Precordial Steering Wheel: A Fortunate Accident

Background: Myocardial ischemia has been associated with motor vehicle collisions (MVCs). However, we were unable to find reported cases of ST-segment elevation myocardial infarction (STEMI) leading to ventricular tachyarhythmia and subsequent MVC. In such patients, decisions regarding antiplatelet and antithrombotic therapy need to balance the risk of ongoing myocardial ischemia and hemorrhage. Objectives: To describe a case of STEMI and ventricular fibrillation (VF) associated with a head-on MVC, and to describe the management decisions involved in the care of such a patient. Case report: A 47-year-old man presented to the Emergency Department after a single-car head-on collision with a wall at high speed. He had a facial degloving injury as well as right-sided flail chest. An electrocardiogram demonstrated ST-segment elevation in the inferior and anterior leads. Due to the patient's significant traumatic injuries, he underwent a rapid trauma evaluation and was transferred for emergent cardiac catheterization, which demonstrated evidence of plaque rupture in the right coronary artery (RCA). Flow distal to the lesion was preserved, so stent implantation was initially deferred out of concern for hemorrhage secondary to the aggressive antiplatelet and antithrombotic regimen requisite with stent implantation. The patient then went into VF in the cardiac catheterization laboratory, and repeat angiography demonstrated an occluded RCA, and the patient underwent successful stent implantation. Conclusion: The management of STEMI in the setting of trauma is complex. Pharmacologic agents used in STEMI increase the risk of bleeding, and management must balance the risk of prolonged ischemia with the risk of hemorrhage.     

舟曲救灾官兵体育锻炼与业务能力、心理创伤和自尊研究

目的了解参与舟曲救灾官兵的体育锻炼及其对心理创伤、业务能力和自尊的影响。方法采用事件冲击量表修订版（ISE-R）、自尊量表（SES）和自编体育锻炼情况调查表,对160名舟曲救灾官兵进行调查。结果①舟曲救灾官兵的体育锻炼次数较多且锻炼时间较长;并与其业务能力（r=0.255）、自尊（r=0.249）呈正相关;②舟曲救灾官兵的心理创伤程度较重,与其体育锻炼水平相关（t=-2.06,P=0.04）;③舟曲救灾官兵的心理创伤程度与其业务能力无关（r=-0.111,P=0.288）,但不同自尊水平官兵的心理创伤水平（t=-3.08,P=0.003）差别显著。结论体育锻炼能够降低心理创伤,自尊可以直接预测心理创伤水平。     

The Double-Line Sign: A False Positive Finding on the Focused Assessment with Sonography for Trauma (FAST) Examination

Background: Emergency physicians commonly perform Focused Assessment with Sonography for Trauma (FAST) examinations to evaluate for free intraperitoneal fluid. Many ultrasound findings can be misinterpreted as free fluid, resulting in false-positive FAST examinations. Objectives: To describe a previously unreported ultrasound finding that can be misinterpreted as free intraperitoneal fluid. Case Report: A 32-year-old man was stabbed in the left upper abdomen. A FAST examination was performed and a right perinephric fat pad was interpreted as showing free fluid in Morison's pouch. After transfer to a trauma center, a repeat FAST examination revealed no signs of intraperitoneal free fluid. Wound exploration showed no signs of penetration into the peritoneal cavity. Conclusions: When performing a FAST examination, a wedge-shaped hypoechoic area in Morison's pouch that is bounded on both sides by echogenic lines (the “FAST Double-Line Sign”) is likely to represent perinephric fat and may result in a false-positive FAST examination.     

BOARDING SCHOOL SYNDROME: BROKEN ATTACHMENTS A HIDDEN TRAUMA

The aim of this paper is to identify a cluster of symptoms and behaviours, which I am proposing be classified as ‘Boarding School Syndrome’. These patterns are observable in many of the adult patients, with a history of early boarding, who come to psychotherapy. Children sent away to school at an early age suffer the sudden and often irrevocable loss of their primary attachments; for many this constitutes a significant trauma. Bullying and sexual abuse, by staff or other children, may follow and so new attachment figures may become unsafe. In order to adapt to the system, a defensive and protective encapsulation of the self may be acquired; the true identity of the person then remains hidden. This pattern distorts intimate relationships and may continue into adult life. The significance of this may go unnoticed in psychotherapy. It is proposed that one reason for this may be that the transference and, especially the breaks in psychotherapy, replay, for the patient, the childhood experience between school and home. Observations from clinical practice are substantiated by published testimonies, including those from established psychoanalysts who were themselves early boarders.     

Posttraumatic Stress Disorder in New Mothers: Results from a Two‐Stage U.S. National Survey

Abstract: Background: Prevalence rates of women in community samples who screened positive for meeting the DSM‐IV criteria for posttraumatic stress disorder after childbirth range from 1.7 to 9 percent. A positive screen indicates a high likelihood of this postpartum anxiety disorder. The objective of this analysis was to examine the results that focus on the posttraumatic stress disorder data obtained from a two‐stage United States national survey conducted by Childbirth Connection: Listening to Mothers II (LTM II) and Listening to Mothers II Postpartum Survey (LTM II/PP). Methods: In the LTM II study, 1,373 women completed the survey online, and 200 mothers were interviewed by telephone. The same mothers were recontacted and asked to complete a second questionnaire 6 months later and of those, 859 women completed the online survey and 44 a telephone interview. Data obtained from three instruments are reported in this article: Posttraumatic Stress Disorder Symptom Scale‐Self Report (PSS‐SR), Postpartum Depression Screening Scale (PDSS), and the Patient Health Questionnaire‐2 (PHQ‐2). Results: Nine percent of the sample screened positive for meeting the diagnostic criteria of posttraumatic stress disorder after childbirth as determined by responses on the PSS‐SR. A total of 18 percent of women scored above the cutoff score on the PSS‐SR, which indicated that they were experiencing elevated levels of posttraumatic stress symptoms. The following variables were significantly related to elevated posttraumatic stress symptoms levels: low partner support, elevated postpartum depressive symptoms, more physical problems since birth, and less health‐promoting behaviors. In addition, eight variables significantly differentiated women who had elevated posttraumatic stress symptom levels from those who did not: no private health insurance, unplanned pregnancy, pressure to have an induction and epidural analgesia, planned cesarean birth, not breastfeeding as long as wanted, not exclusively breastfeeding at 1 month, and consulting with a clinician about mental well‐being since birth. A stepwise multiple regression revealed that two predictor variables significantly explained 55 percent of the variance in posttraumatic stress symptom scores: depressive symptom scores on the PHQ‐2 and total number of physical symptoms women were experiencing at the time they completed the LTM II/PP survey. Conclusion: In this two‐stage national survey the high percentage of mothers who screened positive for meeting all the DSM‐IV criteria for a posttraumatic stress disorder diagnosis is a sobering statistic. (BIRTH 38:3 September 2011)     

Reduction in deep vein thrombosis incidence in intensive care after a clinician education program

Summary.  Background : Deep vein thrombosis (DVT) is a major complication in intensive care units (ICU) but dedicated guidelines on its management are still lacking. Objectives and Methods : This study investigated the effect of a 1-year educational program for the implementation of DVT prophylaxis on the incidence of inferior limb DVT in a mixed-bed ICU that admits high-risk surgical and trauma patients, investigated during a first retrospective phase [126 patients, SAPS II score 42 (28–54)] and a following prospective phase [264 patients, SAPS II score II 41 (27–55)]. The role of baseline and time-dependent DVT risk factors in DVT occurrence was also investigated during the prospective phase. Results : The educational program on implementation of DVT prophylaxis was associated with a significant decrease in DVT incidence from 11.9% to 4.5% ( P  < 0.01) and in the mean length of ICU stay ( P  < 0.01). Combined with pharmacological prophylaxis, the use of elastic compressive stockings significantly also increased in the prospective phase ( P  < 0.01). The duration of mechanical ventilation, vasopressor administration and neuromuscular block were significantly different between DVT-positive and DVT-negative patients ( P  < 0.01). Multivariate analysis identified neuromuscular block as the strongest independent predictor for DVT incidence. Conclusion : One-year ICU-based educational programs on implementation of DVT prophylaxis were associated with a significant decrease in the incidence of DVT and also in the length of stay in ICU.     

Isolated fracture of the malleus handle: A video clip

Isolated malleus fracture is a rare clinical entity, and usually the handle of the malleus is involved. We report a video, to our knowledge the first in the literature, of a diagnostic otoscopy of a malleus fracture showing the movement of a left fractured malleus handle during a Valsalva maneuver (see the video online at www.laryngoscope.com ). Laryngoscope, 2010