Childhood adversities and risk of posttraumatic stress disorder and major depression following a motor vehicle collision in adulthood.

AIMS: Childhood adversities (CAs) predict heightened risks of posttraumatic stress disorder (PTSD) and major depressive episode (MDE) among people exposed to adult traumatic events. Identifying which CAs put individuals at greatest risk for these adverse posttraumatic neuropsychiatric sequelae (APNS) is important for targeting prevention interventions. METHODS: Data came from n = 999 patients ages 18-75 presenting to 29 U.S. emergency departments after a motor vehicle collision (MVC) and followed for 3 months, the amount of time traditionally used to define chronic PTSD, in the Advancing Understanding of Recovery After Trauma (AURORA) study. Six CA types were self-reported at baseline: physical abuse, sexual abuse, emotional abuse, physical neglect, emotional neglect and bullying. Both dichotomous measures of ever experiencing each CA type and numeric measures of exposure frequency were included in the analysis. Risk ratios (RRs) of these CA measures as well as complex interactions among these measures were examined as predictors of APNS 3 months post-MVC. APNS was defined as meeting self-reported criteria for either PTSD based on the PTSD Checklist for DSM-5 and/or MDE based on the PROMIS Depression Short-Form 8b. We controlled for pre-MVC lifetime histories of PTSD and MDE. We also examined mediating effects through peritraumatic symptoms assessed in the emergency department and PTSD and MDE assessed in 2-week and 8-week follow-up surveys. Analyses were carried out with robust Poisson regression models. RESULTS: Most participants (90.9%) reported at least rarely having experienced some CA. Ever experiencing each CA other than emotional neglect was univariably associated with 3-month APNS (RRs = 1.31-1.60). Each CA frequency was also univariably associated with 3-month APNS (RRs = 1.65-2.45). In multivariable models, joint associations of CAs with 3-month APNS were additive, with frequency of emotional abuse (RR = 2.03; 95% CI = 1.43-2.87) and bullying (RR = 1.44; 95% CI = 0.99-2.10) being the strongest predictors. Control variable analyses found that these associations were largely explained by pre-MVC histories of PTSD and MDE. CONCLUSIONS: Although individuals who experience frequent emotional abuse and bullying in childhood have a heightened risk of experiencing APNS after an adult MVC, these associations are largely mediated by prior histories of PTSD and MDE.

Prior differences in previous trauma exposure primarily drive the observed racial/ethnic differences in posttrauma depression and anxiety following a recent trauma.

BACKGROUND: Racial and ethnic groups in the USA differ in the prevalence of posttraumatic stress disorder (PTSD). Recent research however has not observed consistent racial/ethnic differences in posttraumatic stress in the early aftermath of trauma, suggesting that such differences in chronic PTSD rates may be related to differences in recovery over time. METHODS: As part of the multisite, longitudinal AURORA study, we investigated racial/ethnic differences in PTSD and related outcomes within 3 months after trauma. Participants (n = 930) were recruited from emergency departments across the USA and provided periodic (2 weeks, 8 weeks, and 3 months after trauma) self-report assessments of PTSD, depression, dissociation, anxiety, and resilience. Linear models were completed to investigate racial/ethnic differences in posttraumatic dysfunction with subsequent follow-up models assessing potential effects of prior life stressors. RESULTS: Racial/ethnic groups did not differ in symptoms over time; however, Black participants showed reduced posttraumatic depression and anxiety symptoms overall compared to Hispanic participants and White participants. Racial/ethnic differences were not attenuated after accounting for differences in sociodemographic factors. However, racial/ethnic differences in depression and anxiety were no longer significant after accounting for greater prior trauma exposure and childhood emotional abuse in White participants. CONCLUSIONS: The present findings suggest prior differences in previous trauma exposure partially mediate the observed racial/ethnic differences in posttraumatic depression and anxiety symptoms following a recent trauma. Our findings further demonstrate that racial/ethnic groups show similar rates of symptom recovery over time. Future work utilizing longer time-scale data is needed to elucidate potential racial/ethnic differences in long-term symptom trajectories.

Pain distribution and predictors of widespread pain in the immediate aftermath of motor vehicle collision.

BACKGROUND: Musculoskeletal pain is common after motor vehicle collision (MVC). The study objective was to evaluate distribution of pain and predictors of widespread musculoskeletal pain in the early aftermath (within 48 h) of collision. METHODS: European American adults aged 18-65 years presenting to the emergency department (ED) after collision who were discharged to home after evaluation were eligible. Evaluation included an assessment of reported pre-collision psychological characteristics, crash characteristics, current pain severity and location, and current psychological symptoms. Adjusted risk ratios were estimated using generalized linear models. RESULTS: Among 890 participants included in the study, 589/890 (66%) had pain in three or more regions, and 192/890 (22%) had widespread musculoskeletal pain (pain in seven or more regions). In adjusted analyses, the presence of widespread pain was strongly associated with depressive and somatic symptoms prior to collision, pain catastrophizing, and acute psychological symptoms, and was not associated with most collision characteristics (road speed limit, extent of vehicle damage, collision type, driver vs. passenger, airbag deployment). The reported number of body regions that struck an object during the collision was associated with both reported pre-collision depressive symptoms and with widespread pain. CONCLUSION: More than one in five individuals presenting to the ED in the hours after MVC have widespread pain. Widespread pain is strongly associated with patient characteristics known to be modulated by supraspinal mechanisms, suggesting that stress-induced hyperalgesia may influence acute widespread pain after collision.

Clinical characteristics as predictors of recurrent alcohol-related seizures.

OBJECTIVE: To determine whether clinical data available in the emergency department can accurately predict a subset of patients at low risk of developing recurrent seizures following one or more initial alcohol-related seizures in the out-of-hospital arena. METHODS: This was a retrospective secondary analysis of data obtained from the placebo arms of two prospective, randomized trials of drug treatments for the prevention of recurrent alcohol-related seizures. Subjects with and without one or more recurrent alcohol-related seizures during the study period were compared according to the following characteristics: 1) age, 2) gender, 3) daily ethanol consumption, 4) years of ethanol abuse, 5) previous alcohol-related seizure, 6) previous seizure of other etiology, 7) temperature, 8) heart rate, 9) systolic blood pressure, 10) diastolic blood pressure, 11) respiratory rate, and 12) ethanol level. Data were analyzed with t-tests and chi-square where appropriate. RESULTS: One hundred five placebo-treated patients were analyzed and 31 (30%) developed recurrent alcohol-related seizures. None of the listed characteristics were statistically different between the two groups except for the initial ethanol level. Subjects with an ethanol level higher than 100 mg/dL were less likely (0%) to develop recurrent seizures than patients with a level equal to or below 100 mg/dL (36%) (p < 0.01). CONCLUSIONS: An initial ethanol level higher than 100 mg/dL was significantly associated with a low risk for recurrent alcohol-related seizures during the observation period. No other low-risk clinical characteristics could be identified.

Lorazepam for the prevention of recurrent seizures related to alcohol.

BACKGROUND AND METHODS: Alcohol abuse is one of the most common causes of seizures in adults. In a randomized, double-blind study, we compared lorazepam with placebo for the prevention of recurrent seizures related to alcohol. Over a 21-month period, we studied consecutive patients with chronic alcohol abuse who were at least 21 years of age and who presented to the emergency departments of two hospitals in Boston after a witnessed, generalized seizure. The patients were randomly assigned to receive either 2 mg of lorazepam in 2 ml of normal saline or 4 ml of normal saline intravenously and then observed for six hours. The primary end point was the occurrence of a second seizure during the observation period. RESULTS: Of the 229 patients who were initially evaluated, 186 met the entry criteria. In the lorazepam group, 3 of 100 patients (3 percent) had a second seizure, as compared with 21 of 86 patients (24 percent) in the placebo group (odds ratio for seizure with the use of placebo, 10.4; 95 percent confidence interval, 3.6 to 30.2; P<0.001). Forty-two percent of the placebo group were admitted to the hospital, as compared with 29 percent of the lorazepam group (odds ratio for admission, 2.1; 95 percent confidence interval, 1.1 to 4.0; P=0.02). Seven patients in the placebo group and one in the lorazepam group were transported to an emergency department in Boston with a second seizure within 48 hours after hospital discharge. CONCLUSIONS: Treatment with intravenous lorazepam is associated with a significant reduction in the risk of recurrent seizures related to alcohol.

The lack of efficacy of phenytoin in the prevention of recurrent alcohol-related seizures.

STUDY OBJECTIVE: To determine the effectiveness of IV phenytoin in the prevention of recurrent alcohol-related seizures during a six-hour observation period. DESIGN: Prospective, randomized, double-blind trial comparing IV phenytoin with normal saline placebo, conducted from January 1990 through December 1991. SETTING: Emergency department of an inner-city, university-affiliated, teaching hospital. PARTICIPANTS: One hundred forty-seven consecutive adults more than 25 years of age who presented with a witnessed generalized seizure in the setting of chronic alcohol abuse. INTERVENTIONS: Eligible subjects received 15 mg/kg of phenytoin or normal saline at an equivalent volume over 20 minutes by IV pump. Patients were observed for six hours in the ED after drug administration. Those experiencing a second seizure were admitted to the hospital. RESULTS: One hundred patients completed the study. Recurrent alcohol-related seizures occurred in ten of 49 patients (20.4%) in the phenytoin group and in 12 of 51 patients (23.5%) in the placebo group. chi 2 analysis revealed no statistically significant difference between the two groups (chi 2 = 0.142; P = .706). The 95% confidence interval for the difference was -0.13 to + 0.19. The relative risk of recurrence between groups was 0.868 with a 95% confidence interval of 0.412 to 1.826. CONCLUSION: No significant benefit of phenytoin administration in the prevention of recurrent alcohol-related seizures during a six-hour observation period was demonstrated.