Post-traumatic stress disorder-related symptoms after intensive care

AIM

To determine the incidence of Post Traumatic Stress Disorder (PTSD) related symptoms in a population of intensive care unit (ICU) admitted patients and the relationship between PTSD-related symptoms and memories of ICU.

METHODS

Adults consecutively admitted to an ICU of a University hospital during 1 year, who stayed in the ICU at least 3 days, were prospectively studied. A questionnaire (ICU memory tool) was administered to 84 patients 1 week after ICU discharge and to 63 of them after 3 months. Past medical history and clinical variables present during ICU stay were collected.

RESULTS

At the 1st interview, 5 patients (5.9%) did not remember to have been in ICU. Of the remaining 79 patients (males 59.5%, median age 69 years, SAPS II 34, APACHE II 14 and ICU stay 5 days), 4 reported intrusive memories and none panic attacks. The Impact of Events Scale (IES), available in 3 of them, scored in medium/high levels. Only the median number of factual memories reported by the patients with and without intrusive memories was significantly different (4 interquartile range 2-5 vs 8 interquartile range 6-10; p=0.002). The patients with intrusive memories at the 1st interview did not report them at the 2nd interview. Two patients not having panic or intrusive memories at the 1st interview reported PTSD-related symptoms after 3 months.

CONCLUSIONS

In a general ICU population, few patients (5%) have PTSD-related symptoms and those who present those symptoms report less factual memories of ICU stay.

Validation of severity scoring systems SAPS II and APACHE II in a single-center population

OBJECTIVE

To validate two severity scoring systems, the Simplified Acute Physiology Score (SAPS II) and Acute Physiology and Chronic Health Evaluation (APACHE II), in a single-center ICU population.

DESIGN AND SETTING

Prospective data collection in a two four-bed multidisciplinary ICUs of a teaching hospital.

PATIENTS AND METHODS

Data were collected in ICU over 4 years on 1,721 consecutively admitted patients (aged 18 years or older, no transferrals, ICU stay at least 24 h) regarding SAPS II, APACHE II, predicted hospital mortality, and survival upon hospital discharge.

RESULTS

At the predicted risk of 0.5, sensitivity was 39.4 % for SAPS II and 31.6 % for APACHE II, specificity 95.6 % and 97.2 %, and correct classification rate 85.6 % and 85.5 %, respectively. The area under the ROC curve was higher than 0.8 for both models. The goodness-of-fit statistic showed no significant difference between observed and predicted hospital mortality (H = 7.62 for SAPS II, H = 3.87 for APACHE II; and C = 9.32 and C = 5.05, respectively). Observed hospital mortality of patients with risk of death higher than 60 % was overpredicted by SAPS II and underpredicted by APACHE II. The observed hospital mortality was significantly higher than that predicted by the models in medical patients and in those admitted from the ward.

CONCLUSIONS

This study validates both SAPS II and APACHE II scores in an ICU population comprised mainly of surgical patients. The type of ICU admission and the location in the hospital before ICU admission influence the predictive ability of the models.

Relationship between physical activity level and bone mineral density in two groups of female athletes

In order to evaluate the possible relationships among hormonal status, physical activity and bone density, we carried out a study on two groups of female athletes engaged in different levels of physical activity. We measured the following hormones: luteinizing hormone (LH), folliculo-stimulating hormone (FSH), 17-beta-oestradiol (E2), progesterone (PRG), prolactin (HPRL), estrone (E1), thyreo-stimulating hormone (TSH), free thyroxine (FT4), and the markers of phosphate-calcium metabolism: calcitonine (CT), parathormone (PTH), and osteocalcine (BGP). We also measured bone mineral density (BMD). All of these variables were related to the amount of work performed during training. The groups were defined as follows: medium workload (group M, n = 10) and heavy workload (group H, n = 20), engaged in 10 and 18 hours of weekly training at 35 and 60 average percent of VO2max, respectively. All of the hormones and the markers of calcium-phosphate metabolism studied were normal; BMD was also normal for all subjects except for two sisters in group M with reduced BMD. The group H athletes with regular menstrual cycles were found to have an upper limit normal BMD. From these data we conclude that in regularly menstruating athletes an increase in BMD induced by heavy physical activity is evident, while in dysmenorrhoeic athletes the effect of physical activity compensates, to some extent, for the hypothetical bone mineral reduction possibly caused by the hormonal imbalance.

[Normal ranges of bone mineral content of the distal radius determined with single photon absorptiometry. Study of 1521 cases]

The normal ranges and mathematical equations of bone mineral content (BMC), normalized to radial width (BMC/W) vs. age at the distal radius, were obtained by single photon absorptiometry (SPA), and compared in two different normal populations, one of postmenopausal females and the other of control males. The female population included 1359 postmenopausal women, aged 35 to 75 years; normal control males were 162, of the same age. The results obtained in the two groups of patients show a statistically significant (p less than 0.001) correlation between age and BMC/W, expressed in a polinomial third-degree regression. The slope of the regression curves is quite different between males and females: the mean decrement, evaluated from regression polinomial fits, results 0.5% per year for normal females, and 0.3% per year for normal males. The maximum decrement (1% per year) is observed at the mean age of 51 years, which is the average age of peri-menopausal women in our province (Ferrara). The authors believe SPA to be a simple and reliable technique in measuring peripheral bone loss rate. SPA may be useful in the diagnosis and treatment of postmenopausal women, but is not recommended in the short-term follow-up of osteoporosis.

Plasma levels of atrial natriuretic peptide are increased in normotensive postmenopausal women as a function of age

The aim of this study was to assess the changes in atrial natriuretic peptide (ANP) levels before and after menopause and to test whether they depend on age or are an integral part of the hormonal changes in menopause. We measured plasma ANP, plasma renin activity (PRA), plasma aldosterone, serum estradiol-17 beta and progesterone concentrations in 103 normotensive women, either in premenopause (n = 35; mean age: 24 years), in physiological menopause (n = 34; mean age: 43 years) or surgically induced menopause (n = 34; mean age: 55 years). The last two groups were matched for duration of menopause and were comparable in their estrogen and progesterone status. PRA and plasma aldosterone concentrations decreased in postmenopausal women, whereas systolic blood pressure and ANP increased. These results were not confirmed after adjustment for age by covariance analysis. In all of the groups, plasma ANP concentrations were not significantly correlated with systolic or diastolic blood pressure, nor with plasma aldosterone, estrogen and progesterone concentrations. These correlations were not improved by correction for age. Plasma ANP concentrations were consistently correlated with age. These data suggest that the increase in plasma ANP levels found in postmenopausal women is related with age and that ANP does not play a direct role in the physiological hormonal changes of menopause.

[Quantitative analysis of bone density in multiple myeloma]

Bone lesions are the main sign of neoplastic proliferation of multiple myeloma (MM), a disseminated malignant disease which originates in, invades and replaces normal bone marrow. The most characteristic radiographic pattern is a focal lytic lesion, well-defined or "punched-out", generally with no surrounding bone reaction. The association is confirmed between MM and osteoporosis, as reduced bone density (osteopenia) and pathologic fractures (ribs, spine). This paper is aimed at evaluating the importance of osteopenia in both diagnosis and prognosis of MM. Eighteen patients affected with MM were examined with quantitative computed tomography (QCT) and dual-energy X-ray absorptiometry (DEXA) for bone densitometry in lumbar spine and proximal femur. The patients (12 males and 6 females) were classified according to Durie's clinical criteria and to the radiographic patterns suggested by Merlini. The results indicate the patients with an advanced clinical stage (III) and scintigraphic expansion of bone marrow to have low densitometric values on both QCT and DEXA. There was substantial agreement between the 2 methods, but DEXA had a higher number of false positives. Instrumental diagnostic protocol may be thus planned as follows: 1) conventional radiography; 2) bone marrow scintigraphy; 3) bone densitometry of lumbar spine, with QCT. The patient is then to be followed with conventional and/or digital radiography in symptomatic locations, and with bone scintigraphy.