Psychological trauma in patients with psychogenic nonepileptic seizures: trauma characteristics and those who develop PTSD

OBJECTIVES

The first objective of this study was to examine and describe the demographic, psychiatric, and trauma characteristics of our sample with PNESs as a whole. Subsequently, a comparison between traumatized and nontraumatized patients with PNESs was performed with regard to descriptive and trauma characteristics and general psychopathology symptoms. Lastly, we analyzed the predictive value in distinguishing patients with "likely" vs. "not likely" PTSD utilizing a model derived from our patients' psychometric test results.

METHODS

We collected and tallied demographic and psychiatric information and trauma characteristics on 61 patients with PNESs who had confirmed or denied having experienced trauma in their lifetime. We then studied this group with the Trauma Symptom Inventory-2 (TSI-2) and the Minnesota Multiphasic Personality Inventory-2RF (MMPI-2RF). Traumatized patients were subsequently classified as "PTSD likely" and "PTSD not likely" based on TSI-2 criteria and compared on demographic, psychiatric, and trauma characteristics and MMPI-2RF scores.

RESULTS

Our study revealed that 45 out of 61 (73.8%) patients reported experiencing at least one traumatic event in their lifetime. Approximately 40% reported physical or sexual abuse followed in percentage size by loss of a significant other, psychological abuse, witnessing the abuse of others, and medical trauma. Traumatized vs. nontraumatized and "PTSD likely" and "PTSD not likely" patients differed significantly on several clinical variables, as well as MMPI-2RF scores. Scores from TSI-2 produced a model that accurately predicted "no PTSD" in 21/26 (80.77%) subjects who denied a history of PTSD and "PTSD" in 5/6 subjects (83.33%) who endorsed a history of PTSD.

CONCLUSION

This study showed that overall exposure to psychological trauma is much more prevalent in patients with PNESs than in the general population with an inordinately high exposure to sexual and physical abuse as well as a variety of other types of abuse. Psychopathology was identified in the group with PNESs as a whole with discrete distinctions in clinical symptoms and characteristics of the traumatized as well as the "PTSD likely" subgroups. These findings contribute useful information in understanding intragroup differences in what is increasingly appearing to be a heterogeneous psychiatric condition composed of distinguishable subgroups.

Psychogenic non-epileptic seizures: predisposing factors to diminished quality of life

OBJECTIVE

The objective of this study was to examine the factors that contribute to the reports of diminished quality of life (QOL) in patients with psychogenic non-epileptic seizures (PNES).

METHODS

We assessed 62 patients with PNES for quality of life, anger expression and personality, and psychiatric, social and medical histories.

RESULTS

Diagnosis of depression, pain syndromes, older age of onset and shorter duration of PNES correlated with poorer quality of life. Elevated anger state, trait and total anger scores correlated with worse quality of life and with Quality of Life in Epilepsy 31 subscales of emotional well-being, medication, cognitive and social effects, seizure worry, and fatigue.

CONCLUSION

Our study verifies reported correlations between depression and somatic symptoms and quality of life. A novel finding is that of a relationship between quality of life in PNES and anger expression. This result has important implications for psychotherapeutic treatment of PNES in that it provides a potentially modifiable target.

Predictive value of Spanish neuropsychological testing for laterality in patients with epilepsy

In presurgical treatment planning for patients with epilepsy, neuropsychological testing assists in lateralization of the seizure focus. Previous research with English speakers has shown that patients with left hemisphere (LH) onsets versus right hemisphere (RH) onsets perform worse on naming and other verbal skills tests, but similar findings with Hispanic patients are limited. Thirty-nine Spanish-speaking patients were administered a comprehensive battery of neuropsychological tests in Spanish. LH-onset patients performed significantly worse than RH-onset patients on verbal comprehension (P=0.006), visual matching (P=0.047), the Ponton-Satz Boston Naming Test (P=0.001), and the dominant hand trial of the Grooved Pegboard Test (P=0.012). A stepwise regression model to predict seizure laterality from these tests was significant (F=12.10, P=0.001), but only the Ponton-Satz Boston Naming Test was retained. This comprehensive battery of neuropsychological tests in Spanish proved useful in predicting lateralization in patients with partial epilepsy.

Etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis: a systematic review and economic evaluation

BACKGROUND

Etanercept, infliximab and adalimumab are licensed in the UK for the treatment of active and progressive psoriatic arthritis (PsA) in adults who have an inadequate response to standard treatment.

OBJECTIVE

To determine the clinical effectiveness, safety and cost-effectiveness of these biologic agents in the treatment of active and progressive PsA.

DATA SOURCES

Systematic reviews were performed, with data sought from 10 electronic databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Science Citation Index, Conference Proceedings Citation Index - Science, ClinicalTrials.gov, metaRegister of Current Controlled Trials, NHS Economic Evaluation Database, Health Economic Evaluations Database and EconLit) up to June 2009.

REVIEW METHODS

Full paper manuscripts of titles/abstracts considered relevant were obtained and assessed for inclusion by two reviewers according to criteria on study design, interventions, participants and outcomes. Data on study and participant characteristics, efficacy outcomes, adverse effects, costs to the health service and cost-effectiveness were extracted, along with baseline data where reported. The primary efficacy outcomes were measures of anti-inflammatory response, skin lesion response and functional status, and the safety outcome was the incidence of serious adverse events. The primary measure of cost-effectiveness was incremental cost per additional quality-adjusted life-year (QALY). Standard meta-analytic techniques were applied to efficacy data. Published cost-effectiveness studies and the economic analyses submitted to the National Institute for Health and Clinical Excellence (NICE) by the biologic manufacturers were reviewed. An economic model was developed by updating the model produced by the York Assessment Group for the previous NICE appraisal of biologics in PsA.

RESULTS

Pooled estimates of effect demonstrated a significant improvement in patients with PsA for all joint disease and functional status outcomes at 12-14 weeks' follow-up. The biologic treatment significantly reduced joint symptoms for etanercept [relative risk (RR) 2.60, 95% confidence interval (CI) 1.96 to 3.45], infliximab (RR 3.44, 95% CI 2.53 to 4.69) and adalimumab (RR 2.24, 95% CI 1.74 to 2.88), with 24-week data demonstrating maintained treatment effects. Trial data demonstrated a significant effect of all three biologics on skin disease at 12 or 24 weeks. Evidence synthesis found that infliximab appeared to be most effective across all outcomes of joint and skin disease. The response in joint disease was greater with etanercept than with adalimumab, whereas the response in skin disease was greater with adalimumab than with etanercept, although these differences are not statistically significant. Under base-case assumptions, etanercept was the most likely cost-effective strategy for patients with PsA and mild-to-moderate psoriasis if the threshold for cost-effectiveness was £20,000 or £30,000 per QALY. All biologics had a similar probability of being cost-effective for patients with PsA and moderate-to-severe psoriasis at a threshold of £20,000 per QALY.

LIMITATIONS

Limited available efficacy data and difficulty in assessing PsA activity and its response to biologic therapy.

CONCLUSIONS

The data indicated that etanercept, infliximab and adalimumab were efficacious in the treatment of PsA compared with placebo, with beneficial effects on joint symptoms, functional status and skin. Short-term data suggested that these biologic agents can delay joint disease progression and evidence to support their use in the treatment of PsA is convincing. Future research would benefit from long-term observational studies with large sample sizes of patients with PsA to demonstrate that beneficial effects are maintained, along with further monitoring of the safety profiles of the biologic agents.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Continuous long-term immunomodulatory therapy in relapsing multiple sclerosis: results from the 15-year analysis of the US prospective open-label study of glatiramer acetate

The ongoing US Glatiramer Acetate (GA) Trial is the longest evaluation of continuous immunomodulatory therapy in relapsing-remitting multiple sclerosis (RRMS). The objective of this study was to evaluate up to 15 years of GA as a sole disease-modifying therapy. Two hundred and thirty-two patients received at least one GA dose since study initiation in 1991 (mITT cohort), and 100 (43%, Ongoing cohort) continued as of February 2008. Patients were evaluated every 6 months using the Expanded Disability Status Scale (EDSS). Mean GA exposures were 8.6 +/- 5.2, 4.81 +/- 3.69, and 13.6 +/- 1.3 years and mean disease durations were 17, 13, and 22 years for mITT, Withdrawn and Ongoing cohorts, respectively. For Ongoing patients, annual relapse rates (ARRs) maintained a decline from 1.12 +/- 0.82 at baseline to 0.25 +/- 0.34 per year; 57% had stable/improved EDSS scores (change < or = 0.5 points); 65% had not transitioned to secondary progressive multiple sclerosis (SPMS); 38%, 18%, and 3% reached EDSS 4, 6, and 8. For all patients on GA therapy (the mITT cohort), ARRs declined from 1.18 +/- 0.82 to 0.43 +/- 0.58 per year; 54% had stable/improved EDSS scores; 75% had not transitioned to SPMS; 39%, 23%, and 5% reached EDSS 4, 6, and 8. In conclusion, multiple sclerosis patients with mean disease duration of 22 years administering GA for up to 15 years had reduced relapse rates, and decreased disability progression and transition to SPMS. There were no long-term safety issues.

A profile of nurses working in acute medicine units: what is the future?

A survey of registered nurses working in two acute medicine acute medicine units (AMUs) was conducted between May & September 2009 to enable a focussed understanding of nursing recruitment and retention, to guide nurse managers for future workforce planning. The NHS collects national information regarding recruitment, retention and leavers, but this is sporadic and hampered by a lack of feedback to clinical areas. In this study, fifty completed questionnaires were collated, totalling a response rate of 57.5%. The results demonstrate that while recruitment is currently buoyant, nurses with significant experience are becoming dissatisfied through lack of opportunity to advance. It concludes that further national research is required to inform a strategy fit for the future development of nursing in acute medicine.

A systematic review of presumed consent systems for deceased organ donation

OBJECTIVES

To examine the impact of presumed consent legislation on organ donation and to review data on attitudes to presumed consent among the public, professionals and any other stakeholders.

DATA SOURCES

Eight electronic databases (MEDLINE, MEDLINE In-Process, EMBASE, CINAHL, PsycINFO, HMIC, PAIS International and OpenSIGLE) were searched from inception to January 2008. Supplementary internet searches were also performed.

REVIEW METHODS

A systematic review of studies comparing donation rates in a single country before and after the introduction of a presumed consent law or in countries with and without presumed consent systems. The methodological quality of these studies was assessed and a narrative synthesis of results undertaken. Surveys of attitudes towards presumed consent legislation were also included.

RESULTS

Over 2000 potentially relevant citations were identified, of which 13 studies met the inclusion criteria for the primary objective and 13 for the secondary objective. For the primary objective, eight studies were between-country comparisons and five were before-and-after studies. Four of the between-country comparisons were of sufficient methodological quality to provide reliable results. In all four studies presumed consent law or practice was associated with increased rates of organ donation, ranging from an increase of 2.7 donors per million population (pmp) in one study to 6.14 donors per million in another, and an increase of between 20% and 30% in two other studies. Factors other than presumed consent that had an impact on organ donation rates were mortality from road traffic accidents and cerebrovascular accident, the transplant capacity of a country, gross domestic product per capita and health expenditure per capita, religion, education, public access to information and a common law legal system. The five before-and-after studies represented three countries, all of which reported an increase in donation rates following the introduction of a presumed consent system (Austria, from 4.6 to 27.2 donors pmp over a 5-year period; Belgium, increase in kidney donation from 10.9 to 41.3 pmp during a 3-year period; Singapore, increase in kidney procurement from 4.7 to 31.3 per year in the 3 years after the change in legislation). There was very limited investigation of any other changes taking place concurrently with the changes in legislation across this set of studies. Of the 13 studies addressing the secondary objective, eight were surveys of the UK public, four were from other countries and one was an international survey of health professionals. There was variation among the UK surveys in the level of support for presumed consent, with surveys conducted before 2000 reporting the lowest levels of support (28-57%). The most recent survey by YouGov in 2007 reported that 64% of respondents supported a change to presumed consent.

CONCLUSIONS

Presumed consent alone is unlikely to explain the variation in organ donation rates between different countries. A combination of legislation, availability of donors, transplantation system organisation and infrastructure, wealth and investment in health care, as well as underlying public attitudes to and awareness of organ donation and transplantation, may all play a role, although the relative importance of each is not clear. Further reviews could investigate the factors likely to modify donor rates, such as procedures for family involvement. The way in which families of any potential donor are approached is likely to be an important factor and a review of qualitative research examining the experience of relatives in this context would be useful.

Molecular profiling of heparinase-I resistant glycosaminoglycans in contaminated heparins. Comparative studies with uncontaminated heparin and porcine oversulfated chondroitin sulfate

AIM

Heparin is a widely used anticoagulant which is usually obtained from porcine mucosal tissue. The structure of heparin is comparable to other naturally occurring glycosaminoglycans such as chondroitin sulfate and dermatan sulfate. The commercially available heparin preparations may contain small amounts of dermatan sulfate as a carry-over impurity. More recently (November 2007 to April 2008), an increased incidence of adverse events and deaths associated with the use of heparin alerted regulatory agencies to investigate the composition of heparin. As a result, oversulfated chondroitin sulfate was found to be the main determinant of the observed adverse reactions. This glycosaminoglycan is not usually found in the mammalian tissues.

METHODS

This investigation reports on the comparison of contaminant free and contaminated heparins and their digestion by heparinase-I. It also describes the molecular profile of the contaminant isolated from the recalled heparin preparations in comparison to oversulfated chondroitin sulfate. The anticoagulant and anti-Xa activities are also reported.

RESULTS

The contaminant is found to be comparable to the synthesized OSCS as both were resistant to heparinase-I digestion. The contaminant and OSCS exhibited weaker anticoagulant activities than heparin and did not have any anti-Xa effects.

CONCLUSION

This data strongly suggests that such glycosaminoglycans as chondroitin sulfate can be structurally modified to exhibit anticoagulant activities and their molecular weight can be adjusted to mimic heparin.