Post-traumatic pancreatitis with left pyelo-pancreatic fistula]

The authors report a case of special anatomical interest and emphasize the frequency of post-traumatic pancreatitis, the importance of cutaneous and joint manifestations revealing certain pancreatic diseases.     

Chronic obstructive pancreatitis as a delayed complication of pancreatic trauma.

Increasing surgical experience with the immediate consequences of pancreatic injuries has resulted from parallel growth in the volume of motor vehicle accidents and societal violence. However, few surgeons are aware that complications may be considerably delayed following pancreatic trauma, occurring in some cases months to years after apparent recovery from the original injury. In four patients with blunt pancreatic trauma initially treated by non-operative means, stricture of the main pancreatic duct developed over a period of months as a result of progressive fibrosis at the site of ductal injury. Pancreatic duct hypertension was demonstrated to be present in the obstructed duct, and secondary changes of chronic pancreatitis developed in the obstructed segment of the gland ("upstream" chronic pancreatitis). Seven similar patients with delayed onset of chronic obstructive pancreatitis after pancreatic trauma were found in the literature. Symptoms related to these acquired ductal strictures are most commonly those of abdominal pain and recurrent episodes of acute pancreatitis. Recognition of post-traumatic chronic obstructive pancreatitis principally involves awareness that injuries to the pancreatic duct can produce remote complications. Pancreatoenteric drainage, or resection of the obstructed segment of pancreas, provides prompt and effective relief.     

Traumatic pancreatitis and pseudocyst in children: current management

Twenty years ago, we reviewed the pediatric surgical experience with traumatic pancreatitis and pseudocysts at a large children's hospital. That series encompassed 13 years, during which time 23 cases were found. Six of these had pseudocysts, five of which were managed by external catheter drainage and one by excision. The present series spans 10 years and consists of nine cases of post-traumatic pediatric pancreatitis, seven of which progressed to pseudocysts. Four of these were externally drained, one was excised, and two resolved spontaneously. We have reviewed this recent experience in order to re-evaluate the efficacy of external drainage of pseudocysts in pediatric patients. We continue to believe that external drainage is the most effective method of therapy. Internal drainage is usually unnecessary unless the drainage from the ductal disruption does not resolve.     

Episodes of amnesia following whiplash injury to the cervical spine

A so-called conscious post-traumatic twilight state ("besonnener D?mmerzustand") after a whiplash injury is described here, showing up its similarities with a classic post-traumatic conscious twilight state on the one hand and a classic transient global amnesia on the other hand. The term "conscious twilight state" is analysed and found inappropriate for the state it is meant to describe, and hence the term "post-traumatic transient global amnesia" is proposed instead. A post-traumatic transient global amnesia after whiplash injury is considered to be caused by a concussion.     

Ulnar procedures for post-traumatic disorders of the distal radioulnar joint

Post-traumatic abnormality of the distal radioulnar joint (DRUJ) still presents a therapeutic challenge to orthopaedic surgeons. The most common difficulty is a failure to diagnose these injuries early, resulting in chronic post-traumatic disorders of the DRUJ. The main aim of therapy is to avoid adverse sequelae. This is of particular importance in malunion of the distal radius, the most common cause for post-traumatic disorders of the DRUJ. Distal radial malunion can be avoided by early appropriate treatment and the need for subsequent ulnar procedures reduced. Ulnar procedures for post-traumatic disorders of the DRUJ are intended to improve function and to decrease pain. Many methods to improve post-traumatic DRUJ function have been described. This article reviews the current state of the art in dealing with post-traumatic disorders of the distal radioulnar joint and presents algorithms to help in decision making.     

Pathophysiologie der posttraumatischen Osteitis

Over the last few decades, significant reduction of post-traumatic infections could be attained by establishing novel surgical techniques and tactics, by adapting surgical decisions to the risk of infection, by employing chemotherapeutic agents, and by developing new implants. Here a novel understanding of the pathophysiologic mechanisms of post-traumatic and postoperative osteomyelitis were directive. Nevertheless, post-traumatic infections later cause significant physical and economic sequelae. This article sums up the fundamental pathophysiological mechanisms of post-traumatic infection. New ideas about post-traumatic prevention and therapy of osteomyelitis are discussed.     

Risk factors for the development of post-traumatic cerebral vasospasm

BACKGROUND: Post-traumatic vasospasm is a well-recognized sequela of head injury. The risk factors associated with post-traumatic vasospasm have not been well defined. We studied 119 consecutive patients with head injury to determine the risk factors for post-traumatic vasospasm. METHODS: Twenty-nine (27.1%) patients were excluded from the study because of poor insonation (n = 12) or a hospital stay of less than 72 hours (n = 17). Seventy (77.8%) of 90 patients suffered severe head injury. Sixteen (17.8%) patients sustained moderate head injury and four (4.4%) patients sustained mild head injury. All patients were monitored with transcranial Doppler (TCD) ultrasonography daily. RESULTS: Post-traumatic vasospasm was detected in 32 (35.6%) of 90 patients. Among these patients, 29 (90.6%) had severe head injury, and three (9.4%) had moderate head injury. None of the patients with mild head injury suffered post-traumatic vasospasm. In most cases, the onset of post-traumatic vasospasm began on the fifth day and lasted 1 to 9 days. In 8 (25%) patients, post-traumatic vasospasm began within the first three days of the head injury. Among 32 patients with post-traumatic vasospasm, 10 (31.2%) patients had mild vasospasm, 20 (65.5%) had moderate vasospasm, and 2 (6.3%) had severe post-traumatic vasospasm. Clinical deterioration was documented in two (2.5%) patients. CONCLUSIONS: Development of post-traumatic vasospasm correlated only with severe subarachnoid hemorrhage on initial computed tomographic scan. There was an increased incidence of post-traumatic vasospasm in patients with epidural hematomas, subdural hematomas, and intracerebral hemorrhages. The Glasgow Coma Scale (GCS) score on admission was inversely related to the development of post-traumatic vasospasm. In most cases, the period of vasospasm was short and clinical deterioration was rare. Probably, two varieties of post-traumatic vasospasm exist, one that lasts a shorter time and does not correlate with the presence of SAH, and a second that correlates with the presence of SAH, lasts longer, and resembles aneurysmal vasospasm.     

Pathophysiology of posttraumatic osteitis

Over the last few decades, significant reduction of post-traumatic infections could be attained by establishing novel surgical techniques and tactics, by adapting surgical decisions to the risk of infection, by employing chemotherapeutic agents, and by developing new implants. Here a novel understanding of the pathophysiologic mechanisms of post-traumatic and postoperative osteomyelitis were directive. Nevertheless, post-traumatic infections later cause significant physical and economic sequelae. This article sums up the fundamental pathophysiological mechanisms of post-traumatic infection. New ideas about post-traumatic prevention and therapy of osteomyelitis are discussed.     

IQ levels following trauma

One hundred fifteen consecutive trauma patients who experienced a head injury and were administered a Wechsler Intelligence Scale as outpatients were selected for study from the Neuropsychology Registry. These patients ranged in age from 4 to 61 years. At the time of examination, all were living at home with their families. Dividing this group of patients on the basis of a Glasgow Coma Score (GCS) of 10 revealed significant differences in group mean post-traumatic IQs. The more severely injured group of patients had a mean post-traumatic IQ of 93.6; the less severely injured patients had a mean IQ of 103.5. The difference between these two groups is significant (p less than 0.005). When divided on the basis of a GCS of 13, the more severely injured group of patients had a mean post-traumatic IQ of 94.2 and the less severely injured group of patients had a mean post-traumatic IQ of 104.2. The difference between these two groups is also statistically significant (p less than 0.0005). There was no statistically significant (p greater than 0.05) difference in the mean post-traumatic IQs of these patients divided on the basis of an Injury Severity Score (ISS) of 15. However, there was a significant difference (p less than 0.05) when the patients were divided at ISS of 17. The less severely injured patients had a mean post-traumatic IQ of 101.2 and the more severely injured patients had a mean post-traumatic IQ of 95.8. The difference between these two groups is statistically significant (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Obstruction-strangulation of post-traumatic diaphragmatic hernia--delayed diagnosis and fatal outcome

The radiological and clinical features of 9 cases of obstructed post-traumatic diaphragmatic hernia are reviewed. In none of these patients was the diagnosis of a diaphragmatic hernia considered before radiography, all cases being clinically diagnosed as 'acute abdomen', most frequently pancreatitis or perforated peptic ulcer. Even after radiographs had shown opacity at the left base in all 9 cases, together with a distended proximal bowel in 6, the correct diagnosis was made in only 4. Through lack of correct radiological diagnosis, there was a delay of at least 1 day between admission and operation in 6 patients, and 3 of the 4 deaths occurred in this group. Obstruction-strangulation of diaphragmatic hernia should be considered as a possible cause of 'acute abdomen' in the presence of a left basal abnormality, especially in patients from areas with a high incidence of assault. Confirmatory contrast studies should be done only if they can be done immediately and quickly. Pregnancy can cause hernias to become obstructed and strangulated, but this can be averted by obtaining a history of previous trauma early in the pregnancy.     

The effectiveness of cognitive-behavioural therapy for post-traumatic headaches

Post-traumatic headache is one of the most common symptoms following mild and moderate head injury. Psychological factors are believed to play a role in the cause, maintenance and relief from chronic post-traumatic headache. This research evaluated the effectiveness of a multi-dimensional cognitive-behavioural approach towards rehabilitation of post-traumatic headaches. The sample included 20 participants with post-traumatic headaches from an original sample of 41. Participants acted as their own controls. Outcome measures consisted of self-rating questionnaires to assess headache severity, intensity, duration, functioning and emotional well-being. Emotional and functional headache characteristics were studied using a multi-dimensional investigation which included relatives' perceptions of the sufferers headaches. The intervention proved effective and beneficial for the 20 therapy participants. It is concluded that cognitive-behavioural therapy provides a useful supplement to the treatment of post-traumatic headache.     

Post-traumatic high flow priapism: Demonstrable findings of penile enhanced computed tomography

Post-traumatic high flow priapism is a rare disease. A review of English published reports revealed 63 cases. Enhanced computed tomography (CT) of the penis has not previously been used as a diagnostic method for post-traumatic high flow priapism. We present a case of post-traumatic high flow priapism diagnosed with enhanced CT of the penis. Additionally, diagnostic modalities for post-traumatic high flow priapism are discussed with review of published work.     

Epidemiological risk factors for non-traumatic osteonecrosis

Certain fractures and/or dislocations of the femoral head are known to cause arterial injury and result in post-traumatic osteonecrosis. However, the more complex etiology of non-traumatic osteonecrosis is multifactorial and includes chemotherapy, radiotherapy, thermal injuries, and especially coagulopathies, which are now commonly observed in these patients. Intravascular coagulation with fibrin thrombosis begins in the capillaries and sinusoids of the intraosseous microcirculation, and residual venous thrombosis is more likely to occur if there is coexistent hypofibrinolysis. Coagulopathies are intermediary events, which are always activated by some underlying etiologic risk factor(s). Conditions capable of triggering intravascular coagulation include familial thrombophilia (resistance to activated protein C, decreased protein C, protein S, or antithrombin III, and hyperhomocystinemia), hyperlipemia and embolic lipid (alcoholism and hypercortisonism), hypersensitivity reactions (allograft organ rejection, immune complexes, and antiphospholipid antibodies), bacterial endotoxic (Shwartzman) reactions and various viral infections, proteolytic enzymes (pancreatitis), tissue factor release (inflammatory bowel disease, malignancies, neurotrauma, and pregnancy), and other thrombophilic and hypofibrinolytic disorders. Currently known risk factors for non-traumatic osteonecrosis of the femoral head are described briefly in this review article.     

Respiratory insufficiency in severely burned patients]

The increasing number of respiratory insufficiency, as well as of pulmonary complications after burns and their role in the post-traumatic mortality are pointed out by the author.The pathophysiological processes responsible for the development of post-traumatic pulmonary complications are shortly resumed. In respect of the clinical picture, three groups are distinguished by the author. One case is reported in detail. In the development of post-traumatic respiratory insufficiency important role is attributed by the author to the syndromes of micro-embolism. This supposition is supported by the laboratory examination of 10 patients. Finally the problems of prevention and therapy are discussed and the importance of the iatrogenic damages is emphasized.     

Traumatic responses among battered women who kill

This study compared levels of violence, social support, and post-traumatic stress between battered women charged with a violent crime against an abusive partner and those seeking help from a mental health clinic. Results indicated that forensic battered women were more likely than clinical battered women to report experiencing severe violence, including sexual abuse, in their relationships. Women in the forensic sample also reported less social support and greater post-traumatic stress than women in the clinical sample. However, when social support and level of violence were accounted for, levels of general post-traumatic stress indicators (MMPI-PTSD, CR-PTSD, GSI) were no longer different between groups, although levels of specific post-traumatic stress indicators (intrusion, avoidance) remained higher for battered women in the forensic sample. Implications for understanding battered women's response to violence and their post-traumatic reactions to it are discussed.     

The collapse of a structure: A structural approach to trauma

Applying an analytic approach to the concept of trauma, the authors differentiate trauma from other stress disorders and define trauma as the collapse of the structure of self along all its referential planes, resulting from the encounter of a catastrophic threat and a chaotic response, producing the unique traumatic experience. The post-traumatic state is conceptualized as a reorganizing transitional state, aimed at restoring autonomy, which can proceed by encapsulation only. The post-traumatic stress disorder is regarded as the manifest clinical syndrome of the post-traumatic state. By providing a systematic conceptual framework, the analytic structural approach to trauma allows clearer guidelines for the diagnosis and treatment of traumatized patients.     

Post-traumatic headache

Opinion statement  

Early seizures following non-penetrating traumatic brain injury in adults: risk factors and clinical significance

Background : In the literature dissenting data are obtained about risk factors for early post-traumatic seizures and their impact on outcome. This study was conducted to obtain more information about the clinical significance of early seizures and their possible impact on the treatment of traumatic brain injury.

Methods and results : A consecutive series of 1868 adult patients with head injury were analysed retrospectively. Demographic data of the patients, characteristics of the injury, and findings on CT scan were recorded. Risk factors for early post-traumatic seizures were identified using univariate statistics. A multivariate logistic regression was performed to look for interaction of different variables. The impact of early post-traumatic seizures on outcome was examined in an analogous way. Chronic alcohol abuse, subdural haematoma and brain contusion were identified as independent risk factors for early post-traumatic seizures. A significant association of early post-traumatic seizures with an unfavourable outcome was observed, but this effect was small compared to other variables.

Conclusions : Early post-traumatic seizures appear to be an acute reaction of the brain to cortical damage with little independent impact on the management of head injury.     

Autoimmune pancreatitis: unveiling a hidden entity

HYPOTHESIS: After alcohol-induced and hereditary disease, idiopathic chronic pancreatitis is the most common cause of calcifying pancreatitis. This designation is used when no associated cause of chronic pancreatitis is found. We present 6 cases of idiopathic pancreatitis in which the postoperative pathological examination results demonstrated lymphoplasmacytic sclerosing pancreatitis or autoimmune pancreatitis. DESIGN: Retrospective case series. The medical records of 6 patients referred and treated for autoimmune pancreatitis were reviewed. The duration of follow-up varies, the longest being 5 years. The disease and a literature review are reported. SETTING: A 200-bed community hospital located in a large city. The patients were referred after being treated elsewhere for recurrent pancreatitis. PATIENTS AND METHODS: Six patients with chronic recurrent pancreatitis were evaluated. They were selected because pathological review indicated that they all had autoimmune pancreatitis. RESULTS: Six cases of lymphoplasmacytic sclerosing pancreatitis are presented and suggest that lymphoplasmacytic sclerosing pancreatitis should be thought of more often in chronic autoimmune pancreatitis. CONCLUSION: Lymphoplasmacytic sclerosing pancreatitis is an increasingly recognized cause of chronic pancreatitis and should be considered in the evaluation of patients with chronic pancreatitis and no discernible cause.     

Relationship between postpartum mood disorder and birth experience: a prospective observational study

BackgroundThis study aims to investigate the relationship between the birth experience and the risk of developing postpartum depression or post-traumatic stress disorder.MethodsIn this prospective, longitudinal, observational study, women were assessed at different time points for depression and post-traumatic stress disorder. The risk of depression or post-traumatic stress disorder based on patient characteristics and specific birth events was assessed within three months postpartum.ResultsWe enrolled 600 women; 426 were eligible for postpartum assessment. At six weeks and three months postpartum, 15.9% and 12.7% screened positive for depression respectively. Positive post-traumatic stress disorder screenings at six weeks and three months postpartum were 6.2% and 5.1% respectively. Twenty-seven women (8.3%) with a negative screening at six weeks converted to a positive depression or post-traumatic stress disorder screening at three months. A pre-existing history of anxiety or depression was associated with an increased risk of developing depression (aOR 2.12, 95% CI 1.30 to 3.47) and post-traumatic stress (aOR 3.15, 95% CI 1.42 to 7.02) within three months postpartum. The risk of developing post-traumatic stress disorder within three months postpartum was also increased among patients experiencing their first delivery (aOR 2.55, 95% CI 1.10 to 5.88) or operative management of postpartum hemorrhage (aOR 4.44, 95% CI 1.16 to 17.02).ConclusionDepression and post-traumatic stress symptoms either persisted or had new onset at three months postpartum. Mental health screening and postpartum follow-up after six weeks should be considered in high-risk patients who have a history of psychopathology, nulliparity, or undergo operative management of postpartum hemorrhage.