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PubMed1994

CT findings of hypoxic basal ganglia damage.

The outcome of hypoxic ischemic injury ranges from complete recovery to a persistent vegetative state or death, depending on the length of time the patient remains unconscious and the degree of associated cardiac failure. We describe three patients who were comatose from a hypoxic and/or ischemic injury and whose principal computed tomographic (CT) finding was bilateral basal ganglia hypodensities. Two of these patients were discharged from the hospital with minimal residual neurologic deficits. These cases and review of the literature suggest that ischemic basal ganglia signs on CT scan are not necessarily a predictor of severe neurologic sequelae.

Adult↗
PubMed2006

Ethics update: lessons learned from Terri Schiavo: the importance of healthcare proxies in clinical decision-making.

PURPOSE OF REVIEW: In this review, we discuss issues of privacy and personal choice in end-of-life decision-making and existing options for directing end-of-life care, and highlight important differences between living wills, advance directives and other forms of healthcare proxies. RECENT FINDINGS: The events surrounding the death of Terri Schiavo raise many ethical, legal and moral issues that warrant discussion. In that context, we examine the implications associated with family disagreement over end-of-life care, the ramifications for healthcare providers and the role played by politicians, the courts and the media in galvanizing the debate. Groups promoting a variety of causes seized the opportunity to further their own agenda by using the internet and other methods to rapidly disseminate often false information, fueling arguments over misdiagnosis of persistent vegetative state and raising false hopes for neurological recovery. SUMMARY: It is incumbent upon the medical community, political and religious leaders and the media to educate the public appropriately about options regarding end-of-life issues and to foster open discourse and encourage the execution of advance directives or healthcare proxies. Although the content of this article deals with a specific case and legal rulings pertaining to the USA, the issues and questions raised are pertinent to healthcare providers and individuals around the world.

Florida↗
PubMed2006

Decision tools for life support: a review and policy analysis.

OBJECTIVE: To identify, describe, and compare published documents intended to guide decisions about the administration, withholding, or withdrawal of life support in critical care. DESIGN: Review article. SETTING AND SOURCES: Publicly available, English-language guidelines or decision tools for life support, identified through systematic literature search. MEASUREMENTS AND MAIN RESULTS: Forty-nine documents were included and coded for authorship, source, development methodology, format, and positions taken on 12 common life-support issues. Sources were independent academics (n=21, 43%), professional organizations (n=19, 44%), and provider organizations. Eighteen documents (37%) described no development method. Twenty-three (47%) were produced collectively (e.g., by committees or consensus conference), 7 (14%) mentioned a literature review, and 2 (4%) were based upon the author's professional experience. Tools differed in format and focus; we characterize three types as decision schemas (involving clinical practice algorithms; n=7, 14%), decision guides (reviewing legal or professional positions; n=29, 59%), and decision counsels (more discursive and focusing typically on ethical issues; n=13, 27%). Tools addressed 12 common life-support issues: advance directives (67%), resource considerations (51%), ICU discharge criteria (27%), ICU admission criteria (16%), whether withholding differs from withdrawing life support (59%), whether nutrition and hydration decisions are different from decisions about other types of life support (61%), euthanasia (49%), double effect (47%), brain death (35%), special considerations for patients in a persistent vegetative state (51%), potential organ donors (12%), and pregnant patients (10%). Positions on these key life-support issues varied. CONCLUSIONS: Published tools for guiding life-support decisions vary widely in their genesis, authorship, format, focus, and practicality. They also differ in their attention to, and positions on, key life-support dilemmas. Future research on decision tools should focus on how users interpret and apply the messages in these tools and their impacts on practice, quality of care, participant experiences, and outcomes.

Decision Support Techniques↗
PubMed2005

The interpretation of the EEG in stupor and coma.

This review discusses a variety of causes of stupor and coma and associated electroencephalographic (EEG) findings. These include metabolic disturbances such as hepatic or renal dysfunction, which are often characterized by slowing of background rhythms and triphasic waves. Hypoxia and drug intoxications can produce a number of abnormal EEG patterns such as burst suppression, alpha coma, and spindle coma. Structural lesions, either supra- or infratentorial, are reviewed. EEGs in the former may show focal disturbances such as delta and theta activity, epileptiform abnormalities, and attenuation of faster frequencies. In infratentorial lesions, the EEG may appear normal, particularly with a pontine lesion. Some patients may be encephalopathic because of ongoing epileptic activity with minimal or no motor movements. This entity, nonconvulsive status epilepticus (NCSE), is difficult to diagnose in obtunded/comatose patients, and an EEG is required to verify the diagnosis and to monitor treatment. Several EEG patterns and their interpretation in suspected cases of NCSE such as periodic lateralized epileptiform discharges (PLEDs), bilateral independent periodic lateralized epileptiform discharges (BIPLEDs), generalized periodic epileptiform discharges (GPEDs), and triphasic waves are reviewed. Other entities discussed include the locked-in syndrome, neocortical death, persistent vegetative state, brainstem death, and brain death.

Animals↗
PubMed2006

Oligodendrocytes within astrocytes ("emperipolesis") in the cerebral white matter in hepatic and hypoglycemic encephalopathy.

We report the occurrence of oligodendrocytes within astrocytes ("emperipolesis") in two autopsy cases of metabolic encephalopathy: one patient with hepatic encephalopathy due to citrullinemia who suffered recurrent unconsciousness (clinical duration, 32 months) and another with hypoglycemic encephalopathy who lapsed into a persistent vegetative state (clinical duration, 22 months). In both cases, hypertrophic astrocytes were found to have engulfed one to several oligodendrocytes in the devastated cerebral white matter. Previous studies have reported that emperipolesis occurs in various CNS diseases showing destruction of myelin or inflammation of the white matter, including multiple sclerosis, cerebral infarct and CJD. The present findings suggest that emperipolesis can occur even in chronic metabolic disorders that extensively involve the cerebral white matter.

Aged↗
PubMed1999

The EEG and prognosis in status epilepticus.

PURPOSE: To examine the relation between specific EEG features and clinical outcome, determine whether a predictable sequence of EEG patterns exists during status epilepticus (SE), and examine the relation between periodic epileptiform discharges (PEDs) and SE. METHODS: EEG records of 50 patients with SE admitted to Graduate Hospital between January 1990 and July 1995 were reviewed. Ictal EEGs were available in 72%; 28% had only postictal EEGs. Poor outcome was defined as death or persistent vegetative state, and good outcome as all others. Fisher's Exact test, chi2, and t tests were performed for data analysis. RESULTS: Of 50 patients, 72% had a good outcome and 28%, a poor outcome. If PEDs were present at any time during or after SE, outcome tended to be worse (p = 0.053). With PEDs, eight (44%) of 18 had a poor outcome; without PEDs, six (19%) of 32 had a poor outcome. Etiologies for SE did not substantially differ in patients with or without PEDs, and structural abnormalities were not more associated with the presence of PEDs. PEDs were seen both early and late, during and after SE. Other EEG characteristics (lateralized vs. bilateral symmetric ictal EEG, discrete vs. continuous ictal activity, and postictal focal slowing) did not relate to outcome. No predictable sequence of EEG changes was found during SE. CONCLUSIONS: PEDs are the only EEG feature related to outcome in SE and are associated with poor outcome independent of etiology.

Adolescent↗
PubMed1990

The case of Ms. Nancy Cruzan and the care of the elderly.

The case of Ms. Nancy Cruzan is the first so-called "right to die" case to be heard by the US Supreme Court. The Missouri Supreme Court had ruled that Ms. Cruzan's parents, who are also her court-appointed guardians, cannot authorize the withdrawal of artificial hydration and nutrition from their daughter. Ms. Cruzan has been in a persistent vegetative state since an auto accident more than six years ago. Even though Ms. Cruzan is only 32 years old, the decision in her case will have serious implications for care of the elderly. Key features of the Missouri Supreme Court decision include their claims that (1) the authority for surrogate decision-making flows from the parens patriae power of the State rather than from the authority of the incompetent person, (2) the State has an unqualified interest in the preservation of life, and (3) the medical provision of nutrition and hydration ought to be considered differently than other forms of medical treatment. Such claims are at considerable variance from accepted standards of ethically defensible decision-making that focus on the well-being of the patient understood according to the patient's own values and life goals. If the US Supreme Court restricts decisions to forgo life-sustaining treatment according to patient prognosis, capacity for decision-making, type of treatment, or state of residence, then a patient-centered standard of medical decision-making will be impossible to sustain and the maximization of life extension will be required without regard to the suffering thereby imposed.

Adult↗
PubMed1987

Neurostimulation for patients in vegetative status.

Dorsal column stimulation has been used in four patients who were in a persistent vegetative state. There was improvement of the EEG in four patients and clinical improvement in three patients. Stimulation was for 12 hours per day at 100 Hz, 5 to 8 volts, and with a pulse width of 0.12 msec. The mechanism of improvement may involve changes in cerebral blood flow.

Adult↗
PubMed1992

Do those who cannot speak really have a voice?

Joseph Finelli, after a heart transplant, is being artificially maintained by medications and a gastrostomy tube (G-tube). He is not brain dead nor in a persistent vegetative state. In my role as court-appointed Guardian ad Litem (GAL-court investigator), it appears to me that Mr. Finelli is being treated against his stated goals and values. After applying the substituted judgment factors, I recommend the withdrawal of the medication which sustains his life. His family adamantly opposes my position.

Brain Diseases↗
PubMed2001

A practical outcome scale for paediatric head injury.

Traumatic brain injury (TBI) is the commonest cause of acquired disability in childhood. A major obstacle to the evaluation of acute and rehabilitative therapies after TBI is the lack of simple descriptors of outcome. We developed the King's Outcome Scale for Childhood Head Injury (KOSCHI), as a specific paediatric adaptation of the original adult Glasgow Outcome Scale (GOS). The KOSCHI expands the five category GOS to provide increased sensitivity at the milder end of the disability range. The GOS category of "persistent vegetative state" was replaced by "vegetative". "Good recovery" was allocated two categories, in acknowledgement of the long term importance of relatively minor sequelae in a developing child. The scale was quick and easy to use. Inter-rater reliability studies show that even with such an apparently simple scale, some training may be required. The KOSCHI provides a practical scale for paediatric head injury which will enable clinicians to describe rate and extent of recovery, and evaluate the effects of service and research interventions.

Adolescent↗
PubMed1999

Outcome after severe head injury treated by an integrated trauma system.

OBJECTIVES: To describe outcome after treatment of severe head injury within an integrated trauma system. METHODS: A retrospective analysis of all patients with severe head injury admitted to the Royal London Hospital by the Helicopter Emergency Medical Service (HEMS) between 1991 and 1994. Type of injury was defined on initial computed tomography of the head and outcomes assessed 12 months after injury using the Glasgow outcome score. RESULTS: 6.5% of HEMS patients had long term severe disability (severe disability or persistent vegetative state on the outcome score); 34.5% made a good recovery. CONCLUSIONS: The concern that a large number of severely disabled long term survivors might result as a consequence of this system of trauma management is not confirmed. The case mix of severity of extracranial injuries in these patients makes comparison with other published series difficult, but these data fit the hypothesis that pre-hospital correction of hypoxia and hypotension after head injury improves outcome.

Abbreviated Injury Scale↗
PubMed1992

Assessment of the percutaneous endoscopic gastrostomy feeding tube as part of an integrated approach to enteral feeding.

The insertion of percutaneous endoscopic gastrostomy has been well documented. The possible benefits for patient nutrition and nursing practice have, however, not been assessed. We report a study of enteral feeding by percutaneous endoscopic gastrostomy in 30 patients, the majority with a persistent vegetative state. All patients had previously been fed through a nasogastric tube using manual administration and a dietitian assessed protein calorie intake. Based upon body mass index (weight/height2), midarm circumference and triceps skinfold thickness, 20 (67%) were malnourished, with 10 patients having a body mass index less than 17 (severe malnutrition); attributed to high rates of both tube displacement and feed regurgitation. Patients were observed over six to 12 months after percutaneous endoscopic gastrostomy insertion combined with overnight continuous pump feeding. All patients attained a body mass index greater than 17, and 17 (56%) of the total number achieved the normal range with no change in protein-calorie intake (pre: 2110 kcal, post: 1880 kcal). Complications of percutaneous endoscopic gastrostomy in the study group included peritonitis (one), tube site infection (two) and displacement (two); all without serious sequelae. As part of an integrated approach percutaneous endoscopic gastrostomy proved a safe and efficient method of enteral feeding and justifies wider consideration in the United Kingdom.

Adult↗
PubMed1997

Congenital quadricuspid aortic valve anomaly associated with hypertrophic non-obstructive cardiomyopathy: a case report and review of the literature.

A case is reported of a 38 year old woman without known cardiac congenital abnormality but a history of well controlled arterial hypertension who was admitted to hospital after successful resuscitation at home following cardiac arrest. There was no evidence of myocardial infarction on 12-lead electrocardiogram but there were signs of left ventricular hypertrophy. Transoesophageal echocardiography revealed a rare quadricuspid aortic valve (QAV) malformation with concomitant mild aortic regurgitation. The left ventricle showed a massive concentric hypertrophy without obstruction. The patient was eventually transferred in a persistent vegetative state to a home care facility. A review of the literature revealed 70 cases of QAV diagnosed by transthoracic or transoesophageal echocardiography (26 cases), at necropsy (25), during surgery (15), and during angiography (4). The present case is the first report of QAV associated with non-obstructive hypertrophic cardiomyopathy.

Adult↗
PubMed2001

Deprivations, futures and the wrongness of killing.

In my essay, Why abortion is immoral, I criticised discussions of the morality of abortion in which the crucial issue is whether fetuses are human beings or whether fetuses are persons. Both argument strategies are inadequate because they rely on indefensible assumptions. Why should being a human being or being a person make a moral difference? I argued that the correct account of the morality of abortion should be based upon a defensible account of why killing children and adults is wrong. I claimed that what makes killing us wrong is that our premature deaths deprive us of our futures of value, that is, the goods of life we would have experienced had we survived. This account of the wrongness of killing explains why killing is one of the worst of crimes and how killing greatly harms the victim. It coheres with the attitudes of those with cancer or HIV facing premature death. It explains why we believe it is wrong to kill infants (as personhood theories do not). It does not entail that it wrongs a human being to end her life if she is in persistent vegetative state or if her future must consist only of unbearable physical suffering and she wants to die (as sanctity of human life theories do not). This account of the wrongness of killing implies (with some defensible additional assumptions) that abortion is immoral because we were fetuses once and we know those fetuses had futures of value. Mark Brown claims that this potential future of value account is unsound because it implies that we have welfare rights to what we need to stay alive that most people would reject. I argue that Brown is incorrect in two ways: a welfare right to what we need to stay alive is not directly implied by my account and, in addition, most of us do believe that dependent human beings have substantial welfare rights to what they need to stay alive. Brown argues that depriving us of a future of value of which we have mental representations both is a better explanation of the wrongness of killing and does not imply that abortion is immoral. I reply that (a) if Brown's arguments against my view were sound, those arguments could be easily adapted to show that his view is unsound as well and (b) Brown's view is both ambiguous and unsound on any interpretation. The most popular class of pro-choice argument strategies appeals to the view that some or all fetuses lack either a mental state or function or a capacity for a mental state or function necessary for possession of the right to life. Desires, interests, sentience, various concepts, moral agency, and rationality have all been suggested as candidates for this crucial mental role. Brown's analysis is one member of this class of strategies. I believe that it is possible to show that none of these strategies is reasonable. However, there are so many of these strategies that the required argument demands something more like a book and less like a short essay. The argument of the following essay is a piece of this larger argument.

Abortion, Induced↗
PubMed1987

Transcranial pulsed Doppler ultrasound findings in brain stem death.

Data are presented from transcranial insonation of the middle cerebral artery (MCA) performed at intervals in 23 unconscious children for whom the outcome was subsequently poor. Once an MCA signal had been observed over a 30 minute period with time averaged velocity less than 10 cm s-1 and/or a direction of flow index, DFI, defined as 1 minus the ratio of reverse to forward flow of less than 0.8, recovery to forward flow throughout diastole was never observed and no patient recovered brain stem reflexes. Recovery of forward flow in diastole, and of brain stem function, was seen in cases with time averaged MCA velocity in the range 10 to 25 cm s-1 and with reverse flow but a DFI of greater than 0.8 for short periods of time. All but one of the 13 children fulfilling clinical criteria for brain stem death had MCA signals with time averaged velocity of less than 10 cm/s and DFI of less than 0.8. This type of signal was not observed in five children who were left in a persistent vegetative state.

Adolescent↗
PubMed1993

Management of raised intracranial pressure.

This review has been written at an unfortunate time. Novel questions are being asked of the old therapies and there is an abundance of new strategies both to lower ICP and protect the brain against cerebral ischaemia. In the United Kingdom, the problem is to ensure that appropriate patients continue to be referred to centres where clinical trials of high quality can be undertaken. One of the success stories of the past decade has been the decline in the number of road accidents as a result of seat belt legislation, improvements in car design and the drink/driving laws. Hence, fortunately there are fewer patients with head injuries to treat and it is even more important that patients are appropriately referred if studies to assess efficacy of the new strategies are not to be thwarted. The nihilistic concept that intensive investigation with ICP monitoring for patients with diffuse head injury or brain swelling following evacuation of a haematoma or a contusion has no proven beneficial effect on outcome, requires revision. A cocktail of therapies may be required that can be created only when patients are monitored in sufficient detail to reveal the mechanisms underlying their individual ICP problem. Ethical problems may arise over how aggressively therapy for intracranial hypertension should be pursued and for how long. There has always been the concern that cranial decompression or prolonged barbiturate coma may preserve patients but with unacceptably severe disability. Some patients may be salvaged from herniating with massive cerebral infarction with the use of osmotherapy but is the outcome acceptable? Similar considerations apply to some children with metabolic encephalopathies. Where such considerations have been scrutinised in patients with severe head injury, the whole spectrum of outcomes appears to be shifted so that the number of severe disabilities and persistent vegetative states are not increased. However, it is important to be sensitive to such issues based on experience of the particular cause of raised intracranial pressure in a given age group.

Brain↗
PubMed1995

Sleep abnormalities in traumatic apallic syndrome.

Sleep patterns in 10 patients with traumatic apallic syndrome were studied, together with 10 healthy controls matched for sex and age. All patients underwent neurological examination, brain CT, and polysomnographic recording within six months (mean 99 (SD 45) range 47-180 days) from the onset of symptoms. Clinical follow up was performed six months after enrollment in the study. Sleep patterns were recorded in nine out of 10 patients. In the tenth patient there was no rhythm resembling physiological sleep. This patient was the only one who remained in a persistent vegetative state and died before the six month follow up. The severity of neurological deficit at follow up was significantly related to the duration of coma. There was no significant difference between patients and controls with respect to sleep architecture. The time spent awake after sleep onset was longer in patients than controls. Our data highlight the presence of sleep fragmentation in traumatic apallic syndrome, which might be due to changes in brain structures responsible for sleep maintenance. The absence of sleep-wake cycles might indicate a poor outcome.

Adolescent↗