemic stroke. RP reduces the severity of ischemia/reperfusion kidney injury during transplantation. RIP has been established to prevent contrast-induced nephropathy. There is a need for a multicenter trial to evaluate the efficiency of RIP in patients with abdominal aortic aneurysm repair. Analysis of the presented data indicates that RIP fails to prevent cardiorenal syndrome in infants and children during cardiac surgery. The data available in the literature on the capacity of RIP to provide nephroprotective effect in patients after coronary artery bypass surgery are discordant and indicative of the advisability of a multicenter study.
Collapse
Affiliation(s)
- L N Maslov
- Research Institute of Cardiology, Tomsk, Russia
| | - S Yu Tsibulnikov
- Research Institute of Cardiology, Tomsk, Russia; National Research Tomsk Polytechnic University, Tomsk, Russia
| | - A V Tsepokina
- Research Institute for Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - M V Khutornaya
- Research Institute for Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - A G Kutikhin
- Research Institute for Complex Problems of Cardiovascular Diseases, Kemerovo, Russia
| | - M R Tsibulnikova
- Research Institute of Cardiology, Tomsk, Russia; National Research Tomsk Polytechnic University, Tomsk, Russia
| | - M V Basalay
- Republican Research and Practical Center of Cardiology, Minsk, Belarus
| | - A G Mrochek
- Republican Research and Practical Center of Cardiology, Minsk, Belarus
| |
Collapse
|
100
|
Manji RA, Grocott HP, Manji JS, Menkis AH, Jacobsohn E. Recurrent Seizures Following Cardiac Surgery: Risk Factors and Outcomes in a Historical Cohort Study. J Cardiothorac Vasc Anesth 2015; 29:1206-11. [DOI: 10.1053/j.jvca.2015.03.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Indexed: 11/11/2022]
|