Sensorimotor central conduction time in comatose patients

Motor evoked potentials (MEPs) following magnetic stimulation were recorded in 22 patients comatose as a result of head injury (13 cases), stroke (7 cases) or anoxia (2 cases). Somatosensory evoked potentials (SEPs) from median nerve were recorded as well in 19 cases in the same session.Thirteen patients died or remained vegetative (59.1%), 3 were severely disabled (13.6%) and 6 showed a good recovery (27.3%). MEPs were significantly related to the outcome; they appeared to be a more accurate prognostic indicator than the Glasgow Coma Scale (GCS). However, 1 out of 6 patients with bilaterally absent MEPs (16.7%) showed a good recovery.SEPs were significantly related to the outcome as well, but the combined use of SEP and MEP improved the outcome prediction, decreasing the rate of false negatives. Two patients had normal sensorimotor function, 13 a combined sensorimotor dysfunction, while 4 had a pure motor dysfunction.Our results suggest that SEPs and MEPs may improve the assessment of sensorimotor dysfunction in comatose patients. A significant relationship between MEPs and outcome appears to exist, but the assessment of MEP reliability requires further study.     

Workshop for Disabled Survivors of Severe Head Injury

Existing services for the disabled do not cater for the needs of lame-brain survivors of severe head injury who may be capable of productive work though they may never become employable. A grant from the Nuffield Provincial Hospitals Trust made it possible to set up in 1967 a special workshop in premises provided by the regional hospital board. The hospital management committee assumed financial responsibility for the centre after three years, and after five years the Department of Health and Social Security purchased adjoining premises, which will double the present accommodation for about 35 persons. Though 45% of the 101 patients attending the workshop have returned to work, no financial support has yet been received from the Department of Employment. A suitably staffed hostel is needed for patients who live too far away to travel daily to and from the workshop. This undertaking has shown a need for special facilities for some of the victims of severe head injury, who differ in many important ways from other disabled persons.     

Age,pattern of consultation,and functional disability in elderly patients in one general practice.

OBJECTIVE--To examine how functional disability varies with sex, age, and other variables in patients aged 75 and over living in the community and to ascertain whether a statistical model derived from the variables in this population usefully predicted functional disability in another of similar age. DESIGN--Retrospective study of data collected by interview and by examination of medical records. SETTING--An urban general practice with five partners and a list of 15,000 patients, very few of whom belonged to ethnic minorities. PATIENTS--775 Patients (252 men, 523 women) aged 75 and over living in the community between September 1985 and August 1986; 13 other patients considered to be unsuitable and 14 who declined an interview were excluded. Also 94 patients who became 75 or joined the practice after August 1986. MAIN OUTCOME MEASURE--The proportions of fit, partially disabled, and severely disabled (housebound) patients. RESULTS--90 Men (35.7%) and 128 women (24.5%) were fit, and 27 men (10.7%) and 116 women (22.2%) were housebound; in all age groups women were significantly more likely to be disabled than men. A significant trend towards greater disability was shown with increasing age and, more noticeably, with pattern of consultation when patients were divided into three categories based on the number of times they had attended the surgery and been visited at home over about two years. Statistical models gave the forecast percentage of fit and severely disabled patients for each sex, age group, and pattern of consultation, and a simple scheme was derived to identify from information wholly contained in medical records most of those patients most prone to severe disability. The scheme was verified applying it to a population of 94 elderly patients in 1988-9. CONCLUSION--Sex, age, and pattern of consultation together provide a quick indication of elderly patients'' tendency to severe disability, which can help in screening and in day to day consultations.     

Disability in young people and adults one year after head injury: prospective cohort study

ObjectiveTo determine the frequency of disability in young people and adults admitted to hospital with a head injury and to estimate the annual incidence in the community.DesignProspective, hospital based cohort study, with one year follow up of sample stratified by coma score.SettingFive acute hospitals in Glasgow.Subjects2962 patients (aged 14 years or more) with head injury; 549 (71%) of the 769 patients selected for follow up participated.ResultsSurvival with moderate or severe disability was common after mild head injury (47%, 95% confidence interval 42% to 52%) and similar to that after moderate (45%, 35% to 56%) or severe injury (48%, 36% to 60%). By extrapolation from the population identified (90% of whom had mild injuries), it was estimated that annually in Glasgow (population 909 498) 1400 young people and adults are still disabled one year after head injury.ConclusionThe incidence of disability in young people and adults admitted with a head injury is higher than expected. This reflects the high rate of sequelae previously unrecognised in the large number of patients admitted to hospital with an apparently mild head injury.     

Census of mental hospital patients and life expectancy of those unlikely to be discharged.

A census in a London mental hospital was performed so that the numbers of patients requiring permanent care for the next 20 to 40 years could be estimated. Of 1467 resident patients 20% had been admitted in the preceding five months and 15% in the year before that. Of the 65% who had been in hospital for over 17 months 1% (16 patients) had been in hospital for over 5o years. Altogether 257 (18%) patients would probably be discharged, 339 (23%) might possibly be discharged if there were adequate community facilities, but 871 (59%) were not likely to be discharged; 239 patients under the age of 65 who had been admitted between 1950 and 1973 were unlikely to be discharged. There were about 10 new younger long-stay patients from each year''s admissions. Three conditions--schizophrenia, organic brain syndrome, and affective illness--affected 79% of the population. Fourteen per cent had been employed on admission and 28% were considered employable or possibly employable. Half of those who might be considered for discharge (296) would need a hostel. No rehabilitation was needed or possible for 40% of the patients; 299 (20%) patients were chairbound or bedridden and 400 (27%) were totally dependent on nursing and 587 (40%) partly dependent. Twenty months after the census 361 (25%) patients had left (59 had been readmitted), 284 (19%) had died, and 822 (56%) had remained as inpatients. The most realistic future prediction was that 210 (14%) of these patients would still be in the hospital in 20 years and 43 (3%) in 40 years. In the light of these findings and the scarceness of resources current Department of Health and Social Security plans for phasing out mental hospitals must be challenged.     

Le rythme lent postérieur: étude électroclinique de 100 nouveaux cas

One hundred patients with slow rhythmical electro-encephalographic (EEG) activity in the posterior regions were classified according to their clinical symptomatology. Correlations were established between the occurrence of the slow posterior rhythm (SPR) and head injury, and psychological, autonomic or vascular disturbances. In contrast to most previous publications, the patients with head injury constituted only one-half of the series. Autonomic and psychological complaints were frequently encountered in this group. A second group of 11 patients had some type of vascular pathology. A third group of 39 patients had symptoms of anxiety and autonomic system disturbance. The importance of head injury as a factor responsible for SPR seems to have been overrated. Regardless of classification, psychological symptoms were found in 50% and autonomic dysfunction in 53% of all patients. It is apparent that the origin and significance of slow posterior rhythm have not yet been eludicated.     

Serious head injury in sport.

Of 1900 head injuries serious enough to be admitted to the neurosurgical unit in Glasgow over a five year period, 52 (2.7%) were due to "sport." Golf, horse-riding, and Association football were the sports most commonly linked with serious head injury. Golfing injuries were all compound depressed fractures, and all these patients made a good recovery; horse-riding produced more severe injuries, three of the eight patients being left with residual disability. Much attention has been directed to preventing repeated minor head injury in boxing, but this study emphasises the need for preventing both the primary head injury and secondary complications associated with other sports.     

重度颅脑损伤合并神经原性肺水肿机械通气的观察与护理

目的：探讨重型颅脑损伤合并神经原性肺水肿（NPE）病人机械通气的护理经验,提高此类病人的治疗成功率。方法：回顾性分析2000年～2007年18例颅脑损伤患者合并NPE的临床护理资料,对这些患者进行了机械通气治疗,观察和总结护理的临床效应。结果：18例患者中肺水肿消退11例,死亡7例。11例存活患者经过随访,死亡4例,植物生存1例,重残1例,中残2例,好3例。结论：重型颅脑损伤合并NPE预后不良,死亡率高;机械通气是治疗NPE的有效方法,正确积极的护理可提高患者的治愈率。     

Rehabilitation in Disseminated Sclerosis: An Evaluation of 28 Patients

The results of rehabilitation have been described and evaluated in a group of 28 patients moderately severely disabled with disseminated sclerosis between the ages of 19 and 71 years and in a controlled hospital setting. Twenty-three suffered chronic progressive disease and five were in remission from an acute exacerbation. They had had the disease an average of 12.7 years and were hospitalized an average of 5.4 months. On admission, 24 required much assistance with their activities of daily living, six had poor control of elimination, and four were depressed. On discharge, 13 cared for themselves with little or no help, four had overcome their problems of elimination, and three had improved emotionally. A major symptom in 13, fatigue, did not preclude successful performance, but a progression of disease or failure to react steadfastly did. None were gainfully employed. Six years after discharge, 18 of 20 were alive and happy at home.     

Projecting the number of patients with first ever strokes and patients newly handicapped by stroke in England and Wales.

The common assumption that future increases in the number of elderly people will result in a parallel increase in the burden of care of long term disabled survivors of stroke was examined. The number of patients with first ever strokes and the net number of people handicapped after these strokes in England and Wales every five years until 2023 have been projected. Between the base year 1983 and the year 2023 an increase in population of about 5% will occur; first ever strokes are projected to increase by about 30% and deaths within six months of first ever strokes by about 40%. The net number of severely handicapped people six months after a first ever stroke is projected to increase by only about 8%, however, and the net number of people who are moderately or severely handicapped by only 4%. This paradox occurs because first ever stroke often kills people who have been handicapped by other causes, particularly if they are elderly. It is concluded that despite the limitations of these data they strongly suggest that the increased burden of health care of patients with first ever strokes in the next 40 years will be primarily that of caring for those in the acute stages of stroke and not with the management of chronic handicap after a stroke.     

Bicycle-related injuries: a survey in a pediatric emergency department.

The number of bicycle-related injuries has risen significantly with the increased popularity of bicycle riding in Canada. The risk of injury is highest among children. To assess the magnitude of the problem and to identify the contributing factors we used a questionnaire, injury reports and patient charts to survey bicycle-related injuries among children brought to the emergency department of the Children''s Hospital of Eastern Ontario, Ottawa, between May 1 and Sept. 30, 1988. The questionnaire was completed for 517 (91%) of the 568 children; 70% were boys, and the mean age was 9.4 years. Only 2% of the patients had been wearing a helmet at the time of injury, although 13% claimed to own one for cycling. Over 60% of the accidents were attributable to carelessness or poor bicycle control; mechanical failure and environmental hazards were minor factors. Over 80% of the injuries occurred within a kilometre of the child''s home. Of the 97 children admitted to hospital 49% had head and skull injuries and 40% had limb fractures. Bicycle-related injuries represented 14.8% of all nonwinter (Apr. 1 to Oct. 31) trauma admissions among children 5 years or older. Our results further document bicycle-related injuries as an important childhood problem and underscore the need for improved safety measures.     

Role of the physician in screening for carriers of Tay-Sachs disease.

A screening test for carriers of Tay-Sachs disease has been available in Toronto for more than 6 years. In that time more than 11 000 Jewish residents have been tested. Most had requested testing after hearing about the screening program from friends or the media; few had been advised by their physicians to be tested. To sample the attitudes of physicians in Toronto towards carrier screening, we studied questionnaire responses of 42 physicians whose practices were composed largely of Jewish patients. Only 31% regularly advised their young adult Jewish patients to have a carrier screening test but 76% said they had patients who asked if they should be tested. Of the 14 (33%) who had had one or more patients with Tay-Sachs disease 6 did not advise carrier testing. There was a positive correlation between specialty training and support for the screening program. Methods for increasing physician advocacy of these programs are discussed.     

Self-inflicted injury: a follow-up study of 43 patients.

Forty-three patients, 38 women and 5 men, with self-inflicted skin lesions were studied. Thirty-three were followed up for up to 22 years. In most cases dermatitis artefacta was only one incident in a long history of psychogenic illness. Of the 43 patients, 13 (30%), 12 women and one man, continued to produce lesions or were disabled with other psychiatric disorders more than 12 years after the onset of symptoms. Prognosis was difficult but recovery seemed to occur when the patient''s life circumstances changed rather than as a result of treatment.     

Avoidable factors contributing to death after head injury.

We reviewed 116 patients, known to have talked before dying after head injury, to discover factors which had contributed to death but which might have been avoided. All the patients were admitted to a neurosurgical unit and had a neuropathological post-mortem examination. One or more avoidable factors were identified in 86 patients (74%); an avoidable factor was judged certainly to have contributed to death in 63 patients (54%). The most common avoidable factor was delay in the treatment of an intracranial haematoma; others included poorly controlled epilepsy, meningitis, hypoxia, and hypotension. Changes in the management of patients with head injuries which reduce the incidence of avoidable factors should decrease mortality from this condition.     

Early mobilisation and outcome in acute sprains of the neck.

OBJECTIVE--To assess the long term effect of early mobilisation exercises in patients with acute sprains of the neck after road accidents. DESIGN--Single blind randomised prospective study of patients receiving physiotherapy, advice on mobilisation, or on an initial period of rest followed up after two years by postal questionnaire. SETTING--Accident and emergency department in urban hospital. PATIENTS--247 Consecutive patients (mean age at injury 30.6 years) presenting within 48 hours after injury with no pre-existing disease of the neck or serious skeletal injury. Of these, 167 patients responded to the questionnaire; 77 who responded but had not completed their treatment or review course were included in the analysis as a fourth group (non-attenders). MAIN OUTCOME MEASURE--Presence of symptoms after two years. RESULTS--Of the 167 patients (68%) responding, the percentage of patients still with symptoms was not significantly different in those receiving rest or physiotherapy (46%, 12/26 v 44%, 24/54), but that in those receiving advice on early mobilisation was significantly lower (23%, 11/48, p = 0.02). Of the 104 patients without symptoms, 94 (90%) recovered within six months and 62 (60%) within three months. Patients without symptoms who received advice or physiotherapy wore a collar for a significantly shorter time than those with persistent symptoms (mean duration 1.4 (SD 0.7) months v 2.8 (1.6) months, p = 0.005 and 1.6 (1.1) months v 1.8 (1.3) months, p = 0.006 respectively). CONCLUSIONS--Advice to mobilise in the early phase after neck injury reduces the number of patients with symptoms at two years and is superior to manipulative physiotherapy. Prolonged wearing of a collar is associated with persistence of symptoms.     

Follow up study of angina in patients aged 30 to 59 in general practice.

In 1979, 51 general practitioners in the Northern region identified 336 patients aged 30 to 59 who had angina pectoris. Information was obtained on their treatment and how angina affected their daily lives. This study reviews the same patients after an interval of four years. Of the 307 who were not lost to follow up, 38 (12%) had died and 44 (14%) were free from angina in the last year. Drugs seemed to be used to their best advantage, with a fourfold increase in the use of the newer calcium antagonists and long acting trinitrate preparations. Many patients still suffered from angina, which was severely affecting their daily lives, but only 41 patients had had exercise electrocardiograms recorded or more detailed investigations; this includes 16 (6%) patients who had had coronary artery bypass surgery.     

Arsine toxicity aboard the Asiafreighter.

Eight sailors on board the Asiafreighter were exposed to arsine that had escaped from a cylinder in the cargo hold. Four suffered severe toxicity and within a few hours had developed fever, weakness, nausea, vomiting, diarrhoea, abdominal pain, and haemoglobinuria. These patients had pronounced intravascular haemolysis, which in one patient was complete. This patient was also stuporose and anoxic, a condition attributed to failure of oxygen transport and sludging of red cell debris in the cerebral and pulmonary circulations, but he regained a normal level of consciousness after exchange transfusion. Evidence of marrow depression was present: the reticulocyte response to the haemolysis was poor and there was a thrombocytopenia. All four patients developed renal failure, one being totally anuric for five weeks. Two patients developed peripheral neuropathy, and one was still severely disabled six months after the incident. The other four patients had a similar, though less severe, illness.     

Factors associated with Danish cancer patients' return to work. A report from the population-based study 'The Cancer Patient's World'

Purpose: If patients facing difficulties in the process of returning to work after treatment of cancer could be identified, these patients could be assisted in the transition. This might help some patients to stay in work. We therefore assessed demographic and clinical factors associated with returning to work after a cancer diagnosis. Materials and methods: In this cross-sectional survey, 1490 cancer patients who had been in contact with a hospital department during the past 12 months in three Danish counties responded to a mailed questionnaire. Factors associated with employment and return to work (i.e., working more than 0 h in the past month) respectively, were assessed in multivariate ordinal logistic regression models. Results: Of the 598 patients below age 65 who were employed at the time of diagnosis, 75% were still employed when answering the questionnaire at a median of 2.8 years after diagnosis and 63% were working. In multivariate analyses, younger and more recently diagnosed patients were more often employed. Patients diagnosed with lung or head and neck cancer were least likely to be employed and having returned to work. Advanced cancer at diagnosis was associated with loss of employment. Advanced cancer and being in active treatment were associated with not having returned to work. Conclusion: A quarter of the patients had lost their employment probably resulting in economic consequences on the individual as well as at the societal level. The highest risk was observed for older patients and those diagnosed with lung or head and neck cancer.     

Blocked beds.

In a cross-sectional survey of 325 surgical and orthopaedic beds 43 (16%) of the 265 occupied beds were filled by patients who had no medical need to be in an acute ward. They had been in hospital for a median time of 40 weeks up to the survey date. Of the 43 patients, 11 were awaiting transfer to a geriatric ward; 13 to community residential care; and seven to their homes. There was no plan for discharge or transfer for the remaining 12 (28%). Those "at risk" of becoming long-stay patients for social reasons on these wards were women, over 75, living alone or with one relative, who had been admitted to hospital in emergency with a fractured femur, head injury, or other trauma. Action necessary to reduce the number of social long-stay patients includes (a) changing attitudes to the solving of social case problems; (b) revising procedures of assessment and planning of future care; (c) improving teamwork and record keeping within the hospital and the community services; (d) providing a better balance of acute, medium and long-stay hospital beds; and (e) putting more resources into rehabilitation.