A persistent vegetative state (PVS) is a condition of patients with severe brain damage in whom coma has progressed to a state of wakefulness without detectable awareness. The term symptom (from the Greek meaning chance, mishap or casualty, itself derived from συμπιπτω meaning to fall upon or to happen to) has two similar meanings in the context of physical and mental health: Strictly, a symptom is a sensation or change in health function experienced by a patient. ... In medicine, a sign is a feature of disease as detected by the doctor during physical examination of a patient. ... The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ... The following codes are used with International Statistical Classification of Diseases and Related Health Problems. ... The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ... The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. ... Brain damage or brain injury is the destruction or degeneration of brain cells. ... In medicine, a coma (from the Greek koma, meaning deep sleep) is a profound state of unconsciousness. ... In biological psychology, awareness describes a human or animals perception and cognitive reaction to a condition or event. ...

History

The syndrome was first described 1940 by Ernst Kretschmer who called it apallic Syndrome.^[1] Ernst Kretschmer (October 8, 1888 - February 8, 1964) German Psychiatrist. ...

The term was coined in 1972 by Scottish spinal surgeon Bryan Jennett and American neurologist Fred Plum to describe a syndrome that seemed to have been made possible by medicine's increased capacities to keep patients' bodies alive.^[2] 1972 (MCMLXXII) was a leap year starting on Saturday. ... Motto (Latin) No one provokes me with impunity Wha daur meddle wi me?(Scots)1 Anthem (Multiple unofficial anthems) Scotlands location in Europe Capital Edinburgh Largest city Glasgow Official languages English, Gaelic, Scots3 Government Constitutional monarchy  -  Queen Queen Elizabeth II  -  Prime Minister Tony Blair MP  -  First Minister Jack McConnell... Look up spine on Wiktionary, the free dictionary. ... Surgeon may refer to: a practitioner of surgery the moniker of British electronic music producer and DJ, Anthony Child; see Surgeon (musician) This is a disambiguation page—a list of articles associated with the same title. ... Neurology is the branch of medicine that deals with the nervous system and disorders affecting it. ... medicines, see medication and pharmacology. ...

Signs and symptoms

Patients in a persistent vegetative state are usually considered to be unconscious and unaware. They are unresponsive to external stimuli, except, possibly, pain stimuli. Unlike coma, in which the patient's eyes are closed, PVS patients often open their eyes. Their eyes might be in a relatively fixed position, or track moving objects, or move in a disconjugate (i.e. completely unsynchronised) manner. They may experience sleep-wake cycles, or be in a state of chronic wakefulness. They may exhibit some behaviors that can be construed as arising from partial consciousness, such as grinding their teeth, swallowing, smiling, shedding tears, grunting, moaning, or screaming without any apparent external stimulus. Unconsciousness is the absence of consciousness. ... In medicine, a coma (from the Greek koma, meaning deep sleep) is a profound state of unconsciousness. ... Sleep is the state of natural rest observed in most mammals, birds, fish, as well as invertebrates such as the fruitfly Drosophila. ... In physiology, a stimulus is a detectable change in the internal or external environment. ...

Diagnosis

Many patients emerge from a vegetative state within a few weeks, but those who do not recover within 30 days are said to be in a persistent vegetative state.^[3] The chances of recovery depend on the extent of injury to the brain and the patient's age—younger patients having a better chance of recovery than older patients. Generally, adults have a 50 percent chance and children a 60 percent chance of recovering consciousness from a PVS within the first 6 months. After a year, the chances that a PVS patient will regain consciousness are very low and most patients who do recover consciousness experience significant disability. The longer a patient is in a PVS, the more severe the resulting disabilities are likely to be. Rehabilitation can contribute to recovery, but many patients never progress to the point of being able to take care of themselves.

Controversy, recoveries, possible contributing factors

In the United States, it is estimated that there may be between 15,000-40,000 patients who are in a persistent vegetative state, but due to poor nursing home records exact figures are hard to determine.^[4]

Recovery after long periods of time in a PVS state have been reported on several occasions and are often treated as spectacular events. In fact on March 7, 2007, a woman named Christa Lilly awakened from a vegetative state after 6 years of being in a coma that involved her eyes being open most of the time, tracking moving objects. She spoke to family and a local news group saying she was fine. The hardest part she said was learning how to speak again. Lilly slipped back into the vegetative state after 3 days.

Misdiagnosis of PVS is not uncommon. One study of 40 patients in the United Kingdom reported that 43% of those patients classified as in a PVS were misdiagnosed and another 33% able to recover whilst the study was underway.^[5] Some cases of PVS may actually be cases of patients being in an undiagnosed minimally conscious state.^[6] Since the exact criteria of the minimally conscious state were formulated only in 2002, there may be chronic patients diagnosed as PVS before the notion of the minimally conscious state became known. Can there be conscious awareness in vegetative state? Three completely different aspects of this issue should be distinguished. First, some patients can be conscious simply because they are misdiagnosed (see above). In fact, they are not in vegetative state. Second, sometimes a patient was correctly diasgnosed but, then, examined during a beginning recovery. Third, perhaps some day the very notion of the vegetative state will change so that to include elements of conscious awareness. The inability to disentangle these three cases leads to confusion. An example of such confusion are the responses to a recent experiment using magnetic resonance imaging which revealed that a woman diagnosed with PVS was able to activate predictable portions of her brain in response to the tester's requests that she imagine herself playing tennis or moving from room to room in her house. The brain activity in response to these instructions was indistinguishable from those of healthy patients.^[7] Because such activations can only be obtained if a patient has clear awareness and concentrated attention, this was obviously a diagnostic error. Therefore, the experiment did not show awareness in vegetative state in any reasonable sense of word; rather, it showed that magnetic resonance imaging, combined with sophisticated stimulation, can effectively be used to disclose major diagnostic errors. A minimally conscious state (MCS) is a condition distinct from coma or the vegetative state, in which a patient exhibits deliberate, or cognitively mediated, behavior often enough, or consistently enough, for clinicians to be able to distinguish it from entirely unconscious, reflexive responses. ... Magnetic Resonance Image showing a median sagittal cross section through a human head. ... Magnetic Resonance Image showing a median sagittal cross section through a human head. ...

Additional controversy has been caused by the discovery that in many nursing homes and hospitals unheated oxygen is given to non-responsive patients via tracheal intubation. This bypasses the warming of the upper respiratory tract and causes a chilling of aortic blood and chilling of the brain. In a small number of cases, removal of the chilled oxygen has been followed by recovery from the PVS state. Additional research has been recommended to determine if this chilling effect may either delay recovery or even may contribute to brain damage.^[8]

Possible treatment

Up to now (written in April 2007), no treatment for vegetative state exists that would satisfy the efficiency criteria of the evidence-based medicine. Several methods have been proposed which can roughly be subdivided into four categories: pharmacological methods, surgery, physical therapy, and various stimulation techniques. Pharmacological therapy mainly uses activating substances such as tricyclic antidepressants or methylphenidate. Promising results have been reported on dopaminergic drugs, particularly amantadine. Presently the first randomized controlled trial amantadine versus placebo is running; its results have not been published yet. Surgical methods such as deep brain stimulation are rarely used. Stimulation techniques include sensory stimulation, sensory regulation, music and musicokinetic therapy, social-tactile interaction, etc.

Medical definition

Terminology in this area is somewhat confused. While the term 'persistent vegetative state' is the most frequent in media usage and legal provisions, it is discouraged by neurologists, who favour the use of the Royal College of Physicians (RCP) (1996) typology which refers only to the vegetative state, the continuing vegetative state, and the permanent vegetative state. This typology distinguishes various stages of the condition rather than using one term for them all. In his most recent book The Vegetative State, Jennett himself adopts this usage, on the grounds that "the 'persistent' component of this term...may seem to suggest irreversibility". The Australian National Health and Medical Research Council has suggested "post coma unresponsiveness" as an alternative term.

Legal definition

As opposed to brain death, PVS is not recognized as death in any known legal system. This legal grey area has led to several court cases involving people in a PVS, those who believe that they should be allowed to die, and those who are equally determined that, if recovery is possible, care should continue. Well-known cases include Paul Brophy, Sunny von Bülow and Tony Bland, whose case created a precedent in the UK. The highly publicised case of Terri Schiavo in the United States involved disputes over a diagnosis of PVS given by several court-appointed doctors. Ultimately the court challenges were unsuccessful and Schiavo's feeding tube was removed, leading to her subsequent death. Brain death is defined as a complete and irreversible cessation of brain activity. ... This article or section does not adequately cite its references or sources. ... Gray Area n. ... For the 1987 film, see Right to Die (film) The term right to die refers to various issues around the death of an individual when that person could continue to live with the aid of life support, or in a diminished or enfeebled capacity. ... Paul Brophy was an energetic middle-aged fireman in Massachusetts who entered a persistent vegetative state with no believed chance of recovery. ... Martha Sharp Crawford von Bülow (Sunny) (born September 1, 1932 in Manassas, Virginia) is an American heiress and was a socialite and philanthropist in earlier years. ... Anthony David (Tony) Bland (21 September 1970 - 3 March 1993) was a supporter of Liverpool football club injured in the Hillsborough disaster. ... Theresa Marie Terri Schiavo (December 3, 1963 – March 31, 2005), from St. ... A feeding tube is a medical device used to provide nutrition to patients who cannot or refuse to (cf. ...

Notable PVS patients

• Terri Schiavo
• Nancy Cruzan
• Karen Ann Quinlan
• Ariel Sharon
• Sunny von Bülow
• Gary Dockery
• Tony Bland
• George Workman
• Haleigh Poutre

Theresa Marie Terri Schiavo (December 3, 1963 – March 31, 2005), from St. ... Nancy Beth Cruzan (July 20, 1957–December 26, 1990) was a figure in the right-to-die movement. ... Karen Ann Quinlan (March 29, 1954 – June 11, 1985) was an important figure in the history of the right to die debate in United States. ...   (Hebrew: , also known by his diminutive Arik אָרִיק) (born February 27, 1928) is a former Israeli politician and general. ... Martha Sharp Crawford von Bülow (Sunny) (born September 1, 1932 in Manassas, Virginia) is an American heiress and was a socialite and philanthropist in earlier years. ... Gary French Dockery (1954 - April 15, 1997), was a police officer in Walden, Tennessee who made world headlines after emerging from a 7 ½ year coma-like state and started talking enthusiastically, recognizing friends and recalling events from past years. ... Anthony David (Tony) Bland (21 September 1970 - 3 March 1993) was a supporter of Liverpool football club injured in the Hillsborough disaster. ...

Notes and references

1. ^ Das apallische Syndrom, in .Neurol.Psychiat, 169,576-579 (1940).
2. ^ "The Vegetative State: Medical facts, ethical and legal dilemmas" (9 page PDF file) Bryan Jennett, University of Glasgow, Scotland.
3. ^ "The Vegetative State: Medical facts, ethical and legal dilemmas" (9 page PDF file) Bryan Jennett, University of Glasgow, Scotland.
4. ^ Hirsch, Joy. (May 2, 2005). "Raising consciousness". The Journal of Clinical Investigation. American Society for Clinical Investigation. 115(5): 1102.
5. ^ BMJ 1996;313:13-16 (6 July) Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit.
6. ^ Giacino JT, et al. Neurology 2002, v. 58, p. 349-353.
7. ^ Owen AM, Coleman MR, Boly M, Davis MH, Laureys S, Pickard JD. Detecting awareness in the vegetative state. Science. 2006 Sep 8;313(5792):1402.
8. ^ Ford GP, Reardon DC. Prolonged unintended brain cooling may inhibit recovery from brain injuries: case study and literature review. Med Sci Monit. 2006 Aug;12(8):CS74-9. Epub 2006 Jul 12.

• Jennett, B. The vegetative state: Medical facts, ethical and legal dilemmas, New York, CUP, 2002
• Jennett B, Plum F. (1972). Persistent vegetative state after brain damage. A syndrome in search of a name. Lancet 1 (7753), 734–737. PMID 4111204.
• Multi-Society Task Force on PVS (1994). Medical aspects of the persistent vegetative state. N Engl J Med (330), 1499–508. PMID 7818633, PMID 8177248.
• National Health and Medical Research Council, Post-coma unresponsiveness (Vegetative State): a clinical framework for diagnosis, NHMRC, Canberra, 2003 [1]
• Royal College of Physicians, Guidance on diagnosis and management: Report of a working party of the Royal College of Physicians, London, Royal College of Physicians, 1996
• Borthwick C (1996) The permanent vegetative state: ethical crux, medical fiction? Issues Law Med. 1996 Fall;12(2):167-85. The author questions the validity of most PVS diagnoses, and the validity of the basic nosology. The fulltext is available on the author's website.
• Andrews K, Murphy L, Munday R, Littlewood C. (1996). Misdiagnosis of the vegetative state: retrospective study in a rehabilitation unit. BMJ (313), 13–16. PMID 8664760.
• Ford GP, Reardon DC. "Prolonged unintended brain cooling may inhibit recovery from brain injuries: case study and literature review." Med Sci Monit. 2006 Aug;12(8):CS74-9. Epub 2006 Jul 12. http://www.medscimonit.com/pub/vol_12/no_8/8795.pdf

This article contains text from the NINDS public domain pages on TBI at http://www.ninds.nih.gov/health_and_medical/disorders/tbi_doc.htm and http://www.ninds.nih.gov/health_and_medical/pubs/tbi.htm Lancet may refer to: A lancet is a medical instrument, similar to a scalpel but with a double-edged blade. ... The New England Journal of Medicine (NEJM) is a peer-reviewed medical journal published by the Massachusetts Medical Society with the highest impact factor for a general medical journal. ... The British Medical Journal (BMJ) is a medical journal published weekly in the United Kingdom by the British Medical Association (BMA)which published its first issue in 1845. ...