Group treatment of trauma survivors following a fatal bus accident: Integrating theory and practice.

There is a growing body of theory and initial research into the application of group interventions with survivors of trauma, whether natural disaster, accidental, or man-made. This article reviews current thought and practice as well as recent studies of group interventions with trauma survivors. A case study involving a fatal bus accident during an international studies program is presented, along with observational outcomes and a discussion of future research directions for this unique and critical form of group work. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A giant lymphangioma of the trunk with a fatal outcome

The authors describe the case of a 2-month-old male brought to the emergency room in a preagonal state cause by extensive septic necrosis of an enormous lymphangioma located on the left lateral trunk. In spite of emergency treatment the child expired shortly after admission. Our observation of this case prompted a review of the literature on the treatment approaches currently used for these tumors. Emphasis is placed on the necessity for early treatment in order to avoid infectious complications that, if neglected, can lead to unmanageable and possibly fatal sepsis.     

Brief early psychological interventions following trauma: a systematic review of the literature

A systematic literature search/review was undertaken of brief early psychological interventions following trauma. Only six randomized controlled trials were found, and none of these included group interventions. Of the six trials, two studies associated the intervention with a positive outcome, two demonstrated no difference on outcome between intervention and non-intervention groups, and two showed some negative outcomes in the intervention group. This review suggests that early optimism for brief early psychological interventions including debriefing was misplaced and that there is an urgent need for randomized controlled trials of group debriefing and other early interventions.     

Hypothermia: impact on the trauma victim

When bacterial cells are shifted to higher temperatures their degree of DNA supercoiling changes. Topoisomerases are involved in bacterial adaptation to environmental changes requiring rapid shifts in gene expression. This role in heat shock has been elucidated by genetic studies on the Escherichia coli topA gene and its sigma 32-dependent promoter, P1. Other studies have shown that certain gyrA mutants have increased thermoresistance.     

Multi-resistant tuberculosis of fatal outcome in a patient without HIV infection

Fifty six patients with typhoid enteric perforation who underwent operative treatment were randomly assigned to 2 groups. Twenty seven patients in group A underwent laparotomy via the Rutherford-Morrison incision while 29 patients in group B underwent the same procedure via a right paramedian incision. Surgical treatment consisted of two layer closure of the perforation with peritoneal lavage and tube drainage in all cases. Mean operating time in group A and group B was 45 +/- 10 minutes and 73 +/- 6 minutes respectively (p < 0.001). Postoperative wound dehiscence in group A and group B was observed in 2 and 11 cases respectively (p < 0.001). Incisional hernia developed in 8 patients in group B and none in group A (p < 0.01). Two patients in group A and 10 in group B developed adhesion-obstruction (p < 0.05). Differences in wound sepsis, pelvic abscess and mortality were not significant. Mean hospital stay in groups A and B was 12.4 days and 16.8 days respectively (p < 0.001). We conclude that in the presence of a confirmed preoperative diagnosis of typhoid enteric perforation, laparotomy via the Rutherford-Morrison incision may significantly reduce postoperative wound complications and morbidity without significantly altering the overall outcome.     

A case of multiple trauma following a motor cycle accident

This paper reports a fractured femur, jejunal laceration and a torn aorta in a young man who appeared reasonably well on admission to hospital. The diagnostic problems and treatment of this case are discussed.     

An examination of verbal supraspan in normal adults and patients with head trauma or unilateral cerebrovascular accident.

Provided a normative data base for a measure of verbal supraspan based on 301 neurologically intact adults (aged 18–91 yrs) and examined the test's clinical sensitivity in 3 patient groups. Data from 55 patients with severe head trauma, 38 with right hemisphere and cerebrovascular accident (CVA), and 15 with left hemisphere CVA reveal significant age-related differences, with older Ss performing below levels obtained by younger ones. Group data reveal that Ss in all 3 groups performed significantly below levels obtained by age-matched controls. Supraspan scores did not correlate appreciably with years of education. However, scores on the supraspan test correlated modestly with Wechsler Adult Intelligence Scale—Revised (WAIS—R) Information and Block Design scores, suggesting that task performance may be dependent in part on the S's general level of cognitive functioning. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evaluation of trauma care in a developing country highlighted by a major aircraft accident

Transjugular intrahepatic portosystemic shunt (TIPS) is a side-to-side portocaval shunt for threatening complications of portal hypertension. The purpose of this study was to evaluate in first 33 patients indicated for TIPS insertion in our institution the efficacy, complications, and mortality. Indication was failure of sclerotherapy or ligation in control either of acute (n = 4) or repetitive (n = 25) variceal bleeding and refractory ascites (n = 4). The technical success rate was with 70% (21/30) lower than expected, but the complication rate was also very low. There were no fatal complications, only one subcapsular liver hematome, and in one patient repetitive punction of biliary tract. The 30-days mortality was 10% (2/21) and rebleeding was 15% (3/20), caused always by thrombosis of the shunt. TIPS seems to be a promising therapeutic procedure after failed endoscopic therapy of esophageal varices without the mortality and morbidity of an open surgical procedure. Recent indications for TIPS are acute variceal hemorrhage refractory to endoscopic treatment and recurrent variceal bleeding despite sclerotherapy or band ligation. Promising seems to be TIPS insertion in the treatment of refractory ascites.     

Psychiatric disorders in refugees and asylum seekers: psychological trauma as a cause?

Posttraumatic stress disorder was diagnosed in two patients, men aged 26 and 29, an asylum seeker from the Middle East and a refugee from former Yugoslavia respectively. They had experienced severe psychotraumatic events. They were referred to a clinic for traumatised refugees and asylum seekers. Their psychiatric disturbances did not fit posttraumatic stress disorder, however. The former suffered from a schizophrenic disorder, the latter from psychosis and depression based on alcohol dependence. Growing awareness of the high prevalence of traumatic experiences in the population leads to a contextual shift in therapists regarding their understanding of the short and long term effects of traumatization in their patients. Exclusive focus on the traumatic history, however, biases the diagnostic process and could lead to wrong conclusions about a causal relationship between traumatic experiences and the psychopathology observed in the patient. When treating asylum seekers or refugees the risk of jumping to this false conclusion is even higher, partially due to cultural and language barriers.     

Cranioencephalic trauma in adults: clinical and radiologic features

BACKGROUND: To analyse extracranial complications and basic variables in head-injury patients, such as Glasgow coma score (GCS), intracranial pressure (ICP) and cranial computerized tomography (CT), in relation to the outcome of these patients. PATIENTS AND METHODS: 64 consecutive patients (47 males and 17 females) with head injury, admitted from January 1992 to May 1994, were studied in this prospective study. Mean age was 37 +/- 18 years. Overall mortality was 23% (15/64). Student-t and Chi-square tests were used for statistical analysis, and p < 0.05 was considered statistical significant. RESULTS: Overall GCS was 7 +/- 3, survivors presenting GCS of 7.7 +/- 2.9 and non-survivors 4.7 +/- 1.5 (p = 0.04). CT were classified as follows: diffuse injury, 4 patients (7%); focal injury, 32 (53%), and mixed injury 24 (40%). Depending on the presence or absence of mesencephalic cisterns in the CT, GSC was 7.6 +/- 2.8 and 4.3 +/- 1.4, respectively (p = 0.04). Subarachnoid hemorrhage (SAH) was associated to a GCS of 6.3 +/- 2.5 and its absence to 8 +/- 3.3 (p = 0.03). The absence of mesencephalic cisterns and SAH were more frequent in the non-survivors, 72% and 32% (p = 0.01 and 0.04), respectively. ICP was recorded in 42 patients. Regarding to ICP, mortality was: 6.7% with ICP < or = 20 mmHg, 37% with ICP 21-30, 44% with ICP 31-40 and 67% with ICP > 50 mmHg (p = 0.03). Diabetes insipidus, cardiorespiratory arrest, shock, prolonged mechanical ventilation, SDRA and sepsis were the most frequent extracranial complications in non-survivors. CONCLUSIONS: There is an association between the outcome of head-injury patients with the GCS and ICP values. Absence of mesencephalic cisterns and SAH were radiologic signs of poor prognosis. Patients who died had more extracranial complications.     

Adverse psychological impact of operative obstetric interventions: a prospective longitudinal study

OBJECTIVE: This paper reports the findings of a prospective longitudinal study of 272 nulliparous pregnant women, which investigated as one of its objectives the psychological sequelae of obstetric procedures. METHOD: Participants completed structured interviews and standardised, published psychometric questionnaires, including the Rosenberg Self-Esteem Scale and the Profile of Mood States late in pregnancy and again early in the postpartum period. RESULTS: Little evidence was found to support the notion that the total number of obstetric interventions was linked to a deterioration in postpartum mood. Significant adverse psychological effects were associated with the mode of delivery. Those women who had spontaneous vaginal deliveries were most likely to experience a marked improvement in mood and an elevation in self-esteem across the late pregnancy to early postpartum interval. In contrast, women who had Caesarean deliveries were significantly more likely to experience a deterioration in mood and a diminution in self-esteem. The group who experienced instrumental intervention in vaginal deliveries fell midway between the other two groups, reporting neither an improvement nor a deterioration in mood and self-esteem. CONCLUSIONS: The findings of this study suggest that operative intervention in first childbirth carries significant psychological risks rendering those who experience these procedures vulnerable to a grief reaction or to posttraumatic distress and depression.     

Comparison of two different trauma assessment scores in predicting trauma outcome

We treated two patients with gastric cancer for whom surgery was delayed and the natural course of the tumor could be observed pre and postoperatively. A 70-year-old man with a well differentiated adenocarcinoma in the upper portion of the stomach underwent resection 6 years after the clinical diagnosis. Despite extension upwards towards the lower esophagus during a 6-year period, the tumor could be resected. In a poorly differentiated adenocarcinoma in the lower third of the stomach in a 40-year-old woman, the primary lesion was not distinct on the upper GI series done 6 months before, while at the time of laparotomy, disseminating metastases and pancreas invasion made it impossible to resect the stomach together with the tumor. The tumor in the man had a low DNA ploidy, while the lesion in the woman was characterized by a high ploidy. These findings show the distinct difference in the biological behavior of the tumor in these two patients. The possible correlation between DNA content with speed of growth warrants further attention.     

About this issue: Diversity and convergence in the study of psychological trauma.

In this editorial, the editor discusses the diversity of material in the current issue of Psychological Trauma: Theory, Research, Practice and Policy (PT: TRPP). He addresses questions that were raised by the pieces in this issue including ones as fundamental as what constitutes a psychological trauma. The editors believe that it is extremely important that as many facets of this terrain be examined and represented in the pages of PT: TRPP as possible. Only by continually and actively striving to maintain an inclusive perspective can we hope to work toward evolving a reasonable level of understanding of psychological trauma in all its richness and complexity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Long-term patient-oriented outcome study of a modified Evans procedure

More than 50 surgical procedures have been described for treatment of chronic lateral ankle instability. Anatomic repairs have come into favor in the recent literature based on short-term studies, which have used objective measures for outcome. A long-term (range, 7-20 years; average, 12.6) patient-oriented outcome analysis was performed on 20 patients that underwent a modified Evans procedure for chronic lateral ankle instability by the senior author over a 13-year period. There was a 91% follow-up on all located patients (20 of 22). All patients had mechanical and functional instability, and all had failed conservative therapy. A questionnaire, based on the outcomes questionnaire developed by the American Academy of Orthopaedic Surgeons was used to determine functional stability. The patient's ability to perform recreational or competitive sporting activities at specific time intervals were also assessed (preinjury, 1 year postoperatively, present time). Overall result was considered satisfactory if five criteria were met: patents (a) were happy with the outcome of surgery, (b) were able to perform desired level of activities, (c) had functional stability, (d) were pain free performing desired level activities, (e) would undergo procedure again. The entire cohort demonstrated satisfactory results in 19 (95%) of 20 respondents at 1 year and 17 (85%) at present time. Grouping patients into competitive (12 cases) and recreational (eight cases) athletes demonstrated six of 12, and seven of eight reached their preinjury level (p = 0.074). In this study, we showed that surgical reconstruction using a modified Evans procedure is a reliable and effective treatment for chronic lateral instability. This procedure has proved to stand the test of time, as demonstrated by a patient-oriented outcome analysis. The elite athlete may be better served by a procedure using the principles of anatomic rather than augmented repair; however, the long-term data to our knowledge has yet to be published.     

Assessing suicidality in adults: Integrating childhood trauma as a major risk factor.

Can knowing whether an adult client was abused as a child assist psychologists when assessing suicidality? Reviewing the files of 200 outpatients revealed, in keeping with previous studies, that child abuse was related not only to previous psychiatric admissions and younger age at first treatment and first admission, but also to past and present suicidality. Current suicidality was predicted better by child sexual abuse (experienced on average 20 years previously) than by a current diagnosis of depression. Evidence that abuse histories are not routinely taken, and recommendations for why, and how, taking abuse histories should be integrated into suicide assessment and treatment, are presented. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Streptococcal pharyngitis: impact of a high-sensitivity antigen test on physician outcome

The purpose of the present study was to determine whether the availability of results from a high-sensitivity, rapid test for group A streptococci (Strep A OIA; BioStar, Inc., Boulder, Colo.) improves physician outcome. The study population included 465 consecutive patients with symptoms of acute pharyngitis seen in two outpatient clinics in a large suburban medical center; one clinic, a walk-in clinic (WIC), primarily saw adult patients, and one clinic, a pediatric and adolescent medicine clinic (PED), primarily saw pediatric patients. We measured improvement in physician outcome by comparing physician intent for prescribing an antibiotic based on clinical impression with physician practice once the results of the Strep A OIA were known. Based upon intent, the physicians seeing WIC patients (WIC physicians) would have prescribed an appropriate antibiotic course for 42% of patients with cultures positive for group A beta-hemolytic streptococci (GABHS) and 61% of patients with cultures negative for GABHS. After receiving the results of the Strep A OIA, WIC physicians prescribed an appropriate antibiotic course for 81% of patients with positive cultures and 72% of patients with negative cultures. Based upon intent, the physicians seeing PED patients (PED physicians) would have prescribed an appropriate antibiotic course for 35% of patients with positive cultures and 77% of patients with negative cultures. After receiving the results of the Strep A OIA, PED physicians prescribed an appropriate antibiotic course for 90% of patients with positive cultures and 81% of patients with negative cultures. Based on a 14.5% prevalence of GABHS among WIC patients, Strep A OIA improved the overall WIC physician outcome from 58 to 74%. Based on a 31.5% prevalence of GABHS among PED patients, Strep A OIA improved the PED physician outcome from 64 to 84%. Had Strep A OIA alone guided therapeutic choice, physicians would have prescribed an appropriate antibiotic course for 95% of the patients at the time of the initial encounter. We conclude that the use of Strep A OIA improves physician outcome.     

Prediction of posttraumatic stress disorder by immediate reactions to trauma: a prospective study in road traffic accident victims

Road traffic accidents often cause serious physical and psychological sequelae. Specialists of various medical faculties are involved in the treatment of accident victims. Little is known about the factors which might predict psychiatric disorders, e.g. Posttraumatic Stress Disorder (PTSD) after accidents and how psychological problems influence physical treatment. In a prospective study 179 unselected, consecutively admitted road traffic accident victims were assessed a few days after the accident for psychiatric diagnoses, severity of injury and psychopathology. All were inpatients and had to be treated for bone fractures. At 6-months follow-up assessment 152 (85%) of the patients were interviewed again. Of the patients, 18.4% fulfilled the criteria for Posttraumatic Stress Disorder (DSM-III-R) within 6 months after the accident. Patients who developed PTSD were injured more severely and showed more symptoms of anxiety, depression and PTSD a few days after the accident than patients with no psychiatric diagnosis. Patients with PTSD stayed significantly longer in the hospital than the other patients. Multiple regression analysis revealed that the length of hospitalization was due mainly to a diversity of factors such as severity of injury, severity of accident, premorbid personality and psychopathology. Posttraumatic stress disorder is common after road traffic accidents. Patients with PTSD at follow-up can be identified by findings from early assessment. Untreated psychological sequelae such as PTSD cause longer hospitalization and therefore more costs than in non-PTSD patients.     

After the storm: Katrina's impact on psychological practice in New Orleans.

The impact of Hurricane Katrina on 4 senior New Orleans-based psychologists, both professionally and personally, is described. The authors are pediatric, adult, and family therapists and neuropsychologists; by employment, they are medical center academics, independent practitioners, administrators, and staff/consulting psychologists at medical and psychiatric hospitals. Their diverse experiences following Katrina are similar to the experiences of many individuals in the professional community of the Gulf Coast. In the face of the storm, they departed New Orleans and afterward returned at varying intervals. The homes of all of the 4 New Orleans authors were damaged or destroyed. All of their practice locations were closed for varying periods, and 2 were closed permanently. Of the 4 who returned to New Orleans, only 2 remained 18 months after the storm; the others had relocated to other states. This article reflects on their collective experience as mental health professionals living in New Orleans after Katrina and lessons learned from that experience. (PsycINFO Database Record (c) 2010 APA, all rights reserved)