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Yang Y, Xu Z, Guo J, Xiong Z, Hu B. Exploring the gut microbiome-Postoperative Cognitive Dysfunction connection: Mechanisms, clinical implications, and future directions. Brain Behav Immun Health 2024; 38:100763. [PMID: 38682010 PMCID: PMC11052898 DOI: 10.1016/j.bbih.2024.100763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 03/22/2024] [Accepted: 03/28/2024] [Indexed: 05/01/2024] Open
Abstract
Postoperative Cognitive Dysfunction (POCD) is a common yet poorly understood complication of surgery that can lead to long-term cognitive decline. The gut-brain axis, a bidirectional communication system between the central nervous system and the gut microbiota, plays a significant role in maintaining cognitive health. The potential for anesthetic agents and perioperative medications to modulate the gut microbiota and influence the trajectory of POCD suggests the need for a more integrated approach in perioperative care. Perioperative medications, including opioids and antibiotics, further compound these disruptions, leading to dysbiosis and consequent systemic and neuroinflammation implicated in cognitive impairment. Understanding how surgical interventions and associated treatments affect this relationship is crucial for developing strategies to reduce the incidence of POCD. Strategies to preserve and promote a healthy gut microbiome may mitigate the risk and severity of POCD. Future research should aim to clarify the mechanisms linking gut flora alterations to cognitive outcomes and explore targeted interventions, such as probiotic supplementation and microbiota-friendly prescription practices, to safeguard cognitive function postoperatively.
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Affiliation(s)
- Yan Yang
- Department of Anesthesiology, Xuzhou Renci Hospital, Xuzhou, 221000, Jiangsu Province, China
| | - Zhipeng Xu
- Department of Anesthesiology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, 2800 Gongwei Road, Pudong, Shanghai, 201399, China
| | - Jianrong Guo
- School of Gongli Hospital Medical Technology, University of Shanghai for Science and Technology, Shanghai, 200093, China
| | - Zhiqiang Xiong
- Shanghai Engineering Research Center of Food Microbiology, School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, 200093, China
| | - Baoji Hu
- Department of Anesthesiology, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, 2800 Gongwei Road, Pudong, Shanghai, 201399, China
- School of Gongli Hospital Medical Technology, University of Shanghai for Science and Technology, Shanghai, 200093, China
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Bratke S, Schmid S, Ulm B, Jungwirth B, Blobner M, Borgstedt L. Genotype- and sex-specific changes in vital parameters during isoflurane anesthesia in a mouse model of Alzheimer's disease. Front Med (Lausanne) 2024; 11:1342752. [PMID: 38601113 PMCID: PMC11004241 DOI: 10.3389/fmed.2024.1342752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 02/20/2024] [Indexed: 04/12/2024] Open
Abstract
Background The prevalence of neurodegenerative diseases is increasing as is life expectancy with Alzheimer's disease accounting for two-thirds of dementia cases globally. Whether general anesthesia and surgery worsen cognitive decline is still a matter of debate and most likely depending on the interplay of various influencing factors. In order to account for this complexity, Alzheimer's disease animal models have been developed. The Tg2576 model of Alzheimer's disease is a well-established mouse model exhibiting amyloidopathy and age-dependent sex-specific differences in Alzheimer's disease symptomology. Yet, data on anesthesia in this mouse model is scarce and a systematic comparison of vital parameters during anesthesia with wild-type animals is missing. In order to investigate the safety of general anesthesia and changes in vital parameters during general anesthesia in Tg2576 mice, we did a secondary analysis of vital parameters collected during general anesthesia in aged Tg2576 mice. Methods After governmental approval (General Administration of the Free State of Bavaria, file number: 55.2-1-54-2532-149-11) 60 mice at 10-12 months of age were exposed to isoflurane (1.6 Vol%) for 120 min, data of 58 mice was analyzed. During general anesthesia, heart rate, respiratory rate, temperature, isoflurane concentration and fraction of inspired oxygen were monitored and collected. Data were analyzed using univariate and multivariate linear mixed regression models. Results During general anesthesia, heart rate decreased in a sex-specific manner. Respiratory rate decreased and body temperature increased dependent on genotype. However, the changes were limited and all vital parameters stayed within physiological limits. Conclusion Isoflurane anesthesia in the Tg2576 mouse model is safe and does not seem to influence experimental results by interacting with vital parameters. The present study provides information on appropriate anesthesia in order to advance research on anesthesia and AD and could contribute to improving laboratory animal welfare.
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Affiliation(s)
- Sebastian Bratke
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Ulm, Ulm, Germany
| | - Sebastian Schmid
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Ulm, Ulm, Germany
| | - Bernhard Ulm
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Ulm, Ulm, Germany
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Bettina Jungwirth
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Ulm, Ulm, Germany
| | - Manfred Blobner
- Department of Anesthesiology and Intensive Care Medicine, Faculty of Medicine, University of Ulm, Ulm, Germany
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
| | - Laura Borgstedt
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, Technical University of Munich, Munich, Germany
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Hughes GC, Chen EP, Browndyke JN, Szeto WY, DiMaio JM, Brinkman WT, Gaca JG, Blumenthal JA, Karhausen JA, Bisanar T, James ML, Yanez D, Li YJ, Mathew JP. Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest Trial (GOT ICE): A Randomized Clinical Trial Comparing Outcomes After Aortic Arch Surgery. Circulation 2024; 149:658-668. [PMID: 38084590 PMCID: PMC10922813 DOI: 10.1161/circulationaha.123.067022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/10/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Deep hypothermia has been the standard for hypothermic circulatory arrest (HCA) during aortic arch surgery. However, centers worldwide have shifted toward lesser hypothermia with antegrade cerebral perfusion. This has been supported by retrospective data, but there has yet to be a multicenter, prospective randomized study comparing deep versus moderate hypothermia during HCA. METHODS This was a randomized single-blind trial (GOT ICE [Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest]) of patients undergoing arch surgery with HCA plus antegrade cerebral perfusion at 4 US referral aortic centers (August 2016-December 2021). Patients were randomized to 1 of 3 hypothermia groups: DP, deep (≤20.0 °C); LM, low-moderate (20.1-24.0 °C); and HM, high-moderate (24.1-28.0 °C). The primary outcome was composite global cognitive change score between baseline and 4 weeks postoperatively. Analysis followed the intention-to-treat principle to evaluate if: (1) LM noninferior to DP on global cognitive change score; (2) DP superior to HM. The secondary outcomes were domain-specific cognitive change scores, neuroimaging findings, quality of life, and adverse events. RESULTS A total of 308 patients consented; 282 met inclusion and were randomized. A total of 273 completed surgery, and 251 completed the 4-week follow-up (DP, 85 [34%]; LM, 80 [34%]; HM, 86 [34%]). Mean global cognitive change score from baseline to 4 weeks in the LM group was noninferior to the DP group; likewise, no significant difference was observed between DP and HM. Noninferiority of LM versus DP, and lack of difference between DP and HM, remained for domain-specific cognitive change scores, except structured verbal memory, with noninferiority of LM versus DP not established and structured verbal memory better preserved in DP versus HM (P = 0.036). There were no significant differences in structural or functional magnetic resonance imaging brain imaging between groups postoperatively. Regardless of temperature, patients who underwent HCA demonstrated significant reductions in cerebral gray matter volume, cortical thickness, and regional brain functional connectivity. Thirty-day in-hospital mortality, major morbidity, and quality of life were not different between groups. CONCLUSIONS This randomized multicenter study evaluating arch surgery HCA temperature strategies found low-moderate hypothermia noninferior to traditional deep hypothermia on global cognitive change 4 weeks after surgery, although in secondary analysis, structured verbal memory was better preserved in the deep group. The verbal memory differences in the low- and high-moderate groups and structural and functional connectivity reductions from baseline merit further investigation and suggest opportunities to further optimize brain perfusion during HCA. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02834065.
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Affiliation(s)
- G Chad Hughes
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - Edward P Chen
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - Jeffrey N Browndyke
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences (J.N.B., J.A.B.), Duke University Medical Center, Durham, NC
| | - Wilson Y Szeto
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia (W.Y.S.)
| | - J Michael DiMaio
- The Heart Hospital, Baylor Scott and White, Plano, TX (J.M.D., W.T.B.)
| | | | - Jeffrey G Gaca
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - James A Blumenthal
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences (J.N.B., J.A.B.), Duke University Medical Center, Durham, NC
| | - Jorn A Karhausen
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
| | - Tiffany Bisanar
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
| | - Michael L James
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
- Department of Neurology (M.L.J.), Duke University School of Medicine, Durham, NC
| | - David Yanez
- Department of Biostatistics and Bioinformatics (D.Y., Y.-J.L.), Duke University School of Medicine, Durham, NC
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics (D.Y., Y.-J.L.), Duke University School of Medicine, Durham, NC
| | - Joseph P Mathew
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
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Walker KA, Le Page LM, Terrando N, Duggan MR, Heneka MT, Bettcher BM. The role of peripheral inflammatory insults in Alzheimer's disease: a review and research roadmap. Mol Neurodegener 2023; 18:37. [PMID: 37277738 PMCID: PMC10240487 DOI: 10.1186/s13024-023-00627-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 05/24/2023] [Indexed: 06/07/2023] Open
Abstract
Peripheral inflammation, defined as inflammation that occurs outside the central nervous system, is an age-related phenomenon that has been identified as a risk factor for Alzheimer's disease. While the role of chronic peripheral inflammation has been well characterized in the context of dementia and other age-related conditions, less is known about the neurologic contribution of acute inflammatory insults that take place outside the central nervous system. Herein, we define acute inflammatory insults as an immune challenge in the form of pathogen exposure (e.g., viral infection) or tissue damage (e.g., surgery) that causes a large, yet time-limited, inflammatory response. We provide an overview of the clinical and translational research that has examined the connection between acute inflammatory insults and Alzheimer's disease, focusing on three categories of peripheral inflammatory insults that have received considerable attention in recent years: acute infection, critical illness, and surgery. Additionally, we review immune and neurobiological mechanisms which facilitate the neural response to acute inflammation and discuss the potential role of the blood-brain barrier and other components of the neuro-immune axis in Alzheimer's disease. After highlighting the knowledge gaps in this area of research, we propose a roadmap to address methodological challenges, suboptimal study design, and paucity of transdisciplinary research efforts that have thus far limited our understanding of how pathogen- and damage-mediated inflammatory insults may contribute to Alzheimer's disease. Finally, we discuss how therapeutic approaches designed to promote the resolution of inflammation may be used following acute inflammatory insults to preserve brain health and limit progression of neurodegenerative pathology.
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Affiliation(s)
- Keenan A Walker
- Laboratory of Behavioral Neuroscience, National Institute On Aging. Baltimore, Baltimore, MD, USA.
| | - Lydia M Le Page
- Departments of Physical Therapy and Rehabilitation Science, and Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Niccolò Terrando
- Department of Anesthesiology, Cell Biology and Immunology, Duke University Medical Center, Durham, NC, USA
| | - Michael R Duggan
- Laboratory of Behavioral Neuroscience, National Institute On Aging. Baltimore, Baltimore, MD, USA
| | - Michael T Heneka
- Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Belvaux, Luxembourg
| | - Brianne M Bettcher
- Behavioral Neurology Section, Department of Neurology, University of Colorado Alzheimer's and Cognition Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Payne T, Taylor J, Casey C, Kunkel D, Parker M, Blennow K, Zetterberg H, Pearce RA, Lennertz RC, Sanders RD. Prospective analysis of plasma amyloid beta and postoperative delirium in the Interventions for Postoperative Delirium: Biomarker-3 study. Br J Anaesth 2023; 130:546-556. [PMID: 36842841 PMCID: PMC10273086 DOI: 10.1016/j.bja.2023.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 01/03/2023] [Accepted: 01/15/2023] [Indexed: 02/28/2023] Open
Abstract
BACKGROUND The effect of postoperative delirium on the amyloid cascade of Alzheimer's dementia is poorly understood. Using early postoperative plasma biomarkers, we explored whether surgery and delirium are associated with changes in amyloid pathways. METHODS We analysed data from 100 participants in the Interventions for Postoperative Delirium: Biomarker-3 (IPOD-B3) cohort study in the USA (NCT03124303 and NCT01980511), which recruited participants aged >65 yr undergoing non-intracranial surgery. We assessed the relationship between the change in plasma amyloid beta ratio (AβR; Aβ42:Aβ40) and delirium incidence (defined by the 3-Minute Diagnostic Confusion Assessment Method) and severity (quantified by the Delirium Rating Scale-Revised-98, the study's primary outcome). We also tested the relationship between plasma amyloid beta and intraoperative variables. RESULTS Across all participants, the plasma AβR increased from the preoperative period to postoperative Day 1 (Wilcoxon P<0.001). However, this increase was not associated with delirium incidence (Wilcoxon P=0.22) or peak severity after adjusting for confounders (log[incidence rate ratio]=0.43; P=0.14). Postoperative Day 1 change in plasma AβR was not associated with postoperative Day 1 change in plasma tau, neurofilament light, or inflammatory markers (interleukin [IL]-1β, IL-1Ra, IL-2, IL-4, IL-6, IL-8, IL-10, and IL-12), or with operative time or low intraoperative arterial pressure. CONCLUSIONS Perioperative changes in plasma amyloid do not appear to be associated with postoperative delirium. Our findings do not support associations of dynamic changes in amyloid with postoperative delirium. CLINICAL TRIAL REGISTRATION .NCT03124303 and NCT01980511.
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Affiliation(s)
- Thomas Payne
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
| | - Jennifer Taylor
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia
| | - Cameron Casey
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - David Kunkel
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Maggie Parker
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden; Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden; Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK; UK Dementia Research Institute at UCL, London, UK; Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
| | - Robert A Pearce
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Richard C Lennertz
- Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Robert D Sanders
- Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Department of Anaesthetics, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia; Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, NSW, Australia; NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia.
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6
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Sprung J, Laporta ML, Knopman DS, Petersen RC, Mielke MM, Jack CR, Martin DP, Hanson AC, Schroeder DR, Schulte PJ, Przybelski SA, Valencia Morales DJ, Weingarten TN, Vemuri P, Warner DO. Association of Indication for Hospitalization With Subsequent Amyloid Positron Emission Tomography and Magnetic Resonance Imaging Biomarkers. J Gerontol A Biol Sci Med Sci 2023; 78:304-313. [PMID: 35279026 PMCID: PMC9951063 DOI: 10.1093/gerona/glac064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hospitalization in older age is associated with accelerated cognitive decline, typically preceded by neuropathologic changes. We assess the association between indication for hospitalization and brain neurodegeneration. METHODS Included were participants from the Mayo Clinic Study of Aging, a population-based longitudinal study, with ≥1 brain imaging available in those older than 60 years of age between 2004 and 2017. Primary analyses used linear mixed-effects models to assess association of hospitalization with changes in longitudinal trajectory of cortical thinning, amyloid accumulation, and white matter hyperintensities (WMH). Additional analyses were performed with imaging outcomes dichotomized (normal vs abnormal) using Cox proportional hazards regression. RESULTS Of 2 480 participants, 1 966 had no hospitalization and 514 had ≥1 admission. Hospitalization was associated with accelerated cortical thinning (annual slope change -0.003 mm [95% confidence interval (CI) -0.005 to -0.001], p = .002), but not amyloid accumulation (0.003 [95% CI -0.001 to 0.006], p = .107), or WMH increase (0.011 cm3 [95% CI -0.001 to 0.023], p = .062). Interaction analyses assessing whether trajectory changes are dependent on admission type (medical vs surgical) found interactions for all outcomes. While surgical hospitalizations were not, medical hospitalizations were associated with accelerated cortical thinning (-0.004 mm [95% CI -0.008 to -0.001, p = .014); amyloid accumulation (0.010, [95% CI 0.002 to 0.017, p = .011), and WMH increase (0.035 cm3 [95% CI 0.012 to 0.058, p = .006). Hospitalization was not associated with developing abnormal cortical thinning (p = .407), amyloid accumulation (p = .596), or WMH/infarctions score (p = .565). CONCLUSIONS Medical hospitalizations were associated with accelerated cortical thinning, amyloid accumulation, and WMH increases. These changes were modest and did not translate to increased risk for crossing the abnormality threshold.
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Affiliation(s)
- Juraj Sprung
- Address correspondence to: Juraj Sprung, MD, PhD, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA. E-mail:
| | - Mariana L Laporta
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David S Knopman
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Michelle M Mielke
- Division of Epidemiology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Clifford R Jack
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - David P Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew C Hanson
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Darrell R Schroeder
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Phillip J Schulte
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Scott A Przybelski
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Silber JH, Rosenbaum PR, Reiter JG, Hill AS, Jain S, Wolk DA, Small DS, Hashemi S, Niknam BA, Neuman MD, Fleisher LA, Eckenhoff R. Alzheimer's Dementia After Exposure to Anesthesia and Surgery in the Elderly: A Matched Natural Experiment Using Appendicitis. Ann Surg 2022; 276:e377-e385. [PMID: 33214467 PMCID: PMC8437105 DOI: 10.1097/sla.0000000000004632] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this study was to determine whether surgery and anesthesia in the elderly may promote Alzheimer disease and related dementias (ADRD). BACKGROUND There is a substantial conflicting literature concerning the hypothesis that surgery and anesthesia promotes ADRD. Much of the literature is confounded by indications for surgery or has small sample size. This study examines elderly patients with appendicitis, a common condition that strikes mostly at random after controlling for some known associations. METHODS A matched natural experiment of patients undergoing appendectomy for appendicitis versus control patients without appendicitis using Medicare data from 2002 to 2017, examining 54,996 patients without previous diagnoses of ADRD, cognitive impairment, or neurological degeneration, who developed appendicitis between ages 68 through 77 years and underwent an appendectomy (the ''Appendectomy'' treated group), matching them 5:1 to 274,980 controls, examining the subsequent hazard for developing ADRD. RESULTS The hazard ratio (HR) for developing ADRD or death was lower in the Appendectomy group than controls: HR = 0.96 [95% confidence interval (CI) 0.94-0.98], P < 0.0001, (28.2% in Appendectomy vs 29.1% in controls, at 7.5 years). The HR for death was 0.97 (95% CI 0.95-0.99), P = 0.002, (22.7% vs 23.1% at 7.5 years). The HR for developing ADRD alone was 0.89 (95% CI 0.86-0.92), P < 0.0001, (7.6% in Appendectomy vs 8.6% in controls, at 7.5 years). No subgroup analyses found significantly elevated rates of ADRD in the Appendectomy group. CONCLUSION In this natural experiment involving 329,976 elderly patients, exposure to appendectomy surgery and anesthesia did not increase the subsequent rate of ADRD.
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Affiliation(s)
- Jeffrey H. Silber
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- The Departments of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA
| | - Paul R. Rosenbaum
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, PA
| | - Joseph G. Reiter
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Alexander S. Hill
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Siddharth Jain
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - David A. Wolk
- Department of Neurology, The Perelman School of Medicine, University of Pennsylvania
| | - Dylan S. Small
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Statistics, The Wharton School, University of Pennsylvania, Philadelphia, PA
| | - Sean Hashemi
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Bijan A. Niknam
- Center for Outcomes Research, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Mark D. Neuman
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, PA
| | - Lee A. Fleisher
- The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Center for Perioperative Outcomes Research and Transformation, University of Pennsylvania, Philadelphia, PA
| | - Roderic Eckenhoff
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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8
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Borgstedt L, Bratke S, Blobner M, Pötzl C, Ulm B, Jungwirth B, Schmid S. Isoflurane has no effect on cognitive or behavioral performance in a mouse model of early-stage Alzheimer’s disease. Front Neurosci 2022; 16:1033729. [DOI: 10.3389/fnins.2022.1033729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundPatients with Alzheimer’s disease show a sex-dependent decline of cognitive and behavioral performance. It is controversially discussed whether general anesthesia itself can aggravate or even cause this neurocognitive decline. Therefore, we investigated the effect of general anesthesia on neurocognitive and behavioral function and amyloidopathy in a mouse model of early-stage Alzheimer’s disease with respect to sex.MethodsAfter governmental approval 10 months old Tg2576 mice and wild type (total 85 mice) either underwent general anesthesia with 1.0 minimal alveolar concentration of isoflurane for 2 h or were not exposed to isoflurane (controls). Following cognitive and behavioral testing using the modified hole board test (mHBT), brains were investigated regarding amyloidopathy, inflammation, and apoptosis. Data were analyzed using repeated measure analysis of variance (ANOVA) and univariate analysis of variance (UNIANOVA).ResultsTg2576 mice showed a decline in memory function (p < 0.001), less anxiety (p = 0.022 and p = 0.024), increased locomotor activity (p = 0.025), and impaired fine motor skills (p < 0.001). Amyloid precursor protein (p < 0.001), soluble amyloid-beta (p < 0.001) and insoluble amyloid deposits (p < 0.001) were increased in Tg2576 animals. Neither sex nor exposure to isoflurane had an effect on cognitive or behavioral testing or expression of amyloid-related biomarkers.Discussion and conclusionWe found that 10 months old Tg2576 showed typical signs of early-stage Alzheimer’s disease and corresponding histopathological alterations. Relevant sex-specific differences or an effect of isoflurane anesthesia could not be detected at this early stage of the disease.
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Vacas S, Canales C, Deiner SG, Cole DJ. Perioperative Brain Health in the Older Adult: A Patient Safety Imperative. Anesth Analg 2022; 135:316-328. [PMID: 35584550 PMCID: PMC9288500 DOI: 10.1213/ane.0000000000006090] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
While people 65 years of age and older represent 16% of the population in the United States, they account for >40% of surgical procedures performed each year. Maintaining brain health after anesthesia and surgery is not only important to our patients, but it is also an increasingly important patient safety imperative for the specialty of anesthesiology. Aging is a complex process that diminishes the reserve of every organ system and often results in a patient who is vulnerable to the stress of surgery. The brain is no exception, and many older patients present with preoperative cognitive impairment that is undiagnosed. As we age, a number of changes occur in the human brain, resulting in a patient who is less resilient to perioperative stress, making older adults more susceptible to the phenotypic expression of perioperative neurocognitive disorders. This review summarizes the current scientific and clinical understanding of perioperative neurocognitive disorders and recommends patient-centered, age-focused interventions that can better mitigate risk, prevent harm, and improve outcomes for our patients. Finally, it discusses the emerging topic of sleep and cognitive health and other future frontiers of scientific inquiry that might inform clinical best practices.
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Affiliation(s)
- Susana Vacas
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Cecilia Canales
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Stacie G Deiner
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Daniel J Cole
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
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10
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Niikura R, Miyazaki T, Takase K, Sasaguri H, Saito T, Saido TC, Goto T. Assessments of prolonged effects of desflurane and sevoflurane on motor learning deficits in aged App NL-G-F/NL-G-F mice. Mol Brain 2022; 15:32. [PMID: 35387663 PMCID: PMC8988377 DOI: 10.1186/s13041-022-00910-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/16/2022] [Indexed: 11/10/2022] Open
Abstract
As the proportion of elderly in society increases, so do the number of older patients undergoing surgical procedures. This is concerning as exposure to anesthesia has been identified as a risk factor for Alzheimer's disease (AD). However, the causal relationship between clinical AD development and anesthesia remains conjectural. Preclinical studies have demonstrated that anesthesia, such as halothane, isoflurane, and sevoflurane, induces AD-like pathophysiological changes and cognitive impairments in transgenic mouse models of AD. Desflurane does not have these effects and is expected to have more potential for use in elderly patients, yet little is known about its effects, especially on non-cognitive functions, such as motor and emotional functions. Thus, we examined the postanesthetic effects of desflurane and sevoflurane on motor and emotional function in aged AppNL-G-F/NL-G-F (App-KI) mice. This is a recently developed transgenic mouse model of AD exhibiting amyloid β peptide (Aβ) amyloidosis and a neuroinflammatory response in an age-dependent manner without non-physiological amyloid precursor protein (APP) overexpression. Mice were subjected to a short behavioral test battery consisting of an elevated plus maze, a balance beam test, and a tail suspension test seven days after exposure to 8.0% desflurane for 6 h or 2.8% sevoflurane for 2 h. App-KI mice showed significant increments in the percentage of entry and time spent in open arms in the elevated plus maze, increments in the number of slips and latency to traverse for the balance beam test, increments in the limb clasping score, increments in immobile duration, and decrements in latency to first immobile episode for the tail suspension test compared to age-matched wild type (WT) controls. Desflurane- and sevoflurane-exposed App-KI mice showed a delayed decrement in the number of slips for each trial in the balance beam test, while air-treated App-KI mice rapidly improved their performance, and increased their clasping behavior in the tail suspension test. Furthermore, App-KI inhibited the change in membrane GluA3 following exposure to anesthetics in the cerebellum. These results suggest high validity of App-KI mice as an animal model of AD.
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Affiliation(s)
- Ryo Niikura
- Department of Anesthesiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Tomoyuki Miyazaki
- Department of Anesthesiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan. .,Department of Physiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
| | - Kenkichi Takase
- Laboratory of Psychology, Jichi Medical University School of Medicine, Simotsuke, Tochigi, Japan.
| | - Hiroki Sasaguri
- Laboratory for Proteolytic Neuroscience, RIKEN Center for Brain Science, Wako, Saitama, Japan
| | - Takashi Saito
- Laboratory for Proteolytic Neuroscience, RIKEN Center for Brain Science, Wako, Saitama, Japan.,Department of Neurocognitive Science, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Takaomi C Saido
- Laboratory for Proteolytic Neuroscience, RIKEN Center for Brain Science, Wako, Saitama, Japan
| | - Takahisa Goto
- Department of Anesthesiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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11
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Shen Y, Zhang T, Zhang Y, Wang Y, Yao J. Stress Granules Modulate SYK to Cause Tau-Associated Neurocognitive Deterioration in 5XFAD Mouse After Anesthesia and Surgery. Front Aging Neurosci 2021; 13:718701. [PMID: 34512311 PMCID: PMC8430336 DOI: 10.3389/fnagi.2021.718701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/31/2021] [Indexed: 11/20/2022] Open
Abstract
Background Alzheimer’s disease (AD) is the most common type of dementia. However, no curative therapy has been found effective to slow down the process of AD. It is reported that anesthesia and surgery will induce neurocognitive deterioration in AD, but the mechanism is not quite clear. In this study, we aim to compare the cognitive impairment between 5XFAD transgenic (Tg) mice and its littermate (LM) after isoflurane anesthesia and surgery to clarify the specific impacts of anesthesia and surgery on individuals with AD and to explore the mechanisms. Methods We performed abdominal surgery in cognitively impaired, 4-month-old female 5XFAD mice and LM control mice. Isoflurane anesthesia (1.4%) was induced and maintained over 2 h. Open field and fear conditioning tests were conducted on 1, 3 and 7 days after anesthesia and surgery. The total distance, velocity and freezing time were the major outcomes. P-tau (AT8), tau oligomers (T22), stress granules (SGs), the SYK tyrosine kinase and p-SYK in the hippocampus at postoperative day 1 were evaluated by Western Blot assays. The colocalization of SGs, SYK, p-SYK, and neurons in the hippocampus section was assessed using qualitative immunofluorescence. Results In the open field test, no difference between the distance moved and the velocity of LM mice and 5XFAD Tg mice were found on day 1 after anesthesia and surgery. 5XFAD Tg mice exhibited reduced freezing time of fear conditioning context test on postoperative day 3, but not on day 7; the LM mice showed no changes in FCTs. Furthermore, p-tau, tau oligomers, SGs, SYK and p-SYK were evident in the hippocampus region of 5XFAD Tg mice on a postoperative day 1. In addition, SGs, SYK, p-SYK were colocalized with hippocampus neurons, as shown by immunofluorescence. Conclusion This study demonstrates that anesthesia and surgery may induce tau-associated neurocognitive deterioration in individuals with AD. The mechanism under it may be associated with SGs and the tyrosine kinase, SYK. After anesthesia and surgery, in 5XFAD Tg mice, SGs were formed and SYK was phosphorylated, which may contribute to the phosphorylation of tau protein. This study provided hints that individuals with AD may be more vulnerable to anesthesia and surgery.
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Affiliation(s)
- Yang Shen
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tong Zhang
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yinglin Zhang
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yinuo Wang
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junyan Yao
- Department of Anesthesiology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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12
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Neuroanesthesiology Update. J Neurosurg Anesthesiol 2021; 33:107-136. [PMID: 33480638 DOI: 10.1097/ana.0000000000000757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 12/18/2020] [Indexed: 11/27/2022]
Abstract
This review summarizes the literature published in 2020 that is relevant to the perioperative care of neurosurgical patients and patients with neurological diseases as well as critically ill patients with neurological diseases. Broad topics include general perioperative neuroscientific considerations, stroke, traumatic brain injury, monitoring, anesthetic neurotoxicity, and perioperative disorders of cognitive function.
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13
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Sprung J, Warner DO, Knopman DS, Petersen RC, Mielke MM, Jack CR, Martin DP, Hanson AC, Schroeder DR, Przybelski SA, Schulte PJ, Laporta ML, Weingarten TN, Vemuri P. Brain MRI after critical care admission: A longitudinal imaging study. J Crit Care 2020; 62:117-123. [PMID: 33340966 DOI: 10.1016/j.jcrc.2020.11.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 10/14/2020] [Accepted: 11/30/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE To investigate the association between episodes of critical care hospitalizations and delirium with structural brain changes in older adults. MATERIALS AND METHODS We included Mayo Clinic Study of Aging participants ≥60 years old at the time of study enrollment (October 29, 2004, through September 11, 2017) with available brain MRI and 'amyloid' positron emission tomography (PET) scans. We tested the hypothesis that a) intensive care unit (ICU) admission is associated with greater cortical thinning and atrophy in entorhinal cortex, inferior temporal cortex, middle temporal cortex, and fusiform cortex (Alzheimer''s disease-signature regions); b) atrophy in hippocampus and corpus callosum; c) delirium accelerates these changes; and d) ICU admission is not associated with increased deposition of cortical amyloid. RESULTS ICU admission was associated with cortical thinning in temporal, frontal, and parietal cortices, and decreases in hippocampal/corpus callosum volumes, but not Alzheimer''s disease-signature regions. For hippocampal volume, and 10 of 14 cortical thickness measurements, the change following ICU admission was significantly more pronounced for those who experienced delirium. ICU admission was not associated with an increased amyloid burden. CONCLUSIONS Critical care hospitalization is associated with accelerated brain atrophy in selected brain regions, without increases in amyloid deposition, suggesting a pathogenesis based on neurodegeneration unrelated to Alzheimer''s pathway.
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Affiliation(s)
- Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - David O Warner
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - David S Knopman
- Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - Ronald C Petersen
- Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - Michelle M Mielke
- Department of Neurology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA; Health Sciences Research, Division of Epidemiology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - Clifford R Jack
- Department of Radiology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - David P Martin
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - Andrew C Hanson
- Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - Darrell R Schroeder
- Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - Scott A Przybelski
- Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - Phillip J Schulte
- Health Sciences Research, Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - Mariana L Laporta
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - Prashanthi Vemuri
- Department of Radiology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
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14
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Borgstedt L, Blobner M, Musiol M, Bratke S, Syryca F, Rammes G, Jungwirth B, Schmid S. Neurotoxicity of different amyloid beta subspecies in mice and their interaction with isoflurane anaesthesia. PLoS One 2020; 15:e0242989. [PMID: 33270674 PMCID: PMC7714346 DOI: 10.1371/journal.pone.0242989] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 11/12/2020] [Indexed: 12/01/2022] Open
Abstract
Background The aim of this study was to assess different amyloid beta subspecies’ effects on behaviour and cognition in mice and their interaction with isoflurane anaesthesia. Methods After governmental approval, cannulas were implanted in the lateral cerebral ventricle. After 14 days the mice were randomly intracerebroventricularly injected with Aβ 1–40 (Aβ40), Aβ 1–42 (Aβ42), 3NTyr10-Aβ (Aβ nitro), AβpE3-42 (Aβ pyro), or phosphate buffered saline. Four days after the injection, 30 mice (6 animals per subgroup) underwent general anaesthesia with isoflurane. A “sham” anaesthetic procedure was performed in another 30 mice (6 animals per subgroup, 10 subgroups in total). During the next eight consecutive days a blinded assessor evaluated behavioural and cognitive performance using the modified hole-board test. Following the testing we investigated 2 brains per subgroup for insoluble amyloid deposits using methoxy staining. We used western blotting in 4 brains per subgroup for analysis of tumour-necrosis factor alpha, caspase 3, glutamate receptors NR2B, and mGlu5. Data were analysed using general linear modelling and analysis of variance. Results Aβ pyro improved overall cognitive performance (p = 0.038). This cognitive improvement was reversed by isoflurane anaesthesia (p = 0.007), presumably mediated by decreased exploratory behaviour (p = 0.022 and p = 0.037). Injection of Aβ42 was associated with increased anxiety (p = 0.079). Explorative analysis on a limited number of brains did not reveal insoluble amyloid deposits or differences in the expression of tumour-necrosis factor alpha, NR2B, mGlu5, or caspase 3. Conclusions Testing cognitive performance after intracerebroventricular injection of different amyloid beta subspecies revealed that Aβ pyro might be less harmful, which was reversed by isoflurane anaesthesia. There is minor evidence for Aβ42-mediated neurotoxicity. Preliminary molecular analysis of biomarkers did not clarify pathophysiological mechanisms.
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Affiliation(s)
- Laura Borgstedt
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Manfred Blobner
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm University, Ulm, Germany
| | - Maximilian Musiol
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Sebastian Bratke
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Finn Syryca
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Gerhard Rammes
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Bettina Jungwirth
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm University, Ulm, Germany
| | - Sebastian Schmid
- Department of Anaesthesiology and Intensive Care Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm University, Ulm, Germany
- * E-mail:
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15
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Jin Z, Hu J, Ma D. Postoperative delirium: perioperative assessment, risk reduction, and management. Br J Anaesth 2020; 125:492-504. [DOI: 10.1016/j.bja.2020.06.063] [Citation(s) in RCA: 232] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/22/2020] [Accepted: 06/20/2020] [Indexed: 12/20/2022] Open
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16
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Untangling anaesthesia and amyloid. Br J Anaesth 2020; 125:232-235. [PMID: 32690248 DOI: 10.1016/j.bja.2020.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/27/2020] [Accepted: 06/01/2020] [Indexed: 11/21/2022] Open
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