体外循环心脏术后并发精神障碍65例临床分析

目的　提高对体外循环心脏手术后并发精神障碍的认知与防治。方法　分析体外循环心脏手术后出现精神运动性障碍和情感障碍的病人的临床表现和转归。结果　本组并发精神障碍的发生率为 3 .2 5 % (65/ 2 0 0 0 ) ,61例病人精神障碍治愈 ,2例有阳性精神病家族史的患者好转出院 ,2例死亡。结论　体外循环中脑血流灌注不足 ,术后并发心、脑、肺、肾功能障碍及感染是病人出现精神障碍的主要原因。对于有阳性精神病家族史的病人 ,手术创伤可能是精神障碍的诱发因素。及时治疗躯体疾病及心理治疗 ,病人大多可获治愈。     

颅脑术后并发精神障碍

颅脑术后并发精神障碍并不少见 ,但常易被忽视而延误治疗。我院于 1991年 10月～ 2 0 0 0年 10月间 ,共治疗颅脑术后并发精神障碍 50例 ,占同期手术的 0 9% ,本文对颅脑术并发精神障碍有关问题进行探讨。1 临床资料一般资料 ,本组 50例中 ,男 2 8例 ,女 2 2例 ,年龄 10～ 61岁 ,平均 4 0岁。其中双侧额叶脑挫伤伴脑内血肿 2 6例 ;左侧额颞脑内血肿 9例 (外伤性 6例 ,自发性 3例 ) ;右额颞顶硬膜下血肿 9例 ;右额大脑镰旁脑膜瘤 3例 ;左额硬膜外血肿伴颅底骨折 1例 ;右额颞胶质瘤 1例 ;左额颞转移瘤 1例。临床表现　兴奋、躁动、狂呼乱叫 2 …     

颅脑术后并发精神障碍(附42例报告)

目的：探讨颅内术后并发精神障碍的发病因素、机制和临床表现特点。方法：通过对我院1991年1月－2002年1月间，42例颅脑术后并发精神障碍的临床有关资料进行分析研究。结果：本组42例，占同期颅脑手术的0．87％，出院随访2－6个月，精神障碍无一例复发或加重，痊愈36例，显著进步4例，进步2例，治愈85．7％。结论：颅脑术后并发精神障碍主要是因手术和脑部原发病变对脑组织的损害，导致司管情感部位的脑细胞功能下降，与手术创伤程度、手术时间、脑部原发病变的部位及病人术前的心因基础有着密切的关系，精神障碍一般持续时间短暂，多以兴奋和偏执症状为主，并随着颅脑术后恢复而逐渐好转，预后令人满意。     

体外循环心脏术后并发精神障碍的临床分析

目的探讨对体外循环(CPB)心脏术后并发精神障碍的可能原因和防治方法。方法回顾性分析我院2010-01～2010-12施行的1 128例体外循环心脏术后并发精神障碍45例的临床资料和防治措施。结果除2例因多脏器衰竭而死亡,其余均经治疗1～2周内康复而出院。随访1～3个月均未再出现精神障碍表现。结论体外循环心内直视手术后发生精神障碍是包括体外循环、生理功能、环境、心理等多因素共同作用的结果,应采取综合防治措施。     

心脏手术后精神障碍的临床分析

为研究心脏手术后精神障碍的病因、发病机理及防治措施，对２０５３例心脏手术病人进行了观察。结果显示，５４例病人出现精神障碍并发症，发生率为２．６３％；其中体外循环术后发生率为３．１２％，非体外循环术后发生率为１．４７％，两者间差异有显著性（Ｐ＜０．０５）。术前心功能状况较差者，更易出现精神障碍（Ｐ＜０．０１）。病人均为成年人，症状大多出现于２周以内，表现为躁狂状态、抑郁状态、精神分裂样状态及神经症性反应，经治疗后均痊愈。认为心脏术后精神障碍主要与精神因素、体外循环损伤、心功能状况、年龄等有关，强调精神因素所起的作用，提示应采取综合治疗及预防。     

癫痫伴发精神障碍71例临床分析

癫痫伴发精神障碍７１例临床分析福建医学院附属第二医院（３６２０００）杨东华福建省泉州市第三人民医院胡永寿，翁信会为探讨癫痫伴发精神障碍的临床表现，现将收集７１例患者进行临床分析，其结果报导如下。１对象与方法本文对１９８９年以来就诊的癫痫患者４５９例的...     

体外循环心脏术后精神障碍原因及护理干预

我科2004-01-2009—03收治心内直视手术500例,其中术后出现精神障碍者10例,通过实施护理干预均顺利出院,3个月后随访均未再出现精神障碍。现报告如下。     

冠脉旁路移植术后并发精神障碍临床分析

目的探讨冠脉旁路移植术后并发精神障碍的高危因素。方法回顾性分析634例行冠脉旁路移植术患者资料,分析术后并发精神障碍者的危险因素、临床表现、预后及原因。结果冠脉旁路移植术死亡9例,并发精神障碍的发生率为15.14%(96/634),余均痊愈出院。同期心脏外科手术共4 429例,术后精神障碍共337例,发生率为7.61%(337/4 429)。冠心病组精神障碍发生率高于总体发生率,差异有统计学意义(u=15.41,P0.01)。结论合并颈动脉狭窄、术中的脑部低灌注、常温下的内环境紊乱等是冠脉旁路移植术后并发精神障碍特有的高危因素。冠脉旁路移植术前正确评估脑血管风险,避免或减少高危因素。     

Psychosis after epilepsy surgery: report of three cases

Temporal lobe epilepsy surgery has become a successful alternative in patients with refractory epilepsy. However, the outcome of epilepsy surgery may be affected by the occurrence of postsurgical psychiatric symptoms, such as psychosis. This report describes three cases of refractory temporal lobe epilepsy and hippocampal sclerosis, which, after anterior temporal lobectomy, presented with acute psychosis. One of them had a history of acute psychosis, and all of them met criteria for Cluster A personality disorder (schizoid/schizotypal) during psychiatric assessment prior to surgery. The three cases had a good seizure outcome (Engel I), but, on follow-up during the first year after surgery, developed an acute psychotic episode compatible with schizoaffective disorder; brief psychotic disorder; and a delusional disorder, respectively, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Treatment with low-dose risperidone was successful.     

Heart-focused anxiety before and after cardiac surgery

OBJECTIVE: We investigated the degree and course of heart-focused anxiety (HFA) in patients with cardiac diseases before and after cardiac surgery. METHODS: We examined 90 patients undergoing coronary bypass, valve replacement, or combined surgery before surgery, 6 weeks after surgery, and 6 months after surgery. Patients completed the Cardiac Anxiety Questionnaire (CAQ), which assesses heart-focused fear, attention, and avoidance, and a set of other questionnaires assessing general anxiety, depression, and quality of life. Data were compared with an age- and sex-controlled contrast group of 72 orthopedic patients with no history of cardiac disease. RESULTS: All dimensions of HFA were elevated in patients before surgery. CAQ-Fear was significantly reduced 6 weeks after surgery and at 6-month follow-up. CAQ-Avoidance was stable after surgery but declined on follow-up, while there was only a statistical tendency indicating reduction in CAQ-Attention. Approximately 20% of patients continued to experience clinically elevated levels of HFA at 6-month follow-up. Furthermore, we found decreases in global anxiety and depression, and an increase in quality of life after surgery. CONCLUSIONS: In contrast to global psychosocial indicators, the more specific assessment of HFA may help identify individuals with elevated levels of HFA who might benefit from interventions to help them adjust to the effects of surgery and lingering cardiac problems.     

Low prevalence of heparin-induced thrombocytopenia after cardiac surgery in Thai patients

Introduction

Heparin induced-thrombocytopenia (HIT) has been well recognized in Western countries. However, there are no data in the Thai population. We therefore investigated the prevalence of anti-platelet factor 4 (PF4)/heparin antibodies, HIT, and its thrombotic complications in Thai patients undergoing cardiac surgery using unfractionated heparin.

Materials and methods

Seventy-three consecutive patients were prospectively enrolled in this study. Blood samples before operation and week 1, week 2, and week 3 after operation were collected from each patient for HIT antibody screening by enzyme-linked immunosorbent assay using IgG antibody specific to the PF4/heparin complex. Positive samples were further analyzed by ¹⁴C-serotonin release assay. Complete blood count was performed daily during the first week, then weekly for 3 weeks.

Results

No patient had detectable anti-PF4/heparin antibodies at baseline. Five patients sero-converted during the course of the study for anti-PF4/heparin IgG: 3 (4.1%) at week 1, 4 (5.5%) at week 2, and 5 (6.8%) at week 3 after surgery. However, none of these patients had anti-PF4/heparin antibodies that resulted in ¹⁴C-serotonin release to be considered clinically significant antibodies. Post-operative thrombocytopenia after the operation was found in 35 patients (47.9%), but was not considered to be caused by HIT. Thromboembolic events occurred in 3 patients (4.1%) during follow up; however, none of these patients had positive PF4/heparin antibody tests.

Conclusions

Our study represents the first study to examine Thai patients exposed to heparin in the context of cardiac surgery. We found a lower prevalence of positive anti-PF4/heparin antibodies and clinical HIT than previously published studies.     

Autopsy study of cerebral complications of congenital heart disease and cardiac surgery

Summary Detailed histological investigation of the brains of 45 neonates, infants and children who had died of various congenital heart defects revealed that the damage to the white matter occurred mostly below 3 months of age, while that to the grey matter occurred above this age. The lesions (glial fatty metamorphosis, telencephalic leucoencephalopathy, focal white matter necrosis, focal nerve cell pyknosis and symmetrical cortical necrosis) were often combined with each other. The necroses were generally not a consequence of microembolization. Various cerebral complications occurred in most of the patients who had undergone cardiac surgery. However, the various cerebral lesions each had several causes and in general the accumulation of predisposing damaging noxae resulted in more serious changes.     

Neural correlates of cognitive dysfunction after cardiac surgery

Patients who underwent cardiac surgery and their relatives often complain on postoperative memory impairment. Most prospective neuropsychological studies also found postoperative cognitive decline early after surgery. Nevertheless, recently several reports questioned the existence of long-term brain alterations in these patient cohorts. The present review was aimed to clear up the true cardiac surgery effects on brain and cognitive functions. The reviewed data evidence that cardiac surgery interventions induce persistent localized brain ischemic lesions along with rapidly reversing global brain swelling and decreased metabolism. A range of studies showed that left temporal region was especially prone to perioperative ischemic injury, and these findings might explain persistent verbal short-term memory decline in a considerable proportion of cardiac surgery patient cohorts. Speed/time of cognitive performance is commonly decreased early after on-pump surgery either. Nevertheless, no association between psychomotor speed slowing and intraoperative embolic load was found. The rapid recovery of the latter cognitive domain might be better explained by surgery related acute global brain metabolism changes rather than ischemic injury effects. Hence, analyses of performance on separate cognitive tests rather than summarized cognitive indexes are strongly recommended for future neuropsychological studies of cardiac surgery outcomes.     

Preoperative predictors of delirium after cardiac surgery: a preliminary study

Preoperative risk factors of postoperative delirium were evaluated in 260 patients admitted for open heart surgery. The incidence of delirium was 11.5%. Independent predictors included cognitive impairment, atrial fibrillation, a history of peripheral vascular disease major depression and advanced age. Aforementioned factors might be helpful in predicting delirium following cardiac surgery.     

Preexisting depressive symptoms are associated with long-term cognitive decline in patients after cardiac surgery

Objective

To examine whether preoperative psychological dysfunctions rather than intraoperative factors may differentially predict short- and long-term postoperative cognitive decline (POCD) in patients after cardiac surgery.

Method

Forty-two patients completed a psychological evaluation, including the Trail Making Test Part A and B (TMT-A/B), the memory with 10/30-s interference, the phonemic verbal fluency and the Center for Epidemiological Studies of Depression (CES-D) scale for cognitive functions and depressive symptoms, respectively, before surgery, at discharge and at 18-month follow-up.

Results

Ten (24%) and 11 (26%) patients showed POCD at discharge and at 18-month follow-up, respectively. The duration of cardiopulmonary bypass significantly predicted short-term POCD [odds ratio (OR)=1.04, P< .05], whereas preoperative psychological factors were unrelated to cognitive decline at discharge. Conversely, long-term cognitive decline after cardiac surgery was significantly predicted by preoperative scores in the CES-D (OR=1.26, P< .03) but not by intraoperative variables (all Ps > .23).

Conclusions

Our findings showed that preexisting depressive symptoms rather than perioperative risk factors are associated with cognitive decline 18 months after cardiac surgery. This study suggests that a preoperative psychological evaluation of depressive symptoms is essential to anticipate which patients are likely to show long-term cognitive decline after cardiac surgery.     

Neurologic complications after surgery for obesity

Bariatric surgical procedures are increasingly common. In this review, we characterize the neurologic complications of such procedures, including their mechanisms, frequency, and prognosis. Literature review yielded 50 case reports of 96 patients with neurologic symptoms after bariatric procedures. The most common presentations were peripheral neuropathy in 60 (62%) and encephalopathy in 30 (31%). Among the 60 patients with peripheral neuropathy, 40 (67%) had a polyneuropathy and 18 (30%) had mononeuropathies, which included 17 (94%) with meralgia paresthetica and 1 with foot drop. Neurologic emergencies including Wernicke's encephalopathy, rhabdomyolysis, and Guillain-Barré syndrome were also reported. In 18 surgical series reported between 1976 and 2004, 133 of 9996 patients (1.3%) were recognized to have neurologic complications (range: 0.08-16%). The only prospective study reported a neurologic complication rate of 4.6%, and a controlled retrospective study identified 16% of patients with peripheral neuropathy. There is evidence to suggest a role for inflammation or an immunologic mechanism in neuropathy after gastric bypass. Micronutrient deficiencies following gastric bypass were evaluated in 957 patients in 8 reports. A total of 236 (25%) had vitamin B(12) deficiency and 11 (1%) had thiamine deficiency. Routine monitoring of micronutrient levels and prompt recognition of neurological complications can reduce morbidity associated with these procedures.     

Incidence and predictors of delirium after cardiac surgery: Results from The IPDACS Study

Objective

Delirium after cardiac surgery is a serious complication that results in higher morbidity and mortality rates, and prolongs hospitalisation. However, the knowledge base regarding the issue of postoperative delirium is still limited. Therefore, in the current study, we evaluated the incidence and independent perioperative risk factors of delirium after cardiac surgery.

Methods

The IPDACS Study recruited 563 consecutive patients undergoing cardiac surgery with cardiopulmonary bypass. The subjects were preoperatively examined by psychiatrists using the Mini-Mental State Examination and the Mini International Neuropsychiatric Interview to assess psychiatric comorbidity. Additionally, other variables connected to the patients' medical condition and surgical and anaesthetic procedures were evaluated. A diagnosis of delirium following surgical intervention was based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria.

Results

The incidence of postoperative delirium according to DSM-IV criteria was 16.3% (95% confidence interval: 13.5-19.6). Multivariate stepwise logistic regression analysis revealed that advanced age, preoperative cognitive impairment, an ongoing episode of major depression, anaemia, atrial fibrillation, prolonged intubation and postoperative hypoxia were independently associated with delirium after cardiac surgery.

Conclusion

According to the current analysis, the aforementioned conditions independently predispose to delirium following cardiac surgery. Since some of these factors can be successfully treated and eliminated preoperatively and postoperatively, this study should be helpful in reducing the risk of delirium and in improving the medical care of patients undergoing cardiac surgery (Clinical Trials Identifier: NCT00784576).     

Validation of the Korean Version of the Psychosis Screener to Identify Patients With Psychosis

ObjectiveThis study aimed to validate the Korean version of a short screening tool for psychosis as the first stage in finding undiagnosed psychosis in the community. MethodsThe sample contained 126 consecutive psychiatric outpatients in National Medical Center, Seoul, Korea, between July 20 and July 22, 2020. The Psychosis Screener (PS) comprises 7 items covering psychotic symptoms. The presence of each psychotic symptom was determined by a trained mental health professional and coded “yes” or “no.” Two psychiatrists reviewed the medical records independently and extracted the ICD-10-based diagnoses. Any differences between the two clinicians were resolved by consensus, and the agreed diagnosis was used as a gold standard in the study. ResultsAmong 126 psychiatric outpatients who were enrolled in a consecutive manner during the study period, the proportion of psychosis was 15.1%. The PS showed 78.9% sensitivity and 72.0% specificity when the optimal cut-off was 2, indicating that a score of 2 or more on the screener identified a likely case of psychosis. The area under the curve for the PS was 0.78 (95% CI: 0.67–0.87). ConclusionThe Korean version of the PS has an ability to discriminate between those who meet the diagnostic criteria for psychosis and those who do not in a high-prevalence group.