London bombings July 2005: the immediate pre-hospital medical response

On July 7th 2005 a series of terrorist bombs exploded in London. The transport system was targeted and at least 54 passengers were killed and around 700 injured. This paper describes the immediate pre-hospital medical response to the four scenes. From the perspective of the London Helicopter Emergency Medical Service the deployment, difficulties on scene and the initial lessons learned are discussed.     

Number and Type of Post-Traumatic Stress Disorder Symptom Domains Are Associated With Patient-Reported Outcomes in Patients With Chronic Pain

Post-traumatic stress disorder (PTSD) commonly accompanies complex chronic pain, yet PTSD is often overlooked in chronic pain management. Using the 4-item Primary Care (PC)-PTSD screening tool, we evaluated the relationship between the number and type of PC-PTSD symptoms endorsed and a set of patient-reported outcomes, including: pain intensity and interference, function, mood, quality of life, and substance abuse risk in a consecutive sample of patients with chronic pain (n?=?4,402). Patients completed PainTracker, a Web-based patient-reported outcome tool that provides a multidimensional evaluation of chronic pain, as part of their intake evaluation at a specialty pain clinic in a community setting. Twenty-seven percent of the sample met PC-PTSD screening criteria for PTSD by endorsing 3 of the 4 symptom domains. Significant ordinal trends were observed between increasing number of PTSD symptoms and all outcomes evaluated. The occurrence of even 1 PTSD symptom was associated with overall poorer outcomes, suggesting that subsyndromal PTSD is clinically significant in the context of chronic pain. Among the 4 PTSD domains assessed, “numbness/detachment” was most strongly associated with negative pain outcomes in relative weight analysis. Results from this cross-sectional study suggest that a range of pain-related outcomes may be significantly related to comorbid PTSD.

Pain symptomatology and pain medication use in civilian PTSD

The comorbidity of pain syndromes and trauma-related syndromes has been shown to be high. However, there have been limited data, especially in civilian medical populations, on the role of trauma-related disorders such as posttraumatic stress disorder (PTSD) on chronic pain and pain medication use. We analyzed 647 general hospital patients in primary care and obstetrics and gynecological waiting rooms for the experience of trauma and PTSD-related stress disorders. PTSD symptoms were found to be significantly positively correlated with pain ratings (r = .282, P < 0.001) and pain-related functional impairment (r = 0.303, P < 0.001). Those with a current PTSD diagnosis had significantly higher subjective pain and pain-related impairment ratings than those with no PTSD. Furthermore, those with a current diagnosis of PTSD were significantly more likely to have used opioid analgesics for pain control compared to those without a diagnosis of PTSD (χ² = 8.98, P = 0.011). When analyzing the separate PTSD symptom subclusters (re-experiencing, avoidance, and hyperarousal), all symptom clusters were significantly related to pain and pain-related impairment ratings, but only the avoidance cluster was significantly related to prior opioid pain medication use. We conclude that PTSD and trauma-related disorders are common in impoverished medical populations and that their presence should be examined in patients with pain syndromes. Furthermore, these data suggest that PTSD and pain may share a vulnerability pathway, including the endogenous opioid neurotransmission systems.     

汶川地震极重灾区780名受灾群众心理状况调查

目的了解汶川地震受灾群众的受灾情况及心理状况，为进一步开展心理干预提供依据。方法采用横断面调查方法，对成都市2个临时居住点极重灾区受灾群众登记人口学背景、受灾情况及PTSD（Post—traumatic stress disorder）检查量表平民版（PCL—C）评估，依据DSM-Ⅳ的诊断标准，进行急性应激障碍（ASD）临床检查。结果780名受灾群众完成登记评估。在完成登记的资料中729份有效，其中450份PCL—C有效；男女比例为1：1.31。平均年龄36．73±20．82岁；9．5％患有躯体疾病，9．7％生活需人协助，70．7％被动和没有参加社区活动，9．1％严重心理问题。ASD的发生率为30．9％（139／450），PCL—C≥38分有186（41．3％）例，PCL—C≥45分有100（22．2％）例，PCL—C≥50分者有83（18．4％）例，PCL—C≥45分筛查结果与临床诊断结果一致性检验较好（Kappa=0．780，P=0．033）。ASD组和非ASD组性别构成比差异无统计学意义（P〉0．05），ASD组与非ASD组年龄差异有统计学意义（P〈0．05）。结论来自地震极重灾区的受灾群众较早出现了心理问题。在生命救助的同时，应该尽早关注他们的心理问题。     

Unravelling the Relationship Between Parent and Child PTSD and Pediatric Chronic Pain: the Mediating Role of Pain Catastrophizing

Clinically elevated rates of post-traumatic stress disorder (PTSD) symptoms are found among many youth with chronic pain and their parents and are linked to worse child pain outcomes. Conceptual models of mutual maintenance in pediatric PTSD and chronic pain posit that child and parent pain catastrophizing are key mechanisms underlying this co-occurrence. To our knowledge, the current study is the first to examine child and parent pain catastrophizing as potential mediators in the child PTSD-child pain and parent PTSD-child pain relationships among a cohort of youth with chronic pain. One hundred two children (72.5% female, mean age=13.5 years), recruited from a tertiary level chronic pain program, and 1 of their parents participated. At intake, parents completed psychometrically sound self-report measures of PTSD symptoms and catastrophizing about child pain. Children completed self-report measures of PTSD symptoms, pain catastrophizing, pain interference, and pain intensity. Findings revealed that relationships between child PTSD and child pain as well as parent PTSD and child pain were mediated by child (but not parent) pain catastrophizing. This suggests that children's catastrophic thinking about pain may explain how child and parent PTSD symptoms influence children's experience of chronic pain and is a potential target in family-based interventions to improve pain and mental health outcomes.

Blood and bombs: the demand and use of blood following the London Bombings of 7 July 2005--a retrospective review

Mass casualty events (MCE) present health systems with a sudden demand on key services. The overall objective of this study was to describe the experience of the National Blood Service (NBS) following the largest UK MCE in recent times. Data was collated from the NBS database and directly from the hospitals involved. All data was collected immediately following the event and included: all blood components requested, issued and transfused in relation to the bombings, blood stock levels at the time and the injury profiles of the casualties transfused. The total NBS order from hospitals for the event was 1455 units of blood components. All requests were fulfilled, this included: 978 units of red cells (RC), 36 doses of platelets, 141 units of fresh frozen plasma (FFP) and 300 doses of cryoprecipitate. The amount of blood ordered was three times that initially used and the total number of RC transfused in treating all victims from admission to discharge was approximately 440 units. The greatest use of blood components was for those casualties who had sustained traumatic amputations amongst their injury profile. Published data with which to compare these results is lacking, although the RC use was similar to the initial mean individual usage described in previous military and civilian bombings. The overall implication for any blood service remains, there is now likely to be a far greater demand for plasma, platelets and cryoprecipitate in any future incidents involving victims suffering major haemorrhage.     

Sensitivity and specificity of a screening test to document traumatic experiences and to diagnose post-traumatic stress disorder in ARDS patients after intensive care treatment

Objective: Many survivors of critical illness and intensive care unit (ICU) treatment have traumatic memories such as nightmares, panic or pain which can be associated with the development of post-traumatic stress disorder (PTSD). In order to simplify the rapid and early detection of PTSD in such patients, we modified an existing questionnaire for diagnosis of PTSD and validated the instrument in a cohort of ARDS patients after long-term ICU therapy. Design: Follow-up cohort study. Setting: The 20-bed ICU of a university teaching hospital. Patients: A cohort of 52 long-term survivors of the acute respiratory distress syndrome (ARDS). Interventions and measurements: The questionnaire was administered to the study cohort at two time points 2 years apart. At the second evaluation, the patients underwent a structured interview with two trained psychiatrists to diagnose PTSD according to Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria. The reliability and validity of the questionnaire was then estimated and its specificity, sensitivity and optimal decision threshold determined using receiver operating characteristic (ROC) curve analyses. Results: The questionnaire showed a high internal consistency (Crohnbach's α = 0.93) and a high test-retest reliability (intraclass correlation coefficient α = 0.89). There was evidence of construct validity by a linear relationship between scores and the number of traumatic memories from the ICU the patients described (Spearman's ϱ = 0.48, p < 0.01). Criterion validity was demonstrated by ROC curve analyses resulting in a sensitivity of 77.0 % and a specificity of 97.5 % for the diagnosis of PTSD. Conclusions: The questionnaire was found to be a responsive, valid and reliable instrument to screen survivors of intensive care for PTSD. Received: 23 November 1998 Final revision received: 18 March 1999 Accepted: 3 May 1999     

Emotional numbing and pain intensity predict the development of pain disability up to one year after lateral thoracotomy

Little is known about the factors that predict the transition of acute, time limited pain to chronic pathological pain following postero-lateral thoracotomy. The aim of the present prospective, longitudinal study was to determine the extent to which (1) pre-operative pain intensity, pain disability, and post-traumatic stress symptoms (PTSS) predict post-thoracotomy pain disability 6 and 12 months later; and (2) if these variables, assessed at 6 months, predict 12 month pain disability. Fifty-four patients scheduled to undergo postero-lateral thoracotomy for intrathoracic malignancies were recruited before surgery and followed prospectively for one year. The incidence of chronic post-thoracotomy pain was 68.1% and 61.1% at the 6 and 12 month follow-ups, respectively. Multiple regression analyses showed that neither pre-operative factors nor acute movement-evoked post-operative pain predicted 6 or 12 month pain disability. However, concurrent pain intensity and emotional numbing, but not avoidance symptoms, made unique, significant contributions to the explanation of pain disability at each follow-up (total R² = 76.3.0% and 63.9% at 6 and 12 months, respectively, both p < 0.0009). The relative contribution of pain intensity decreased, while that of emotional numbing increased with time, indicating a progressive de-coupling of pain intensity and disability and a concomitant strengthening of the link between emotional numbing and disability. This suggests that pain may serve as a traumatic stressor which causes increased emotional numbing. The results also support recent suggestions that avoidance and emotional numbing constitute separate PTSS clusters. Further research is required to determine the source(s) of emotional numbing after postero-lateral thoracotomy and effective interventions.     

Pain and the onset of depressive and anxiety disorders

Patients with pain may be at increased risk of developing a first episode of depressive or anxiety disorder. Insight into possible associations between specific pain characteristics and such a development could help clinicians to improve prevention and treatment strategies. The objectives of this study were to examine the impact of pain symptomatology on depression and anxiety onset and to determine whether these associations are independent of subthreshold depressive and anxiety symptoms. Data from the Netherlands Study of Depression and Anxiety, collected between 2004 and 2011, were used. A total of 614 participants with no previous history and no current depression or anxiety at baseline were followed up for 4 years. Onset of depressive or anxiety disorder was assessed at 2- and 4-year follow-up by Composite International Diagnostic Interview. Baseline pain characteristics were location, duration, and severity, as assessed by chronic pain grade. Onset of depressive or anxiety disorder occurred in 15.5% of participants. Using Cox survival analyses, onset of depression and anxiety was associated with 6 pain locations (neck, back, head, orofacial area, abdomen, and joints; hazard ratio [HR] = 1.96 to 4.02; P < .05), increasing number of pain locations (HR = 1.29; P < .001), and higher severity of pain (HR = 1.57; P < .001). By contrast, there was no association with duration of pain symptoms (HR = 1.47; P = .12). Independent of subthreshold affective symptoms, only joint pain and increasing number of pain locations were still significantly associated with depression and anxiety onset. Clinicians should be aware that regardless of affective symptoms, pain, particularly at multiple locations, is a risk indicator for developing depressive and anxiety disorders.     

Developing a framework for implementing intensive care unit diaries: a focused review of the literature

ObjectiveIntensive care unit diaries have been shown to improve post-critical illness recovery, however, prior reports of diary implementation are heterogeneous. We sought to construct a common framework for designing and implementing Intensive Care Unit diaries based on prior studies.Review method used/data sourcesWe conducted a focused review of the literature regarding intensive care diaries based on a systematic search of several databases. Two reviewers assessed 56 studies and data were abstracted from a total of 25 eligible studies conducted between 1990 and 2014. We identified key information regarding the development, design, and implementation of the journals. We then grouped elements that appeared consistently across these studies within three main categories: (1) diary target populations; (2) diary format and content; and (3) the manner of diary return and follow-up.ResultsMost studies were conducted in European countries in adult intensive care units and targeted patients in both medical and surgical units. The timing of diary initiation was based on the elapsed length of stay or duration of mechanical ventilation. We categorised diary format and content as: entry content, authors, use of standardised headings, type of language, initiation, frequency of entries, and physical location of diaries. Diaries were hand written and many studies found that photographs were an essential element in ICU diaries. We categorised the manner of diary return and follow-up. The context in which intensive care unit diaries were returned were felt to be important factors in improving the use of diaries in recovery.ConclusionsIn conclusion, we describe a common framework for the future development of intensive care unit diaries that revolves around the target population for the diaries, their format and content, and the timing of their use. Future studies should address how these elements impact the mechanisms by which intensive are diaries exert beneficial effects.     

Prevalence of post-traumatic stress disorder after earthquakes among the elderly in China: A meta-analysis

BACKGROUND: The study aims to investigate the occurrence of post-traumatic stress disorder (PTSD) after earthquakes among the elderly.     

Neuropsychological function in children following admission to paediatric intensive care: a pilot investigation

OBJECTIVE: Little is known about neuropsychological status following acute severe paediatric illness. This pilot study explored the effects on memory function of severe acute paediatric illness and associations between memory functioning and psychiatric sequelae. DESIGN AND SETTING: Case control study of children after paediatric intensive care unit (PICU) discharge and healthy volunteers. PATIENTS AND PARTICIPANTS: 16 PICU discharged children comprised of 11 boys and 5 girls (mean age 9.44 +/- 2.85 years) tested a mean of 4.8 +/- 1.4 months following hospital discharge, and 16 age- and sex-matched controls. MEASUREMENTS AND RESULTS: Visual-spatial memory and attention were assessed using the CANTAB battery (visual memory) and verbal memory with the Children Memory Scale; Intelligence Quotient was tested using the Wechsler Abbreviated Scale of Intelligence. Emotional and behavioural function was measured with the Strengths and Difficulties Questionnaire and Impact of Event Scales. Children admitted to PICU displayed statistically poorer performance on tests of spatial memory (spatial working memory) sustained attention (rapid visual information) and verbal memory (word pairs learning and delayed recognition). Septic illness was specifically associated with poorer pattern recognition memory on the CANTAB. There were significant correlations in the PICU group between cognitive functioning and emotional/behaviour scores. CONCLUSIONS: Our results suggest impaired memory and attention in children following acute severe paediatric illness, a specific deficit in children with septic illness and links between memory anomalies and emotional/behavioural problems. The findings and their clinical significance require replication and clarification in a larger sample.     

舟曲特大山洪泥石流灾后住院幸存者心理健康与应激障碍调查研究

目的评估舟曲泥石流灾害中灾区住院幸存者的心理状况,为当地针对性开展灾害心理干预提供依据。方法采用心理健康自评问卷、焦虑自评量表(SAS)、抑郁自评量表(SDS)和PTSD-SS量表对67名住院幸存者和同期病情相似的非灾区住院患者47名进行调查。结果灾后住院幸存者出现不同程度的心理健康问题和不同程度的创伤后心理应激障碍症状,与对照组比较差异有统计学意义(P<0.01、P<0.01)。灾后住院幸存者SAS平均得分48.44±15.648分,SDS平均得分52.92±11.672分,均明显高于对照组(P<0.01、P<0.05)。结论泥石流灾害给灾区民众带来了不同程度的心理伤害和创伤。因此,在救治幸存者生理疾病的同时,对灾后住院幸存者针对性开展和加强灾后心理救援的心理干预和调控,以缓解和降低其心理问题极其必要。     

强化镇痛对急性创伤患者创伤后应激障碍发病的影响

目的:探讨强化镇痛对急性创伤患者创伤后应激障碍（post-traumatic stress disorder,PTSD）发病的影响,为PTSD的防治拓展思路。方法:采用前瞻性观察性研究方法,以2018年1月至2019年11月就诊于徐州医科大学附属医院急救中心且符合纳入排除标准的创伤患者为研究对象。根据伤后30 d内平均...     

Prevalence and risk factors for post-traumatic stress disorder in relatives of out-of-hospital cardiac arrest patients

Aim

Prognostic uncertainty and surrogate decision-making demands associated with prolonged unconsciousness in out-of hospital cardiac arrest (OHCA) patients in the intensive care unit (ICU) may increase post-traumatic stress disorder (PTSD) risk in their relatives. Our aim was to study PTSD frequency and risk factors in relatives of OHCA patients.

Methods

In this observational study 101 consecutive eligible adult relatives of OHCA patients were interviewed using validated questionnaires, the “Impact of Event Scale-Revised” to detect PTSD and the “Family-Satisfaction with Care in the ICU” to assess potential PTSD risk factors.

Results

PTSD was detected in 40/101 relatives (40%). Multivariate logistic regression identified three significant PTSD predictors [odds ratio, 95% confidence interval]: female gender [3.30, 1.08–10.11], history of depression [3.63, 1.02–12.96], family perception of the patient's therapy as insufficient [18.40, 1.52–224.22]. Three other predictors were not significantly associated with PTSD (hypothermia treatment of the patient [2.86, 0.96–8.48]), delayed delivery of prognostic information by ICU staff [2.11, 0.83–5.38], family-ICU staff conflict [3.61, 0.71–18.40]). A prediction rule including six factors (p < 0.15 each) showed high discrimination (area under the receiver-operating characteristic curve 0.74) with a stepwise increase in risk for PTSD from 0% (no risk factor) to 63% (≥3 risk factors). There was no evidence for effect modification either by survival status or neurological outcome.

Conclusion

Relatives of OHCA patients treated in the ICU are at increased risk of PTSD, which can be predicted based on six factors, three ICU-related and potentially at least partly modifiable. Further research is needed to validate our findings and to develop strategies to prevent PTSD in OHCA patients’ relatives.     

Validation of the Pain Sensitivity Questionnaire in chronic pain patients

Recently, a self-rating measure for pain perception based on imagined painful daily life situations, the Pain Sensitivity Questionnaire (PSQ), has been developed and shown to correlate with experimentally obtained pain intensity ratings in healthy subjects. Here, we assessed the validity of the PSQ for investigation of general pain perception (ie, pain perception outside the site of clinical pain) in chronic pain patients. PSQ scores were obtained in 134 chronic pain patients and compared to those of 185 healthy control subjects. In a subgroup of 46 chronic pain patients, we performed experimental pain testing outside the clinical pain site, including different modalities (heat, cold, pressure, and pinprick) and different measures (pain thresholds, pain intensity ratings). Results show that PSQ scores were significantly correlated with both experimental pain intensity ratings (Pearson's r=0.71, P<.001) and experimental pain thresholds (r=-0.52, P<.001). In addition, chronic pain patients exhibited significantly elevated PSQ scores as compared to healthy controls, consistent with the generalized increase of experimentally determined pain perception that has repeatedly been reported in chronic pain patients. These results demonstrate that the PSQ constitutes a valid self-rating measure of pain perception outside the clinical pain site in chronic pain patients and might serve as an alternative to experimental assessment of pain perception outside the clinical pain site in situations where experimental pain testing is not feasible.     

叙事护理对首次确诊妇科恶性肿瘤患者创伤后应激障碍的影响研究

目的 探讨叙事护理对首次确诊妇科恶性肿瘤患者创伤后应激障碍(Post-traumatic stress disorder, PTSD)的应用效果。方法 采用便利抽样法,选取2021年10月—2023年3月在南京市某三级甲等医院住院的88例首次确诊妇科恶性肿瘤患者作为研究对象,按照随机数字表法将研究对象划为研究组和对照组各44例。干预时间为确诊后3个月每次住院期间,共干预4次。研究组每次住院期间在常规妇科专科护理工作的基础上开展叙事护理,对照组实施常规妇科专科护理工作。比较两组患者创伤后应激障碍平民版量表(PCL?C)得分、心理弹性量表(CD?RISC)得分和疾病接受度量表得分。结果 干预前研究组和对照组PTSD发生率为11.36%和18.18%,差异无统计学意义(P>0.05)。干预后研究组患者的创伤后应激障碍评分低于对照组,研究组患者的心理弹性得分、疾病接受度得分高于对照组,差异均具有统计学意义(P<0.05)。结论 实施叙事护理能有效改善首次确诊妇科恶性肿瘤患者的PTSD水平,提高患者的心理弹性和疾病接受度,降低PTSD的发生率。     

Validating the Psychometric Characteristics of the Perinatal Posttraumatic Stress Disorder Questionnaire (PPQ) in a Chinese Context

Background

Perinatal posttraumatic stress disorder (PPTSD) is a common stress-induced mental disorder worldwide. The Perinatal Posttraumatic Stress Disorder Questionnaire (PPQ) is an excellent questionnaire that measures the symptoms of PPTSD, but has not been translated into Chinese yet.