Differential Cognitive Functioning and Benefit From Surgery in Patients Undergoing Coronary Artery Bypass Grafting and Carotid Endarterectomy

Background

Stenosing atherosclerosis in both coronary and carotid arteries can adversely affect cognition. Also their surgical treatments, coronary artery bypass grafting (CABG) and carotid endarterectomy (CEA), are associated with cognitive changes, but the mechanisms of cognitive decline or improvement may not be the same. This study was designed to compare the cognitive profile and outcome in patients undergoing surgical treatment for coronary or carotid disease.

Methods

A total of 100 CABG patients and 44 CEA patients were recruited in two previously reported studies. They were subjected to a comprehensive neuropsychological examination prior to surgery and in the acute (3-8 days) and stable (3 months) phase after operation. A group of 17 matched healthy controls were assessed with similar intervals. We used linear mixed models to compare cognitive trajectories within six functional domains between the CABG, CEA and control groups. Postoperative cognitive dysfunction (POCD) and improvement (POCI) were determined with the reliable change index method in comparison with healthy controls.

Results

Before surgery, the CEA patients performed worse than CABG patients or healthy controls in the domains of executive functioning and processing speed. The CABG patients exhibited postoperative cognitive dysfunction more often than the CEA patients in most cognitive domains in the acute phase but had regained their performance in the stable phase. The CEA patients showed more marked postoperative improvement in executive functioning than the CABG group in the acute phase, but the difference did not reach significance in the stable phase.

Conclusion

Our findings suggest that anterior cerebral dysfunction in CEA patients impairs preoperative cognition more severely than global brain dysfunction in CABG patients. However, CEA may have more beneficial effects on cognition than CABG, specifically in executive functions mainly operated by the prefrontal lobes. In addition, the results underline that POCD is a heterogeneous condition and dependent on type of revascularization surgery.

Postoperative cognitive change after cardiac surgery predicts long-term cognitive outcome

OBJECTIVES

Postoperative cognitive dysfunction (POCD) is a common consequence of coronary artery bypass grafting. However, domain-specific associations between postoperative changes and long-term performance are poorly known. The aim of this study was to investigate whether domain-specific cognitive changes after cardiac surgery predict long-term cognitive outcome.

MATERIALS AND METHODS

We assessed 100 patients (86 men, mean age 60) before coronary artery bypass grafting, with re-examinations after one week, three months, and a mean of 6.7 years. The extensive neuropsychological test battery was organized into seven functional cognitive domains. Cognitive decline and improvement were defined with the reliable change index derived from 17 matching healthy controls. Analyses were adjusted for baseline cognitive performance, age, gender, education and cardiovascular risks factors.

RESULTS

On group level, one week after surgery 71% patients showed cognitive decline and 9% improvement in any functional domain, as compared to preoperative results. Three months postsurgery, decline was observed in 47% and improvement in 25% of patients. Executive functioning was the most sensitive domain to both decline and improvement. Postoperative dysfunction predicted long-term cognitive deterioration six years after operation, particularly in the domain of executive functioning.

CONCLUSIONS

POCD after coronary artery bypass grafting is an essential risk factor for long-term deterioration and an indication for neuropsychological follow-up. Assessment of change in executive functioning after coronary artery bypass grafting may help to identify patients at risk for unfavorable long-term outcome.

Electrocoagulation treatment of peat bog drainage water containing humic substances

Electrocoagulation (EC) treatment of 100 mg/L synthetic wastewater (SWW) containing humic acids was optimized (achieving 90% CODMn and 80% DOC removal efficiencies), after which real peat bog drainage waters (PBDWs) from three northern Finnish peat bogs were also treated. High pollutant removal efficiencies were achieved: Ptot, TS, and color could be removed completely, while Ntot, CODMn, and DOC/TOC removal efficiencies were in the range of 33-41%, 75-90%, and 62-75%, respectively. Al and Fe performed similarly as the anode material. Large scale experiments (1 m(3)) using cold (T = 10-11 °C) PBDWs were also conducted successfully, with optimal treatment times of 60-120 min (applying current densities of 60-75 A/m(2)). Residual values of Al and Fe (complete removal) were lower than their initial values in the EC-treated PBDWs. Electricity consumption and operational costs in optimum conditions were found to be low and similar for all the waters studied: 0.94 kWh/m(3) and 0.15 €/m(3) for SWW and 0.35-0.70 kWh/m(3) and 0.06-0.12 €/m(3) for the PBDWs (large-scale). Thus, e.g. solar cells could be considered as a power source for this EC application. In conclusion, EC treatment of PBDW containing humic substances was shown to be feasible.

Histamine is required for H₃ receptor-mediated alcohol reward inhibition, but not for alcohol consumption or stimulation

BACKGROUND AND PURPOSE

Conflicting data have been published on whether histamine is inhibitory to the rewarding effects of abused drugs. The purpose of this study was to clarify the role of neuronal histamine and, in particular, H₃ receptors in alcohol dependence-related behaviours, which represent the addictive effects of alcohol.

EXPERIMENTAL APPROACH

Alcohol-induced conditioned place preference (alcohol-CPP) was used to measure alcohol reward. Alcohol-induced locomotor stimulation, alcohol consumption and kinetics were also assessed. mRNA levels were quantified using radioactive in situ hybridization.

KEY RESULTS

Low doses of H₃ receptor antagonists, JNJ-10181457 and JNJ-39220675, inhibited alcohol reward in wild-type (WT) mice. However, these H₃ receptor antagonists did not inhibit alcohol reward in histidine decarboxylase knock-out (HDC KO) mice and a lack of histamine did not alter alcohol consumption. Thus H₃ receptor antagonists inhibited alcohol reward in a histamine-dependent manner. Furthermore, WT and HDC KO mice were similarly stimulated by alcohol. The expression levels of dopamine D₁ and D₂ receptors, STEP61 and DARPP-32 mRNA in striatal subregions were unaltered in HDC KO mice. No differences were seen in alcohol kinetics in HDC KO compared to WT control animals. In addition, JNJ-39220675 had no effect on alcohol kinetics in WT mice.

CONCLUSIONS AND IMPLICATIONS

These data suggest that histamine is required for the H₃ receptor-mediated inhibition of alcohol-CPP and support the hypothesis that the brain histaminergic system has an inhibitory role in alcohol reward. Increasing neuronal histamine release via H₃ receptor blockade could therefore be a novel way of treating alcohol dependence.

Performance of a commercial industrial-scale UF-based process for treatment of oily wastewaters

An evaluation was made of the performance of a commercial industrial-scale ultrafiltration (UF)-based process for treatment of highly concentrated oily wastewaters. Wastewater samples were gathered from two plants treating industrial wastewaters in 2008, and in 2011 (only from one of the plants), from three points of a UF-based treatment train. The wastewater samples were analyzed by measuring the BOD7, COD, TOC and total surface charge (TSC). The inorganic content and zeta potentials of the samples were analyzed and GC-FID/MS analyses were performed. The removal performances of BOD7, COD, TOC and TSC in 2008 and 2011 for both plants were very high. Initial concentrations of contaminants in 2011 were lower than in 2008, therefore the COD and TSC reductions were also lower in 2011 than three years before. Regardless of the high performance of UF-based processes in both plants, at times the residual concentrations were considerable. This could be explained by the high initial concentrations and also by the presence of the dissolved compounds that were characterized. Linear correlation was observed between COD and TOC, and between COD and TSC. The correlation between COD and TSC could be utilized for process control purposes.

Coagulation of wood extractives in chemical pulp bleaching filtrate by cationic polyelectrolytes

The purpose of this research was to investigate the effectiveness of short-chain cationic polyelectrolytes of different molecular weights and charge densities in reducing turbidity and selectively removing toxic wood extractives from chemical birch pulp filtrate. The effects of chemical type, dosage and temperature were of interest. An effective performance was achieved with a copolymer of acrylamide and methacrylate of medium molecular weight and medium charge density at 72 degrees C and pH 5-6. The dosage range optimum for reducing the turbidity was 102-142 mg/L. Up to 92% of the wood extractives was selectively removed.

Investigation of multimodal zeta potential and size distribution in chemical pulp process water

Multimodal zeta potential distribution in chemical birch pulp process water was studied by filtrating the water into fractions and subsequently measuring zeta potential, charge quantity, turbidity and organic substances. Filtrations were made using 12 microm, 1.6 microm, 1.2 microm, 0.45 microm and 0.1 microm membranes. The number of populations with different zeta potentials diminished with filtration. With the unfiltrated water, 12 microm and 1.6 microm filtrates, three or four different zeta potentials were observed. When the filtration was performed with a 1.2 microm membrane or smaller, only two populations of different zeta potentials were detected. The charge quantity steadily approached zero from unfiltrated water towards a 1.6 microm fraction filtrate. After that, it remained constant. Turbidity constantly decreased when using smaller membranes. The amount of wood extractives decreased to half with 0.1 microm filtration. No significant difference in the amount of carbohydrates and lignin between the filtrated fractions and the unfiltrated water was detected. A comparison dealing with particle size analysis between two different apparatuses was also made.

Activation of neutrophils and monocytes by a leukocyte-depleting filter used throughout cardiopulmonary bypass

OBJECTIVE

Cardiopulmonary bypass elicits systemic inflammation. Depletion of circulating leukocytes might alleviate inflammatory response. We studied the effects of a leukocyte-depleting filter on phagocyte activation during cardiopulmonary bypass.

METHODS

Fifty patients undergoing coronary artery bypass grafting were randomly allocated into an arterial line leukocyte filter group (n = 25) with a Pall LeukoGuard 6 leukocyte-depleting filter (LG6; Pall Biomedical, Portsmouth, United Kingdom) and a control group without any filter (n = 25). Blood sampling took place from arterial line at predetermined time points. In the filter group, the sample was taken immediately before the filter; to evaluate activation at the site, an additional sample was taken immediately after the filter. CD11b/CD18 and L-selectin expressions and basal production of hydrogen peroxide were determined with whole-blood flow cytometry, and plasma lactoferrin level was determined with enzyme-linked immunosorbent assay.

RESULTS

Neutrophil CD11b expression was higher in the filter group than in the control group (P < .001). Likewise, monocyte CD11b expression, neutrophil hydrogen peroxide production, and lactoferrin plasma levels were all significantly higher, whereas neutrophil and monocyte counts and neutrophil L-selectin expression were all significantly lower in the filter group (all P < .001). At 5 minutes of CPB, CD11b expression increased across the filter on neutrophils (median difference 197 relative fluorescence units, range 45-431 relative fluorescence units, P < .001) and monocytes (median difference 26 relative fluorescence units, range -68-111 relative fluorescence units, P < .001).

CONCLUSION

The LG6 arterial line leukocyte filter is ineffective in its principal task of diminishing phagocyte activation during cardiopulmonary bypass.

No effect of cardiopulmonary bypass on hypnosis in patients anaesthetized with propofol and alfentanil

BACKGROUND

The effect of cardiopulmonary bypass (CPB) on the level of anaesthetic depth has not been studied previously in a randomized way.

METHODS

We assessed the effect of CPB on the propofol needed to maintain a fixed bispectral index score, and on the recovery from anaesthesia in 22 patients undergoing coronary artery bypass graft surgery with CPB (on-pump) compared with 18 patients operated on without CPB (off-pump). Anaesthesia was induced and maintained with propofol and alfentanil. Throughout the procedure, the infusion rate of propofol was adjusted to keep the BIS value at 40 +/- 5.

RESULTS

With the off-pump technique, the duration of surgery and anaesthetic administration were significantly greater. The need for propofol in proportion to time was exactly the same in both groups. During anaesthesia and the first 3 h thereafter, the BIS recordings were similar in both groups. No differences were detected in the time to awakening or tracheal extubation.

CONCLUSIONS

CPB does not affect propofol requirements or immediate postoperative recovery compared with the off-pump technique.

Degradation of EDTA and DTPA in chlorine dioxide bleaching conditions

The decomposition of EDTA and DTPA was studied in simulated chlorine dioxide bleaching conditions. Under the investigated conditions EDTA and DTPA decomposed readily. Accordingly, feeding the chelating agents to the first chlorine dioxide stages (D0) should be reconsidered, when successful metal removal is desired. On the other hand, chlorine dioxide water may be utilized to degrade the chelating agents.

Myocardial metabolism on off-pump surgery; a randomized study of 50 cases

OBJECTIVE

To study the inflammatory reaction and myocardial metabolism in off-pump and on-pump coronary artery bypass patients.

DESIGN

Fifty coronary artery bypass patients were randomized to off-pump or on-pump operations. Myocardial biopsies were taken to determine myocardial metabolism and inflammation (glutathione (GSH), superoxide dismutase (SOD) and myeloperoxidase (MP)) and plasma samples for indicators of oxidative stress (conjugated dienes (s-BDC), oxidative products of proteins (s-ox-Prot) and low-density lipoprotein (LDL)-total peroxyl radical trapping antioxidant potential (s-TRAP)).

RESULTS

s-ox-Prot 10 min was 2.11 +/- 0.75 vs 2.69 +/- 0.60 (p = 0.014), s-TRAP 5 min was 861 +/- 180 vs 969 +/- 192 (p = 0.032) and s-TRAP 10 min 857 +/- 176 vs 985 +/- 166 (p = 0.011), GSH 10 min 0.55 +/- 0.19 vs 0.72 +/- 1.16 (p = 0.007) (off-pump vs on-pump). The monobasic (MB) fraction of the creatinine kinase 24 h after the operation was significantly lower in the off-pump group, 20.5 +/- 24.2 vs 61.8 +/- 84.6 (p = 0.023).

CONCLUSION

GSH levels from the biopsies were increased in the perfusion group early in the reperfusion time showing that myocardial tissue was well protected and recovered more rapidly after cross-clamping than after the occlusion of the coronary arteries. However, release of creatinine kinase was lower in the off-pump group showing that cardiopulmonary bypass has more deleterious effects later after the operation.

Evaluation of the relationship between preoperative risk scores, postoperative and total length of stays and hospital costs in coronary bypass surgery

OBJECTIVES

Several risk indices have been developed for the prediction of postoperative mortality and morbidity in coronary artery bypass operations, in which the risk scores are currently recorded as routine praxis. The aim of the present study was to determine whether the risk scores can be used to predict the hospital (LOS) and postoperative (POS) lengths of stay and total costs among coronary artery bypass graft (CABG) patients.

METHODS

All first-time CABG patients (n=2104) treated at Helsinki University Central Hospital during 1997-1998 were preoperatively scored using the Cleveland Clinic preoperative model. A multivariate analysis was used to evaluate the effects of the risk scores on the LOS and POS and total costs.

RESULTS

The mean preoperative risk score for the patients was 1.69. The increase in preoperative risk score was associated with an increase in the LOS (0.8 days by point), and POS (with 0.55 days by point). An age over 74 years increased the LOS by an extra day. The mean total cost for the CABG procedure was 8750 euros (SD 4430 euros). The costs increased as the risk score increased. Compared with the zero risk score, a score value of 2 was associated with a 1300 euros increase in total cost and a score value of over 6 was associated with an over 7000 euros cost increase. On average, the costs increased by 6980 euros (80%) for one major complication and by 935 euros (10%) in the elderly (>74 years of age).

CONCLUSIONS

The results show that increasing risk scores were associated with longer postoperative hospital lengths of stay (POS and LOS) and with increased total costs. An age over 74 years appears to be an independent risk factor in increased POS, LOS and total cost. These results may help to estimate the impact of the preoperative risk profile on the resource requirement in CABG surgery.

Adsorption of metal-ethylenediaminetetraacetic acid chelates onto lake sediment

The adsorption of Ethylenediaminetetraacetic acid (EDTA) and its metal complexes, Cu, Fe(III), Hg, Mn and Ni, onto lake sediment was studied. The results reveal that EDTA and metal-EDTA complexes, even though being hydrophilic compounds, are indeed adsorbed within one months' contact time to some extent (6.3-24.8%). Less than 10% of Ni-EDTA, Cu-EDTA and EDTA salt was adsorbed, while the mass amount of Mn EDTA, Hg-EDTA and Fe(III)-EDTA found in sediment exceeded 15% after the contact period. Thus, adsorption of metal-EDTA chelates might be a relevant process in their removal from the aquatic environment. The metal-EDTA chelates in aqueous and solid phases were determined by gas chromatography-nitrogen phosphorus detection (GC-NPD) system. The complexes were extracted by phosphate solution prior to analysis. The ability of EDTA to desorb adsorbed heavy metals from sediments is also discussed.

Determination of Mn, Fe, and Cu in chemically-treated wood pulps by the XRF addition method

A rapid X-ray fluorescence addition method has been developed for quantification of the technically most important metals in wood pulp matrix (Mn, Fe, and Cu). Pretreatment consisted of just two steps: first, acid was added to the sample to achieve homogeneous distribution of the metals; the pulp was then pressed lightly on to Mylar film. Total analysis time was less than 10 min. The concentration range investigated was up to 15 mg kg(-1) for Mn and up to 5 mg kg(-1) for Fe and Cu. Metal concentrations in Scandinavian pulps are not expected to exceed these amounts. The quantification limit was 2 mg kg(-1) for all three metals. The reproducibilities and repeatabilities were concentration-dependent and varied between 3 and 19% and between 1 and 17%, respectively. The squares of the linear correlation coefficients between measured intensity and added metal concentration were 0.994, 0.950, and 0.932 for Mn, Fe, and Cu, respectively.

The importance of ligand speciation in environmental research: a case study

The speciations of EDTA and DTPA in process, waste and river waters are modelled and simulated, specifically to the mode of occurrence in the pulp and paper mill effluents and subsequently in receiving waters. Due to relatively short residence times in bleaching process and waste water treatment and slow exchange kinetics, it is expected that the thermodynamic equilibrium is not necessarily reached. Therefore, the initial speciation plays a key role. As such, the simulations have been extended to the process waters of the pulp and paper industry taking into account estimated average conditions. The results reveal that the main species are; Mn and Ca complexes of EDTA and DTPA in pulp mill process waters; Fe(III) and Mn complexes of EDTA and DTPA in waste waters; Fe(III) and Zn complexes of EDTA and DTPA in receiving waters. It is also shown how the increasing concentration of complexing agents effects the speciation. Alkaline earth metal chelation plays a significant role in the speciation of EDTA and DTPA when there is a noticeable molar excess of complexing agents compared with transition metals.

The effect of nitecapone on early graft function in experimental single lung transplantation

Nitecapone is an antioxidant molecule which has been shown to protect the heart against ischemia-reperfusion injury. We investigated whether a similar effect could be detected on lung graft preservation in a porcine model of single lung transplantation. Donors received either nitecapone or placebo in a modified Euro-Collins pulmonary flush solution. After cold storage for 19 h the left lung was transplanted. Patients in the nitecapone group received a nitecapone infusion during the graft reperfusion. A right-side heart bypass was used to measure flow distribution and pulmonary vascular resistance (PVR) in the recipient's transplanted and native lungs, respectively. Pulmonary vein blood samples were analyzed for blood gases, free radical trapping capacity and diene conjugates. PVR was high in the transplanted lung, which received only 20% of the blood flow. Oxygen tension in the transplanted lung was low (2.3-26.7 kPa). Nitecapone treatment increased the plasma free radical trapping capacity threefold. In spite of this increase in antioxidative capacity nitecapone could not protect the lung against ischemia-reperfusion injury when pulmonary hemodynamics, gas exchange or plasma diene conjugates were used as measures of lung graft function.

Twelfth-rib syndrome simulating intra-abdominal disease. Case report

A remarkable syndrome of bilateral intercostal neuralgia with pain in the loin, lower abdomen, groin and thigh was cured by resection of the 11th and 12th ribs. The pathways for the pain referral are discussed. The syndrome should be considered in the differential diagnosis of chronic abdominal pain.

Methylprednisolone in acute canine hemorrhagic pancreatitis

The effect of methylprednisolone on hemodynamics and oxygen transport was investigated in acute hemorrhagic pancreatitis in 13 dogs randomly allocated to a fluid treatment group, a methylprednisolone prophylaxis (MPP) group and a methylprednisolone therapy (MP) group. Methylprednisolone (30 mg/kg) was given as a bolus dose, starting 30 min before induction of pancreatitis in the MPP group and 30 min after induction in the MP group. Acute hemorrhagic pancreatitis was induced with a mixture of trypsin and sodium taurocholate, and hemodynamics and blood gases were monitored for 4.5 hours. MPP improved cardiac output significantly and prevented the initial increase in the arteriovenous oxygen content difference. In the MP group there were no significant differences from the control group in hemodynamics or oxygen transport. Prophylactically administered methylprednisolone thus partially attenuated the hemodynamic changes caused by acute hemorrhagic pancreatitis. It seemed especially to improve cardiac performance, assessed from changes in cardiac output.

Prostacyclin and thromboxane in acute hemorrhagic pancreatitis in dogs

To study the role of the vasodilatory, antiaggregatory prostacyclin (PGI2) and its endogenous antagonist thromboxane A2 (TxA2) in acute pancreatitis, we measured serum thromboxane B2 (TxB2, which indicates platelet TxA2 production) and plasma 6-keto-prostaglandin F1 alpha (6-keto-PGF1 alpha, which indicates systemic PGI2 production) from sequential blood samples in trypsin and taurocholate induced acute canine hemorrhagic pancreatitis (AHP). In addition the effect of a prostaglandin synthesis inhibitor, ibuprofen, was studied and systemic (MAP) and pulmonary artery pressure (MPAP) were recorded for 4.5 hr. The animals were divided into a sham-operated group, an AHP group, an ibuprofen prophylaxis group, and an ibuprofen therapy group. In the sham group the parameters remained stable throughout the experiment. In the AHP group MAP decreased steadily and 6-keto-PGF1 alpha rose significantly from 80.0 +/- 7.8 to 956.0 +/- 287.0 pg/ml (P less than 0.001), whereas serum TxB2 and MPAP remained unchanged. Ibuprofen prophylaxis eliminated the initial fall in MAP and the rise of 6-keto-PGF1 alpha. Ibuprofen therapy normalized the initially decreased MAP and depressed the level of 6-keto-PGF1 alpha. We conclude that PGI2 may at least partly mediate the initial hypotension in canine AHP, whereas platelet TxA2 production obviously has a negligible role in the development of hemodynamic changes in AHP.

Occurrence of pancreatic ductal cell dysplasia in rats fed with a high fat diet and ethanol

The effects of alcohol and diet on acute pancreatitis were studied in 192 male Wistar rats. The animals were fed with standard laboratory food up to three months of age and, after that, were divided into four groups of 48 animals, each group receiving a different diet: standard, fat-rich, protein-rich or carbohydrate-rich. In each diet group, 24 animals obtained 15% (v/v) ethanol in their drinking solution while the other 24 rats had water ad libitum. The diet period lasted for 12 weeks, after which acute experimental pancreatitis was induced under diethyl ether anesthesia by ductal injection of rat bile into the pancreatic ducts. Moderate or severe ductal cell dysplasia developed in three of the 15 survivors in the group fed with a high-fat diet and 15% ethanol in their drinking solution. Mild acute pancreatitis was histologically found in 13 rats and moderate pancreatitis in one rat in this group. One rat did not show any pancreatic parenchymal changes. Two of the rats with ductal cell dysplasia had mild pancreatitis and the pancreas of the third rat was normal in this respect. Dysplastic changes were not found in any other experimental group used in the study. The observation is statistically significant at p less than 0.025 level. The results indicate that alcohol and a high fat diet together might have a carcinogenic effect on pancreatic ductal epithelium in rats.