Assessment of long-term cognitive dysfunction in older patients who undergo heart surgery / Deterioro cognitivo a largo plazo tras cirugía cardiaca en pacientes de edad avanzada

Introduction: Older patients are more likely to have cognitive dysfunction, and a great pro-portion of patients undergone surgical procedures are older adults. Postoperative cognitivedysfunction (POCD) has been shown as a consistent complication after major surgical proceduressuch as heart surgery.Aim: To determine the presence of long-term POCD in ≥65-year-old patients undergoing coro-nary artery bypass grafting and aortic valve replacement, and to establish related risk factors.Methods: We prospectively and sequentially included 44 patients with coronary disease andaortic stenosis scheduled for heart surgery. Follow-up of all patients was standardized anda neurocognitive evaluation were performed preoperatively and at 1, 6 and 12 months aftersurgery.Results: Patients experienced a significantly postoperative cognitive dysfunction (33.5%, 63.4%and 38.9% at 1, 6 and 12 months, respectively) from baseline (20.5%). Patient-associated aspectssuch as age (p < 0.01), history of smoking (p < 0.01), arterial hypertension (p = 0.022), diabetesmellitus (p = 0.024), heart failure (p = 0.036) and preoperative cognitive dysfunction (p < 0.01),and surgery-associated aspects such as EuroSCORE (p < 0.01) and operation time (p < 0.01) wereidentified as related risk factors. Conclusions: Older patients who underwent heart surgery had long-term POCD. Both patient-and surgery-related risk factors were established as related risk factors. These findings suggestthat the prevalence of cognitive dysfunction after cardiac surgery in older patients could berelated to a possible progression to dementia. In addition, many of the risk factors identifiedmay be modifiable but in practice, these patients are not attended to for their possible cognitiveimpairment.(AU)

Introducción: Los pacientes de edad avanzada tienen más riesgo de sufrir deterioro cognitivo, yson cada vez más frecuentemente sometidos a una cirugía. El deterioro cognitivo posquirúrgico(DCP) tras cirugía cardiaca se ha mostrado como una complicación importante.Objetivos: Determinar la presencia del DCP a largo plazo en pacientes ≥ 65 a˜nos intervenidosde derivación coronaria y reemplazo de válvula aórtica, y establecer los factores de riesgorelacionados.Métodos: Se realizó un estudio en el que se incluyeron de forma prospectiva y secuen-cial 44 pacientes con enfermedad coronaria y estenosis aórtica programados para cirugía. Elseguimiento fue estandarizado y se realizaron evaluaciones neuropsicológicas preoperatoria-mente a los 1, 6 y 12 meses postoperatorios.Resultados: Se observó la presencia de un DCP significativo (33,5, 63,4 y 38,9% a 1, 6 y 12 meses,respectivamente) respecto al nivel basal (20,5%). Se identificaron como factores de riesgo varia-bles asociadas al paciente como la edad (p < 0,01), el tabaquismo (p < 0,01), la hipertensiónarterial (p = 0,022), la diabetes mellitus (p = 0,024), la insuficiencia cardiaca (p = 0,036) y el dete-rioro cognitivo preoperatorio (p < 0,01), y variables quirúrgicas como el EuroSCORE (p < 0,01) yel tiempo de intervención (p < 0,01).Conclusiones: Los pacientes de edad avanzada sometidos a cirugía cardiaca presentaron DCP alargo plazo. Variables asociadas al paciente y quirúrgicas se mostraron como factores de riesgo,muchas de ellas modificables. Estos hallazgos sugieren que la presencia de DCP en pacientes demás edad podría suponer mayor riesgo de evolución a demencia. En la práctica clínica habitualno es evaluado el rendimiento cognitivo.(AU)

Assessment of long-term cognitive dysfunction in older patients who undergo heart surgery.

INTRODUCTION: Older patients are more likely to have cognitive dysfunction, and a great proportion of patients undergone surgical procedures are older adults. Postoperative cognitive dysfunction (POCD) has been shown as a consistent complication after major surgical procedures such as heart surgery. AIM: To determine the presence of long-term POCD in ≥65-year-old patients undergoing coronary artery bypass grafting and aortic valve replacement, and to establish related risk factors. METHODS: We prospectively and sequentially included 44 patients with coronary disease and aortic stenosis scheduled for heart surgery. Follow-up of all patients was standardized and a neurocognitive evaluation were performed preoperatively and at 1, 6 and 12 months after surgery. RESULTS: Patients experienced a significantly postoperative cognitive dysfunction (33.5%, 63.4% and 38.9% at 1, 6 and 12 months, respectively) from baseline (20.5%). Patient-associated aspects such as age (p<0.01), history of smoking (p<0.01), arterial hypertension (p=0.022), diabetes mellitus (p=0.024), heart failure (p=0.036) and preoperative cognitive dysfunction (p<0.01), and surgery-associated aspects such as EuroSCORE (p<0.01) and operation time (p<0.01) were identified as related risk factors. CONCLUSIONS: Older patients who underwent heart surgery had long-term POCD. Both patient- and surgery-related risk factors were established as related risk factors. These findings suggest that the prevalence of cognitive dysfunction after cardiac surgery in older patients could be related to a possible progression to dementia. In addition, many of the risk factors identified may be modifiable but in practice, these patients are not attended to for their possible cognitive impairment.

Assessment of long-term cognitive dysfunction in older patients who undergo heart surgery.

INTRODUCTION: Older patients are more likely to have cognitive dysfunction, and a great proportion of patients undergone surgical procedures are older adults. Postoperative cognitive dysfunction (POCD) has been shown as a consistent complication after major surgical procedures such as heart surgery. AIM: To determine the presence of long-term POCD in ≥65-year-old patients undergoing coronary artery bypass grafting and aortic valve replacement, and to establish related risk factors. METHODS: We prospectively and sequentially included 44 patients with coronary disease and aortic stenosis scheduled for heart surgery. Follow-up of all patients was standardized and a neurocognitive evaluation were performed preoperatively and at 1, 6 and 12 months after surgery. RESULTS: Patients experienced a significantly postoperative cognitive dysfunction (33.5%, 63.4% and 38.9% at 1, 6 and 12 months, respectively) from baseline (20.5%). Patient-associated aspects such as age (p<0.01), history of smoking (p<0.01), arterial hypertension (p=0.022), diabetes mellitus (p=0.024), heart failure (p=0.036) and preoperative cognitive dysfunction (p<0.01), and surgery-associated aspects such as EuroSCORE (p<0.01) and operation time (p<0.01) were identified as related risk factors. CONCLUSIONS: Older patients who underwent heart surgery had long-term POCD. Both patient- and surgery-related risk factors were established as related risk factors. These findings suggest that the prevalence of cognitive dysfunction after cardiac surgery in older patients could be related to a possible progression to dementia. In addition, many of the risk factors identified may be modifiable but in practice, these patients are not attended to for their possible cognitive impairment.

Predicted change in the number of permanent medical teachers from 2017 to 2026. The training of future physicians in critical condition. / Evolución previsible en el número de profesores permanentes de Medicina del 2017 al 2026. La formación de los futuros médicos en situación crítica.

The significant and progressive reduction in the number of permanent teachers in medical schools (professor, associate professor and assistant professor) is a reason for concern for the National Conference of Deans. This reduction will intensify in the coming decade (2017-2026). Forty-three percent of the permanent faculty will retire, as will 55% of the faculty linked to clinical areas, 34% of the faculty not linked to clinical areas and 32% of the faculty of basic areas. This deficit is significant now, and, in a few years, the situation will be unsustainable, especially in the clinical areas. This report reveals the pressing need to adopt urgent measures to alleviate the present situation and prevent a greater problem. The training of future physicians, immediately responsible for the health of our society, depends largely on the theoretical and practical training taught in medical schools, with the essential collaboration of healthcare institutions. Paradoxically, while the number of teachers decreases substantially, there is an exponential increase in the number of medical schools and students who are admitted every year without academic or healthcare justification.

[Evaluation and treatment of sleep problems in children diagnosed with attention deficit hyperactivity disorder: an update of the evidence]. / Evaluacion y tratamiento de los problemas de sueño en niños diagnosticados de trastorno por deficit de atencion/hiperactividad: actualizacion de la evidencia.

INTRODUCTION: Attention deficit hyperactivity disorder (ADHD) affects approximately 5% of all children and adolescents, and these patients frequently suffer from sleep problems. The association between sleep disorders and ADHD, however, is multifaceted and complex. AIMS: To explore the relationship between sleep disorders and ADHD. DEVELOPMENT: Sleep problems in children with ADHD include altered sleep and specific disorders per se or that may be due to comorbid psychiatric disorders or to the stimulants they receive as treatment for their ADHD. Today, an evaluation of the sleep conditions in children with ADHD is recommended before starting pharmacological treatment. The first step in managing their sleep problems is good sleep hygiene and cognitive-behavioural psychotherapy. Another option is to consider modifying the dosage and formulation of the stimulants. Atomoxetine and melatonin are therapeutic alternatives for children with ADHD and more severe sleep problems. Specific treatments exist for respiratory and movement disorders during sleep. CONCLUSIONS: It is important to evaluate sleep in children who present symptoms suggestive of ADHD, since problems during sleep can play a causal role or exacerbate the clinical features of ADHD. Correct evaluation and treatment of sleep disorders increase the family's and the child's quality of life and can lessen the severity of the symptoms of ADHD.

TITLE: Evaluacion y tratamiento de los problemas de sueño en niños diagnosticados de trastorno por deficit de atencion/hiperactividad: actualizacion de la evidencia.Introduccion. El trastorno por deficit de atencion/hiperactividad (TDAH) afecta aproximadamente al 5% de los niños y adolescentes, y los problemas del sueño son comunes en estos pacientes. Sin embargo, la asociacion entre los trastornos del sueño y el TDAH es multifacetica y compleja. Objetivo. Explorar la relacion entre los trastornos del sueño y el TDAH. Desarrollo. Los problemas del sueño en niños con TDAH incluyen alteraciones del sueño y trastornos especificos per se o debidos a trastornos psiquiatricos comorbidos o a los farmacos estimulantes para el TDAH. Actualmente se recomienda la evaluacion de las condiciones del sueño en niños con TDAH antes de la iniciacion del tratamiento farmacologico. La primera linea de actuacion para el manejo de los problemas de sueño es la higiene del sueño y la psicoterapia cognitivo-conductual. Otra opcion es considerar la modificacion de la posologia y formulacion de los farmacos estimulantes. La atomoxetina y la melatonina son alternativas terapeuticas para los niños con TDAH y problemas del sueño mas graves. Para los trastornos respiratorios y del movimiento en el sueño existen tratamientos especificos. Conclusiones. Es importante evaluar el sueño en los niños que presentan sintomas sugestivos de TDAH, ya que los problemas en el sueño pueden desempeñar un papel causal o exacerbar la clinica del TDAH. Una correcta evaluacion y tratamiento de los trastornos del sueño aumentan la calidad de vida de la familia y del niño y pueden disminuir la gravedad de los sintomas del TDAH.

Neurons of the A5 region are required for the tachycardia evoked by electrical stimulation of the hypothalamic defence area in anaesthetized rats.

In order to assess the possible interactions between the pontine A5 region and the hypothalamic defence area (HDA), we have examined the pattern of double staining for c-Fos protein immunoreactivity (c-Fos-ir) and tyrosine hydroxylase, throughout the rostrocaudal extent of the A5 region in spontaneously breathing anaesthetized male Sprague-Dawley rats during electrical stimulation of the HDA. Activation of the HDA elicited a selective increase in c-Fos-ir with an ipsilateral predominance in catecholaminergic and non-catecholaminergic A5 somata (P < 0.001 in both cases). A second group of experiments was done to examine the importance of the A5 region in modulating the cardiorespiratory response evoked from the HDA. Cardiorespiratory changes were analysed in response to electrical stimulation of the HDA before and after ipsilateral microinjection of muscimol within the A5 region. Stimulation of the HDA evoked an inspiratory facilitatory response, consisting of an increase in respiratory rate (P < 0.001) due to a decrease in expiratory time (P < 0.01). The respiratory response was accompanied by a pressor response (P < 0.001) and tachycardia (P < 0.001). After muscimol microinjection within the A5 region, pressor and heart rate responses to HDA stimulation were reduced (P < 0.01 and P < 0.001, respectively). The respiratory response persisted unchanged. Finally, to confirm functional interactions between the HDA and the A5 region, extracellular recordings of putative A5 neurones were obtained during HDA stimulation. Seventy-five A5 cells were recorded, 35 of which were affected by the HDA (47%). These results indicate that neurones of the A5 region participate in the cardiovascular response evoked from the HDA. The possible mechanisms involved in these interactions are discussed.

Influence of age, sex, and education on the Visual Object and Space Perception Battery (VOSP) in a healthy normal elderly population.

The assessment of visual perception and cognition forms an important part of any general cognitive evaluation. We have studied the possible influence of age, sex, and education on a normal elderly Spanish population (90 healthy subjects) in performance in visual perception tasks. To evaluate visual perception and cognition, we have used the subjects performance with The Visual Object and Space Perception Battery (VOSP). The test consists of 8 subtests: 4 measure visual object perception (Incomplete Letters, Silhouettes, Object Decision, and Progressive Silhouettes) while the other 4 measure visual space perception (Dot Counting, Position Discrimination, Number Location, and Cube Analysis). The statistical procedures employed were either simple or multiple linear regression analyses (subtests with normal distribution) and Mann-Whitney tests, followed by ANOVA with Scheffe correction (subtests without normal distribution). Age and sex were found to be significant modifying factors in the Silhouettes, Object Decision, Progressive Silhouettes, Position Discrimination, and Cube Analysis subtests. Educational level was found to be a significant predictor of function for the Silhouettes and Object Decision subtests. The results of the sample were adjusted in line with the differences observed. Our study also offers preliminary normative data for the administration of the VOSP to an elderly Spanish population. The results are discussed and compared with similar studies performed in different cultural backgrounds.

A5 region modulation of the cardiorespiratory responses evoked from parabrachial cell bodies in the anaesthetised rat.

We have examined the importance of the A5 region modulating cardiorespiratory responses evoked from the parabrachial complex (PB) in spontaneously breathing rats. Cardiorespiratory changes were analyzed in response to electrical stimulation and glutamate microinjections into the PB (10-20 nl, 1-2 nmol) before and after ipsilateral microinjection of muscimol (50 nl, 0.25 nmol) or lidocaine (50 nl, 0.5 nmol) within the A5 region. Stimulation of medial parabrachial and Kölliker-Fuse nuclei (mPB-KF) evoked a decrease in respiratory rate (P<0.001) with a rise in blood pressure (P<0.001) and heart rate (P<0.05). After muscimol or lidocaine microinjections within the A5 region, the pressor and heart rate responses to mPB-KF stimulation were reduced (P<0.05, both cases). Muscimol within the A5 region altered the respiratory response to glutamate stimulation of mPB-KF, evoking an increase in respiratory rate (P<0.05). Lidocaine abolished the respiratory response to mPB-KF stimulation. Stimulation of the lateral parabrachial nuclei (lPB) caused an increase in respiratory rate (P<0.001) with a rise in blood pressure (P<0.001) and heart rate (P<0.05). Muscimol or lidocaine microinjections within A5 region decreased heart rate (P<0.05) and pressor responses (P<0.05) evoked from lPB. The increase of respiratory rate persisted unchanged. To confirm functional interactions between A5 and PB, extracellular recordings of putative A5 neurones were obtained during PB stimulation. Eighty-three A5 cells were recorded, 35 were activated from the mPB-KF (42%). The results indicate that neurones of the A5 region participate in the cardiorespiratory response evoked from the different regions of the PB complex. The possible mechanisms involved in these interactions are discussed.

Laryngeal effects of stimulation of rostral and ventral pons in the anaesthetized rat.

In order to study the importance of two pontine regions modulating laryngeal resistance, electrical current or microinjections of glutamate (10-30 nl, 1-3 nmol) were made into the pontine parabrachial complex and the A5 region in spontaneously breathing anaesthetized rats. Two distinct patterns of laryngeal and respiratory responses were elicited. An increase of subglottal pressure was accompanied with an expiratory facilitatory response consisted of a decrease in both respiratory rate and phrenic nerve activity. A decrease of subglottal pressure was accompanied with an inspiratory facilitatory response consisted of an increase in both respiratory rate and phrenic nerve activity. The modification of laryngeal calibre occurred during both respiratory phases in most cases. The concomitant cardiovascular changes of these responses were also analyzed. Controls using guanethidine to block autonomic responses which might interact with respiratory control were also made. Histological analysis of stimulation sites showed a topographical organization of these responses: laryngeal constriction was evoked from Kölliker-Fuse, medial parabrachial nuclei and A5 region, whilst the laryngeal dilation was evoked from the lateral parabrachial nucleus.

Respiratory effects of stimulation of cell bodies of the A5 region in the anaesthetised rat.

To assess the importance of the pontine A5 region in modulating respiratory activity, electric current or microinjections of glutamate (10-30 nl, 1-3 nmol) were used to stimulate discrete zones within this region in the spontaneously breathing, anaesthetised rat. These stimuli evoked an expiratory facilitatory response, consisting of a decrease in respiratory rate (P < 0.01 electrical, P < 0.001 chemical) due to an increase of expiratory time (P < 0.01 in both cases) as measured from recordings of phrenic nerve activity. No changes were observed in inspiratory time. To avoid changes in PCO2, which could modulate the respiratory response, stimulation was also made during artificial ventilation. Under these conditions the expiratory facilitatory response elicited by glutamate was still present (P < 0.05), although its duration was reduced (P < 0.05), as was the magnitude of the phrenic burst (P < 0.05). At all the sites at which electrical stimulation and glutamate injection had evoked a respiratory response, electrical stimulation evoked a concomitant increase in both blood pressure and heart rate. Glutamate injection evoked a pressor response in 21 out of 30 animals. In eight animals the rise in blood pressure was followed by a fall in blood pressure and in one animal, a depressor response was observed. In all cases glutamate evoked an increase in heart rate. The expiratory facilitatory response was not evoked as a consequence of the increase of blood pressure since it was still present after the administration of guanethidine, which abolished the blood pressure changes. As glutamate is believed to excite perikarya rather than axons of passage these data indicate that expiratory facilitatory responses and the accompanying cardiovascular changes are the consequence of activating neurones located within the A5 region. The possible interactions between the A5 region and the medullary respiratory complex in eliciting these changes are discussed.

Cardiovascular and respiratory effects of stimulation of cell bodies of the parabrachial nuclei in the anaesthetized rat.

1. In order to assess the importance of the parabrachial nuclei in modulating cardiorespiratory activity, electric current or microinjections of glutamate were used to stimulate discrete regions of the parabrachial nuclei in anaesthetized rats. 2. Stimulation of cell bodies in the medial region of the parabrachial nuclei and in the Kölliker-Fuse nuclei, caused an expiratory facilitatory response. This consisted mainly of a decrease in respiratory rate as measured by observing phrenic nerve activity. 3. Stimulation of cell bodies in the lateral region of the parabrachial nuclei caused an inspiratory facilitatory response. This consisted mainly of an increase in respiratory rate. 4. At the majority of sites (16 out of 20) where changes in respiratory rate were elicited by glutamate injection or electrical stimulation an increase in blood pressure was observed. The coexistence of increases in blood pressure and heart rate indicates the presence of inhibition of the heart rate component of the baroreflex and/or an increase in cardiac sympathetic drive. 5. The expiratory facilitatory response was not evoked reflexly by the rise in blood pressure since it was still present after administration of guanethidine, which abolished the rise in blood pressure. 6. The interactions between the parabrachial nuclei and the medullary respiratory complex in eliciting these changes are discussed.

Effects of bronchoconstriction on the cough reflex in the cat.

The present study was aimed to analyse the influence of bronchoconstriction (Carbachol, 10 micrograms/kg, i.v.) on the cough response to mechanical stimulation of the tracheal mucosa. Experiments were performed in anaesthetised and spontaneously breathing cats, using the isolated glottis technique. Airflow, pleural pressure, subglottic pressure, blood pressure and total lung resistance were recorded. During bronchoconstriction, the cough response was inhibited significantly as shown by the decrease in the number of cough efforts (p < 0.001), in maximum flow during inspiratory (p < 0.001) and expiratory (p < 0.001) movements and in the change of the expiratory (p < 0.01) and inspiratory (p < 0.01) pleural pressures. The mechanical stimulation of the tracheal mucosa evoked always a prolonged decrease of the larynx resistance, including those cases with inhibition of the cough. This study shows that the activation of some type of receptors during bronchoconstriction can modify the cough response to mechanical stimulation of the tracheal mucosa. On the other hand, the widening of the glottis, an associated component of the cough response, can be obtained separately, suggesting that the laryngeal response is centrally integrated via different mechanisms.

Activity of inspiratory neurones of the ambiguus complex during cough in the spontaneously breathing decerebrate cat.

In spontaneously breathing, decerebrate cats, extracellular recordings in the intermediate region of the ambiguus complex have been used to characterize the activity of inspiratory laryngeal motoneurones (ILMNs) during mechanical stimulation of tracheal irritant receptors. Laryngeal resistance was measured using an isolated larynx in situ. The effect of tracheal stimulation was analysed successfully in twenty-seven neurones. Eleven were ILMNs and sixteen inspiration-related neurones. Inspiration-related neurones increased their phasic discharge frequency during tracheal stimulation while ILMNs fired tonically, during both the inspiratory and the expiratory efforts of the cough. The tonic discharge of ILMNs coincided with a decrease of laryngeal resistance.

Electroencephalographic study of naloxone effects in the recovery of an acute alcoholic intoxication.

Experimental assays analysing EEG changes during the recovery of an acute alcoholic intoxication were carried out in three groups of cats: 1) Recovery of acute alcoholic intoxication produced by continuous intravenous perfusion of ethanol, 0.06 g/kg/min, during 20 minutes. 2) Recovery of acute alcoholic intoxication by injecting naloxone (400 micrograms/kg), just after finishing alcohol perfusion. 3) Recovery of acute alcoholic intoxication by injecting naloxone (400 micrograms/kg), 15 min after finishing perfusion. Naloxone administered after an acute alcoholic intoxication worsens the recovery of EEG parameters; 1-2 (p less than 0.05), 1-3 (p less than 0.05).

[Changes in laryngeal resistance and bronchial tonus]. / Cambios de la resistencia laríngea y tono bronquial.

The modifications of larynx resistance changing bronchial tone were studied in cats. Changes on bronchial tone were evoked by intravenous administration of Carbachol (10 micrograms/kg) as bronchoconstrictor, and by Fenoterol (10 micrograms/kg) and Isoprenaline (0.1 mg/kg) as bronchodilators. The effects of Carbachol administration after these drugs were also studied. Larynx resistance was measured by the subglottic pressure value using the in situ isolated glottis technique. Subglottic pressure increases after Carbachol administration (p less than 0.001) and decreases after Fenoterol (p less than 0.02) and Isoprenaline (p less than 0.01). When Carbachol was administered after the bronchodilators subglottic pressure values were similar to those observed in control situations. A high positive correlation between changes of subglottic pressure and total lung resistance (p less than 0.01) was also observed. These results could suggest that glottis contraction was reflexively modified by bronchial tone.

[Effects of tobacco smoke applied on various levels of the respiratory tract]. / Efecto del humo del tabaco aplicado en distintos niveles de las vías respiratorias.

The respiratory and cardiovascular reflex responses of tobacco smoke inhaled through an isolated larynx and directly into the lungs were studied in cats. The inhalation of tobacco smoke directly into the lungs showed the following: tachypnea (p less than 0.01), an increase in inspiratory and expiratory pleural pressure (p less than 0.01, p less than 0.001) with an increase in total lung resistance (p less than 0.01), a decrease in inspiratory and expiratory subglottic pressure (p less than 0.001, p less than 0.02) and an increase in mean arterial pressure (p less than 0.001) with a non significant slight increase of cardiac rate. The inhalation through an isolated larynx showed: bradypnea (p less than 0.01), a non significative decrease in inspiratory and expiratory pleural pressure with no changes in total lung resistance, and an increase in expiratory subglottic pressure (p less than 0.01) with no changes in inspiratory pressure accompanied by several glottic closures. No changes in arterial pressure and cardiac rate were observed. This study shows the existence of two respiratory reflex responses induced by tobacco smoke depending on the respiratory airway level application.