Xuena Zhang

Prognosis of Diabetic Patients Undergoing Coronary Artery Bypass Surgery Compared With Nondiabetics: A Systematic Review and Meta–analysis

OBJECTIVE The influence of diabetes mellitus (DM) on mortality and morbidity in patients undergoing coronary artery bypass graft (CABG) surgery has remained uncertain due to conflicting conclusions from clinical trials measuring the association between diabetes and perioperative risk. Therefore, a quantitative meta-analysis was undertaken to evaluate the available evidence from prospective and historic cohort clinical trials. The purpose of this study was to determine the significance and magnitude of impact of DM on mortality, morbidity and resource-related outcomes for patients undergoing CABG over the past few decades and in the contemporary setting. METHODS MEDILINE, EMBase, BIOSIS Preview, CBMDisc, CNKI and WanFang databases were searched, supplemented by hand search, without language limitations, for studies published from January 1981 to October 2008. Data extraction included study design, setting, inclusion/exclusion criteria, population characteristics, statistical method, length of follow-up and clinical outcomes. Eligible studies were assessed for quality. RESULTS Of the 132 identified studies, 24 cohort studies with a median follow-up of 4.3 years were selected for analysis. A total of 100,217 patients (28,168 with DM and 72,049 without DM), were included in the meta-analysis. The pooled RR (95% CI) for mortality of diabetic versus non-diabetic patients was significantly increased at 30 days (RR 1.64, 95% CI 1.39, 1.93), 1 year (RR 1.83, 95% CI 1.56, 2.15), 3 years (RR 1.81, 95% CI 1.58, 2.09), 5 years (RR 1.66, 95% CI 1.53, 1.79) and 10 years (RR 1.55, 95% CI 1.43, 1.68) after CABG. Significant differences were also found for DM versus non-DM patients post-CABG for perioperative cerebrovascular accidents (RR 1.52; 95% CI 1.31, 1.77), postoperative acute renal failure (RR 1.63; 95% CI 1.48, 1.79), sternal infection (RR; 1.70, 95% CI 1.41-2.04) and blood transfusion (RR 1.15; 95% CI 1.08, 1.21). No significant differences were found for postoperative atrial fibrillation (AF), postoperative myocardial infarction (MI) and re-exploration for bleeding. Insufficient and/or heterogeneous data did not allow for pooled analysis of ventilator time, ICU stay, angina recurrence, repeat revascularization, hospital stay and hospital costs. CONCLUSIONS Current evidence suggests that patients with DM who are undergoing CABG are at increased risk of mortality, stroke, renal failure, sternal infection and blood transfusion when compared to those without DM. This increased relative risk for perioperative mortality and complications has remained, despite evolving definitions of DM and practice patterns. Future randomized studies should focus on interventions targeted toward these complications to mitigate the risk for patients with DM.

Isoflurane-induced spatial memory impairment by a mechanism independent of amyloid-beta levels and tau protein phosphorylation changes in aged rats

Abstract Objectives: The molecular mechanism of postoperative cognitive dysfunction is largely unknown. Isoflurane has been shown to promote Alzheimer’s disease neuropathogenesis. We set out to determine whether the effect of isoflurane on spatial memory is associated with amyloid-beta (A-beta) levels and tau phosphorylation in aged rats. Methods: Eighteen-month-old male Sprague–Dawley rats were randomly assigned as anesthesia group (n = 31, received 1·4% isoflurane for 2 hours and had behavioral testing), training group (n = 20, received no anesthesia but had behavioral testing), and control group (n = 10, received no anesthesia and had no behavioral testing). Spatial memory was measured before and 2 days after the anesthesia by the Morris water maze. We divided the anesthesia group into an isoflurane-induced severe memory impairment group (SIG, n = 6) and a no severe memory impairment group (NSIG, n = 25), according to whether the escape latency was more than 1·96 stand deviation of that from the training group. Levels of A-beta and tau in the hippocampus were determined by enzyme-linked immunosorbent assay and quantitative western blot at the end of behavioral testing. Results: We found that isoflurane increased the escape latency in the SIG as compared to that in the training group and NSIG without affecting swimming speed. However, there were no differences in the levels of A-beta and tau among SIG, NSIG, training, and control groups. Conclusions: Isoflurane may induce spatial memory impairment through non-A-beta or tau neuropathogenesis mechanisms in aged rats.

Proteomic profiling of the insoluble fractions in the rat hippocampus post-propofol anesthesia.

Cognitive dysfunction after propofol anesthesia has been previously found. The underlying mechanisms of this sequel remain unclear. Insoluble proteins as major targets of anesthetics participated in various pathophysiological processes. This study aimed to provide evidence that changes in insoluble proteome in rat hippocampus may be involved in molecular mechanism of cognitive dysfunction following propofol anesthesia. Proteins extracted from rat hippocampus were separated by two-dimensional electrophoresis (2-DE). Their expression patterns were observed at 1, 6, 24 h and 7 days after 3 h of propofol anesthesia. Differentially expressed protein spots among groups were submitted to matrix-assisted laser desorption/ionization time of flight mass spectrometer (MALDI-TOF MS) assay and peptide mass fingerprinting (PMF) identification. Identified proteins were further analyzed through Gene Ontology (GO). Results of 2-DE were selectively assayed using Western blot and RT-PCR. Fifty-nine differentially expressed proteins were detected, among which 43 were identified through MALDI-TOF MS. Most identified proteins were distributed in organelles and membranes. According to biological process category, 27 proteins were involved in metabolic process, 19 in developmental process, 14 in stimulus-response, and 21 in biological regulation. Most changes took place within 24 h, with more down-regulation within 6 h. Twelve proteins did not restore to the basic level until the 7th day after propofol anesthesia. Expressions of insoluble proteome dynamically changed following propofol anesthesia. Down-regulations at early stage might produce depressive effects, which may be involved in molecular mechanism of cognitive dysfunction after propofol anesthesia.

Intra-arterial thrombolysis for acute central retinal artery occlusion.

Abstract Objective: In this study, we aimed at exploring the effect and safety of local intra-arterial thrombolysis on acute central retinal artery occlusion. Methods: Retrospective data analysis of 49 consecutive acute central retinal occlusion patients was performed. All the patients were treated with urokinase perfusion through the ophthalmology artery within the first 6 hours after central retinal artery occlusion attack. Conventional treatments including intra-ocular pressure decreasing, microcirculation improvement, neuroprotection and antiplatelet aggregation were conducted. The visual acuity (with International Snellen Chart) and field of vision were detected after thrombolysis. The complications and adverse events were observed. Results: Recanalization was found in 71% of patients. The visual acuity improvement was greater in the recanalization group (n=35) than in the non-recanalization group (n=14). The averaged visual acuity was 0.15±0.02, 0.25±0.03 and 0.4±0.05 after 2, 28 days and 6 months, respectively. Of the patients, 24.5% regained >0.6 of visual acuity, and the visual field deficit was less than 30% in 34.7% of patients after 28 days. Six months later, 36.7% patients regained visual acuity of >0.6, and the field deficit was less than 30% in 44.9% of patients. The difference between visual acuity in recanalization (0.6±0.04) and non-recanalization (0.002±0.0012) patients after 6 months after thrombolysis was significant (p>0.05). Conclusions: Intra-arterial thrombolysis could obviously improve the short- and long-term visual function for patients with acute central retinal artery occlusion within 6 hours of symptom onset.

Closed-Loop Control Better than Open-Loop Control of Profofol TCI Guided by BIS: A Randomized, Controlled, Multicenter Clinical Trial to Evaluate the CONCERT-CL Closed-Loop System

Background The CONCERT-CL closed-loop infusion system designed by VERYARK Technology Co., Ltd. (Guangxi, China) is an innovation using TCI combined with closed-loop controlled intravenous anesthesia under the guide of BIS. In this study we performed a randomized, controlled, multicenter study to compare closed-loop control and open-loop control of propofol by using the CONCERT-CL closed-loop infusion system. Methods 180 surgical patients from three medical centers undergone TCI intravenous anesthesia with propofol and remifentanil were randomly assigned to propofol closed-loop group and propofol opened-loop groups. Primary outcome was global score (GS, GS = (MDAPE+Wobble)/% of time of bispectral index (BIS) 40-60). Secondary outcomes were doses of the anesthetics and emergence time from anesthesia, such as, time to tracheal extubation. Results There were 89 and 86 patients in the closed-loop and opened-loop groups, respectively. GS in the closed-loop groups (22.21±8.50) were lower than that in the opened-loop group (27.19±15.26) (p=0.009). The higher proportion of time of BIS between 40 and 60 was also observed in the closed-loop group (84.11±9.50%), while that was 79.92±13.17% in the opened-loop group, (p=0.016). No significant differences in propofol dose and time of tracheal extubation were observed. The frequency of propofol regulation in the closed-loop group (31.55±9.46 times/hr) was obverse higher than that in the opened-loop group (6.84±6.21 times/hr) (p=0.000). Conclusion The CONCERT-CL closed-loop infusion system can automatically regulate the TCI of propofol, maintain the BIS value in an adequate range and reduce the workload of anesthesiologists better than open-loop system. Trial Registration ChiCTR ChiCTR-OOR-14005551

NK-1-receptor-mediated lesion of spinal post-synaptic dorsal column neurons might improve intractable visceral pain of cancer origin

The cancer-related visceral pain has traditionally been frustrating to treat by either medical or surgical means. Recent investigations from bench and bedside have suggested that a critical visceral nociceptive pathway originates from post-synaptic dorsal column (PSDC) neurons located in the central area of the spinal-cord. Interruption of the PSDC pathway using different surgical approaches effectively relieves intractable visceral pain in cancer patients. However, the indications of surgical lesion of DC are very limited in clinical setting because of the surgical risks and complications. Thus, a means of high-specific pharmacological lesion of DC pathway is necessary. Some evidence has shown that spinal PSDC neurons start to express neurokinin-1 (NK-1) receptors after visceral stimulation, suggesting new targets for the development of pharmacological strategies for the control of visceral pain. Here, we present our hypothesis that the targeted cytoxin composed of substance P coupled to the cytotoxic ribosome inactivating protein, saporin, might selectively destroy spinal PSDC neurons expressing NK-1 receptors, which will lead to pharmacological interruption of PSDC pathway and will greatly improve intractable visceral pain of cancer origin. Based on the data from related research, we believe that the current therapy we propose might be one of the optimal pharmacological approaches to replace the neurosurgical interruption of DC pathway and could be used for cancer-related visceral pain in wider clinical indications.

Comparison of C50 for Propofol-remifentanil Target-controlled Infusion and Bispectral Index at Loss of Consciousness and Response to Painful Stimulus in Elderly and Young Patients

Background: In this prospective randomized study, we compared the predicted blood and effect-site C50 for propofol and remifentanil target-controlled infusion (TCI) and the bispectral index (BIS) values at loss of consciousness (LOC) and response to a standard noxious painful stimulus (LOS) in elderly and young patients, respectively. We hypothesized that the elderly patients will require lower target concentration of both propofol and remifentanil at above two clinical end-points. Methods: There were 80 American Society of Anesthesiologists (ASA) physical status I–II unpremedicated patients enrolled in this study, they were divided into elderly group (age ≥65 years, n = 40) and young group (aged 18–64 years, n = 40). Propofol was initially given to a predicted blood concentration of 1.2 &mgr;g/ml and thereafter increased by 0.3 &mgr;g/ml every 30 s until Observers Assessment of Alertness and Sedation score was 1. The propofol level was kept constant, and remifentanil was given to provide a predict blood concentration of 2.0 ng/ml, and then increased by 0.3 ng/ml every 30 s until loss of response to a tetanic stimulus. BIS (version 3.22, BIS Quattro sensor) was also recorded. Results: In elderly group, the propofol effect-site C50 at LOC of was 1.5 (1.4–1.6) &mgr;g/ml, was significantly lower than that of young group, which was 2.2 (2.1–2.3) &mgr;g/ml, the remifentanil effect-site C50 at LOS was 3.5 (3.3–3.7) ng/ml in elderly patients, was similar with 3.7 (3.6–3.8) ng/ml in young patients. Fifty percent of patients lost consciousness at a BIS value of 57.3 (56.4–58.1), was similar with that of young group, which was 55.2 (54.0–56.3). Conclusion: In elderly patients, the predicted blood and effect-site concentrations of propofol at LOC were lower than that of young patients. At same sedation status, predicted blood and effect-site concentrations of remifentanil required at LOS were similar in elderly and young patients. BIS were not affected by age. Low-propofol/high-opioid may be optional TCI strategy for elderly patients.

Dexmedetomidine as a neuraxial adjuvant for prevention of perioperative shivering: Meta-analysis of randomized controlled trials

Background Dexmedetomidine, a highly selective α2-adrenoceptor agonist, has been investigated for anti-shivering effects in some trials. This current meta-analysis was conducted to evaluate the effectiveness of dexmedetomidine as a neuraxial adjuvant in preventing perioperative shivering. Methods This systematic review and meta-analysis was registered in PROSPERO [www.crd.york.ac.uk/PROSPERO] with the unique identification number CRD42017055991. The electronic databases PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) were searched to select high-quality randomized controlled trials (RCTs) that evaluated the anti-shivering efficacy for neuraxial application dexmedetomidine as local anesthetic adjuvant. Effects were summarized using pooled risk ratios (RRs), weighed mean differences (MDs), or standardized mean differences (SMDs) and corresponding 95% confidence intervals (Cls) with random effect model. Heterogeneity assessment, sensitivity analysis, and publication bias were performed. The primary outcome was perioperative shivering. Results A total of 1760 patients from 24 studies were included in this meta-analysis. Compared with the placebo, dexmedetomidine reduced the incidence of perioperative shivering (RR: 0.34; 95% Cl: 0.21 to 0.55; P < 0.00001), with a maximum effective dose of 5μg via subarachnoid space injection (RR: 0.55; 95% CI: 0.32 to 0.92; P = 0.02), especially in cesarean section (RR: 0.20; 95% CI: 0.09 to 0.45; P = 0.0001). Dexmedetomidine also could improve the characteristics of the block, with an increase only in the incidence of bradycardia (RR: 2.11; 95% CI: 1.23 to 3.60; P = 0.006). No significant difference could be found compared dexmedetomidine with other adjuvants, except morphine. Conclusions This meta-analysis shows that dexmedetomidine as a neuraxial adjuvant had statistically significant efficacy on prevention of perioperative shivering. Moreover, dexmedetomidine could improve the characteristics of the block. However, the potential induction of bradycardia should be taken seriously.