Cases Of Persistent Vegetative State Research Articles

Zolpidem Arousing Effect In Persistent Vegetative State Patients: Autonomic, Eeg And Behavioral Assessment

To study the Zolpidem arousing effect in persistent vegetative state (PVS) patients combining clinical evaluation, autonomic assessment by heart rate variability (HRV), and EEG records. We studied a group of 8 PVS patients and other 8 healthy control subjects, matched by age and gender. The patients and controls received drug or placebo in two experimental sessions, separated by 10-14 days. The first 30 minutes of the session were considered the basal record, and then Zolpidem was administered. All participants were evaluated clinically, by EEG, and by HRV during the basal record, and for 90 minutes after drug intake. We found in all patients, time-related arousing signs after Zolpidem intake: behavioral (yawns and hiccups), activation of EEG cortical activity, and a vagolytic chronotropic effect without a significant increment of the vasomotor sympathetic tone. We demonstrated time-related arousing signs after Zolpidem intake. We discussed possible mechanisms to explain these patho-physiological findings regarding EEG cortical activation and an autonomic vagolytic drug effect. As this autonomic imbalance might induce cardiocirculatory complications, which we didn't find in any of our patients, we suggest developing future trials under control of physiological indices by bedside monitoring. However, considering that this arousing Zolpidem effect might be certainly related to brain function improvement, it should be particularly considered for the development of new neuro-rehabilitation programs in PVS cases. According to the literature review, we claim that this is the first report about the vagolitic effect of Zolpidem in PVS cases.

Traumatic Cerebrovascular Injury Following Severe Head Injury: Proper Diagnostic Timetable and Examination Methods

Traumatic cerebrovascular injury (TCVI) is a serious complication of severe head injury, with a high mortality rate. To establish a proper treatment strategy for TCVI, we investigated patients with a high risk of TCVI according to the Guidelines for the Management of Severe Head Injury (hereafter "the Guidelines") to elucidate the validity of the criteria for TCVI in the Guidelines and the appropriate screening timing and methods. Of those transported to our facility between December 2008 and June 2012, 67 individuals with a high risk of TCVI were evaluated to reveal the proper timing and methods of vascular evaluation. Of the 67 patients, 21 had a diagnosis of TCVI based on cerebral angiography, three-dimensional computed tomography angiography (3DCTA), or magnetic resonance imaging (MRI), accounting for 6.4% of all patients with severe head injury and as high as 31.3% of patients with a high risk of TCVI according to the Guidelines. In addition, according to the Glasgow Outcome Scale (GOS), outcomes were three deaths due to primary brain injury, six cases of persistent vegetative state, five cases of severe disability, three cases of moderate disability, and four cases of good recovery. Although 3DCTA is a simple and convenient diagnostic method, cerebral angiography is necessary to evaluate dissecting lesions. If patients have any signs or symptoms of TCVI, as described in the Guidelines, cerebral angiography or 3DCTA should be performed as an initial screening method within 72 hours of admission, followed by cerebral angiography on postadmission Day 14 ± 2 to prevent failed diagnosis.

Causes and Outcomes of Persistent Vegetative State in a Chinese Versus American Referral Hospital

To compare the etiologies and clinical outcomes of patients in a persistent vegetative state (PVS) between a Chinese and US referral hospital. A retrospective, observational study at the Peking Union Medical College Hospital, Beijing, China and Johns Hopkins Hospital, Baltimore, USA (2001-2010) was performed. There were 36 cases of PVS diagnosed. In Beijing, there were 19 cases: mean age 57 years, range 3-86, (42 %) female, with 37 % of patients observed to survive more than 1 year (range >1 month to >28 years, median >6 months). Causes of PVS in Beijing were hemorrhagic stroke (n = 4, 21 %), ischemic stroke (n = 2, 11 %), cardiac arrest (n = 5, 26 %, including 4 with attempted cardiopulmonary resuscitation (CPR)), traumatic brain injury (n = 3, 16 %), and one each of mitochondrial encephalomyopathy, acute disseminated encephalomyelitis, Lennox Gastaut Syndrome, and epilepsy with craniopharyngioma (n = 4, 21 %). In Baltimore, there were 17 cases of PVS: mean age 43 years, range 15-83, 59 % female, with 41 % observed to survive more than 1 year (range >1 month to >10 years, median >3 years). Causes of PVS in Baltimore were ischemic stroke (n = 3, 18 %), cardiac arrest (n = 3, 18 %, including one with attempted CPR), traumatic brain injury (n = 3, 18 %), neurodegenerative conditions (n = 2, 12 %), and hypoxic ischemic encephalopathy due to respiratory arrest (n = 3, 18 %), metabolic derangements (n = 2, 12 %), and meningitis (n = 1, 6 %). There may be a long survival period for patients with PVS, including in China where resource constraints exist for acute neurologic care. Stroke appears to be the most common underlying cause of PVS in Chinese patients, followed closely by cardiac arrest with attempted CPR. There appear to be more varied causes of PVS in the US referral hospital with a predominance of stroke, cardiac arrest, and traumatic brain injury.

Heart rate variability changes induced by auditory stimulation in persistent vegetative state

Previous studies, using neuroimaging and electrophysiology, have identified the presence of cerebral responses to auditory stimulation in clinically unresponsive persistent vegetative state (PVS) patients. In normal individuals, it has been shown that stimulation with emotional content has a strong influence on autonomic cardiovascular regu­lation tested by heart rate variability (HRV). In this paper, we assessed responses to auditory stimulation with emotion­al content in PVS and minimally conscious (MCS) cases by HRV. We found a pattern of changes induced by auditory stimulation in three of our patients (decreased heart rate, increased HRV, decrease power in the low and increased power in high frequencies) consistent with increased cardiovagal stimulation. Both time and frequency domain changes were more pronounced during affective than during non-affective auditory stimulation, suggesting that PVS patients are able to discriminate between stimuli of different content and are more reactive to emotional than non-emotional stimulation. Our results demonstrate (is a conclusion, should be in present) that auditory stimulation can induce recordable changes in HRV in some PVS cases, providing evidence that these patients retain some preserved cognitive function examined by cardiovascular correlates. The use of HRV to study residual cognitive functions could have practical implications for the management of PVS and MCS.

The law on dying.

The law on dying.

Ethics Consultants' Recommendations for Life-Prolonging Treatment of Patients in a Persistent Vegetative State

OBJECTIVE--Surprisingly little is known about the content of ethics consultants' recommendations. We chose to study this issue using hypothetical persistent vegetative state (PVS) cases. We addressed four questions: What recommendations do ethics consultants give regarding life-prolonging treatment (LPT) in PVS cases? To what degree is there consensus? What factors influence recommendations? Do recommendations conform to established guidelines? DESIGN--Questionnaire survey. Our questionnaire asked subjects what they would recommend for seven hypothetical vignettes involving a PVS patient that varied with respect to advance directives and family wishes. We also questioned subjects about demographic characteristics, ethics consultation experience, and personal preference for LPT in PVS. SUBJECTS--Attendees at an annual meeting of the Society for Bioethics Consultation (n = 154). RESULTS--The response rate was 77%. Eighty-one percent of respondents were ethics committee members and 62% were ethics consultants. There was general agreement among respondents for only one of seven vignettes: in the case of a PVS patient whose advance directive and family agree that LPT be stopped, 93% recommended stopping all LPT. Responses to other vignettes varied considerably. Although patient wishes were an important factor influencing recommendations, none of the respondents adhered invariably to the patient's advance directive. Recommendations were also influenced by family wishes, resource allocation considerations, legal constraints, and personal preference for LPT in PVS. Guidelines we examined were generally too equivocal to be useful for evaluating ethics consultants' recommendations. CONCLUSIONS--The finding of wide variability in ethics consultants' recommendations suggests a need to clarify standards for ethics consultation.

Ethics consultants' recommendations for life-prolonging treatment of patients in a persistent vegetative state

<h3>Objective.</h3> —Surprisingly little is known about the content of ethics consultants' recommendations. We chose to study this issue using hypothetical persistent vegetative state (PVS) cases. We addressed four questions: What recommendations do ethics consultants give regarding life-prolonging treatment (LPT) in PVS cases? To what degree is there consensus? What factors influence recommendations? Do recommendations conform to established guidelines? <h3>Design.</h3> —Questionnaire survey. Our questionnaire asked subjects what they would recommend for seven hypothetical vignettes involving a PVS patient that varied with respect to advance directives and family wishes. We also questioned subjects about demographic characteristics, ethics consultation experience, and personal preference for LPT in PVS. <h3>Subjects.</h3> —Attendees at an annual meeting of the Society for Bioethics Consultation (n=154). <h3>Results.</h3> —The response rate was 77%. Eighty-one percent of respondents were ethics committee members and 62% were ethics consultants. There was general agreement among respondents for only one of seven vignettes: in the case of a PVS patient whose advance directive and family agree that LPT be stopped, 93% recommended stopping all LPT. Responses to other vignettes varied considerably. Although patient wishes were an important factor influencing recommendations, none of the respondents adhered invariably to the patient's advance directive. Recommendations were also influenced by family wishes, resource allocation considerations, legal constraints, and personal preference for LPT in PVS. Guidelines we examined were generally too equivocal to be useful for evaluating ethics consultants' recommendations. <h3>Conclusions.</h3> —The finding of wide variability in ethics consultants' recommendations suggests a need to clarify standards for ethics consultation. (<i>JAMA</i>. 1993;270:2578-2582)