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PubMed2006

Establishing a prognosis for functional outcome during coma recovery.

PRIMARY OBJECTIVE: One of the most challenging tasks for clinicians caring for survivors of severe brain injury (BI) is establishing a prognosis, for long-term functional outcome, while the patient is unconscious. The objective of this article is to report findings regarding the prediction of functional outcomes 1-year after severe BI using data available when the patient is unconscious. RESEARCH DESIGN: Longitudinal prognostication study. METHODS AND PROCEDURES: Persons unconscious after severe BI who present to inpatient (IP) rehabilitation hospitals in the Midwestern US are enrolled in an ongoing study. Each subject is followed for 1-year and the final outcome interview includes approximately 70 questions; 32 of these questions are from the Craig Handicap Assessment and Reporting Technique (CHART). A sample of 63 persons was abstracted from the study database to examine the predictability of 42 independent variables and 16 dichotomous outcomes. MAIN OUTCOMES AND RESULTS: Twelve of the 16 dichotomous outcomes were found to be significantly predictable (p < 0.05). These involve activity, participation, environment and quality of life outcomes. Ten predictors were found to be significant (p < 0.05): aetiology (Closed Head Injury vs. Other BI), presence of urinary tract infection (UTI), seizure, hypertension during IP rehabilitation, veteran benefit eligibility, health insurance, marital status at injury, whether or not recovery of consciousness occurred within 1 year, the number of days between injury and admission to acute rehabilitation and the average length of IP rehabilitation stay. Eight of the 10 variables are available early after injury or when the patient is unconscious.

Activities of Daily Living↗
PubMed1994

Involuntary conscious memory and the method of opposition.

Priming in an indirect test of stem completion should reflect involuntary memory, but can be accompanied by conscious awareness of the past (involuntary conscious memory) or unaccompanied by such awareness (involuntary unconscious memory). We adapted the method of opposition developed by Jacoby, Woloshyn, and Kelley (1989) to obtain a measure of stem-completion priming that should reflect only involuntary unconscious memory. Subjects completed stems with the first word coming to mind, but wrote down a different word if the word that came to mind first had been previously encountered. Facilitatory priming was expected only when involuntary unconscious influences outweighed inhibitory effects of involuntary conscious memory, or of intentional retrieval. We observed a facilitation effect for items processed graphemically at encoding, in conjunction with an inhibition effect for items processed semantically at encoding. In contrast, a standard indirect test showed similar levels of priming following graphemic and semantic encoding, whereas a direct test showed a strong advantage of semantic over graphemic encoding. We argue that the two encoding activities produced approximately equivalent involuntary influences of memory, but that items encoded semantically were associated with involuntary conscious memory to a greater extent than were items encoded graphemically. Comparing indirect and opposition test performance can provide a quantitative index of relative levels of involuntary conscious and involuntary unconscious memory.

Analysis of Variance↗
PubMed2005

Detection of consciousness by electroencephalogram and auditory evoked potentials.

BACKGROUND: A set of electroencephalographic and auditory evoked potential (AEP) parameters should be identified that allows separation of consciousness from unconsciousness (reflected by responsiveness/unresponsiveness to command). METHODS: Forty unpremedicated patients received anesthesia with remifentanil and either sevoflurane or propofol. With remifentanil infusion (0.2 microg . kg . min), patients were asked every 30 s to squeeze the investigator's hand. Sevoflurane or propofol was given until loss of consciousness. After intubation, propofol or sevoflurane was stopped until patients followed the command (return of consciousness). Thereafter, propofol or sevoflurane was started again (loss of consciousness), and surgery was performed. Return of consciousness was observed after surgery. The electroencephalogram and AEP from immediately before and after the transitions were selected. Logistic regression was calculated to identify models for the separation between consciousness and unconsciousness. For the top 10 models, 1,000-fold cross-validation was performed. Backward variable selection was applied to identify a minimal model. Prediction probability was calculated. The digitized electroencephalogram was replayed, and the Bispectral Index was measured and accordingly analyzed. RESULTS: The best full model (prediction probability 0.89) contained 15 AEP and 4 electroencephalographic parameters. The best minimal model (prediction probability 0.87) contained 2 AEP and 2 electroencephalographic parameters (median frequency of the amplitude spectrum from 8-30 Hz and approximate entropy). The prediction probability of the Bispectral Index was 0.737. CONCLUSIONS: A combination of electroencephalographic and AEP parameters can be used to differentiate between consciousness and unconsciousness even in a very challenging data set. The minimal model contains a combination of AEP and electroencephalographic parameters and has a higher prediction probability than Bispectral Index for the separation between consciousness and unconsciousness.

Adult↗
PubMed2004

Prognostic value of S100B protein in carbon monoxide-poisoned rats.

OBJECTIVE: To assess the possible role of S100B, a structural protein of astroglial cells, as a biochemical marker in acute carbon monoxide-poisoned rats and to compare its prognostic value with consciousness level, which is one of the major parameters for treatment decision in acute carbon monoxide poisoning. DESIGN: Nonrandomized, controlled interventional trial. SETTING: University laboratory. SUBJECTS: Male Wistar rats weighing 263 +/- 18 g. INTERVENTIONS: The rats were exposed to a mixture of 3000 ppm carbon monoxide in air for 60 mins (group 1) and a mixture of 5000 ppm carbon monoxide in air for 30 mins (group 2). Blood samples were taken from the jugular vein just before and immediately after the carbon monoxide poisoning. The level of consciousness was evaluated at the end of the exposure, and the survival rate was monitored for 7 days. The S100B concentrations were measured with a commercial immunoluminometric assay. MEASUREMENTS AND MAIN RESULTS: In the first group, the unconscious rats after carbon monoxide exposure had significantly higher S100B levels compared with the rats without loss of consciousness. In the second group, the unconscious rats that later died had significantly higher S100B levels compared with the unconscious rats that survived. The S100B levels of all conscious and unconscious surviving rats were not significantly different. The serum level of S100B below 0.44 microg/L predicted survival of carbon monoxide-poisoned rats, with a sensitivity of 100% and a specificity of 86%. CONCLUSIONS: Acute carbon monoxide poisoning is associated with elevated S100B levels. S100B is a better predictor of final outcome than the consciousness level, so it could be used as a prognostic parameter for acute carbon monoxide poisoning in rats.

Animals↗
PubMed1993

Course and outcome of patients in vegetative state of nontraumatic aetiology.

A follow up study is reported of 100 consecutive unconscious patients admitted to an intensive care coma facility with a history of 30 days or more of unconsciousness of nontraumatic cause. Twenty recovered consciousness, all within 5 months of injury. 31 of the remaining patients died within 6 months following injury, while 49 continued unconscious until death. The mean life expectancy of these 49 was 26-34 months from that time. All 20 patients who recovered awareness continued to suffer from major disability. The prognosis for life or death and for recovery or not of consciousness was not significantly correlated with age or aetiology of the vegetative state. Among those who recovered consciousness, the younger patients showed somewhat better results in three parameters of function: locomotion, ADL and day-placement, but not in cognition, behaviour or speech accuracy and fluency. The overall results for these nontraumatic patients with postcomatose unawareness are clearly worse than those for patients with a similar period of unconsciousness following craniocerebral trauma.

Activities of Daily Living↗
PubMed1999

Apolipoprotein E-epsilon4 genotype predicts a poor outcome in survivors of traumatic brain injury.

OBJECTIVE: To determine the ability of apolipoprotein E (APOE) genotypes to predict days of unconsciousness and a suboptimal functional outcome in traumatic brain injury (TBI) survivors. BACKGROUND: TBI is known to be associated with neuropsychological deficits and functional disability. Recent evidence indicates that APOE plays a pivotal role in CNS response to injury. METHODS: In this prospective study the authors determined the APOE genotypes and tested their ability to predict days of unconsciousness and functional outcome after at least 6 months in 69 survivors of TBI. A good functional outcome was defined as no dysarthria, behavioral abnormalities, or dysphasia; no severe cognitive abnormalities; and the ability to live independently. RESULTS: The odds ratio of more than 7 days of unconsciousness was 5.69 in those with the APOE-epsilon4 allele compared with those without the epsilon4 allele (95% CI, 1.69 to 20.0; p = 0.001). Only 1 of 27 subjects (3.7%) with the epsilon4 allele had a good functional outcome compared with 13 of 42 (31.0%) of those without the epsilon4 allele (p = 0.006). The OR of a suboptimal outcome (fair or unfavorable) was 13.93 for those with the epsilon4 allele compared with those without the allele after controlling for age and time of unconsciousness (95% CI, 1.45 to 133.97; p = 0.02). CONCLUSION: The results demonstrate a strong association between the APOE-epsilon4 allele and a poor clinical outcome, implying genetic susceptibility to the effect of brain injury. Additional studies of TBI patients are warranted to confirm their findings.

Adolescent↗
PubMed2003

The observing ego as voyeur.

A resistance to self-observation and self-reflection is discussed in which there is a perversion of the observing ego. The observing ego has been unconsciously recruited in the service of enacting an unconscious fantasy: the fantasy of being an excited observer of a primal scene who is punished for making forbidden observations. This voyeuristic observing ego is pathologically enmeshed in a love triangle with the patient's seductive superego (i.e. identification with the desired but unfaithful parent) and with the patient's punitive superego (i.e. identification with the rivalrous parent). This unconscious scenario is played out in the clinical situation as the patient unreflectively cycles through phases of denial (i.e. self-seduction) and moral masochism (i.e. self-betrayal). A case study illustrates how humor may be employed to free the observing ego from being enthralled by a perverse superego. Humor may unconsciously enable a rebellious attitude toward the omnipotent sadism of a perversely oppressive superego and thus enable the observing ego to break free from its pathological enmeshment.

Denial, Psychological↗
PubMed1999

Investigation of an epidemic of Reye's syndrome in northern region of India.

OBJECTIVE: To determine the extent, epidemiological and clinical features of an epidemic of non-inflammatory encephalopathy in northern region of India. DESIGN: Surveillance of referred cases having unconsciousness after a short bout of fever during October and November 1997. Case control study in 7 most affected villages. METHODS: Active case finding was done to assess the extent and severity of the epidemic by interviewing health professionals and by reviewing mortality records in 10 districts of Haryana, Punjab and Chandigarh. A house to house survey was conducted in seven most affected villages. A case was defined as any child of less than 15 years of age, who had prodromal fever followed by vomiting and unconsciousness with subsequent recovery or death. Two age and sex matched controls who had fever without unconsciousness were taken for each case, one from nearby house and another staying furthest from the affected house. These groups were compared for various epidemiologic factors, clinical features and treatment pattern. Residual medicines used by affected patients were tested for presence of salicylate. Local village practitioners were interviewed for their knowledge and attitude towards use of aspirin in a febrile child. RESULTS: Information regarding 129 affected children (M: F=1 : 1) could be obtained. Age ranged between 1 to 12 years (mean 5.8 years). Most were from rural or semi-suburban areas. Attack rate was 5.4/1000 and case fatality rate was 72%. Multiple sibs were affected in 9.3%. History of fever was reported by 83%, vomiting preceding unconsciousness by 83% and abnormal behavior by 65%. Abnormal posturing was reported in 55%. Seventeen (61%) of 28 samples had IgM antibodies in serum/CSF against measles. Twelve (36%) of 33 serum samples tested positive for Varicella zoster virus. None gave history of aspirin intake and 10 samples of residual drugs did not contain salicylate. However, 6 out of 19 blood samples taken from affected patients contained salicylate. Environmental factors were in favor of Japanese encephalitis (JE) but brain biopsy and serology disproved it. Based on earlier report of JE from this area, the cases in present epidemic were being reported as JE before this study was undertaken. Intensive fogging with malathion was being undertaken as antimosquito measure, specially around the affected houses. Local village practitioners (n = 37) were unaware of contraindications of aspirin in a febrile child. CONCLUSION: Measles and varicella zoster emerged as the probable etiologies for the viral prodrome precipitating these cases of Reye's syndrome. Aspirin might have a contributory role. Malathion is another putative cofactor.

Case-Control Studies↗
PubMed2003

How (un) ethical are you?

Answer true or false: "I am an ethical manager." If you answered "true," here's an Uncomfortable fact: You're probably wrong. Most of us believe we can objectively size up a job candidate or a venture deal and reach a fair and rational conclusion that's in our, and our organization's, best interests. But more than two decades of psychological research indicates that most of us harbor unconscious biases that are often at odds with our consciously held beliefs. The flawed judgments arising from these biases are ethically problematic and undermine managers' fundamental work--to recruit and retain superior talent, boost individual and team performance, and collaborate effectively with partners. This article explores four related sources of unintentional unethical decision making. If you're surprised that a female colleague has poor people skills, you are displaying implicit bias--judging according to unconscious stereotypes rather than merit. Companies that give bonuses to employees who recommend their friends for open positions are encouraging ingroup bias--favoring people in their own circles. If you think you're better than the average worker in your company (and who doesn't?), you may be displaying the common tendency to overclaim credit. And although many conflicts of interest are overt, many more are subtle. Who knows, for instance, whether the promise of quick and certain payment figures into an attorney's recommendation to settle a winnable case rather than go to trial? How can you counter these biases if they're unconscious? Traditional ethics training is not enough. But by gathering better data, ridding the work environment of stereotypical cues, and broadening your mind-set when you make decisions, you can go a long way toward bringing your unconscious biases to light and submitting them to your conscious will.

Administrative Personnel↗
PubMed1988

[Epidural hematoma without intradural lesions--clinical study of 120 cases].

One hundred twenty cases of epidural hematoma without intradural lesion treated between 1975 and 1983 to which CT scan was available, were presented. Mortality rate was 1.7% and morbidity rate was 6.7%. In all cases of epidural hematoma including with and without intradural lesion in the same term (164 cases), mortality and morbidity rate were 7.3 and 10.4% respectively. Ninety five cases were male and 25 cases were female. Causes of injury were falls from a height (42 cases, 35%), traffic accident (41 cases, 34%), and falls at ground level (24 cases, 20%). The site of hematoma in 120 cases of 128 hematoma were frontal (17 cases, 13%), temporoparietal (74 cases, 58%), parasagittal (4 cases, 3%), middle fossa (8 cases, 6%), occipital (16 cases, 13%) and posterior fossa (9 cases, 7%). Fractures were shown in 109 cases out of 120 cases on skull X-P and depressed fractures were 12 cases. Those which showed no fracture on skull X-P, revealed slow growth of hematoma and delayed onset of clinical signs and were mainly children. Seven operated cases of epidural hematoma does not show fractures on skull X-P nor initial unconscious. Clinical course of disturbance of consciousness were divided in five types as follows; I. no unconsciousness (22 cases, 18%), II. latent interval (17 cases, 14%), III. primary but no secondary unconsciousness (29 cases, 24%), IV. lucid interval (22 cases, 18%), V. unconscious throughout (16 cases, 14%) and unknown (14 cases, 12%). Cases which Glasgow Coma Scale Score were over 7 showed good recovery in Glasgow Outcome Scale.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1987

Effects of oedipal triumph caused by collapse or death of the rival parent.

It is suggested that the threat of castration at the phallic-oedipal phase results in repression, effecting no change in the unconscious fantasy, that the resolution of the Oedipus complex depends on developments during latency and adolescence, and that during this period one of the determinants impeding the resolution may be the collapse or death of the rival parent. Death of the oedipal rival results in a confusion of the unconscious wish with an external happening. The child, unable to cope with the consequent guilt, resorts to repression. Thus, the critical aspects of the oedipal triumph remain potentially operative in the unconscious, hindering the patient's functioning in all closely associated areas. Three clinical illustrations of oedipal triumph are described to indicate some of the psychodynamic issues that arise in the analysis of such patients. Of particular importance are: the concept of reality testing; differential adaptation to the unconscious sense of guilt; the varying degrees of resistance evidenced in the analysis of such patients; and the impact of oedipal determinants in differential outcome of bereavement.

Adult↗
PubMed1993

["Mother" and "father" in psychoanalytic case vignettes. On some latent rules in the discourse of psychoanalysis].

Proceeding from the conviction that there is a collective gender-specific unconscious within the community of psychoanalysts which determines latent rules operative in psychoanalytic discourse, the authors have conducted a research project extending over a number of years and systematically examining case descriptions in psychoanalytic journals to see to what extent those latent gender-specific rules are in fact observed in such publications. The project examines the way in which male and female analysts employ the terms "mother" and "father" in these publications and also the frequency and connotations of concepts related to "mother" and "father". Significant differences between male and female analysts become apparent, substantiating the assumption of a collective gender-specific unconscious. The authors conclude that this unconscious finds its way into psychoanalytic therapy, leading to unconscious counter-transference reactions that are acted out rather than worked on.

Countertransference↗
PubMed1996

Outcome of admitted malaria cases by treatment at Manicaland Provincial Hospital, Zimbabwe.

OBJECTIVE: To determine the outcome of admitted malaria cases according to age, late presentation, and antimalarial drug treatments received. DESIGN: We reviewed all March 1994 hospital and laboratory records of patients with a clinical diagnosis of malaria. SETTING: Manicaland Provincial Hospital. SUBJECTS: 319 clinical malaria cases. MAIN OUTCOME MEASURES: Cases were classified as uncomplicated, complicated and unconscious. RESULTS: Of the 319 cases reviewed, 213 slide examinations were done and 174 (82pc) were slide positive. Of slide positive admissions, 91 (52pc) were complicated and 37 (21pc) were unconscious; 22 (13pc) died. Case fatality was two pc in uncomplicated cases, six pc in complicated cases, and 46pc in unconscious cases. Uncomplicated and complicated cases did as well on chloroquine (none of the 53 died) as on other treatments (four of the 76 died), whereas unconscious patients did poorly regardless of therapy received. Twelve patients received no therapy on their first hospital day and four died. There was no significant association between young age (age < 5 years) and complications or death, nor between late presentation (illness onset > or = 3 days before hospital presentation) and complications or death.

Adolescent↗
PubMed1996

[Nurses' experiences with euthanasia in AIDS patients].

This article describes the experiences of nurses concerning the activities related to euthanasia of patients with aids. The nurses were employed in departments where relatively young, mature people wanted to arrange their own death. Our findings are based on six in-depth interviews with experienced nurses, that are part of a qualitative study into the experiences of nurses in taking leave of terminal patients with aids. The research strategy was based on the Grounded Theory. In order to analyse the experiences of the nurses, four phases were distinguished: set date and time unto application of lethal agent; application unto becoming unconscious; unconsciousness to death; death until transferring the body from the unit. Feelings that occur when taking leave of the patient, if not already taken care of at an earlier instant, play a major role in the phase from application to becoming unconscious. The fact that a deadly agent is being administered can generate feelings of guilt and anxiety. The period from unconsciousness to death is one of waiting. During this period nurses feel alienated and alone. The nurses indicated explicitly that an adequate preparation, evaluation and support are extremely important.

Acquired Immunodeficiency Syndrome↗
PubMed1979

Some factors determining prognosis in young people with severe head injuries.

Eighty-four patients under the age of 40 were rehabilitated after severe head injuries. All had been unconscious for at least 24 hours, and 35 were unconscious for more than four weeks. The mean length of treatment was 30.2 weeks. Seventy were discharged home, 13 remained in hospital, and one died. Seventy-two of the patients were followed up nine months to 15 years after the injury. Twenty-eight were working, 27 were at home but not working, 13 were in hospital, and four were dead. Prolonged unconsciousness, extensive neurological damage, and severe mental changes were found to be the main factors adversely affecting the prognosis; an inadequate family background and cerebral hypoxia were also considered to have an influence.

Accidents, Traffic↗
PubMed1999

Recurrent psychogenic coma following tracheal stenosis repair.

Medication, intracranial hemorrhage, infarction, infection, hypoxia, organ failure, and nutritional deficiency may cause unconsciousness following successful emergence from anesthesia. A 39-year-old woman with a history of tracheal stenosis, depression, and anxiety had complete unconsciousness on 3 separate occasions following surgical repair of her tracheal stenosis. In each case, the patient's endotracheal tube had been removed; she was alert and oriented to person, time, and place; and she was admitted to the hospital for observation. Within a few hours after the tube was removed, the patient became abruptly unconscious for periods of 36, 18, and 30 hours. Each time, the results of cardiac, pulmonary, metabolic, and neurologic examinations and radiological studies were normal. We hypothesize that the patient's apparent comas were the result of an underlying conversion disorder precipitated by unresolved psychological conflict surrounding a long history of abuse in which she was repeatedly smothered by a pillow.

Adult↗
PubMed1985

Separation and loss in psychoanalytic therapy with borderline patients: further remarks.

This paper is a continuation of an earlier one concerning borderline patients, and I can recapitulate only a few of the many areas touched upon here. The borderline individual is faced continually with the threat of loss, either of his tenuously established individual identity, through fusion with the other person, or of his fragile interpersonal relatedness, through uncontrollable flight into autism of psychotic degree. A basic theme in one's work with these persons is that of unconscious, fantasied omnipotence, variously an aspect of the patient's unconscious self-image or projected into the therapist. The acting-out which the patient does consists in his inflicting loss, deprivation, and other forms of injury upon his introjects of part-aspects of the therapist. The grief involved in the relinquishment of so-called bad introjects is discussed. The patient early in therapy is aware of his inability to grieve, and endeavors to conceal this deficiency by spurious emotionality. I give examples of patients' manifesting regressive dedifferentiation to fusion with elements of the nonhuman environment, as an unconscious defense against feelings of separation and loss. Effective therapy with these patients involves the therapist's deeper working through of his own losses. The significant losses occurred so early in these patients' lives that the therapeutic exploration of these areas may enable the therapist to gain access to comparably early losses on his own part, losses from a developmental era which many a training analysis may not have explored at all adequately.

Anxiety, Separation↗
PubMed2000

Eye care for the critically ill.

PURPOSE: To evaluate the effectiveness and efficiency of an algorithm in the prevention of ocular surface disease in sedated and unconscious patients in the intensive care unit (ICU). METHODS: The eyes of all sedated and unconscious patients admitted to an ICU between September and December 1998 were managed according to an eye care algorithm. The applications of the preventive measures were assessed by a single observer twice weekly. The lid position, the presence and degree of keratopathy, sedation score, and the treatment received were documented at every assessment. RESULTS: Thirty-four patients were recruited for management according to the eye care algorithm over a period ranging from 1 to 28 days. Four patients were excluded because of failure by staff to adhere to the protocol. In 18 patients no active treatment was required. Out of six patients who had conjunctival exposure and were given ocular lubricants, four maintained clear corneas. No corneal or conjunctival staining was noted in two of the four patients whose lids required closure with Micropore tape for corneal exposure. Use of lid taping and lubricants prevented corneal abrasion in two patients who were prone ventilated. The prevalence of ocular surface abnormalities was 8.7 % where the algorithm was properly followed (23 patients). CONCLUSION: The proposed eye care algorithm appears to be effective in preventing ocular surface abnormalities in the sedated and unconscious patients in the ICU, and efficient in that it may reduce the workload required for critically ill patients.

Adult↗