Premorbid Health Research Articles

Does post-traumatic stress disorder occur after stroke: a preliminary study.

Psychological reactions after stroke have been recognized for some time. The present study examined whether psychological symptoms consistent with post-traumatic stress disorder (PTSD) could occur after stroke as a consequence of the sudden and unpredictable occurrence of a life-threatening internal stressor. Sixty-one patients who had experienced a first-ever stroke or transient ischaemic attack were assessed using standard self-report clinical measures for anxiety, depression and PTSD. Those patients who fulfilled criteria on at least one PTSD self-report measure were subsequently assessed using a structured clinical interview for PTSD. Six (9.8%) patients fulfilled criteria for PTSD. No significant differences were found between the post-stroke PTSD group and the non-PTSD group in terms of premorbid health and lifestyle, or experiences of adverse life events. Significant differences were noted with respect to self-reported post-stroke mental health and premorbid neuroticism. The post-stroke PTSD group also scored consistently higher on measures of anxiety, depression and psychiatric caseness. The results of this study demonstrate a number of close similarities between post-stroke PTSD and classical PTSD. We therefore conclude that PTSD or a PTSD-like syndrome can occur after stroke.

Tertiary peritonitis: clinical features of a complex nosocomial infection.

The objective of this study was to define risk factors for and the clinical course of recurrent or tertiary peritonitis. Intensive supportive care of patients with life-threatening intraabdominal infections has led to the emergence of a new clinical syndrome, tertiary peritonitis, defined as the persistence or recurrence of intraabdominal infection following apparently adequate therapy of primary or secondary peritonitis. We undertook a retrospective study of 59 patients admitted with intraabdominal infection to a surgical intensive care unit (ICU). Tertiary peritonitis developed in 74% (44/59) of patients. Despite comparable premorbid health status, source of peritonitis, and admission APACHE II scores, patients with tertiary peritonitis had a significantly longer ICU stay (21.8 +/- 14.9 vs. 8.5 +/- 7.9 days), more advanced organ dysfunction reflected in higher organ dysfunction scores (13.3 +/- 5.1 vs. 7.7 +/- 3.3), and higher ICU mortality (64% vs. 33%) than patients with uncomplicated secondary peritonitis. The most common infecting organisms in patients with tertiary peritonitis were Enterococcus, Candida, Staphylococcus epidermidis, and Enterobacter. Infectious foci were rarely amenable to percutaneous drainage and were found to be poorly localized at laparotomy. Recurrent, or tertiary, peritonitis is a common complication of intraabdominal infection in patients admitted to an ICU. It differs from uncomplicated secondary peritonitis in its microbial flora and lack of response to appropriate surgical and antibiotic therapy. Like nosocomial pneumonia in the critically ill patient, the syndrome appears to be more a reflection than a cause of adverse outcome.

Reduced cognitive functions in a group of whiplash patients with demonstrated disturbances in the posture control system

Past studies examining whether or not cognitive changes actually have occurred as a result of a whiplash (WL) accident have produced varying results. The aim of this study was to identify possible cognitive dysfunctions in a group with persistent problems after whiplash due to injuries to the posture control system and related structures. The whiplash subjects (n = 23) were selected on the basis of their reduced gain in the Smooth Pursuit Neck Torsion test (SPNT). The WL group differed significantly from a closely matched control group on tests of learning and memory, and prolonged divided attention and concentration. After attempting to rule out other ways of interpreting these differences (such as pain, depression, medication, and premorbid health problems), these data were interpreted as lending support to the notion of a causal connection between the disturbed posture control system and some cognitive malfunctions.

Surprising Neurobehavioral Functioning and Brief Major Depression Following Penetrating Brain Injury in an Adolescent

Abstract We present a case focusing on the surprising paucity of changes in behavior and executive functioning following accidental gunshot injury in an adolescent. Detailed image analysis revealed lesions in the right frontopolar, anterior orbitofrontal, temporal polar, anterior inferior temporal cortices and amygdala. It is possible that partial sparing of the orbitofrontal area and the fact that the lesion was unilateral, in addition to the subject's superior preinjury intellectual status, premorbid psychiatric health and healthy family functioning, are relevant factors in his excellent overall short-term outcome. Neuropsychiatric aspects of major depression in the subject are also reviewed. The subject's lesion is consistent with a depressive symptom complex, described previously following focal right frontal lesions in children and adolescents as well as in adult studies of penetrating brain injury. The case is unique in that extensive baseline data are available from 16, 13 and 4 months before the p...

Surprising neurobehavioral functioning and brief major depression following penetrating brain injury in an adolescent

We present a case focusing on the surprising paucity of changes in behavior and executive functioning following accidental gunshot injury in an adolescent. Detailed image analysis revealed lesions in the right frontopolar, anterior orbitofrontal, temporal polar, anterior inferior temporal cortices and amygdala. It is possible that partial sparing of the orbitofrontal area and the fact that the lesion was unilateral, in addition to the subject's superior preinjury intellectual status, premorbid psychiatric health and healthy family functioning, are relevant factors in his excellent overall short-term outcome. Neuropsychiatric aspects of major depression in the subject are also reviewed. The subject's lesion is consistent with a depressive symptom complex, described previously following focal right frontal lesions in children and adolescents as well as in adult studies of penetrating brain injury. The case is unique in that extensive baseline data are available from 16, 13 and 4 months before the penetrating brain injury as well as follow-up data at 8 months following this injury.

Traumatic distress symptoms in early breast cancer. II: Outcome six weeks post surgery

One hundred and six consecutive patients with a confirmed diagnosis of breast cancer were studied before and after surgery with a clinical psychiatric interview and questionnaires (Impact of Event Scale, General Health Questionnaire and Clinical Global Impression scale). The traumatic stress response after six weeks was related to sociodemographic factors, premorbid health problems, negative life events and clinical-oncological parameters. Symptoms of traumatic distress were significantly reduced post-surgery compared to acutely, and most so among patients with no premorbid health problems and negative life events according to pre-surgery interview and self-report data. Eighteen percent of the patients reported a high level (>19) of intrusive symptoms and 14%, avoidance symptoms. Patients with premorbid impairment in work, family and social functioning and patients who during the last year had experienced the death of a close relative or a serious illness other than cancer showed the greatest distress. Previous consultations for nervous problems, age, marital status, stage of disease, type of surgery (breast-conserving versus mastectomy) and adjuvant cytostatic treatment did not influence the traumaticstress response six weeks after surgery. The level of acute posttraumatic stress response to breast cancer surgery seems best predicted by premorbid variables.

Conversion disorder after maxillofacial trauma and surgery

Three cases of conversion disorder are reported: one after orthognathic surgery and two after facial trauma. Two of the cases involved facial anesthesia and one case involved facial palsy. It was thought to be important to bring this phenomenon to the attention of oral and maxillofacial surgeons, to consider its management, and to define the patients with a high risk of developing conversion disorder. The prognosis is dependent on the circumstances of the onset of the disorder, the premorbid psychologic health of the patient, and how rapidly treatment is prescribed.

Self-rated health and physical disability in elderly survivors of a major medical event.

This article describes change and stability in self-rated health after a major medical event. Using a prospective design, it examines the ability of premorbid and post-illness health perceptions to predict physical disability independently of medical, psychosocial, and behavioral variables. Participants (N=254) were a subsample of the New Haven cohort of the Established Populations for Epidemiologic Studies of the Elderly (EPESE) project who had survived hospitalization for stroke, myocardial infarction, or hip fracture. Data came from premorbid EPESE interviews, medical records, and interviews at 6 weeks and at 6 months after hospitalization. Health perceptions did not universally decline after the illness. Self-rated health at 6 weeks predicted disability at 6 months, but premorbid self-rated health did not, suggesting that illness-related changes in health perceptions influenced the recovery process. The effects of 6-week self-rated health on disability were independent of physical inactivity. The mechanisms by which health perceptions influence recovery are unclear.

The Effect of the Total Cumulative Epinephrine Dose Administered During Human CPR on Hemodynamic, Oxygen Transport, and Utilization Variables in the Postresuscitation Period

Studies evaluating the dose of epinephrine required to optimize return of spontaneous circulation and survival after CPR have shown that doses greater than recommended by advanced cardiac life support (ACLS) improve coronary perfusion pressure and short-term resuscitation rates. Since survival has not improved, it is possible that higher doses of epinephrine may be physiologically detrimental in the postresuscitation period. The object of this study is to measure the effect of the total cumulative dose of epinephrine given during ACLS on the hemodynamic, oxygen transport, and utilization variables in the postresuscitation period. A prospective nonrandomized control trial of inception cohorts. A large urban emergency department and intensive care unit. Forty-nine successfully resuscitated witnessed, normothermic, nontraumatic, out-of-hospital patients, who had suffered cardiac arrests. All patients were treated according to ACLS guidelines; however, the epinephrine dose (0.01 to 0.2 mg/kg or 1 to 14 mg) was selected at the clinician's discretion and given through central venous access every 3 to 5 min. Hemodynamic, oxygen transport, and utilization variables were measured on a return of spontaneous circulation, and at least every 30 min thereafter under a standardized postresuscitation protocol. Hemodynamic, oxygen transport/utilization variables, and mortality in patients resuscitated from cardiac arrest. The total cumulative dose of epinephrine given during ACLS until a return of spontaneous circulation was recorded. A total cumulative epinephrine dose of 15 mg was found to best predict 24-h mortality. Of the 49 patients, 20 received less than 15 mg (group 1) and 29 received greater than 15 mg (group 2). Age, premorbid health status, sex, presenting rhythm, and duration of cardiac arrest were similar in both groups. The 24-h survival was 17 of 20 (85%) and 12 of 29 (41%) in group 1 and 2, respectively (p < 0.002). Over the first 6 h of the postresuscitation period, both groups had similar mean arterial pressure (MAP), mixed venous oxygen saturation, and systemic oxygen extraction ratio (all p > 0.1). Group 2, however, had a significantly lower cardiac index (CI), systemic oxygen consumption (VO2), and systemic oxygen delivery (DO2) (all p < 0.01). Systemic vascular resistance index (SVRI), initial and 6-h lactic acid levels were significantly higher in group 2 (all p < 0.03). The administration of all doses of epinephrine during the resuscitation of out-of-hospital cardiac arrest is associated with impairment of DO2 and VO2 in the postresuscitation period. Both duration and severity of these impairments correlate with the total cumulative epinephrine dose given during the resuscitation. Thus, inadvertent catecholamine toxicity represents a further complicating factor in the production of postresuscitation disease. Diagnostic and therapeutic interventions addressed toward mitigating these potentially reversible adverse effects may impact morbidity and mortality in out-of-hospital cardiac arrests.

APACHE II scoring system on a general intensive care unit: audit of daily APACHE II scores and 6-month survival of 691 patients admitted to a general intensive care unit between May 1990 and December 1991.

In this paper we present a detailed analysis of the use of the APACHE II (acute physiological and chronic health evaluation) scoring system on all of the patients admitted to the general intensive care unit at the Bristol Royal Infirmary over a 20-month period. The 6-month survival of 691 adult medical and surgical patients following intensive care was recorded and this data was analysed with admission and daily APACHE II scores using a relational database. Our data confirms the relationship between admission APACHE II scores and outcome, with mean scores decreasing as duration of survival increases. We also demonstrate that the best day one scores are approximately 50% less than the admission score, irrespective of outcome, indicating the benefit of intensive care. By contrast, however, the scores on day one have either not improved or have worsened since admission, reflecting the importance of the pre-morbid health status of the patient in determining outcome from intensive care.

Electrostimulation Effects of the Vagus Nerve on Balance in Epilepsy

Preliminary results of selected postural measures in quiet standing indicate that stimulation of the vagus nerve appears not to be producing adverse effects. With this specific sample size, more testing is needed to determine long-term effects and future data analyses will examine correlations between electroencephalogram results, drug levels, and seizure frequency. In the present study three subjects have had old injuries to hips and ankles. Two subjects had normal values for postural control prior to stimulation, while other subjects were severely abnormal. In future, studies should include larger homogeneous sample sizes, as the current subjects show marked variability in age and premorbid health backgrounds. Future work should also control more vigorously for variables such as visual input (i.e., blindfolding subjects instead of simply closing the eyes). Evaluation of postural control mechanisms will be continued to assess stability changes in these patients as seizure frequency continues to subside.

A selective review of recent North American long-term followup studies of schizophrenia.

North American outcome studies of schizophrenia conducted within the past quarter century are reviewed if their minimum average followup is 10 years and they meet at least some modern design criteria. Ten such investigations are described and summarized. Taken as a whole, they demonstrate that schizophrenia can be a chronic disease whose outcome on the average is worse than that of other major mental illnesses. It is associated with an increased risk for suicide, physical illness, and mortality. The schizophrenic process, however, is not relentlessly progressive, as originally described, but appears to plateau after 5-10 years of manifest illness. Overall, outcome is heterogeneous, but much of the variance can be linked to sample characteristics, including expressions of psychopathology (broad vs. narrow diagnostic criteria, subtypes, and comorbidity), dimensions of chronicity (length of manifest illness, treatment resistance, age of onset, and institutionalization), and other predictor variables (gender, marital status, socioeconomic status, physical setting, and premorbid health). Long-term followup studies have yet to demonstrate clearly any effect of treatment on the natural history of schizophrenia. Finally, these studies support a broad definition of schizophrenia.

Post-traumatic headache patients I: Demographics, injuries, headache and health status.

SYNOPSISWhile research has recently focused on the perceptions of general headache patients of their disorders, little attention has been paid to post‐traumatic headache patients, their perceptions of their disorder and of its course, and their perception of the health care system in which they have become participants. The present study was designed to provide data on these aspects. The respondents were new and return post‐traumatic headache patients in a headache treatment center. A survey form was employed and, in a twelve month sampling effort, the opinions of one hundred seventeen patients were obtained. This report describes demographic characteristics of the sample, the patients' premorbid and postmorbid health status, the status of headache and associated symptoms, and descriptions of injuries and of post‐traumatic amnesia. Patients and their families are often demoralized by both the symptoms and their slow resolution. They lack information around which to build long term coping strategies. The data in this report can be helpful in tailoring treatment programs and guiding patients with respect to prognosis.