Volume 89  ·   Issue 33  ·  2009

Alzheimer's disease (AD) is a neurodegenerative disease, and there is no effective treatment at present. With the gradual prolongation of human life, the incidence of AD also increases correspondingly, which is 2% in developed countries, and the incidence increases obviously after the age of 70. Nearly half of the elderly people over 85 years old will develop AD. The medical expenses of AD patients in the United States exceed 100 billion US dollars every year, which has become a serious medical and social problem.

The elderly are the group with the highest anesthesia-related mortality except newborns [1], and anesthesia for the elderly is a challenge to the anesthesiologist's ability. The decline of organ function only reduces the reserve function, but it can also meet the general physiological needs. Therefore, anesthesia for healthy elderly is mainly to avoid excessive stress state and prevent organ failure. At the same time, the elderly are prone to cardiovascular and cerebrovascular diseases, respiratory diseases, diabetes, and fatal complications such as heart failure, respiratory failure and infection after operation, but these risk factors cannot be accurately evaluated before operation, so there are no targeted preventive measures, and "unexpected" complications are difficult to avoid. Therefore, aiming at the above characteristics, how to improve the safety of anesthesia for elderly patients, improve the speed and quality of postoperative rehabilitation is the focus of future research, and the research on anesthesia for elderly will run through the whole perioperative process.

Objective To investigate whether preoperative chemotherapy history could influence the incidence of early postoperative cognitive dysfunction(POCD)in elderly tumor patients.Methods A total of 107 tumor patients(≥60 years old,tumor TNM stages T2～T3,N0～N3,ASA Ⅰ-Ⅲ class)undergoing elective radical surgery of gastric or colorectal cancer were selected and assigned into two groups according to preoperative chemotherapy history:with preoperative chemotherapy history group(C group,n=52)and without preoperative chemotherapy history group(N group,n = 55).Patients in two groups received radical surgery under intravenous-inhalation general anesthesia combined with epidural anesthesia.Cognitive function was assessed using a battery of neuropsychological tests from five aspects including memory,verbal intelligence,visual-motor,executive function and motor function at 1 day preoperatively and 3 days postoperatively.Results There was no significant difference in general state of patient preoperatively health including sex ratio,body mass index,complications,cancer types and stages,ASA classification between two groups(P ＞ 0.05).Neither significant difference was found in duration of anesthesia and surgery,intra-operative bleeding volume and transfusion volume between two groups(P ＞0.05).There was no significant difference in ICU admission rate,ICU stay,incidence of complications,hospitalization duration and mortality rate between two groups(P ＞ 0.05).Preoperative neuropsychological test score in group C was slightly lower than that in group N,but the difference was not significant(P ＞ 0.05).Impaired incidence rate of digit-symbol substitution test,controlled oral word association test,grooved pegboard nondominant hand test and semantic fluency test at 3 days postoperation in group C were significantly higher than those in N group(P ＜ 0.05).Incidence of POCD at 3 days postoperation in group C was significantly higher than that in group N(42.3% vs 15.4%,P ＜ 0.05).Conclusion Chemotherapy preoperatively could increase the incidence of early postoperative cognitive dysfunction in elderly with tumor.

Objective To study the correlation between the Narcotrend index,cerebral state index and predicted effect site concentration during different state of consciousness in the absence of surgery in elderly patients with target controlled infusion of propofol.Methods Twenty patients aged from 65-75 years categorized as ASA class Ⅰ-Ⅱ who were scheduled to undergo general surgery under general anesthesia with target controlled infusion of propofol were recruited.During the target controlled infusion of propofol,the propofol infusion was set at an initial effect site concentration of 0.5 mg/L and increased by 0.5 mg/L every 5 min until the modified observer's assessment of alertness / sedation scale(OAA/S)values of zero.The predicted effect site concentration of propofol,the values of CSI and NCT were recorded and the sedation level was examined by the modified OAA/S every 20 s.The predicted effect site concentrations of propofol in target controlled infusion(TCI)system were recorded when they increased by more than 0.1 mg/L.The predicted effect site concentrations of propofol and the values of NCT and CSI at LVC and LOC of the patients were recorded.Results There was a good linear correlation between NCT and the predicted effect site concentration of propofol(R2 = 0.867,P ＜ 0.01),as well as that between CSI and the predicted effect site concentration of propofol(R2 = 0.893,P ＜ 0.01).The predicted effect site concentrations of propofol at LVC was(1.56±0.13)mg/L while the values of NCT was 74.00±4.69 and CSI 69.82±5.47.The predicted effect site concentrations of propofol at LOC was(2.15±0.27)mg/L while the values of NCT and CSI were 63.30±7.50 and 58.78±6.90 respectively.All of the values of NCT,CSI and the predicted effect site concentrations had a good linear correlation with OAA/S.There was a negative correlation between OAA/S and the predicted effect site concentration.At the same time,there was a positive correlation between OAA/S and NCT as well as that between OAA/S and CSI.And the correlation coefficients were0.968,0.938,0.940 respectively(P ＜0.01).The values of NCT were higher significantly than that of CSI in different degree of LOC(P ＜0.01).Conclusion During elder people's target controlled infusion of propofol,LVC and LOC occur within a definite range of predicted effect site concentrations.There is a good linear correlation between NCT,CSI and the predicted effect site concentrations of propofol.For the elders,both NCT and CSI reflect the sedation level of propofol.Although there is a significant correlation between NCT and CSI,a deviation does exist in a certain range.Therefore a simple 1:1 transfer from NCT to CSI is inadequate.

Objective To investigate the general anesthetic's effect upon cholinergic system to examine whether the regional and progressive cholinergic changes may lead to postoperative cognitive dysfunction(POCD).Method A model of hippocampus microdialysis was established in aging rats(18 months old).The tissue levels of choline(Ch)and acetylcholine(Ach)were determined in hippocampus.The post-anesthesia learning capability and spatial memory were tested in Morris maze.Using in vivo microdialysis,the releases of Ach and Ch,functional parameters of cholinergic system,were determined in freely moving rats.The contents of both in perfusate were quantified by HPLC-ECD as described for the function of cholinergic system.Results The learning curve of the control group demonstrated differences from the experiment group.Changes in hippocampal Ach and Ch levels were observed in both cognition markedly impaired group and cognition lightly impaired group,accompanied by performance failure in water maze test.In the experiment group,the hippocampal releases of Ach and Ch were markedly different between cognition markedly impaired group and cognition lightly impaired group.Conclusion Cholinergic system dysfunction in hippocampus may be responsible for behavioral abnormality in learning and spatial memory tasks in senescent rats.

Objective To describe the characteristics of patients diagnosed with intraparenchymal sylvian meningioma at our department.Methods A retrospective review was performed over 5 patients with intraparenchymal sylvian fissure meningioma confirmed by histopathology and receiving treatment at our department during January 1997 to September 2008.Results The mean age was 19.4 years old and there were 3 males and 2 females.On CT scanning,intraparenchymal sylvian meningioma was iso-or slightly hyper-dense masses.On MR imaging,tumors showed iso-or hypo-intense signal on T1W1 and hyperintense signal on T2WI.After contrast enhancement,T1-weighted images revealed well-demarcated enhancing masses and intimately associated with the middle cerebral artery and its branches in the sylvian fissure.All the patients underwent eraniotomy.Conclusion As a rare disease with radiographic characteristics similar to those of general meningiomas,intraparenchymal sylvian fissure meningioma does not adhere to the dura matter but adhere to or even encase the middle cerebral artery and its branches in the sylvian fissure.All of the above have differential values.During the surgical procedures,a proper handling of tumor and encompassed main trunk of middle cerebral artery and its branches is crucial to patient prognosis.

Objective To build a mathematical model for diagnosing liver fibrosis progression by using conventional laboratory indicators,and to evaluate its clinical value of predicting hepatic fibrosis and bepatocirrhosis in chronic hepatitis B.Methods Liver biopsy and routine laboratory tests were performed in 391 patients with chronic hepatitis B.Using Multiple logistic regression to analyse evidently relevant indicators,then the models predicting for different stages of liver fibrosis were built and analyzed by receiver operating characteristic(ROC)curve.Results Age,platelet(PLT),international rate(INR),total bilirubin,albumin(ALB),aspartate aminotransferase,gamlna-glutamyhranspeptidase(GGT),total bile acid and cholinesterase(CHE)were correlated with liver fibrosis stage.Multiple Logistic regression analysis showed that PLT,INR,ALB,GGT and C HE were independent predictors of three models(S≥2,S≥ 3,S =4).We finally built the predicting models and got Fibrosis scores(FS).ROC curve analysis revealed that the area under the curve was 0.784 in model-1(S≥2),0.768 in model-2(S≥3)and 0.806 in model-3 (S =4).A FS1 cutoff point of 7.09 had 67.4% sensitivity,79.3% specificity and 71.1% accuracy in Model-1.A FS2 cutoff point of 5.67 had 75.0% sensitivity,67.7% specificity and 72.9% accuracy in Model-2.A FS3 cutoff point of 3.65 had 71.4% sensitivity,78.5% specificity and 73.7% accuracy in Model-3.Conclusion The mathematical models using conventional laboratory indicators have fairly well value for predicting hepatic fibrosis progressing in chronic hepatitis B.

Objective To study the clinical efficacy of lymphadenectomy of lung cancer by videoassisted thoracic small incision surgery.Methods Radical lobectomy or pneumonectomy and systemic lymphadenectomy were performed in 197 patients with NSCLC through video-assisted thoracospic surgery.Pathological type and grade,total number of dissected lymph nodes,number of metastatic lymph nodes,survival and life quality were evaluated.Results The average of dissected lymph nodes was 11.61 and 471 lymph nodes from 382 regions were confirmed to have metastasis.The metastatic rates were 24.1% and 20.6% respectively.There were no significant difference between video-assisted thoracic small incision surgery and conventional thoracotomy.The 1,3,5-year survival rates of stage Ⅰ,Ⅱ and Ⅲ a had no significant difference between video-assisted thoracic small incision surgery and conventional thoracotomy.Conclusion Video-assisted thoracic small incision surgery achieves a similar efficacy as the traditional iymphadenectomy and lung cancer radical resection.

Objective To study the short-term clinical outcome of transforaminal lumbar interbody fusion(TLIF)by minimally invasive approach in the treatment of simple fomminal stenosis(SFS).Methods Thirty four cases(M:F = 19:15)diagnosed with SFS from January.2007 to March.2009 were included.Age ranged from 47 to 62(mean:57)years old.Patients generally had degenerative changes and decreased disc height on X-ray films at the indexed level.No stenosis within the spinal canal was found on myelograph and CTM.Sagittal images of MRI usually demonstrated narrowed foramina.Selective radiculograph and radicular blocking was used to make the definite diagnosis and to locate the involved nerve root.Double paramedian intermuscular approaches were adopted in all cases.Minimally invasive retractor systems,such as X-Tube and Pipeline etc.,were used to facilitate the exposure,pedicle screw instrumentation and TLIF.Results The average operation time was 2.76 hours.The average blood loss was 387.16ml.All patients were encouraged to ambulate 2-3 days post-operation- The incisions healed uneventfully.At the final follow-up,instrumentations were maintained in an excellent position in all cases and JOA score improved by 31.14%.Conclusions TLIF by minimally invasive approach is an effective method in treating patients with lumbar foraminal stenosis.The short-term clinical outcomes are satisfactory.This approach may avoid the injuries to paraspinal muscles,posterior ligaments,dura and nerve root of the uninvolved side.

Objective To investigate the expressions of cyclinB1,FHIT and Ki-67 in gastric carcinoma and their clinical significance.Methods Immunohistochemistry(PV6000 method)was used to detect the expressions of cyelinB1,FHIT and Ki-67 in paraffin-embedded gastric carcinoma tissues of 336 cases and paracancerous normal mucosa of 60 cases.All cases were successfully followed up.Results The positive expression rates of cyclinB1,FHIT and Ki-67 in gastric carcinoma were 66.1%(222/336),39.9%(134/336)and 58.3%(196/336)respectively.CyclinBl and Ki-67 were all correlated with tumor size,differentiation degree,infiltrative depth,clinical stage,lymphatic invasion and distant metastasis(P ＜0.05).And FH1T showed a correlation with differentiation degree,lymphatic invasion and clinical stage (P＜0.05).The 5-year survival rate of patients with positive cyclinBl and Ki-67 expressions were both lower than those with negative expressions(P ＜0.05),whereas FHIT had the opposite pattern(P =0.025).The cyclinB1 expression in gastric carcinoma was positively correlated with the Ki-67 expression (r =0.249,P =0.0001).The expressions of cyclinB1 and Ki-67 in carcinoma were significantly higher than those in normal mucosa tissues(P ＜ 0.05),but FHIT had the opposite pattern.Ki-67 was an independent prognostic indicator for post-operative survival time.Conclusion CyclinB1,FHIT and Ki-67 may play significant roles in the occurrence and evolution of gastric carcinoma.And they can be used as useful indicators for clinical assessment of tumor biological behaviors and prognosis in patients with gastric carcinoma.

Objective To discuss the clinical feature,treatment and prognosis of intracranial nongerminomatous malignant germ cell tumors(NGMGCT).Methods The records of 39 patients receiving treatment at our hospital between 1995 and 2007 were reviewed retrospectively.According to the classification of Matsutani,they were grouped into intermediate prognosis and poor prognosis groups based on tumor histology.Clinical manifestations,diagnosis,treatment and outcome were analyzed in each group.Results In these 39 cases,there were 15 mix germ cell tumors,15 immature teratomas,7 embryonal carcinomas and 2 yolk sac tumors.All patients were treated surgically.The tumor was totally removed in 29 cases,sub-totally in 5 and partially in 3.Biopsy was performed in the other 2 cases.Thirty-four patients (87.2%)were followed up.The overall 5-year survival rate was 36.8%.The 5-year actuarial survival rote for patients in the intermediate prognosis and poor prognosis groups were 42.6% and 0 respectively.Chemoradiotherapy had a significant correlation with the prognosis of intermediated prognosis group(P =0.039).The 5-year survival rate of immature teratoma patients receiving post-operative gamma knife surgery was 100%.It had significant difference(P =0.0049)as compared to the 5-year survival rate of patients receiving no gamma knife surgery.Conclusion NGMGCT can be divided into the intermediate and poor groups based on the prognosis(P = 0.0003).Embryonal carcinoma can be classified to the intermediate prognosis group because of its similar prognosis with immature teratoma and mixed tumors composed mainly of germinoma or teratoma.Surgery remains the first choice for NGMGCT since treatment should be based on tumor histology.For patients in the intermediate prognosis group,a combined regimen of surgical resection,radiotherapy,chemotherapy and gamma knife surgery is mostly effective.

Objective Brain activities in responses to amplitude modulation(AM)was evaluated using functional MRI(fMRI)in subjects with sudden unilateral sensorineural hearing loss(SSNHL)and those with normal hearing(NH).Methods Totally 25 subjects with normal hearing and 30 with SSNHL were examined with fMRI in response to AM tones of 500,2000 and 4000 Hz respectively with the modulation frequency at 8 Hz.The fMRI was examined within 12 days after the onset of SSNHL.The AM signals were presented at 96 dB SPL binaurally.An event-related design was combined with a sparse clustered volume acquisitioning paradigm in data collection in the attempt to reduce the influence of acoustic scanner noise.SPM2 software was used for offline data analyzing.Results Brain activation in fMRI image was found mainly in the primary auditory cortex(PAC)in both subjects with NH and SSNHL.NH subjects showed a clear lateralization to left cerebral hemisphere(11/16)and SSNHL patients showed a lateralizatiun ipsilateral to the impaired ear(16/22).The activation voxel and intensity shown in BOLD were found to be decreased with increasing signal frequency in both groups.Conclusion The difference in the lateralization between the two groups suggests that an adaptive process occurs shortly after the onset of SSNHL.

Objective To make a systematic review of risk factors associated with motor complications in Parkinson's disease(PD).Methods Medline,EMbase and Cochrane Database were used to search for prospective and retrospective studies on the factors associated with dyskinesia and motor fluctuations.Methodological quality Was checked by two independent reviewers.Results Earlier age at onset.female gender and a long disease duration might be the risk factors of motor complications.Conclusion More high-quality clinical trials are required to evaluate the factors associated with motor complications.

Objective To investigate the effect of vitamin C(VC)on visceral lipid oxidative injury during oral fluid resuscitation of burn shock.Methods Twelve male Beagle dogs were surgically prepared for arterial and venous cannulation,and 24 hours later they were subjected to a 50% TBSA full-thickness flame injury.In the first 24 hours after burn dogs were resuscitated with gastric infusion of either glucoseelectrolyte solution(GES group,n =6)or GES containing 250 mg/kg of VC(GES/VC group，n =6).The delivery rate and volume of GES was in accordance with that of Parkland formula(4 ml·kg-1·1% TBSA-1 in the first 24 hours).In the second 24 hours all animals received delayed IV fluid resuscitation.At end of 72 hours after injury，animals were sacrificed，and specimens of heart,lung,liver,kidney and jejunum were harvested for evaluation of xanthine oxidase(XOD),malondialdehyde(MDA)and assessment of the tissue water content(ratio of dry to wet weight)of organs.The plasma levels of alanineaminotransferase(ALT),creatinine(Cr),MB isoenzyme of creatine kinase(CK-MB)and diamine oxidase (DAO)were determined at same time.Results At 72 hours after burn it was showed significant higher activities of XOD in GES/CAR than GES group in heart,kidney and jejunum,and lower contents of MDA in heart,lung,hver,kidney and jejunum(P all ＜0.01).Tissue water contents were significantly lower in GES/CAR than GES group in heart[(75.4±1.1)% vs(78.5±0.8)%],lung[(68.1±0.9)% vs(73.9±1.0)%],liver[(75.2±0.8)% vs(78.3±1.2)%],kidney[(73.8±1.1)% vs(78.1±0.8)%]and jejunum[(76.3±0.8)% vs(80.4±0.6)]respectively,all P ＜ 0.01.The levels of ALT，CK-MB,Cr and DAO in GES/CAR group were(46.6±2.49)U/L,(43.4±7.05)tool/L,(7156±596)U/L and(1.86±0.45)U/L respectively,all significantly lower than those of the GES group[(86.9±7.89)U/L,(95.2±1.23)mol/L,(8023±384)U/L and(2.68±0.61)U/L respectively,all P＜0.05].Condusion The results indicated that vitamin C alleviated visceral tissue edema and organ injury by inhibiting free radical production during oral fluid resuscitation of bum shock.

Objective To fully demonstrate the alterations about the viscoelastic properties of chondrocytes in rabbit knee articular cartilage.Methods Fifteen New Zealand white rabbits were divided into 3 age groups:young group(1 month),adult group(8 months)and old group(31 months).All rabbits were sacrificed and isolated from knee joint and digested into chondrocytes.The micropipette aspiration combined with Half-space model was used to quantify changes in viscoelastic properties of chondrocytes.Results Experimental studies have shown that the changes of aspiration length with time in old group were obviously different from young group and adult group.But similar variations were found between the latter two groups.The viscoelastic properties of chondrocytes in old group exhibited a significantly lower instantaneous modulus E0(0.55±0.05 kPa),equilibrium modulus E∞(0.28±0.04 kPa)and apparent viscosity μ(4.10±0.61 kPa·s)as compared with young group(0.67±0.10),(0.37±0.09),(6.29±0.92)kPa·s(P＜0.001)versus adult group:(0.65±0.07),(0.35±0.05),(6.01±0.89)kPa·s(P＜0.001).But no difference were found between the latter two groups(P ＞0.05).Conclusion In response to a step pressure,chondrocytes in each group exhibited the viscoelastic solid creep behavior.The viscoelastic properties of chondrocytes markedly decreased in old group.

Objective To investigate the effect of propofol upon acute cerebral insult during wholebody hyperthermia(WBH)in rats.Methods Sixty male Wister rats were randomly divided into 6 groups.All the animals were trained with place navigation test of Morris water maze(MWM)for 5 days pre-study.After training,some rats received anesthesia only but not WBH treatment as control,other rats were anesthetized with intraperitoneal injection of 3.0 ml/kg of chloral hydrate and 100 or 150 mg/kg of propofol followed with WBH process(keeping rat core temperature at 42℃ for 30 min).Space memory was checked using spatial probe test 24 h after WBH intervention.Rat brain was then removed in 24 h POst-WBH to separate hippocampal regions for the detection of neuronal apoptosis with TUNEL method and ultramicrostructural changes by electron microscope.Results The escape latency were smaller in groups B0,C0,D0,C and D than that in group B(P＜0.05)while smaller in groups B0,C0,D0 than in groups B,C,D respectively.The amount of apoptotic neurons in hippocampus increased orderly as following with no significant differences in group B0,C0 and D0:group B0,C0,D0＜group D＜group C＜group B (P ＜0.05).The injury degree of neuronal ultramicrostructure in hippocampus in group C after WBH were more severe than that in group D but better than that in group B.Conclusion Propofol alleviates the WBHinduced acute cerebral insult by inhibiting the hippocampal neural apoptosis.

A 57-year-old male was admitted to the hospital on October 8, 2008 due to sudden chest, back and abdomen pain for 2 months. The patient underwent enhanced CT examination on the second day of onset, which showed aortic dissection, Stanford B type (Figure 1). The rupture was located in the posterior wall of the aortic arch, near the left subclavian artery, and torn downward below the bifurcation of the common iliac artery. The true lumen of the abdominal aorta was severely narrowed, and the right renal artery and left common iliac artery were supplied with blood from the false lumen, and the perfusion was good. The celiac trunk, superior mesenteric artery and left renal artery originated from the true cavity, were poorly perfused, and the right common iliac artery was occluded. After 2 weeks of antihypertensive and sedative treatment, the chest pain was relieved, but paroxysmal abdominal pain existed, which was aggravated after eating, accompanied by intermittent claudication of the right lower extremity. Two months later, enhanced CT examination was performed again (Figure 2), which showed the development of the lesion, with aortic dissection involving the left common carotid artery, left subclavian artery dissection, and bilateral external iliac artery occlusion.

The most common site of bone metastasis in spinal foot tumor, about 50% of tumor patients will have spinal metastasis in the disease progression, and the site is more common in thoracic vertebra, followed by lumbar vertebra and cervical vertebra [1]. The treatment of spinal metastasis can not only relieve pain, improve nerve compression symptoms, maintain spinal mechanical stability, but also control tumor growth.With the development of tumor related disciplines, there are more and more treatment methods for spinal metastasis. According to the specific situation of patients, it is often necessary for oncology department, radiotherapy department, chemotherapy department, surgery department and other departments to jointly formulate individualized treatment plan with low risk and good curative effect [2-4].

A 46-year-old male was admitted to hospital on August 18, 2007 due to "neck sore and swollen for 2 years, left hand numb for 1 year, aggravated for 1 month". Physical examination showed that there was physiological curvature of cervical spine, no obvious tenderness. Pain in left hand decreased, especially numbness in ring finger and pinky finger. There was no obvious decrease in right hand sensation, no obvious atrophy of both upper limb muscles, and no obvious decrease in muscle strength. The left Hoffman sign was positive, the bilateral knee reflex and Achilles tendon reflex were normal, the bilateral straight leg elevation test was negative, the anal reflex was present, and the bilateral Babinski sign was negative. The sellar sensation was present. The blood and urine routine were normal. No abnormalities were found in chest X-ray and echocardiography.