Background The neuropsychological consequences of exposure to environmental hypobaric hypoxia (EHH) remain unclear. We thus investigated them in a large group of healthy volunteers who trekked to Mount Everest base camp (5,300 m). Methods A neuropsychological (NP) test battery assessing memory, language, attention, and executive function was administered to 198 participants (age 44.5±13.7 years; 60% male). These were studied at baseline (sea level), 3,500 m (Namche Bazaar), 5,300 m (Everest Base Camp) and on return to 1,300 m (Kathmandu) (attrition rate 23.7%). A comparable control group (n = 25; age 44.5±14.1 years; 60% male) for comparison with trekkers was tested at/or near sea level over an equivalent timeframe so as to account for learning effects associated with repeat testing. The Reliable Change Index (RCI) was used to calculate changes in cognition and neuropsychological function during and after exposure to EHH relative to controls. Results Overall, attention, verbal ability and executive function declined in those exposed to EHH when the performance of the control group was taken into account (RCI .05 to -.95) with decline persisting at descent. Memory and psychomotor function showed decline at highest ascent only (RCI -.08 to -.56). However, there was inter-individual variability in response: whilst NP performance declined in most, this improved in some trekkers. Cognitive decline was greater amongst older people (r = .42; p < .0001), but was otherwise not consistently associated with socio-demographic, mood, or physiological variables. Conclusions After correcting for learning effects, attention, verbal abilities and executive functioning declined with exposure to EHH. There was considerable individual variability in the response of brain function to sustained hypoxia with some participants not showing any effects of hypoxia. This might have implications for those facing sustained hypoxia as a result of any disease.

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.

Background: 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.Method: One hundred and fifty-five patients newly diagnosed with breast cancer were assessed after surgery. Several aspects of religiousness/spirituality in relation to anxiety and depression were examined: religiosity/spirituality, strength of faith, belief in God, private and public practices, spiritual involvement, perceived spiritual support and positive and negative religious coping strategies. Non-religious coping, social support and optimism were also assessed.Results: 'Feeling punished and abandoned by God' significantly explained 5% of the variance in increased levels of anxiety but was partially mediated by denial coping. It was also partially mediated by acceptance coping, lowering levels of anxiety. Feeling punished and abandoned by God was a significant independent predictor of depressed mood, explaining 4% of the variance.Conclusion: Using religious/spiritual resources in the coping process during the early stages of breast cancer may play an important role in the adjustment process in patients with breast cancer. Patients may benefit from having their spiritual needs addressed as experiencing some form of religious/spiritual struggle may serve as a barrier to illness adjustment. Implications for research and clinical practices are discussed. Copyright (C) 2012 John Wiley & Sons, Ltd.

With the advent of improved medical and surgical care in congenital heart disease, there has been an increase in the number of patients who survive into adulthood, giving rise to a new patient population 'Adults with congenital heart disease'. In the past, morbidity and mortality were the primary concerns for this group. However, with improvements in outcome attention has shifted to other factors such as psychosocial and cognitive functioning. This paper reviews the literature on the cognitive functioning in adult congenital heart disease patients. A total of five relevant articles were retrieved via electronic searches of six databases, including MEDLINE, EMBASE, CINAHL, AMED, PsychINFO, and PubMed. The results displayed a consensus on the presence of some cognitive difficulties in adult congenital heart disease patients. The aetiology of cognitive dysfunctions appears to be multifactorial. The literature is limited by the very small number of studies looking at adults with congenital heart disease, with the majority focusing on cognitive functioning among children with congenital heart disease. However, the presence of cognitive dysfunctions and the resulting impact on the patient's day to day lives warrant for a more detailed and prospective research to enhance the understanding of its aetiology and impact.

CONTEXT:Previous research has shown that most patients are satisfied with their anaesthetic care. For those who are not the causes may be multifactorial including dissatisfaction with surgical outcomes.OBJECTIVES:We aimed to identify whether quality of recovery after anaesthesia and surgery measured in multiple domains affects patient satisfaction.DESIGN:Sub-group analysis of previously published observational cohort study of quality of recovery after surgery (using the Postoperative Quality of Recovery Scale) was used to identify predictors of incomplete satisfaction 3 days after surgery.SETTING:Multicentre perioperative surgery.PATIENTS:Patients ≥6 years old, undergoing a variety of operation types and all receiving general anaesthesia.OBSERVATIONS:Of 701 patients, 573 completed the satisfaction question on day 3. Satisfaction was rated by a single five-point rating question. Patients were divided into two groups: 477 (83%) were completely satisfied and 96 (17%) were not completely satisfied. Multivariable logistic regression analysis was performed on preoperative and patient characteristics and recovery in five domains as follows: physiological, nociceptive (pain and nausea), emotive (anxiety and depression), activities of daily living and cognition. Recovery was defined as return to baseline values or better for all questions within each domain.RESULTS:Incomplete satisfaction was predicted by persistent pain or nausea at day 3 [OR 8.2 (95% CI 2.5 to 27), P<0.01] and incomplete satisfaction at day 1 [OR 28 (95% CI 10 to 77), P<0.01]. Paradoxically, incomplete satisfaction was less likely to occur if pain or nausea was present 15 min after surgery [OR 0.34 (95% CI 0.11 to 0.99), P<0.05] or at day 1 [OR 0.30 (95% CI 0.10 to 0.91), P=0.03]. Incomplete recovery in the other domains did not influence satisfaction.CONCLUSION:Of the recovery domains measured using the Postoperative Quality of Recovery Scale, only nociception (pain or nausea) contributed to incomplete satisfaction.

We aimed to measure cerebral microemboli load during total hip [THA] and knee arthroplasty (TKA) using transcranial Doppler ultrasound (TCD) and to investigate whether cerebral embolic load influences neuropsychiatric outcome. The timing of the microemboli was also related to certain surgical activities to determine if a specific relationship exists and the presence of a patent foramen ovale was investigated. Patients undergoing primary THA and TKA underwent a battery of ten neuropsychiatric tests pre-operatively and at 6 weeks and 6 months post-operatively. Microembolic load was recorded using TCD onto VHS tape for subsequent analysis. Patent foramen ovale detection was performed using bolus intravenous injection of agitated saline followed by valsalva manoeuvre. The timing of specific surgical steps was recorded for each operation and embolic load calculated for that period. All patients were assessed for quality of life and orthopaedic outcome measures. Results 45 THA patients and 50 TKA patients were studied. Cerebral microembolisation occurred in 35% of all patients (10 THA patients and 19 TKA patients). Mean microembolic load was 2.8 per patient for THA and 3.76 per patient for TKA patients. PFO was detected in 29 patients overall. Insertion of the femoral component and deflation of the tourniquet were associated with a larger microembolic loads. Neuropsychiatric outcome was not affected by the low embolic loads. Quality of life and Orthopaedic outcome at 6 months was good. Conclusion Cerebral microembolisation occurs in a significant proportion of patients during total hip and knee arthroplasty. The presence of a patent foramen ovale does not appear to influence the incidence of microembolisation or load. Specific surgical activities are associated with generating greater embolic loads and methods of avoiding these emboli such as venting the femur may minimise complications and optimise outcomes. Neuropsychiatric outcomes do not seem to be affected by microembolisation of the brain during total joint arthroplasty.

Little is known on long-term outcomes in kidney transplantation. This study evaluated changes and predictors of generic and transplantation-specific health-related quality of life (HQoL) over six years inN=102kidney transplant survivors using the Short-form Health Survey-36 and the Transplant Effects questionnaire. Mixed models analysis was used to determine long-term outcomes. Emotional HQoL improved over time: Mental Component score, Mental Health, Energy (Ps=.000). Physical HQoL deteriorated: Physical Component Score (P=.001), Pain (P=.002). LRD transplant recipients had greater decline in physical functioning (P=.003) and PCS (P=.000) compared to cadaver recipients. Worry about the transplant (P=.036) and feelings of responsibility (P=.008) increased significantly over time. Worry about the transplant and perceived ability to work predicted 12.7% and 31.1% in variance in MCS and PCS, respectively. Efforts should be made to maintain HQoL and emotional outcomes with ongoing monitoring and support programs throughout the course of posttransplant care.

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.

BACKGROUNDAlthough 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 DESIGNProspective single-cohort study.SETTING & PARTICIPANTS145 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.PREDICTORSCognitive 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 & MEASUREMENTSAll-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.RESULTS98 (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).LIMITATIONSSmall sample size and number of events.CONCLUSIONSCognitive 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.

Background Intraoperative cerebral microembolization occurs in a substantial proportion of patients undergoing THA. Historically, postoperative cognitive dysfunction has been attributed to different factors, including anesthesia, but the influence of the surgery has not been thoroughly examined. Questions/purposes We conducted a prospective, controlled clinical trial to assess intraoperative cerebral microembolization during THA and neuropsychologic outcome. Methods The presence of a patent foramen ovale (PFO) also was investigated, using transcranial Doppler, to determine whether this affected cerebral microembolic incidence and load and whether microemboli occurred as a result of specific surgical activity. Forty-five patients were recruited who underwent THA and neuropsychologic assessment; a battery of tests was administered preoperatively and at 6 weeks and 6 months postoperatively. Results Overall, patients showed improvement in total neuropsychologic change scores at both postoperative intervals. The incidence of cerebral microembolization for THA was 23%. The prevalence of PFO was 37%. PFO did not appear to influence microemboli load or incidence. More microemboli were seen during femoral component insertion and impaction. Conclusions Intraoperative cerebral microembolization occurs in a substantial proportion of patients during THA recorded by transcranial Doppler. The microemboli load is low and is not influenced by the presence of PFO. Certain surgical activities seem responsible for greater cerebral microemboli generation. However, neuropsychologic outcome was not affected postoperatively by microemboli or other operative or patient variables.

This study compared the occurrence of intraoperative microemboli and postoperative changes in neuropsychological performance in 195 patients undergoing coronary artery bypass grafting who were randomized to intermittent crossclamp fibrillation or cardioplegic arrest. Cerebral microemboli were recorded from cannulation to 15 min after decannulation, using transcranial Doppler in 166 patients. Microemboli in relation to 9 surgical events were also noted. Neuropsychological change scores were obtained by comparing cognitive performance preoperatively with that at 6–8 weeks after surgery. The median number of microemboli detected was 105 (range, 9–1,757) in the fibrillation group, and 110 (range, 1–1,306) in the cardioplegia group, with no significant difference between groups. There was also no significant difference between groups in the generation of microemboli during any of the surgical events. Neuropsychological tests were completed postoperatively by 177 participants, with no significant differences in performance found between the 2 groups. Given the equivalence of the effect of intermittent crossclamp fibrillation and cardioplegic arrest on microemboli and neuropsychology, consideration of which form of myocardial protection to employ should perhaps focus more on which method affords most protection to the heart.

Fat embolism during total joint arthroplasty or intramedullary procedures is well documented and is infrequently fatal. Considerable morbidity is associated with fat embolism syndrome, and post operative cognitive dysfunction is frequently seen, yet the exact pathophysiology remains unclear. Intraoperative cerebral microemboli can be detected using transcranial Doppler ultrasound and moreover the presence of a patent foramen ovale (PFO) may be examined for using a validated technique employing this modality. Persistent patent foramen ovale may act as a conduit for embolic material to traverse from the venous to the systemic circulation and consequently affect cerebral function. We wished to 1) investigate the incidence of cerebral microembolisation during primary hybrid total hip arthroplasty and compare this with hip resurfacing, 2) examine the influence of patent foramen ovale on cerebral microembolisation and 3)assess the influence of cerebral microemboli on the outcome of patients undergoing these procedures. We prospectively compared 12 patients undergoing hip resurfacing with 12 patients undergoing hybrid total hip replacement (THR) for the incidence and load of intraoperative cerebral microemboli, using transcranial Doppler. All patients were tested for the presence of a patent foramen ovale using a validated technique. Outcome was assessed using the WOMAC, Harris Hip Score, Oxford Hip Score and EuroQoL quality of life measure. No patient in the hip resurfacing group demonstrated intra-operative cerebral microembolisation. Five patients in the THR group showed transcranial Doppler evidence of microemobli during the procedure. With the small numbers of patients available, there was not a significant difference in microemboli load between the groups (p = 0.09). There was no significant difference between the groups regarding the incidence of PFO (p = 0.78). There was no significant relationship between the incidence and total microemboli load and the incidence of PFO (p = 0.56). There was no significant difference in outcome at six months between patients who demonstrated microemboli and those who did not. The incidence of cerebral microembolisation during hip resurfacing appears to be very low. Although our study demonstrated cerebral microemboli in a significant proportion of patients undergoing primary hybrid THR, the numbers of microemboli were low and the presence of a patent foramen ovale did not influence microemboli incidence or load. Finally, patients who demonstrated cerebral microemboli did not have a worse outcome than patients who did not.

Coping is a key concept in psychological medicine, which refers to the way in which people deal with the stress of illness. Voice disorders may have pervasive effects upon the individual's life beyond the vocal impairment yet, there is little reference in current literature as to how people cope with voice problems. This study explored and validated the Voice Disability Coping Questionnaire (VDCQ), a newly developed disease-specific coping measure, which elicits how patients cope with voice problems. Eighty subjects presenting with muscle tension dysphonia (MTD) and adductor spasmodic dysphonia (ASD) completed a 28-item VDCQ as part of an initial assessment protocol before intervention, within a longitudinal study. Principal component analyses were used to investigate the underlying structure of this questionnaire; analyses of variance were used to determine group differences in coping strategies. The principal component analyses generated four coping subscales: "social support," "passive coping," "avoidance," and "information seeking" measured over 15 items. The subscales revealed logical correlations between them. Avoidance and passive coping were found to be used by the ASD group significantly more than the MTD group. This study provided initial evidence for the validity and reliability of the VDCQ; it differentiated between clinical groups and may facilitate a patient-centered approach, which enhances the understanding of voice disorders.

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.

OBJECTIVESThere are a number of techniques available to assess the aorta for atheromatous disease in the intraoperative period. This study compared the relationship among the findings of digital palpation (DP), transesophageal echocardiography (TEE), and epiaortic ultrasound (EAU) in the detection of atheroma in the ascending aorta.DESIGNA prospective, observational study.SETTINGA single-institution, cardiothoracic specialty hospital.PARTICIPANTSOne hundred fifty-four patients undergoing elective cardiac surgery.INTERVENTIONSThe ascending aorta of patients undergoing elective coronary artery bypass surgery was assessed for atheroma by means of the 3 techniques. Atheroma was scored as present or absent. The sensitivity and specificity of the techniques were compared.MEASUREMENTS AND MAIN RESULTSAssuming EAU provides the "gold standard," the sensitivity of both TEE and DP were low. Digital palpation identified only 20 patients (12%); TEE 31 patients (20%); and, in contrast, EAU detected atheroma in 81 patients (53%). There were 3 and 6 false-positives by DP and TEE, respectively.CONCLUSIONAssuming EAU as the "gold standard" to detect atheroma, this study has shown that when assessing the ascending aorta neither DP nor TEE appear sensitive. This study supports the proposal that detection of atheroma should be performed by EAU.

Thrombo-embolism and haemodynamic ischaemia secondary to atheromatous stenotic disease of the carotid and vertebral arteries are important causes of ischaemic stroke. In those patients with carotid stenosis the risk of stroke has been directly related to the severity of stenosis and the presence of symptoms (Inzitari et al., 2000). The average risk of stroke following a transient ischaemic attack (TIA) is about 8% in the first year and then 5% per annum, but, in patients with severe carotid stenosis, the risk even with medical treatment increases up to 28% over 2 years (NASCETC, 1991). Detection of significant carotid or vertebral artery stenosis after a TIA or stroke provides the opportunity for secondary preventive treatment of the stenosis to prevent a further stroke (see also 'Stroke').