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An Update on Postoperative Cognitive DysfunctionTiffany L. Tsai, BA*, Laura P. Sands, PhD#, and Jacqueline M. Leung, MD, MPH¶Department of Anesthesia & Perioperative Care, University of California, San Francisco,94143-0648 (Tsai & Leung), and School of Nursing, Purdue University, West Lafayette, IN47907-2069 (Sands)IntroductionPostoperative cognitive dysfunction or decline (POCD) is increasingly recognized as acommon phenomenon after major surgery. 1-4 Because older age is a strong preoperativerisk factor of POCD,2 5 the incidence of POCD is expected to increase as the population ofolder surgical patients grows. Improving the measurement of POCD and identifying itsetiology is clinically important, as recent studies have associated POCD with impairments indaily functioning,6 premature departure from the labor market,7 and dependency ongovernment economic assistance after hospital discharge.7In this chapter, we will review the definitions of POCD and discuss current methodologicalissues in this growing area of research. We will also present relevant hypotheses on itspathophysiology and discuss the long-term significance of POCD.Broadly speaking, POCD refers to problems in thinking and memory after surgery. POCD isnot recognized yet in the International Classification of Diseases and is not listed as adiagnosis in the Diagnostic and Statistical Manual. The term POCD is used mostly inliterature to represent a decline in a variety of neuropsychological domains includingmemory, executive functioning, and speed of processing. POCD has been defined in aconsensus statement as "a spectrum of postoperative central nervous system (CNS)dysfunction both acute and persistent … including brain death, stroke, subtle neurologicsigns and neuropsychological impairment." 8POCD should be distinguished from delirium or dementia. Delirium describes an acuteconfusional state featuring disturbances in attention and decreased awareness of theenvironment.9,10 Delirium symptoms fluctuate during the course of the day, and the patientoften is disoriented. In addition, hallucinations and inappropriate communication orbehavior may be observed in the presence of delirium. In contrast, a typical patient withPOCD is oriented but exhibits significant declines from his or her own baseline level ofperformance on one or more neuropsychological domains.11-14 After surgery, changes incognitive status may present in the form of a frank delirium or POCD, or both. POCDdiffers from dementia, which describes a chronic, often insidious, decline in cognitiveCorresponding Author: Jacqueline M. Leung, MD, MPH.*Research Associate#Professor, School of Nursing¶Professor of Anesthesia & Perioperative CarePublisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to ourcustomers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review ofthe resulting proof before it is published in its final citable form. Please note that during the production process errors may bediscovered which could affect the content, and all legal disclaimers that apply to the journal pertain.NIH Public AccessAuthor ManuscriptAdv Anesth. Author manuscript; available in PMC 2011 January 1.Published in final edited form as:Adv Anesth. 2010 ; 28(1): 269–284. doi:10.1016/j.aan.2010.09.003.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript
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function. Alzheimer's disease remains the most common form of dementia, but there isconsiderable overlap in neurodegenerative disease.Selection of neurocognitive tests to measure POCDMost studies of POCD have focused on describing changes in brain functioning, and morespecifically, have studied either performance-based or self-report perceptions of changes inmemory, executive function, attention, learning, language, visual spatial skills, mathematics,motor function and anxiety or depression.15 Selection of neurocognitive tests to documentthese cognitive changes varies extensively between studies.15 This variability in choice oftests may be due to the absence of a clear, theoretically derived and empirically tested modelwhich describes the causes and outcomes of cognitive changes associated with the surgicalexperience. Therefore, while a consensus-recommended battery of tests was established over10 years ago,8 it was not accompanied by this necessary model,16 nor did it have anexplanation of how the tests within the battery met the consensus definition of POCD.Without the adoption of such a model, it is difficult to conclude whether tools intended todetect POCD are, in fact, assessing the presence of POCD.Since the consensus guidelines were published in 1995, diagnostic criteria for POCD havebeen suggested. One stated criterion specified that there must be significant changes inneuropsychological tests involving several of the following domains: learning and memory,attention, executive functioning and language.17 Additional areas for assessment suggestedby Deiner and Silverstein include declines in perception and abstract thinking.18 Althoughthese guidelines provide guidance for the selection of tools to assess for POCD, they werenot accompanied with specific justification for the choice of cognitive domains that shouldbe assessed when testing a patient for POCD. 16Recent reviews of POCD after cardiac 15 and noncardiac 19 surgery reveal that the two mostcommonly assessed cognitive domains assessed were 1) learning and memory and 2)attention and concentration. Of the studies included in these reviews, 97% of studiesincluding patients undergoing cardiac surgery included a memory and learning test and 70%of studies including patients undergoing noncardiac surgery included a memory and learningtest. Similarly, 94% of studies including patients undergoing cardiac surgery included anattention and concentration test and 57% of studies including patients undergoingnoncardiac surgery included an attention and concentration test. About one-third of studiesincluded tests of verbal and language skills and tests of visual and spatial skills. Still, fewerstudies included tests of numerical reasoning (6% for both types of subjects) or executivefunction (14% for cardiac surgery and 6% for noncardiac surgery subjects.) Few studiesreported the percent of subjects who experienced significant decline in performance aftersurgery for each cognitive test. Consequently, it is difficult to determine whether patterns ofdeficits in specific domains emerge across studies. One review concluded that declines inmemory and attention and psychomotor function were consistently found after coronaryartery bypass graft (CABG), but cautioned that the domains of POCD detected are likely tobe a function of the tests used to assess POCD. 20 Increased reporting of results forindividual tests would help inform the development of a conceptual framework that explainswhich domains of cognitive functioning are expected to be affected by different surgicalexperiences.Many studies have used composite measures of cognitive functioning to assess patients forthe presence of POCD. Nearly a third of studies of POCD in patients undergoing noncardiacsurgery incorporated composite measures of functioning in their protocol. 19 The mostcommonly used composite measure was the Mini Mental State Examination (MMSE); itwas included in 21% of reviewed studies. An important debate is whether compositeTsai et al.Page 2Adv Anesth. Author manuscript; available in PMC 2011 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript
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measures and composite scores should be used to detect POCD. Composite measures andcomposite scores do not differentiate which areas of neuropsychological functioning areaffected by the surgical experience. Understanding specific areas of neuropsychologicalfunctioning involved in POCD would not only advance conceptual models of POCD, butwould also help in specifying which self-care activities are likely to be affected by POCD.In contrast, Rasmussen and colleagues 21 suggest that the use of composite tests or scores isnot problematic because the purpose of the postoperative neuropsychological testing is todetect the presence of general, rather than specific, changes in cognitive functioning.Administration of neuropsychological testsThere are many procedural issues that should be considered when administering aneuropsychological protocol for the purpose of detecting POCD. 21,22 Those issues mightbe categorized into the following: test selection, test administration, and test scoring for thepurpose of detection of POCD. Test selection should be guided by choosing tests that havevalidity for detecting change in functioning in those domains of expected to be negativelyaffected by the surgical experience. In addition, there are several practical issues that shouldbe considered when choosing tests for the assessment of POCD. For example, it is importantto choose tests with difficulty levels that do not result in floor effects (many subjects scoringthe lowest score possible) or ceiling effects (many subjects scoring the highest scorepossible). 22 Tests that do not have floor or ceiling effects are likely to have greatersensitivity to detecting a change in functioning associated with surgery. Choosing tests withparallel versions reduces potential practice effects from remembering test stimuli fromearlier administrations. This is particularly problematic for word-list learning tasks becausesome subjects are able to recall words from a prior administration of the task. The parallelversions should be administered in a different order between subjects (e.g. orderedaccording to a Latin-square design) to avoid a potential form by occasion bias in results. 23Tests should be validated for the language in which they will be administered. For example,the difficulty of word list generation tasks that require the subject to list as many words aspossible that begin with a specific letter varies depending on the letter specified. 24Difficulty levels will vary across languages for the same letter.Administration of tests used to detect POCD should be standardized across occasions andsubjects. Consensus recommendations include that testing be conducted by "the samesuitably qualified and trained individual and that the tests minimize subjectivity and beperformed in a standardized manner."8 This recommendation is meant to reduce variance insubjects' tests scores that cannot be ascribed to the subjects' ability alone. Becausepreoperative performance may be negatively affected by surgery-associated anxiety, 22 it hasbeen suggested that the administration of mood and anxiety scales with theneuropsychological tests would allow for statistical adjustment of cognitive test scores bysubjects' mood state. 21Although a variety of scoring methods for the detection of POCD have been used acrossstudies, investigators generally agree that scoring methods should consider 1) baselineperformance, 2) practice effects, and 3) change on more than one neuropsychological test.8,16,22,25 Baseline assessments allow determination of whether an actual change in cognitivefunctioning occurred subsequent to the surgical event. Nearly half of studies of POCD havebeen conducted in adults undergoing cardiac surgery, a population at risk for cognitivechanges due to underlying heart or vessel disease. 26 Practice effects refer to improvement inperformance due to familiarity with test procedures and can occur in patients with 27 andwithout existing cognitive impairment. 28 A common way of measuring practice effects is tomeasure the average improvement in performance for a group of matched controls. Animportant question is how well the matched controls truly match the surgical population toTsai et al.Page 3Adv Anesth. Author manuscript; available in PMC 2011 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript
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which they are compared. For example, studies that provide comparisons between subjectsand controls reveal that controls differ from subjects with fewer males,5,29 lower depressionlevels,5 and lower rates of co-morbidity 30 and lower attrition rates in the control group.29Timing of Assessment for POCDAnother methodology issue in the study of POCD is that no general consensus has beenestablished thus far regarding the optimum timing of assessments after surgery. In previousstudies, cognitive function was measured beginning 1 day to as long as 5 years after surgery.POCD can be broadly divided into acute, intermediate and late or long-term changes basedon information from previous studies. Specifically, acute POCD has been used to describecognitive decline detected within one week after surgery, intermediate POCD for changeswithin 3 months, and long-term POCD for changes 1-2 years following surgery. However,the exact significance of detecting POCD at these various time points is unclear. The timeinterval at which a diagnosis of POCD holds the greatest clinical significance has not beendetermined, nor have any studies invalidated the importance of conducting assessments at aspecific time point.Early assessments of POCD likely capture a different phenomenon than what lateassessments of POCD capture, and each are accompanied by a unique set of issues. Surgery-related factors may affect test performance in the immediate postoperative period, includingacute pain,31-33 the use of drugs,23,34 nausea, limited mobility, and fatigue. Thus, it hasbeen argued that patients should not be evaluated for POCD until at least one weekpostoperatively.8,13,35 Recent evidence suggested this delay might be arbitrary, as negativeoutcomes are associated with POCD detected in the first week after surgery. In a 2008 studyof patients undergoing noncardiac surgery, POCD detected at hospital discharge (meanduration of stay, <7 days) was associated with an increased risk of death within the first 3months after surgery.5 Restricting testing to only the later postoperative period is alsoproblematic because many patients are already discharged within one week after surgery. Infact, recent data from the National Center for Health Statistics showed that the averagelengths of stay for patients between the ages of 45 to 84 years are currently between 5.0 to5.6 days.36 It has been reported that the average length of stay of patients over 50 years ofage who underwent major noncardiac surgery with no postoperative complications was 4days.37 In our study, 88% of those identified with POCD were discharged within a week ofsurgery.33 In addition, Rohan and colleagues reported that 47% of patients undergoingminor noncardiac surgery were found to have POCD before discharge. 38 These findingssuggest that limiting screening for POCD to seven days after surgery could result in missedrecognition of POCD in many surgical patients. In-hospital patient education usuallyincludes detailed instructions for wound care, administration of new medications, symptommonitoring, and details of needed restrictions in daily activities. If post-surgical patients areexperiencing POCD at the time of they are given self-care discharge instructions, theirability to understand and recall these instructions may be limited and may put them at riskfor post-surgical complications.The rate of patient attrition is noted to be lower in studies assessing for early than latePOCD. Newman et al. 19 reported a 5.4% attrition rate for evaluations performed between 7and 21 days after noncardiac surgery; 19% for evaluations between 22 days and 132 days;and 17% for evaluations beyond 6 months postoperatively. Patient attrition may be selective.In cohort studies, patients unavailable for follow up were more likely to be older patientswho had worse baseline cognitive performance39 or were sicker.40 If patients experiencingcognitive decline are more likely to decline assessment, this selective attrition will biasstudy results toward the null, obscuring the detection of cognitive changes postoperatively.Tsai et al.Page 4Adv Anesth. Author manuscript; available in PMC 2011 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript
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POCD assessments that occur in the immediate postoperative period are important forelucidating the relationship between POCD and delirium. Because POCD and delirium bothfeature deficits in attention, whether they are related events on a continuum or distinctconditions remains unclear. In a retrospective analysis of the International Study forPostoperative Cognitive Dysfunction (ISPOCD) research data, patients with postoperativedelirium had a higher incidence of POCD one week postoperatively.39 The ISPOCD studywas not initially designed to measure postoperative delirium as a primary outcome, sovalidated measures of delirium were not incorporated in the study protocol. It is not clearwhether detection of delirium via chart reviews and the Mini Mental State Examination(MMSE) performance has similar sensitivity and specificity for detecting delirium as that ofcommonly used measures such as the Confusion Assessment Methods (CAM).10 Althoughthe ISPOCD results seem to suggest that postoperative delirium and POCD appear to bediscrete events, other research provides support to the continuum hypothesis, specifically,that POCD is a subclinical from of delirium. For example, Monk et al. found that patientswho were delirious after major noncardiac surgery were also more likely to have POCD athospital discharge. 5 Furthermore, areas of cognitive functioning that show decline inpatients with POCD such as attention are common with criteria for detecting delirium. In astudy of older orthopedic patients, Lowry et al. identified a group of patients with "subsyndrome delirium," defined as those not meeting the CAM criteria for delirium butshowing a decline in global cognitive functioning as measured by the MMSE.41 Thesepatients exhibited greater declines in performance on attention tasks than did non-deliriouspatients within the first week after surgery. Because most cases of delirium occur in theearly postoperative period, an improved understanding of the relationship between POCDand delirium will be derived from additional studies that perform neurocognitive testing anddelirium assessment simultaneously within the first several days after surgery.Pathophysiology of POCDThe exact pathophysiology of POCD remains undefined. Previous studies on POCD havefocused on investigating the risk factors associated with early POCD. Table 1 describes thevariables that have been shown to be associated with early/intermediate POCD. In terms ofpatient-related baseline factors, or sometimes called predisposing factors, increasing age andlower levels of education have been identified as the main ones in the early study by theInternational Study on Postoperative Dysfunction (ISPOCD) 2. In a subsequent study byJohnson et al. 3 that included only a subset of the population reported in the initial study, theavoidance of alcohol intake was determined to be a predisposing factor for POCD. Patient'spreoperative cognitive status also has been shown to be associated with POCD. 42Whether patients have a genetic predisposition for development of POCD genotype is notwell understood because findings from studies to date are conflicting. Genetic studies frompopulation-based investigations 43,44 have demonstrated a relationship between certaingenotypes and the risk of dementia and cognitive decline. Specifically, elevated risk ofAlzheimer's disease has been demonstrated among individuals with the E4 allele of theapolipoprotein E (APOE) gene in many populations.45,46 The E4 allele of APOE isassociated with earlier onset of Alzheimer's disease. 47 However, the APOE E4 genotype isneither necessary nor sufficient for the occurrence of Alzheimer's disease. 47 The APOEpolymorphism also affects response to trauma, age-related cognitive decline 48 and severalother disorders. 49-51 APOE is a polymorphic protein associated with plasma lipoproteins.Three major isoforms can be recognized, designated as APOE2, APOE3 and APOE4,according to their relative position after isoelectric focusing. 52 APOE is unique amongapolipoproteins in that it has a special relevance to nervous tissue. 53 APOE is involved inthe mobilization and redistribution of cholesterol in repair, growth, and maintenance ofmyelin and neuronal membranes during development or after injury. 54-56 The three smallerTsai et al. Page 5Adv Anesth. Author manuscript; available in PMC 2011 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript
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studies that demonstrated an association between APOE allele and cognitive decline wereconducted in patients undergoing carotid endarterectomy and cardiac operations. 57-59 Thelargest study that failed to demonstrate an association between apolipoprotein E genotypeand POCD measured at one week or 3 months after surgery was conducted in patientsundergoing noncardiac surgery. 60 However, this study likely underestimated the incidenceof POCD since they considered any patients who were not "fit enough for testing" as nothaving POCD. Recently, McDonagh et al. conducted a study in 394 older patientsundergoing noncardiac surgery and similarly reported that apolipoprotein E4 was notassociated with POCD measured at 6 weeks or at one year after surgery. 42 Similarly, otherbiomarkers such as B-type natriuretic peptide, C-reactive protein, D-dimer, matrixmettaloproteinase-9, neuron-specific enolase, and S-100b also had no association withPOCD measured at 6 weeks or at one year after surgery. The results on apolipoprotein E4are in contrast to our work in 190 older patients undergoing noncardiac surgery, in which,the presence of one copy of the E4 allele was associated with an increased risk of earlypostoperative delirium. 61 Even after adjusting for co-variates, patients with one copy of thee4 allele were still more likely to have an increased risk of early postoperative deliriumcompared to those without the E4 allele. In contrast to the studies by Abildstrom et al., 60and by McDonagh et al., 42 we measured delirium in the first few days after surgery whereasthe other investigators measured POCD at 6 weeks after surgery. One small study incritically ill patients corroborated our findings that apolipoprotein E4 was associated with alonger duration of delirium. 62 Methodological differences between delirium and cognitiveassessments, difference in the timing of assessments, and potential differences in patientpopulations among different studies may result in differences in the findings. Nevertheless,the possible link between postoperative delirium and genetic predisposition is intriguing.What is the possible mechanism between apolipoprotein and postoperative delirium?Previous studies suggest that the effects of APOE are mediated through alterations in lipidtransport in regenerating neurons, proinflammatory cytokine release from activatedmicroglia, amyloid precursor protein metabolism, increased blood brain carrier permeability,alterations in platelet function, and systemic inflammation. 63,64,65 One hypothesizedmechanism is that APOE e4 allele diminishes the capacity for repair in cases of cerebralinjury or capacity for homeostasis/maintenance. Whether this mechanism occurs to increasethe likelihood of developing postoperative delirium remains to be proven.In addition to predisposing risk factors, numerous potential precipitating risk factors forPOCD have been investigated (table 2). The early ISPOCD study reported that the durationof anesthesia, a second operation, postoperative infections, and pulmonary complications2increase the risk of POCD. In cardiac surgery, the use of cardiopulmonary bypass has beenimplicated as one of the precipitating factors. 66,67 During cardiopulmonary bypass,cannulation of the aortic root may result in cerebral microemboli, which could lead toPOCD. 68 In addition, a profound systemic inflammatory response occurs withcardiopulmonary bypass, which may contribute to POCD. 69 However, despite the earlierreports that POCD is prevalent after cardiac surgery, 66,67 studies in patients who underwentcardiac surgery without the use of cardiopulmonary bypass did not demonstrate a lowerincidence of POCD, despite a smaller embolic load in the middle cerebral artery measuredby Doppler in patients undergoing off-pump surgery. 70,71 Thus, it remains inconclusivehow surgery type actually affects POCD. Similarly, whether the type of anesthesia affectsPOCD remains inconclusive. In experimental settings involving animals, general anestheticsproduced neurotoxicity and subsequent cognitive impairment in young and aged animals,but whether these changes are reproducible in clinical studies has not been determined. 72Most previous studies compared the cognitive outcomes between general vs. regionalanesthesia. Earlier studies suggested an association between general anesthesia and a higherincidence of cognitive dysfunction relative to epidural anesthesia. 73,74 However, recentTsai et al.Page 6Adv Anesth. Author manuscript; available in PMC 2011 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript
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studies concluded that there was no relationship between anesthetic techniques and themagnitude or pattern of postoperative cognitive dysfunction. 1,2,4,75If anesthesia type did not seem to affect POCD, what about the conduct of anesthesia? Theinfluence of intraoperative hypotension on POCD has also been evaluated. In a prospective,randomized study of older adults (age > 50 years) undergoing total hip replacement,Williams-Russo et al. 76 demonstrated that patients who underwent epidural anesthesia andwere rendered markedly hypotensive had similar incidence of postoperative cognitivedysfunction as those who were maintained in the normotensive state. Taken together, todate, no single anesthetic type or technique has been identified to be superior in minimizingPOCD for older surgical patients.Given that the type of surgery and anesthetic type and management do not appear toinfluence rates of POCD, our group has focused on events in the postoperative period thatmay influence POCD, given that patients experience substantial pain postoperatively and areadministered many medications with central nervous system effects. In 225 patients ≥ 65years of age undergoing noncardiac surgery, we measured POCD in the first twopostoperative days. 33 In patients without postoperative delirium, 13% of patientsexperienced POCD on day 1, 7% on day 2, and 15% had POCD on either day 1 or day 2after the surgery. Multivariate regression analyses revealed that only postoperative analgesiawas associated with the development of POCD. Compared to those receiving postoperativeanalgesia through a patient-controlled analgesia device that administered opioidsintravenously, those who received postoperative analgesia orally were at significantly lowerrisk for the development of POCD. Our results demonstrate that older patients undergoingnoncardiac surgery who are not delirious can experience significant declines in cognitivefunctioning postoperatively. Those at least risk of experiencing POCD were those whoreceived postoperative analgesia orally. Opioid analgesics administered orally may result ina lower blood level of the drug due to first-pass effect when compared to intravenouslyadministered narcotics which may directly cross the blood brain barrier. Alternatively, theuse of oral narcotics for postoperative analgesia may be a marker for a less painful state.However, this result remains significant even when adjusting for the level of pain.In addition to studies targeting the identification of risk factors of POCD, recentinvestigations have focused on identifying the pathophysiology for POCD. Surgery canresult in a complex systemic response, which includes neuroinflammation. 77 Systemic andneural inflammation, which occur as a result of surgery, may directly affect patient outcome.For example, blood loss and tissue injury in orthopedic procedures might affect the immunesystem to produce an inflammatory response. 78 Data from preclinical studies support theconcept that inflammation is a possible pathogenic mechanism for POCD, and cytokinessuch as interluekin-1β have been implicated. 79-81 However, the clinical relevance of theseexperimental findings remains to be determined. Future studies using translational andmultidisciplinary approaches are indicated to determine the role of inflammation as apossible causative factor in the pathophysiology of POCD.Finally, cognitive reserve and a patient's propensity in developing adverse postoperativeneurological outcomes need to be considered when discussing the pathophysiology ofPOCD. A hypothetical construct coined "cognitive reserve" has been used to describemodels of cognitive aging and situations where the brain sustains injury.82 Surrogates ofcognitive reserve have included education level, occupational attainment, and performanceon tests of knowledge (such as vocabulary). Evidence that greater educational attainment isassociated with a reduced relative risk of developing Alzheimer's disease has beendemonstrated in many previous studies.83-85 The association between lower occupationalattainment and incident dementia has been found in a number of studies as well.86 AlthoughTsai et al.Page 7Adv Anesth. Author manuscript; available in PMC 2011 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript
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cognitive reserve is typically invoked as an important concept in dementia research, there isalso evidence that cognitive reserve may play a protective role against POCD. As a result,future research targeting the role of cognitive reserve in POCD and postoperative delirium isan intriguing idea and should be pursued.Long-term significance of POCDThe question of whether major surgery and anesthesia ultimately lead to long-term cognitivedecline is controversial. In a population study, Dijkstra et al.87 reported that the number ofoperations and the total duration of anesthesia were related to the number of subject health-related complaints but did not predict cognitive performance or memory complaints. Severalother studies that included assessments more than 6 months after surgery similarly reportedno decline in cognitive status from that measured before surgery.88-92 However, two recentstudies that included patients who had undergone noncardiac surgery reported that acutePOCD was associated with increased mortality after surgery (for one study, at one year; andfor the second study, at 3 months).5,7 Also, in cardiac surgical patients, Newman et al.93provided data showing that cognitive function at discharge was a significant predictor oflong-term cognitive function. In contrast, a recent study by Avidan et al., provide results tothe contrary. 94 In this study, the investigators enrolled participants from an Alzheimer'sdisease research center who had substantial pre-event data. The subjects were stratified intothree groups based on whether they underwent surgery, were admitted to a hospital for amajor illness not requiring surgery, or did not undergo surgery and had no major illness(control group). Subjects were assessed annually, and some were assessed for as many as 21years. The battery of neuropsychological tests administered at each occasion wascomprehensive of those domains of cognitive function known to be affected in the presenceof drugs and other precipitating events. The sophisticated statistical methods used in thisstudy allowed assessments of subjects' trajectory of cognitive performance before and afterthe event of interest. The study findings suggested that neither non-demented nor mildlydemented individuals had accelerated long-term decline in cognitive function attributable tosurgery or major illness compared with matched controls. Clearly, whether early POCD isrelated to accelerated long-term decline in cognitive function was not completely addressedby this study since cognitive assessments were not synchronized with hospitalization.Therefore, a definitive study to address the prognostic significance of cognitive dysfunctionassociated with surgery and/or hospitalization needs to include sufficient sample size andboth short-term and long-term longitudinal assessments to more fully understand how majorillness and surgery impacts quality of life and cognitive functioning, and to determineultimately if there are reversible precipitating factors that are modifiable. Continuingresearch on POCD may also shed light about the pathophysiology of otherneurodegenerative disease including Alzheimer's disease.SummaryNumerous studies over the past decade have reported an acute change in cognitive status inadult patients after major surgery. Most evidence suggests that these early cognitive changesare transitory and do not persist in the long term. However, the prognostic significance ofPOCD remains a hotly debated topic, especially in light of recent data showing that patientswith early POCD were at higher risk of mortality after discharge.Furthermore, whether patients with early POCD actually have preexisting mild cognitiveimpairment and experience a steeper downward cognitive trajectory independent of theeffect of anesthesia and surgery is another question that warrants further investigation. Weanticipate that future studies will elucidate better the pathophysiology of POCD through theuse of large sample sizes and longitudinally collected patient data in both the early and lateTsai et al.Page 8Adv Anesth. Author manuscript; available in PMC 2011 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript
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postoperative period. We also advocate for a theoretically derived and empirically testedmodel which describes the causes and outcomes of POCD. Such a model must beestablished in order to truly standardize the neurocognitive test battery and timing ofadministration in the study of POCD.AcknowledgmentsSupported in part by NIH 1RO1AG031795-02References1. Williams-Russo P, Sharrock N, Mattis S, Szatrowski T, Charlson M. Cognitive effects after epiduralvs general anesthesia in older adults. JAMA 1995;274:44–50. [PubMed: 7791257]2. Moller J, Cluitmans P, Rasmussen L, Houx P, Rasmussen H, Canet J, Rabbitt P, Jolles J, Larsen K,Hanning C, Langeron O, Johnson T, Lauven P, Kristensen P, Biedler A, van Beem H, Fraidakis O,Silverstein J, Beneken J, Gravenstein J, ISPOCD investigators. Long-term postoperative cognitivedysfunction in the elderly: ISPOCD1 study. Lancet 1998;351:857–861. [PubMed: 9525362]3. Johnson T, Monk T, Rasmussen LS, Abildstrom H, Houx P, Korttila K, Kuipers HM, Hanning CD,Siersma VD, Kristensen D, Canet J, Ibanaz MT, Moller JT. Postoperative cognitive dysfunction inmiddle-aged patients. Anesthesiology 2002;96:1351–7. [PubMed: 12170047]4. Rasmussen LS, Johnson T, Kuipers HM, Kristensen D, Siersma VD, Vila P, Jolles J, PapaioannouA, Abildstrom H, Silverstein JH, Bonal JA, Raeder J, Nielsen IK, Korttila K, Munoz L, Dodds C,Hanning CD, Moller JT. Does anaesthesia cause postoperative cognitive dysfunction? Arandomised study of regional versus general anaesthesia in 438 elderly patients. Acta AnaesthesiolScand 2003;47:260–6. [PubMed: 12648190]5. Monk TG, Weldon BC, Garvan CW, Dede DE, van der Aa MT, Heilman KM, Gravenstein JS.Predictors of cognitive dysfunction after major noncardiac surgery. Anesthesiology 2008;108:18–30. [PubMed: 18156878]6. Phillips-Bute B, Mathew JP, Blumenthal JA, Grocott HP, Laskowitz DT, Jones RH, Mark DB,Newman MF. Association of neurocognitive function and quality of life 1 year after coronary arterybypass graft (CABG) surgery. Psychosom Med 2006;68:369–75. [PubMed: 16738066]7. Steinmetz J, Christensen KB, Lund T, Lohse N, Rasmussen LS. Long-term consequences ofpostoperative cognitive dysfunction. Anesthesiology 2009;110:548–55. [PubMed: 19225398]8. Murkin J, Newman S, Stump D, Blumenthal J. Statement of consensus on assessment ofneurobehavioral outcomes after cardiac surgery. Annals of Thoracic Surgery 1995;59:1289–1295.[PubMed: 7733754]9. Lipowski Z. Delirium (acute confusional states). JAMA 1987;258:1789–1792. [PubMed: 3625989]10. Inouye S, vanDyck C, Alessi C, Balkin S, Siegal AP, Horwitz R. Clarifying confusion: theconfusion assessment method. Annals of Internal Medicine 1990;113:941–948. [PubMed:2240918]11. Blumenthal J, Mahanna E, Madden D, White W, Croughwell N, Newman M. Methodologicalissues in the assessment of neuropsychologic function after cardiac surgery. Ann Thorac Surg1995;59:1345–1350. [PubMed: 7733766]12. Makensen G, Gelb A. Postoperative cognitive deficits: more questions than answers. EuropeanJournal of Anaesthesiology 2004;21:85–88. [PubMed: 14977337]13. Hanning CD. Postoperative cognitive dysfunction. Br J Anaesth 2005;95:82–7. [PubMed:15640305]14. Wu C, Hsu W, Richman J, Raja S. Postoperative cognitive function as an outcome of regionalanesthesia and analgesia. Regional Anesthesia and Pain Medicine 2004;29:257–268. [PubMed:15138912]15. Rudolph J, Schreiber K, Culley D, McGlinchey R, Crosby G, Levitsky S, Marcantonio E.Measurment of post-operative cognitive dysfunction after cardiac surgery: as systematic review.Acta Anaesthesiological Scandinavica 2010;54:663–677.Tsai et al.Page 9Adv Anesth. Author manuscript; available in PMC 2011 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript
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16. Lewis M, Maruff P, Silbert B. Statistical and conceptual issues in defining postoperative cognitivedysfunction. Neurosci Biobehav Rev 2004;28:433–40. [PubMed: 15289007]17. Bekker A, Weeks E. Cognitive function after anaesthesia in the elderly. Best Practices andResearch in Clinical Aneaesthesiology 2003;17:259–273.18. Deiner S, Silverstein JH. Postoperative delirium and cognitive dysfunction. Br J Anaesth 2009;1031:i41–46. [PubMed: 20007989]19. Newman S, Stygall J, Hirani S, Shaefi S, Maze M. Postoperative cognitive dysfunction afternoncardiac surgery. Anesthesiology 2007;106:572–590. [PubMed: 17325517]20. Symes E, Maruff P, Ajani A, Currie J. Issues associated with the identification of cognitive changefollowing coronary artery bypass grafting. Aust N Z J Psychiatry 2000;34:770–84. [PubMed:11037363]21. Rasmussen L, Larsen K, Houx P, Skovgaard L, Hanning C, Moller J. The assessment ofpostoperative cognitive function. Acta Anaesthesiological Scandinavica 2001;45:275–289.22. Funder K, Steinmetz J, Rasmussen L. Methodological issues of postoperative cognitivedysfunction research. Seminars in cardiothoracic and vascular anesthesia 2010;14:119–122.[PubMed: 20478952]23. Sands L, Katz I, Doyle S. Detecting subclinical change in cognitive functioning in older adults.Part I: Explication of the method. Am J Geriatr Psychiatry 1993;1:1–13.24. Borkowski J, Benton A, Spreen O. Word fluency and brain damage. Neuropsychologica1967;5:135–140.25. Sauer AM, Kalkman C, van Dijk D. Postoperative cognitive decline. J Anesth 2009;23:256–9.[PubMed: 19444566]26. Rafnsson SB, Deary IJ, Smith FB, Whiteman MC, Fowkes FG. Cardiovascular diseases anddecline in cognitive function in an elderly community population: the Edinburgh Artery Study.Psychosom Med 2007;69:425–34. [PubMed: 17556639]27. Sands LP, Phinney A, Katz IR. Monitoring Alzheimer's patients for acute changes in cognitivefunctioning. American Journal of Geriatric Psychiatry 2000;8:47–56. [PubMed: 10648295]28. Sands L, Katz I, Doyle S. Detecting sublinical change in cognitive functioning in older adults: part2 initial validation of the method. The American Journal of Geriatric Psychiatry 1993;1:275–287.29. Keizer AM, Hijman R, Kalkman CJ, Kahn RS, van Dijk D. The incidence of cognitive declineafter (not) undergoing coronary artery bypass grafting: the impact of a controlled definition. ActaAnaesthesiol Scand 2005;49:1232–5. [PubMed: 16146457]30. Silbert BS, Maruff P, Evered LA, Scott DA, Kalpokas M, Martin KJ, Lewis MS, Myles PS.Detection of cognitive decline after coronary surgery: a comparison of computerized andconventional tests. Br J Anaesth 2004;92:814–20. [PubMed: 15064253]31. Duggleby W, Lander J. Cognitive status and postoperative pain: older adults. J Pain SymptomManage 1994;9:19–27. [PubMed: 8169456]32. Heyer E, Sharma R, Winfree C, Mocco J, McMahon D, McCormick P, Quest D, McMurtry J,Riedel C, Lazar R, Stern Y, Connolly E. Severe pain confounds neuropsychological testperformance. Journal of Clinical and Experimental Neuropsychiatry 2000;22:633–639.33. Wang Y, Sands L, Vaurio L, Mullen A, Leung J. The effects of postoperative pain and itsmanagement on postoperative cognitive dysfunction. Am J Geriatr Psychiatry 2007;15:50–59.[PubMed: 17194815]34. Ersek M, Cherrier MM, Overman SS, Irving GA. The cognitive effects of opioids. Pain ManagNurs 2004;5:75–93. [PubMed: 15297954]35. Rasmussen, L.; Stygall, J.; Newman, SP. Cognitive Dysfunction and Other Long-TermComplications of Surgery and Anesthesia. In: Miller, RD., editor. Miller's Anesthesia. 7th. Vol. 2.Philadelphia, PA: Churchill Livingstone/Elsevier; 2009. p. xxiip. 3084p. I-8936. National Center for Health Statistics (U.S.). Health, United States, 2009: With Special Feature onMedical Technology. Hyattsville, Md.: Dept. of Health and Human Services, Centers for DiseaseControl and Prevention, National Center for Health Statistics; 2010.37. Fleischmann KE, Goldman L, Young B, Lee TH. Association between cardiac and noncardiaccomplications in patients undergoing noncardiac surgery: outcomes and effects on length of stay.Am J Med 2003;115:515–20. [PubMed: 14599629]Tsai et al.Page 10Adv Anesth. Author manuscript; available in PMC 2011 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript
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38. Rohan D, Buggy DJ, Crowley S, Ling FK, Gallagher H, Regan C, Moriarty DC. Increasedincidence of postoperative cognitive dysfunction 24 hr after minor surgery in the elderly. Can JAnaesth 2005;52:137–42. [PubMed: 15684252]39. Rudolph JL, Marcantonio ER, Culley DJ, Silverstein JH, Rasmussen LS, Crosby GJ, Inouye SK.Delirium is associated with early postoperative cognitive dysfunction. Anaesthesia 2008;63:941–7.[PubMed: 18547292]40. Borowicz LM, Goldsborough MA, Selnes OA, McKhann GM. Neuropsychologic change aftercardiac surgery: a critical review. J Cardiothorac Vasc Anesth 1996;10:105–11. quiz 111-2.[PubMed: 8634375]41. Lowery DP, Wesnes K, Brewster N, Ballard C. Subtle deficits of attention after surgery:quantifying indicators of sub syndrome delirium. Int J Geriatr Psychiatry. 201042. McDonagh DL, Mathew JP, White WD, Phillips-Bute B, Laskowitz DT, Podgoreanu MV,Newman MF. Cognitive function after major noncardiac surgery, apolipoprotein E4 genotype, andbiomarkers of brain injury. Anesthesiology 2010;112:852–9. [PubMed: 20216394]43. Yaffe K, Cauley J, Sands L, Browner W. Apolipoprotein E phenotype and cognitive decline in aprospective study of elderly community women. Arch Neurol 1997;54:1110–1114. [PubMed:9311354]44. Slooter A, Tang MX, van Duign C, Stern Y, Ott A, Bell K, Breteler M, Broeckhoven C, TatemichiT, Tycko B, Hofman A, Mayeux R. Apolipoprotein E ε4 and the risk of dementia with stroke. Apopulation-based investigation. JAMA 1997;277:818–821. [PubMed: 9052712]45. Henderson A, Easteal S, Jorm A, Mackinnon A, Korten A, Christensen H, Croft L, Jacomb P.Apolipoprotein E allele ε4, dementia, and cognitive decline in a population sample. Lancet1995;346:1387–1390. [PubMed: 7475820]46. Maestre G, Ottman R, Stern Y, Gurland B, Chun M, Tang M, Shelanski M, Tycko B, Mayeux R.Apolipoprotein E and Alzheimer's disease: ethnic variation in genotypic risks. Ann Neurol1995;37:254–259. [PubMed: 7847867]47. Bird TD. Genetic factors in Alzheimer's disease. N Engl J Med 2005;352:862–4. [PubMed:15745976]48. Dik M, Jonker C, Bouter L, Geerlings M, van Kamp G, Deeg D. APOE-e4 is associated withmemory decline in cognitively impaired elderly. Neurology 2000;54:1429–1497.49. Lahoz C, Schaefer E, Cupples L, Wilson P, Levy D, Osgood D, Parpos S, Pedro-Botet J, Daly J,Ordovas J. Apolipoprotein E genotype and cardiovascular disease in the Framingham Heart Study.Atherosclerosis 2001;154:529–537. [PubMed: 11257253]50. Davignon J, Gregg R, Sing C. Apolipoprotein E polymorphism and atherosclerosis.Arteriosclerosis 1988;8:1–21. [PubMed: 3277611]51. Stengard J, Zebra K, Pekkanen J, Ehnholm C, Nissinen A, Sing C. Apolipoprotein Epolymorphism predicts death from coronary heart disease in a longitudinal study of elderly Finnishmen. Circulation 1995;91:265–269. [PubMed: 7805227]52. Mahley, R.; Rall, S. Type III hyperlipoproteinemia (dysbetalipoproteinemia): the role ofapolipoprotein E in normal and abnormal lipoprotein metabolism. In: Scriver, C.; Beaudet, A.; Sly,W.; Valle, D., editors. The metabolic and molecular bases of inherited disease. New York:McGraw-Hill; 2001. p. 2835-2862.53. Poirier J, Hess M, May P, Finch C. Astrocytic apolipoprotein E mRNA and GFAP mRNA inhippocampus after entorhinal cortex lesioning. Mol Brain Res 1991;11:97–106. [PubMed:1661818]54. Boyle J, Zoellner C, Anderson L. A role for apolipoprotein E, apolipoprotein A-1, and low densitylipoprotein receptors in cholesterol transport during regeneration and remyelination of rat sciaticnerve. J Clin Invest 1989;83:1015–1031. [PubMed: 2493483]55. LeBlanc A, Poduslo J. Regulation of apolipoprotein E gene expression after injury of the rat sciaticnerve. J Neurosci Res 1990;25:162–171. [PubMed: 2319626]56. Mahley R. Apolipoprotein E: Cholesterol transport protein with expanding role in cell biology.Science 1988;1988:622–630. [PubMed: 3283935]57. Tardiff BE, Newman MF, Saunders AM, Strittmatter WJ, Blumenthal JA, White WD, CroughwellND, Davis RD Jr, Roses AD, Reves JG. Preliminary report of a genetic basis for cognitive declineTsai et al.Page 11Adv Anesth. Author manuscript; available in PMC 2011 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript
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after cardiac operations. The Neurologic Outcome Research Group of the Duke Heart Center. AnnThorac Surg 1997;64:715–20. [PubMed: 9307463]58. Heyer EJ, Wilson DA, Sahlein DH, Mocco J, Williams SC, Sciacca R, Rampersad A, Komotar RJ,Zurica J, Benvenisty A, Quest DO, Todd G, Solomon RA, Connolly ES Jr. APOE-epsilon4predisposes to cognitive dysfunction following uncomplicated carotid endarterectomy. Neurology2005;65:1759–63. [PubMed: 16207841]59. Lelis RG, Krieger JE, Pereira AC, Schmidt AP, Carmona MJ, Oliveira SA, Auler JO Jr.Apolipoprotein E4 genotype increases the risk of postoperative cognitive dysfunction in patientsundergoing coronary artery bypass graft surgery. J Cardiovasc Surg (Torino) 2006;47:451–6.60. Abildstrom H, Christiansen M, Siersma VD, Rasmussen LS. Apolipoprotein E genotype andcognitive dysfunction after noncardiac surgery. Anesthesiology 2004;101:855–61. [PubMed:15448517]61. Leung J, Sands L, Wang Y, Poon A, Kwok PY, Kane J, Pullinger C. Apolipoprotein E e4 alleleincreases the risk of early postoperative delirium in older patients undergoing noncardiac surgery.Anesthesiology 2007;107:406–411. [PubMed: 17721242]62. Ely EW, Girard TD, Shintani AK, Jackson JC, Gordon SM, Thomason JW, Pun BT, Canonico AE,Light RW, Pandharipande P, Laskowitz DT. Apolipoprotein E4 polymorphism as a geneticpredisposition to delirium in critically ill patients. Crit Care Med 2007;35:112–7. [PubMed:17133176]63. Parihar MS, Hemnani T. Alzheimer's disease pathogenesis and therapeutic interventions. J ClinNeurosci 2004;11:456–67. [PubMed: 15177383]64. Tsuang DW, Bird TD. Genetics of dementia. Med Clin North Am 2002;86:591–614. [PubMed:12171060]65. Moretti EW, Morris RW, Podgoreanu M, Schwinn DA, Newman MF, Bennett E, Moulin VG, MbaUU, Laskowitz DT. APOE polymorphism is associated with risk of severe sepsis in surgicalpatients. Crit Care Med 2005;33:2521–6. [PubMed: 16276176]66. Newman MF, Mathew JP, Grocott HP, Mackensen GB, Monk T, Welsh-Bohmer KA, BlumenthalJA, Laskowitz DT, Mark DB. Central nervous system injury associated with cardiac surgery.Lancet 2006;368:694–703. [PubMed: 16920475]67. Selnes OA, Goldsborough MA, Borowicz LM, McKhann GM. Neurobehavioural sequelae ofcardiopulmonary bypass. Lancet 1999;353:1601–6. [PubMed: 10334272]68. Pugsley W, Klinger L, Paschalis C, Treasure T, Harrison M, Newman S. The impact ofmicroemboli during cardiopulmonary bypass on neuropsychological functioning. Stroke1994;25:1393–9. [PubMed: 8023354]69. Mathew JP, Shernan SK, White WD, Fitch JC, Chen JC, Bell L, Newman MF. Preliminary reportof the effects of complement suppression with pexelizumab on neurocognitive decline aftercoronary artery bypass graft surgery. Stroke 2004;35:2335–9. [PubMed: 15331798]70. Jensen J, Hedin L, Widell C, Agnhom P, Andersson B, Fu M. Characteristics of heart failure in theelderly--a hospital cohort registry-based study. Int J Cardiol 2008;125:191–6. [PubMed:18029036]71. Liu YH, Wang DX, Li LH, Wu XM, Shan GJ, Su Y, Li J, Yu QJ, Shi CX, Huang YN, Sun W. Theeffects of cardiopulmonary bypass on the number of cerebral microemboli and the incidence ofcognitive dysfunction after coronary artery bypass graft surgery. Anesth Analg 2009;109:1013–22.[PubMed: 19762724]72. Culley DJ, Xie Z, Crosby G. General anesthetic-induced neurotoxicity: an emerging problem forthe young and old? Curr Opin Anaesthesiol 2007;20:408–13. [PubMed: 17873593]73. Hole A, Terjesen T, Brevik H. Epidural versus general anaesthesia for total hip arthroplasty inelderly patients. Acta Anaesthesiol Scand 1980;24:279–287. [PubMed: 7468115]74. Berggren D, Gustafson Y, Eriksson B, Bucht G, Hansson LI, Reiz S, Winblad B. Postoperativeconfusion after anesthesia in elderly patients with femoral neck fractures. Anesth Analg1987;66:497–504. [PubMed: 3578861]75. O'Hara D, Duff A, Berlin J, Poses R, Lawrence V, Huber E, Noveck H, Strom B, Carson J. Theeffect of anesthetic technique on postoperative outcomes in hip fracture repair. Anesthesiology2000;92:947–957. [PubMed: 10754613]Tsai et al.Page 12Adv Anesth. Author manuscript; available in PMC 2011 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript
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96. Leung J, Sands L, Mullen E, Wang Y, Vaurio L. Preoperative depression increases the risk ofpostoperative delirium in geriatric surgical patients. Anesthesiology (abstract) 2004:A-66.97. Leung JM, Sands LP, Vaurio LE, Wang Y. Nitrous oxide does not change the incidence ofpostoperative delirium or cognitive decline in elderly surgical patients. Br J Anaesth 2006;96:754–60. [PubMed: 16670110]98. Leung JM, Sands LP, Paul S, Joseph T, Kinjo S, Tsai T. Does postoperative delirium limit the useof patient-controlled analgesia in older surgical patients? Anesthesiology 2009;111:625–31.[PubMed: 19672166]99. Vaurio L, Sands L, Wang Y, Mullen E, Leung J. The role of pain and medications on postoperativedelirium. Anesth Analg 2006;102:267–273.Tsai et al.Page 14Adv Anesth. Author manuscript; available in PMC 2011 January 1.NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author Manuscript
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NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptTsai et al.Page 15Table 1Patient-related risk factors for early/intermediate POCDPatient-related risk factorsSupporting evidenceAgeISPOCD, Stockton, Ancelin, Monk 2,5,91,95EducationISPOCD, Monk 2,5Burden of illnessMonk 5Preoperative depressionLeung (delirium only) 96Preoperative cognitive impairmentJohnson 3Preoperative habits and drug useMonk 5Apolipoprotein E4Heyer, Telis, Leung, Tardiff57-59,61Proposed patient-related risk factors of POCD and studies with supporting evidence.ISPOCD = International Study on Post-Operative Cognitive DysfunctionAdv Anesth. Author manuscript; available in PMC 2011 January 1.
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NIH-PA Author ManuscriptNIH-PA Author ManuscriptNIH-PA Author ManuscriptTsai et al.Page 16Table 2Precipitating factors for early/intermediate POCDPrecipitating factorsSupporting evidenceRefuting evidenceSecond operationISPOCD 2Monk 5Postoperative infectionISPOCD 2Monk 5Respiratory complicationsISPOCD 2Monk 5General anesthetic?ISPOCD, Williams-Russo4,76Anesthetic type?Leung 97Anesthetic maintenance (hypotension)?Williams-Russo1Pain managementLeung 98,99?Proposed precipitating factors for early or intermediate POCD and studies with supporting or refuting evidence.ISPOCD = International Study on Post-Operative Cognitive DysfunctionAdv Anesth. Author manuscript; available in PMC 2011 January 1.


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Community Programme
In the last three years Surbiton Hockey Club has been working with schools and School Sports Partnerships to deliver a programme of hockey to local children. From September 2011 this programme will continue and grow, but under a new name – Suburban Hockey. We are in the process of registering this activity as a charity and will report back when the process is complete.
It is our intention to be able to deliver an 8-week coaching programme, based on England Hockey's Quicksticks activity, to children in Yrs 4, 5 6 and 7 in state schools free of charge. A form is attached here for schools to complete if they wish to be considered for this activity. We will be looking to attract funding from local companies and other organisations to support the work in the community.
Click here to find out more about Quicksticks
The coaching team for Suburban Hockey is headed by Will Fulker. All the coaches are CRB checked and fully qualified and experienced. We will still be using the Surbiton HC facilities and would like to be able to offer a number of bursaries to children to join the Club in the future.
We are delighted to say that a growing number of the children taking part in school clubs are signing up to join Surbiton HC and other local hockey clubs.
When we are invited to go to a school, our energetic and enthusiastic coaches work with the children during each session to teach them the basics of hockey in a fun, lively but safe environment. Consistency is critical and, where possible the same coach will attend the school club each week to ensure the children are familiar and comfortable with the coach. At the end of an 8-week programme the children will be invited to take part in a tournament, held at SHC. Staff at the schools will be included in hockey coaching so that they can deliver a similar programme to other groups at their schools should they wish to do so. The syllabus followed is designed to complement the curriculum requirements for ball skills.
As extra "added value", all children taking part in the Suburban Hockey school coaching programme will be invited to attend a community session, free of charge, on Monday evenings at Surbiton HC in Long Ditton. The aim is to encourage the children to experience hockey on a full size pitch, outside the school environment. These sessions are staffed by members of Suburban Hockey's coaching team, often the person delivering the coaching to the children in their school.
Over the last twelve months the schools which have benefited from the Surbiton HC's expertise include Tiffin, Tiffin Girls, St Josephs, Latchmere, St John's, Kings Oak Primary, King Athelstan, Hinchley Wood Primary and Secondary, St Agatha's Fern Hill , Malden Manor, Lovelace, St Paul's Catholic Primary, Coombe Hill Juniors, Chessington Community College, Southborough High, Coombe Girls, Tolworth Girls, Long Ditton St Mary's, Holy Cross Senior Girls, Holy Cross Prep, Weston Green Prep, Surbiton High, Hurst Park, Thamesmead, Philip Southcote. Click here to read more.
Our experienced team of qualified coaches all undertake regular CRB (Criminal Records Bureau) checks and can provide copies of their Enhanced Disclosure Forms before going into schools and leading sessions.In addition, our coaching team each have public liability insurance and have passed a First Aid Certificate within the last three years. If you would be interested in joining our coaching team, click here for more information or to download an application form.
Equipment & Facilities
We are happy to bring all of the necessary equipment (bibs, cones, balls, sticks, etc) with us to each of the sessions, if the school does not have their own set. Unfortunately we are not able to leave equipment at the school in between sessions, as we need it for many of the other schools we work with.
Whilst our own Club training sessions and fixtures all take place on astroturf pitches, to run school sessions, we simply need space! This can be in the form of an outdoor tarmac area or school field, netball court or school hall.
If your schools would like to take advantage of the hockey coaching sessions, but is not eligible to be considered for the free service, then we are happy to run the sessions at a cost of £50 per hour, which includes planning, delivery of the sessions and (where required) the loan of our Suburban Hockey kit. We would be happy to talk to you about funding options.

subset: commoncrawl


text:
Hatter by Shermie-CosplayWatch
©2014-2016 Shermie-Cosplay
Daily DeviationGiven 2014-08-19
The suggester says, "A gorgeous image; I absolutely love how crisp it is. The lighting is wonderful and the outfit is very well done and beautiful. The colored contacts are a really nice touch - they make the image pop!"
Hatter by Shermie-Cosplay ( Suggested by SirCassie and Featured by 3wyl )
Hatter by Shermie-Cosplay ( Suggested by SirCassie and Featured by 3wyl )
Dat hat
Good work I love it
By far the most beautiful hatter i have ever seen
Such amazing detail.
Wow, simply masterpiece, congrats on the DD
Fantastic. Makes me think of Death, Neil Gaimen Style...a little Twee, a little 'tude, and all perfect.
wow nice one
Incredible cosplay!))))))
Wow, you look amazing!
Are those eyes real?
amazing outfit <3 absolutely stunning
Well deserved!
This picture just made my day
my vocabulary simply isn't expansive enough for how delightful this costume is. Don't even...
the first thing i saw, i would have to say were your eyes... god idk if im slightly internally fearful... or mesmerized by the orange of those eyes o_o
This girl be stylin'! ;D
Beautiful lady
I reaaly like this picture! Very nice!!!
I freaking love this.
U look awesome
Gratz on the DD!
Gratz on the DD!
Oh wow!
Hermosa foto.
I love this outfit. It has just enough steampunk touches to it. The clock in the background is a nice touch~
Very beautiful! ^^
linda!!! <3
epicly amazing!
This is an excellent photo! Love it!
Congratulations on the DD!
She looks like a 'HighClass Caitlyn' from League of Legends.
Either way, stunning outfit.
Either way, stunning outfit.
Parabéns Gabi!!!
Aww! Beautiful Shermie gets a DD!
Congrats and well deserved
Congrats and well deserved
"Cutieful" Hatter
Very nice! Congrats on the DD
steampunk *-*
so pretty <3
Cool costuming and great make-up, they complement each other equally. Great Job!
well deserved DD *w* I am especially in love with your make up! >v<
congrats on the Daily Deviation!
dat outfit.... *^* <3
wow your outfits are pretty cool ! *v*


text: Shot a 10' 6" mamba in Limpopo (2005) at a waterhole with a "rented bow (Old left handed Hoyt Viper) and borrowed arrows." My bow was stuck in London. In the one photo you can see the arrow in the tree behind the mamba. The next shows me holding the snake -- I was on a slope. And lastly the warthog picture shows that old Hoyt with an ivory handle. I should have bought that bow at the time. View attachment 13946 View attachment 13947 View attachment 13948


text:
16 years of experience
Accepting new patients
Video profile
Cleveland, OH 44185 Phone number & directions
Patient Reviews
Patient Reviews ? Write a Review
Overall Rating:
Total Ratings
Total Reviews
Bad person
Outstanding surgeon. Worth waiting unlimited time if need be, but had short wait.
Very disappointing experience.
This response is written to rebut a BOGUS and False negative review on Vitals.com, dated 8/1, which was falsely and maliciously attributed to myself (entitled: âask Dr. Hakimâ) by a dishonest âanonymousâ source. Dr. Wael Barsoum is an OUTSTANDING orthopedic surgeon at the Cleveland Clinic. I have personally known Dr. Barsoum for years and have always found him to be extremely caring and professional. His surgical outcomes, bedside manner and patient/family responsiveness, both pre and post-surgery are excellent. Never trust an âanonymousâ posting on the internet. Signed: Lawrence Hakim, MD
Dr. Barsoum did an excellent job on my hip replacement, but trying follow up with him is very difficult. I get the impression that he spends more time lecturing than spending time following up with patients. Its very hard to make appointments with him, and the last appointment I had with him, I had to wait three (3) hours. Which is completely unacceptable. I was going to leave a note at leave, but would just have to make another appointment, which would be another six month wait, which I couldn't afford. I guess in summary I would have to say Dr. Barsoum is an excellent surgeon but has much to desired when it comes to follow through/up.
Great doctor. Very detailed and thoughtful


text: I can not say anything wrong about staying in the H1 Hotel in Nice. Rooms are very clean and good equipped. The owner of the hotel does everything just to make his guests satisfied. If you've got any problem, just ask him and he will help you in each way. The price is perfect. Don't expect 5 stars hotel but,... More


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Great textures, great shot
The question is y not .
Congrats on the DD!
Belated Congrats !! Freut mich, Chris !!
Herzlichen Glückwunsch Chris zu Deiner wohlverdienten DD!
Wauw, beautiful! v
So this person took a photo of the ground and got a DD? Or am I not seeing something here?
plain awesome.
This is interesting.
Well seen!
Maybe it's just an illusion, but I immediately thought that this a photo from standing on a walkway/street and facing two flights of outdoor stairs (maybe cement or stone or something?) where the walls of the stairs are the same design as the wall behind it...and the place where the hand rail would be is just smoothed cement painted white. Is this just me? I hope my definition makes sense, I don't know how else to describe what I'm looking at haha...
I actually considered it to be a set of overlapping metallic plates, with a rough texture worked in.
Your description makes perfect sense
Mine was influenced by the fact that I do a bit of metalwork in my spare time
Your description makes perfect sense
Mine was influenced by the fact that I do a bit of metalwork in my spare time
i thought so too
It was odd of them to shape a sidewalk like that .
Ein Klassiker in deiner Gallerie,
nice work
Congrats on the DD^^
Great vision!
I dont... understand why this is a DD?
Someone took a picture of the ground omg
some people like the composition and the shapes. you can see different things in such a simple picture, for example, i see two cliffs. its just the simplicity of the shapes that can make certain people think.
if all you see is a picture of the ground, thats fine, but i wish people would have at least a little faith in the people who choose DDs.
Because it's an interesting photo that someone wanted to share with the rest of dA.
Yeah...why does Stuff like this get it? There is this one incredible picture i Have suggested like 5 times and it still hasn't gotten one, But this did...
I don't see your point. It is indeed a picture of a sidewalk. It's also a nice, pretty composition.
i just don't see so deeply into stuff like that? and if it's so...nice... why do they name it that...and dont even give it a description... O.O
It has a neat composition and texture. Not everyone understands abstract art, and that's perfectly okay, but that doesn't make it less DD worthy. XD
Huh, very interesting Congrats on the DD!
!!! Congrats! *
Congratulations on the DD!
A worthy DD for the abstract category!
A worthy DD for the abstract category!
This is so amazing! Very good style and composition!
Fantastic composition!
Congratulations on you DD!
Congratulations on you DD!
Nice and simple. Congratulations!
- Congrats on the DD!
Have a nice day!


text:
Cok memnun kaldim. Odalar ferah, calisanlar guleryuzlu ve servis basarili"
Otel fiyat performans açısından çok başaralı, tek sorun oda servisi çok dikkatli değil. Banyoda 2 gün aynı leke aynı noktada kaldı, muhtemelen odaya girdiğimizde de vardı."
We had an overnight. The staff is professional and helpful. It is not like a 4-star city hotel, but good enough if you don't like to spend all of your time in the room. Our standard room was not so much spacious. The location is central, just opposite of famous Zamecke Lazne (Castle Spa). If you travel with your car, they offer you an open parking place with reservation for a very reasonable value per day; you have to walk 2 minutes only. The hotel itself has a good restaurant, but if you prefer to dine outside, it is adjacent to the awarded best restaurant(Michelin recommended, French style) on one side, and to the one of best recommended Czech cuisine restaurant with eco/good value on the other side; so dinner is not a problem. I recommend you to take the breakfast in the hotel, as they have great breakfast with many varieties. Overall very good price/satisfaction ratio, definitely would go for my next visit."
Çek Cumhuriyetinin adeta kültürle tarihi buluşturan başkenti Prag sayısız müzesi ve galerisiyle Altın...


text:
Bio Engineered Dragriph by ProlificPenWatch
©2010-2016 ProlificPen
Older original creature design from college.
Woah, beautiful!
Nice one
that is badass in so many ways
wow, amazing pic I have a request. Can you take a look at my gallery and leave some comments please. Im just starting out and what to know how I can improve my future work. Thanks
Thanks! I don't have time to really look, but I can give you some basic advice. If you are serious about art, don't do it half assed, to make any impact at all in art today, you have to be nearly perfect at what you do. Go to an art college get a real training, don't draw from photographs, draw from real life. Pick some artists that you want to be as good at some day, that have a similar style, try to do what they do, only better, and eventually you will surpass them. Study art history constantly. Know what area of art you want to be in, pick a specific focus. For example, I've chosen to go into entertainment design, with a specialty on rendering science fiction technology. To get to that point though, took fifteen years of constant drawing, anatomy study, apprenticeships all over the world ranging from sculpture to oil painting. I took years of art history classes, as well as instructionals from industry professionals. And when I'm not doing that I'm practicing, or self educating myself from DVD's and magazines. If you want to do this, be prepared to devote your life.
I love it so much.
real nice movement and flow dood
dude... just absolute amazing
very cool details on that griffin
how did you do him, its cool
how did you do him, its cool
I start with a sketch, then scan it in to photoshop. I carefully ink it and then color it with a combination of photoshop and painter using mostly basic brushes.
that's one awesome crossing of creatures that i wouldn't want to come across at night
great work
great work
Muy bueno
really cool
amazing combination, very imaginative
Really awsome design, and great depiction.
Stunning work, like it
awsome job! ^^
Lovely! Is this some kind of griffin?
That's absolutely badass!


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Inman Gallery
(713) 526-7800
3901 Main Street
Houston, TX 77002
David Aylsworth: Sweet sweet sweet sweet sweet tea.
January 8 - February 20, 2016
A solo exhibition by David Aylsworth.
An exhibition of works on paper by Carl Suddath, Gilad Efrat and Jim Verburg.
Tommy Fitzpatrick: Cat's Cradle
An exhibition of paintings by Tommy Fitzpatrick. "Working from photographs of loose-limbed wooden lattices, he translates volume, perspective and light into hard-edged pattern, quixotically pursuing an...Read More
Demetrius Oliver: Anemometer
An exhibition of works by New York-based artist Demetrius Oliver. Drawing from a variety of intellectual interests, Oliver's work records the active act of observation.
Sunset Haircut
A group exhibition including new work by David Aylsworth, Michael Jones McKean, Demetrius Oliver, Jim Richard, Dario Robleto, Robert Ruello, Sigrid Sandström and Brent Steen,...Read More
Michael Jones McKean: A hundred twenty six billion acres
An exhibition of new work by Michael Jones McKean–assembled sculptures and wall-works in unexpected configurations.
Darren Waterston / Yuko Murata
Two exhibitions: Darren Waterston's Pavo is a series of 36 new works on paper referencing both the opulence and decay of James McNeill Whistler's Peacock...Read More
Gilad Efrat: Sandwalk / Brad Tucker: Wobbles
Two concurrent exhibitions, featuring paintings by Gilad Efrat and silkscreens by Brad Tucker.
Carlee Fernandez: Arranging Family
Carlee Fernandez' photographs and sculptures explore personal identity by finding connections and blurred familial boundaries.
Angela Fraleigh: Ghosts in the Sunlight
Former Core Fellow Angela Fraleigh returns to Houston to show a new body of work based on the complex theme of desire.
Dario Robleto: Life, Left to Struggle in the Sun
Three Thousand Times, Each Hour, a Different Terrain: Titus Kaphar, Wardell Milan, Demetrius Oliver
Kaphar, Milan and Oliver were all 2006 residents at the Studio Museum in Harlem. This show of their individual work highlights considerations of landscape among...Read More
Inga Kerber: Cliché of a Flower Bouquet
Inga Kerber is a German artist who makes photographic prints in fussed-with multiples.
Shaun O'Dell: Mourning Air
Shimon Minamikawa: Play, Play
Minamikawa's paintings respond to the storefronts, objects and passersby of his native Tokyo.
Jamal Cyrus: Melizmatik
Cyrus uses melisma, the musical technique of singing one extended syllable across several notes, as a framework to address the tonal variations of history, context...Read More
FOTOFEST 2014: Linarejos Moreno: Fragmented Past/Reconstructed Present and Amy Blakemore: More Pictures
This will be Moreno's first exhibition and Blakemore's sixth solo exhibition with Inman.
Jason Salavon: The Top 100,000,000
Salavon develops data sets and using homemade software, turns them into prints, videos, and installations. His programs transform collections of cable television footage, Western painting,...Read More
Lokalkolorit (local color)
This show grew out of a visit to Leipzig, one of Houston's official sister cities (Karachi in Pakistan is one too!) by Kerry Inman and Lea...Read More
Katrina Moorhead: The Bird that Never Lands(cape)
Moorhead's fifth solo show with Inman presents new objects and gestures, titled in honor of the Arctic Tern, known, like the artist for ceaseless, lengthy...Read More
The Menil/Fiesta Project
A two-day exhibition collecting ten years of paintings based on the contents of two nearby boxlike buildings in Montrose, by University of Houston painting students...Read More
Tommy Fitzpatrick: Flatland
Geometric paintings inspired by Edwin Abbott's 1884 novella Flatland.
Emily Joyce: Some Tree Rings, a Vision, and the Third of May
Emily Joyce's recent silkscreen print series interprets tree-rings, knots, and cuts -as startling optical abstractions.
Darren Waterston: Stabat Mater
Robert Ruello: Open Other Side
Paintings from the artist's recent series "Unknown Adventures in Unknown Spaces."
Jim Richard: Excuse The Mess...
Richard's paintings seamlessly collages fine art objects into stylized 1960s and 70s living rooms. Extending this mashup to gallery and studio interiors, Richard comically probes...Read More
Farewell Ruins: Julia Haft-Candell and Julia Kunin
Recent ceramic-based work: Haft-Candell assembles hand-painted clay fragments, fabric surfaces, and structural wire and rebar to manifest surreal architectures. Julia Kunin aggregates casts of natural...Read More
Beth Secor: Trees
New paintings on paper of Texas trees, produced while the artist's father was passing away.
Sigrid Sandström: Viewfinders
Gilad Efrat: Negev
In a new series of nine paintings Efrat depicts the empty, abstract space of Israel's southern hinterland, the Negev desert.
Art and Paper Open House
The galleries of Isabella Court welcome members and guests of ART + PAPER to a mini-gallery crawl beginning at Inman Gallery. Dena Woodall of the...Read More
Dana Frankfort: For the Birds
The works in Frankfort's third solo exhibition at the gallery focus on the landscape from observation.


text:
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text:
This is the before shot of the Dash.
Now that all the parts have all arrived, except for the wiring harness it's time to get started.
Received the custom chassis today.
Ordered from forum member blk02si. (Great work and great thread check it out LINK I then proceeded to take apart the screen to mount it to the Metra Kit. As it turns out the new Xenarc has been changed and it now only has two connectors on it when you take it apart.
One for the speaker which we no longer need and one for the screen back light. All of the electronics are now on one board. This will complicate matters as there is little flexibility to the ribbon cable that is attached to the screen.
Here is the screen trim mounted to the Metra Trim Kit.
Still needs filling sanding filling sanding and so on, you know the routine and then paint. :lol: Now if I could only find the matching paint!
Next: I have to make some brackets to hold the screen PC board.


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External Web sites
Britannica Web sites
Articles from Britannica encyclopedias for elementary and high school students.
- gospel music - Children's Encyclopedia (Ages 8-11)
Gospel music is a form of African American religious music. At some Christian church services, people sing gospel music as a part of the preacher's sermon. The word gospel means "good news," and gospel songs often praise God or Jesus. Many gospel songs also describe struggles and hard times.
- gospel music - Student Encyclopedia (Ages 11 and up)
A form of American religious music, gospel is rooted in the Protestant religious revivals of the 19th century. It developed in different directions within the white (European American) and the black (African American) communities of the United States. Over the decades, both the white and the black traditions have spread through concerts, recordings, and radio and television broadcasts of religious services. In the later 20th century gospel music developed into a popular commercial genre, with artists touring worldwide.


text: Can the Islamist movements deliver - opinions - Gulf in the Media HomePoliticsEconomy Opinions "Postings of opinions published in the Gulf and international newspapers Record Not Available Fate of Iran's next parliament may already be sealed Source : Al Arabiya TV Date : 2016-02-10 Author : Camelia Entekhabi-Fard While asking voters to participate at two upcoming elections to nominate the next Iranian parliament and the country's Assembly of Experts, Iran's supreme leader did not shy away from saying... The Syrian regime has never negotiated Source : Al Arabiya TV Date : 2016-02-10 Author : Khairalla Khairalla It was normal to suspend the Syria talks in Geneva, considering it was more of a dialogue of the deaf. There is no point meeting to tackle the crisis amid... The West London Friends and Syria Source : Asharq Al-Awsat Date : 2016-02-10 Author : Ali Ibrahim Fighters from Chechnya are on both sides of the conflict; on one side they guide Russian aircraft to their targets and on the other they fight with ISIS extremists in... Cut in drug prices by Oman brings cheer to citizens Source : Oman Daily Observer Date : 2016-02-10 Author : Haider Al Lawati The announcement by Dr Ahmed bin Mohammed al Saeedi, Minister of Health, regarding the cut in prices of medicines in Oman is welcomed by many citizens.... Sovereign wealth funds playing a leading role Source : Oman Daily Observer Date : 2016-02-10 Author : Mohammed Al Riyami A SWF is an entity or fund that is state owned and can be considered as a source of surplus cash received from energy receipts, balance of payments, governmental payments,... Syria's human tragedy Source : Kuwait Times Date : 2016-02-10 Author : Labeed Abdal Finding the bodies of six people, including and an infant, off the shores of Kos island after a boat carrying refugees from Turkey to Greece capsized, calls for more cooperation... Rebels say failure of US talks costs Syrian lives Source : The Peninsula Date : 2016-02-10 Author : Josh Rogin In the days since the collapse of the Syria peace talks championed by US Secretary of State John Kerry, the humanitarian catastrophe in northern Syria has grown, tens of thousands... The Middle East's crisis is Europe's too Source : The Peninsula Date : 2016-02-10 Author : David Hearst We live in an age of sentimentality and brutality - little different from Victorian Britain or Tsarist Russia. For the latest dollop of sentimentality, go no further than Bob Geldof,... UAE, India have the power to shape the future Source : Khaleej Times Date : 2016-02-10 Author : Najla Al Rostamani As the UAE grew in strength as an important emerging power in the region, so did its outlook and horizon in terms of its relations with other countries. It is... Women terrorists Source : Saudi Gazette Date : 2016-02-10 Author : Hala Al-Qahtani There is no study on the reasons that encourage women to commit crimes in Saudi Arabia. It may be because all major crimes in the country were committed by men... Give rights before thanksgiving Source : Saudi Gazette Date : 2016-02-10 Author : Dr. Ali Al-Ghamdi The King Salman Social Center in Riyadh has recently launched a campaign titled "Shukran" aimed at thanksgiving in word and deed, according to a report carried by the Saudi Press... Moscow: Then and now Source : Arab News Date : 2016-02-10 Author : Abdulrahman al-Rashed A recently published book by Syrian Vice President Farouq Al-Sharaa, who has been out of sight since 2012, describes how Russia agreed to receive Rifaat Assad, who had a dispute... Syrians left to suffer Source : Arab News Date : 2016-02-10 Author : Osama Al Sharif The collapse of the preparatory round of Geneva 3 talks last week was expected. The government delegation was not ready to acquiesce to opposition demands that the humanitarian clauses of... The UAE's Ministry of Happiness Source : Arab News Date : 2016-02-10 Author : Mohammed Fahad Al-Harthi Sheikh Mohammed bin Rashid Al-Maktoum, vice president and prime minister of the UAE and ruler of Dubai, surprised the World Government Summit held in Dubai this week when he announced... As Syria talks fail, should we prepare for the worst? Source : Al Arabiya TV Date : 2016-02-09 Author : Brooklyn Middleton The latest round of peace talks on Syria fell apart after only two days with the opposition High Negotiations Committee (HNC) rightly refusing to meet with representatives of Bashar al-Assad's... Total 200 Results in 14 Pages 1 2 3 4 5 6 7 8 9 10 For more news, views and reports about this topic, please subscribe to GRC website: www.grc.net Thu Feb 11, 2016| 02-جماد أول-1437هـ Saudi Arabia proud of its 'brave armed forces' UAE and US trade grows 2.25 per cent We are on outskirts of Sanaa: Yemeni Veep Bahah Iran nuclear deal delays bomb by 10-15 years: IISS chief Gulf sukuk body stresses debt capital market opportunities Oman, India boost defence cooperation Kuwait to raise crude output, sign export deals Iraq says it is in control of Ramadi Iranian oil minister calls for $200bn of investment US welcomes Saudi troop offer for Syria: Jubeir Russian strikes in Aleppo made Syria talks 'very very difficult' - Kerry Qatar external debt at 88.5% of GDP seen well within repaying capacity Kerry lauds KSA fight against terror Saudi economic slowdown to continue in 2016 Qatar and Saudi ministers discuss investment plans Op-Ed Hubs of growth Zika alert Moscow: Then and now The UAE's Ministry of Happiness More>> Reports GCC Markets Performance - January 2016 Saudi Budget 1437/1438 (2016) More>> GCC Press Agencies Day's main stories from the GCC Press Agencies GRC Analysis Renewable Energy in GCC Paris Climate Deal and Oil-rich Countries Combating Climate Change and Terrorism GRC Commentary Using the Iran Nuclear Accord to Advance Regional Security Reduce your Footprint in Ramadan A Gulf Perspective on the 'Obama Doctrine' GRC Press Release Gulf Research Center press releases to the media GRC Publications Gulf Cities as Interfaces Africa and the Gulf Region: Blurred Boundaries and Shifting Ties Sustainable Development Challenges in the Arab States of the Gulf GRC Newsletters/Bulletins Enter your email to get the Newsletter Go Privacy Policy | Contact Us | Terms & Conditions | About Us | Weather | Qibla Directions | Hijri Date Conversion Tool Copyright © 2002-2015 Gulf Research Center. 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Just tide. I also removed all the hardware and reflectors like pastorbobnlnh.
Type: Posts; User: jdefran; Keyword(s):
Just tide. I also removed all the hardware and reflectors like pastorbobnlnh.
okane Have caution watching them in the machine..I would hand wash to prevent a tearing.
I have a matching yellow rear pannier set with handle bar bag.. Unfortunately I washed them (in the machine) and there's a slight tear in each pannier. Are the frames of these panniers sought after...
+1. If you end ever carry it in an external drink holder of a bag like the one below make sure it's secure. I've lost one over some rough terrain. In a standard bottle cage it would fine. ...
Reviving a thread here.. Any ideas on how to achieve such a nice bend without a vice?
Hope you caught there is a crack in the seat tube. It's a shame he doesn't provide a photograph, that is rather misleading.
For sure, I would at least get the comp. Do you have a pic of yours? Any specifics you want to share about the ride?
Could you please measure your rear dropout width? Just trying to see what wheel...
Considering the purchase of a Trek Crossrip for my commute. All of my current road bikes are traditional steel, sport touring bikes from the 80s. I built them, used the parts I wanted, enjoyed them,...
Thank you, very informative!
I have a Shimano XT M739 crankset with rings.. it's in rider condition. You could strip the anodizing and polish to make like new.. PM me if interested.
I'd love to see a video of the STI/Ergos in action on the non traditional drop bar (dirt/mustache). Having a hard time visualizing the shifting action at a different angle..
Some photos might be helpful so we can provide accurate advice
I have a white exage group if you go this route..
Might help to get a photo of the complete bike from the drive side.
Has anyone here tried using the Shimano Claris STIs on an existing 8 speed set up?
I had the same problem with a 1989 Trek 420.. Even though it has the investment cast Trek lugs and everything I read said a 27.2, I ended up using 27.0
2X8 Shimano Tri-Color STIs
3X8 Shimano STIs of similar era
Non-aero brake levers with turkey levers (restoring a Panasonic sport deluxe for my father-in-law and he likes 'em)
Hopefully something you need
Nice bike, the color is pretty.
So is it a 12 or 14 speed? You mentioned 12 speed and 7 speed..
The seat post is probably steel, put a magnet up to it to test. You can get an alloy one for...
If you only need friction, I have set of first generation dura ace downtube shifters. PM me if interested.
Ha, I can just picture it!
The lady did provide some back story so far:
Agreed, it would make a great single track bike I can ride hard and not worry about abusing it.
Luckily I have some...
Thank you for the fork recommendation.
Great eyes, doesn't help I'm unfamiliar with the brand. That tape is another thing to inspect closely.
I'll definitely look over the chain stay seat clamp area.
What is TCO?
Looking at it tomorrow after work, the seller seems to be a nice older lady and wouldn't sell it before then.
I'm considering a rigid carbon fork or kona project 2.
Looking to the wise forumites for some input regarding the frame below:
From what I can tell it is a 1996 Ibis Mojo, going...


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|Page 1 of my comic Little Bot.
|Page 1 of my comic Little Bot.
This is the first thing that popped into my head when I saw Pearl make a hologram of Rose.
One day I'll draw fan art of Pearl that isn't making fun of her.
Hello, my name is Chase Craft; Born and raised in Galax, Virginia and eventually moved to Virginia Beach where I live now. I have been practicing art for about 7 years, I am getting gradually better. I hope one day to become a great artist, so I can move to New York City to attend the School of Visual Arts.
Although I don't have a job, and I'm not very well known as an artists. One day want to become a graphic novelist, or become a concept artists for video games.
Current Residence: Galax, Virginia
deviantWEAR sizing preference: Medium
Print preference: N/A
Favourite genre of music: Rock
Favourite photographer: Zsolt Zsigmond
Favourite style of art: Cartooning, Comic art, and Manga
Operating System: Photoshop
MP3 player of choice: iPad
Favourite cartoon character: Avatar Aang, Avatar Roku