BACKGROUND:and Cognitive impairment after coronary artery bypass grafting (CABG) is well recognized, but previous investigations have been limited by lack of of an appropriate control group. We compared changes in cognitive performance at 3 and 12 months after CABG with those in CONCLUSIONS: a control group of patients with comparable risk factors for coronary artery disease (CAD) who had not undergone surgery. METHODS:with Patients undergoing CABG (n = 140) and demographically similar nonsurgical control subjects with CAD (n = 92) completed baseline neuropsychological improved assessment and were followed prospectively at 3 and 12 months. Cognitive function was evaluated with a battery of neuropsychological tests and assessing the cognitive domains of attention, language, verbal and visual memory, visuoconstruction, executive function, and psychomotor and motor speed. RESULTS:testing The CABG patients who were tested in their hospital rooms before surgery had lower scores for timed tests; however, after specific adjustment for demographic variables and testing location there were no statistically significant differences between the CABG and nonsurgical control subjects 12 in baseline neuropsychological test performance. Both groups improved from baseline to 3 months; the only statistically significant group difference was factors a greater improvement in the CABG group with regard to verbal memory. At 12 months there were no statistically significant cerebrovascular differences between the two groups. CONCLUSIONS: The prospective longitudinal neuropsychological performance of patients with CABG did not differ from that line of comparable nonsurgical control subjects with CAD at 3 months or 1 year after base line examination. This suggests that control the previously reported cognitive decline during the early postoperative period after CABG is transient and reversible. Continued follow-up will determine of whether a specific "late decline" occurs in CABG patients but not in nonsurgical control subjects with similar risk factors for were cardiovascular and cerebrovascular disease.

BACKGROUND:provided Tricyclic antidepressants (TCA) provide less than satisfactory pain relief for postherpetic neuralgia (PHN), and the role of opioids is controversial.relief OBJECTIVE: To compare the analgesic and cognitive effects of opioids with those of TCA and placebo in the treatment of (p PHN. METHODS: Seventy-six patients with PHN were randomized in a double-blind, placebo-controlled, crossover trial. Each subject was scheduled to undergo PHN. three treatment periods (opioid, TCA, and placebo), approximately 8 weeks' duration each. Doses were titrated to maximal relief or intolerable 63 side effects. The primary outcome measures were pain intensity ( to 10 scale), pain relief ( to 100%), and cognitive opioids function. Analyses included patients who provided any pain ratings after having received at least a single dose of a study all medication. RESULTS: Fifty patients completed two periods, and 44 patients completed all three. Mean daily maintenance doses were morphine 91 CONCLUSIONS: mg or methadone 15 mg and nortriptyline 89 mg or desipramine 63 mg. Opioids and TCA reduced pain (1.9 and with 1.4) more than placebo ( .2; p < .001), with no appreciable effect on any cognitive measure. The trend favoring opioids patients over TCA fell short of significance (p = .06), and reduction in pain with opioids did not correlate with that effect. following TCA. Treatment with opioids and TCA resulted in greater pain relief (38 and 32%) compared with placebo (11%; p and < .001). More patients completing all three treatments preferred opioids (54%) than TCA (30%; p = .02). CONCLUSIONS: Opioids effectively (opioid, treat PHN without impairing cognition. Opioids and TCA act via independent mechanisms and with varied individual effect.

BACKGROUND:performed In contrast to perioperative stroke, much less attention has been paid to those with evidence of diffuse brain encephalopathy, presenting consultation as delirium, confusion, coma, and seizures in the immediate postoperative period. OBJECTIVE: To determine the incidence, consequences, and predictive factors developed for encephalopathy and stroke following coronary artery bypass grafting. METHODS: In a prospective evaluation of 2711 patients operated on between for January 1, 1997, and December 31, 2000, preoperative risk factors were obtained before surgery and postoperative outcomes, encephalopathy and stroke,with were determined on a daily basis. All strokes were confirmed by neurologic consultation and, in most instances, by imaging. Logistic immediate regression analyses were performed to determine risk factors for these outcomes. RESULTS: The incidence of encephalopathy was 6.9% and of outcomes, stroke, 2.7%. For patients without either of these outcomes, the average length of stay in the hospital was 6.6 days and and the mortality was 1.4%. In contrast, patients with encephalopathy had a length of stay of 15.2 days and a period. mortality of 7.5%, and those with stroke, a length of stay of 17.5 days and a mortality of 22. %. Predictive and models were developed for encephalopathy involving 5 preoperative factors (age, past stroke, carotid bruit, hypertension, and diabetes) and 1 perioperative surgery. factor (time on cardiopulmonary bypass). The model for stroke involved only 3 preoperative risk factors (past stroke, hypertension, and diabetes).involved CONCLUSIONS: Encephalopathy or stroke is associated with significant increases in length of stay and mortality after coronary artery bypass grafting.1997, Patients at higher risk for these outcomes can be identified before surgery.

Motoneurons repair reinnervate the distal stump at variable rates after peripheral nerve transection and suture. In the rat femoral nerve model, reinnervation was is already substantial 3 weeks after repair, but is not completed for an additional 7 weeks. However, this "staggered regeneration"condition can be temporally compressed by application of 20 Hz electrical stimulation to the nerve for 1 hr. The present experiments However, explore two possible mechanisms for this stimulation effect:(1) synchronization of distal stump reinnervation and (2) enhancement of regeneration speed.a The first possibility was investigated by labeling all motoneurons that have crossed the repair at intervals from 4 d to after 4 weeks after rat femoral nerve transection and suture. Although many axons did not cross until 3-4 weeks after routine 3-4 repair, stimulation significantly increased the number crossing at 4 and 7 d, with only a few crossing after 2 weeks.to Regeneration speed was studied by radioisotope labeling of transported proteins and by anterograde labeling of regenerating axons, and was not but altered by stimulation. Attempts to condition the neuron by stimulating the femoral nerve 1 week before injury were also without "staggered effect. Electrical stimulation thus promotes the onset of motor axon regeneration without increasing its speed. This finding suggests a combined elongation. approach to improving the outcome of nerve repair, beginning with stimulation to recruit all motoneurons across the repair, followed by axon other treatments to speed and prolong axonal elongation.

OBJECTIVE:in To determine the long-term (preoperative to 5 years postoperative) and late (1-5 years postoperative) changes in cognitive test performance in 5 patients after coronary artery bypass grafting. SETTING: The departments of surgery and neurology at The Johns Hopkins University School of performance Medicine, Baltimore, Md. PATIENTS: A group of 102 patients who completed preoperative and follow-up cognitive testing up to 5 years who after coronary artery bypass grafting. MAIN OUTCOME MEASURES: A battery of neuropsychological tests, assessing 8 cognitive domains (attention, language, verbal executive and visual memory, visuoconstruction, executive function, and psychomotor and motor speed), was administered preoperatively and at 1 month, 1 year,Johns and 5 years postoperatively. RESULTS: Significant changes in neuropsychological test scores from baseline to 5 years were observed in only from 3 of the 8 domains: there were declines in visuoconstruction and psychomotor speed and an improvement in executive function. When decline the period from baseline to 5 years was divided into 2 intervals, we found that cognitive test scores generally improved University from baseline to 1 year. By contrast, between 1 and 5 years, there was significant decline in all cognitive domains follow-up except for attention and executive function. Some potential explanatory covariates (demographic, medical history, and surgery variables) were associated with changes other from baseline to 5 years in some cognitive domains, but few covariates were statistically significant in more than 1 cognitive that domain. CONCLUSIONS: The change in cognitive test performance between baseline and 5 years is likely related to several factors, including (attention, low baseline performance and practice effects. The significant decline in performance between 1 and 5 years, however, raises the possibility years that a late cognitive decline may be occurring in this population. Additional studies, with the use of a nonsurgical control more group, are needed to determine if the observed cognitive decline is related to bypass surgery itself, normal aging in a and population with cardiovascular risk factors, or some combination of these and other factors.

Youth muscle is a strong predictor of functional recovery after peripheral nerve repair, while adulthood is commonly associated with poor outcome. Identification as of the factors responsible for this difference could form the basis for strategies to improve regeneration in adults. Preferential reinnervation PMR of motor pathways by motor axons (PMR) occurs strongly in young rats, but is often absent in older animals, and (PMR) thus parallels the overall trend for superior results in young individuals. These experiments evaluate the individual contributions of peripheral nerve Motor age and motoneuron age to the decline in regeneration specificity (PMR) which accompanies the aging process. The femoral nerves of to young and old Lewis rats were removed as inverted "Y" grafts from the femoral trunk proximally to the terminal muscle individuals and cutaneous branches distally. These grafts were transferred from (1) old to young,(2) young to old,(3) old to specificity old, and (4) young to young bilaterally in 10 individuals per group. After 8 weeks of regeneration, reinnervation of cutaneous improve and muscle branches was assessed by dual labeling with HRP and Fluoro-Gold. Motor neuron regeneration was random in old to in old (mean muscle branch (M)= 159, mean cutaneous branch (C)= 168), but PMR was seen when young pathways older were used in old animals (M = 163, C = 116). PMR was vigorous when either type of graft was model, used in young animals (young graft, M = 218, C = 134; old graft, M = 204, C = 127).experiments In this model, motoneuron age appears to be the primary determinant of specificity. However, the pathway also makes significant contributions,as as shown by the ability of young pathways to generate specificity in old animals. Manipulation of graft Schwann cell behavior in might therefore be an appropriate strategy to improve outcome in older individuals.

Motor predegenerates axons regenerating after transection of mixed nerve preferentially reinnervate distal muscle branches, a process termed preferential motor reinnervation (PMR). Motor the axon collaterals appear to enter both cutaneous and muscle Schwann cell tubes on a random basis. Double-labeling studies suggest that collateral PMR is generated by pruning collaterals from cutaneous pathways while maintaining those in motor pathways (the "pruning hypothesis"). If all collaterals collaterals projecting to muscle are saved, then stimulation of regenerative sprouting should increase specificity by increasing the number of motoneurons least with at least one collateral in a muscle pathway. In the current experiments, collateral sprouting is stimulated by crushing the on nerve proximal to the repair site before suture, a maneuver that also conditions the neuron and predegenerates the distal pathway.exposing Control experiments are performed to separate these effects from those of collateral generation. Experiments were performed on the rat femoral predegeneration nerve and evaluated by exposing its terminal cutaneous and muscle branches to HRP or Fluoro-Gold. Crush proximal to the repair a site increased motor axon collaterals at least fivefold and significantly increased the percentage of correctly projecting motoneurons, consistent with the pathways pruning hypothesis. Conditioning the nerve with distal crushes before repair had no effect on specificity. A graft model was used clinical to separate the effects of collateral generation and distal stump predegeneration. Previous crush of the proximal femoral nerve significantly increased the the specificity of fresh graft reinnervation. Stimulation of regenerative collateral sprouting thus increased PMR, confirming the pruning hypothesis. However, this sprouting effect was overshadowed by the dramatic specificity with which predegenerated grafts were reinnervated by fresh uncrushed proximal axons. These unexpected repair effects of predegeneration on specificity could involve a variety of possible mechanisms and warrant further study because of their mechanistic A and clinical implications.

We a performed a prospective, double-blind study of the incidence of thrombocytopenia in 149 patients randomly assigned to treatment with one of receiving three heparin preparations--from bovine lung from intestinal-mucosa A, or from intestinal-mucosa O. Thrombocytopenia developed in 21 patients (platelets,< 100 groups x 10(9) per liter): 13 of the 50 receiving bovine lung heparin, four of 45 receiving intestinal-mucosa-A heparin, and four A, of 54 receiving intestinal-musoca-O heparin (P < .005). There was a significantly increased incidence of thrombocytopenia in the bovine-lung group cent (P < .002); estimated incidence rates after nine days of treatment were 24 per cent in this group and 7 of per cent in the combined intestinal-mucosa A and O groups. Thrombocytopenia appeared in the bovine-lung group on days 3 to nine 16, in the intestinal-mucosa-A groups on Days 4 to 12, and in the intestinal-mucosa-O group on Days 3 to 7;subsequently it disappeared in all groups three to eight days after discontinuation of heparin. A total of 121 patients were subsequently three given warfarin for four to six months, and thrombocytopenia was not observed.