Jan Stygall

Postoperative cognitive dysfunction after noncardiac surgery: a systematic review.

This article describes a systematic review on the research into postoperative cognitive dysfunction (POCD) in noncardiac surgery to ascertain the status of the evidence and to examine the methodologies used in studies. The review demonstrated that in the early weeks after major noncardiac surgery, a significant proportion of people show POCD, with the elderly being more at risk. Minimal evidence was found that patients continue to show POCD up to 6 months and beyond. Studies on regional versus general anesthesia have not found differences in POCD. Many studies were found to be underpowered, and a number of other methodologic difficulties were identified. These include the different types of surgery in studies and variations in the number and range of neuropsychological tests used. A particular issue is the variety of definitions used to classify individuals as having POCD.

Comparison of Microembolism Detected by Transcranial Doppler and Neuropsychological Sequelae of Carotid Surgery and Percutaneous Transluminal Angioplasty

BACKGROUND AND PURPOSE Percutaneous transluminal angioplasty (PTA) is currently being assessed for the treatment of carotid stenosis. In comparison with carotid endarterectomy (CEA), there is evidence of an increased risk of cerebral microembolism during the procedure. We have sought evidence of any neuropsychological sequelae of carotid PTA and compared it with CEA to demonstrate the relative safety of the 2 treatment options. METHODS The neuropsychological outcomes after CEA and PTA were compared in 2 matched groups of patients with severe symptomatic carotid stenosis, 96% of whom had been randomized in the Carotid and Vertebral Artery Transluminal Angioplasty Study (CAVATAS), at a single center. Transcranial Doppler insonation of the middle cerebral artery was used to measure cerebral reactivity in response to carbon dioxide inhalation before treatment and then to detect microembolization of the ipsilateral cerebral hemisphere and measure changes in blood flow velocity during the procedures. The performance on a neuropsychological test battery administered before, 6 weeks after, and 6 months after the procedure was compared in 20 patients undergoing PTA and 26 having CEA. RESULTS At 6 weeks, 5 patients in each group showed a similar decline in neuropsychological performance; global measures showed no significant difference between the 2 procedures, despite a significantly higher incidence of microemboli during PTA. Both groups showed a marked reduction in anxiety after treatment. CONCLUSIONS The findings provide some reassurance that PTA is not associated with greater cerebral complications than CEA, despite the higher embolic load recorded by transcranial Doppler ultrasonography during angioplasty.

Neuroprotection of the Brain During Cardiopulmonary Bypass A Randomized Trial of Remacemide During Coronary Artery Bypass in 171 Patients

BACKGROUND AND PURPOSE Neuropsychological impairment may follow coronary artery bypass surgery as a result of peroperative cerebral microembolism. The hypothesis that remacemide, an NMDA receptor antagonist, would provide protection against such ischemic damage has been tested in a randomized trial. METHODS One hundred seventy-one patients undergoing coronary artery bypass surgery by a single cardiothoracic surgical team were randomized to receive remacemide (up to 150 mg every 6 hours) or placebo from 4 days before to 5 days after their bypass procedure. Peroperative monitoring included an estimate of the number of microembolic events detected by transcranial Doppler ultrasonography of the middle cerebral artery. A battery of 9 neuropsychological tests was administered before and 8 weeks after surgery. RESULTS The proportion of patients showing a decline in performance of 1 SD or more in 2 or more tests was reduced in the treated group (9% versus 12%), but this was not statistically significant. On the other hand, overall postoperative change (reflecting learning ability in addition to reduced deficits) was more favorable in the remacemide group, which demonstrated significantly greater improvement in a global z score (P=0.028) and changes in 3 individual tests (P<0.05). The 2 patient groups were well matched, including for the burden of microembolic events. CONCLUSIONS This is the first study to show statistically significant drug-based neuroprotection during cardiac surgery. In addition to offering improvement in cerebral outcome for such at-risk patients, it supports the hypothesis that drugs acting on the excitotoxic mechanism of ischemic cerebral damage can be effective in humans.

Cognitive impairment and 7-year mortality in dialysis patients.

BACKGROUND Although dementia has predicted mortality in large dialysis cohorts, little is known about the relationship between less pronounced cognitive deficits and mortality in patients with end-stage renal disease. This study assessed whether cognitive impairment without dementia was an independent predictor of 7-year survival in dialysis patients after controlling for other risk factors. STUDY DESIGN Prospective single-cohort study. SETTING & PARTICIPANTS 145 prevalent dialysis patients from 2 units in London, UK, were followed up for 64.3 ± 27.4 months and censored at the time of change to a different treatment. PREDICTORS Cognitive impairment, defined as performance 1 standard deviation less than normative values on 2 or more cognitive tests within a neurocognitive battery assessing attention/concentration, memory, and psychomotor function domains. Depression, quality-of-life, and clinical measures also were obtained. OUTCOMES & MEASUREMENTS All-cause mortality was the primary outcome. Cox proportional hazard models were used to assess the contribution of demographics and clinical and psychological measures and cognitive impairment to mortality. RESULTS 98 (67.6%) patients were cognitively impaired at baseline. At follow-up, 56 (38.6%) patients had died, 29 of cardiac causes. Unadjusted Kaplan-Meier analysis showed higher mortality in cognitively impaired patients, in whom 7-year survival was 49% versus 83.2% in those with no cognitive impairment (P < 0.001). Mortality risk associated with cognitive impairment remained significant in adjusted analysis controlling for sociodemographic, clinical, and psychological factors (adjusted HR, 2.53; 95% CI, 1.03-6.22; P = 0.04). LIMITATIONS Small sample size and number of events. CONCLUSIONS Cognitive impairment is an independent predictor of mortality in dialysis patients. Although the implications of early recognition and treatment of cognitive impairment for clinical outcomes are unclear, these results suggest that patient management protocols should attempt to ensure prevention of cognitive decline in addition to managing coexisting medical conditions.

Development and feasibility of a scale to assess postoperative recovery: the post-operative quality recovery scale.

Background:Good postoperative recovery is increasingly recognized as an important outcome after surgery. The authors created a new Post-operative Quality Recovery Scale (PQRS) that tracks multiple domains of recovery from immediate to long-term time periods in patients of varying ages, languages, and cultures. Methods:The parameters of importance to both clinicians and patients were identified. After an initial pilot study of 133 patients, the PQRS was refined. It consists of six domains (physiologic, nociceptive, emotive, activities of daily living, cognitive, and overall patient perspective). An observational study of 701 patients was performed with the refined PQRS to assess its capacity to evaluate and track recovery and to discriminate between patients. It was conducted in eight countries and in five languages, involving patients more than or equal to 6 yr undergoing elective surgery with general anesthesia. Recovery was assessed before surgery and at multiple time periods postoperatively. Recovery was defined as return to baseline values or better. Results:Seven hundred one patients completed the PQRS. Mean completion time was 4.8 (SD 2.8) min. Recovery scores improved with time. Physiologic recovery was complete in 34% of subjects by 40 min. By the third postoperative day, complete recovery was obtained in 11% of cases (all domains): 48.7% nociceptive, 81.8% emotive, 68.8% activities of daily living, and only 33.5% cognitive. Overall, 95.8% of the patients reported that they were “satisfied or totally satisfied” with their anesthetic care. Conclusion:The scores on the PQRS demonstrated an improvement over time, consistent with an expected recovery after surgery and anesthesia, and an ability to discriminate between individuals. Many patients had incomplete recovery by the third postoperative day.

The role of apolipoprotein E in cognitive decline after cardiac operation

BACKGROUND Recently, Tardiff and colleagues have suggested that the presence of the apolipoprotein E, epsilon4 allele was associated with increased likelihood of cognitive decline after coronary artery bypass grafting. The objective of the current study was to replicate this earlier work using an increased sample size. The increased sample also enabled an analysis by individual genotype in cognitive decline after coronary artery bypass grafting. METHODS Apolipoprotein E genotyping was performed on 111 individuals undergoing coronary artery bypass grafting. Each participant underwent a battery of nine neuropsychological tests before operation and 4 to 7 weeks after operation. RESULTS Cognitive decline, assessed by both continuous Z change scores and two categoric measures of cognitive deficit, was not significantly associated with either individual apolipoprotein E genotypes or categorization by the presence or absence of the epsilon4 allele. The examination of potential moderating factors did not alter this finding. CONCLUSIONS This study suggests that the epsilon4 allele is not associated with cognitive decline in the weeks after coronary artery bypass grafting.

The influence of propofol or desflurane on postoperative cognitive dysfunction in patients undergoing coronary artery bypass surgery

We investigated the influence of either propofol or desflurane on the incidence of postoperative cognitive dysfunction in a randomised trial of 180 patients undergoing coronary artery bypass surgery. The primary outcome was incidence of postoperative cognitive dysfunction at 3 months, defined as ≥ 1 SD deterioration in two or more of 12 neurocognitive tests. Secondary outcomes included early postoperative cognitive dysfunction (between days three and seven), delirium on day one, morbidity and length of hospital stay. Early postoperative cognitive dysfunction was significantly higher with propofol compared with desflurane (56/84 (67.5%) vs 41/83 (49.4%), respectively, p = 0.018), but this effect was not seen at 3 months (10/87 (11.2%) vs 9/90 (10.0%), respectively. There was no difference in delirium (7/89 (7.9%) vs 12/91 (13.2%), respectively, length of hospital stay (median (IQR [range]) 7 (6‐9 [4‐15]) vs 6 (5‐7 [5‐16) days, respectively or other morbidities. Desflurane was associated with reduced early cognitive dysfunction.

Religious/spiritual coping resources and their relationship with adjustment in patients newly diagnosed with breast cancer in the UK

Religious/spiritual resources may serve multiple functions in adjustment to cancer. However, there is very little evidence of the importance of religious/spiritual variables outside the USA. This paper reports the cross‐sectional data of a longitudinal study examining the beneficial and harmful effects of religious/spiritual coping resources on adjustment in the first year after a breast cancer diagnosis.

Quality of life of adult congenital heart disease patients: a systematic review of the literature

AIMS This review explores the quality of life of adult congenital heart disease patients and the relationship between disease severity and quality of life. METHODS We searched seven electronic databases and the bibliography of articles. The 31 selected studies fulfilled the following criteria: adult population; quantitative; assessment of quality of life and/or impact of disease severity on quality of life using validated measures; English language. Data extraction forms were used to summarise the results. RESULTS There are evident methodological limitations within the reviewed studies such as heterogeneous populations, designs, and quality of life conceptualisations and measurements. Despite these problems, findings suggest that the quality of life of adult congenital heart disease patients is compromised in the physical domain compared with their healthy counterparts, whereas no differences were found in relation to the psychosocial and environmental/occupational domain. Some severity variables appear to be significant correlates of quality of life and could be considered in a future standardised classification of disease severity. CONCLUSION The methodological limitations of past research in relation to the definition and measurement of quality of life, the study designs, and disease severity classifications need to be addressed in future studies in order to provide robust evidence and valid conclusions in this area of study. This will enable the development of targeted interventions for the improvement of quality of life in the adult population of congenital heart disease patients.

Religious coping strategies in patients diagnosed with breast cancer in the UK.

Objectives: The use of religious/spiritual coping strategies may be particularly prevalent when dealing with the stress of a cancer diagnosis. There has, however, been very little research conducted on this topic outside the USA. Existing measures of coping largely ignore the complexity of religious/spiritual coping and its potential to be adaptive as well as maladaptive. The aim of this study was to examine the prevalence of various religious coping strategies in a UK cancer sample.