Pre- and post-disaster negative life events in relation to the incidence and severity of post-traumatic stress disorder.

There is evidence suggesting that stressful life events may precede major psychiatric illness, such as major depression, and that the severity of a traumatic event outside the range of usual human experience may provoke post-traumatic stress disorder (PTSD). The present study was carried out to examine the effects of pre- and post-disaster stressful life events on the incidence rate of PTSD following two man-made traumatic events. An epidemiological study examining 127 victims of a flash fire in a ballroom and 55 motor vehicle accident (MVA) victims was undertaken. PTSD symptoms were assessed by means of the Composite International Diagnostic Interview and the pre- and post-disaster stressful life events by means of the Diagnostic Interview Schedule, Disaster Supplement. Binary logistic and multiple linear regression analyses were employed to examine the relationships between PTSD and pre- and post-disaster life events. There were no significant relationships between stressful life events the year prior to the traumatic event and the incidence or severity of PTSD. There were highly significant relationships between the cumulative number and event severity of post-disaster negative life events and the incidence rate and severity of PTSD. The post-disaster life events were significantly more related to the avoidance-depression dimension than to the anxiety-arousal dimension of PTSD. The most significant life events were: loss of job or income, broken relationships, serious illnesses or injuries in the victims and death or illness in close acquaintances. The results of this study show that the number and severity of additional stressful life events signal a higher risk to develop PTSD and a higher severity of the avoidance-depression dimension of PTSD symptomatology.

Risk and preventive factors of post-traumatic stress disorder (PTSD): alcohol consumption and intoxication prior to a traumatic event diminishes the relative risk to develop PTSD in response to that trauma.

BACKGROUND: Previous reports examined the effects of selected pre- (e.g. female gender, previous trauma), peri- (e.g. the horror of the trauma, threatened death) or post-exposure (e.g. the physical injury caused by the trauma) risk factors on the development of post-traumatic stress disorder (PTSD), an anxiety disorder associated with a traumatic event outside the range of usual human experience. We hypothesized that alcohol consumption prior to traumatic events may reduce the incidence rate of PTSD. The aim of this study was to examine the effects of the above risk factors and preventive factors, such as alcohol consumption, on the development of PTSD. METHODS: An epidemiological cohort study was carried out on 127 victims trapped in a ballroom fire. Data were collected, 7-9 months after the traumatic event, by means of the Composite International Diagnostic Interview (CIDI) and structured interviews, aimed to assess the above pre-, peri- and post-exposure factors. Logistic regression analysis was used to examine the association of PTSD with the etiologic factors and to delineate those risk factors which contribute most to the development of PTSD. RESULTS: Female gender, the number of previous trauma, a past history of simple phobia, threatened death, trauma exposure, hospitalization for trauma-induced injuries and the presence of burns increased the odds of PTSD, whereas a sense of control during the trauma, and alcohol consumption and intoxication decreased the odds of PTSD. Six factors made independent contributions to the prediction of PTSD, i.e. the number of previous trauma, a past history of simple phobia, loss of control (increase the odds), a sense of control, alcohol consumption and alcohol intoxication (decrease the odds). CONCLUSIONS: The results of this study show that the development of PTSD is determined by the effects of pre-, peri- and post-exposure risk factors and may be prevented by the effects of peri-traumatic factors, such as sense of control, alcohol consumption and intoxication.

Psychiatric morbidity and comorbidity following accidental man-made traumatic events: incidence and risk factors.

UNLABELLED: The aims of this study were to examine the incidence and risk factors of major depression, bipolar disorder, psychoactive substance use, psychotic and anxiety disorders in relation to post-traumatic stress disorders (PTSD) in a study group exposed to two different traumatic events, i.e. 128 fire and 55 motor vehicle accident victims. Data have been collected 7-9 months after the traumatic event. The diagnosis of axis-I diagnoses, other than PTSD, was made according to DSM-III-R criteria using the Structured Interview according to the DSM-III-R. The incidence of new-onset major depression was 13.4%, generalised anxiety disorder (GAD) 12.6 %, agoraphobia 10.2% and psychoactive substance use disorders 6%. Simple phobia, panic disorder and obsessive compulsive disorder had a much lower incidence (< 2.0%). Fifty-one percent of the victims with PTSD had one or more additional axis-I diagnoses, major depression (26.2%), agoraphobia (21.0%) and generalised anxiety disorder (24.6 %) being the most common. Physical injury was the single best predictor for major depression. The best predictors for the development of new-onset anxiety disorders, other than PTSD, were: type and horror of the trauma, the extent of physical injury, the loss of control during the traumatic event, contextual stimuli, younger age and female sex. IN CONCLUSION: comorbid disorders, such as depression, GAD and agoraphobia, commonly occur within the first few months after man-made accidental traumata. Trauma variables, which are known to be related to the development of PTSD, are also related to the occurrence of these comorbid disorders.

The two-factorial symptom structure of post-traumatic stress disorder: depression-avoidance and arousal-anxiety.

UNLABELLED: The first part of this study showed that the DSM-III-R symptom structure of post-traumatic stress disorder (PTSD), i.e. criteria B (reexperience), C (avoidance-numbing), and D (arousal), and, consequently the diagnosis of PTSD, could not be validated in fire and car-accident victims. The aims of this study were to: (i) determine the factors as well as their structure in the symptoms of PTSD; and (ii) develop a new classification or typology of PTSD. Exploratory and confirmatory factor analyses and cluster analyses were employed to: (i) examine the factors in PTSD symptomatology; and (ii) find and validate adequate diagnostic criteria for PTSD. The Composite International Diagnostic Interview (CIDI), PTSD Module, was used between 7 and 9 months after the traumatic event in a study group of 185 victims of two different traumatic events, i.e. 130 fire and 55 car-accident victims. Our findings support the existence of two factors, i.e. a first labeled 'depression-avoidance (DAV) dimension', as it contains items reminiscent of depression and avoidance, and a second labeled 'the anxiety-arousal (AA) dimension', as it contains symptoms reminiscent of anxiety and increased arousal. Cluster analysis yielded two clusters, i.e. a cluster of subjects with PTSD cases and another with non-cases. Our PTSD algorithm was significantly less restrictive than the DSM-III-R diagnosis of PTSD. There are only quantitative, but no qualitative, differences between the cluster analytically derived classes. IN CONCLUSION: PTSD is not a well-delineated clinical entity, as there is a clinical continuum from PTSD non-cases to cases with less and more severe DAV and AA symptoms. It is more appropriate to express PTSD in terms of general severity of PTSD and severity of the DAV and AA dimensions.

Epidemiologic and phenomenological aspects of post-traumatic stress disorder: DSM-III-R diagnosis and diagnostic criteria not validated.

The aim of this cohort study was: (i) to validate the diagnostic criteria for post-traumatic stress disorder (PTSD) of the DSM-III-R; and (ii) to examine the incidence rate of PTSD in a study population exposed to two different traumatic events, i.e. a fire in a hotel ball-room and a multiple collision car-crash on a Belgian highway. One hundred and eighty-five victims (130 fire and 55 car accident victims) were assessed between 7 and 9 months after the traumatic event using the Composite International Diagnostic Interview (CIDI), PTSD Module, a fully structured diagnostic interview for the assessment of PTSD according to DSM-III-R criteria. Twenty-three percent of the study population met DSM-III-R criteria for PTSD. By means of unsupervised and supervised multivariate statistical analyses we were unable to validate the three-factorial structure, i.e. criteria B, C and D, of the DSM-III-R PTSD diagnosis. The latter relies heavily on the C diagnostic criteria, which appear to be too restrictive. Women were more likely to develop symptoms of reexperience (B) and arousal (D) than men. There was a significantly higher incidence of criteria B, C and D, but not of PTSD, in fire than in car-accident victims. Between 42 and 57% of the victims developed the first PTSD symptoms on the day of the trauma; within the next week these incidence rates increased to 77.1, 57.8 and 73.5% for criteria B, C and D, respectively. In conclusion, this study was unable to demonstrate the validity of the diagnostic criteria for PTSD according to DSM-III-R. The present cohort study has defined a number of factors that may predict new occurrences of PTSD symptoms after a traumatic event, i.e. gender, type of trauma and time delay between the trauma and the assessment of the diagnostic criteria.

[Correction of severe deformities of the foot, using Ilizarov's equipment]. / Correction des déformations sévères du pied par l'appareil d'Ilizarov.

MATERIAL AND METHODS: 38 feet in 36 patients who underwent a progressive foot correction without osteotomies, with an Ilizarov frame have been reviewed. There were 23 equinovarus, 2 equinovalgus, 13 equinus deformities. In 20 patients, the deformity had relapsed after one to four previous operations. The mean follow-up was 22 (12-35) months. The mean age was 17 years (6-68). There were 15 females and 21 males. RESULTS: All but 4 patients were satisfied with the result, although 15 still had pain during daily activities. The shape of the feet was distinctly improved in all patients, although residual equinus was found in 6 patients, residual varus in 2 and forefoot problems in 6. Pintract infections were encountered in half of the patients, all settled with local treatment, adjustement of the tension of the wires and antibiotics. Three specific complications were encountered: talus subluxations (7), toe contractures (6), relapse of equinus (4). DISCUSSION: Few alternatives are available to correct severe foot deformities. Soft tissue releases and/or wedge osteotomies are technically demanding, cause shortening of the foot, correct only one predominant component, are contraindicated in patients with infections or a poor vascular or skin condition. Progressive correction by the Ilizarov method is a valuable alternative, although we would like to stress the importance of some details in order to avoid the specific complications. Progressive correction of foot deformities by the Ilizarov frame is demanding for patient and surgeon. It should be reserved for the indications mentioned earlier and also for foot deformities combined with shortening or axial deviations.

Derotation osteotomy to correct rotational deformities of the lower extremities in children. A comparison of three methods.

Twenty-one supracondylar femoral and 11 tibial derotation osteotomies were performed in 17 patients to correct rotational deformities. Three different methods were used to fix the fragments after derotation: pins incorporated in plaster, plate and screws, and the Ilizarov external fixator. A retrospective review showed no difference in accuracy of derotation between the three methods. However, we recommend the use of the external fixator because it gives less malunion and permits early mobilization and (partial) weight bearing.

Transepiphysial fixation of anterior cruciate avulsion in a child. Report of a complication and review of the literature.

An avulsion of the anterior cruciate of an 11 year old girl was internally fixed with a transepiphysial screw. Two years later, anterior epiphysiodesis was evident, causing hyperextension of the knee. To avoid this complication, we recommend early removal of transepiphysial metalwork in children. Arthroscopical intrafocal fixation is proposed as a safe alternative.

Simple bone cysts. A review of 59 cases with special reference to their treatment.

In a retrospective study, 21 simple bone cysts (SBC) treated by curettage (with or without bone grafting) are compared to 20 SBC treated by intralesional injections of methylprednisolone. Curettage led to 43% favourable results and 29% recurrences. Cortisone injections led to 90% favourable results and 5% recurrences. Combined therapy (curettage and injections) led to results comparable to injections only. In our experience, curettage and hydroxyapatite grafting led to 100% complete healing (only 2 cases). We recommend intralesional methylprednisolone injections because the method is easy, effective and safe.

Chondromatosis of the fifth metacarpophalangeal joint. Case report and review of the literature.

Synovial chondromatosis is extremely rare in small joints. The authors present a case of involvement of the fifth metacarpophalangeal joint, treated by removal of loose bodies and synovectomy.

Bilateral intradeltoid ossification: a cause of glenohumeral abduction contracture.

A case of bilateral glenohumeral abduction contracture is presented. Two features are unique: intradeltoid ossification and progressive deformity without recent trauma. A review of the literature is given.

Posterior tibial tendon transfer in spastic equinovarus.

Twenty-eight posterior tibial tendon transfers through the interosseous membrane were performed to correct spastic equinovarus. All patients improved their gait, and 82% discarded their brace. Foot striking at the beginning of the stance phase was good or satisfactory in 82%; 68% had a neutral position of the heel. The overall score was good in 68%, satisfactory in 21%, and poor in 11%. The main requirements for obtaining good results with this type of transfer are: no fixed varus deformity preoperatively, age at operation between 5 and 10 years, and reinsertion near the midline of the foot.