A Continuous Correlation Between Intracranial Pressure and Cerebral Blood Flow Velocity Reflects Cerebral Autoregulation Impairment During Intracranial Pressure Plateau Waves

Background

In the healthy brain, small oscillations in intracranial pressure (ICP) occur synchronously with those in cerebral blood volume (CBV), cerebrovascular resistance, and consequently cerebral blood flow velocity (CBFV). Previous work has shown that the usual synchrony between ICP and CBFV is lost during intracranial hypertension. Moreover, a continuously computed measure of the ICP/CBFV association (Fix index) was a more sensitive predictor of outcome after traumatic brain injury (TBI) than a measure of autoregulation (Mx index). In the current study we computed Fix during ICP plateau waves, to observe its behavior during a defined period of cerebrovascular vasodilatation.

Methods

Twenty-nine recordings of arterial blood pressure (ABP), ICP, and CBFV taken during ICP plateau waves were obtained from the Addenbrooke’s hospital TBI database. Raw data was filtered prior to computing Mx and Fix according to previously published methods. Analyzed data was segmented into three phases (pre, peak, and post), and a median value of each parameter was stored for analysis.

Results

ICP increased from a median of 22–44 mmHg before falling to 19 mmHg. Both Mx and Fix responded to the increase in ICP, with Mx trending toward +1, while Fix trended toward ?1. Mx and Fix correlated significantly (Spearman’s R = ?0.89, p < 0.000001), however, Fix spanned a greater range than Mx. A plot of Mx and Fix against CPP showed a plateau (Mx) or trough (Fix) consistent with a zone of “optimal CPP”.

Conclusions

The Fix index can identify complete loss of cerebral autoregulation as the point at which the normally positive CBF/CBV correlation is reversed. Both CBF and CBV can be monitored noninvasively using near-infrared spectroscopy (NIRS), suggesting that a noninvasive method of monitoring autoregulation using only NIRS may be possible.     

Cerebral Critical Closing Pressure: Is the Multiparameter Model Better Suited to Estimate Physiology of Cerebral Hemodynamics?

Background

Cerebral critical closing pressure (CrCP) is the level of arterial blood pressure (ABP) at which small brain vessels close and blood flow stops. This value is always greater than intracranial pressure (ICP). The difference between CrCP and ICP is explained by the tone of the small cerebral vessels (wall tension). CrCP value is used in several dynamic cerebral autoregulation models. However, the different methods for calculation of CrCP show frequent negative values. These findings are viewed as a methodological limitation. We intended to evaluate CrCP in patients with severe traumatic brain injury (TBI) with a new multiparameter impedance-based model and compare it with results found earlier using a transcranial Doppler (TCD)–ABP pulse waveform-based method.

Methods

Twelve severe TBI patients hospitalized during September 2005–May 2007. Ten men, mean age 32 years (16–61). Four had decompressive craniectomies (DC); three presented anisocoria. Patients were monitored with TCD cerebral blood flow velocity (FV), invasive ABP, and ICP. Data were acquired at 50 Hz with an in-house developed data acquisition system. We compared the earlier studied “first harmonic” method (M1) results with results from a new recently developed (M2) “multiparameter method.”

Results

M1: In seven patients CrCP values were negative, reaching ?150 mmHg. M2: All positive values; only one lower than ICP (ICP 60 mmHg/ CrCP 57 mmHg). There was a significant difference between M1 and M2 values (M1 < M2) and between ICP and M2 (M2 > ICP).

Conclusion

M2 results in positive values of CrCP, higher than ICP, and are physiologically interpretable.

     

Cessation of Diastolic Cerebral Blood Flow Velocity: The Role of Critical Closing Pressure

Background

Reducing cerebral perfusion pressure (CPP) below the lower limit of autoregulation (LLA) causes cerebral blood flow (CBF) to become pressure passive. Further reductions in CPP can cause cessation of CBF during diastole. We hypothesized that zero diastolic flow velocity (FV) occurs when diastolic blood pressure becomes less than the critical closing pressure (CrCP).

Methods

We retrospectively analyzed studies of 34 rabbits with CPP below the LLA, induced with pharmacologic sympathectomy (N = 23) or cerebrospinal fluid infusion (N = 11). Basilar artery blood FV and cortical Laser Doppler Flow (LDF) were monitored. CrCP was trended using a model of cerebrovascular impedance. The diastolic closing margin (DCM) was monitored as the difference between diastolic blood pressure and CrCP. LDF was recorded for DCM values greater than and less than zero.

Results

Arterial hypotension caused a reduction of CrCP (p < 0.001), consistent with decreased wall tension (p < 0.001) and a drop in intracranial pressure (ICP; p = 0.004). Cerebrospinal infusion caused an increase of CrCP (p = 0.002) accounted for by increasing ICP (p < 0.001). The DCM was compromised by either arterial hypotension or intracranial hypertension (p < 0.001 for both). When the DCM reached zero, diastolic FV ceased for a short period during each heart cycle (R = 0.426, p < 0.001). CBF pressure passivity accelerated when DCM decreased below zero (from 1.51 ± 0.51 to 2.17 ± 1.17 % ΔLDF/ΔmmHg; mean ± SD; p = 0.010).

Conclusions

The disappearance of diastolic CBF below LLA can be explained by DCM reaching zero or negative values. Below this point the decrease in CBF accelerates with further decrements of CPP.     

Monitoring cerebral autoregulation after head injury. Which component of transcranial Doppler flow velocity is optimal?

Background

Cerebral autoregulation assessed using transcranial Doppler (TCD) mean flow velocity (FV) in response to various physiological challenges is predictive of outcome after traumatic brain injury (TBI). Systolic and diastolic FV have been explored in other diseases. This study aims to evaluate the systolic, mean and diastolic FV for monitoring autoregulation and predicting outcome after TBI.

Methods

300 head-injured patients with blood pressure (ABP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), and FV recordings were studied. Autoregulation was calculated as a correlation of slow changes in diastolic, mean and systolic components of FV with CPP (Dx, Mx, Sx, respectively) and ABP (Dxa, Mxa, Sxa, respectively) from 30 consecutive 10?s averaged values. The relationship with age, severity of injury, and dichotomized 6?months outcome was examined.

Results

Association with outcome was significant for Mx and Sx. For favorable/unfavorable and death/survival outcomes Sx showed the strongest association (F?=?20.11; P?=?0.00001 and F?=?13.10; P?=?0.0003, respectively). Similarly, indices derived from ABP demonstrated the highest discriminatory value when systolic FV was used (F?=?12.49; P?=?0.0005 and F?=?5.32; P?=?0.02, respectively). Indices derived from diastolic FV demonstrated significant differences (when calculated using CPP) only when comparing between fatal and non-fatal outcome.

Conclusions

Systolic flow indices (Sx and Sxa) demonstrated a stronger association with outcome than the mean flow indices (Mx and Mxa), irrespective of whether CPP or ABP was used for calculation.     

Comparison of Non-invasive and Invasive Arterial Blood Pressure Measurement for Assessment of Dynamic Cerebral Autoregulation

Background

There is a growing interest in measuring cerebral autoregulation in patients with acute brain injury. Non-invasive finger photo-plethysmography (Finapres) is the method of choice to relate arterial blood pressure to changes in cerebral blood flow. Among acutely ill patients, however, peripheral vasoconstriction often limits the use of Finapres requiring direct intravascular blood pressure measurement. We evaluated how these two different forms of blood pressure monitoring affect the parameters of dynamic cerebral autoregulation (DCA).

Methods

We performed 37 simultaneous recordings of BP and cerebral blood flow velocity in 15 patients with acute brain injury. DCA was estimated in the frequency domain using transfer function analysis to calculate phase shift, gain, and coherence. In addition the mean velocity index (Mx) was calculated for assessment of DCA in the time domain.

Results

The mean patient age was 58.1 ± 15.9 years, 80 % (n = 12) were women. We found good inter-method agreement between Finapres and direct intravascular measurement using Bland–Altman and correlation analyses. Finapres gives higher values for the efficiency of dynamic CA compared with values derived from radial artery catheter, as indicated by biases in the phase (26.3 ± 11.6° vs. 21.7 ± 10.5°, p = 0.001) and Mx (0.571 ± 0.137 vs. 0.649 ± 0.128, p < 0.001). Gain in the low frequency range did not significantly differ between the two arterial blood pressure methods. The average coherence between CBFV and ABP was higher when BP was measured with arterial catheter for frequencies above 0.05 Hz (0.8 vs. 0.73, p < 0.001).

Conclusion

Overall, both methods yield similar results and can be used for the assessment of DCA. However, there was a small but significant difference for both mean Mx and phase shift, which would need to be adjusted for during monitoring of patients when using both methods. When available, invasive arterial blood pressure monitoring may improve accuracy and thus should be the preferred method for DCA assessment in the ICU.     

Critical Closing Pressure During Intracranial Pressure Plateau Waves

Background

Critical closing pressure (CCP) denotes a threshold of arterial blood pressure (ABP) below which brain vessels collapse and cerebral blood flow ceases. Theoretically, CCP is the sum of intracranial pressure (ICP) and arterial wall tension (WT). The aim of this study is to describe the behavior of CCP and WT during spontaneous increases of ICP, termed plateau waves, in order to quantify ischemic risk.

Methods

To calculate CCP, we used a recently introduced multi-parameter method (CCPm) which is based on the modulus of cerebrovascular impedance. CCP is derived from cerebral perfusion pressure, ABP, transcranial Doppler estimators of cerebrovascular resistance and compliance, and heart rate. Arterial WT was estimated as CCPm-ICP. The clinical data included recordings of ABP, ICP, and transcranial Doppler-based blood flow velocity from 38 events of ICP plateau waves, recorded in 20 patients after head injury.

Results

Overall, CCPm increased significantly from 51.89 ± 8.76 mmHg at baseline ICP to 63.31 ± 10.83 mmHg at the top of the plateau waves (mean ± SD; p < 0.001). Cerebral arterial WT decreased significantly during plateau waves by 34.3 % (p < 0.001), confirming their vasodilatatory origin. CCPm did not exhibit the non-physiologic negative values that have been seen with traditional methods for calculation, therefore rendered a more plausible estimation of CCP.

Conclusions

Rising CCP during plateau waves increases the probability of cerebral vascular collapse and zero flow when the difference: ABP–CCP (the “collapsing margin”) becomes zero or negative.     

ICP Versus Laser Doppler Cerebrovascular Reactivity Indices to Assess Brain Autoregulatory Capacity

Background

To explore the relationship between various autoregulatory indices in order to determine which approximate small vessel/microvascular (MV) autoregulatory capacity most accurately.

Methods

Utilizing a retrospective cohort of traumatic brain injury patients (N = 41) with: transcranial Doppler (TCD), intracranial pressure (ICP) and cortical laser Doppler flowmetry (LDF), we calculated various continuous indices of autoregulation and cerebrovascular responsiveness: A. ICP derived [pressure reactivity index (PRx)—correlation between ICP and mean arterial pressure (MAP), PAx—correlation between pulse amplitude of ICP (AMP) and MAP, RAC—correlation between AMP and cerebral perfusion pressure (CPP)], B. TCD derived (Mx—correlation between mean flow velocity (FVm) and CPP, Mx_a—correlation between FVm and MAP, Sx—correlation between systolic flow velocity (FVs) and CPP, Sx_a—correlation between FVs and MAP, Dx—correlation between diastolic flow index (FVd) and CPP, Dx_a—correlation between FVd and MAP], and LDF derived (Lx—correlation between LDF cerebral blood flow [CBF] and CPP, Lx_a—correlation between LDF-CBF and MAP). We assessed the relationship between these indices via Pearson correlation, Friedman test, principal component analysis (PCA), agglomerative hierarchal clustering (AHC), and k-means cluster analysis (KMCA).

Results

LDF-based autoregulatory index (Lx) was most associated with TCD-based Mx/Mx_a and Dx/Dx_a across Pearson correlation, PCA, AHC, and KMCA. Lx was only remotely associated with ICP-based indices (PRx, PAx, RAC). TCD-based Sx/Sx_a was more closely associated with ICP-derived PRx, PAx and RAC. This indicates that vascular-derived indices of autoregulatory capacity (i.e., TCD and LDF based) covary, with Sx/Sx_a being the exception, whereas indices of cerebrovascular reactivity derived from pulsatile CBV (i.e., ICP indices) appear to not be closely related to those of vascular origin.

Conclusions

Transcranial Doppler Mx is the most closely associated with LDF-based Lx/Lx_a. Both Sx/Sx-a and the ICP-derived indices appear to be dissociated with LDF-based cerebrovascular reactivity, leaving Mx/Mx-a as a better surrogate for the assessment of cortical small vessel/MV cerebrovascular reactivity. Sx/Sx_a cocluster/covary with ICP-derived indices, as seen in our previous work.

     

Continuous Monitoring of Cerebrovascular Reactivity Using Pulse Waveform of Intracranial Pressure

Background

Guidelines for the management of traumatic brain injury (TBI) call for the development of accurate methods for assessment of the relationship between cerebral perfusion pressure (CPP) and cerebral autoregulation and to determine the influence of quantitative indices of pressure autoregulation on outcome. We investigated the relationship between slow fluctuations of arterial blood pressure (ABP) and intracranial pressure (ICP) pulse amplitude (an index called PAx) using a moving correlation technique to reflect the state of cerebral vasoreactivity and compared it to the index of pressure reactivity (PRx) as a moving correlation coefficient between averaged values of ABP and ICP.

Methods

A retrospective analysis of prospective 327 TBI patients (admitted on neurocritical care unit of a university hospital in the period 2003?C2009) with continuous ABP and ICP monitoring.

Results

PAx was worse in patients who died compared to those who survived (?0.04?±?0.15 vs. ?0.16?±?0.15, ??²?=?28, p?2?=?6, p?=?0.01).

Conclusions

PAx is a new modified index of cerebrovascular reactivity which performs equally well as established PRx in long-term monitoring in severe TBI patients, but importantly is potentially more robust at lower values of ICP. In view of establishing an autoregulation-oriented CPP therapy, continuous determination of PAx is feasible but its value has to be evaluated in a prospective controlled trail.     

Comparison of frequency and time domain methods of assessment of cerebral autoregulation in traumatic brain injury

The impulse response (IR)-based autoregulation index (ARI) allows for continuous monitoring of cerebral autoregulation using spontaneous fluctuations of arterial blood pressure (ABP) and cerebral flow velocity (FV). We compared three methods of autoregulation assessment in 288 traumatic brain injury (TBI) patients managed in the Neurocritical Care Unit: (1) IR-based ARI; (2) transfer function (TF) phase, gain, and coherence; and (3) mean flow index (Mx). Autoregulation index was calculated using the TF estimation (Welch method) and classified according to the original Tiecks'' model. Mx was calculated as a correlation coefficient between 10-second averages of ABP and FV using a moving 300-second data window. Transfer function phase, gain, and coherence were extracted in the very low frequency (VLF, 0 to 0.05 Hz) and low frequency (LF, 0.05 to 0.15 Hz) bandwidths. We studied the relationship between these parameters and also compared them with patients'' Glasgow outcome score. The calculations were performed using both cerebral perfusion pressure (CPP; suffix ‘c'') as input and ABP (suffix ‘a''). The result showed a significant relationship between ARI and Mx when using either ABP (r=−0.38, P<0.001) or CPP (r=−0.404, P<0.001) as input. Transfer function phase and coherence_a were significantly correlated with ARI_a and ARI_c (P<0.05). Only ARI_a, ARI_c, Mx_a, Mx_c, and phase_c were significantly correlated with patients'' outcome, with Mx_c showing the strongest association.     

Continuous Cerebral Blood Flow Autoregulation Monitoring in Patients Undergoing Liver Transplantation

Background

Clinical monitoring of cerebral blood flow (CBF) autoregulation in patients undergoing liver transplantation may provide a means for optimizing blood pressure to reduce the risk of brain injury. The purpose of this pilot project is to test the feasibility of autoregulation monitoring with transcranial Doppler (TCD) and near-infrared spectroscopy (NIRS) in patients undergoing liver transplantation and to assess changes that may occur perioperatively.

Methods

We performed a prospective observational study in 9 consecutive patients undergoing orthotopic liver transplantation. Patients were monitored with TCD and NIRS. A continuous Pearson??s correlation coefficient was calculated between mean arterial pressure (MAP) and CBF velocity and between MAP and NIRS data, rendering the variables mean velocity index (Mx) and cerebral oximetry index (COx), respectively. Both Mx and COx were averaged and compared during the dissection phase, anhepatic phase, first 30?min of reperfusion, and remaining reperfusion phase. Impaired autoregulation was defined as Mx????0.4.

Results

Autoregulation was impaired in one patient during all phases of surgery, in two patients during the anhepatic phase, and in one patient during reperfusion. Impaired autoregulation was associated with a MELD score?>15 (p?=?0.015) and postoperative seizures or stroke (p?p?=?0.0029). The relationship between COx and Mx remained when only patients with bilirubin?>1.2?mg/dL were evaluated (p?=?0.0419). There was no correlation between COx and baseline bilirubin (p?=?0.2562) but MELD score and COx were correlated (p?=?0.0458). Average COx was higher for patients with a MELD score?>15 (p?=?0.073) and for patients with a neurologic complication than for patients without neurologic complications (p?=?0.0245).

Conclusions

These results suggest that autoregulation is impaired in patients undergoing liver transplantation, even in the absence of acute, fulminant liver failure. Identification of patients at risk for neurologic complications after surgery may allow for prompt neuroprotective interventions, including directed pressure management.     

Should the Neurointensive Care Management of Traumatic Brain Injury Patients be Individualized According to Autoregulation Status and Injury Subtype?

Introduction

The status of autoregulation is an important prognostic factor in traumatic brain injury (TBI), and is important to consider in the management of TBI patients. Pressure reactivity index (PRx) is a measure of autoregulation that has been thoroughly studied, but little is known about its variation in different subtypes of TBI. In this study, we examined the impact of PRx and cerebral perfusion pressure (CPP) on outcome in different TBI subtypes.

Methods

107 patients were retrospectively studied. Data on PRx, CPP, and outcome were collected from our database. The first CT scan was classified according to the Marshall classification system. Patients were assigned to “diffuse” (Marshall class: diffuse-1, diffuse-2, and diffuse-3) or “focal” (Marshall class: diffuse-4, evacuated mass lesion, and non-evacuated mass lesion) groups. 2 × 2 tables were constructed calculating the proportions of favorable/unfavorable outcome at different combinations of PRx and CPP.

Results

Low PRx was significantly associated with favorable outcome in the combined group (p = 0.002) and the diffuse group (p = 0.04), but not in the focal group (p = 0.06). In the focal group higher CPP values were associated with worse outcome (p = 0.02). In diffuse injury patients with disturbed autoregulation (PRx >0.1), CPP >70 mmHg was associated with better outcome (p = 0.03).

Conclusion

TBI patients with diffuse injury may differ from those with mass lesions. In the latter higher levels of CPP may be harmful, possibly due to BBB disruption. In TBI patients with diffuse injury and disturbed autoregulation higher levels of CPP may be beneficial.     

Effectiveness of the Tobacco Tactics Program in the Department of Veterans Affairs

Purpose

The purpose was to determine the effectiveness of the Tobacco Tactics program in three Veterans Affairs hospitals.

Methods

In this effectiveness trial, inpatient nurses were educated to provide the Tobacco Tactics intervention in Ann Arbor and Detroit, while Indianapolis was the control site (N?=?1,070). Smokers were surveyed and given cotinine tests. The components of the intervention included nurse counseling, brochure, DVD, manual, pharmaceuticals, 1-800-QUIT-NOW card, and post-discharge telephone calls.

Results

There were significant improvements in 6-month quit rates in the pre- to post-intervention time periods in Ann Arbor (p?=?0.004) and Detroit (p?Conclusion The Tobacco Tactics program, which meets the Joint Commission standards that apply to all inpatient smokers, has the potential to significantly decrease smoking among Veterans.     

Sexual maturation among youth with ADHD and the impact of stimulant medication

Objective

Evaluate the differences in achieving puberty between ADHD and non-ADHD participants and the effects of medication on that process among ADHD participants.

Procedure

A subset of participants with ADHD from the Multimodal Treatment study of ADHD (n = 342) were compared with respect to Tanner staging to participants from a comparison group without ADHD (n = 159) at the 36-month follow-up assessment. Further comparisons were made for Tanner stages and Auxology of the participants in the ADHD group who were always (n = 61), never (n = 56), newly (n = 74) and inconsistently (n = 116) treated with stimulants.

Results

No statistically significant differences in Tanner stages of sexual development were found between the ADHD and non-ADHD groups at the age of assessment (between 10 and 14 years of age) or among the ADHD medication subgroups, although a trend was observed for stimulant-associated delayed pubertal initiation using auxological analysis.

Conclusion

Children with or without ADHD did not differ in Tanner stages at the 3-year follow-up assessment, and exposure to stimulant medication does not appear to affect sexual development within this age range.     

Warfarin and Statins are Associated with Hematoma Volume in Primary Infratentorial Intracerebral Hemorrhage

Background and purpose

Despite extensive studies of supratentorial intracerebral hemorrhage (ICH), limited data are available on determinants of hematoma volume in infratentorial ICH. We therefore aimed to identify predictors of infratentorial ICH volume and to evaluate whether location specificity exists when comparing cerebellar to brainstem ICH.

Methods

We undertook a retrospective analysis of 139 consecutive infratentorial ICH cases (95 cerebellar and 44 brainstem ICH) prospectively enrolled in a single-center study of ICH. ICH volume was measured on the CT scan obtained upon presentation to the Emergency Department using an established computer-assisted method. We used linear regression to identify determinants of log-transformed ICH volume and logistic regression to evaluate their role in surgical evacuation.

Results

Median ICH volumes for all infratentorial, cerebellar, and brainstem ICH were nine [interquartile range (IQR), 3–23], ten (IQR, 3–25), and eight (IQR, 3–19) milliliters, respectively. Thirty-six patients were on warfarin treatment, 31 underwent surgical evacuation, and 65 died within 90 days. Warfarin was associated with an increase in ICH volume of 86 % [β = 0.86, standard error (SE) = 0.29, p = 0.003] and statin treatment with a decrease of 69 % (β = ?69, SE = 0.26, p = 0.008). Among cerebellar ICH subjects, those on warfarin were five times more likely to undergo surgical evacuation (OR = 4.80, 95 % confidence interval 1.63–14.16, p = 0.005).

Conclusions

Warfarin exposure increases ICH volume in infratentorial ICH. Further studies will be necessary to confirm the inverse relation observed between statins and ICH volume.     

An examination of the effects of intra and inter-individual changes in wellbeing and mental health on self-rated health in a population study of middle and older-aged adults

Purpose

Self-rated health is frequently used as an indicator of health and quality of life in epidemiological studies. While the association between self-rated health and negative mental health is well established, associations with indictors of positive wellbeing are less clear. Data from the Dynamic Analyses to Optimise Ageing (DYNOPTA) project were used to compare the effects of vitality and mental health on self-rated health.

Methods

Participants (n = 40,712) provided information on vitality, mental health and self-rated health, were aged 45–95 years at baseline, and were followed between 1 and 10 years (M = 5.6; SD = 2.9).

Results

In comparison with mental health, multi-level modelling indicated between- and within-person change in vitality was more strongly associated with self-rated health. Bivariate dual change score modelling of the cross-lagged associations between vitality and self-rated health indicated vitality to be a stronger predictor of change in self-rated health. Self-rated health was unrelated to change in vitality.

Conclusion

Vitality accounted for most of the mental health effect on self-rated health and was identified as a significant predictor of change in self-rated health over a 10-year period. Promoting wellbeing and psychological functioning may have significant protective effects on negative health outcomes throughout the adult lifespan and into late life.     

Levetiracetam Versus Phenytoin: A Comparison of Efficacy of Seizure Prophylaxis and Adverse Event Risk Following Acute or Subacute Subdural Hematoma Diagnosis

Background

Although both levetiracetam and phenytoin are used for seizure prophylaxis in subdural hematomas (SDHs), there is little data on their comparative efficacies. We compared the efficacy and risk of using levetiracetam versus phenytoin for seizure prophylaxis following acute or subacute SDH diagnosis.

Methods

In this retrospective cohort study, the clinical data registry at a tertiary care hospital was searched for all cases of acute or subacute SDHs that were admitted to hospital in 2002, 2003, or 2011. Risk of clinical and/or electrographic seizures, and risk of adverse drug events were compared between the two exposure arms.

Results

124 subjects in the phenytoin arm and 164 subjects in the levetiracetam arm were included. There was no significant difference in clinical and/or electrographic seizure risk, though there was a decreased risk of adverse events in the levetiracetam arm (p < 0.001). In subjects with midline shift >0 mm, levetiracetam was associated with an increased risk of electrographic seizures during hospitalization (p = 0.028) and a decreased risk of adverse drug effects (p = 0.001), compared with phenytoin use.

Conclusions

Levetiracetam generally appears to have a similar efficacy to phenytoin in preventing clinical and/or electrographic seizures following acute/subacute SDH diagnosis, though patients with midline shift >0 mm may have associated with a higher risk of electrographic seizures on levetiracetam compared with patients on phenytoin. Levetiracetam is associated with a lower risk of adverse drug effects. A prospective, randomized study would more definitively determine any difference in efficacy and risk between phenytoin and levetiracetam.     

Patterns of victimization,suicide attempt,and posttraumatic stress disorder in Greenlandic adolescents: a latent class analysis

Aim

The current study had two main aims. The first was to identify groups of adolescents based on their similarity of responding across a number of victimizing and potentially traumatic events (PTEs). In doing so, we employed the statistical technique of Latent Class Analysis (LCA). The second aim was to assess the relationship between our resultant classes and the covariates of gender, suicide attempt, and PTSD.

Methods

Two hundred and sixty-nine Greenlandic school students, aged 12–18 (M = 15.4, SD = 1.84) were assessed for their level of exposure to PTEs. In addition, adolescents were assessed for the psychological impact of these events. A LCA was performed on seven binary indicators representing PTEs. Logistic regression was subsequently implemented to ascertain the relationships between latent classes and covariates.

Results

Three distinct classes were uncovered: a violence, neglect, and bullying class (class 1), a wide-ranging multiple PTE class (class 2), and a normative/baseline class (class 3). Notably, classes 1 and 2 were largely separated by the presence or absence of sexual PTEs. Individuals who reported having previously attempted suicide were almost six times more likely to be members of class 1 (OR = 5.97) and almost four times more likely to be members of class 2 (OR = 3.87) compared to the baseline class (class 3). Individuals who met the diagnostic criteria for PTSD were five times as likely to be members of class 1 and class 2 (OR = 5.09) compared to the baseline class. No significant associations were found between classes and gender.

Conclusion

The results underline the complexity of the interplay between multiple victimization experiences, traumatization, and suicide attempts.     

Moderating factors for the effectiveness of group art therapy for schizophrenia: secondary analysis of data from the MATISSE randomised controlled trial

Purpose

Although some studies suggest that art therapy may be useful in the treatment of negative symptoms of schizophrenia, a recent large trial of group art therapy found no clinical advantage over standard care, but the study population was heterogeneous and uptake of the intervention was poor. This study aimed to investigate whether art therapy was more effective for specific subgroups of patients.

Methods

Secondary analysis of data from a randomised controlled trial of group art therapy as an adjunctive treatment for schizophrenia (n = 140) versus standard care alone (n = 137). Positive and Negative Syndrome Scale scores at 12 months were compared between trial arms. Interaction between intervention effect and different subgroups, including those with more severe negative symptoms of schizophrenia, and those who expressed a preference for art therapy prior to randomisation, was tested using a linear mixed model.

Results

The clinical effectiveness of group art therapy did not significantly differ between participants with more or less severe negative symptoms [interaction for difference in PANSS = 1.7, 95 % CI (?8.6 to 12.1), P = 0.741], or between those who did and did not express a preference for art therapy [interaction = 3.9, 95 % CI (?6.7 to 14.5), P = 0.473]. None of the other exploratory subgroups suggested differences in intervention effect.

Conclusions

There was no evidence of greater improvement in clinical symptoms of schizophrenia for those with more severe negative symptoms or those with a preference for art therapy. Identification of patients with schizophrenia who may benefit most from group art therapy remains elusive.     

Physical diseases among persons with obsessive compulsive symptoms and disorder: a general population study

Purpose

This study aimed at evaluating the comorbidity between DSM-IV obsessive compulsive disorder (OCD) and subthreshold forms and physical diseases in the general population as well as disability associated with comorbidity.

Methods

We used data from the 1998 German Mental Health Survey, a representative survey of the German population. Mental disorders and physical diseases of 4181 subjects (aged 18–65) were cross-sectionally assessed. Mental disorders were diagnosed using the M-CIDI/DIA-X interview. Physical diseases were assessed through a self-report questionnaire and a standardized medical interview. We created three groups of obsessive–compulsive symptoms: (1) no obsessive compulsive symptoms (n = 3,571); (2) obsessive compulsive symptoms (OCS, n = 371; endorsement of OCS (either obsession or compulsion) without fulfilling any core DSM-IV criteria); (3) subthreshold OCD/OCD (n = 239; fulfilling either some or all of the core DSM-IV criteria).

Results

In comparison to subjects without OCS, subjects with subthreshold OCD/OCD showed higher prevalence rates of migraine headaches (OR 1.7; 95 % CI 1.1–2.5) and respiratory diseases (OR 1.7; 95 % CI 1.03–2.7); subjects with OCS showed higher prevalence rates of allergies (OR 1.6; 95 % CI 1.1–2.8), migraine headaches (OR 1.9; 95 % CI 1.4–2.7) and thyroid disorders (OR 1.4; 95 % CI 1.01–2.0). Subjects with both OCS and physical disease reported the highest number of days of disability due to physical or psychological problems during the past 30 days compared to subjects with only OCS, only physical disease or neither of them.

Conclusions

OCD and subthreshold forms are associated with higher comorbidity rates with specific physical diseases and higher disability than subjects without OCS. Possible etiological pathways should be evaluated in future studies and clinicians in primary care should be aware of these associations.