Diabetes is associated with risk of postoperative cognitive dysfunction: A meta-analysis

Itaconate alleviates anesthesia/surgery-induced cognitive impairment by activating a Nrf2-dependent anti-neuroinflammation and neurogenesis via gut-brain axis

BACKGROUND

Postoperative cognitive dysfunction (POCD) is a common neurological complication of anesthesia and surgery in aging individuals. Neuroinflammation has been identified as a hallmark of POCD. However, safe and effective treatments of POCD are still lacking. Itaconate is an immunoregulatory metabolite derived from the tricarboxylic acid cycle that exerts anti-inflammatory effects by activating the nuclear factor erythroid 2-related factor 2 (Nrf2) pathway. In this study, we investigated the effects and underlying mechanism of 4-octyl itaconate (OI), a cell-permeable itaconate derivative, on POCD in aged mice.

METHODS

A POCD animal model was established by performing aseptic laparotomy in 18-month-old male C57BL/6 mice under isoflurane anesthesia while maintaining spontaneous ventilation. OI was intraperitoneally injected into the mice after surgery. Primary microglia and neurons were isolated and treated to lipopolysaccharide (LPS), isoflurane, and OI. Cognitive function, neuroinflammatory responses, as well as levels of gut microbiota and their metabolites were evaluated. To determine the mechanisms underlying the therapeutic effects of OI in POCD, ML385, an antagonist of Nrf2, was administered intraperitoneally. Cognitive function, neuroinflammatory responses, endogenous neurogenesis, neuronal apoptosis, and Nrf2/extracellular signal-related kinases (ERK) signaling pathway were evaluated.

RESULTS

Our findings revealed that OI treatment significantly alleviated anesthesia/surgery-induced cognitive impairment, concomitant with reduced levels of the neuroinflammatory cytokines IL-1β and IL-6, as well as suppressed activation of microglia and astrocytes in the hippocampus. Similarly, OI treatment inhibited the expression of IL-1β and IL-6 in LPS and isoflurane-induced primary microglia in vitro. Intraperitoneal administration of OI led to alterations in the gut microbiota and promoted the production of microbiota-derived metabolites associated with neurogenesis. We further confirmed that OI promoted endogenous neurogenesis and inhibited neuronal apoptosis in the hippocampal dentate gyrus of aged mice. Mechanistically, we observed a decrease in Nrf2 expression in hippocampal neurons both in vitro and in vivo, which was reversed by OI treatment. We found that Nrf2 was required for OI treatment to inhibit neuroinflammation in POCD. The enhanced POCD recovery and promotion of neurogenesis triggered by OI exposure were, at least partially, mediated by the activation of the Nrf2/ERK signaling pathway.

CONCLUSIONS

Our findings demonstrate that OI can attenuate anesthesia/surgery-induced cognitive impairment by stabilizing the gut microbiota and activating Nrf2 signaling to restrict neuroinflammation and promote neurogenesis. Boosting endogenous itaconate or supplementation with exogenous itaconate derivatives may represent novel strategies for the treatment of POCD.

Triglyceride-glucose index predicts postoperative delirium in elderly patients with type 2 diabetes mellitus: a retrospective cohort study

BACKGROUND

Postoperative delirium (POD) is more prevalent among elderly patients with type 2 diabetes mellitus (T2DM). Insulin resistance (IR) can be assessed using the triglyceride-glucose (TyG) index, a novel biomarker. This study aims to investigate the predictive potential of the TyG index for POD in elderly patients with T2DM.

MATERIALS AND METHODS

Elderly patients (≥ 65) with T2DM who underwent non-neurosurgery and non-cardiac surgery were enrolled. Univariate and multivariate logistic regression analyses were conducted to assess the association between the TyG index and POD. Additionally, subgroup analyses were performed to compare the sex-specific differences in the predictive ability of the TyG index for POD.

RESULTS

A total of 4566 patients were included in this retrospective cohort. The receiver operating characteristic (ROC) curve analysis determined the optimal cut-off value for the TyG index to be 8.678. In the univariate model, a TyG index > 8.678 exhibited an odds ratio (OR) of 1.668 (95% CI: 1.210-2.324, P = 0.002) for predicting POD. In the multivariate regression models, the ORs were 1.590 (95% CI: 1.133-2.252, P < 0.008), 1.661 (95% CI: 1.199-2.325, P < 0.003), and 1.603 (95% CI: 1.137-2.283, P = 0.008) for different models. Subgroup analyses demonstrated that the predictive ability of the TyG index was more pronounced in females compared to males.

CONCLUSION

The TyG index shows promise as a novel biomarker for predicting the occurrence of POD in elderly surgical patients with T2DM.

Knowledge, attitudes, and practice toward postoperative cognitive dysfunction among anesthesiologists in China: a cross-sectional study

BACKGROUND

To investigate the knowledge, attitudes, and practice (KAP) toward postoperative cognitive dysfunction (POCD) among anesthesiologists in China.

METHODS

This cross-sectional study was conducted nationwide among Chinese anesthesiologists between December 2022 and January 2023. The demographic information and KAP scores of the respondents were collected using a web-based questionnaire. The mean KAP dimension scores ≥ 60% were considered good.

RESULTS

This study enrolled 1032 anesthesiologists (51.2% male). The mean total scores of knowledge, positive attitude, and positive practice were 9.3 ± 1.2 (max 12), 34.8 ± 3.3 (max 40), and 30.6 ± 6.7 (max 40), respectively. The knowledge items with correctness scores < 60% were "the anesthetic drugs that tend to cause POCD" (23.3%) and "Treatment of POCD" (40.3%). Multivariable analysis showed that ≥ 40 years old, master's degree or above, intermediate professional title (i.e., attending physician), senior professional title (i.e., chief physician), and working in tertiary hospitals were independently associated with adequate knowledge. Multivariable analysis showed that the attitude scores, middle professional title, and ≥ 16 years of experience were independently associated with good practice.

CONCLUSIONS

These results suggest that Chinese anesthesiologists have good knowledge, favorable attitudes, and good practice toward POCD. Still, some points remain to be improved (e.g., the drugs causing POCD and managing POCD) and should be emphasized in training and continuing education.

TRIAL REGISTRATION

ChiCTR2200066749.

Diabetes, antidiabetic medications and risk of dementia: A systematic umbrella review and meta-analysis

AIMS

The objective of this umbrella review and meta-analysis was to evaluate the effect of diabetes on risk of dementia, as well as the mitigating effect of antidiabetic treatments.

MATERIALS AND METHODS

We conducted a systematic umbrella review on diabetes and its treatment, and a meta-analysis focusing on treatment. We searched MEDLINE/PubMed, Embase, PsycINFO, CINAHL and the Cochrane Library for systematic reviews and meta-analyses assessing the risk of cognitive decline/dementia in individuals with diabetes until 2 July 2023. We conducted random-effects meta-analyses to obtain risk ratios and 95% confidence intervals estimating the association of metformin, thiazolidinediones, pioglitazone, dipeptidyl peptidase-4 inhibitors, α-glucosidase inhibitors, meglitinides, insulin, sulphonylureas, glucagon-like peptide-1 receptor agonists (GLP1RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2is) with risk of dementia from cohort/case-control studies. The subgroups analysed included country and world region. Risk of bias was assessed with the AMSTAR tool and Newcastle-Ottawa Scale.

RESULTS

We included 100 reviews and 27 cohort/case-control studies (N = 3 046 661). Metformin, thiazolidinediones, pioglitazone, GLP1RAs and SGLT2is were associated with significant reduction in risk of dementia. When studies examining metformin were divided by country, the only significant effect was for the United States. Moreover, the effect of metformin was significant in Western but not Eastern populations. No significant effect was observed for dipeptidyl peptidase-4 inhibitors, α-glucosidase inhibitors, or insulin, while meglitinides and sulphonylureas were associated with increased risk.

CONCLUSIONS

Metformin, thiazolidinediones, pioglitazone, GLP1RAs and SGLT2is were associated with reduced risk of dementia. More longitudinal studies aimed at determining their relative benefit in different populations should be conducted.

Comparison of Volatile Anesthetics Versus Propofol on Postoperative Cognitive Function After Cardiac Surgery: A Systematic Review and Meta-analysis

OBJECTIVE

To compare the effects of volatile anesthetics and propofol on neurocognitive function after cardiac surgery.

DESIGN

A systematic review and meta-analysis of randomized controlled trials.

SETTING

A literature search of PubMed, EMBASE, CENTRAL, CINAHL, Scopus, and Web of Science databases was conducted.

PARTICIPANTS

A total of 10 randomized controlled trials comparing volatile anesthetics and propofol in cardiac surgery were included in the study.

INTERVENTIONS

The standardized mean difference and risk ratio were calculated to estimate pooled effect sizes.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was the postoperative neurocognitive function score, and the secondary outcome was the incidence of delirium after cardiac surgery. The analysis did not show significant differences in postoperative neurocognitive function scores (standardized mean difference -0.06, 95% CI -0.81-0.69; p = 0.879). The incidences of delirium (risk ratio 1.10, 95% CI 0.81-1.50) between the volatile anesthetics and propofol groups were not significant (p = 0.533).

CONCLUSIONS

Unlike noncardiac surgery, there are no differences between volatile anesthetics and propofol regarding postoperative neurocognitive dysfunction after cardiac surgery.

Association between cerebrovascular disease and perioperative neurocognitive disorders: a retrospective cohort study

BACKGROUND

Previous studies have shown that patients with cerebrovascular disease (CVD) have a significantly increased risk of cognitive decline or dementia; however, the association between preoperative CVD and perioperative neurocognitive disorders (PNDs) remains unclear. This study aimed to explore the correlation between preoperative CVD and PNDs, as well as combine logistic regression and receiver operating characteristic (ROC) curves to construct a clinical prediction PND model.

MATERIALS AND METHODS

This retrospective cohort study evaluated 13 899 surgical patients of a large-scale comprehensive hospital between January 2021 and January 2022 to explore the association between preoperative CVD and PNDs, with follow-up to monitor postoperative survival until 28 February 2023, unless the patient died. The study participants comprised all inpatients from the Bone and Joint Surgery, Spine Surgery, Urology, Hepatobiliary Surgery, Gastrointestinal Surgery, and Thoracic Surgery departments. Patients were classified into two groups: the CVD group with a confirmed diagnosis and the noncerebrovascular disease group. The incidence of PNDs was measured, and potential associations between patient demographic information, preoperative comorbidities, and CVD, as well as the correlation between preoperative CVD and PNDs, were investigated by multivariate logistic regression analysis. Next, the authors constructed a clinical prediction PND model by drawing the ROC curve. The postoperative survival of all patients was tracked, and a survival curve was constructed and incorporated into the Cox proportional hazard regression model to analyze the relationship between preoperative CVD and the overall postoperative survival rate.

RESULTS

Of the included 13 899 patients, propensity score matching yielded 1006 patient pairs. Multivariate logistic regression analysis revealed that CVD was an independent risk factor for PNDs [odds ratio: 10.193; 95% CI: 7.454-13.938; P <0.001]. Subsequently, the authors developed a clinical prediction model for PNDs by multivariate logistic regression analysis. The area under the ROC curve was 0.798 (95% CI: 0.765-0.830). The survival of 11 702 patients was followed up. Multivariate Cox hazard ratio regression analysis revealed that CVD affected the overall postoperative survival rate (hazard ratio, 1.398; 95% CI: 1.112-1.758; P <0.001).

CONCLUSION

CVD was an independent risk factor for PNDs and affected the overall postoperative survival rate of surgical patients with preoperative CVD.

Perioperative neurocognitive disorder changes in elderly diabetes patients within 30 days after surgery: a retrospective cohort study

BACKGROUND

Perioperative neurocognitive disorders (PND) are a common central nervous system complication that predominantly affects the elderly. PND after surgery includes postoperative delirium (POD), delayed neurocognitive recovery up to 30 days (DNR), and postoperative neurocognitive disorder up to 12 months. Diabetes is an important independent risk factor for PND. Over the years, few studies have assessed the incidence of PND and the difference in serum biomarkers between diabetic and non-diabetic patients. We sought to examine the difference in the incidence of PND between elderly diabetic and non-diabetic patients in China and identify the risk factors of PND in elderly diabetics.

METHODS

We conducted a secondary and exploratory data analysis from our prior studies, including patients aged 65 years or older who underwent non-cardiac elective surgery with general anesthesia. We used the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and Montreal Cognitive Assessment (MoCA) to assess patient cognition.

RESULTS

A total of 236 patients were analyzed; the incidence of PND was significantly higher in diabetic than in non-diabetic patients within 30 days (59.2% vs. 36.8%) (P = 0.022). Multivariate logistic regression analysis showed that the preoperative MoCA was an independent risk factor for PND (odds ratio, 0.88 [0.8 to 0.97]; P = 0.014), and Hosmer-Lemeshow tests showed that it could predict PND in diabetic patients (P = 0.360). According to the maximum Youden index, the optimal cutoff for preoperative MoCA was 21.5 points, yielding a specificity and sensitivity of 88.0% and 55.2% for PND. The levels of glial fibrillary acidic protein (GFAP) and Tau in diabetic patients before and after surgery were significantly higher than in non-diabetic patients among cases of PND (P = 0.002 and 0.011, respectively).

CONCLUSION

The incidence of PND is higher in diabetic than in non-diabetic patients in China, and preoperative MoCA is an independent risk factor for PND in diabetics. Meanwhile, the changes in GFAP and p-Tau in diabetic patients who experienced PND were significantly higher than in non-diabetic ones.

Protective effect of intranasal insulin on postoperative cognitive dysfunction in elderly patients with metabolic syndrome undergoing noncardiac surgery: a randomized clinical trial

BACKGROUND

Insulin plays a crucial and multifactorial role in cognitive activity, with insulin resistance appearing in neurodegenerative and metabolic diseases. Insulin resistance contributes to the pathobiology of postoperative cognitive dysfunction (POCD) in experimental models, which can be rescued by intranasal insulin administration.

AIMS

To test the effect of intranasal insulin on the incidence of POCD in elderly patients with metabolic syndrome.

METHODS

The study was designed as a randomized, double-blind, placebo-controlled clinical trial. 116 elderly participants were randomly assigned to receive either 40 IU insulin (n = 58) or placebo (n = 58) for 7 days. The primary outcome was the incidence of POCD at 7 days and 3 months after surgery. Secondary outcomes included the degree of peripheral insulin resistance postoperatively, changes in peripheral inflammation levels and the safety of interventions.

RESULTS

The results showed that POCD occurred in the insulin group on the 7th postoperative day in 11 (20.8%) patients, which was fewer than the 23 (45.1%) patients in the placebo group (P = 0.008). The insulin group indicated better cognitive functional performance on language and memory test than the placebo group (P < 0.05). Mean peripheral plasma concentration of TNF-α (P < 0.05) and CRP (P < 0.001) in the insulin group was significantly declined compared with the placebo group on D3 and D7.

CONCLUSIONS

Intranasal insulin administration reduced the incidence of POCD and alleviated peripheral inflammatory levels in elderly patients with metabolic syndrome.

TRIAL REGISTRY

Chinese Clinical Trial Registry (ChiCTR1800015502).

Dexmedetomidine Regulates Autophagy via the AMPK/mTOR Pathway to Improve SH-SY5Y-APP Cell Damage Induced by High Glucose

Neurodegenerative diseases and postoperative cognitive dysfunction involve the accumulation of β-amyloid peptide (Aβ). High glucose can inhibit autophagy, which facilitates intracellular Aβ clearance. The α2-adrenoreceptor agonist dexmedetomidine (DEX) can provide neuroprotection against several neurological diseases; however, the mechanism remains unclear. This study investigated whether DEX regulated autophagy via the AMPK/mTOR pathway to improve high glucose-induced neurotoxicity in SH-SY5Y/APP695 cells. SH-SY5Y/APP695 cells were cultured with high glucose with/without DEX. To examine the role of autophagy, the autophagy activator rapamycin (RAPA) and autophagy inhibitor 3-methyladenine (3-MA) were used. The selective AMPK inhibitor compound C was used to investigate the involvement of the AMPK pathway. Cell viability and apoptosis were examined by CCK-8 and annexin V-FITC/PI flow cytometric assays, respectively. Autophagy was analyzed by monodansylcadaverine staining of autophagic vacuoles. Autophagy- and apoptosis-related protein expression and the phosphorylation levels of AMPK/mTOR pathway molecules were quantified by western blotting. DEX pretreatment significantly suppressed high glucose-induced neurotoxicity in SH-SY5Y/APP695 cells, as evidenced by the enhanced viability, restoration of cellular morphology, and reduction in apoptotic cells. Furthermore, RAPA had a protective effect similar to that of DEX, but 3-MA eliminated the protective effect of DEX by promoting mTOR activation. Moreover, the AMPK/mTOR pathway was involved in DEX-mediated autophagy. Compound C significantly suppressed autophagy and reversed the protective effect of DEX against high glucose in SH-SY5Y/APP695 cells. Our findings demonstrated that DEX protected SH-SY5Y/APP695 cells against high glucose-induced neurotoxicity by upregulating autophagy through the AMPK/mTOR pathway, suggesting a role of DEX in treating POCD in diabetic patients.

Metabolic syndrome and the risk of postoperative delirium and postoperative cognitive dysfunction: a multi-centre cohort study

BACKGROUND

Metabolic syndrome and its components are risk factors for cognitive impairment, but their contribution to perioperative neurocognitive disorders is unknown. We examined their associations with the risk of postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) in older patients.

METHODS

In 765 male and female participants aged ≥65 years, we measured preoperative metabolic parameters and screened for POD for 7 days or until discharge. POCD was defined through comparison of cognitive change on six neuropsychological tests with non-surgical controls. Multiple logistic regression analyses examined the association of metabolic parameters with risk of POD and POCD with adjustment for age, sex, and surgery type.

RESULTS

A total of 149 patients (19.5% of 765) developed POD and 53 (10.1% of 520 attendees) had POCD at 3 months. Patients with metabolic syndrome were at 1.85-fold higher risk of POD (95% confidence interval [CI] 1.26-2.70). Each 1 mmol L^-1 higher high-density lipoprotein cholesterol (HDL-C) was associated with a 0.47-fold lower POD risk (95% CI 0.30-0.74). Each 1 kg m^-2 higher body mass index (BMI) was associated with a 1.09-fold higher POCD risk (95% CI 1.02- 1.16).

CONCLUSIONS

Older surgical patients with metabolic syndrome were at increased risk of POD. Only reduced HDL-C was significantly associated with POD. For POCD, a higher preoperative BMI was identified as a risk factor. These findings add to mounting evidence of a distinct epidemiology of POD and POCD. Screening programmes taking advantage of HDL-C and BMI measurements and of metabolic interventions in reducing perioperative neurocognitive disorders should be evaluated.

CLINICAL TRIAL REGISTRATION

NCT02265263.

Peri-Operative Risk Factors Associated with Post-Operative Cognitive Dysfunction (POCD): An Umbrella Review of Meta-Analyses of Observational Studies

This umbrella review aimed to systematically identify the peri-operative risk factors associated with post-operative cognitive dysfunction (POCD) using meta-analyses of observational studies. To date, no review has synthesised nor assessed the strength of the available evidence examining risk factors for POCD. Database searches from journal inception to December 2022 consisted of systematic reviews with meta-analyses that included observational studies examining pre-, intra- and post-operative risk factors for POCD. A total of 330 papers were initially screened. Eleven meta-analyses were included in this umbrella review, which consisted of 73 risk factors in a total population of 67,622 participants. Most pertained to pre-operative risk factors (74%) that were predominantly examined using prospective designs and in cardiac-related surgeries (71%). Overall, 31 of the 73 factors (42%) were associated with a higher risk of POCD. However, there was no convincing (class I) or highly suggestive (class II) evidence for associations between risk factors and POCD, and suggestive evidence (class III) was limited to two risk factors (pre-operative age and pre-operative diabetes). Given that the overall strength of the evidence is limited, further large-scale studies that examine risk factors across various surgery types are recommended.

Comparison of Postoperative Neurocognitive Function in Older Adult Patients with and without Diabetes Mellitus

INTRODUCTION

Delayed neurocognitive recovery (DNR; neurocognitive disorder up to 30 days postoperative) and postoperative neurocognitive disorders (POCD; neurocognitive disorder 1-12 months postoperative) occur frequently after surgery, with diabetes mellitus (DM) suggested to contribute to this. This was a single-center prospective cohort study. The main aim of this study was to investigate the role of DM and preoperative hemoglobin A1c (HbA1c) in the development of POCDs after noncardiac surgery.

METHODS

Older adult patients ≥65 years of age scheduled for elective surgery were recruited. The Modified Telephone Interview for Cognitive Status questionnaire (TICS-M), a test of global cognitive functioning, was administered to determine cognition. Preoperative, 30-day postoperative, and 6-month postoperative cognition were compared for patients with and without DM. Cognitive decline was subdivided into mild (1 to 2 standard deviations below controls) and major (≥2 standard deviations below controls) DNR or POCD. Preoperative HbA1c levels were correlated with TICS-M scores.

RESULTS

We analyzed 102 patients [median (IQR [range]) age 72.0 (5 [68-74])]), who were divided into patients with DM (80 patients [78%]) and patients without DM (22 patients [22%]). Baseline cognitive function was similar for both groups. Repeated measures ANOVA showed that mean DM patient TICS-M scores decreased 30 days postoperative (F(2, 200) = 4.0, p = 0.02), with subsequent recovery 6-month postoperative, compared to stable TICS-M scores in non-DM patients. There were significantly more DM patients with DNR than non-DM patients (n = 11 [50%] vs. n = 14 [17.5%]; p = 0.031). There were no between-group differences in mild or major POCD. Higher preoperative HbA1c levels were significantly correlated with decreased 30-day Δcognition scores (F(1, 54) = 9.4, p = 0.003) with an R2 of 0.149 (β -0.45, 95% confidence interval: -0.735 to -0.154).

CONCLUSIONS

Older adult patients with DM undergoing surgery have an increased risk of DNR compared to older adult non-DM patients, but no increased risk of POCD. In DM patients, higher preoperative HbA1c levels were associated with an increased risk of DNR.

Mineralocorticoid receptor agonist aldosterone rescues hippocampal neural stem cell proliferation defects and improves postoperative cognitive function in aged mice

OBJECTIVES

Hippocampal neurogenesis is closely related to learning and memory, and hippocampal neurogenesis disorders are involved in the development of many neurodegenerative diseases. Mineralocorticoid receptor (MR) plays a vital role in regulating stress response, neuroendocrine and cognitive functions, and is involved in regulating the integrity and stability of neural networks. However, the potential role of MR in the pathogenesis of postoperative cognitive dysfunction (POCD) is unclear. Therefore, this study evaluated the effect and mechanism of MR activation on postoperative hippocampal neurogenesis and cognitive function in aged mice.

METHODS

18-month-old male Kunming mice were randomly divided into Control group (C group), Surgery group (S group), Surgery+ Aldosterone group (S+Aldo group), Surgery + Wortmannin group (S+Wort group), Surgery + Aldosterone + Wortmannin group (S+Aldo+Wort group). Laparotomy was used to establish an animal model of postoperative cognitive dysfunction. After surgery, mice were intraperitoneally injected with aldosterone (100 ug/kg,150 ug/kg,200 ug/kg) and / or wortmannin (1 mg/kg); One day before the sacrifice, mice were injected intraperitoneally with BrdU (100 mg / kg / time, 3 times in total). Mice were subjected to Morris water maze and field tests at 1, 3, 7, and 14 days after surgery. Immunofluorescence was used to detect the number of BrdU +, Nestin +, BrdU/Nestin + positive cells in the hippocampal dentate gyrus of mice at 1, 3, 7 and 14 days after surgery. Western-blot was used to detect PI3K/Akt/GSK-3β signaling pathway related proteins Akt, p-Akt, GSK-3β, P-GSK-3β expression.

RESULTS

Stress impairs the performance of aged mice in water maze and open field tests, reduces the number of BrdU/Nestin+ cells in the hippocampal dentate gyrus, and inhibits the phosphorylation of Akt and GSK-3β proteins in the hippocampus. Aldosterone treatment promotes P-Akt, P-GSK-3β protein expression and hippocampal neural stem cell proliferation, and improves postoperative cognitive dysfunction. However, wortmannin treatment significantly reversed these effects of aldosterone.

CONCLUSIONS

The mineralocorticoid receptor agonist aldosterone promotes the proliferation of hippocampal neural stem cells and improves cognitive dysfunction in aged mice after surgery, and the mechanism may be related to activation of PI3K/Akt/GSK-3β signaling.

Post-operative cognitive dysfunction in patients following gastrointestinal endoscopic treatment

We aimed to explore the changes in post-operative cognitive dysfunction (POCD) after gastrointestinal endoscopic treatment using detailed neuropsychological assessments. Patients hospitalized for gastrointestinal endoscopic polypectomy were recruited for neuropsychological evaluations, which included the Chinese version of the Mini-Mental State Examination (MMSE), Auditory-Verbal Learning Test, Digit Span Test (DST), Trail Making Task (TMT), Verbal Fluency Test, Clock Drawing Test, and Stroop test. Cognitive assessments were performed twice: one day before and 24 h after treatment. Healthy control subjects participated in the neuropsychological assessment during the same intervals. Detailed cognitive assessments were performed for 40 patients and 60 control subjects. Based on the Z scores, the incidence of POCD 24 h after gastrointestinal endoscopic treatment was 20%. Patients with POCD had significant impairment in the post-operative MMSE, forward DST, TMT, and Stroop interference effect correct count tests (all p < 0.05). Our preliminary results showed that patients were not fully recovered, and 20% had impairment in multiple cognitive assessments 24 h after a gastrointestinal endoscopy. As attention was affected, safety while discharging those patients should be a concern.

Prospective comparison of three methods for detecting peri-operative neurocognitive disorders in older adults undergoing cardiac and non-cardiac surgery

Postoperative neurocognitive disorders occur frequently in older adult patients. Neuropsychological assessment is the gold standard for diagnosis, but the resources required for routine use are significant. Instead, it is common for simplified and unvalidated tests to be used for trials and in clinical practice. We undertook a single-centre prospective observational study in elective surgical patients aged ≥ 65 years recruited between September 2019 and January 2021. Patients underwent neuropsychological assessment, the Modified Telephone Interview for Cognitive Status and Montreal Cognitive Assessment before surgery. Tests were repeated at approximately four to eight postoperative weeks. We included 105 patients and 28 (27%) were lost to follow-up. Pre-operative Modified Telephone Interview for Cognitive Status and cognitive domain scores were very weakly to moderately correlated (r = 0.09-0.41). Pre-operative Montreal Cognitive Assessment and cognitive domain scores were very weakly to weakly correlated (r = 0.17-0.37) Postoperative Modified Telephone Interview for Cognitive Status and cognitive domain scores were very weakly to weakly correlated (r = 0.09-0.36). Postoperative Montreal Cognitive Assessment score and cognitive domain scores were very weakly to weakly correlated (r = 0.07-0.36). Overall, there was limited agreement between tests. We conclude that the Modified Telephone Interview for Cognitive Status and Montreal Cognitive Assessment should not be used in isolation to diagnose postoperative neurocognitive disorders. There seems to be little to no pre-operative, postoperative or pre- to postoperative correlation between these tests and the neuropsychological assessment in older adults without pre-operative cognitive impairment.

Heterogeneous nuclear ribonucleoprotein A2/B1 as a novel biomarker in elderly patients for the prediction of postoperative neurocognitive dysfunction: A prospective nested case-control study

Background and objective

Postoperative neurocognitive dysfunction (PND) occurs in up to 54% of older patients, giving rise to the heavy psychological and economic burdens to patients and society. To date, the development of PND biomarkers remains a challenge. Heterogeneous nuclear ribonucleoprotein A2/B1 (hnRNPA2/B1) is an RNA-binding protein whose prion-like structure is prone to mutation and hence leads to neurodegenerative diseases, but its expression changes in PND remains unclear. Here, we detect the preoperative hnRNPA2/B1 level in patients with PND, and to explore its value in the prediction and diagnosis of PND.

Methods

The study included 161 elderly patients undergoing lumbar decompression and fusion in Nankai University Affinity the Third Central Hospital from September 2021 to July 2022. Neuropsychological and psychometric evaluations were performed before surgery, 1 week and 3 months after surgery to diagnose the occurrence of PND, then the peripheral blood was collected from patients before induction of anesthesia. The concentration in plasma of hnRNPA2/B1 and amyloid-β 42 were determined by enzyme-linked immunosorbent assay. The median fluorescence intensity and mRNA levels of hnRNPA2/B1 in peripheral blood mononuclear cells was detected by indirect intracellular staining flow cytometry and quantitative real-time PCR, respectively.

Results

The preoperative hnRNPA2/B1 level in patients with PND was higher both in short-time and long-time follow-up. We found significantly higher concentrations of hnRNPA2/B1 in PND at 7 days after surgery (median, 72.26 pg/mL vs. 54.95 pg/mL, p = 0.022) compared with patients without PND, and so as 3 months after surgery (median, 102.93 pg/mL vs. 56.38 pg/mL, p = 0.012). The area under the curve (AUC) was predicted to be 0.686 at 7 days after surgery and 0.735 at 3 months. In addition, when combining several clinical information, the diagnostic efficiency of hnRNPA2/B1 for PND could further increase (AUC, 0.707 at 7 days, 0.808 at 3 months).

Conclusion

Based on the findings reported here, hnRNPA2/B1 may serve as a new and powerful predictive biomarker to identify elderly patients with PND.

Insulin signaling in the central nervous system, a possible pathophysiological mechanism of anesthesia-induced delayed neurocognitive recovery/postoperative neurocognitive disorder: a narrative review

INTRODUCTION

Impairment in neurocognitive functions ranges between delayed neurocognitive recovery (DNR) and postoperative neurocognitive disorders (pNCD). Incidence varies from 11% after noncardiac surgery to 60% after cardiac surgery.

AREAS COVERED

Insulin receptors (IRs) signaling pathway in the central nervous system (CNS) could be a possible pathophysiological mechanism of anesthesia-induced DNR/pNCD and perioperative intranasal insulin administration could be a preventive approach. This hypothesis is supported by the following evidence: effects of IRs-CNS signaling pathway on neuromodulation; higher incidence of DNR/pNCD in patients with insulin resistance; neurotoxicity of IRs signaling pathways after anesthetic exposure; improvement of neurocognitive impairment after insulin exposure. This narrative review was conducted after a literature search of PubMed, EMBASE and SCOPUS online medical data performed in May 2022.

EXPERT OPINION

Perioperative intranasal insulin is shown to be protective and future studies should address: the role of insulin as a neuromodulator; its integration into neuroprotection approaches; patient populations that might benefit from this approach; a well-defined protocol of intranasal insulin administration in a perioperative background and other disciplines; and possible collateral effects.

Meta-Analysis of the Correlation between Postoperative Cognitive Dysfunction and Intraoperative Cerebral Oxygen Saturation

Objective

This study is aimed at performing a meta-analysis for discussing the association between postoperative cognitive dysfunction (POCD) and cerebral cortical oxygen saturation after surgery (rSO2).

Method

Search common English databases such as Cochrane Library, PubMed, and Embase databases to evaluate the quality of all references. According to the normalized mean difference (SMD) and 95% confidence interval calculated by the revman5 software, the correlation between reported POCD and rSO2 was evaluated. The retrieval time is up to February 1, 2021.

Results

A total of 7 randomized controlled trials and 564 POCD patients were included in the study, with follow-up duration of 1-12 months. All patients were divided into control and operation subgroups. In the subgroup analysis of elderly patients, abdominal surgery, and orthopedic surgery, the mean intraoperative cerebral oxygen saturation of patients with POCD was significantly lower than those of patients without POCD (I 2 = 55%, SMD = -0.57).

Conclusion

Lower intraoperativersO2 was associated with reduced incidence of neurological complications and renal alure as well as the length of stay in the intensive care unit and the total hospital stay.

Perioperative neurocognitive disorders: A narrative review focusing on diagnosis, prevention, and treatment

Perioperative neurocognitive disorders (NCDs) refer to neurocognitive abnormalities detected during the perioperative periods, including preexisting cognitive impairment, preoperative delirium, delirium occurring up to 7 days after surgery, delayed neurocognitive recovery, and postoperative NCD. The Diagnostic and Statistical Manual of Mental Disorders‐5th edition (DSM‐5) is the golden standard for diagnosing perioperative NCDs. Given the impracticality of using the DSM‐5 by non‐psychiatric practitioners, many diagnostic tools have been developed and validated for different clinical scenarios. The etiology of perioperative NCDs is multifactorial and includes predisposing and precipitating factors. Identifying these risk factors is conducive to preoperative risk stratification and perioperative risk reduction. Prevention for perioperative NCDs should include avoiding possible contributors and implementing nonpharmacologic and pharmacological interventions. The former generally includes avoiding benzodiazepines, anticholinergics, prolonged liquid fasting, deep anesthesia, cerebral oxygen desaturation, and intraoperative hypothermia. Nonpharmacologic measures include preoperative cognitive prehabilitation, comprehensive geriatric assessment, implementing fast‐track surgery, combined use of regional block, and sleep promotion. Pharmacological measures including dexmedetomidine, nonsteroidal anti‐inflammatory drugs, and acetaminophen are found to have beneficial effects. Nonpharmacological treatments are the first‐line measures for established perioperative NCDs. Pharmacological treatments are still limited to severely agitated or distressed patients.

Prognosis and Risk Factors of Stroke After Thoracic Endovascular Aortic Repair for Stanford Type B Aortic Dissection

Background: Stroke is a severe complication of patients with type B aortic dissection (TBAD) after thoracic endovascular aortic repair (TEVAR). Our aim is to identify predictors of stroke after TEVAR.

Methods: From February 2016 to February 2019, 445 patients with TBAD who underwent TEVAR were retrospectively analyzed. Univariate and multivariate analyses were performed to identify predictors of stroke after TEVAR.

Results: The total incidence of stroke was 11.5%, with transient neurological dysfunction (TND) of 10.6% and permanent neurological dysfunction (PND) of 0.9%. The average age of the patients was 53.0 ± 3.2 years, and the male/female ratio was 1.17. Univariate analysis suggested that age, body mass index (BMI), diabetes mellitus, chronic obstructive pulmonary disease (COPD), the urgency of repair, type of anesthesia, and left subclavian artery (LSCA) processing were potential risks factors of stroke after TEVAR. Multiple logistic regression identified that LSCA coverage (OR = 5.920, 95% CI: 2.077–16.878), diabetes mellitus (OR = 3.036, 95% CI: 1.025–8.995), and general anesthesia (OR = 2.498, 95% CI: 1.002–6.229) were independent predictors of stroke after TEVAR.

Conclusions: Left subclavian artery (LSCA) coverage, diabetes mellitus, and general anesthesia were independent risk factors of stroke after TEVAR for TBAD.

An Update on Postoperative Cognitive Dysfunction Following Cardiac Surgery

Postoperative cognitive dysfunction is extremely prevalent following cardiac surgery. The increasing patient age and comorbidity profile increases their susceptibility to cognitive impairment. The underlying pathophysiological mechanisms leading to cognitive impairment are not clearly elucidated. Using the contemporary literature (2015-present), this narrative review has three aims. Firstly, to provide an overview of postoperative cognitive impairment. Secondly, to analyse the predominant pathophysiological mechanisms leading to cognitive dysfunction following cardiac surgery such as inflammation, cerebral hypoperfusion, cerebral microemboli, glycaemic control and anaesthesia induced neurotoxicity. Lastly, to assess the current therapeutic strategies of interest to address these pathophysiological mechanisms, including the administration of dexamethasone, the prevention of prolonged cerebral desaturations and the monitoring of cerebral perfusion using near-infrared spectroscopy, surgical management strategies to reduce the neurological effects of microemboli, intraoperative glycaemic control strategies, the effect of volatile vs. intravenous anaesthesia, and the efficacy of dexmedetomidine.

The effect of type 2 diabetes mellitus on perioperative neurocognitive disorders in patients undergoing elective noncardiac surgery under general anesthesia. A prospective cohort study

Background and Aims:

Preliminary evidence suggests a possible relationship between type 2 diabetes mellitus (T2DM) and perioperative neurocognitive disorders (NCD). We sought to investigate whether patients with T2DM, undergoing elective noncardiac surgery under general anesthesia, are at increased risk of perioperative NCD.

Material and Methods:

A prospective cohort study was designed. One-hundred and forty-four patients with T2DM and 144 healthy controls were recruited. Controls were matched for sex, age, type of operation, and educational background. Postoperative delirium (POD), delayed neurocognitive recovery and postoperative NCD were evaluated.

Results:

Two hundred twenty-eight patients were analyzed. Compared to controls, patients with T2DM were diagnosed with higher rates of NCD preoperatively (n = 96 vs. n = 26, P < 0.05) and higher POD up to 4 days postoperatively (n = 204 vs. n = 68, P < 0.05). Increased rates of delayed neurocognitive recovery and postoperative NCD were recorded in patients with T2DM up to 9 months postoperatively (n = 473 vs. n = 192, P < 0.05). Insulin-dependent patients had higher rates of POD on the second (n = 38 vs. n = 24, P < 0.05) and third day (n = 27 vs. n = 16, P < 0.05) when compared to noninsulin-dependent patients. Logistic multivariable analysis revealed that patients with T2DM are at increased risk for postoperative cognitive disorders.

Conclusion:

Patients with type 2 diabetes mellitus appear to be at a higher risk of perioperative NCDs up to 9 months after elective noncardiac surgery under general anesthesia.

Construction and Application of a Model for Predicting the Risk of Delirium in Postoperative Patients With Type a Aortic Dissection

Background: Postoperative delirium (POD), an alteration in a patient's consciousness pattern, can affect the treatment and prognosis of a disease.

Objective: To construct a prediction model for delirium in patients with type A aortic dissection after surgery and to validate its effectiveness.

Methods: A retrospective cohort design was used to study 438 patients undergoing surgical treatment for type A aortic dissection from April 2019 to June 2020 in tertiary care hospitals. POD (n = 78) and non-delirium groups (n = 360) were compared and analyzed for each index in the perioperative period. A prediction model was established using multifactorial logistic regression, and 30 patients' perioperative data were collected for model validation.

Results: Eight predictors were included in this study: smoking, diabetes, previous cardiovascular surgery, ejection fraction (EF), time to aortic block, acute kidney injury, low cardiac output syndrome, and pulmonary complications. The area under the receiver operating characteristic (ROC) curve of the constructed prediction model was 0.98 ± 0.005, and the Youden index was 0.91. The validation results showed 97% sensitivity, 100% specificity, and 93% accuracy. The expression of the model was Z = Smoking assignment^* – 2.807 – 6.009^*Diabetes assignment – 2.994^*Previous cardiovascular surgery assignment – 0.129^*Ejection fraction assignment + 0.071^*Brain perfusion time assignment – 2.583^*Acute kidney injury assignment – 2.916^*Low cardiac output syndrome assignment – 3.461^*Pulmonary related complications assignment + 20.576.

Conclusion: The construction of an effective prediction model for the risk of delirium in patients after type A aortic stratification can help identify patients at high risk of POD early. It also provides a reference for healthcare professionals in the prevention and care of these patients.

mTOR-mediated autophagy in the hippocampus is involved in perioperative neurocognitive disorders in diabetic rats

Introduction

Perioperative neurocognitive disorders (PND) are common neurological complications after surgery. Diabetes mellitus (DM) has been reported to be an independent risk factor for PND, but little is known about its mechanism of action. Mammalian target of rapamycin (mTOR) signaling is crucial for neuronal growth, development, apoptosis, and autophagy, but the dysregulation of mTOR signaling leads to neurological disorders. The present study investigated whether rapamycin can attenuate PND by inhibiting mTOR and activating autophagy in diabetic rats.

Methods

Male diabetic Sprague‐Dawley rats underwent tibial fracture surgery under isoflurane anesthesia to establish a PND model. Cognitive functions were examined using the Morris water maze test. The levels of phosphorylated mTOR (p‐mTOR), phosphorylated tau (p‐tau), autophagy‐related proteins (Beclin‐1, LC3), and apoptosis‐related proteins (Bax, Bcl‐2, cleaved caspase‐3) in the hippocampus were examined on postoperative days 3, 7, and 14 by Western blot. Hippocampal amyloid β (Aβ) levels were examined by immunohistochemistry.

Results

The data showed that surgical trauma and/or DM impaired cognitive function, induced mTOR activation, and decreased Beclin‐1 levels and the LC3‐II/I ratio. The levels of Aβ and p‐tau and the hippocampal apoptotic responses were significantly higher in diabetic or surgery‐treated rats than in control rats and were further increased in diabetic rats subjected to surgery. Pretreatment of rats with rapamycin inhibited mTOR hyperactivation and restored autophagic function, effectively decreasing tau hyperphosphorylation, Aβ deposition, and apoptosis in the hippocampus. Furthermore, surgical trauma‐induced neurocognitive disorders were also reversed by pretreatment of diabetic rats with rapamycin.

Conclusion

The results demonstrate that mTOR hyperactivation regulates autophagy, playing a critical role in the mechanism underlying PND, and reveal that the modulation of mTOR signaling could be a promising therapeutic strategy for PND in patients with diabetes.

Amelioration of Hippocampal Insulin Resistance Reduces Tau Hyperphosphorylation and Cognitive Decline Induced by Isoflurane in Mice

General anesthetics can induce cognitive impairments and increase the risk of Alzheimer’s disease (AD). However, the underlying mechanisms are still unknown. Our previous studies shown that long-term isoflurane exposure induced peripheral and central insulin resistance (IR) in adult mice and aggravated IR in type 2 diabetes mellitus (T2DM) mice. Clinical and preclinical studies revealed an association between impaired insulin signaling and tau pathology in AD and other tauopathies. We investigated if alleviation of hippocampal IR by the antidiabetic agent metformin could reduce tau hyperphosphorylation and cognitive decline induced by isoflurane in mice. The effects of prolonged (6 h) isoflurane anesthesia on hippocampal IR, hippocampal tau hyperphosphorylation, and hippocampus-dependent cognitive function were evaluated in wild type (WT) adult mice and the high-fat diet plus streptozotocin (HFD/STZ) mouse model of T2DM. Here we shown that isoflurane and HFD/STZ dramatically and synergistically induced hippocampal IR and fear memory impairment. Metformin pretreatment strongly ameliorated hippocampal IR and cognitive dysfunction caused by isoflurane in WT mice, but was less effective in T2DM mice. Isoflurane also induced hippocampal tau hyperphosphorylation and metformin reversed this effect. In addition, isoflurane significantly increased blood glucose levels in both adult and T2DM mice, and metformin reversed this effect as well. Administration of 25% glucose to metformin-pretreated mice induced hyperglycemia, but surprisingly did not reverse the benefits of metformin on hippocampal insulin signaling and fear memory following isoflurane anesthesia. Our findings show hippocampal IR and tau hyperphosphorylation contribute to acute isoflurane-induced cognitive dysfunction. Brief metformin treatment can mitigate these effects through a mechanism independent of glycemic control. Future studies are needed to investigate whether long-term metformin treatment can also prevent T2DM-induced hippocampal IR and cognitive decline.

Cognitive Dysfunction of Pregnant Women with Gestational Diabetes Mellitus in Perinatal Period

Purpose

To explore whether pregnant women with gestational diabetes mellitus (GDM) had cognitive impairment and assess cognitive function in normal pregnant women.

Methods

A total of 75 consecutive women diagnosed with GDM (GDM group), 70 normal pregnant women (NP group) without diabetes and matched for age, and 51 female volunteers (CG group) with the similar age level, normal blood glucose, and nonpregnancy were included in the study. For the assessment of cognitive functions, Montreal Cognitive Assessment (MoCA) was performed. Venous blood samples were collected to measure blood glucose, glycated hemoglobin (HbA1c), methylglyoxal (MGO), beta amyloid (Aβ), and tau protein.

Results

The score of MoCA of GDM was lowest, and the score of the NP group was lower than volunteers (P < 0.05). The incidence of cognitive dysfunction increased significantly in the GDM group with statistical significance (P < 0.05). The levels of tau and MGO in the GDM group were significantly less than those in the NP and CG groups, and Aβ in the GDM group was significantly more than that in the NP and CG groups (P < 0.05), but the differences between NP and CG groups were not statistically significant (P < 0.05).

Conclusion

The pregnant women with GDM showed a significant decline in cognitive function, and the normal pregnant women also showed a decline in cognitive function which is very light.

Developing an intervention to optimise the outcome of cardiac surgery in people with diabetes: the OCTOPuS pilot study

BACKGROUND

Cardiothoracic surgical outcomes are poorer in people with diabetes compared with those without diabetes. There are two important uncertainties in the management of people with diabetes undergoing major surgery: (1) how to improve diabetes management in the weeks leading up to an elective procedure and (2) whether that improved management leads to improved postoperative outcomes. The aim of this study was to develop and pilot a specialist diabetes team-led intervention to improve surgical outcomes in people with diabetes.

DESIGN

Open pilot feasibility study SETTING: Diabetes and cardiothoracic surgery departments, University Hospital Southampton NHS Foundation Trust PARTICIPANTS: Seventeen people with diabetes undergoing cardiothoracic surgery INTERVENTION: Following two rapid literature reviews, a prototype intervention was developed based on a previously used nurse-led outpatient intervention and tested.

PRIMARY OUTCOME

Feasibility and acceptability of delivering the intervention SECONDARY OUTCOMES: Biomedical data were collected at baseline and prior to surgery. We assessed how the intervention was used. In depth qualitative interviews with participants and healthcare professionals were used to explore perceptions and experiences of the intervention and how it might be improved.

RESULTS

Thirteen of the 17 people recruited completed the study and underwent cardiothoracic surgery. All components of the OCTOPuS intervention were used, but not all parts were used for all participants. Minor changes were made to the intervention as a result of feedback from the participants and healthcare professionals. Median (IQR) HbA1c was 10 mmol/mol (3, 13) lower prior to surgery than at baseline.

CONCLUSION

This study has shown that it is possible to develop a clinical pathway to improve diabetes management prior to admission. The clinical and cost-effectiveness of this intervention will now be tested in a multicentre randomised controlled trial in cardiothoracic centres across the UK.

TRIAL REGISTRATION

ISRCTN; ISRCTN10170306 . Registered 10 May 2018.

Effects of Berberine on Diabetes and Cognitive Impairment in an Animal Model: The Mechanisms of Action

Diabetes is a group of metabolic disorders with an increased risk of developing cognitive impairment and dementia. The hippocampus in the forebrain contains an abundance of insulin receptors related to cognitive function and plays an important role in the pathophysiology of neurodegenerative disorders. Berberine from traditional Chinese medicine has been used to treat diabetes and diabetic cognitive impairment, although its related mechanisms are largely unknown. In this study, a STZ diabetes rat model feeding with a high-fat diet was used to test the effects of berberine compared with metformin. Oral glucose tolerance and hyperinsulinemic-euglycemic clamp were used for glucose metabolism and insulin resistance. The Morris water maze was used to observe the compound effects on cognitive impairment. Serum and hippocampal [Formula: see text]-amyloid peptide (A[Formula: see text], Tau and phosphorylated Tau protein deposition in the hippocampi were measured. The TUNEL assay was used to detect the neuronal apoptosis, supported by histomorphological changes and transmissional electron microscopy (TEM) image. Our data showed that the diabetic rats had a significantly cognitive impairment. In addition to improving glucose metabolism and reducing insulin resistance, berberine significantly improved the cognitive function in the rat. Berberine also effectively decreased the expression of hippocampal tau protein, phosphorylated Tau, and increased insulin receptor antibodies. Moreover, berberine downregulated the abnormal phosphorylation of A[Formula: see text] and Tau protein and improved hippocampal insulin signaling. The TUNEL assay confirmed that berberine reduced hippocampal neuronal apoptosis supported by TEM. Thus, berberine significantly improved the cognitive function in diabetic rats by changing the peripheral and central insulin resistance. The reduction of neuronal injury, A[Formula: see text] deposition, abnormal phosphorylation of Tau protein, and neuronal apoptosis in the hippocampus were observed as the related mechanisms of action.

Positive Association Between Serum Insulin-Like Growth Factor-1 and Cognition in Patients with Cerebral Small Vessel Disease

Cognitive impairment is one of the main complications of cerebral small vessel disease (CSVD). Serum insulin-like growth factor-1 (IGF-1) might serve as a marker for the risk of cognitive decline in patients with CSVD. We investigated the association of IGF-1 with the development of cognitive impairment in patients with CSVD. We included 216 patients with CVSD (mean age, 67.57 ± 8.53 years; 31.9% female). We compared 117 (54.2%) patients who developed cognitive impairment with 99 (45.8%) patients without cognitive impairment. Patients who developed cognitive impairment had significantly lower levels of IGF-I (p < 0 .001), suggesting that altered IGF-1 signaling may be a risk factor for cognitive decline in patients with CSVD.

Competing endogenous RNA network analysis explores the key lncRNAs, miRNAs, and mRNAs in type 1 diabetes

BACKGROUND

Type 1 diabetes (T1D, named insulin-dependent diabetes) has a relatively rapid onset and significantly decreases life expectancy. This study is conducted to reveal the long non-coding RNA (lncRNA)-microRNA (miRNA)-mRNA regulatory axises implicated in T1D.

METHODS

The gene expression profile under GSE55100 (GPL570 and GPL8786 datasets; including 12 T1D samples and 10 normal samples for each dataset) was extracted from Gene Expression Omnibus database. Using limma package, the differentially expressed mRNAs (DE-mRNAs), miRNAs (DE-miRNAs), and lncRNAs (DE-lncRNAs) between T1D and normal samples were analyzed. For the DE-mRNAs, the functional terms were enriched by DAVID tool, and the significant pathways were enriched using gene set enrichment analysis. The interactions among DE-lncRNAs, DE-miRNAs and DE-mRNAs were predicted using mirwalk and starbase. The lncRNA-miRNA-mRNA interaction network analysis was visualized by Cytoscape. The key genes in the interaction network were verified by quantitatively real-time PCR.

RESULTS

In comparison to normal samples, 236 DE-mRNAs, 184 DE-lncRNAs, and 45 DE-miRNAs in T1D samples were identified. For the 236 DE-mRNAs, 16 Gene Ontology (GO)_biological process (BP) terms, four GO_cellular component (CC) terms, and 57 significant pathways were enriched. A network involving 36 DE-mRNAs, 8 DE- lncRNAs, and 15 DE-miRNAs was built, such as TRG-AS1-miR-23b/miR-423-PPM1L and GAS5-miR-320a/miR-23b/miR-423-SERPINA1 regulatory axises. Quantitatively real-time PCR successfully validated the expression levels of TRG-AS1- miR-23b -PPM1L and GAS5-miR-320a- SERPINA1.

CONCLUSION

TRG-AS1-miR-23b-PPM1L and GAS5-miR-320a-SERPINA1 regulatory axises might impact the pathogenesis of T1D.

TLR4-mediated hippocampal MMP/TIMP imbalance contributes to the aggravation of perioperative neurocognitive disorder in db/db mice

Although type 2 diabetes is an important predictor of perioperative neurocognitive disorder (PND), little is currently known about its mechanism of action. Adult male db/db and db/m mice were subjected to four different treatments, including either sham or tibial fracture surgery as well as intraperitoneal injection of vehicle or TAK-242 (the selective inhibitor of TLR4) at 1, 24, and 48 h after surgery. The fear conditioning test was performed to detect cognitive impairment on post-operative day (POD) 3. The hippocampus was collected on POD 1 for western-blots and on POD 3 for western-blots, transmission electron microscopy, and electrophysiological experiments. Toll-like receptor 4 (TLR4) inhibition reversed more profound decline in the freezing behavior of db/db mice on POD 3. The surgery reduced the slope of hippocampal field excitatory postsynaptic potentials, and induced blood-brain barrier (BBB) damage in db/db mice on POD 3. The surgery also increased protein levels of TLR4, tumor necrosis factor (TNF)-α, interleukin (IL)-1β, albumin, matrix metalloproteinase (MMP)-2, and MMP-9, and decreased protein levels of claudin-5, occludin, tissue inhibitor of matrix metalloproteinase (TIMP)-1, and TIMP-2 in the hippocampus of db/db and db/m mice. These changes were all reversed by TAK-242 treatment. At last, compared with those in post-operative db/m mice, the surgery increased protein levels of TLR4, TNF-α, and IL-1β, decreased protein levels of claudin-5 and occludin, and sustained the MMP/TIMP imbalance in the hippocampus of db/db mice on POD 3. Our results suggest that TLR4-mediated aggravated hippocampal MMP/TIMP imbalance, BBB disruption, sustained inflammatory cytokine release, and impairment of long-term potentiation play a key role in tibial fracture surgery-induced persistent PND in db/db mice.

A 'real-world' analysis of risk factors for post liver transplant delirium and the effect on length of stay

BACKGROUND

The development of delirium has been previously demonstrated to be associated with an increased risk of mortality and length of stay post liver transplant (LTx) with multiple risk factors being identified in previous studies. In this study, we have aimed to identify the most important variables associated with the onset of post-LTx delirium and understand the effect on length of stay (LOS).

METHODS

All liver transplants for chronic liver disease between 1 August 2012 and 1 August 2017 were included (n = 793). Data were collected for analysis retrospectively from electronic patient records.

RESULTS

Delirium is associated with an overall increased hospital and ICU LOS but not one-year mortality. The risk of developing post-LTx delirium was the greatest among patients: with post-LTx sepsis, who required renal sparing immunosuppression, who received donation after cardiac death (DCD) grafts and who were older. Patients with autoimmune hepatitis, primary biliary cholangitis or primary sclerosing cholangitis seemed to be at lower risk of post-LTx delirium. However, global patient LOS was only prolonged in patients with sepsis and renal failure.

CONCLUSION

Many of the risk factors previously described to be associated with the development of post-LTx delirium were not demonstrated to be significant in this study. Sepsis, renal failure, older age and DCD use are associated with delirium post-LTx. It is unclear if this syndrome is an independent risk factor for increased LOS or if it is a symptom of well established syndromes associated with increased LOS. The role for prophylactic strategies to reduce the incidence of post-LTx delirium is therefore unclear.

Cognitive Deficits Following Intensive Care

BACKGROUND

Illnesses that necessitate intensive care can impair cognitive function severely over the long term, leaving patients less able to cope with the demands of everyday living and markedly lowering their quality of life. There has not yet been any comprehensive study of the cognitive sequelae of critical illness among non- surgical patients treated in intensive care. The purpose of this review is to present the available study findings on cognitive deficits in such patients, with particular at- tention to prevalence, types of deficit, clinical course, risk factors, prevention, and treatment.

METHODS

This review is based on pertinent publications retrieved by a selective search in MEDLINE.

RESULTS

The literature search yielded 3360 hits, among which there were 14 studies that met our inclusion criteria. 17-78% of patients had cognitive deficits after dis- charge from the intensive care unit; most had never had a cognitive deficit before. Cognitive impairment often persisted for up to several years after discharge (0.5 to 9 years) and tended to improve over time. The only definite risk factor is delirium.

CONCLUSION

Cognitive dysfunction is a common sequela of the treatment of non-surgical patients in intensive care units. It is a serious problem for the affected persons and an increasingly important socio-economic problem as well. The effective management of delirium is very important. General conclusions are hard to draw from the available data because of heterogeneous study designs, varying methods of measurement, and differences among patient cohorts. Further studies are needed so that study designs and clinical testing procedures can be standard- ized and effective measures for prevention and treatment can be identified.

Postoperative cognitive dysfunction in elderly patients undergoing hip arthroplasty

Even after successful hip arthroplasty, elderly patients who have undergone this procedure remain subject to cognitive decline and may collectively develop postoperative cognitive dysfunction (POCD). However, no consensus exists as to the risk factors resulting in a higher likelihood that a patient may present with this complication, and the aetiology of POCD is not well understood. We conducted a systematic review of papers concerning the influence of POCD-related risk factors in patients undergoing hip arthroplasty but limited the literature search to papers in English. A systematic and electronic search for manuscripts in the PubMed database was performed in order to identify all studies in which the risk factors for POCD were investigated. Articles were also obtained from the authors' files. Keywords for the search were postoperative cognitive dysfunction/change/impairment/decline/deficit, elderly/older/aged patients, and hip arthroplasty/replacement surgery. The evidence published to date suggests that POCD is a multifactorial disease, which includes an individual patient's characteristics, surgery, type of anaesthesia, and pain levels. All of these factors can increase the risk of POCD incidence. There are a number of factors that appear to influence the risk of early cognitive dysfunction after hip arthroplasty. Nevertheless, the specific mechanism and explicit risk factors associated with this cognitive dysfunction are not completely understood. Hip arthroplasty has made it possible for older patients to find relief from pain and improve their function, whereas it also increases the risk for suffering POCD that may affect these patients' quality of life and increase their mortality. Therefore, it is worthwhile investigating the mechanism of POCD in future studies in order to prevent and treat this condition.

Cancer-Related Anemia Is a Risk Factor for Medium-Term Postoperative Cognitive Dysfunction in Laparoscopic Surgery Patients: An Observational Prospective Study

Anemia in the elderly may impair cognitive function. Our primary objective was to determine whether cancer-related anemia was associated with postoperative cognitive dysfunction (POCD) in nonelderly patients. We conducted an observational prospective study of 177 patients scheduled for laparoscopic surgery. Patients aged 18-64 were divided into two groups according to whether they were anemic due to cancer or not. The cognitive function was assessed by the Mini-Mental State Examination (MMSE) 1 day before and 1 week after operation. The cognitive function of the patients was evaluated by using the Telephone Interview for Cognitive Status-Modified (TICS-M) 3 months after operation. The quality of life of patients was evaluated after operation. The hemoglobin level and other clinical data were recorded before operation. Of the 170 patients, 100 without anemia and 70 anemia patients had been evaluated 1 week after operation. POCD was detected in 43 cases (25.3% of 170 cases) at 1 week and 30 cases (19% of 158 cases) at 3 months postoperatively. Anemia was an independent risk factor for 3-month POCD occurrence (P = 0.034). The education level of the patients who had POCD at 1 week and 3 months after operation was lower (P < 0.001, P = 0.011, respectively). Age was independently associated with the incidence of POCD at 3 months (P = 0.011). In general, these findings suggested that anemia may increase the incidence of medium-term POCD in cancer patients undergoing laparoscopic surgery.

Comparison of Cognitive Function After Robot-Assisted Prostatectomy and Open Retropubic Radical Prostatectomy: A Prospective Observational Single-Center Study

OBJECTIVE

To assess the effects of robot-assisted radical prostatectomy in the Trendelenburg position on postoperative neurocognitive outcomes this study compared cognitive function between patients who underwent robot-assisted radical prostatectomy and those who underwent open retropubic radical prostatectomy.

METHODS

Objective evaluations of pre- and postoperative cognitive function were performed upon admission and before hospital discharge, by using a neuropsychological test battery. We collected self-reported data on cognitive failures at 3 months postoperatively. Binary logistic regression analysis was used to assess the effects of surgical technique on postoperative cognitive performance.

RESULTS

The pre- and postoperative neuropsychological assessments were completed by 367 patients with a median age of 64 years (range 44-76). The incidence of postoperative cognitive dysfunction was 23.9% after robot-assisted (39/165) and 22.3% after open radical prostatectomy (45/202). There was no significant difference in postoperative cognitive function during the early postoperative period (P = 0.758) and self-reported cognitive failures at 3 months (P = 0.303) between robot-assisted and open surgery. Surgical technique was not associated with early postoperative cognitive dysfunction in multivariable analysis (OR 1.012, 95%CI: 0.608-1.685, P = 0.962).

CONCLUSION

Compared with open surgery in supine position postoperative neurocognitive disorders do not occur more frequently after robot-assisted radical prostatectomy in the extreme Trendelenburg position. Based on these findings potential adverse effects on cognitive function do not have to be considered in the choice of surgical approach for radical prostatectomy.

Are Standard Follow-Up Parameters Sufficient to Protect Neurocognitive Functions in Patients with Diabetes Mellitus who Underwent Coronary Artery Bypass Grafting?

OBJECTIVE

We aimed to compare the effectiveness of cognitive function protection between the standard follow-up parameters and advanced neuromonitoring methods in diabetic patients who underwent coronary artery bypass grafting during cardiopulmonary bypass.

METHODS

Study design was prospective and observational. Patients were separated into two groups, treated only with standard follow-up parameters (Group 1) and followed up with the change of regional cerebral tissue oxygenation (rSO2) by near-infrared spectroscopy (Group 2). Neurocognitive functions were evaluated preoperatively and postoperatively before discharge in all patients using the Montreal Cognitive Assessment (MoCA) test.

RESULTS

Cognitive functions of Group 2 patients in the postoperative period were significantly higher than Group 1 patients (P=0.001). The mean postoperative MoCA score of patients was significantly lower than the mean preoperative MoCA score in Group 1 (24.8±2.2 vs. 23.6±2.6, P=0.02). However, mild cognitive dysfunction was significantly lower in Group 2, compared to Group 1 (P=0.02).

CONCLUSION

In patients followed up with standard parameters, a significant decrease in cognitive function was observed in the early period. However, the use of advanced neuromonitoring methods can significantly prevent this decrease in cognitive functions.

Neurological dysfunction after cardiac surgery and cardiac intensive care admission: A narrative review part 2: Cognitive dysfunction after critical illness; potential contributors in surgery and intensive care; pathogenesis; and therapies to prevent/treat perioperative neurological dysfunction

Severe cognitive decline and cognitive dysfunction has been attributed to patient's stay in the cardiovascular intensive care unit. Prolonged mechanical ventilation, long duration of stay, sedation protocols, and sleep deprivation contribute to patients developing neurocognitive disorder after intensive care admission and it is associated with poor clinical outcomes. Trauma of surgery, stress of critical care, and administration of anaesthesia evoke a systemic inflammatory response and trigger neuroinflammation and oxidative stress. Anaesthetic agents modulate the function of the GABA receptors. The persistence of these effects in the postoperative period promotes development of cognitive dysfunction. A number of drugs are under investigation to restrict or prevent this cognitive decline.

The mechanism of lipopolysaccharide administration-induced cognitive function impairment caused by glucose metabolism disorder in adult rats

This essay aims to make investigation on the mechanism of glucose metabolism disorder and Lipopolysaccharide administration-induced cognitive function impairment in adult rats with surgery. Methods: Divide the objects, 40 male Sprague-Dawley rats at the age of 9 months, into 4 groups. Provide unilateral nephrectomy surgery and/or lipopolysaccharide intraperitoneal injection. Postoperative cognitive function evaluation would be tested by the Morris water maze. Rats with Postoperative Cognitive Dysfunction (POCD) were scanned to analyze the brain glucose metabolism by means of 18F-FDG PET/CT. Phosphatidylinositol 3-Kinase (PI3K), Protein Kinase β (AKT), Insulin Substrates Receptor-2 (IRS-2) and Glucose Transporter 4 (GLUT4) were detected as well. Data will be captured through gene expression in POCD rats via Quantitative Real-Time PCR (QRT-PCR). On the other side, Western Blot was used to measure the expression levels of IRS-2, p-IRS-2, p-PI3K, PI3K, p-AKT, AKT, GLUT4, and p-GLUT4. Results: During the Morris water maze test, the staging time (latency) of rats in each group was becoming short gradually as the training progressed. The incubation time of Day 5 of each group was shorter than that of Day 1 (P < 0.05). On the Day 3 after the surgery, the average target quadrant residence time of Group S+L (100 μg/Kg) was shorter, compared with Group C, L and S. Of which, the average number of perforation was reduced greater than that of Group C (P < 0.05). The average swimming speed of the groups is of no distinct difference (P > 0.05). After the operation, there was no great difference shown among the subjects (P > 0.05) in the average residence time of the target quadrant, the mean number of passages, and the mean swimming speed. On Day 3, the average latency of Group S+L (100 μg/Kg) was longer than Group C (P < 0.05) in the working memory test after the operation. The average latency of rats in Group L and S was showed longer than that in Group C, with tiny difference (P > 0.05). In the 7-Day working memory test, the average latency of the rats in Group L, S and S+L (100 μg/Kg) was obviously longer than that in Group C. Comparing to preoperative rats, POCD rats of Group S+L (100 μg/Kg) were scanned by 18F-FDG PET/CT three days later after the operation. Its SUVmax of the frontal and temporal lobe areas were decreased significantly (P < 0.05). However, difference degree was not significantly shown in the SUVmax between Group C and the preoperative rats (P > 0.05). In comparison with the gene expression of of Group C, the PI3K, IRS-2, AKT and GLUT4 mRNA genes are the key genes in the insulin signaling pathways of the hippocampus of the POCD rats. The expression level was reduced. The expression level of all protein of PI3K, IRS-2, GLUT4 and AKT in the POCD rats was of no great contrast with that in Group C. But for IRS-2 protein, the phosphorylation level has increased, and meanwhile decreased for AKT, PI3K and GLUT4 proteins (P < 0.05). Conclusions: Adult SD rats cognitive dysfunction model treated with unilateral nephrectomy combined and 100 μg/kg LPS intraperitoneal injection were led to abnormal both brain glucose metabolism and insulin expression. The proved phenomenal results signal pathway-related proteins PI3K, IRS-2, AKT and GLUT4. It reached the conclusion that surgical trauma, rather than anesthesia, leads to impaired cognitive function. PI3K, IRS-2, AKT, and GLUT4pathway of brain can be partial explanations of the pathogenesis of POCD.

Insulin Resistance Predicts Postoperative Cognitive Dysfunction in Elderly Gastrointestinal Patients

Background

Members of the aging population who undergo surgery are at risk of postoperative cognitive dysfunction (POCD). Exploring an effective and reliable early predictor of POCD is essential to the identification of high-risk patients and to making prospective decisions. The purpose of this study was to examine whether preoperative insulin resistance is an independent predictor of POCD.

Methods

A total of 124 patients aged 60 years and older and who were scheduled for gastrointestinal surgery were enrolled in a prospective observational clinical study. All participants completed a battery of neuropsychological tests before surgery and 7 days later. POCD was defined as a decline of at least 1.5 SD on two or more of neuropsychological tests. Plasma concentration of the tumor necrosis factor α (TNF-α), C-reactive protein (CRP), and S-100β protein were measured. The status of insulin resistance was assessed by Homeostasis Model Assessment–Insulin Resistance (HOMA-IR). The relationship between HOMA-IR and POCD was assessed by Multivariable logistic regression models and the receiver operating characteristic (ROC) curve.

Results

Fifty one patients (41.1%) were diagnosed with POCD at 7 days after surgery. Preoperative HOMA-IR values of the POCD group were significantly higher than the non-POCD group. Furthermore, CRP and TNF-α levels of the POCD group were significantly higher at each postoperative time point (P < 0.05). The preoperative HOMA-IR value was an independent predictor of POCD (adjusted OR 1.88, 95% CI, 1.18–2.99) even after adjust for confounding variables, and when dichotomized, individuals above the HOMA-IR threshold (HOMA-IR > 2.6) had a three-times higher risk of POCD (OR 3.26; 95% CI, 1.07–9.91) compared to individuals below the threshold. The areas under the ROC curve of HOMA-IR was 0.804 (95% CI, 0.725–0.883; P < 0.001). The optimal cut-off value was found to be 0.583, with a sensitivity of 84.3% and specificity of 74%. The HOMA-IR value was positively associated with the TNF-α concentration at baseline (R² = 0.43, P < 0.01) and 1 day after surgery (R² = 0.3861, P < 0.01).

Conclusion

Preoperative insulin resistance is an effective predictor for the occurrence of POCD. Targeted prevention and treatment strategies of insulin resistance may be effective interventions of patients at risk for POCD.

Diabetes, but Not Hypertension and Obesity, Is Associated with Postoperative Cognitive Dysfunction

BACKGROUND/AIMS

Older people undergoing surgery are at risk of developing postoperative cognitive dysfunction (POCD), but little is known of risk factors predisposing patients to POCD. Our objective was to estimate the risk of POCD associated with exposure to preoperative diabetes, hypertension, and obesity.

METHODS

Original data from 3 randomised controlled trials (OCTOPUS, DECS, SuDoCo) were obtained for secondary analysis on diabetes, hypertension, baseline blood pressure, obesity (BMI ≥30 kg/m2), and BMI as risk factors for POCD in multiple logistic regression models. Risk estimates were pooled across the 3 studies.

RESULTS

Analyses totalled 1,034 patients. POCD occurred in 5.2% of patients in DECS, in 9.4% in SuDoCo, and in 32.1% of patients in OCTOPUS. After adjustment for age, sex, surgery type, randomisation, obesity, and hypertension, diabetes was associated with a 1.84-fold increased risk of POCD (OR 1.84; 95% CI 1.14, 2.97; p = 0.01). Obesity, BMI, hypertension, and baseline blood pressure were each not associated with POCD in fully adjusted models (all p > 0.05).

CONCLUSION

Diabetes, but not obesity or hypertension, is associated with increased POCD risk. Consideration of diabetes status may be helpful for risk assessment of surgical patients.

Preoperative smoking history is associated with decreased risk of early postoperative cognitive dysfunction in patients of advanced age after noncardiac surgery: a prospective observational cohort study

Objective

Prevention of postoperative cognitive dysfunction (POCD) in patients of advanced age remains unclear. Studies have shown that the cholinergic anti-inflammatory pathway contributes to a decreased risk of POCD and that nicotine stimulates the cholinergic anti-inflammatory pathway. We investigated whether patients of advanced age with a preoperative smoking history have a decreased risk of POCD.

Methods

In total, 382 patients (190 smokers, 192 nonsmokers) aged ≥60 years who underwent major noncardiac surgery were enrolled. Cognitive function was assessed, and multivariate logistic regression analyses were performed to identify risk factors.

Results

On postoperative days 5 and 7, 111 (29.05%) and 90 (23.56%) patients exhibited POCD, respectively. A preoperative smoking history was significantly correlated with a decreased risk of POCD. A high serum tumor necrosis factor-α (TNF-α) level on the operative day was significantly associated with an increased risk of POCD. Early POCD was significantly associated with the sufentanil dosage, age, and education level. The hospital stay in patients with and without POCD was 10.54 ± 2.03 and 8.33 ± 1.58 days, respectively.

Conclusion

A preoperative smoking history was associated with a decreased risk of early POCD, and a high serum TNF-α level was significantly associated with an increased risk of POCD.

Thinking about brain insulin resistance

INTRODUCTION

Dementia and type 2 diabetes mellitus (T2DM) are two of the epidemics of our time; in which insulin resistance (IR) is playing the central role. Epidemiological studies found that different types of dementia development may be promoted by the presence of T2DM.

OBJECTIVES

We aimed in this review to highlight the role of insulin and the IR in the brain as a pathophysiological factor of dementia development and also to expand our understanding of T2DM as a mediator of IR in the brain and to review the possible mechanisms of action that may explain the association.

METHODOLOGY

A critical review of the relevant published English articles up to 2018, using PubMed, Google Scholar, Science Direct, ADI, and WHO database was carried out. Keywords were included insulin resistance, T3DM, T2DM, dementia, brain insulin resistance were used.

CONCLUSION

The rapidly increased prevalence of dementia concurrently with T2DM and obesity need urgent action to illustrate guidelines for prevention, modifying, and treatment based on mechanistic studies.

Does Dexmedetomidine Ameliorate Postoperative Cognitive Dysfunction? A Brief Review of the Recent Literature

PURPOSE OF REVIEW

Postoperative cognitive dysfunction (POCD) occurs in 20-50% of postsurgical patients with a higher prevalence in elderly patients and patients with vascular disease and heart failure. In addition, POCD has been associated with many negative outcomes, such as increased hospital length of stay, increased rates of institutionalization, and higher patient mortality. This brief review discusses select evidence suggesting an association between neuroinflammation and POCD and whether the use of dexmedetomidine, a short-acting alpha 2 agonist, may ameliorate the incidence of POCD. We review the recent evidence for neuroinflammation in POCD, dexmedetomidine's properties in reducing inflammatory-mediated brain injury, and clinical studies of dexmedetomidine and POCD.

RECENT FINDINGS

There is evidence to support the anti-inflammatory and immunomodulatory effects of dexmedetomidine in animal models. Several clinical investigations have demonstrated favorable outcomes using dexmedetomidine over placebo for the reduction of postoperative delirium. Few studies have used high-quality endpoints for the assessment of POCD and no demonstrable evidence supports the use of dexmedetomidine for the prevention of POCD. While evidence exists for the neural anti-inflammatory properties of dexmedetomidine, human trials have yielded incomplete results concerning its use for the management of POCD. Dexmedetomidine may reduce acute postoperative delirium, but further studies are needed prior to recommending the use of dexmedetomidine for the direct reduction of POCD.

Incidence and risk factors of postoperative delirium in the elderly patients with hip fracture

Background

To investigate the incidence and related risk factors of delirium in elderly patients with hip fracture.

Methods

This is a retrospective study, performed in a medical center from October 2014 to February 2017, which enrolled all subjects aged over 65 years who were admitted for hip surgeries (hip arthroplasty, proximal femoral nail fixation). Univariate and multivariate logistic analysis was used to determine the incidence and risk factors of delirium. Delirium was assessed according to the Confusion Assessment Method (CAM).

Results

Overall, 19.29% of total 306 patients (mean age 81.9 ± 5.4 years) were identified as delirium. The delirium was significantly associated (p < 0.05) with the factors of age, hospitalization, diabetes, preoperative hematocrit (HCT), perioperative protein consumption, transfusion volume, preoperative leukocyte level, albumin level, American Society of Anesthesiologists (NYHA) classification, American Society of Anesthesiologists (ASA) classification, blood loss, coronary heart disease, and cerebral infarction. Multivariate analysis of the variables confirmed that age (> 75 years old), diabetes, and ASA classification (> 2 level) are the independent risk factors of postoperative delirium (POD). In addition, patients in delirium had prolonged hospitalization and high perioperative albumin infusion.

Conclusion

The elderly patients over the age of 75 years with the history of diabetes or ASA classification > 2 level were at higher risk of POD. Delirium is an important postoperative complication, which had prolonged hospitalization and high perioperative albumin infusion.

Level of evidence: III