Lucid Interval Research Articles

‘Talk and Die’ patients presenting to a major trauma centre over a 10 year period: A critical review

‘Talk and die patients’ describes a small number of patients who present with a mild head injury (Glasgow Coma Scale [GCS] 13–15) and then subsequently deteriorate and die from intracranial causes. We analysed the medical records of all those adult patients whose primary diagnosis as the cause of death was head injury, as determined by the coroner, who were admitted to a major Australian trauma centre between January 1994 and December 2003 (a 10-year period). The clinical profile of those patients who fulfilled the criteria of ‘talk and die’ were documented, including age, mode of injury, initial GCS, lucid interval, CT scan reports, operation performed, post mortem findings and intracranial cause of death. Factors considered potentially contributory to the patients’ deterioration, such as delays in CT scanning or patient transfer, coagulopathy or hypoxic episodes were also noted. The incidence of ‘talk and die’ patients was 2.6% (15 out of 569) overall and the annual incidence did not significantly alter over the 10-year period of the study. The small number of patients precludes inferences regarding causal relationships, although potentially preventable factors, which could have been contributory to patient deterioration, were identified.

The Education of Sisyphus

This article examines the idea of suicide as a metaphor for transformative education. Camus's The Myth of Sisyphus is used as a framework for discussing the absurdity of education as well as the lucidity available through an openness to personal and professional transformation. An argument is made for a rhythmic progression of lucidity and comfort where occurrences of transformation (suicide) allow moments of freedom from the continual tension of lucidity as well as stimuli for new periods of lucidity. By way of this progression, existence remains firmly within the absurd while allowing for a “hopeful hopelessness” that perpetuates action in the face of unreasonable circumstances. Also examined is the quality that marks a suicidal (educative) transformation in contrast to a nonsuicidal (additive) transformation. The article concludes with a classroom narrative that depicts the absurd situation and the resulting suicide.

Duration of Postictal Psychotic Episodes

To clarify duration of postictal psychosis (PIP) episodes and identify factors that influence its duration. Fifty-eight patients with epilepsy exhibited 151 PIP episodes during a mean follow-up period of 12.8 years. Distribution of the duration of these episodes was determined, and factors potentially affecting were analyzed. Factors analyzed included PIP-related variables (i.e., antecedent seizures and the lucid interval) and patient characteristics (i.e., type of epilepsy, lateralization of EEG abnormalities, and intellectual functioning). The mean duration of the 58 first PIP episodes was 10.5 days, and that of all 151 PIP episodes (including multiple episodes) was 9.2 days. Approximately 95% of the PIP episodes resolved within 1 month. Most PIP-related variables, except for antipsychotic drugs administered, were not associated with duration of the episodes. Several patient characteristics, i.e., history of interictal psychosis, family history of psychosis, and intellectual functioning, were associated with duration of the PIP episodes. This study showed that most PIP episodes last less than 1 month. PIP episodes appear to be prolonged when individuals have an underlying vulnerability to psychosis. Clinical phenomena that can trigger PIP may not determine the course of the PIP episode.

Central Nervous System Dysfunction after Noncardiac Surgery and Anesthesia in the Elderly

Central Nervous System Dysfunction after Noncardiac Surgery and Anesthesia in the Elderly

A Prospective Study of Postictal Psychoses with Emphasis on the Periictal Type

To assess prospectively episodes of postictal psychosis. We followed 108 consecutive patients with temporal lobe epilepsy, who were divided into three groups: those without psychotic episodes (n=87, N group), those with interictal psychosis (n=13, IIP group), and those with postictal psychosis (n=8, PIP group). The first episode of postictal psychosis, which was defined as a psychotic episode that occurred within 1 week after the end or within 3 days before the beginning of seizure clusters, was assessed with the Brief Psychiatric Rating Scale (BPRS) and Social Dysfunction and Aggression Scale (SDAS) during the observation period. The duration of illness was significantly different between the N and PIP groups (p=0.004) and between the N and IIP groups (p=0.039). The average initial BPRS score (obtained 3.0 days after the end of the seizure cluster) was 19.7, and then decreased to 5.8 after 1 week, and finally normalized at 1.5 after 1 month. A statistically significant decrease in BPRS scores was found between the initial assessment and those obtained after 1 week (p=0.011). Those who had psychotic episodes without a lucid interval tended to have episodes more often than monthly, and experienced additional seizure recurrence even during the psychotic episodes. Two patients exhibited a frank manic phase, and three patients showed excessively aggressive behavior, as determined by the SDAS. Postictal psychosis should be subdivided into the nuclear type, with an established clinical picture as an indirect aftereffect of seizure activity, and the atypical periictal type, which is a direct manifestation of limbic discharge.

Persistent Auditory Hallucinations That Are Unresponsive to Antipsychotic Drugs

Persistent Auditory Hallucinations That Are Unresponsive to Antipsychotic Drugs

Subacutely Progressive Epidural Hematoma in the Absence of a “Lucid Interval”

Subacutely Progressive Epidural Hematoma in the Absence of a “Lucid Interval”

Citalopram Treatment for Inappropriate Sexual Behavior in a Cognitively Impaired Patient

Citalopram Treatment for Inappropriate Sexual Behavior in a Cognitively Impaired Patient

Minor Head Trauma–Induced Sporadic Hemiplegic Migraine Coma

Familial hemiplegic migraine is a severe, rare subtype of migraine. Gene mutations on chromosome 19 have been identified in the calcium channel, voltage-dependent, P/Q type, alpha-1A subunit gene (chromosome 19p13) for familial hemiplegic migraine. Recently a gene mutation (Serine-218-Leucine) for a dramatic syndrome associated with familial hemiplegic migraine, commonly named "migraine coma", has implicated exon 5 of this gene. The occurrence of trivial head trauma, in such familial hemiplegic migraine patients, may also be complicated by severe, sometimes even fatal, cerebral edema and coma occurring after a lucid interval. Sporadic hemiplegic migraine shares a similar spectrum of clinical presentation and genetic heterogeneity. The case report presented in this article implicates the involvement of the Serine-218-Leucine mutation in the extremely rare disorder of minor head trauma-induced migraine coma. We conclude that the Serine-218-Leucine mutation in the calcium channel, voltage-dependent, P/Q type, alpha-1A subunit gene is involved in sporadic hemiplegic migraine, delayed cerebral edema and coma after minor head trauma.

The Side of the Road

The Side of the Road Ed Roberson (bio) What is passed corrects the mirages as we go along it aims their shrill silence back at them by our approach continually tearing out the window of their panoramas. We watch them break into pools we can see ourselves in the present the shattering song we can't hear making itself up. The moment will sometimes stop singing and pull over—no matter the present goes on more intensely without movement— onto where road and the land it crosses meet. An avatar of horizon and equivalent mirages, also a crossroad, the spirit of the roadside repeats: destroys and clarifies the desires of your reach. Ed Roberson Ed Roberson retired, in 2002, from administrative work at Rutgers University, where he once briefly taught. At the present time, this distinguished poet is Visiting Artist at Columbia College in Chicago. He is author of seven volumes of poems, including Lucid Interval As Integral Music, When Thy King Is a Boy, Voices Cast Out to Talk Us In, and Atmosphere Conditions. Atelos Press will soon publish City Eclogue, his seventh volume of poems, and Brent Hayes Edwards (of Rutgers University) is currently guest editing a special issue of Callaloo focusing on Ed Roberson as poet. Copyright © 2006 Charles H. Rowell

Penalty Fee

Penalty Fee Ed Roberson (bio) My partner is penalty for the me I live with paying late fees enough to be support of this other person in the person of my disorders: penalty for myself. He's expensive I replace more of him than of myself if his catch up has to ride taxi He doesn't pay rent unless I send him next day special class He eats out a lot on the run he always runs dropping items from any schedule I try making good on: my shadow dropping time from my life through that point where our hour glass bulbs flower each into the other dust to dust time to eternity it all paid up. Ed Roberson Ed Roberson retired, in 2002, from administrative work at Rutgers University, where he once briefly taught. At the present time, this distinguished poet is Visiting Artist at Columbia College in Chicago. He is author of seven volumes of poems, including Lucid Interval As Integral Music, When Thy King Is a Boy, Voices Cast Out to Talk Us In, and Atmosphere Conditions. Atelos Press will soon publish City Eclogue, his seventh volume of poems, and Brent Hayes Edwards (of Rutgers University) is currently guest editing a special issue of Callaloo focusing on Ed Roberson as poet. Copyright © 2006 Charles H. Rowell

Persistent and recurrent hyperparathyroidism.

Abstract During the past 11 years at Hammersmith Hospital 11 patients have had parathyroid operations following a previous neck exploration. Six had persistent hyperparathyroidism and 5 had recurrent hyperparathyroidism with a “lucid interval” of biochemical normality of from 5 months to 11 years. Sucessful results were obtained in 9 of the 11 patients after a total of 29 operations, 4 of which were combined with sternotomy. The reasons for failure at operation and the medical and surgical management of these patients are reviewed.

Exertional Heat Stroke in Competitive Athletes

Exertional heat stroke (EHS) is a serious medical condition that can have a tragic outcome if proper assessment and treatment are not initiated rapidly. This article focuses on critical misconceptions that pertain to the prevention, recognition, and treatment of EHS, including 1) the randomness of EHS cases, 2) the role of nutritional supplements in EHS, 3) temperature assessment, 4) onset of EHS and the possible lucid interval, 5) rapid cooling, and 6) return to play. Exploration of these topics will enhance the medical care regarding EHS.

Initial Neurologic Presentation in Young Children Sustaining Inflicted and Unintentional Fatal Head Injuries

BACKGROUND: It remains unclear if fatal brain injuries in young children are characterized by immediate rapid deterioration or can present after an initial period of lucidity. This issue has legal implications in child abuse, for which understanding the clinical course affects perpetrator identification. OBJECTIVE: To determine patterns of neurologic presentation on hospital admission in infants and toddlers who die of inflicted and unintentional injury. DESIGN/METHODS: Data on children 7, and 1.9% presented with a GCS score of >12 (lucid). The incidence of admission a GCS score of >7 varied by mechanism. Overall, children with inflicted injury were 3 times more likely to present with a GCS score of >7 than those injured in MVCs (odds ratio [OR]: 3.6; 95% confidence interval [CI]: 1.2-10.3), but incidence of a GCS score of >7 did not differ between inflicted injuries and falls. Similarly, when considering only those children >or=24 months old, a GCS score of >7 did not differ by mechanism. In contrast, in those 10 times more likely to have a GCS score of >7 than those who died as a result of a MVC (OR: 9.36; 95% CI: 1.3-80.9). CONCLUSIONS: The data suggest an age- and mechanism-dependent presentation of neurologic status in children with fatal head injury. Although infrequent, young victims of fatal head trauma may present as lucid (GCS score: >12) before death. Furthermore, children 7) than those in MVCs. This effect is amplified in the youngest children (12 [5 of 6]). It is unclear whether these differences are the result of inadequate tests to evaluate consciousness in younger children or differences in biomechanical mechanisms of inflicted trauma. Language: en

Initial Neurologic Presentation in Young Children Sustaining Inflicted and Unintentional Fatal Head Injuries

It remains unclear if fatal brain injuries in young children are characterized by immediate rapid deterioration or can present after an initial period of lucidity. This issue has legal implications in child abuse, for which understanding the clinical course affects perpetrator identification. To determine patterns of neurologic presentation on hospital admission in infants and toddlers who die of inflicted and unintentional injury. Data on children <48 months of age who sustained a fatal head injury from 1986-2002 were extracted from the Pennsylvania Trauma Outcomes Study. Only those with external-causes-of-injury codes for inflicted injury, falls, and motor vehicle crashes (MVCs) with a recorded Glasgow Coma Scale (GCS) on admission were included. The GCS was compared across mechanisms and age groups (0-11, 12-23, 24-35, and 36-47 months). Of the 314 fatally injured children, 37% sustained inflicted injury, 13% sustained a fall, and 49% sustained an MVC. At admission, 6.8% of all children had a GCS score of >7, and 1.9% presented with a GCS score of >12 (lucid). The incidence of admission a GCS score of >7 varied by mechanism. Overall, children with inflicted injury were 3 times more likely to present with a GCS score of >7 than those injured in MVCs (odds ratio [OR]: 3.6; 95% confidence interval [CI]: 1.2-10.3), but incidence of a GCS score of >7 did not differ between inflicted injuries and falls. Similarly, when considering only those children >or=24 months old, a GCS score of >7 did not differ by mechanism. In contrast, in those <24 months old, children who died as a result of inflicted injury were >10 times more likely to have a GCS score of >7 than those who died as a result of a MVC (OR: 9.36; 95% CI: 1.3-80.9). The data suggest an age- and mechanism-dependent presentation of neurologic status in children with fatal head injury. Although infrequent, young victims of fatal head trauma may present as lucid (GCS score: >12) before death. Furthermore, children <48 months old sustaining inflicted injury are 3 times more likely to be assessed with a moderate GCS score (>7) than those in MVCs. This effect is amplified in the youngest children (<24 months old): those with inflicted injury were 10 times more likely to present with moderate GCS scores than those in MVCs. In addition, this youngest age group seems to be overrepresented in those who present as lucid (GCS score: >12 [5 of 6]). It is unclear whether these differences are the result of inadequate tests to evaluate consciousness in younger children or differences in biomechanical mechanisms of inflicted trauma.

Specific Kinetic Alterations of Human CaV2.1 Calcium Channels Produced by Mutation S218L Causing Familial Hemiplegic Migraine and Delayed Cerebral Edema and Coma after Minor Head Trauma

Mutation S218L in the Ca(V)2.1 alpha(1) subunit of P/Q-type Ca(2+) channels produces a severe clinical phenotype in which typical attacks of familial hemiplegic migraine (FHM) triggered by minor head trauma are followed, after a lucid interval, by deep (even fatal) coma and long lasting severe cerebral edema. We investigated the functional consequences of this mutation on human Ca(V)2.1 channels expressed in human embryonic kidney 293 cells and in neurons from Ca(V)2.1 alpha(1)(-/-) mice by combining single channel and whole cell patch clamp recordings. Mutation S218L produced a shift to lower voltages of the single channel activation curve and a consequent increase of both single channel and whole cell Ba(2+) influx in both neurons and human embryonic kidney 293 cells. Compared with the other FHM-1 mutants, the S218L shows one of the largest gains of function, especially for small depolarizations, which are insufficient to open the wild-type channel. S218L channels open at voltages close to the resting potential of many neurons. Moreover, the S218L mutation has unique effects on the kinetics of inactivation of the channel because it introduces a large component of current that inactivates very slowly, and it increases the rate of recovery from inactivation. During long depolarizations at voltages that are attained during cortical spreading depression, the extent of inactivation of the S218L channel is considerably smaller than that of the wild-type channel. We discuss how the unique combination of a particularly slow inactivation during cortical spreading depression and a particularly low threshold of channel activation might lead to delayed severe cerebral edema and coma after minor head trauma.

Free Communications: Psychiatric Problems

Free Communications: Psychiatric Problems

Commentary: The Diagnosis of Delirium in Pediatric Patients

Delirium is characterized by an acute onset and fluctuating course, impairment in attention, disorientation, deficits in language and visuospatial skills, and a deterioration in cognition not explained by an underlying dementia (Murphy, 2000). The disorder appears as a consequence of an illness or its treatment. In adult patients, delirium is considered an independent predictor of higher 6-month mortality and longer hospital stays (Ely et al., 2004). Pediatric patients seem to be especially vulnerable to toxic, metabolic, or traumatic CNS insults and are at greater risk of delirium with fever regardless of the etiology. Developmental limitations, in the areas of communication and cognition, prevent a thorough evaluation of the young patient for delirium. Only the most severe cases are identified, and the remainder is either ignored or mismanaged under incorrect diagnoses. Despite the importance of the diagnosis in the care of medically ill patients, few studies examine delirium in pediatric patients. Schieveld and Leentjens take on this task through the case reports of two young children. They describe the profound effects of delirium on the care of these patients and the emotional stability of both the child and caregiver. Delirium presents diagnostic challenges that are particularly relevant when attempting to evaluate a pediatric population. Physicians rarely conduct objective screening for the disorder, in part because of ambiguous diagnostic terminology. The effect of the diagnosis on medical care is poorly understood. Physicians are, therefore, less motivated to identify or treat delirium. The hypoactive subtype of the disorder is either infrequently recognized or misdiagnosed as depression. This is more likely in children who volunteer little information and, without obvious behavioral problems, may be ignored. These patients may also be perceived as calm and somnolent by the medical staff. Patients with paranoia, hallucinations, and aggressive behaviors are considered oppositional, defiant and difficult and demand immediate attention. Delirium symptoms fluctuate throughout the day with lucid intervals alternating with periods of confusion and agitation. Making the correct diagnosis may depend on the time of the assessment. Cases can also be very complicated with multifactorial causes of delirium that include aspects of treatment as well as illness (Lawlor and Bruera, 2002). Determining the cognitive status of the patient requires baseline information that existed before the hospitalization. Adults recognize declines in memory, orientation, writing, or mathematical skills. Children are either not aware of the deterioration from their previous level of functioning or are terrified of the circumstances and possible consequences. They may not actively participate in their treatment because they are unable to effectively communicate their needs and wants to medical staff and family members. Medical staff members may interpret distress secondary to mental status change as an indication of inadequate analgesic coverage. For example, the 28month-old child in the first case was given a variety of medications including opioids and benzodiazepines in an effort to comfort her. These drugs may also be an inappropriate treatment for a missed diagnosis of delirium. Recent adult studies of delirious patients discovered a circadian distribution to analgesic coverage. Patient with delirium are more likely to receive rescue medications for breakthrough pain in the evening and through the night, whereas patients without delirium receive most of their pain medication during the day. Accepted November 16, 2004. Dr. Martini is with the Department of Child and Adolescent Psychiatry, Children’s Memorial Hospital, and the Departments of Psychiatry and Behavioral Sciences and Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago. Correspondence to Dr. D. Richard Martini, Department of Child and Adolescent Psychiatry, Children’s Memorial Hospital, 2300 Children’s Plaza, #10, Chicago, IL 60614; e-mail: d-martini@nwu.edu. 0890-8567/05/4404–0395 2005 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000153716.52154.cf

Prolonged postictal psychosis with forced normalization (Landolt) in temporal lobe epilepsy

We report two patients with temporal lobe epilepsy who developed prolonged episodes of postictal psychosis (⩾12 weeks) following a bout of seizures and a lucid interval. No drug toxicity was noted, and no recurrent or continuous seizures were observed during their prolonged psychotic episodes. Repeated EEGs during the period of psychosis showed that their habitual focal epileptiform abnormalities had disappeared. Responses to neuroleptic treatments were not remarkable. Their psychotic symptoms gradually dispelled after their epileptiform abnormalities reappeared. These observations may suggest possible overlapping mechanisms between a prolongation of psychosis and suppression of epileptiform discharges on a scalp EEG.

Relation of hepatolithiasis to helminthic infestation

The relation of helminthic infestation to hepatolithiasis is a subject of dispute. This case-control study was undertaken to evaluate the prevalence of helminthiasis in hepatolithiasis patients and to compare the clinicopathological features of hepatolithiasis between patients with and without helminthiasis. The prevalence of ascariasis or clonorchiasis was evaluated using ELISA in 131 patients with hepatolithiasis who were treated at Show-Chwan Memorial Hospital and 121 subjects who constituted a control group. The patients' detailed histories and medical charts were reviewed. The prevalence of positive immunodiagnosis of ascariasis and clonorchiasis was higher in patients with hepatolithiasis than in control subjects (33.6%, 44/131 vs 17.4%, 21/121, odds ratio [OR] = 2.41, 95% confidence interval [CI] = 1.28-4.56, P = 0.005; and 6.9%, 9/131 v 0.8%, 1/121, OR = 8.85, 95% CI = 1.12-188.69, P = 0.02). Patients with helminthiasis rarely had concurrent gallbladder stones (26%, 12/47 vs 55%, 46/84, OR = 0.28, 95% CI = 0.12-0.66, P = 0.002). Prior to the diagnosis of hepatolithiasis in adulthood, most of the patients with helminthiasis tended to have a history of recurrent abdominal pain in their childhood and an asymptomatic 'lucid interval' during their teenage years (70.2%, 33/47 vs 39.3%, 33/84, OR = 3.64, 95% CI = 1.59-8.42, P = 0.0005). However, the prevalence of intrahepatic duct stricture (38.3%, 18/47 vs 40.5%, 34/84, OR = 0.91, 95% CI = 0.41-2.02, P > 0.05), secondary biliary cirrhosis (6.4%, 3/47 vs 3.6%, 3/84, OR = 1.84, 95% CI = 0.28-12.03, P > 0.05), cholangiocarcinoma (2.1%, 1/47 vs 0%, 0/84, OR = approximately , P > 0.05), and stone recurrence (54.8%, 24/42 vs 50.0%, 38/76, OR = 1.33, 95% CI = 0.58-3.06, P > 0.05) did not significantly increase. Helminthiasis is a possible risk factor for hepatolithiasis, although it is unlikely to increase the incidence of complications, including bile duct stricture, secondary biliary cirrhosis, and cholangiocarcinoma. Patients with helminthiasis tend to have a history of an asymptomatic 'lucid interval' between the periods of recurrent abdominal pain in their childhood and the diagnosis of hepatolithiasis in their adulthood.