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Coma and the etiology of violence, Part 1.

Coma and the etiology of violence are explored by the author through a review of the literature. Animal studies, post-traumatic psychic disorder studies, post-traumatic anger and violence studies, tumor and lesion of the limbic system studies, temporal lobe epilepsy studies, and episodic dysfunction syndrome studies, minimal brain studies are reviewed in Part 1 of this article. Part 2, to be published in a later issue of the journal, will conclude the review with clinical surveys on violent individuals and studies on clinical treatment of violence.These studies reveal the etiologic significance of central nervous system dysfunction in the production of violent behavior. Because central nervous system factors are involved in some instances of violent behavior, physicians clearly have a role in the early identification of potentially violent subjects and in the intervention or treatment of individuals who have been violent toward others. Studies have consistently found that lower socioeconomic groups are more predisposed to brain injury from trauma, and several studies have indicated that this is true for segments of the black community. Therefore, investigations in the relationship between central nervous system injury and violence should be a major goal of the black community. Black physicians should assume a lead role in these inquiries and in the prevention and treatment of violence, specifically black-on-black murder.

Adult↗

Muscle flap closure for salvage of complex back wounds.

STUDY DESIGN: The use of muscle flaps for closing complex thoracolumbar and lumbar spine wounds was studied retrospectively. Five patients in whom traditional, conservative treatment modalities did not work underwent a variety of muscle flap closures with successful healing. OBJECTIVES: Patients with complicated back wounds ranging from exposed hardware to post-traumatic defects were treated initially with conservative treatments. The authors evaluated the efficacy of applying techniques and knowledge gained from complex lower extremity wound coverage of back wounds. SUMMARY OF BACKGROUND DATA: Six muscle transfer procedures were performed on five patients. All patients were closed with local muscle flaps using the trapezius and latissimus dorsi muscles. METHODS: Success was defined as a closed stable wound that needed no future surgery nor allowed the primary defect to heal before hardware removal. There was no evidence of chronic infection. Surgical hardware was salvaged in one of three patients. RESULTS: All were successfully closed and have been followed up to 30 months without evidence of recurrence. CONCLUSIONS: The cases presented illustrate the usefulness of rotation flaps when there is an extensive soft tissue defect that has exposed neural, osseous, and foreign structures. The use of local transposition muscle flaps as an adjunct in closing complex back wounds has been very successful in our experience. Although recurrent infection may occur, this technique has facilitated the establishment of a soft tissue envelope to achieve short- and long-term wound healing.

Adult↗

Enhanced release of plasminogen activator inhibitor(s) but not of plasminogen activators by cultured rat glial cells treated with interleukin-1.

Astroglial cells are known to proliferate during development of the nervous system, as well as during post-traumatic gliosis. We have previously shown that the proliferation of cultured astrocytes can be stimulated by the urokinase-type (uPA) of plasminogen activator (PA) and that astrocytes are able to release such uPA upon stimulation with basic fibroblast growth factor, which is known to act as a mitogen for these cells. Here we report studies on the effects of human interleukin-1 (IL-1) on the release of PA activity by cultured newborn rat astroglial cells. Whereas there is controversy in the literature as to whether IL-1 stimulates multiplication of astroglial cells, we failed to observe such an effect in our system. We did observe, however, a dose-dependent decrease in PA activity in the supernatant of the IL-1 treated cultures. Further analysis revealed that this apparent decrease in PA release was in fact due to an increased release of plasminogen activator inhibitor (PAI). A similar IL-1 induced increase in PAI release was also found to occur in cultures of transformed astrocytes (human glioma LN18) and in cultured Schwann cells, but not in cultures of neurons or neuronal tumour cells. Since protease inhibitors are known to possess neuritogenic properties, our results suggest that IL-1, by its capacity to induce PAI, may promote neuritogenesis.

Adrenal Gland Neoplasms↗

Anterior surgery of the upper cervical spine.

The authors report the results obtained in a series of more than 80 cases submitted to 76 operations of the upper cervical spine by transoral approach with a minimum follow-up of two years. The cases include: 15 unstable fractures or non-union of the odontoid processes; 28 cases of post-traumatic instability of C1-C2 level without fracture of the odontoid process; 13 cases of rheumatoid arthritis with instability at C1-C2; 14 cases of severe anomalies of the craniovertebral junction, often associated with basilar impression and spinal cord compression, of which 7 cases presented with tetraparesis; 6 malignant tumors. The method used involves an anterior transoral approach, more often without tracheotomy, and with exposure of the anterior aspect of the atlas and of the odontoid process by means of a midline incision of the posterior wall of the pharynx. When spinal cord lesion was present, decompression and reconstruction by bone grafts taken from the iliac crest were performed. In nearly all of the cases osteosynthesis with an anterior plate was used. Complications were mild. There were two cases of infection, observed at the onset of our experience, which were resolved after removal of the instrumentation. There was loosening of a screw in three cases; this was eliminated through the digestive tube with no consequences. There were no early intra- or postoperative deaths. Consolidation was obtained in most of the patients, and only in three cases did we observe a loss of postoperative reduction. Among patients affected with tetraparesis we observed many cases of neurological recovery.(ABSTRACT TRUNCATED AT 250 WORDS)

Cervical Vertebrae↗

[Percutaneous gastrostomy. Personal experience in 137 cases].

Percutaneous gastrostomy is reported to be an effective alternative to total parenteral feeding or long-term nasogastric tube in the treatment of mechanical or functional dysphagia. The authors report their personal experience with 137 percutaneous gastrostomies performed on 98 men and 39 women from January 1986 through December 1993. All the maneuvers were performed under fluoroscopic guidance in the patients with head or neck cancer, neoplastic, vascular or post-traumatic neuropathy and upper GI tract cancer. To avoid left hepatic lobe trauma, percutaneous gastrostomy needs to be performed under US guidance. A 7F nasogastric tube is used to fill the stomach with air. After distending the gastric cavity, with the Seldinger technique under local anesthesia, fascial dilators of progressively increasing caliber are introduced into the gastric cavity and the final 12F gastrostomy catheter is positioned under fluoroscopic guidance. No major complications, such as hemorrhage or peritonitis, occurred. In one case, during the maneuver, the patient complained of severe epigastric pain which regressed with no further problems two hours later. In three cases the gastrostomy catheter fell out of place and was replaced by running the fistolous tract with a venous cannula and then a guidewire for gastrostomy repositioning. With this type of treatment, the patient can be given enteral feeding the following day. The maneuver requires approximately 10 minutes to perform and is well tolerated by the patient as it requires no general anesthesia. Percutaneous gastrostomy is more cost-effective than surgery or endoscopy and hospitalization is shorter. The only contraindications to this maneuver are hepatomegaly (because of the risk of liver trauma during percutaneous maneuvers), ascites (because of the risk of infection) and finally the complications resulting from gastric resection.

Adult↗

An unusual cause of benign paroxysmal positional vertigo.

Benign paroxysmal positional vertigo (BPPV) is a self-limiting condition characterized by vertigo and nystagmus induced by certain head positions. The most common causes of BPPV are post-traumatic following head injury and post-viral labyrinthitis. We present an interesting case of BPPV following an otherwise uneventful neurosurgical removal of a parietal osteoma using hammer and chisel. Caution should be exercised during such procedures as disabling vertigo can result for a considerable period of time.

Adult↗

[Dynamics and pathogenesis of traumatic subdural hygroma].

Of 2005 patients, who had suffered blunt skull trauma, 108 developed post-traumatic subdural hygromas (TSH). CT was used to observe the course of subdural hygromas not treated surgically, with particular reference to the time of their appearance and regression. The relative incidence of TSH, and of the severity of head trauma quantified on a 5-grade scale was determined in different age groups. From the traumatic changes demonstrated on CT, some conclusions could be drawn regarding the pathogenesis. A hypothetical model has been developed which explains TSH as a result of shearing forces.

Brain Injuries↗

Angiosarcomas in lymphedematous limbs.

The clinical and histopathological features of four cases of angiosarcoma in congenital, post-traumatic, and post-hysterectomy lymphedematous limbs are reported. A good correlation between histologic and ultrastructural findings and clinical course was observed.

Cell Transformation, Neoplastic↗

Cone biopsy causes cervical endometriosis and tubo-endometrioid metaplasia.

Cervices from 42 hysterectomies performed from 1 to 91 months (mean 12.2) following conization were re-examined in order to assess the possible effects of post-traumatic regeneration on the endocervix. Twenty-nine (69%) showed a continuum of abnormalities in which the shared finding was the presence of tubo-endometrioid glands, accompanied in many cases by varying amounts of endometrial-type stroma. Thus, 18 post-conization cervices (43%) showed endometriosis, and a further 11 cases (26%) contained tubo-endometrioid glands without demonstrable endometrial-type stroma. These abnormalities were situated at the healed cone biopsy site, either superficially within the new transformation zone and/or within the cone biopsy scar. Post-conization cervical endometriosis occurred from 2 to 91 months (mean 17.8) and tubo-endometrioid metaplasia 2-24 months (mean 11.0) after the cone biopsy. It is concluded that cervical endometriosis and tubo-endometrioid metaplasia are common complications of conization, and that they represent aberrant differentiation following injury. The demonstration of endometriosis and tubo-endometrioid metaplasia in 69% of post-conization cervices has implications for the interpretation of cervical biopsies and smears from this group of women.

Adult↗

Homovanillic acid and 5-hydroxyindole-acetic acid in the csf of patients after a severe head injury. II. Ventricular csf concentrations in acute brain post-traumatic syndromes.

Ventricular concentrations of homovanillic acid (HVA) and 5-hydroxyindole-acetic acid (5HIAA) were measured in 7 patients a few days after a severe traumatic brain injury. Both acid metabolites were elevated in respect to control patients values, however, the rise was more consistent for 5HIAA (258 +/- 86 ng/ml) with a 5HIAA/HVA ratio of 0.85 +/- 0.35. The data support previous hypothesis on the profound involvement of serotoninergic structures in the early stages of acute traumatic brain syndromes and on the role of 5HT in maintaining edema and vasospasm.

Adolescent↗

[Post-traumatic hemoperitoneum: a rare complication of peritoneal splenosis].

Peritoneal splenosis is a frequent condition after traumatic spleen fracture, which, given that it is usually asymptomatic, is often not diagnosed unless a laparotomy is performed for some other reason. The case is presented of a 9 year old boy splenectomized a few years earlier because of traumatism, who again suffers abdominal injury with the development of hemoperitoneum, observing during surgery multiple splenosis foci disseminated all over the abdominal cavity, some of which present rupture and hemorrhage, constituting the cause of hemoperitoneum.

Abdominal Injuries↗

[Post-traumatic astrocytoma].

A 25 year old woman developed a mixed pilocytic and fibrillary astrocytoma in scar tissue 20 years after the brain contusion. The case fulfilled the criteria of traumatic etiology of this brain tumor.

Adult↗

[External immobilization of cervical spine with a halo vest--experience with 31 cases].

Post-traumatic or post-operative immobilization of cervical spine often requires long term bed-rest. But, bed-rest indeed gave discomfort to patients, nonetheless, sometimes complete external fixation cannot be gained. Since 1982, we have applied Halo vest to the patients who required external immobilization of cervical spine. In this paper, we reported our experiences with 31 cases who were treated by Halo vest. Thirty-one cases comprised 19 cases of cervical spinal trauma, 5 cases of atlanto-axial dislocation, 1 case of foramen magnum meningioma, and 6 cases of ossification of posterior longitudinal ligament (OPLL). In traumatic cases, Halo vest was used as external fixation of injured spine in 8 cases, and as an adjunct to surgical fusion in other cases. In case of atlanto-axial dislocation, 3 cases underwent posterior fusion, and 2 cases underwent anterior fusion. Anterior fusion of C1-2 was also done in case of foramen magnum meningioma after total excision of tumor. Six cases of OPLL underwent anterior decompression and anterior fusion. Mean immobilization time by Halo vest was as follows: 58 days (28-113) in case of cervical spinal trauma, 85 days (56-144) in case of atlanto-axial dislocation who underwent posterior fusion, 92 days (89-93) in case of atlanto-axial dislocation and foramen magnum meningioma who underwent anterior fusion, 59 days (54-70) in case of OPLL. Early ambulation was achieved in many cases. Good external fixation and result was obtained 27 cases out of 31 cases. Re-dislocation of cervical spine occurred in 1 case of cervical spinal trauma while he was in Halo vest.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

Microvascular surgery in maxillo-facial reconstruction.

The recent advances in microvascular surgery have been applied to maxillo-facial reconstruction in the area of the lower jaw and soft tissue of the face. Five cases are presented, demonstrating some of the techniques and results in patients suffering from congenital, post-traumatic and post-cancer resection deformities.

Adult↗

Role of cholesterol and calcium bilirubinate crystals in acute postoperative acalculous cholecystitis.

Acute acalculous cholecystitis is rather unusual, but it is considered an increasing entity. Particularly interesting are the post-traumatic or post-operative forms of acute acalculous cholecystitis. Ischemia of the gallbladder and biliary stasis are the most likely pathogenetic factors. A case of acute acalculous cholecystitis after total gastrectomy for cancer is presented. Particular emphasis is put on the significance of cholesterol and calcium bilirubinate crystals findings in the bile of the gallbladder. The pathogenetic role of this microscopic form of lithiasis in post-operative acalculous cholecystitis is discussed. It is concluded that all surgeons should be aware of this pathology since it is becoming much more common to be faced with elderly patients having life-threatening post-operative gallbladder complications unrelated to macroscopic lithiasis.

Acute Disease↗

[Desmoid fibroma of bone. An histoenzymological and ultrastructural study of the mandible in one case (author's transl)].

A case of post-traumatic desmoid tumor of the mandible is reported in a 4-year old girl. This tumor was considered typical clinically and by light microscopy. Four years later, the patient was symptomless, without evidence of recurrence. Histoenzymology showed a high level of leucine aminopeptidase activity. On electron microscopy, a part from a few primitive mesenchymal cells, abnormal fibroblasts represented the principal cellular component. These cells showed evidence of intracytoplasmic collagen fibers synthesis and of myoid differentiation (numerous filaments and endocytosis vacuoles). Myofibroblasts, with a microfibrillary network showing areas of dense osmiophilic condensation in the vicinity of cell membrane were also present. This atypical ultrastructural feature suggests, in this case, the non-neoplastic nature of this lesion. It seems to reflect an abnormal reaction to a traumatic aggression, characterized by proliferation of myofibroblasts (which normally disappear in the late stages of healing) and to have, thus, the signification of pathologic scar.

Child, Preschool↗

[Filling of bone defects using biphasic macroporous calcium phosphate ceramic. Apropos of 23 cases].

PURPOSE OF THE STUDY: The authors report their experience with the use of a biphasic macroporous calcium phosphate bone substitute. MATERIALS AND METHODS: In 23 cases (22 patients) a biphasic macroporous calcium phosphate ceramic was used to fill a pathological bone defect. The ceramic used in this study was a macroporous (400 to 600 mu) component consisting of 60 per cent hydroxyapatite and 40 per cent beta-tricalcium phosphate. It was in the form of granules (2 to 3 mm), sticks (20 x 5 x 5 or 10 x 5 x 5 mm) or custom made blocks. In 6 cases, the ceramic was used alone; in 12 cases with autologous bone marrow and in 5 cases with autologous cancellous bone grafts. In 14 cases, the bone defect was due to conservative treatment of a benign tumor, in 3 cases due to aseptic post-traumatic non union, in 3 cases due to wide resection for malignant tumors of the pelvis and in 3 cases following osteotomy. Post operative assessment was made from clinical, radiographic and histological findings. RESULTS: 2 patients died 6 and 8 months post operatively and 2 were lost to follow up at 2 and 5 months with both having good clinical and radiographic results when last seen. For the remaining 19 cases, the average follow-up was 20 months (from 6 to 62 months). No local, regional or general deleterious effects were noted. Radiologically the bone ceramic junction healed in all cases except 2 within 3 months. In these last two cases, healing required 6 and 7 months. No radiolucent line appeared around the ceramic. No stress fractures occurred in the substitute. Histologically, 3 biopsies showed new bone formation throughout the ceramic with apposition of a well differentiated lamellar bone directly apposed to the ceramic. DISCUSSION: Animal experimentations have proven the interest of similar ceramics: macroporosity enhances bone rehabilitation and the biphasic characteristics associate the advantages of slow resorption of hydroxyapatite and more easily resorbed beta-calcium phosphate. No deleterious clinical, radiographical or histological effects were observed, confirming the biocompatibility of this substitute. Despite the poor mechanical properties of this macroporous ceramic before implantation, good clinical and radiographic results suggest improvement of these properties in the composite new formed bone-ceramic after implantation. CONCLUSION: We believe that macroporous biphasic ceramic is a good substitute for use in bone defects when good primary mechanical stability and contact with the host bone are present. Further clinical and experimental studies are necessary to determine the limits of such a substitute in terms of volume and to control its mechanical properties following implantation.

Adolescent↗