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Biomedical subjects

T M McMillan

Publications and source records attributed to T M McMillan.

At least 19 recordsLinked to original sources
PubMed2006

Errors in self-report of post-traumatic stress disorder after severe traumatic brain injury.

Assessing PTSD by questionnaire can lead to false positive diagnosis after severe traumatic brain injury. Sumpter and McMillan, reported quantitative data on 34 people with severe TBI; 59% were PTSD 'cases' by questionnaire assessment, but only 3% using a structured interview. The present paper describes ways in which these individuals made errors on questionnaires. Some did not follow questionnaire instructions because of inattention and concrete thinking or instead reported effects of brain injury. Symptom overlap between TBI and PTSD, including insomnia, irritability and impaired concentration can cause errors. Brain injury can also provoke curiosity about loss of memory (during coma, retrograde and post-traumatic amnesia), decreased participation, social withdrawal and difficulty adjusting to injury that may be mistaken for fear-associated PTSD symptoms. Assessment of PTSD by questionnaire can lead to erroneous conclusions and factors related to brain injury must be carefully considered when investigating PTSD.

Adult↗
PubMed2006

Disability in young people and adults after head injury: 5-7 year follow up of a prospective cohort study.

BACKGROUND: Improvement 1-2 years after head injury is well established but the pattern thereafter is unclear. Past studies have not examined representative head injury populations and typically report findings in terms of functioning across social, psychological, neurobehavioural, or cognitive domains rather than global outcome. OBJECTIVE: To determine the late outcome of a representative cohort of participants admitted to hospital after a head injury 5-7 years previously and to identify early and late factors correlating with persisting disability and change between one and 5-7 years. METHODS: A representative cohort of head injured people whose outcome one year after injury was reported previously, were followed up 5-7 years after injury. Participants were assessed using structured and validated measures of global outcome (Glasgow Outcome Scale Extended), cognitive impairment, psychological wellbeing, health status, and social factors. RESULTS: Of 475 survivors studied at one year, 115 (24%) had died by seven years. In survivors at 5-7 years, disability remained frequent (53%); and the rate, similar to that found at one year (57%). Sixty three participants (29%) had improved but 55 (25%) deteriorated. The persistence of disability and its development after previous recovery each showed stronger associations with indices of depression, anxiety, and low self-esteem than with initial severity of injury or persisting cognitive impairment. CONCLUSIONS: Admission to hospital after head injury is followed 5-7 years later by disability in a high proportion of survivors. Persistence of disability and development of new disability are strongly associated with psychosocial factors that may be open to remediation, even late after injury.

Adult↗
PubMed2005

Opinion about post-concussion syndrome in health professionals.

OBJECTIVE: To compare opinion about post-concussion syndrome (PCS) in accident and emergency doctors, clinical neuropsychologists and neurosurgeons. METHOD: A UK postal survey was sent to all accident and emergency doctors, neurosurgeons and clinical neuropsychologists listed by their professional bodies. Predictions of symptom complaint were made from a vignette about minor traumatic brain injury and a questionnaire about PCS-symptoms, cause, recovery and treatment. RESULTS: All professional groups named headache, attention and memory difficulties as most common symptoms. Clinical neuropsychologists listed more symptoms at recall, more often achieved 'caseness' (Diagnostic and Statistical Manual-IV or International Classification of Diseases-10 criteria) and were more optimistic about treatment effectiveness. Neurosurgeons were more pessimistic about recovery. Organic factors were most frequently cited as the main cause of PCS, followed by emotional factors and then compensation factors. CONCLUSIONS: There was fair consistency between professional groups regarding PCS. Differences may reflect differing clinical roles between the professions, in terms of early care and late rehabilitation. The usefulness of the concept of PCS is discussed. All groups and particularly those working in acute settings may benefit from further information about minor brain injury including the effectiveness of psychological interventions.

Attitude of Health Personnel↗
PubMed2005

Knowledge of post-concussional syndrome in naïve lay-people, general practitioners and people with minor traumatic brain injury.

BACKGROUND: Expectations about effects of minor traumatic brain injury (MTBI) may play a role in maintaining symptoms, the ability to simulate post-concussion syndrome (PCS) and the extent to which professionals might associate patient complaints with MTBI. In turn, expectations will be related to knowledge about MTBI. This study investigates knowledge of PCS in people with MTBI compared with general practitioners (GPs) and lay-people, using recall (a vignette) and symptom guessing or recognition (checklists). METHODS: Thirty GPs, 30 people with MTBI, and 30 lay-people generated symptoms from a vignette describing a MTBI. They then completed a PCS checklist or a checklist containing PCS and 'bogus' items pertaining to the vignette. RESULTS: Only 1 of 90 participants reported enough PCS symptoms to indicate 'caseness' from the vignette alone. Using checklists, more GPs (60%) than controls (20%) ticked enough symptoms to attain PCS 'caseness'. Few people with MTBI who did not themselves achieve PCS 'caseness' by self-report using checklists achieved 'caseness' using the vignette and checklists. The frequency of non-physical symptom reporting was higher than for physical symptom reporting. The addition of 'bogus' items to checklists did not affect responding. CONCLUSIONS: It is unlikely that pre-injury expectations about MTBI maintain PCS symptoms. PCS was difficult to simulate without prompting, even by GPs and PCS 'cases'. The use of 'caseness', rather than simple symptom scores, and further development of checklists with 'bogus' items may provide a more valid assessment of MTBI effects. GPs may benefit from further information about PCS and available treatments.

Adult↗
PubMed2004

Further recovery in a potential treatment withdrawal case 10 years after brain injury.

A young woman was rendered tetraplegic and anarthric as a result of a traumatic brain injury in 1993. Two years later, she was considered to be in a minimally conscious state and became the subject of legal debate in the UK with regard to withdrawal of artificial feeding and hydration. Before injury, she made a verbal advanced directive that she would not wish to continue living if ever becoming severely disabled. Neuropsychological assessment found statistically significant evidence for sentience and expression of a wish to live and the application to Court was withdrawn. Further meaningful recovery occurred between 7-10 years after injury. She now lives in the community with 24 hour care. She speaks, initiates conversation and actions, expresses clear and consistent preferences and has a spontaneous sense of humour. She uses an electric wheelchair, eats solid food and drinks through a straw. Her mood is variable and sometimes low. This case demonstrates the need for careful consideration of advanced directives and for specialist neuropsychological assessment in people with severe cognitive and communication difficulties. It supports the view that routine assessment and follow-up of people thought to be in minimally conscious states is important. In addition, it shows that recovery with reduction in disability and significant implications for quality of life can continue for at least 10 years after extremely severe traumatic brain injury.

Activities of Daily Living↗
PubMed2004

Young adults with acquired brain injury in nursing homes in Glasgow.

OBJECTIVE: To survey the characteristics, level of disability and services received by young adults with acquired brain injury (ABI) resident in nursing homes in Greater Glasgow. DESIGN: Telephone survey of 75 nursing homes followed by a questionnaire survey and review of medication cardexes. Included were all people under 65 years with ABI resident in nursing homes in Greater Glasgow between 1 February 2000 and 31 January 2001. SETTING: Twenty-eight nursing homes in Greater Glasgow, Scotland (population 0.9 million). SUBJECTS: Young adults (16-64) with ABI. MAIN OUTCOME MEASURES: Structured questionnaire, Barthel Index, Office of Population Census Survey (OPCS) Disability Form, review of medication cardexes. RESULTS: Information was obtained on all cases identified in 75 nursing homes. There were 92 people with ABI in 28 nursing homes; 43/92 were in three homes. Only 42 had inpatient rehabilitation preadmission. Severe disability (OPCS categories 7-10) was found in 54 cases and minimal/minor disability (OPCS categories 1-2) in 18. Thirty-two exhibited challenging behaviour, nine of these were physically violent. Homes were staffed by unqualified assistants, supervised by nurses. No home itself offered rehabilitation, but some had accessed an NHS physical disability community team (28/92 cases) or other community teams (5/92). Proactive medical review was uncommon. Medication had been reviewed since admission in a minority (21/92). Most had regular visits from relatives. CONCLUSIONS: There is a wide range of disability in nursing home residents in Greater Glasgow. Proactive, routine review of medical, rehabilitation and medication needs is rare, as is rehabilitation pre and post discharge. This is serious given the likelihood of reduced intellectual and/or physical capacity in this population. Nursing homes should have hospital discharge reports that inform about immediate preadmission history, rationale for medication and placement. There is a need for regular and ongoing health service review of nursing home residents including potential for rehabilitation and return to community living.

Adolescent↗
PubMed2002

Neuropsychological deficits and opiate abuse.

Cognitive functioning was examined in people with a current or past history of opiate abuse using a range of neuropsychological tests. Sixty percent of those currently abusing opiates showed impairments of at least two standard deviations from the published norms on two or more neuropsychological tests, a significantly higher incidence than found in matched controls with no history of drug abuse. The drug free group of recovering addicts fell between the other groups without significant differences. It was concluded that the risk of neuropsychological impairment is greater in opiate abusers, and that recovery may occur during abstinence.

Adult↗
PubMed2001

Errors in diagnosing post-traumatic stress disorder after traumatic brain injury.

Evidence to support the view that post-traumatic stress disorder (PTSD) can occur after traumatic brain injury (TBI) continues to grow. However, the reported incidence of cases with both diagnoses ranges widely, from less than 1% to more than 50%. Given that the incidence of TBI is high, a more precise incidence has to be established if screening and treatment resources are to be considered. Are cases being missed or are they over-diagnosed? The single case report presented here does not definitively answer this question, but illustrates the potential shortcomings of diagnosing PTSD using questionnaire measures alone (Impact of Events Scale, Post-traumatic Stress Diagnostic Scale and General Health Questionnaire) and indicates a need for a conjoint interview which takes into account the common effects of TBI and the symptom overlap between PTSD and TBI.

Activities of Daily Living↗
PubMed2001

A survey of services provided by community neurorehabilitation teams in South East England.

OBJECTIVE: To survey the role, function and staffing of community rehabilitation teams in London and the South East NHS Region of England who work with neurologically disabled people, with emphasis on services provided for traumatic brain injury. DESIGN: Telephone survey using a structured interview with team leaders. SETTING: London and South East NHS Regions of England (population 15.6 million). SUBJECTS: Community rehabilitation teams. MAIN OUTCOME MEASURES: A structured interview about service provision. RESULTS: Thirty-five teams were found in 25 Health Authorities serving 14 million people. In a further five Health Authorities, another five teams did not participate. There were fewer than 1.5 community team professionals for 4,000-5,000 neurologically disabled. Teams had seen less than 3% of disabled traumatic brain injuries. Most focused on physical disability. Only two teams specialized in consequences of cognitive impairment or personality change. Stroke and multiple sclerosis were the most common referrals. Sixty per cent of teams had no clinical psychologist. The composition of teams is described, as is caseload, clinical role, outcome measures used, professional links, work practice and staffing issues. CONCLUSIONS: Community physical disability teams seem insufficiently resourced to provide a comprehensive service for the neurologically disabled. There are not enough teams generally, and too few specialize in psychosocial problems. All teams should include a clinical psychologist, should have specialist resources for cases from ethnic minorities and formal policies for staff security. There needs to be clarity over the range of services provided and to whom, and this linked to prevalence of disability and team resourcing.

Brain Injuries↗
PubMed2001

The ability of naive participants to report symptoms of post-traumatic stress disorder.

OBJECTIVE: Research suggests that naive participants can simulate PTSD (post-traumatic stress disorder) using a symptom checklist. Is successful faking of DSM-IV criteria B-D on PTSD checklists due to prior knowledge of PTSD, the leading nature of symptom checklists, or a combination? DESIGN: Between-groups design. METHOD: Naïve participants self-generated PTSD symptoms from a vignette. They were then randomly assigned to groups given a standard symptom checklist or a checklist containing bogus items not normally associated with PTSD. RESULTS: Less than 1% self-generated symptoms that met DSM-IV criteria B-D for PTSD. It was found that 94% of participants satisfied these criteria using the standard checklist and 90% on the modified checklist. Participants incorrectly identified 38% of bogus symptoms as symptoms of PTSD. CONCLUSIONS: Despite poor prior knowledge of PTSD, 94% of participants fulfilled diagnostic criteria using a standard checklist. This is probably due to symptom 'guessing'.

Adult↗
PubMed2000

Neuropsychological assessment of a potential "euthanasia" case: a 5 year follow up.

McMillan reported a neuropsychological assessment procedure which was used to determine whether or not there was evidence for sentience in a young woman who had been rendered tetraplegic and anarthric as a result of a road traffic accident. An application to court had been made to withdraw feeding and this was supported by medical evidence which gave the view that the individual was functioning little beyond vegetative state, had a poor quality of life and had little prospect of further recovery. Evidence for an ability to communicate reliably was found including for a wish to continue living, and as a consequence the application to court was withdrawn. This paper describes further recovery 2-4 years after the original assessment (i.e. 4-6 years post-injury). At follow-up, she remained dependent for all care, but was now feeding orally and was talking. She could learn new information, some of which she retained for at least 12 months and had greater insight into her condition. She now reported low mood and some pain. As before, she consistently reported a wish to live. The implications of the follow-up are discussed in the context of assumptions made about quality of life and decision making about euthanasia in brain injured people who are severely disabled, but are not in a vegetative state.

Adult↗
PubMed1997

Minor head injury.

The relationship between brief loss of consciousness, subsequent cognitive and emotional complaints, and impact on daily functioning continues to be hotly debated. The weight of current evidence suggests that uncomplicated minor head injury can cause acute cognitive impairment that is organic in aetiology, but late onset or persisting symptoms result from a psychological response. Traditionally, loss of consciousness has been a prerequisite for the definition of minor head injury but this has been challenged in recent years, although evidence does no more than draw attention to this question. Evidence to support the view that post-traumatic stress disorder can develop after head injury continues to grow. Outcomes in unselected mild head injury patients who attend hospital are not improved by provision of early follow-up.

Animals↗
PubMed1997

Neuropsychology of thallium poisoning.

Cases of thallium poisoning are rare and neuropsychological assessment has only been reported in detail in one other case. In the case reported here, neuropsychological assessments were carried out three, 12, and 54 months after diagnosis of thallium poisoning in a man who had acutely shown a number of neurological signs including confusion and disorientation and generalised slowing of EEG which was more prominent on the left. Evidence suggested that he had been exposed to thallium over a period of weeks. Neuropsychological assessment indicated an unexpected weakness in verbal abilities which persisted. This finding is consistent with the only other published case report which details neuropsychological effects after a single large dose of thallium and which also found a lateralised impairment.

Adult↗
PubMed1997

Neuropsychological assessment after extremely severe head injury in a case of life or death.

A systematic neuropsychological assessment technique is described for use with severely physically disabled people who may be severely brain-damaged, in an incomplete locked-in state or potentially in vegetative state. The technique allows opinions regarding cognitive state to be statistically based. In the case described, the weight of expert opinion had been that involuntary feeding by gastrostomy tube should be terminated because the patient was functioning at a level little beyond the vegetative state, her quality of life was poor and she was unable to form a view about her present or future circumstances. An assessment approach is described which uses binomial statistics and allows for some variability in responding. Methods of minimizing sources of extraneous bias are also discussed. By use of this technique it was demonstrated that the patient was sentient though impaired, and that her own wish at the time of the assessment was to continue living. It is recommended that neuropsycholgical assessment of this kind should take place in all cases in which withdrawal of treatment is being considered and cognitive ability is not certain.

Adult↗
PubMed1996

Post-traumatic stress disorder following minor and severe closed head injury: 10 single cases.

Post-traumatic stress disorder (PTSD) was found to occur after minor or severe closed head injury in 10 single cases which are reported in detail. They were drawn from 312 cases of closed head injury who were referred for neuropsychological assessment or neurorehabilitation. All cases which had been given both diagnoses are presented. Information was collected retrospectively from case notes and reports. It is argued that a continuum of experience, which represents the entirety of an event, is not necessary for PTSD to occur, but that a "window' of real or imagined experience which results from loss of consciousness and post-traumatic amnesia after closed head injury need not prevent the symptoms of PTSD from arising, although they may make them less likely and the phenomenon of the dual diagnoses relatively rare. The issue of whether PTSD found following closed head injury is a subclassification of PTSD is raised.

Adolescent↗
PubMed1996

Assessment of post-traumatic amnesia after severe closed head injury: retrospective or prospective?

BACKGROUND: Post-traumatic amnesia is considered to be the best single indicator of the severity of closed head injury. Usually, it has been estimated retrospectively. For practical reasons this also tends to be the most common clinical method. It has been argued that prospective assessment is more accurate and reliable, but this has never been evaluated empirically in severe head injury. METHODS: Post-traumatic amnesia was initially assessed prospectively and later retrospectively by a separate observer in the same patients. RESULTS: The correlation between the two methods was high. In addition, both measures significantly correlated with other measures of severity of brain injury and with measures of outcome. CONCLUSION: Retrospective measurement of post-traumatic amnesia is a valid method.

Adolescent↗
PubMed1994

Effects of case management after severe head injury.

OBJECTIVES: To examine the effects of early case management for patients with severe head injury on outcome, family function, and provision of rehabilitation services. DESIGN: Prospective controlled unmatched non-randomised study for up to two years after injury. SETTING: Four district general hospitals and two university teaching hospitals, each with neurosurgical units, in east central, north, and north east London and its environs. SUBJECTS: 126 patients aged 16-60 recruited acutely and sequentially after severe head injury. All received standard rehabilitation services in each of the six hospitals and districts: case management was also provided for the 56 patients admitted to three of the hospitals. MAIN OUTCOME MEASURES: Standard measures of patients' physical and cognitive impairment; disability and handicap; and affective, behavioural, and social functioning and of relatives' affective and social functioning. Relatives' perception of burden; changes in patients' and relatives' housing, financial, vocational, recreational, and medical needs; and ongoing requirements for care and support; and the amount and type of paramedical input provided were assessed with structured questionnaires. RESULTS: For a given severity of injury, case management increased the chance and range of contact with inpatient and outpatient rehabilitation services. However, duration of contact was not increased by case management, and there was no demonstrable improvement in outcome in the case managed group. Any trends were in favour of the control group and could be accounted for by group differences in initial severity of injury. CONCLUSIONS: Widespread introduction of early case management of patients after severe head injury is not supported, and early case management is not a substitute for improvement in provision of skilled and specialist rehabilitation for patients.

Activities of Daily Living↗