Changes in plasma IL-1beta, TNF-alpha and IL-6 after total hip replacement surgery in general or regional anaesthesia

Different anaesthetic methods influence the neuro-immuno-endocrine biologic responses to surgery and may thus possibly interfere with the postoperative course and development of complications. The neuroendocrine system is closely related to the cytokine network. In this study, the effects of general anaesthesia (n=6) and regional spinal/epidural anaesthesia (n=6) on the cytokine response (IL-1beta, TNFalpha, IL-6) to uncemented total hip replacement surgery were evaluated. The postoperative clinical course was uneventful in every case. In both groups, only very low values of plasma IL-beta were measured perioperatively, whereas plasma IL-6 increased postoperatively with peak values 4 h after surgery. The changes in plasma TNF-alpha were not significant. No significant differences in plasma TNF-alpha or IL-6 were found between patients operated in general or in regional anaesthesia. This suggests minor influence of plasma cytokines on the possible beneficial effects of regional anaesthesia on the clinical course after surgery in low risk patients. There were slightly higher TNF-alpha and IL-6 levels after the operation and significantly lower cortisol levels during the operation in the regional anaesthesia group compared to the general anaesthesia group, giving rise to a significant inverse correlation between peak values of IL-6 and peak values of cortisol. This supports the theory that after surgery the inhibitory effect of cortisol on monocyte cytokine production overrides adrenergic stimulation.     

Relation between cognitive impairment and early death in the elderly.

STUDY OBJECTIVE--To study the association between cognitive impairment and early death in elderly patients living in the community. DESIGN--Case-control study of 410 patients assessed by the mental status questionnaire and followed up after three years. SETTING--A general practice in Inverurie, Aberdeenshire, with 14,000 patients. PATIENTS--205 Patients aged greater than or equal to 65 with cognitive impairment according to the mental status questionnaire (score less than or equal to 8) and 205 patients scoring greater than 8 on the questionnaire matched for age and sex. MAIN OUTCOME MEASURE--Death. RESULTS--The relative risk of death in the cognitively impaired patients overall was 3.5. Those patients who scored less than or equal to 7 on the mental status questionnaire were five times more likely to die than their controls. There was no difference in risk of death between those with severe or moderate cognitive impairment. CONCLUSIONS--Cognitive impairment is associated with early death.     

长期住院老年精神疾病患者营养状况与认知功能的相关性研究

目的:了解长期住院老年精神疾病患者营养状况及与认知功能的相关性,为临床提供指导。方法:对住院3个月及以上的123例老年精神疾病患者采用简易精神状态检查量表(MMSE)评估认知功能,采用简易微型营养评定精简版(MNA-SF)评估营养状况,并采集一般资料、相关营养生化指标,应用Pearson相关分析MNA-SF评分与MMSE评分的相关性。结果:123例患者中,营养不良风险者67例(54.47%),营养不良者37例(30.08%),营养正常者19例(15.44%)。有认知障碍患者的营养不良发生率显著高于无认知障碍患者营养不良发生率(P<0.05),重度认知障碍者营养不良发生率显著高于轻、中度认知障碍者(P<0.05)。与无认知障碍者比较,中度、重度认知障碍者MNA-SF评分显著降低(P<0.05);与轻度、中度认知障碍者比较,重度认知障碍者MNA-SF评分显著降低(P<0.05)。营养不良者MMSE 6个认知领域评分和认知总评分均显著低于营养不良风险/正常者(P<0.05),Pearson相关分析显示:长期住院老年精神疾病患者MNA-SF评分与MMSE评分呈正相关(r=0.486, P=0.023<0.05)。结论:长期住院老年精神疾病患者营养不良发生率高,且与认知功能密切相关。临床部门需加强老年精神疾病患者,特别是有认知损害老人的营养关切。     

Profile of recovery after general anaesthesia.

The duration of impairment of mental functioning after anaesthesia was studied in 55 patients undergoing hernia repair who were divided into three groups in which the method of induction of anaesthesia (intravenous or inhalational) and ventilation (spontaneous or controlled) was varied. Performance in a five minute serial reaction time test and subjective estimates of coordination were assessed four times a day for two complete postoperative days and were compared with those in a control group of orthopaedic patients in hospital. After considerable impairment initially, reaction times in all groups gradually returned towards control values, but in patients breathing spontaneously during anaesthesia impairment recurred during the second postoperative day. These results suggest that such patients should be advised not to undertake hazardous tasks such as driving a car for at least 48 hours after a general anaesthetic. Discrepancies between subjective and objective assessments of impairment also suggest that patients should not rely on their own assessments of fitness to drive.     

老年患者术后急性精神障碍临床观察与护理体会

目的：观察老年术后急性精神障碍发生的相关原因并总结护理要点。方法：回顾分析老年术后发生急性精神障碍的相关因素包括手术与麻醉时间、术前合并症和术后并发症等。结果：术后急性精神障碍与多种因素相关。与全身麻醉以及术后不良的环境因素密切相关,其他原因包括年龄、术前合并症以及术后并发症的发生等。术后必要的药物治疗以及术后的心理护理是护理工作的关键,患者信赖的医护人员以及亲友的安慰交流有防治效果。结论：老年病人术后精神障碍的发生对围手术期病人的治疗康复具有一定的负面影响,应当引起医护人员的重视并采取有效防治对策。     

Similar effects of general and spinal anaesthesia on perioperative stress response in patients undergoing haemorrhoidectomy

Surgery induces release of neuroendocrine hormones (cortisol), cytokines (interleukin-6: IL-6, tumour necrosis factor-alpha: TNF-alpha), acute phase proteins (C-reactive protein: CRP, leptin). We studied the effects of general and spinal anaesthesia on stress response to haemorrhoidectomy. Patients were assigned to general and spinal anaesthesia groups (n = 7). Blood samples were drawn before induction and 24 hours after surgery. Perioperative levels of IL-6, TNF-alpha, CRP, cortisol, and leptin were comparable among the groups. Twenty four hours after surgery, TNF-alpha and cortisol did not change; IL-6 and CRP increased significantly in all patients. Significant increase in leptin levels was found in patients undergoing spinal anaesthesia. Except for the increase in leptin levels, there was no significant difference related to the effects of general and spinal anaesthesia.     

老年术后疼痛分级与早期认知功能的相关性

目的:探讨老年术后疼痛分级与早期认知功能的相关性。方法:收集我院2014年3月至2014年9月行腹腔镜胆囊切除术的老年患者80例,所有患者麻醉诱导,术中丙泊酚麻醉维持。术后24 h、48 h对患者进行简易智能精神状态量表(MMSE)、画钟测验(CDT)及痛视觉模拟评分(VAS)测验,分析VAS评分与MMSE、CDT评分的相关性。结果:术后48 h较24 h VAS评分降低,而MMSE、CDT评分均升高(P0.05)。术后24 h、48 h VAS评分与MMSE评分无明显相关性(均P0.05);而VAS评分与CDT评分呈明显的负相关关系(r24 h=-0.732,r48 h=-0.659,均P0.05)。结论:老年术后疼痛分级与早期认知功能呈负相关关系。     

Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials

ObjectivesTo obtain reliable estimates of the effects of neuraxial blockade with epidural or spinal anaesthesia on postoperative morbidity and mortality.DesignSystematic review of all trials with randomisation to intraoperative neuraxial blockade or not.Studies141 trials including 9559 patients for which data were available before 1 January 1997. Trials were eligible irrespective of their primary aims, concomitant use of general anaesthesia, publication status, or language. Trials were identified by extensive search methods, and substantial amounts of data were obtained or confirmed by correspondence with trialists.ResultsOverall mortality was reduced by about a third in patients allocated to neuraxial blockade (103 deaths/4871 patients versus 144/4688 patients, odds ratio=0.70, 95% confidence interval 0.54 to 0.90, P=0.006). Neuraxial blockade reduced the odds of deep vein thrombosis by 44%, pulmonary embolism by 55%, transfusion requirements by 50%, pneumonia by 39%, and respiratory depression by 59% (all P<0.001). There were also reductions in myocardial infarction and renal failure. Although there was limited power to assess subgroup effects, the proportional reductions in mortality did not clearly differ by surgical group, type of blockade (epidural or spinal), or in those trials in which neuraxial blockade was combined with general anaesthesia compared with trials in which neuraxial blockade was used alone.ConclusionsNeuraxial blockade reduces postoperative mortality and other serious complications. The size of some of these benefits remains uncertain, and further research is required to determine whether these effects are due solely to benefits of neuraxial blockade or partly to avoidance of general anaesthesia. Nevertheless, these findings support more widespread use of neuraxial blockade.     

Level of nitric oxide in hypertensive patients scheduled on general anaesthesia

In this prospective study we have analysed the level of nitric oxide in hypertensive patients scheduled for general anaesthesia. In the study were included thirty-four patients with chronicle inflammatory disease of the middle ear who have undergone surgical treatment at the Clinic for Ear, Nose and Throat Surgery. The aim of our study was to determine the plasma level of nitric oxide (NO) and its effects on the circulatory system in hypertensive patients during the general anaesthesia maintained with inhalation of oxygen and nitrous oxide (O2/N2O) mixture. Patients were divided in two groups. During the maintenance of general anaesthesia the patients from the first group were ventilated with O2/N2O, while patients from the second group were ventilated with oxygen and air (O2/air) mixture. The other principles during the general anaesthesia were equal for both groups. For determination of the NO plasma levels we have used the enzymatic method according to Conrad et al., 1993. Our results showed that there is a statistically significant difference of NO plasma level between the two groups. The level of NO was higher in the first group (ventilated with O2/N2O) compared to the second group (ventilated with O/air). The mean arterial pressure and systemic vascular resistance were significantly decreased in the first group, as well. Our results suggest that nitrous oxide (N2O) most probably plays the role of NO donor in hypertensive patients during the maintenance of the general anaesthesia with N2O/O2 mixture.     

The assessment of competence in cognitively impaired elderly persons: a closer look at the vignette method

This article focuses on the assessment of competence of elderly persons both with and without cognitive impairment. In total 113 patients of a geriatric clinic were interviewed. Competence was assessed by using two clinical vignettes, representing respectively a hypothetical treatment situation with mild consequences (endoscopy) and one with severe consequences (operation for colon cancer). Competence was evaluated using the following standards: the ability to evidence a choice, the ability to understand a situation, the ability to reason about a choice, and the ability to appreciate a situation. In the vignette with mild consequences, elderly persons with cognitive impairment performed significantly worse on understanding, reasoning and appreciation than elderly persons without cognitive impairment. In the vignette with severe consequences, elderly persons with cognitive impairment performed significantly worse only on understanding as compared to elderly persons without cognitive impairment. No differences were found for reasoning and appreciation between the cognitively impaired and non-impaired elderly persons. We conclude that competence is less limited by cognitive impairment when assessed in a treatment situation with severe consequences. Therefore, the use of hypothetical vignettes should be carefully reconsidered.     

老年患者术后急性精神障碍临床观察与护理体会

目的:观察老年术后急性精神障碍发生的相关原因并总结护理要点。方法:回顾分析老年术后发生急性精神障碍的相关因素包括手术与麻醉时间、术前合并症和术后并发症等。结果:术后急性精神障碍与多种因素相关。与全身麻醉以及术后不良的环境因素密切相关,其他原因包括年龄、术前合并症以及术后并发症的发生等。术后必要的药物治疗以及术后的心理护理是护理工作的关键,患者信赖的医护人员以及亲友的安慰交流有防治效果。结论:老年病人术后精神障碍的发生对围手术期病人的治疗康复具有一定的负面影响,应当引起医护人员的重视并采取有效防治对策。     

Competence to make decisions: the psychology of deliberate decision making

This paper examines the psychological structure of mental competence, conceived of as competence in deliberate decision making. Analysis of that structure may be useful in understanding mental incompetence, as it occurs among some elderly persons. Mental competence not only depends on a number of cognitive abilities, such as foreseeing consequences, but also on the intactness of emotions, insight in one's own emotions, and abilities for emotion regulation.     

Effect of a geriatric consultation service on management of patients in an acute care hospital.

Elderly patients present particular management challenges. We conducted a randomized clinical trial of the effect of a geriatric consultation service on the management of elderly patients in an acute care hospital. A total of 113 patients aged 75 years or more who met certain criteria were assigned to either receive (57 patients) or not receive (56) care by the service. At the end of their hospital stay the patients were assessed with regard to predetermined outcomes. The patients were followed up for 1 year after discharge to determine death rates and direct health care expenditures. The intervention group showed significantly greater improvement in mental status (p less than 0.01), were receiving fewer medications at discharge (p less than 0.05) and had lower short-term death rates (p less than 0.05) than the control group. A geriatric consultation service can improve the hospital care and health of the elderly.     

Apolipoprotein e4 allele and cognitive decline in elderly men.

OBJECTIVES--To determine whether polymorphism of apolipoprotein E--notably, the e4 allele--predicts cognitive deterioration in the general population. DESIGN--Population based cohort investigated in 1990 and in 1993. SETTING--Zutphen, the Netherlands. SUBJECTS--Representative cohort of 538 Dutch men aged 70-89 at baseline. MAIN OUTCOME MEASURES--Cognitive function assessed by mini mental state examination, change in cognitive function and incidence of impaired cognitive function at three years. RESULTS--The baseline prevalence of impaired cognitive function (mini mental state examination score < or = 25) was higher among carriers of the e4 allele compared with men without the allele (41.0% (55) v 31.1% (122) P = 0.03), and this result was still valid after adjustment for age, occupation, smoking, alcohol use, and cardiovascular diseases. The decline in cognitive function at three years was largest in men homozygous for e4 (-2.4 points), intermediate in those heterozygous for e4 (-0.7 points), and lowest in men without e4 (-0.1 points), and it was independent of other risk factors (P = 0.02). The risk of developing impaired cognitive function during follow up was significantly increased in allele carriers compared with non-carriers (27.6% (16/58) v 15.5% (32/207)). The adjusted odds ratio was 2.87 (95% confidence interval 1.29 to 6.42). Twenty two per cent of the risk of developing impaired cognitive function in this population may be attributable to the e4 allele. CONCLUSIONS--The apolipoprotein e4 allele predisposes to cognitive decline in a general population of elderly men.     

Modification of Plasma Corticosteroid Concentrations during and after Surgery by Epidural Blockade

The adrenocortical response to major surgery was assessed by the measurement of plasma corticosteroid concentrations in patients receiving either a general anaesthetic alone or in combination with an epidural block. The expected increase in plasma corticosteroid concentration seen in the general anaesthesia group was significantly inhibited by epidural block. The inhibition was related to the duration of the epidural block. The lack of the normal adrenocortical response to surgery was not associated with cardiovascular collapse and indeed did not seem detrimental in any way. These findings question the need for corticosteroid “cover” for the stress of surgery in patients who have been taking corticosteroid drugs.     

功能性电刺激联合循环运动系统对老年脑卒中后肌肉衰减综合征患者肢体功能、平衡能力以及认知功能的影响

摘要 目的：研究功能性电刺激联合循环运动系统对老年脑卒中后肌肉衰减综合征患者肢体功能、平衡能力以及认知功能的影响。方法：选择2020年6月到2021年6月在我院进行康复治疗的老年脑卒中后肌肉衰减综合征患者64例,据其治疗方式的不同分为对照组和研究组,两组患者均给予常规康复治疗,对照组患者在常规治疗的基础上加用功能性电刺激治疗,而研究组在对照组基础上加用脑循环系统治疗仪进行治疗,比较两组患者临床治疗疗效。使用运动功能评分法（FMA）和上肢功能评定（STEF）评价肢体患者功能,使用平衡量表（BBS）和Fuglg-Meyer平衡量表（FM-B）评价患者平衡能力,使用自拟认知量表评价患者认知功能。结果：（1）研究组患者临床治疗总有效率较对照组高（93.75 % vs 75.00 %,P<0.05）;（2）两组患者治疗后FMA和STEF评分均显著增高（P<0.05）,并且研究组患者治疗后BBS和FM-B评分显著高于对照组患者（P<0.05）;（3）两组患者治疗后BBS和FM-B评分均显著增高,并且研究组患者治疗后BBS和FM-B评分显著高于对照组患者（P<0.05）;（4）两组患者治疗后认知功能评分均升高,并且研究组患者较对照组患者高（P<0.05）。结论：功能性电刺激联合循环运动系统对老年脑卒中后肌肉衰减综合征患者具有显著的临床治疗效果,可显著改善患者肢体功能、平衡能力和认知功能。     

加速康复外科理论对老年股骨颈骨折患者髋关节功能、生活质量及术后认知功能的影响

摘要 目的：探讨加速康复外科理论（ERAS）对老年股骨颈骨折（FNF）患者髋关节功能、生活质量以及术后认知功能的影响。方法：选取2018年7月~2019年10月期间我院收治的80例老年FNF患者,按照随机数字表法分为对照组（n=40）和研究组（n=40）,对照组给予常规围术期处理,研究组围术期应用ERAS进行处理,比较两组患者围术期指标、髋关节功能、生活质量、术后认知功能及并发症发生情况。结果：研究组术中出血量少于对照组,手术时间、住院时间短于对照组（P<0.05）。研究组术后6个月髋关节功能的优良率为92.50%（37/40）,高于对照组的70.00%（28/40）（P<0.05）。两组术后6个月SF-36各维度评分均升高,且研究组高于对照组（P<0.05）。两组术后简易智力状态量表（MMSE）评分均较术前降低,但研究组高于对照组（P<0.05）;研究组的认知功能障碍（POCD）发生率低于对照组（P<0.05）。研究组的并发症总发生率为7.50%（3/40）,低于对照组的25.00%（10/40）（P<0.05）。结论：老年FNF患者应用ERAS进行围术期处理,可促进患者术后恢复,减轻认知功能损害及并发症发生率,同时还可有效改善髋关节功能及生活质量。     

Quantitative trait loci analysis of human event-related brain potentials: P3 voltage

The P3 event-related brain potential (ERP) is a positive-going voltage change of scalp-recorded electroencephalographic activity that occurs between 300–500 ms after stimulus onset. It is elicited when a stimulus is perceived, memory operations are engaged, and attentional resources are allocated toward its processing. Because this ERP component reflects fundamental cognitive processing, it has found wide utility as an assessment of human mental function in basic and clinical studies. In particular, P3 attributes are heritable and have demonstrated considerable promise as a means to identify individuals at genetic risk for alcoholism. We have conducted a quantitative linkage analysis on a large sample from families with a high density of affected individuals. The analyses suggest that several regions of the human genome contain genetic loci related to the generation of the P3 component of the ERP, which are possible candidate loci underlying the functional organization of human neuroelectric activity.     

Randomised trial of impact of model of integrated care and case management for older people living in the community

Objective: To evaluate the impact of a programme of integrated social and medical care among frail elderly people living in the community. Design: Randomised study with 1 year follow up. Setting: Town in northern Italy (Rovereto). Subjects: 200 older people already receiving conventional community care services. Intervention: Random allocation to an intervention group receiving integrated social and medical care and case management or to a control group receiving conventional care. Main outcome measures: Admission to an institution, use and costs of health services, variations in functional status. Results: Survival analysis showed that admission to hospital or nursing home in the intervention group occurred later and was less common than in controls (hazard ratio 0.69; 95% confidence interval 0.53 to 0.91). Health services were used to the same extent, but control subjects received more frequent home visits by general practitioners. In the intervention group the estimated financial savings were in the order of £1125 ($1800) per year of follow up. The intervention group had improved physical function (activities of daily living score improved by 5.1% v 13.0% loss in controls; P<0.001). Decline of cognitive status (measured by the short portable mental status questionnaire) was also reduced (3.8% v 9.4%; P<0.05). Conclusion: Integrated social and medical care with case management programmes may provide a cost effective approach to reduce admission to institutions and functional decline in older people living in the community.

Key messages

• Responsibility for management of care of elderly people living in the community is poorly defined
• Integration of medical and social services together with care management programmes would improve such care in the community
• In a comparison of this option with a traditional and fragmented model of community care the integrated care approach reduced admission to institutions and functional decline in frail elderly people living in the community and also reduced costs

     

Integrity of gut mucosa during anaesthesia in major abdominal surgery

The aim of the study was to examine a perfusion and integrity of small bowel in 60 subsequent patients during the major open abdominal surgery which lasted from 2 to 7 hours. Two samples of the intestinal mucosa were removed: at the beginning, and at the end of the surgical procedure in general anaesthesia. A mucosal injury was classified into 4 grades. pH, PCO2 and lactate level were measured in the blood samples from the arterial and mesenteric vein in one hour time intervals. The changes of intestinal mucosa were found in 31 patients (51.7%): in 19 patients (31.7%) grade 1 changes were recorded, in 10 patients (16.7%) grade 2, and in 2 patients (3.3%) grade 3. Grade 4 lesions were not recorded. There was a statistically significant correlation between grades of the mucosal damage and the surgery duration (p = 0.001). Analysis during the one hour intervals showed that there was no exact time point when the significant aggravation of the pathohistological changes in intestinal mucosa occurred. However, when patients were allocated into two subgroups with surgical procedures lasting less than 4 hours and more than 4 hours, there was a statistically significant difference in the grades of mucosal damage between subgroups (p < 0.05). More biopsies without pathohistological changes were observed in the patients whose procedure duration was < 4 hours. A significantly higher lactate concentrations in arterial and mesenteric venous blood were observed in the patients with pathohistological changes at 6 hours time point as compared to 2 hour time point in the patients without pathohistological changes (p < 0.05). During the open abdominal surgery in general anaesthesia, the length of the procedure influences the grade of the intestinal mucosa injury. Deterioration of the pathohistological findings in the intestinal mucosa correlates with high lactate blood level, suggesting that the cause of these changes may result from tissue hypoxia.