Neurotrauma in country hospitals: the role of computerized tomography scanning.
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Brain Injuries↗
Biomedical subjects
D A Simpson
Publications and source records attributed to D A Simpson.
Cervical spine injuries in road traffic crashes in South Australia, 1981-86.
The records of all cases of injury to the cervical spine sustained in road crashes for the 6 year period (1 January 1981 to 31 December 1986) which were admitted to the Spinal Injuries Unit of the Royal Adelaide Hospital, to the Adelaide Children's Hospital, or were identified at post-mortem examination were examined, and the relevant data extracted. There were 291 cases in the non-fatal group, and 161 in the fatal group. These represent a complete enumeration of all such patients in the state of South Australia over the 6 year period, given that up to 50% of cervical injuries in fatal cases can be missed. Comparison of the two groups showed that the fatal group had a much higher proportion of pedestrians, and persons over 50 years of age. About one-half of the fatal group had injuries at the level of C1 or the atlanto-occipital articulation. The most frequent level of injury in the non-fatal group was C2 (29.2%). About 30% of the non-fatal cases had some spinal cord damage. Case fatality rates were calculated, and ranged from 100% for injury at the atlanto-occipital articulation to 8% at C2. The fatality rate of pedestrians was about 4 times higher than that of vehicle occupants. About three-quarters of all cervical spine injuries occurred in vehicle occupants. There was an increase in the number of cases occurring in each year of the period studied. This rise was noted in non-fatal cases, in males, in vehicle occupants, and in crashes in the country.
Accidents, Traffic↗
Brace treatment of Colles' fracture.
Twenty patients with Colles' fractures were treated with a functional brace that allows wrist motion. The result was compared with a similar group of patients treated with a plaster cast. Dorsal displacement of the fracture was less and wrist function was better in the brace group. Swelling of the hand during the early stages was observed in the brace group; and because this may necessitate brace adjustment, increased medical supervision is necessary for this period.
Adult↗
Helmet-induced skull base fracture in a motorcyclist.
Observations after a fatal motorcycle accident suggested that the face bar of a full-face helmet may transmit an impacting force to the skull base via the chin strap and the mandibular rami and condyles, bypassing the energy-absorbing facial bones. If this mechanism is confirmed, the structural properties of these face bars will need to be reassessed.
Accidents, Traffic↗
Arachnoid cysts: a critical review of 41 cases.
Forty one cases of arachnoid cyst are reviewed that were treated at the Adelaide Children's Hospital and the Royal Adelaide Hospital. The pathogenesis of the cysts is discussed as well as the method of treatment. Certain aspects of this condition are still unsolved.
Adolescent↗
Assessing the conscious level in infants and young children: a paediatric version of the Glasgow Coma Scale.
The Glasgow Coma Scale is widely accepted as a measure of impaired consciousness both in clinical practice and in research. In its standard form, the scale is inapplicable to infants and children below the age of 5 years. We have devised a paediatric coma scale, which recognises that the expected normal verbal and motor responses must be related to the patient's age. This scale has been routinely used in a paediatric teaching hospital over a 10-year period and has appeared to be satisfactory, although it is less sensitive to changes in the conscious level than the adult scale. We have assessed the consistency of observer evaluation, using video tapes of infants and children exhibiting varying levels of consciousness: when conducted after formal instruction, assessments were reasonably consistent.
Child, Preschool↗
Extradural haemorrhage: strategies for management in remote places.
A study of 109 cases of extradural haemorrhage (EDH) treated in South Australia over a period of 7 years showed that 35 cases (32.1 per cent) presented in country areas at considerable distances from a neurosurgical service: the mortality in these country cases was 22.9 per cent, comparing unfavourably with a mortality of 12.2 per cent in metropolitan cases. The country series contained a disproportionately large number of cases with multiple intracranial haemorrhages, which are known to have a poorer outcome; when these cases were excluded, the rural mortality (12.5 per cent) was only a little over the metropolitan mortality (9.7 per cent). These data suggest that it is possible to manage extradural haemorrhages successfully even in places remote from a neurosurgical centre, if communications and air transport are used effectively. However, it was found that emergency operations carried out in country hospitals were sometimes inadequate or done too late. Medical retrieval teams based on city hospitals were sent out on 15 occasions, either to assist a general surgeon to complete an emergency operation, or to provide intensive care during transfer to a neurosurgical unit. Osmotherapy (mannitol and/or frusemide) has been useful in gaining time for transfer; the choice between immediate operation and transfer may be difficult, and decisions should take transfer time, clinical state and rate of deterioration into account.
Acute Disease↗
Technical aspects of the cranio-facial approach to tumours of the orbit and skull base.
During the period July 1980-August 1987, 21 patients required cranio-facial extension of conventional neurosurgical osteotomies for tumours of the skull base and orbit. Five different types of combined osteotomies are described. Their applications to the treatment of various tumours and the subsequent reconstructions are presented and discussed.
Adolescent↗
Purification, characterization, and comparison of the immunoglobulin A1 proteases of Neisseria gonorrhoeae.
Each isolate of Neisseria gonorrhoeae produces one of two distinct immunoglobulin A1 (IgA1) proteases, type 1 or type 2, which are known to possess different cleavage specificities for peptide bonds in the hinge region of human IgA1. Both proteases were secreted into the culture medium throughout exponential growth; however, the activity level of the type 2 protease was 10-fold that observed for the type 1 enzyme. The type 2 protease was quite stable and resistant to a variety of inhibitors. In contrast, the type 1 enzyme was highly unstable and inhibited by low concentrations of metal chelators, salts, and thiol- or serine-specific chemical reagents. Both types of gonococcal IgA1 protease were purified from broth culture supernatants by a combination of anion-exchange, chromatofocusing, and molecular sieve chromatography techniques. The stable type 2 enzyme comprised a 114-kilodalton (kDa) peptide which converted to a still active 109-kDa peptide during isolation. In contrast, the type 1 protease possessed a 112-kDa peptide which did not convert to a smaller form and which could not be dissociated from peptides of 34 and 31 kDa without complete loss of enzyme activity.
Chromatography, Gel↗
Prognostic factors related to survival and groin recurrence following therapeutic lymph node dissection for lower limb malignant melanoma.
A retrospective analysis was carried out of 133 patients undergoing therapeutic lymph node dissection for malignant melanoma of the lower limb. A radical ilio-obturator dissection (RID) was performed in 106 patients and a superficial femoral dissection (SFD) in the remaining 27. On univariate analysis five factors were found to be significant indicators of prognosis. These were: Clark level of the primary (P = 0.02); primary melanoma thickness (P = 0.04); total number of positive nodes (P less than 0.001); number of positive femoral nodes (P less than 0.001); and number of positive ilio-obturator nodes (P less than 0.001). On multiple regression analysis only the number of positive nodes in each compartment remained a significant independent factor (P less than 0.001). The morbidity associated with RID was not significantly greater than after SFD. RID was, however, associated with a reduction in subsequent groin recurrence. Radical nodal clearance is the operation of choice. This technique provides maximum prognostic information, reduces the likelihood of local untreatable disease and possibly improves overall survival rates--especially when only one iliac node is involved.
Adolescent↗
Restriction site polymorphism in genes encoding type 2 but not type 1 gonococcal IgA1 proteases.
Neisseria gonorrhoeae produces two phenotypically distinct types of IgA1 proteases, each of which cleaves a specific peptide bond in the hinge region of the human IgA1 heavy chain. The genes encoding IgA1 protease from twenty-eight different strains of N. gonorrhoeae, including twelve which produce type 1 enzyme, thirteen which produce type 2 enzyme, and three which are protease negative, were analyzed. Nine restriction site patterns were found in the iga genes. All twelve type 1 strains showed identical restriction maps of the iga gene, which differed from all the iga-2 variants. The three protease negative strains each contained DNA homologous to the probe. While strain to strain variation in restriction maps of specific genes is not unique and has been reported in N. gonorrhoeae previously, the existence of such restriction site polymorphism among iga-2 genes contrasts strongly with the lack of such variation among iga-1 genes. The basis for this lack of diversity among the iga-1 genes is under further investigation.
DNA Restriction Enzymes↗
Frontoethmoidal meningoencephaloceles.
Frontoethmoidal meningoencephaloceles constitute a well-defined clinical entity with remarkable epidemiologic peculiarities, being very prevalent in Southeast and Southern Asia, but relatively rare in Western Europe, Japan, Australia, and North America. They do not show an increased risk of recurrence in siblings and offspring, unlike other cephaloceles and neural tube defects generally, from which they should be distinguished. Combined craniofacial and neurosurgical operative treatment permits one-stage correction of the whole deformity, the associated hypertelorism being reduced by selective orbital translocation and the nasal deformity by rhinoplasty. In planning these procedures, three-dimensional CT scanning is very helpful. Although our experience is chiefly with cases referred in childhood, we have some experience with operations done in infancy and believe this to be the ideal age.
Abnormalities, Multiple↗
Use of atracurium during major abdominal surgery in infants with hepatic dysfunction from biliary atresia.
The use of atracurium during major abdominal surgery was assessed in 20 infants with hepatic dysfunction caused by biliary atresia. An initial dose of 0.6 mg kg-1 provided excellent intubating conditions in all patients. Subsequent neuromuscular blockade was monitored with a peripheral nerve stimulator and incremental doses of atracurium were given on reappearance of a single twitch. Neuromuscular conduction was allowed to return at the end of surgery and by careful timing of increments it was necessary to antagonize the neuromuscular blockade in only two patients.
Anesthesia, Endotracheal↗
Preventable causes of death and disability from neurotrauma.
Preventable causes of death and disability have been studied retrospectively in a series of 1161 cases of neurotrauma occurring in New South Wales in 1977-78, and prospectively in 153 cases of neurotrauma occurring in country districts in South Australia in 1981-82. In the first study, it was found that at least 80 deaths could be attributed to preventable causes; chiefly, transfer to an inappropriate hospital and/or delay in instituting treatment. Apparent failures in initial management of shock and airway obstruction were evident in this study and also in the South Australian study, which identified major deficiencies in cardiorespiratory management in 7% of cases transferred from country areas. These studies confirm that there is a need for better training, at all levels, in the management of neurotrauma. They also provide powerful arguments for the concept of an integrated regional trauma service.
Australia↗
Experience with extradural haematomas in New South Wales.
A retrospective study of 126 patients with extradural haematomas was made to determine whether their outcome could be modified by alteration of their management. Poor outcome occurred in those over 65 years of age, in motor smash victims, in those with fixed pupils, in those with major associated injuries or those comatose on hospital admission. The detection of skull fracture or of a lucid interval was not prognostically useful. A graduation in mortality according to the type of hospital was present but did not reach statistical significance. Failure to correct shock and delay in instituting definitive treatment were the major preventable factors which could be modified to improve outcome.
Adolescent↗
Experience with multiple intracranial haematomas in New South Wales.
A retrospective survey of head injuries in NSW in 1977 and 1978 was conducted by the Trauma Subcommittee of the Neurosurgical Society of Australasia. This paper describes the findings for 129 patients who had more than one significant intracranial haematoma. Overall, the case fatality rate for these patients was 85%. The presence of low or fluctuating blood pressure was associated with a significantly higher mortality than in the rest of the group. Bilateral reacting pupils or an improvement in level of consciousness following decompressive surgery carried a more favourable prognosis. There was 100% fatality if surgery was not carried out or if the bleeding was not found at operation. A subset of patients who died was selected on the basis of a calculated prognostic variable, and compared with a similar subset of survivors. A higher proportion of patients who died had a delay in the provision of definitive treatment and failure to correct shock. This comparison was made on two criteria. Using the first accepted optimal treatment in 1984, nearly all cases were treated suboptimally, as might be expected. Using the second, acceptable treatment in 1977-78, it was calculated that between nine and 12 patients died with MIH in NSW in the 2 years of the survey, whose deaths might have been prevented.
Accidents, Traffic↗
Experience with acute subdural haematomas in New South Wales.
A retrospective survey of head injuries in NSW in 1977 and 1978 was conducted by the Trauma Subcommittee of the Neurosurgical Society of Australasia. Two hundred and ninety patients, who were found to have acute or subacute subdural haematomas, were considered. The mortality rate was 76%, with 19% making a satisfactory recovery. Several factors were found to produce significant improvement in outcome. The availability of neurosurgical facilities at the time of admission made a significant difference. Those patients who had decompressive operations also fared better. No patient survived without operation. Shock, defined as a systolic blood pressure lower than 90 mmHg for more than 60 min was associated with significantly increased mortality. The chance of developing a significant hypotensive episode was greater if two or more other parts of the body were injured. If three other areas were injured, the mortality was 100%. A case control study suggested that some 35 (16%) of all deaths could have resulted from preventable causes, notably delay in instituting definitive treatment and/or inadequate treatment of shock.
Acute Disease↗
Epidemiology and clinical outcomes of neurotrauma in New South Wales.
This study of 1161 neurotrauma patients in New South Wales hospitals was designed to examine the role of preventable causes of death and disability in cases of spinal injury, extradural, subdural and multiple intracranial haematomas in order to make recommendations for improvements in accident, emergency, ambulance and hospital services. Methods have been developed for standardizing diagnosis in different classes of hospital for the assessment of severity in terms of the patient's age, sex, physical signs, head and spine injuries and other injuries. Estimates have been made of the number of preventable deaths by a case control study of each category of neurotrauma under study.
Adolescent↗