Psychiatric and psychosocial outcome of cardiac surgery with cardiopulmonary bypass: a prospective 12-month follow-up study

Hesperidin reduces depressive symptoms in post-coronary artery bypass graft patients with mild depression

Previous studies have shown that hesperidin may have beneficial effects on depression; however, to the best of our knowledge, no clinical trial has yet been conducted in this area. The aim of the present study was, therefore, to determine the effects of hesperidin on depression, serum brain-derived neurotrophic factor (BDNF), and serum cortisol levels in post-coronary artery bypass graft (CABG) patients. Toward this goal, 73 post-CABG patients with depression symptoms were enrolled. The participants were randomly divided into two groups to receive either 200 mg/day hesperidin (n = 38) or placebo (n = 35) for 12 weeks. Depressive symptoms, serum BDNF, and cortisol levels were then assessed at the baseline and after intervention. Beck Depression Inventory-II (BDI-II) was also used to determine the severity of depression. Sixty-six patients completed the trial. Hesperidin decreased depression severity after 12 weeks, as compared to placebo (p = .004), but serum BDNF and cortisol were not statistically significantly different in the two groups after the intervention. Subgroup analyses also showed that, while in the patients with mild depression, the score of BDI-II was significantly different in the hesperidin and placebo groups after intervention; there was no difference in the severity of depression between the two groups in patients with moderate-to-severe depression. To conclude, a dose of 200 mg/day hesperidin may reduce depressive symptoms after 12 weeks in post-CABG patients with mild depression.

Association between the presence of delirium during intensive care unit admission and cognitive impairment or psychiatric problems: the Korean ICU National Data Study

Objective

Delirium in the intensive care unit (ICU) may be a preventable risk factor for cognitive impairment or psychiatric problems. We aimed to evaluate the association between the presence of delirium during hospitalization involving ICU care and post-discharge cognitive impairment or psychiatric problems.

Design

A retrospective cohort study.

Setting

A database of nationwide insurance claims data.

Patients

All adult patients aged 18 years or older who were admitted to an ICU between January 1, 2008, and May 31, 2015, and had no history of previous cognitive impairment or psychiatric problems were included in the study.

Interventions

None.

Measurements and main results

Of 306,011 patients who met the inclusion criteria, the proportion of those who experienced delirium during hospitalization was 55.0% (n = 168,190). The patients with delirium during hospitalization had significantly increased odds for cognitive impairment (adjusted hazard ratio [HR] 1.17; 95% confidence interval [CI] 1.05–1.29) and psychiatric problems (adjusted HR 1.78; 95% CI 1.67–1.90) after discharge compared with patients without delirium. In patients who had delirium, the incidence of cognitive impairment was 210.8 per 1000 person-years. In 19,496 patients who were diagnosed with cognitive impairment, depression (n = 3233, 16.5%), sleep disorder (n = 1791, 9.2%), and anxiety (n = 1683, 8.6%) were commonly co-diagnosed. The most common psychiatric problem was sleep disorder (148.7 per 1000 person-years), followed by depression (133.3 per 1000 person-years).

Conclusions

Among patients received ICU care, those who experienced delirium during hospitalization had an increased risk of developing cognitive impairment or psychiatric problems post-discharge. Many patients showed multiple cognitive impairment and psychiatric problems during the follow-up period. Efforts to decrease these problems should be made to increase the quality of life of these ICU survivors.

Delirium Prevention in Postcardiac Surgical Critical Care

This review provides an overview for health care teams involved in the perioperative care of cardiac surgery patients. The intention is to summarize key determinants of delirium, its impact on short- and long-term outcomes as well as to discuss effective management strategies. The first component of this review examines the prevalence and the factors associated with an increased risk of postoperative delirium. A multitude of predisposing (eg, baseline vulnerability and comorbidities) and precipitating (eg, type of cardiac surgery and postoperative care) factors that contribute to the occurrence of delirium are discussed.

Symptoms of anxiety and depression in surgical patients at the hospital, 6 weeks and 6 months postsurgery: A questionnaire study

Aims

To describe prevalence of symptoms of anxiety and depression in surgical patients at three time points: at hospital postsurgery (T1), 6 weeks (T2) and 6 months (T3) postdischarge from hospital; and detect situations and experiences that predict symptoms of anxiety and depression at T2 and T3.

Design

Prospective, explorative two-site follow-up study.

Methods

Patients having selected surgeries from January-July 2016 were invited to participate. Final participation was 390 patients. Participation involved answering questionnaires, including the Hospital Anxiety and Depression Scale (HADS). A stepwise multiple linear regression model was employed to calculate predictors of anxiety and depression.

Results

The proportion of patients presenting with moderate-to-severe anxiety or depression ranged from 5.4%-20.2% at different times. Major predictors of anxiety at both times were not feeling rested upon awakening and higher scores on HADS-Anxiety at T1 and T2 and at T2 also experiencing more distressing postoperative symptoms. For depression, the major predictors were at both times higher scores on HADS-Depression at T2 and T3 and also at T2 not feeling rested upon awakening and at T3 reporting delayed or very delayed recovery.The four models explained from 43.9%-55.6% of the variance in symptoms of anxiety and depression. Our findings show that patients presenting with psychological distress at the hospital are in a vulnerable position. Also, that benefits of good sleep during the recovery should be emphasized during hospital stay.

Quality of Life Is Improved 1 Year After Cardiac Surgery

BACKGROUND

Quality of life (QoL) is increasingly important in the era of patient-centered outcomes and value-based reimbursement. However most follow-up is limited to 30 days, and long-term data on QoL improvement associated with symptom relief are lacking. Therefore we sought to analyze QoL after cardiac surgery in a nonemergent, all-comers population.

METHODS

Four hundred two patients undergoing routine cardiac surgery at 2 large urban hospitals in the Dallas, Texas area were enrolled. Follow-up was complete for 364 patients. Data were collected from August 2013 to January 2017. The Kansas City Cardiomyopathy Questionnaire was administered at baseline, 1 month, and 1 year after surgery. Repeated-measures analysis was used for each domain of the questionnaire for all procedures and stratified by procedure. If time was found to be a significant factor, pairwise analysis was performed with P values adjusted using the Tukey-Kramer method.

RESULTS

There was a significant increase across all domains of Kansas City Cardiomyopathy Questionnaire scores for all procedures and for most domains when stratifying by procedure. This increase in QoL was most marked after 1 month. All domain scores increased through 1 year except symptom stability, which peaked at 1 month postsurgery and then regressed at 1 year, suggesting an overall improvement and stabilization of symptoms. The occurrence of complications did not alter this trajectory.

CONCLUSIONS

QoL and other patient-centered outcomes are improved at 1 month and continue to improve throughout the year. Knowledge of these data is important for patient selection, fully informed consent, and shared decision-making.

Modelling the effect of minor orthopaedic day surgery on patient mood at the early post-operative period: A prospective population-based cohort study

Objective

The effect of minor orthopaedic day surgery (MiODS) on patient’s mood.

Methods

A prospective population-based cohort study of 148 consecutive patients with age above 18 and less than 65, an American Society of Anaesthesiology (ASA) score of 1, and the requirement of general anaesthesia (GA) were included. The Medical Outcomes Study – Short Form 36 (SF-36), Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) were used pre- and post-operatively.

Results

The mean physical component score of SF-36 before surgery was 45.3 (SD = ±10.1) and 8 weeks following surgery was 44.9 (SD = ±11.04) [n= 148,p= 0.51, 95% CI = (−1.03 to 1.52)]. For the measurement of the changes in mood using BDI, BAI and SF-36, latent construct modelling was employed to increase validity. The covariance between mood pre- and post-operatively (cov = 69.44) corresponded to a correlation coefficient,r= 0.88 indicating that patients suffering a greater number of mood symptoms before surgery continue to have a greater number of symptoms following surgery. When the latent mood constructs were permitted to have different means the model fitted well withχ2(df = 1) = 0.86 for whichp= 0.77, thus the null hypothesis that MiODS has no effect on patient mood was rejected.

Conclusions

MiODS affects patient mood which deteriorates at 8 weeks post-operatively regardless of the pre-operative patient mood state. More importantly patients suffering a greater number of mood symptoms before MiODS continue to have a greater number of symptoms following surgery.

Cholinesterase alterations in delirium after cardiosurgery: a German monocentric prospective study

OBJECTIVES

Postoperative delirium (POD) is a common complication after elective cardiac surgery. Recent evidence indicates that a disruption in the normal activity of the cholinergic system may be associated with delirium.

DESIGN

Prospective observational study.

SETTING

Single-centre at a European academic hospital.

PRIMARY AND SECONDARY OUTCOME MEASURES

In our study the enzyme activities of acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) were determined preoperatively as well as on the first and second postoperative day. The confusion assessment method for the intensive care unit was used to screen patients for the presence of POD.

RESULTS

A total of 114 patients were included in the study. POD was associated with a decrease in BChE activity on postoperative day 1 (p=0.03). In addition, patients who developed POD, had significantly lower preoperative AChE activity than patients without POD (p<0.01). Multivariate analysis identified a preoperatively decreased AChE activity (OR 3.1; 95% CI 1.14 to 8.46), anticholinergic treatment (OR 5.09; 95% CI 1.51 to 17.23), elevated European System for Cardiac Operative Risk Evaluation (OR 3.68; 95% CI 1.04 to 12.99) and age (OR 3.02; 95% CI 1.06 to 8.62) to be independently associated with the development of POD.

CONCLUSIONS

We conclude that a reduction in the acetylcholine hydrolysing enzyme activity in patients undergoing cardiac surgery may correlate with the development of POD.

Post-traumatic Stress Disorder Following Acute Delirium

Delirium is a significant medical condition that is common in hospitalized patients. Beyond the increased risk of mortality, patients who experience an episode of delirium often go on to develop long-term psychiatric disturbance, including symptoms of post-traumatic stress disorder (PTSD). While there is a growing interest in understanding the complex relationship between delirium and PTSD, the existing literature is sparse and lacking harmony. Thus, this review seeks to develop a unified and thorough description of the cognitive and psychiatric underpinnings of post-delirium PTSD with the aims of promoting awareness of this condition amongst clinicians in medical settings, improving patient care, and sparking further research on this topic. While specific underlying mechanisms are yet unclear, PTSD was found to be associated with delirium in that delirious patients may have decreased factual recall of hospital events and increased hallucinations/delusions of a traumatic nature. Several potential interventions were identified, as well as suggestions for future research and clinical practice.

Noncontact Measurement of the Deformation of Sternal Skin During Shoulder Movements and Upper Extremity Activities Restricted by Sternal Precautions

BACKGROUND

Existing variation has been identified in the rehabilitation programs for patients following cardiac surgery. Sternal precautions are believed to be overly restrictive and detrimental to patient recovery both physically and psychologically.

OBJECTIVE

The objective of this study was to determine the deformation of sternal skin during shoulder movements and upper extremity activities using a noncontact approach.

DESIGN

This was a cross-sectional, nonexperimental observational study.

METHODS

Two black dots were marked on participants' skin overlying sternoclavicular joints using an erasable marker. The coordinates of the dots were recorded using a digital camera and obtained using ImageJ, a public domain image processing program. Skin deformation between the 2 dots was quantified as biomechanical strain.

RESULTS

The sternal skin strain was - 15.3% (SD = 5.6) and - 12.0% (SD = 7.0) at 90 and 180 degrees of flexion; 0.0% (SD=0.0) and-12.8% (SD=5.8) at 90 and 180 degrees of abduction; and - 6.4% (SD=2.8), - 8.9% (SD=3.8), and - 9.8% (SD=4.6) when lifting the 0-, 5-, and 10-lb weights, respectively. The sternal skin strain was 7.9% (SD=3.9) for extension to the end range and-2.5% (SD=5.8) for pushing up from a chair. There is a trend of strain magnitude decrease with the increase of rhomboid strength, but no statistically significant association was found between them (R=0.12).

LIMITATIONS

Limitations included convenience sampling, small sample size, and using skin deformation as a proxy for mechanical loading of the bony structures.

CONCLUSIONS

The data do not support the restriction on most of the shoulder movements and upper extremity activities following cardiac surgery. The approach has the advantage of measuring skin deformation in the entire sternal region.

Predictors of post-traumatic stress disorder following critical illness: A mixed methods study

Purpose

Post-traumatic stress disorder has been reported in survivors of critical illness. The aim of this study was to investigate the predictors of post-traumatic stress disorder in survivors of critical illness.

Materials and methods

Patients attending the intensive care unit (ICU) follow-up clinic completed the UK-Post-Traumatic Stress Syndrome 14-Questions Inventory and data was collected from their medical records. Predictors investigated included age, gender, Apache II score, ICU length of stay, pre-illness psychopathology; delirium and benzodiazepine administration during ICU stay and delusional memories of the ICU stay following discharge.

Results

A total of 198 patients participated, with 54 (27%) patients suffering with post-traumatic stress disorder. On multivariable logistic regression, the significant predictors of post-traumatic stress disorder were younger age, lower Apache II score, pre-illness psychopathology and delirium during the ICU stay.

Conclusions

The predictors of post-traumatic stress disorder in this study concur with previous research however a lower Apache II score has not been previously reported.

Incidence and Risk Factors for Intensive Care Unit-related Post-traumatic Stress Disorder in Veterans and Civilians

RATIONALE

The incidence and risk factors of post-traumatic stress disorder (PTSD) related to the intensive care unit (ICU) experience have not been reported in a mixed veteran and civilian cohort.

OBJECTIVES

To describe the incidence and risk factors for ICU-related PTSD in veterans and civilians.

METHODS

This is a prospective, observational, multicenter cohort enrolling adult survivors of critical illness after respiratory failure and/or shock from three Veterans Affairs and one civilian hospital. After classifying those with/without preexisting PTSD (i.e., PTSD before hospitalization), we then assessed all subjects for ICU-related PTSD at 3 and 12 months post hospitalization.

MEASUREMENTS AND MAIN RESULTS

Of 255 survivors, 181 and 160 subjects were assessed for ICU-related PTSD at 3- and 12-month follow-up, respectively. A high probability of ICU-related PTSD was found in up to 10% of patients at either follow-up time point, whether assessed by PTSD Checklist Event-Specific Version (score ≥ 50) or item mapping using the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV). In the multivariable regression, preexisting PTSD was independently associated with ICU-related PTSD at both 3 and 12 months (P < 0.001), as was preexisting depression (P < 0.03), but veteran status was not a consistent independent risk factor for ICU-related PTSD (3-month P = 0.01, 12-month P = 0.48).

CONCLUSIONS

This study found around 1 in 10 ICU survivors experienced ICU-related PTSD (i.e., PTSD anchored to their critical illness) in the year after hospitalization. Preexisting PTSD and depression were strongly associated with ICU-related PTSD.

Long-Term Mental Health Problems After Delirium in the ICU

OBJECTIVES

To determine whether delirium during ICU stay is associated with long-term mental health problems defined as symptoms of anxiety, depression, and posttraumatic stress disorder.

DESIGN

Prospective cohort study.

SETTING

Survey study, 1 year after discharge from a medical-surgical ICU in the Netherlands.

PATIENTS

One-year ICU survivors of an ICU admission lasting more than 48 hours, without a neurologic disorder or other condition that would impede delirium assessment during ICU stay.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One year after discharge, ICU survivors received a survey containing the Hospital Anxiety and Depression Scale with a subscale for symptoms of depression and a subscale for symptoms of anxiety, and the Impact of Event Scale 15 item measuring symptoms of posttraumatic stress disorder. Participants were classified as having experienced no delirium (n = 270; 48%), a single day of delirium (n = 86; 15%), or multiple days of delirium (n = 211; 37%) during ICU stay. Log-binomial regression was used to assess the association between delirium and symptoms of anxiety, depression, and posttraumatic stress disorder. The study population consisted of 567 subjects; of whom 246 subjects (43%) reported symptoms of anxiety (Hospital Anxiety and Depression Scale with a subscale for anxiety, ≥ 8), and 254 (45%) symptoms of depression (Hospital Anxiety and Depression Scale with a subscale for depression, ≥ 8). In 220 patients (39%), the Impact of Event Scale 15 item was greater than or equal to 35, indicating a high probability of posttraumatic stress disorder. There was substantial overlap between these mental health problems-63% of the subjects who scored positive for the presence of any three of the mental health problems, scored positive for all three. No association was observed between either a single day or multiple days of delirium and symptoms of anxiety, depression, or posttraumatic stress disorder.

CONCLUSIONS

Although symptoms of anxiety, depression, and posttraumatic stress disorder were found to be common 1 year after critical illness, the occurrence of delirium during ICU stay did not increase the risk of these long-term mental health problems.

Independent Predictors of the Duration and Overall Burden of Postoperative Delirium After Cardiac Surgery in Adults: An Observational Cohort Study

OBJECTIVE

Postoperative delirium (POD) is a common complication after cardiac surgery and is associated with increased patient morbidity and mortality. The objective of this study was to identify risk factors for long duration and overall burden of POD after cardiac surgery.

DESIGN

One-year, single-center, retrospective, observational cohort study.

SETTING

University hospital.

PARTICIPANTS

Adult patients undergoing cardiac surgery with cardiopulmonary bypass in 2013.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were screened for POD using the Intensive Care Delirium Screening Checklist. The primary outcome measure was the incidence of POD. Secondary outcome measures were the duration of POD and the area under the curve determined using the Intensive Care Delirium Screening Checklist score over time. Independent predictors of POD were estimated in multivariable logistic regression models. Hospital length of stay, medications, and outcome data also were analyzed. Among the 656 patients included in the cohort, 618 were analyzed. The overall incidence of POD was 39%. Older patient age (odds ratio [95% confidence interval]) 1.06 [1.04-1.09] for an increase of 1 year, p < 0.001); low preoperative serum albumin (1.08 [1.03-1.13] for a decrease of 1 g/L, p < 0.001); a history of atrial fibrillation (2.30 [1.30-4.09], p = 0.004); perioperative stroke (6.27 [1.54-43.64], p = 0.008); ascending aortic replacement surgery (2.99 [1.50-6.05], p = 0.002); longer duration of procedure (1.37 [1.16-1.63] for an increase of 1 hour, p < 0.001); and increased postoperative C-reactive protein concentration (2.16 [1.49-3.16] for a 2-fold increase, p < 0.001) were associated with higher odds of POD. Among patients affected by POD, older age, perioperative stroke, longer procedure time, and increased postoperative C-reactive protein were consistently predictive of longer duration of POD and greater area under the curve.

CONCLUSIONS

Known risk factors for the development of POD after cardiac surgery also are predictive of prolonged duration and high overall burden of POD.

Neurologic complications of cardiac and vascular surgery

This chapter will provide an overview of the major neurologic complications of common cardiac and vascular surgeries, such as coronary artery bypass grafting and carotid endarterectomy. Neurologic complications after cardiac and vascular surgeries can cause significant morbidity and mortality, which can negate the beneficial effects of the intervention. Some of the complications to be discussed include ischemic and hemorrhagic stroke, seizures, delirium, cognitive dysfunction, cerebral hyperperfusion syndrome, cranial nerve injuries, and peripheral neuropathies. The severity of these complications can range from mild to lethal. The etiology of complications can include a variety of mechanisms, which can differ based on the type of cardiac or vascular surgery that is performed. Our knowledge about neuropathology, prevention, and management of surgical complications is growing and will be discussed in this chapter. It is imperative for clinicians to be familiar with these complications in order to narrow the differential diagnosis, start early management, anticipate the natural history, and improve outcomes.

The effect of education based on the main concepts of logotherapy approach on the quality of life in patients after coronary artery bypass grafting surgery

Background:

Improving the patients’ quality of life (QOL) after coronary artery bypass grafting (CABG) is one of the main concerns of the treatment team. Educational interventions may affect the aspects of QOL in various ways. The present study aimed to investigate the effect of education based on the main concepts of logotherapy approach on the CABG patients’ quality of life.

Materials and Methods:

In this quasi-experimental study, a convenient sample of 67 patients who had undergone CABG in Isfahan Chamran hospital were randomly allocated to two groups of experimental (n = 35) and control (n = 32). While the control group received routine care, the experiment group benefitted from logotherapy-based education program (six 90-min sessions, twice a week). SF-36 questionnaire was completed by both two groups (before and 1 month after intervention). Descriptive and inferential statistical tests (consisting of independent t-test) were employed to analyze data in SPSS version 13.

Results:

The pre-test mean total score of SF-36 questionnaire and also the mean scores of its eight dimensions were not significantly different between the two groups. The post-test mean score change [Standard Error (SE)] in the intervention group was 24.95 (3) and in the control group was 9.27 (0.82). There were significant differences between the two groups (P < 0.001). Moreover, the mean scores of six dimensions of QOL (vitality, bodily pain, general health, emotional role, social functioning, and mental health) changed significantly in the intervention group.

Conclusions:

Our findings indicated that the intervention has improved the patients’ QOL after CABG. Integration of such an intervention in these patients’ rehabilitation programs is recommended.

Ten Years Experiences With Preoperative Evaluation Clinic for Day Admission Cardiac and Major Vascular Surgical Patients: Model for "Perioperative Anesthesia and Surgical Home"

Admission on the day of surgery for elective cardiac and noncardiac surgery is the prevalent practice in North America and Canada. This approach realizes medical, psychological and logistical benefits, and its success is predicated on an effective outpatient preoperative evaluation. The establishment of a highly functional preoperative clinic with a comprehensive set up and efficient logistical pathways is invaluable. This notion in recent years has included the entire perioperative period, and the concept of a perioperative anesthesia/surgical home (PASH) is gaining popularity. The anesthesiologists as perioperative physicians can organize and lead the entire process from the preoperative evaluation, through the hosptial discharge. The functions of the PASH include preoperative optimization of medical conditions and psychological preparation of the patients and their support system; the care in the operating room and intensive care unit; pain management; respiratory therapy; cardiac rehabilitation; and specialized nutrition. Along with oversight of the medical issues, the preoperative visit is an opportune time for counseling, clarification of expectations and discussion of research, as well as for utilization of various informatics systems to consolidate the pertinent information and distribute it to relevant health care providers. We review the scientific foundation and practical applications of a preoperative visit and share our experience with the development of the preoperative evaluation clinic, designed specifically for cardiac and major vascular patients scheduled for day admission surgery. The ultimate goal of preoperative evaluation clinic is to ensure a safe, efficient, and cost-effective perioperative care for patients undergoing a complex type of surgery.

Depressive Symptoms Before, During, and After Delirium: A Literature Review

BACKGROUND

Delirium and depression are often thought of as mutually exclusive conditions. However, several studies cite depression as a risk factor for delirium whereas others note that patients with delirium often manifest depressive symptoms. Whether these depressive symptoms persist after delirium resolves remains unclear.

OBJECTIVES

This article reviews published studies that have investigated the relationship between depression and delirium.

METHODS

Literature searches on PubMed, CINAHL, Cochrane Library, and PsycInfo were conducted using search criteria "delirium" AND "depress⁎" as keywords or MeSH terms.

RESULTS

Of 722 search results, 10 prospective cohort studies were identified for inclusion. These studies were categorized regarding the time of assessment for depressive symptoms. Included studies varied greatly (regarding their index population, their methods of assessment, and their timing of assessments). Of the studies, 3 involved patients undergoing hip fracture repair. They demonstrated more severe depressive symptoms both during delirium and after delirium ended. Conversely, the other studies did not find any statistically significant correlations between the 2 conditions.

CONCLUSIONS

The literature suggests a correlation between depression and delirium in patients with hip fracture. Whether other specific populations have higher comorbidity is unclear. Unfortunately, studies varied widely in their methods, precluding a meta-analysis. Nonetheless, our review provides a foundation for future research.

Preexisting cognitive status is associated with reduced behavioral functional capacity in patients 3 months after cardiac surgery: an extension study

OBJECTIVE

To examine whether preexisting cognitive status rather than short- and middle-term postoperative cognitive decline (POCD) may differentially account for behavioral functional capacity 3 months after cardiac surgery.

METHOD

Seventy-nine patients completed a psychological evaluation, including the Trail Making Test Part B, the memory with 10-s interference, the phonemic fluency and the Instrumental Activities of Daily Living (IADLs) questionnaire for cognitive functions and behavioral functional capacity, respectively, before surgery, at discharge and at 3-month follow-up.

RESULTS

Thirty-one (39%) and 22 (28%) patients showed POCD at discharge and at 3-month follow-up, respectively. Preoperative cognitive status was significantly associated with change in behavioral functional capacity 3 months after surgery (Ps<.003), whereas short- and middle-term POCD and intraoperative risk factors were unrelated to residualized change in IADLs scores (all Ps>.095).

CONCLUSIONS

Preexisting cognitive deficit, especially working memory deficit, rather than short- and middle-term POCD related to intraoperative risk factors is associated with poor behavioral functional capacity 3 months after cardiac surgery. The present study therefore suggests that a preoperative cognitive evaluation is essential to anticipate which patients are likely to show a decline in behavioral functional capacity after cardiac surgery.

Hospitalization and cognitive decline: Can the nature of the relationship be deciphered?

BACKGROUND

Evidence for a relationship between hospitalization and incident cognitive decline exists mainly in the literature focusing on critical care hospitalization. Recent studies, however, have also found an association between noncritical care hospitalization and the development of cognitive decline.

OBJECTIVE

This article will review the literature pertaining to hospitalization and cognitive decline, including hospitalizations for both critical and noncritical care, and in medical and surgical patients. The article will also explore the various factors that have been implicated in the development of cognitive decline and dementia.

METHODS

Review of the literature was completed using PubMed and Medline search programs.

RESULTS

Several articles supporting evidence for the association between hospitalization and cognitive decline are available. Evidence for potential mediating factors also does exist.

CONCLUSIONS

There is evidence to support an association between hospitalization and development of cognitive decline. Factors that could mediate this association include, but may not be limited to, delirium, medications, stress, and depression. There is a need for further research in this area in order to better understand the underlying pathophysiology involved in the development of cognitive decline and dementia and to determine if preventive measures might be beneficial in decreasing risk for cognitive decline for patients who are hospitalized.

A mixed-methods pilot study of the acceptability and effectiveness of a brief meditation and mindfulness intervention for people with diabetes and coronary heart disease

Mindfulness-based interventions can successfully target negative perseverative cognitions such as worry and thought suppression, but their acceptability and effectiveness in people with long-term conditions is uncertain. We therefore pilot tested a six-week meditation and mindfulness intervention in people (n = 40) with diabetes mellitus and coronary heart disease. We used a sequential mixed-methods approach that measured change in worry and thought suppression and qualitatively explored acceptability, feasibility, and user experience with a focus group (n = 11) and in-depth interviews (n = 16). The intervention was highly acceptable, with 90% completing ≥5 sessions. Meditation and mindfulness skills led to improved sleep, greater relaxation, and more-accepting approaches to illness and illness experience. At the end of the six-week meditation course, worry, and thought suppression were significantly reduced. Positive impacts of mindfulness-based interventions on psychological health may relate to acquisition and development of meta-cognitive skills but this needs experimental confirmation.

Perioperative psycho-educational intervention can reduce postoperative delirium in patients after cardiac surgery: a pilot study

OBJECTIVE

Postoperative delirium after cardiac surgery is associated with many consequences such as poorer functional recovery, more frequent postoperative complications, higher mortality, increased length of hospital stay, and higher hospital costs. The aim of this study was to evaluate the efficacy of perioperative psycho-educational intervention in preventing postoperative delirium in post cardiac surgery patients.

METHOD

We conducted a comparative retrospective study between 49 patients who had received perioperative psycho-educational intervention and 46 patients who had received standard care. The primary outcome was the incidence of postoperative delirium. Secondary outcomes included length of ICU stay, and severity and duration of postoperative delirium among the patients who had developed delirium.

RESULTS

The incidence of postoperative delirium was significantly lower in the intervention group than that in the control group (12.24% vs. 34.78%, P = 0.009). Among the patients who had developed postoperative delirium, there was no statistical difference between the two groups regarding secondary outcomes.

CONCLUSIONS

Our results show that the patients who received perioperative psycho-educational intervention were associated with a lower incidence of postoperative delirium after cardiac surgery than those who received standard care. Clinicians would be able to implement this psycho-educational intervention as part of routine practice to reduce delirium.

Perioperative delirium and its relationship to dementia

A number of serious clinical cognitive syndromes occur following surgery and anesthesia. Postoperative delirium is a behavioral syndrome that occurs in the perioperative period. It is diagnosed through observation and characterized by a fluctuating loss of orientation and confusion. A distinct syndrome that requires formalized neurocognitive testing is frequently referred to as postoperative cognitive dysfunction (POCD). There are serious concerns as to whether either postoperative delirium or postoperative cognitive dysfunction leads to dementia. These concerns are reviewed in this article.

Myocardial revascularization for the elderly: current options, role of off-pump coronary artery bypass grafting and outcomes

The increase in life expectancy has confronted cardiac surgery with a rapidly growing population of elderly patients requiring surgical myocardial revascularization. Recent advances in surgical and anesthetic techniques and improvements in postoperative care have made coronary artery bypass grafting an established therapeutic option for the treatment of coronary artery disease in this group of patients. However, conventional coronary artery bypass grafting on cardiopulmonary bypass is associated with significant risk and related morbidity and mortality in the elderly. In recent years off-pump coronary artery bypass grafting has emerged as a safe and less invasive strategy for surgical myocardial revascularization. Off-pump coronary artery bypass grafting by avoiding the deleterious effects of cardiopulmonary bypass can offer potential benefits to elderly patients requiring surgical myocardial revascularization. This review article provides an overview of the age-related cardiovascular changes, epidemiology of coronary artery disease in the elderly and focuses on outcomes of surgical myocardial revascularization with special emphasis on the impact of off-pump coro-nary artery bypass surgery in the elderly.

Incidence and causes of postoperative delirium in patients with esophageal cancer

AIM: To investigate the incidence and causes of postoperative delirium in patients with esophageal cancer.

METHODS: We conducted a retrospective cohort analysis of 124 patients who had undergone an esophagectomy at Tianjin Medical University General Hospital from January 2010 to December 2012. All quantitative data and all qualitative data were analyzed using Student's t test and Chi-square test, respectively.

RESULTS: Postoperative delirium developed in 60 (48.4%) of 124 patients. Elder age (P = 0.007), history of mental illness (P = 0.0001), longer period of time under mechanical ventilation after surgery (P = 0.0001), longer ICU stay after surgery (P = 0.0001), longer period of prohibiting drinking and eating from mouth after surgery (P = 0.0001), and occurrence of postoperative complications (P = 0.002) were significantly associated with the development of postoperative delirium.

CONCLUSION: The development of postoperative delirium in patients with esophageal cancer is a problem that should not be ignored. Causes of postoperative delirium include elder age, history of mental illness, longer periods of time under mechanical ventilation after surgery, longer postoperative ICU stays, longer periods of prohibiting drinking and eating from mouth after surgery, and occurrence of postoperative complications.

Treatment of delirium following cardiac surgery

Postoperative delirium is a common medical complication following cardiac surgery. This paper will outline the treatment options for delirium with a focus on prophylactic use of risperidone before cardiac surgery.

Association of pre-operative brain pathology with post-operative delirium in a cohort of non-small cell lung cancer patients undergoing surgical resection

OBJECTIVE

Post-operative delirium is associated with pre-operative cognitive difficulties and diminished functional independence, both of which suggest that brain pathology may be present in affected individuals prior to surgery. Currently, there are few studies that have examined imaging correlates of post-operative delirium. To our knowledge, none have examined the association of delirium with existing structural pathology in pre-operative cancer patients. Here, we present a novel, retrospective strategy to assess pre-operative structural brain pathology and its association with post-operative delirium. Standard of care structural magnetic resonance imaging (MRIs) from a cohort of surgical candidates prior to surgery were analyzed for white matter hyperintensities and cerebral atrophy.

METHODS

We identified 23 non-small cell lung cancer patients with no evidence of metastases in the brain pre-operatively, through retrospective chart review, who met criteria for post-operative delirium within 4 days of surgery. 24 age- and gender-matched control subjects were identified for comparison to the delirium sample. T1 and fluid-attenuated inversion recovery sequences were collected from standard of care pre-operative MRI screening and assessed for white matter pathology and atrophy.

RESULTS

We found significant differences in white matter pathology between groups with the delirium group exhibiting significantly greater white matter pathology than the non-delirium group. Measure of cerebral atrophy demonstrated no significant difference between the delirium and non-delirium group.

CONCLUSIONS

In this preliminary study utilizing standard of care pre-operative brain MRIs for assessment of structural risk factors to delirium, we found white matter pathology to be a significant risk factor in post-operative delirium. Limitations and implications for further investigation are discussed.

Change in behavioral functional capacity is associated with preexisting cognitive function rather than with cognitive decline in patients 1 year after cardiac surgery

OBJECTIVE

The objective was to examine whether preexisting cognitive function rather than cognitive decline associated with intraoperative procedures may predict change in behavioral functional capacity in patients 1 year after cardiac surgery.

METHOD

Forty-five patients completed a cognitive evaluation, including the Trail Making Test part B (TMT-B) for attention and psychomotor speed, the Memory with 10-s interference for working memory, the Digit Span test for short-term memory and the Instrumental Activities of Daily Living (IADLs) questionnaire for behavioral functional capacity, before surgery and 1 year after cardiac surgery.

RESULTS

Sixteen patients (36%) exhibited cognitive decline after cardiac surgery. Preoperative scores on TMT-B significantly predicted change in behavioral functional capacity as measured by IADLs (beta = 0.371, P < .05), whereas the postoperative cognitive decline and intraoperative variables were unrelated to residualized change scores in IADLs (all Ps > .08).

CONCLUSIONS

Preexisting cognitive dysfunctions as assessed by TMT-B can be a marker of preoperative brain dysfunction, which, in turn, in addition to brain damage caused by cardiac surgery procedures, may further predispose patients to poor behavioral functional capacity and outcome 1 year after surgery. Impaired cognitive functions before surgery should be considered when evaluating the effects of cardiac surgery procedures on long-term behavioral functional status of patients.

The assessment of neural injury following open heart surgery by physiological tremor analysis

INTRODUCTION

The appearance of post-operative cognitive dysfunction as a result of open heart surgery has been proven by several studies. Focal and/or sporadic neuron damage emerging in the central nervous system may not only appear as cognitive dysfunction, but might strongly influence features of physiological tremor.

MATERIAL AND METHODS

We investigated 110 patients (age: 34-73 years; 76 male, 34 female; 51 coronary artery bypass grafting (CABG), 25 valve replacement, 25 combined open heart surgery, 9 off-pump CABG) before surgery and after open-heart surgery on the 3(rd) to 5(th) post-operative day. The assessment of the physiological tremor analysis was performed with our newly developed equipment based on the Analog Devices ADXL 320 JPC integrated accelerometer chip. Recordings were stored on a PC and spectral analysis was performed by fast Fourier transformation (FFT). We compared power integrals in the 1-4 Hz, 4-8 Hz and 8-12 Hz frequency ranges and these were statistically assessed by the Wilcoxon rank correlation test.

RESULTS

We found significant changes in the power spectrum of physiological tremor. The spectrum in the 8-12 Hz range (neuronal oscillation) decreased and a shift was recognised to the lower spectrum (p < 0.01). The magnitude of the shift was not significantly higher for females than for males (p < 0.157). We found no significant difference between the shift and the cross-clamp or perfusion time (p < 0.6450).

CONCLUSIONS

The assessment of physiological tremor by means of our novel, feasible method may provide a deeper insight into the mechanism of central nervous system damage associated with open heart surgery.

The impact of intra- and postoperative albumin levels as a biomarker of delirium after cardiopulmonary bypass: results of an exploratory study

In this prospective study the frequency of delirium after cardiac surgery with cardiopulmonary bypass (CPB) was determined. Furthermore, we investigated the impact of intra- and postoperative levels of albumin as a biomarker of delirium. Thirty-four patients who underwent elective CPB at the Department of Cardiac Surgery, Ludwig-Maximilians-University of Munich, Germany, were enroled in this prospective study. During the intensive care unit (ICU) stay and shortly after discharge from the ICU, delirious state was evaluated daily using the Delirium-Rating-Scale. Albumin was assayed pre-anaesthesia, immediately after induction of anaesthesia, at the beginning of the heart-lung-apparatus period, immediately before the opening and 5min after the opening of the aortic clamp, 24h and 48h postoperatively and on the day before discharge. After CPB, a clinical significant delirious state was observed in 11 patients (32.4%). The albumin level decreased during the surgical intervention and increased postoperatively with a maximum level at the time of discharge. CPB patients with delirious state showed a significantly lower albumin level 24h and 48h postoperatively than those without delirium. A low level of postoperative albumin seems to be a useful biomarker to identify patients with high risk of delirious state after CPB.

Depression, anxiety, and cardiac morbidity outcomes after coronary artery bypass surgery: a contemporary and practical review

Research to date indicates that the number of coronary artery bypass graft (CABG) surgery patients affected by depression (i.e., major, minor, dysthymia) approximates between 30% and 40% of all cases. A longstanding empirical interest on psychosocial factors in CABG surgery patients highlights an association with increased risk of morbidity in the short and longer term. Recent evidence suggests that both depression and anxiety increase the risk for mortality and morbidity after CABG surgery independent of medical factors, although the behavioral and biological mechanisms are poorly understood. Though neither depression nor anxiety seem to markedly affect neuropsychological dysfunction, depression confers a risk for incident delirium. Following a comprehensive overview of recent literature, practical advice is described for clinicians taking into consideration possible screening aids to improve recognition of anxiety and depression among CABG surgery patients. An overview of contemporary interventions and randomized, controlled trials are described, along with suggestions for future CABG surgery research.

Incidence and risk factors of postoperative delirium in patients with esophageal cancer

BACKGROUND

Postoperative delirium is a common complication after major surgery and is characterized by acute confusion with fluctuating consciousness. The aim of this study was to investigate the incidence and risk factors of postoperative delirium in patients with esophageal cancer.

METHODS

We conducted a retrospective cohort analysis of 306 consecutive patients who had undergone an esophagectomy at Keio University Hospital from January 1998 to December 2009. All data were assessed by psychiatrists, and delirium was diagnosed according to criteria of the Diagnostic and Statistical Manual Disorder, fourth edition. Univariate and multivariate analyses were performed.

RESULTS

Postoperative delirium developed in 153 (50.0 %) of 306 patients. One hundred fourteen (37.3 %) of the 306 patients required psychoactive medication for symptoms associated with delirium. Univariate analyses showed that older age, male gender, additional flunitrazepam for sedation in intensive care unit (ICU) after surgery, longer periods of time under mechanical ventilation after surgery, longer ICU stays, occurrence of postoperative complications, and longer hospital stays were significantly associated with postoperative delirium. Multivariate analysis revealed that development of delirium was linked to older age, additional flunitrazepam in ICU, and occurrence of postoperative complication.

CONCLUSIONS

The development of postoperative delirium in patients with esophageal cancer is a problem that cannot be ignored. Our results suggest that the risk of developing delirium is associated with older age, use of flunitrazepam in ICU, and postoperative complications.

Can cardiac surgery cause hypopituitarism?

Apoplexy of pituitary adenomas with subsequent hypopituitarism is a rare but well recognized complication following cardiac surgery. The nature of cardiac on-pump surgery provides a risk of damage to the pituitary because the vascular supply of the pituitary is not included in the cerebral autoregulation. Thus, pituitary tissue may exhibit an increased susceptibility to hypoperfusion, ischemia or intraoperative embolism. After on-pump procedures, patients often present with physical and psychosocial impairments which resemble symptoms of hypopituitarism. Therefore, we analyzed whether on-pump cardiac surgery may cause pituitary dysfunction also in the absence of pre-existing pituitary disease. Twenty-five patients were examined 3-12 months after on-pump cardiac surgery. Basal hormone levels for all four anterior pituitary hormone axes were measured and a short synacthen test and a growth hormone releasing hormone plus arginine (GHRH-ARG)-test were performed. Quality of life (QoL), depression, subjective distress for a specific life event, sleep quality and fatigue were assessed by means of self-rating questionnaires. Hormonal alterations were only slight and no signs of anterior hypopituitarism were found except for an insufficient growth hormone rise in two overweight patients in the GHRH-ARG-test. Psychosocial impairment was pronounced, including symptoms of moderate to severe depression in 9, reduced mental QoL in 8, dysfunctional coping in 6 and pronounced sleep disturbances in 16 patients. Hormone levels did not correlate with psychosocial impairment. On-pump cardiac surgery did not cause relevant hypopituitarism in our sample of patients and does not serve to explain the psychosocial symptoms of these patients.

[Preoperative mood disorders in patients undergoing cardiac surgery: risk factors and postoperative morbidity in the intensive care unit]

INTRODUCTION AND OBJECTIVES

To estimate the preoperative levels of anxiety and depression in patients awaiting heart surgery and to identify the risk factors associated with the development of these mood disorders. To evaluate the relationship between preoperative anxiety and depression and postoperative morbidity.

METHODS

Prospective longitudinal study in a sample of 100 patients undergoing heart surgery. We carried out a preoperative structured interview in which the patient completed the Hospital Anxiety and Depression Scale, and sociodemographic (age, sex, marital status, and income) and surgical variables (surgical risk, type of surgery, length of preoperative hospital stay, and surgical history) were also recorded. Pain, analgesic use, and postoperative morbidity were evaluated in the intensive care unit.

RESULTS

Thirty-two percent of the patients developed preoperative anxiety and 19%, depression. Age < 65 years (odds ratio=3.05; 95% confidence interval, 1.27-7.3) was the only significant risk factor for developing preoperative anxiety. A length of preoperative hospital stay ≥ 3 days was the main risk factor for preoperative depression (odds ratio=4.59; 95% confidence interval, 1.6-13.17). Preoperative anxiety significantly increased the postoperative pain and analgesic consumption. Neither anxiety nor depression significantly modified the rest of the postoperative variables associated with morbidity in the intesive care unit.

CONCLUSIONS

Anxiety and depression are mood disorders that are detected in patients awaiting heart surgery, with age <65 years and a prolonged preoperative hospital stay being decisive factors in the development of these conditions. Although preoperative anxiety increased the postoperative pain in these patients, their state of mind did not modify their postoperative course.

[Emotional status, cognitive performance and quality of life in HIV-infected patients. Results of an exploratory study]

BACKGROUND

Due to the change of HIV disease from an acute life-threatening disease to a chronic infection, it is more psychosocial rather than therapeutic aspects that have become of interest in scientific investigations. The purpose of this exploratory study was to evaluate emotional distress, health-related quality of life (HRQoL) and cognitive performance. The diagnosis of HIV was considered a life event that may lead to post-traumatic stress syndrome.

METHOD

We recruited 37 HIV-positive outpatients and assessed the frequency of depressive (BDI) and post-traumatic stress symptoms (PTSS) due to the diagnosis of HIV (IES), HRQoL (SF-36) and cognitive performance (SKT). Further, the new diagnostic concept of adjustment disorder as a stress response syndrome according to Maercker was considered.

RESULTS

Of the 37 Patients, 67.6% (n=25) of the sample had a post-traumatic stress syndrome. The HIV-related PTSS was considered adjustment disorder using the concept proposed by Maercker. Fourteen patients (37.8%) suffered from a depressive syndrome, and 27% (n=10) showed cognitive deficits (minimal: n=8; mild: n=1; moderate: n =1). HIV-positive patients with PTSS had significantly unfavourable values in the SF-36 domains general health (p=0.003), vitality (p=0.007), social functioning (p=0.000), role-emotional (p=0.016) and mental health (p=0.000).

CONCLUSION

HIV-infected patients may face a major risk of HIV-related PTSS in the sense of adjustment disorder according to Maercker, depression and cognitive dysfunction. The presence of emotional distress is associated with impairments in quality of life. We therefore suggest an early and comprehensive bio-psycho-social assessment and therapy of HIV-infected patients.

Preoperative depression is a risk factor for postoperative short-term and long-term cognitive dysfunction in patients with diabetes mellitus

PURPOSE

To identify whether the presence of preoperative depression in patients with diabetes mellitus is a risk factor for postoperative cognitive dysfunction after coronary artery bypass graft (CABG) surgery.

METHODS

Data from 90 patients with diabetes mellitus undergoing elective CABG were analyzed. Hemodynamic data (arterial and jugular venous blood gas values) were measured during cardiopulmonary bypass. Preoperatively, all patients were given the 21-item Beck depression inventory to identify the presence of depression. In addition, all patients underwent a battery of neurological and neuropsychological tests the day before surgery, 7 days after surgery, and 6 months after surgery.

RESULTS

The rate of cognitive dysfunction was 50% at 7 days and 23% at 6 months after surgery. Age, hypertension, presence of depression, duration of SjvO(2) ≤ 50%, ascending aorta atherosclerosis, diabetic retinopathy, and insulin therapy were independent predictors of short-term cognitive dysfunction, whereas HbA1c, diabetic retinopathy, insulin therapy, and presence of depression were independent predictors of long-term cognitive dysfunction.

CONCLUSIONS

We found that the presence of depression preoperatively is associated with short-term and long-term postoperative cognitive dysfunction in patients with diabetes mellitus.