Constantin Jannes

Short-term and long-term neuropsychological consequences of cardiac surgery with extracorporeal circulation

OBJECTIVE Cognitive dysfunction after extracorporeal circulation is a major continuing problem in modern cardiac surgery. We designed this prospective study to update the incidence of postoperative neuropsychological changes after routine cardiopulmonary bypass (CPB) and to identify perioperative variables associated with these complications. METHODS We assessed the patients with a comprehensive neuropsychological test battery 1 day before, 7 days after (n = 109) and 6 months after (n = 91) cardiopulmonary bypass. We used patients undergoing major vascular or thoracic surgery as a surgical control group (n = 20). RESULTS Repeated measures multivariate analysis of variance (using surgical group as a between-subjects factor) on the group data revealed significant changes early after surgery compared with the preoperative performance (P = 0.001). The early changes are characterized by a significant decrease of visual attention and verbal memory performance (univariate F-tests, always P < 0.05). Cardiac patients showing cognitive impairment after cardiac surgery had lower preoperative ejection fractions (P = 0.014) and a more complicated medical history (P = 0.046). At 6-month follow-up, the patients performed significantly better than before surgery (P < 0.001). CPB patients showing persistent cognitive impairment at follow-up were significantly older at the time of surgery (P = 0.005). Individual comparisons revealed that 45% of the patients undergoing CPB showed evidence of cognitive impairment soon after surgery. In 12% of the patients, the cognitive sequelae persisted at follow-up. Both group data and individual incidence rates revealed neither significant pre-post differences between the surgical groups nor a time-by-group interaction effect. Variables directly associated with CPB were not significantly associated with the occurrence of cognitive impairment after surgery. CONCLUSIONS We conclude that an important proportion of the cognitive impairment after cardiac surgery is likely to be due to nonspecific effects of surgery.

Subjective complaints versus neuropsychological test performance after cardiopulmonary bypass.

The study by Newman et al. (Journal of Psychosomatic Research, 1989) compared subjective reports of cognition with assessed cognitive performance in patients one year after coronary artery bypass surgery. The current study reinvestigated this relation in a larger and more heterogeneous group--90 cardiac patients six months after cardiopulmonary bypass--using a more extensive checklist of subjective complaints and different neuropsychological tests. In agreement with previous research, the patients who reported complaints in specific cognitive areas were not found to have impaired cognitive functions as assessed with appropriate neuropsychological tests. The patients who reported deterioration in cognition after surgery were found to have higher levels of depression and state anxiety. These differences were significant for almost all evaluated cognitive functions. An alternative explanation of the relationship between mood and cognitive complaints based on personality traits, i.e., neuroticism, is offered.

Relationship between emotional variables and cognitive test performance before and after open-heart surgery

Abstract Impending surgery provides a natural stress paradigm within which the effect of stress on cognitive functioning can be assessed. Cardiac patients scheduled for open-heart surgery were tested for cognitive and emotional status on the day before (N = 130) and 7 days after surgery (N = 109). We correlated the self-reported anxiety and depression scores with the performance on 11 neuropsychological tests on both pre-and postoperative examinations. The results indicate that the significantly elevated emotional arousal in these patients has no relevant effect on their cognitive performance. This finding underlines the validity of neuropsychological testing in more acute clinical settings.

Strategies to increase compliance with out-patient aftercare among patients referred to a psychiatric emergency department: a multi-centre controlled intervention study.

BACKGROUND Compliance with referral for out-patient aftercare of psychiatric emergency patients is limited. This study investigated the efficacy of a combination of several referral strategies (fixed appointment, involvement of the family, presence of the aftercare person, motivational counselling) in increasing referral and treatment compliance of patients referred to the psychiatric emergency department of three general hospitals. METHODS A randomized controlled design was used to assess the effect of this experimental condition on referral compliance and on continuation of aftercare treatment. RESULTS A significant beneficial effect on compliance with the referral was found in two hospitals and a near-significant effect in the third. After 3 months of aftercare, the influence of the experimental procedure on adherence to therapy was still significant in two hospitals, but not in the third. CONCLUSIONS Helping the patient to attend an initial appointment can be achieved by a combination of practical and organizational arrangements.

Cerebral perfusion pressure and intracranial pressure in relation to neuropsychological outcome

AbstractObjective: The study attempted to examine the relationship between neuropsychological functioning and reduced cerebral perfusion pressure (CPP), raised intracranial pressure (ICP), and reduced mean arterial pressure (MAP), monitored during intensive care treatment. Design: This prospective follow-up study included consecutive patients and evaluated outcome at 6 months postinjury by the administration of a neuropsychological test battery. Setting: The study was conducted at the University Hospital of Gent, Belgium. Patients and participants: Over a 30-month period, 43 patients were included. Inclusion criteria were the following: hospital admission following closed head injury, ICP monitoring, no medical history of central nervous system disease or mental retardation, survival for at least 6 months, and informed consent for participation. Interventions: All patients received the hospital’s standard treatment for head injury, which remained unchanged during the study period. Measurements and results: Reduced CPP was analyzed using the number of observed values below 70 mmHg, raised ICP using the number of values above 20 mmHg, and MAP using the number of values below 80 mmHg. The neuropsychological test battery included 11 measures of attention, information processing, motor reaction time, memory, learning, visuoconstruction, verbal fluency, and mental flexibility. No linear relationships were found between overall neuropsychological impairment and episodes of reduced CPP, raised ICP, or reduced MAP. Conclusions: Although reduced CPP and raised ICP are frequent, often fatal, complications of head injury, in survivors they do not seem to be related to later neuropsychological functioning.

Prospective evaluation of verbal memory performance after cardiopulmonary bypass surgery

One hundred and four patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) and a surgical control group undergoing major vascular or thoracic surgery (n = 18) were tested with the Auditory Verbal Learning Test (AVLT) at the following intervals: 1 day before, 1 week after, and 6 months after surgery. Early after surgery a significant decline in AVLT-performance was found, characterized by a smaller carry-over of learned words on subsequent acquisition trials. Six-month follow-up data revealed significant improvement in the delayed retention of words as compared to the preoperative assessment. No surgical group differences or time by group interaction effects were found. In the CPB group, deeper levels of hypothermia, reflecting longer and more extensive cardiac surgery, were associated with reduced improvement on retest.

Personality change following head injury: assessment with the NEO Five-Factor Inventory.

We evaluated personality change following head injury in 68 patients at 6 months postinjury using the NEO Five-Factor Inventory to assess the five personality dimensions of the Five-Factor Model of Personality. All items had to be rated twice, once for the preinjury and once for the current status. Twenty-eight trauma patients with injuries to other parts of the body than the head were used as controls. For the head-injured group, 63 relatives also completed the questionnaire. The results showed no differences between the ratings of head-injured patients and the ratings of trauma control patients. Both groups showed significant change in the personality dimensions Neuroticism, Extraversion, and Conscientiousness. Compared to their relatives, head-injured patients report a smaller change in Extraversion and Conscientiousness. Changes were not reported on the Openness and Agreeableness scales, by neither the head-injured or their relatives, nor by the trauma controls.

Effect of asymptomatic carotid artery disease on cognitive outcome after cardiopulmonary bypass

This prospective study reinvestigates the effect of asymptomatic carotid artery disease on the cognitive outcome after cardiopulmonary bypass (CPB) (Harrison et al., 1989). Patients (N = 104) scheduled for cardiac surgery using CPB were classified in one of two groups based on the results of a preoperative duplex B mode Doppler scan of the internal carotid arteries. All patients received a neuropsychological examination before surgery, 8 days after surgery, and 6 months after surgery (n = 79). When group data are considered, patients showed evidence of selective cognitive dysfunction early after surgery. These dysfunctions were resolved by the sixth postoperative month. We found no indications that the presence of asymptomatic carotid artery disease increased the incidence of cognitive disturbances after CPB or differentially affected the postoperative performance. We conclude that mild to moderate asymptomatic carotid artery disease does not appear to play a major role in the genesis of postoperative neuropsychological sequelae.

Patients with psychiatric emergencies transported by an ambulance in an urban region

This paper studies the use of an ambulance service in the case of psychiatric emergency referrals. A cross-sectional design was used to compare the patients brought in by an ambulance with all other psychiatric emergency referrals. The sociodemographic and clinical characteristics as well as the referral pattern of both groups of patients are compared. Results show that an important proportion of patients brought in by an ambulance can be described as high risk referrals. However, for another group of referrals the ambulance is used for other reasons. The possibility of using alternative social services in these cases are discussed.

Epidemiology of Psychiatric Emergency Referrals in Four Regions of Belgium

Over a period of two years, all psychiatric emergency referrals at the emergency department of four public hospitals were monitored using a standardized form. The results showed that the hospitals share a typical profile of the psychiatric emergency department user. The profile is consistent with earlier descriptive studies, in Belgium as well as in other countries. Possible ways to overcome problems with data collection within the setting of a psychiatric emergency department are suggested. Finally, the necessity of monitoring the service needs of specific subgroups is discussed.