Predictors of mortality in the elderly patient with a fracture of the odontoid process

Aims

Fracture of the odontoid process (OP) in the elderly is associated with mortality rates similar to those of hip fracture. The aim of this study was to identify variables that predict mortality in patients with a fracture of the OP, and to assess whether established hip fracture scoring systems such as the Nottingham Hip Fracture Score (NHFS) or Sernbo Score might also be used as predictors of mortality in these patients.

Patients and Methods

We conducted a retrospective review of patients aged 65 and over with an acute fracture of the OP from two hospitals. Data collected included demographics, medical history, residence, mobility status, admission blood tests, abbreviated mental test score, presence of other injuries, and head injury. All patients were treated in a semi-rigid cervical orthosis. Univariate and multivariate analysis were undertaken to identify predictors of mortality at 30 days and one year. A total of 82 patients were identified. There were 32 men and 50 women with a mean age of 83.7 years (67 to 100).

Results

Overall mortality was 14.6% at 30 days and 34.1% at one year. Univariate analysis revealed head injury and the NHFS to be significant predictors of mortality at 30 days and one year. Multivariate analysis showed that head injury is an independent predictor of mortality at 30 days and at one year. The NHFS was an independent predictor of mortality at one year. The presence of other spinal injuries was an independent predictor at 30 days. Following survival analysis, an NHFS score greater than 5 stratified patients into a significantly higher risk group at both 30 days and one year.

Conclusion

The NHFS may be used to identify high-risk patients with a fracture of the OP. Head injury increases the risk of mortality in patients with a fracture of the OP. This may help to guide multidisciplinary management and to inform patients. This paper provides evidence to suggest that frailty rather than age alone may be important as a predictor of mortality in elderly patients with a fracture of the odontoid process. Cite this article: Bone Joint J 2019;101-B:253–259.

Psychological disorders in survivors of torture: exhaustion, impairment and depression

Post-traumatic stress disorder (PTSD) has been described as the characteristic sequel to extreme events in life such as war and especially torture. This limitation to a single approach in regard to diagnosis and treatment has been criticised as being a too narrow concept to describe the effects following extreme events in life, especially as most studies so far were limited to PTSD and a small range of symptoms or disorders. The study presents data on psychiatric disorders in a group of exiled survivors of torture presenting to an out-patient department for psychiatry. A DSM-III-R-based psychiatric interview, including the general assessment of functioning scale (GAF), an open list of symptoms and the Vienna diagnostic criteria in regard to depression were used to evaluate a broader range of possible sequels. The most frequent present diagnosis in 44 patients seen over a period of 3 years was PTSD (n = 40), but criteria for a present diagnosis of other disorders were fulfilled in 34 patients, even years after torture, mainly major depression or dysthymia (n = 26). Criteria for functional psychosis were fulfilled in 4 patients. Many patients reported symptoms not assessed by DSM-III-R criteria, including feelings of shame and guilt, and ruminations on existential fears. The impairment as indicated by the GAF (mean 59.1) correlated best with the presence of the endogenomorphic-depressive axial syndrome, but not with duration of imprisonment, age or other factors. Research on sequels to extreme trauma should not be restricted to a simple diagnosis of PTSD, but should continue to look for a broader conceptualisation, including neglected categories like the axial syndrome, as PTSD is common, but might not be the only factor of importance for research and treatment. ICD-10 might offer a more adequate interpretation of sequels.

Capgras syndrome and functional psychosis in 2 survivors of torture

Functional psychosis has only rarely been described in context with extreme stressors, most studies focusing singularly on posttraumatic stress disorder symptoms. We report for the first time the case histories of 2 patients suffering from Capgras syndrome along with schizoaffective disorder and posttraumatic stress disorder after prior experience of prolonged torture. Interaction of personal life experience and psychiatric disorder are proposed as factors resulting in persistent changes in perception and affect.

Predicting course and outcome in delusional psychoses

Eighty-four of 90 patients with delusional syndromes of different nosological attribution underwent a 7-year follow-up. From 179 items covering the whole spectrum of psychiatric description of index examination, 20 were found to be statistically significant in predicting different aspects of course and outcome by stepwise discriminant analysis. Course and outcome were defined by 6 criteria (course of illness, course of delusion, development of deficiency, length of inpatient care, adequate activity and social adjustment) encompassing separate (but only partly independent) aspects of a disorder. In contrast to the literature, clinical and psychopathological variables have major prognostic weight for different psychopathological as well as psychosocial aspects of outcome. Ten of the 20 significant items cover psychopathology, 4 pre-index course, 3 precipating events, 2 data from childhood, and 1 premorbid personality. Our results stress the importance of sensitive data collection and a clear separation of different outcome variables.

Prognosis of cardiac phobia

The 36 inpatients who entered this prospective study were admitted to hospital because of cardiac phobia. Their treatment consisted of a behavior therapy program. Twenty-nine of them could be reexamined after 2 1/2 years: 41% were free of symptoms during more than 75% of the follow-up period; 59% suffered recurrences of their anxiety. One patient had committed suicide. A lower educational level, being single, and interpersonal difficulties and conflicts were the sociodemographic factors associated with a poor prognosis; a long pretreatment period of illness and the presence of depression or agoraphobia on admission were significantly more frequently correlated with an unfavorable outcome. The onset sequence of depression, agoraphobia and anxiety attacks was also of prognostic relevance.

Dysphoric states in the course of manic-depressive illness

The purpose of the present study is to investigate the relationship between dysphoric states (episodes in which irritable mood is prominent and relatively persistent) and manic-depressive illness. A further purpose is to clarify the probable causal influence of chemotherapy and the social consequences concerning dysphoria. The observations carried out on 14 patients are illustrated by 2 case reports. A strong tie seems to exist between dysphoric state and manic-depressive illness, especially with respect to typical biorhythmic disturbances. Although the origin of such states is generally unknown, there are indications that neuroleptics and lithium may play a major role. Social consequences are on the whole minor, if the disturbances in mood and drive occur acutely and markedly. On the other hand, mild to moderate mood changes (especially when unaccompanied by drive changes) may lead to severe social impairment. The reason for this may be that the latter-mentioned states are misinterpreted by the entourage as personality traits rather than as expressions of an illness.

Approaches to the assessment of schizophrenia in Europe

All definitions of schizophrenia rely more or less on Kraepelin's hypothesis, Bleuler's theory or Schneider's pragmatic criteria. After a discussion on how these assumptions are referred to in classical and operational diagnostic systems in Europe, the results of a survey of 1983 literature are presented to show what kinds of assessments European workers currently employ. Lastly, guidelines are presented to enable psychopharmacological research to make the best use of the diagnostic systems to suit its purposes: essentially, which system or systems (the polydiagnostic approach for example) one should choose depends upon the symptoms the medication to be tested is supposed to treat, keeping in mind that patient sampling varies according to the system in question.

'Paranoid psychoses'. New aspects of classification and prognosis coming from the Vienna Research Group

After a presentation of the traditional principles of diagnosis and a precise definition of terms, the Vienna approach to the classification of delusional conditions is introduced. This approach is multiaxial: the first axis consists of a classification of delusional syndromes based on a cross-sectional description of their structural and constituting elements; on the second axis, the relationship between the delusional world and the real one is described; the third axis is for the recording of delusional contents; the fourth axis serves for an attempt at etiological attribution. The Vienna approach differs principally from the usual systems of classification in that it is purely syndromatological and thus it avoids giving an a priori nosological meaning to the various symptoms making up the delusion (for example, certain delusional themes, certain forms of hallucinations). A definitive nosological diagnosis is only possible when an organic cause is clearly evident, otherwise the suffix '-morphic' (endogenomorphic-schizophrenic, endogenomorphic-cyclothymic, and organomorphic axial syndromes) is added to denote the close resemblance of clinical states to certain disorders whose nosological homogeneity should not be taken for granted. Next, the results of our own catamnestic study on a patient population selected solely on syndromatological grounds are presented. It is shown that no prognostic significance can be attributed to the delusional pictures classified according to their description (paranoic syndromes, systematic and unsystematized paraphrenia); on the other hand, such significance certainly falls to one of the axial syndromes formulated on axis 4 (the endogenomorphic-cyclothymic axial syndrome). Nevertheless, a relatively large portion of the patients eluded attribution to one of the axial syndromes, even after a course of several years. Aside from the possibility that a number of them could be so classified after further cross-sectional evaluation, one may suspect that this group contains patients whose delusional formation stems from a psychogenic etiology; or it may be that these patients represent a third illness entity, distinct from the other two groups of endogenous psychoses.

Heterogeneity of delusional syndromes: diagnostic criteria and course prognosis

In addition to genetic findings and treatment response, the course prognosis is also meant to be a possible validating criterion for diagnosis and diagnostic systems. In our study we used the polydiagnostic approach (i.e. the simultaneous application of various criteria for diagnosing a given disorder to one and the same population) to test the ability of several diagnostic systems to create homogeneous groups regarding the course (episodic/chronic). We applied Schneider's FRS, ICD-9, DSM-III, Spitzer's RDC and the Vienna Research Criteria to 90 patients with the diagnosis of delusional syndrome (aside from any nosological classification), who underwent 6-9 years of follow-up. At the index examination, schizophrenia was most frequently diagnosed with Schneider's FRS, which apparently encompasses a very heterogeneous group of patients regarding psychopathology and course. Diagnostic systems which allowed the diagnosis of affective disorders despite the presence of mood-incongruent delusional symptomatology (DSM-III, RDC, Vienna Criteria) or offered the diagnosis of schizoaffective disorder (DSM-III, RDC) succeeded in separating subgroups with an episodic course on a statistically significant level. In ICD-9 this significance appeared only after exclusion of the schizoaffective cases from the group of schizophrenias. Our data thus uphold the old rule of thumb that affective symptomatology apparently has a very high prognostic value regarding the course of the illness and is in this respect superior to productive symptomatology (such as delusions and hallucinations), still taken to be pathognomonic for schizophrenia by some of the diagnostic criteria under study. This aspect warrants further investigation and should be taken into account in the development and improvement of diagnostic manuals (e.g. ICD-10, DSM-IV).