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David-Bercholz J, Acker L, Caceres AI, Wu PY, Goenka S, Franklin NO, Rodriguiz RM, Wetsel WC, Devinney M, Wright MC, Zetterberg H, Yang T, Berger M, Terrando N. Conserved YKL-40 changes in mice and humans after postoperative delirium. Brain Behav Immun Health 2022; 26:100555. [PMID: 36457825 PMCID: PMC9706140 DOI: 10.1016/j.bbih.2022.100555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/11/2022] [Indexed: 11/19/2022] Open
Abstract
Delirium is a common postoperative neurologic complication among older adults. Despite its prevalence (14%-50%) and likely association with inflammation, the exact mechanisms that underpin postoperative delirium are unclear. This project aimed to characterize systemic and central nervous system (CNS) inflammatory changes following surgery in mice and humans. Matched plasma and cerebrospinal fluid (CSF) samples from the "Investigating Neuroinflammation Underlying Postoperative Brain Connectivity Changes, Postoperative Cognitive Dysfunction, Delirium in Older Adults" (INTUIT; NCT03273335) study were compared to murine endpoints. Delirium-like behavior was evaluated in aged mice using the 5-Choice Serial Reaction Time Test (5-CSRTT). Using a well established orthopedic surgical model in the FosTRAP reporter mouse we detected neuronal changes in the prefrontal cortex, an area implicated in attention, but notably not in the hippocampus. In aged mice, plasma interleukin-6 (IL-6), chitinase-3-like protein 1 (YKL-40), and neurofilament light chain (NfL) levels increased after orthopedic surgery, but hippocampal YKL-40 expression was decreased. Given the growing evidence for a YKL-40 role in delirium and other neurodegenerative conditions, we assayed human plasma and CSF samples. Plasma YKL-40 levels were similarly increased after surgery, with a trend toward a greater postoperative plasma YKL-40 increase in patients with delirium. However, YKL-40 levels in CSF decreased following surgery, which paralleled the findings in the mouse brain. Finally, we confirmed changes in the blood-brain barrier (BBB) as early as 9 h after surgery in mice, which warrants more detailed and acute evaluations of BBB integrity following surgery in humans. Together, these results provide a nuanced understanding of neuroimmune interactions underlying postoperative delirium in mice and humans, and highlight translational biomarkers to test potential cellular targets and mechanisms.
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Key Words
- 4-OHT, 4-hydroxytamoxifen
- 5-CSRTT, 5-Choice Serial Reaction Time Test
- AD, Alzheimer’s disease
- Aging
- Attention
- BBB, blood-brain barrier
- Biomarkers
- CAM, Confusion AssessmentMethod
- CNS, central nervous system
- CSF, cerebrospinal fluid
- Delirium
- ELISA, enzyme-linked immunosorbent assay
- GFAP, glial fibrillary acidic protein
- IHC, immunohistochemistry
- IL-6, interleukin-6
- MMSE, mini-mental status exam
- NfL, neurofilament light chain
- PBS, phosphate-buffered saline
- PFA, paraformaldehyde
- PLC, prelimbic cortex
- ROI, regions of interest
- SIMOA, single molecule array
- Surgery
- TRAP, Targeted Recombination in Active Populations
- YKL-40
- YKL-40, chitinase-3-like protein 1
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Affiliation(s)
| | - Leah Acker
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Ana I. Caceres
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Pau Yen Wu
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Saanvi Goenka
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Nathan O. Franklin
- Department of Psychiatry and Behavioral Sciences, Mouse Behavioral and Neuroendocrine Analysis Core Facility, Duke University Medical Center, Durham, NC, United States
| | - Ramona M. Rodriguiz
- Department of Psychiatry and Behavioral Sciences, Mouse Behavioral and Neuroendocrine Analysis Core Facility, Duke University Medical Center, Durham, NC, United States
| | - William C. Wetsel
- Department of Psychiatry and Behavioral Sciences, Mouse Behavioral and Neuroendocrine Analysis Core Facility, Duke University Medical Center, Durham, NC, United States
- Department of Neurobiology, Duke University Medical Center, Durham, NC, United States
- Department of Cell Biology, Duke University Medical Center, Durham, NC, United States
| | - Michael Devinney
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Mary Cooter Wright
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The 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, Queen Square, London, UK
- UK Dementia Research Institute at UCL, London, UK
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
| | - Ting Yang
- Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
| | - Niccolò Terrando
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, United States
- Department of Cell Biology, Duke University Medical Center, Durham, NC, United States
- Department of Immunology, Duke University Medical Center, Durham, NC, United States
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Nobuhara C, Devinney M, Berger M. Regional vs General Anesthesia and Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery. JAMA 2022; 327:1707-1708. [PMID: 35503352 DOI: 10.1001/jama.2022.3538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Chloe Nobuhara
- Duke University School of Medicine, Durham, North Carolina
| | - Michael Devinney
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Miles Berger
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
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Zietlow KE, Wong S, Heflin MT, McDonald SR, Sickeler R, Devinney M, Blitz J, Lagoo-Deenadayalan S, Berger M. Geriatric Preoperative Optimization: A Review. Am J Med 2022; 135:39-48. [PMID: 34416164 PMCID: PMC8688225 DOI: 10.1016/j.amjmed.2021.07.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/07/2021] [Accepted: 07/13/2021] [Indexed: 02/07/2023]
Abstract
This review summarizes best practices for the perioperative care of older adults as recommended by the American Geriatrics Society, American Society of Anesthesiologists, and American College of Surgeons, with practical implementation strategies that can be readily implemented in busy preoperative or primary care clinics. In addition to traditional cardiopulmonary screening, older patients should undergo a comprehensive geriatric assessment. Rapid screening tools such as the Mini-Cog, Patient Health Questionnaire-2, and Frail Non-Disabled Survey and Clinical Frailty Scale, can be performed by multiple provider types and allow for quick, accurate assessments of cognition, functional status, and frailty screening. To assess polypharmacy, online resources can help providers identify and safely taper high-risk medications. Based on preoperative assessment findings, providers can recommend targeted prehabilitation, rehabilitation, medication management, care coordination, and/or delirium prevention interventions to improve postoperative outcomes for older surgical patients. Structured goals of care discussions utilizing the question-prompt list ensures that older patients have a realistic understanding of their surgery, risks, and recovery. This preoperative workup, combined with engaging with family members and interdisciplinary teams, can improve postoperative outcomes.
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Affiliation(s)
- Kahli E Zietlow
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Michigan Medicine, Ann Arbor.
| | - Serena Wong
- Division of Geriatrics, Department of Medicine, Duke Health, Durham, NC
| | - Mitchell T Heflin
- Division of Geriatrics, Department of Medicine, Duke Health, Durham, NC; Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, NC
| | - Shelley R McDonald
- Division of Geriatrics, Department of Medicine, Duke Health, Durham, NC; Geriatric Research Education and Clinical Center, Durham Veterans Affairs Medical Center, Durham, NC
| | | | - Michael Devinney
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Jeanna Blitz
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | | | - Miles Berger
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
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Acker L, Ha C, Zhou J, Manor B, Giattino CM, Roberts K, Berger M, Wright MC, Colon-Emeric C, Devinney M, Au S, Woldorff MG, Lipsitz LA, Whitson HE. Electroencephalogram-Based Complexity Measures as Predictors of Post-operative Neurocognitive Dysfunction. Front Syst Neurosci 2021; 15:718769. [PMID: 34858144 PMCID: PMC8631543 DOI: 10.3389/fnsys.2021.718769] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 10/12/2021] [Indexed: 11/13/2022] Open
Abstract
Physiologic signals such as the electroencephalogram (EEG) demonstrate irregular behaviors due to the interaction of multiple control processes operating over different time scales. The complexity of this behavior can be quantified using multi-scale entropy (MSE). High physiologic complexity denotes health, and a loss of complexity can predict adverse outcomes. Since postoperative delirium is particularly hard to predict, we investigated whether the complexity of preoperative and intraoperative frontal EEG signals could predict postoperative delirium and its endophenotype, inattention. To calculate MSE, the sample entropy of EEG recordings was computed at different time scales, then plotted against scale; complexity is the total area under the curve. MSE of frontal EEG recordings was computed in 50 patients ≥ age 60 before and during surgery. Average MSE was higher intra-operatively than pre-operatively (p = 0.0003). However, intraoperative EEG MSE was lower than preoperative MSE at smaller scales, but higher at larger scales (interaction p < 0.001), creating a crossover point where, by definition, preoperative, and intraoperative MSE curves met. Overall, EEG complexity was not associated with delirium or attention. In 42/50 patients with single crossover points, the scale at which the intraoperative and preoperative entropy curves crossed showed an inverse relationship with delirium-severity score change (Spearman ρ = -0.31, p = 0.054). Thus, average EEG complexity increases intra-operatively in older adults, but is scale dependent. The scale at which preoperative and intraoperative complexity is equal (i.e., the crossover point) may predict delirium. Future studies should assess whether the crossover point represents changes in neural control mechanisms that predispose patients to postoperative delirium.
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Affiliation(s)
- Leah Acker
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, United States
- Duke Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, United States
| | - Christine Ha
- Duke Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, United States
| | - Junhong Zhou
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life and Harvard Medical School, Boston, MA, United States
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Brad Manor
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life and Harvard Medical School, Boston, MA, United States
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Charles M Giattino
- Center for Cognitive Neuroscience, Duke University, Durham, NC, United States
| | - Ken Roberts
- Center for Cognitive Neuroscience, Duke University, Durham, NC, United States
| | - Miles Berger
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, United States
- Duke Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, United States
- Center for Cognitive Neuroscience, Duke University, Durham, NC, United States
| | - Mary Cooter Wright
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, United States
| | - Cathleen Colon-Emeric
- Duke Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, United States
- Division of Geriatric Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Michael Devinney
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, United States
| | - Sandra Au
- Duke Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, United States
| | - Marty G Woldorff
- Center for Cognitive Neuroscience, Duke University, Durham, NC, United States
- Department of Psychiatry, Duke University, Durham, NC, United States
- Department of Psychology and Neuroscience, Duke University, Durham, NC, United States
| | - Lewis A Lipsitz
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life and Harvard Medical School, Boston, MA, United States
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Heather E Whitson
- Duke Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, United States
- Division of Geriatric Medicine, Department of Medicine, Duke University School of Medicine, Durham, NC, United States
- Geriatrics Research Education and Clinical Center, Durham VA Medical Center, Durham, NC, United States
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Terrando N, Park JJ, Devinney M, Chan C, Cooter M, Avasarala P, Mathew JP, Quinones QJ, Maddipati KR, Berger M. Immunomodulatory lipid mediator profiling of cerebrospinal fluid following surgery in older adults. Sci Rep 2021; 11:3047. [PMID: 33542362 PMCID: PMC7862598 DOI: 10.1038/s41598-021-82606-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/12/2021] [Indexed: 02/06/2023] Open
Abstract
Arachidonic acid (AA), docosahexaenoic acid (DHA), and eicosapentaenoic acid (EPA) derived lipids play key roles in initiating and resolving inflammation. Neuro-inflammation is thought to play a causal role in perioperative neurocognitive disorders, yet the role of these lipids in the human central nervous system in such disorders is unclear. Here we used liquid chromatography–mass spectrometry to quantify AA, DHA, and EPA derived lipid levels in non-centrifuged cerebrospinal fluid (CSF), centrifuged CSF pellets, and centrifuged CSF supernatants of older adults obtained before, 24 h and 6 weeks after surgery. GAGE analysis was used to determine AA, DHA and EPA metabolite pathway changes over time. Lipid mediators derived from AA, DHA and EPA were detected in all sample types. Postoperative lipid mediator changes were not significant in non-centrifuged CSF (p > 0.05 for all three pathways). The AA metabolite pathway showed significant changes in centrifuged CSF pellets and supernatants from before to 24 h after surgery (p = 0.0000247, p = 0.0155 respectively), from before to 6 weeks after surgery (p = 0.0000497, p = 0.0155, respectively), and from 24 h to 6 weeks after surgery (p = 0.0000499, p = 0.00363, respectively). These findings indicate that AA, DHA, and EPA derived lipids are detectable in human CSF, and the AA metabolite pathway shows postoperative changes in centrifuged CSF pellets and supernatants.
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Affiliation(s)
| | - John J Park
- Duke University School of Medicine, Durham, NC, USA
| | | | | | - Mary Cooter
- Duke University Medical Center, Durham, NC, USA
| | | | | | | | | | - Miles Berger
- Duke University Medical Center, Durham, NC, USA.
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Wilkerson JER, Devinney M, Mitchell GS. Intermittent but not sustained moderate hypoxia elicits long-term facilitation of hypoglossal motor output. Respir Physiol Neurobiol 2017; 256:15-20. [PMID: 29074449 DOI: 10.1016/j.resp.2017.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 10/05/2017] [Accepted: 10/16/2017] [Indexed: 01/14/2023]
Abstract
Phrenic long-term facilitation (pLTF) is a form of serotonin-dependent respiratory motor plasticity induced by moderate acute intermittent hypoxia (AIH), but not by moderate acute sustained hypoxia (ASH) of similar cumulative duration. Thus, moderate AIH-induced pLTF is sensitive to the pattern of hypoxia. On the other hand, pLTF induced by severe AIH protocols is neither pattern sensitive nor serotonin dependent (it converts to an adenosine-dependent mechanism). Although moderate AIH also induces hypoglossal LTF (hLTF), no data are available concerning its sensitivity/insensitivity to the pattern of hypoxia. Since hLTF following moderate hypoxia is serotonin-dependent, we hypothesized that hLTF is pattern-sensitive, similar to serotonin-dependent pLTF. Integrated hypoglossal nerve activity was recorded in urethane-anesthetized, vagotomized, paralyzed, and ventilated rats exposed to isocapnic AIH (3, 5min episodes of 11% O2) or ASH (a single 25min episode of 11% O2). Similar to previous studies of pLTF, hypoglossal motor output was elevated for more than 1h following AIH (50±20%, p<0.01), but not ASH (-6±9%, p>0.05). Frequency LTF was not observed following either hypoxic exposure. Thus, in agreement with our hypothesis, hypoglossal LTF following moderate AIH is pattern-sensitive, similar to phrenic LTF.
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Affiliation(s)
- Julia E R Wilkerson
- Department of Comparative Biosciences University of Wisconsin Madison, WI, 53706, USA; Department of Neuroscience, University of Texas Southwestern Medical Center, Dallas, TX, 75390, USA
| | - Michael Devinney
- Department of Comparative Biosciences University of Wisconsin Madison, WI, 53706, USA; Department of Anesthesiology, Duke University, Durham, NC, 27710, USA
| | - Gordon S Mitchell
- Department of Comparative Biosciences University of Wisconsin Madison, WI, 53706, USA; Center for Respiratory Research and Rehabilitation Department of Physical Therapy and McKnight Brain Institute University of Florida, Gainesville, FL, 32610, USA.
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