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PubMed2005

Separating functional and structural damage in persistent vegetative state using combined voxel-based analysis of 3-D MRI and FDG-PET.

Functional and structural damage in postanoxic persistent vegetative state (PVS) was analysed using 18fluorodeoxyglucose PET (FDG-PET) coregistered to 3-D MRI in combination with morphometric 3-D MRI analysis (voxel-based morphometry, VBM). In five patients in late stages of non-traumatic PVS, combined analysis using statistical parametric mapping (SPM2) was performed to compare metabolic impairment and structural loss. FDG-PET showed widespread hypometabolism at p<0.001 (corrected) in the parietal, parietooccipital and frontotemporal cortices, cingulum, frontal medial and precentral gyrus, and within the bilateral thalamus. VBM revealed multilocal structural loss at p<0.001 (corrected) in the inferior parietal and superior/medial frontal cortices, insula and operculum, superior and medial temporal lobes, cingulum and fusiform gyrus, caudate, midbrain, dorsal pons, and the cerebellum, but to a lesser extent in the thalamus. The selective vulnerability of the brain in a sample of PVS patients could be mapped in vivo, indicating that a complex structural and functional lesion pattern of the cerebral networks seems to be associated with this condition.

Adult↗
PubMed1996

Physicians' attitudes about the care of patients in the persistent vegetative state: a national survey.

OBJECTIVE: To study the attitudes and beliefs of physicians who have experience caring for patients in the persistent vegetative state (PVS). DESIGN: Mailed questionnaire survey. PARTICIPANTS: 500 physicians, 250 from the American Academy of Neurology and 250 from the American Medical Directors Association. MEASUREMENTS: Physicians' beliefs about diagnosis of the PVS, patient awareness and suffering, treatment withdrawal, appropriate use of health maintenance and life-prolonging therapies, organ donation, lethal injection, and the treatment they would want if they were in the PVS. RESULTS: 68% of surveyed neurologists and 60% of medical directors responded. Thirteen percent of responders believe that patients in the PVS have awareness and experience hunger and thirst; 30% believe they experience pain. Fewer than 9% believe that respiratory failure, cardiogenic shock, acute renal failure, or cancer should be aggressively treated. Eighty-nine percent believe that it is ethical to withdraw artificial hydration and nutrition. Almost two thirds of responders believe that it would be ethical to use the vital organs of patients in the PVS for transplantation, and 20% believe that it would be ethical to hasten the patient's death by lethal injection. CONCLUSIONS: When evaluating the appropriateness of treatments for patients in the PVS, neurologists and medical directors largely concur. Most physicians in both groups believe that patients in the PVS would be better off dead; that it is not necessary to provide aggressive therapeutic interventions; and that all therapeutic interventions, including artificial nutrition and hydration, can be withheld in certain circumstances. The areas of consensus are remarkable and suggest that an ethical standard that physicians believe should be followed when caring for these patients may be emerging.

Acute Disease↗
PubMed1996

Circadian blood pressure in patients in a persistent vegetative state.

We examined circadian variations in blood pressure, pulse rate, and other physiological variables, including hormone levels, in 16 patients in a persistent vegetative state (mean age -/+ SE; 66.1 -+/ 3.9 yr). Cerebrovascular accident was responsible for brain damage in 12 (75%) of the 16 patients. Blood pressure was measured for 24 h with an ambulatory blood pressure monitoring device. We monitored the temperature of the urinary bladder and measured urinary excretion of epinephrine, norepinephrine, 17-hydroxycorticosteroids, water, and sodium. When data were analyzed by analysis of variance, significant circadian changes were observed in body temperature and urinary excretion of hormones and sodium, but not in blood pressure or pulse rate. Individual analysis of rhythmicity using the cosinor method detected small but significant circadian variations in blood pressure and pulse rate in five of six patients who showed a simple organized response to noxious external stimuli. The disappearance of variation in blood pressure in patients in a vegetative state appeared to be related, in part, to the lack of response to external stimuli. Our findings suggest that the circadian variation in blood pressure may largely depend on external environmental factors.

Adult↗
PubMed2001

Patients in a persistent vegetative state: caregiver attitudes and reactions.

OBJECTIVES: This exploratory study investigated the problems encountered by caregivers of long-stay hospital patients in a persistent vegetative state. MATERIAL AND METHODS: Sixteen primary caregivers completed questionnaires designed to assess their personality, psychophysical distress, coping strategies and caregiving-related problems. RESULTS: Males showed a higher level of emotional distress and neuroticism than females. All of the caregivers used situation-oriented coping strategies less over time. had apparently unsatisfactory family relationships, and their emotional distress increased with disease duration. The thoughts of the possible death of the patient were associated with anxiety and depressive symptoms. The caregivers' everyday lives were characterized by limited social relationships, and indoor and outdoor interests. CONCLUSION: Our study underlines the importance of psychosocially assessing PVS patient caregivers, who are often alone in coping with a irreversible situation. It also introduces a questionnaire (FSQ2) that seems to be sufficient to assess the caregiving-related problems.

Adaptation, Psychological↗
PubMed1993

Persistent vegetative state--clinical and electrophysiologic observations of 5 cases.

Five patients who met the criteria of the persistent vegetative state (PVS), were studied for ten years. Among them, two had fallen into a deep coma after cardiopulmonary resuscitation, and the other three cases were due to cerebrovascular disorders. Four patients died within 10 years. Clinically, all five cases showed characteristic features of wakefulness without cognitive function and movement of the extremities. The brain stem reflexes, such as light reflexes of the pupils and corneal reflexes, were present. The electroencephalograms showed ample low amplitude and nonspecific slow waves. None revealed an isoelectric pattern. Brain stem auditory evoked potential (BAEP) studies were normal or slightly abnormal. Median nerve somatosensory evoked potential (SSEP) studies showed absence of a cortical response. These features suggest that the damage in PVS patients is mainly located in the cerebral cortex. Although electrophysiologic examinations are useful diagnostic procedures for PVS, clinical observation remains the basis of the diagnosis.

Adult↗
PubMed2006

The burdens-benefits ratio consideration for medical administration of nutrition and hydration to persons in the persistent vegetative state.

In this article, Harvey notes the initial confusion about the statement made by the pope concerning artificial nutrition and hydration on patients suffering persistent vegetative states (PVS) due to misunderstanding through the translation of the pope's words. He clarifies and assesses what was meant by the statement. He also discusses the problems of terminology concerned with the subject of PVS. Harvey concludes that the papal allocution was in line with traditional Catholic bioethics, and that while maintaining the life of a patient is favorable, in particular cases this presumption wanes when it is clear that this treatment modality would be futile or very burdensome.

Catholicism↗
PubMed1997

The development and clinical trial of labor-saving care facilities for patients in a persistent vegetative state.

BACKGROUND: In order to reduce the work load of nursing staff who provide long term care to the patients who are in a persistent vegetative state (PPVS), a centralized open care system which can accommodate 140 PPVS was developed. This system contained a multifunctional bed, auto-bathing machine transported by an automatically guided vehicle, a dental cleansing device, remote excreta detection diaper, and a centralized feeding system. METHOD: The multifunctional bed consisted of a modified bed top with automatically controlled moving bars covered by plastic foam to reduce pressure on the back. The inclination of the bed could be adjusted automatically. The patient could be transferred to an auto-bathing shower machine using a robotic arm mounted on the unmanned cart (TRANSCAR). RESULTS: The clothing of the PPVS was modified to a single piece with Velcro closures. A T-shaped diaper contained a sensor and alarm for indicating the presence of excreta. Patients' temperatures were monitored by infrared aural thermometry. An automatic jet-spray and suction device for dental cleansing was also designed. Feeding was delivered by an automatic feeder attached to a minirefrigerating device with a patient centralized control system. The results showed that the system reduced the total nursing hours of each PPVS from 4.60 to 1.83 hours/day. CONCLUSION: A clinical trial of this system with 3 healthy young adults and 3 PPVS was conducted. Many parts of the system need improvement, in order to prevent the slipping of a toe or finger into the moving bars of the bed, keep the whole body clean, and increase the sensitivity of excreta detection.

Adolescent↗
PubMed2004

Therapeutic time window for musicokinetic therapy in a persistent vegetative state after severe brain damage.

OBJECTIVE: To determine the therapeutic time window in which musicokinetic therapy (MKT) could be of potential benefit for a persistent vegetative state (PVS), this study analysed the relationship between the timing of MKT and changes in PVS score following MKT. METHODS: Twenty-six patients who fulfilled the definition of PVS were treated consecutively by MKT employing a trampoline with live music performance for 3 months. The PVS score ranges from 0-30 and the condition which meets the definition of PVS is never scored greater than 20. RESULTS: As compared to patients with brain damage caused by trauma (n=12) or subarachnoid haemorrhage (SAH; n=9), those caused by other cerebrovascular accidents (n=3) or anoxic encephalopathy (n=2) appeared to demonstrate a much smaller improvement in their PVS score. When the patients caused by trauma or SAH were analysed in isolation, the effects of MKT were clearly better in those patients in whom the MKT was initiated within 6 months after brain damage. Among nine patients caused by trauma or SAH who had been in a PVS for more than 12 months, however, six (66.7%) demonstrated improvement of their PVS score by 5 or more and four (33.3%) reached a post-MKT score of greater than 20. CONCLUSIONS: These findings suggest that, contrary to the commonly held belief, the therapeutic time window for MKT is far greater than 6 months, insofar as patients with brain damage caused by trauma or SAH are concerned. Although the benefits of MKT were not proven directly, this inference is consistent with the hypothesis that MKT can induce an improvement in the clinical condition of PVS patients.

Accidents↗
PubMed1998

Applying best interests to persistent vegetative state--a principled distortion?

"Best interests" is widely accepted as the appropriate foundation principle for medico-legal decisions concerning treatment withdrawal from patients in persistent vegetative state (PVS). Its application appears to progress logically from earlier use regarding legally incompetent patients. This author argues, however, that such confidence in the relevance of the principle of best interests to PVS is misplaced, and that current construction in this context is questionable on four specific grounds. Furthermore, it is argued that the resulting legal inconsistency is distorting both the principle itself and, more particularly, individual patient interests.

Decision Making↗
PubMed2005

Advance directives and the persistent vegetative state in Victoria: a human rights perspective.

With advances in medical technology, it is now possible to sustain the life of a person in a persistent vegetative state (PVS) until a decision is made to withhold or withdraw life-sustaining treatment. Who makes that decision? Under the Medical Treatment Act 1988 (Vic) there is no legally enforceable right for a person to choose, in advance, what intervention that person will and will not accept if he or she ends up in a PVS. The best that can be achieved is that a person can appoint an agent who is empowered to refuse medical treatment on the person's behalf in the event of incompetence. It is suggested that this mechanism ignores two fundamental human rights: self-determination and the inherent right to dignity. This article proposes the development of an advance directive mechanism that provides for a person to refuse, in advance, specified intervention, thereby respecting fundamental human rights and alleviating the existing need for an agent to second-guess a person's desires and best interests.

Advance Directives↗
PubMed1992

The persistent vegetative state in children: report of the Child Neurology Society Ethics Committee.

Increasing concern about children in a persistent vegetative state (PVS) prompted a survey of members of the Child Neurology Society regarding aspects of the diagnosis and management of this disorder. Major findings of those responding to this survey (26% response rate) were as follows: (1) 93% believed that a diagnosis of PVS can be made in children, but only 16% believed that this applied to infants younger than 2 months and 70% in the 2-month to 2-year group; (2) a period of 3 to 6 months was believed to be the minimum observation period required before a diagnosis of PVS could be made; (3) 86% believed that the age of the patient would affect the duration of time needed to make the diagnosis of PVS; (4) 78% thought a diagnosis of PVS could be made in children with severe congenital brain malformations; (5) 75% believed that neurodiagnostic studies would be of value and supportive of the clinical diagnosis of PVS; (6) members' opinions as to the average life expectancy (in years) for the following age groups after the patients were considered vegetative were: newborn to 2 months, 4.1; 2 months to 2 years, 5.5; 2 to 7 years, 7.3; and more than 7 years, 7.4; (7) 20% believed that infants and children in a PVS experience pain and suffering; and (8) 75% "never" withhold fluid and nutrition from infants and children in a PVS and 28% "always" give medication for pain and suffering.(ABSTRACT TRUNCATED AT 250 WORDS)

Advisory Committees↗
PubMed1991

HM-PAO-SPECT in persistent vegetative state after head injury: prognostic indicator of the likelihood of recovery?

Management of patients presenting with traumatic persistent vegetative state (PVS) calls for extensive resources. The ability to predict whether or not a patient is likely to recover is a critical issue. In 12 patients with PVS admitted consecutively for early rehabilitation after head injury, pattern of brain activity was measured by 99mTc-hexamethyl-propylenamineoxime (99mTc-HM-PAO) brain SPECT (single photon emission computer tomography). All patients were re-investigated after a mean observation period of 3 years. A global reduction of cortical blood flow was a reliable predictor of poor long-term outcome, but the demonstration of only focal deficits did not reliably indicate a favourable outcome. Brain SPECT may help to improve outcome prediction in patients with traumatic PVS.

Adolescent↗
PubMed1993

Early and late CT manifestations in the persistent vegetative state due to cerebral anoxia-ischemia.

Although there are reports on early CT findings in the persistent vegetative state (PVS) from cerebral anoxia-ischemia, later CT changes have received little attention. CT scans were obtained from six patients who were in PVS from four months to three years. Initial CT scans showed non-specific changes of diffuse cerebral edema. Later CT findings often showed infarction in the superficial or deep border zones (five patients), low density in the basal ganglia (four patients), and infarction in the posterior cerebral artery (PGA) territory (three patients). When the survival time extended beyond eight months, there was an enormous enlargement of the hemispheric ventricles that was disproportionate to the cortical atrophy. The data indicate that border zone and PCA territory infarctions are common in PVS. A progressive, and eventually significant loss of the cerebral mass seems to occur in long-term survivors.

Adolescent↗
PubMed1991

Characterization and modification of brain activity with deep brain stimulation in patients in a persistent vegetative state: pain-related late positive component of cerebral evoked potential.

A series of eight patients in a persistent vegetative state (PVS) were subjected to chronic deep brain stimulation (DBS) for the purpose of promoting recovery from the PVS. The characteristics of the brain activity in these patients were evaluated from the late positive component of the cerebral evoked potential in response to painful stimuli (pain-related P250). While any neurological scoring system for the comatose state includes evaluations of motor reactions to painful stimuli, the pain-related P250 is unique in terms of its ability to assess the cortical responsiveness to painful stimuli directly and quantitatively without involving functions of the motor system. It was found that the pain-related P250 was more or less depressed in patients in a PVS. It was repeatedly demonstrated in four patients, however, that the pain-related P250 could be transiently increased by preceding stimulation of the mesencephalic reticular formation. Furthermore, a persistent increase in the pain-related P250 was produced in these four patients following chronic DBS of the mesencephalic reticular formation or nonspecific thalamic nuclei for more than 6 months, and this was correlated with the clinical improvements. These results imply that responsiveness at the cortical level to pain is depressed in the PVS. It also appears that some fraction of the depression may, however, be functionally produced and potentially reversible.

Brain↗
PubMed2006

Conjugate eye movements and gamma power modulation of the EEG in persistent vegetative state.

BACKGROUND: Power in the gamma band EEG increases during saccades in normal subjects. OBJECTIVE: To develop a potential method to quantify signs of cortical responsiveness in persistent vegetative state (PVS) we quantified gamma range EEG in association with conjugate slow ballistic eye movements (SBEM). METHODS: The EEG and the simultaneous electro-oculogram were recorded in 14 (8F/6M) PVS patients. Clinical scoring was based on the Glasgow Coma Scale (GCS) and Coma Rating Scale (CRS). The Wavelet Transform, followed by Hilbert transform was applied to the EEG and gamma power distribution was quantified relative to the timing of an eye movement. We correlated the clinical and the neurophysiological measures. RESULTS: Gamma activity was present in all PVS patients. Its power was modulated in association with eye movements only in less severely affected patients, with minimum power prior to, and maximum power during the eye movement. In severely affected patients there was no evidence of a temporal relationship between gamma power and the phase of the eye movement. CONCLUSIONS: Detecting changes in the time course of gamma power in relation to conjugate ballistic eye movements provides a quantitative neurophysiological method for prospective longitudinal studies to explore if the preservation of this CNS function relates to the potential for recovery in PVS patients.

Adult↗
PubMed1981

Persistent vegetative state after multiple trauma. A clinicopathologic study.

The clinico-pathological findings are reported in a case with persistent vegetative state after multiple cerebral lesions. The lesions are small in size, and are situated at different levels of the CNS, some of them being important in the maintenance of wakefulness and motor initiative. The differential diagnosis and the isolation of such a syndrome are discussed.

Adult↗