Unusually extensive head trauma in a hydraulic elevator accident: post-mortem MSCT findings, autopsy results and scene reconstruction

Accidental or intentional falls from a height are a form of blunt trauma and occur frequently in forensic medicine. Reports describing elevator accidents as a small subcategory of falls from heights are rare in the medical literature and no report on injury patterns or scene reconstruction of such an accident was found. A case of an accident in a hydraulic elevator with a man falling 3m was examined using post-mortem multi-slice computed tomography (MSCT) and autopsy. The man suffered an unusually extensive trauma and died at the scene. Post-mortem MSCT examination showed a comminute fracture of the skull, the right femur and the first lumbar vertebra. Severe lacerations of the brain with epidural, subdural and subarachnoidal haemorrhages over both hemispheres were diagnosed. Autopsy confirmed these findings. To reconstruct the accident we used radiological and autopsy results as well as findings at the scene.     

Dual blockade of the renin-angiotensin system in type 1 patients with diabetic nephropathy.

BACKGROUND: Albuminuria and hypertension are predictors of poor renal and cardiovascular outcome in patients with diabetes. Approximately 30% of type 1 patients with diabetic nephropathy (DN) have albuminuria >1 g/day, and blood pressure >135 and/or >85 mmHg despite antihypertensive therapy with recommended doses of ACE inhibitor (ACEI) and diuretics. We tested the effect of dual blockade of the renin-angiotensin system (RAS) in these patients. METHODS: We performed a randomised double blind crossover trial with 2 months treatment with Irbesartan 300 mg o.d. and placebo added on top of previous antihypertensive treatment. We included 21 type 1 patients with DN responding insufficiently to ACEI and diuretics, as defined above. At the end of each treatment period, albuminuria, 24-h blood pressure and glomerular filtration rate (GFR) were measured. RESULTS: Addition of 300 mg Irbesartan to the patients' usual antihypertensive therapy induced a mean reduction in albuminuria of 37% (95% CI 20-49, P<0.001); from 1574 mg/24 h (95% CI 1162-2132) to 996 mg/24 h (95% CI 699-1419), a reduction in 24-h blood pressure of 8 mmHg systolic (95% CI -2 to 18) and 5 mmHg diastolic (95% CI 1-9) (P=0.11 and 0.01, respectively) (from placebo, mean (SE) 146 (4)/80 (2) mmHg). GFR remained unchanged. Serum potassium increased (mean 4.3 to 4.6 mmol/l, P=0.02). Intervention to reduce serum potassium was needed in two patients with GFR <35 ml/min/1.73 m(2). Otherwise the dual blockade with Irbesartan was safe and well tolerated. CONCLUSIONS: Dual blockade of the RAS may offer additional renal and cardiovascular protection in type 1 patients with DN responding insufficiently to conventional antihypertensive therapy, including recommended doses of ACEI and diuretics.     

Prevalence of prostatitis-like symptoms in a community based cohort of older men

PURPOSE: We describe a community based study to estimate the prevalence of prostatitis-like symptoms using questions similar to the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI). MATERIALS AND METHODS: Study subjects were a randomly selected sample of Olmsted County, Minnesota white men 40 to 79 years old in January 1990 who participated in a longitudinal study of lower urinary tract symptoms. Subjects were evaluated biennially using self-administered questionnaires. In 2000 questions similar to the NIH-CPSI were incorporated into the questionnaire and questionnaire responses were used to categorize men as having prostatitis-like symptoms. RESULTS: Of 1,541 men 182 (12%) had at least 1 urogenital pain symptom. Pubic (76 men, 4.9%) and testicular (73, 4.7%) pain were the most frequent pain symptoms. A total of 34 men with prostatitis-like symptoms (2.2%) had higher mean pain (6.7 versus 0.5), urinary symptom (3.5 versus 2.1) and quality of life impact (3.7 versus 1.9) scores compared to men who did not (all p <0.001). Pain frequency (OR 39.2, 95% CI 18.8, 81.9) and pain intensity (OR 21.5, 95% CI 8.7, 52.9) were more strongly associated with prostatitis-like symptoms than urinary symptom score (OR 2.8, 95% CI 1.4, 5.6) or quality of life impact score (OR 4.5, 95% CI 1.9, 10.7). CONCLUSIONS: Although urogenital pain is common among community dwelling men, prostatitis-like symptoms based on the modified questions from the NIH-CPSI are less common. While pain measures may be useful in distinguishing between men with and without prostatitis-like symptoms, the urinary symptom and quality of life impact scores could partly reflect benign prostatic hyperplasia.     

Statin use and decreased risk of benign prostatic enlargement and lower urinary tract symptoms

Study Type – Prevention (individual cohort)
Level of Evidence 2b What’s known on the subject? and What does the study add? Statin medications reduce inflammation. Inflammation may be important in causing prostate enlargement and lower urinary tract symptoms in aging men. Therefore, statin use may decrease inflammation and help prevent prostate enlargement and lower urinary tract symptoms. Men who took statin medications were less likely to develop an enlarged prostate or lower urinary tract symptoms compared to men who did not take statins. Additionally, men who took statins for the longest period of time had the lowest risk of developing these urological problems. These results suggest that statin use may help prevent common urological problems in aging men.

OBJECTIVE

• ? To determine whether statin use is associated with a decreased risk of developing benign prostatic enlargement (BPE) and lower urinary tract symptoms (LUTS).

SUBJECTS AND METHODS

• ? We conducted a retrospective, population‐based cohort study of 2447 men, 40–79 years of age, residing in Olmsted County, MN, USA, in 1990, and followed these men biennially through 2007.
• ? Cox proportional hazard models were used to assess associations between statin use and new onset of moderate/severe LUTS (American Urological Association Symptom Index score >7), a decreased maximum urinary flow rate (<12 mL/s) or BPE (prostate volume >30 mL).

RESULTS

• ? Statin use was inversely associated with new onset of LUTS (Hazard ratio (HR) 0.39; 95% confidence interval (CI) 0.31–0.49), a decreased maximum flow rate (HR 0.53; 95% CI 0.34–0.82) and BPE (HR 0.40; 95% CI 0.23–0.69) after adjustment for baseline age and body mass index, diabetes, hypertension, coronary heart disease, smoking, alcohol use, activity level and non‐steroidal anti‐inflammatory use.
• ? The longest duration of statin use was associated with the lowest risk of developing each outcome (all tests for trend: P < 0.001).

CONCLUSION

• ? In this study, statin use was associated with a 6.5‐ to 7‐year delay in the new onset of moderate/severe LUTS or BPE.
• ? While men typically take statin medications to prevent coronary heart disease events and related outcomes, these data suggest that men who use statins may also receive urologic benefits.

     

Hip fractures in a city in Northern Norway over 15?years: time trends, seasonal variation and mortality

Summary  

In this open population-based study from Northern Norway, there was no increase in hip fracture incidence in women and men from 1994 to 2008. Age-adjusted hip fracture rates was lower compared to reported rates from the Norwegian capital Oslo, indicating regional differences within the country.     

Malignant peripheral nerve sheath tumor mimicking carotid body tumor--case report and review

Malignant peripheral nerve sheath tumor is a rare neurogenic tumor that usually presents in geriatic patients. Typically, it is found in the trunk and extremities and rarely presents in the head and neck region. It may mimic a carotid body tumor when it presents in the neck. We report the first case of malignant peripheral nerve sheath tumor of the vagus nerve in an adolescent boy. He presented with an asymptomatic lateral neck lump that was thought to be a benign schwannoma on preoperative imaging. We describe the diagnostic dilemma and management difficulties in this patient and review the literature.     

Diabetes and sexual dysfunction: results from the Olmsted County study of urinary symptoms and health status among men

PURPOSE: We examined the association of diabetes and domains of sexual dysfunction in a population based sample of men residing in Olmsted County, Minnesota. MATERIALS AND METHODS: A cohort of 2,115 white men 40 to 79 years old as of January 1, 1990 was randomly selected from the Olmsted County population. Men who had a history of prostate or bladder surgery, urethral surgery or stricture, or medical or other neurological condition that could affect normal urinary function were excluded from analysis. Diabetes itself was not used as an exclusionary criterion, although those with end stage organ failure as a result of diabetes were excluded. A previously validated male sexual function index was included in the questionnaires administrated to the cohort in 1996, which consisted of 11 questions on the 5 sexual function domains of sexual drive, erectile function, ejaculatory function, sexual problem assessment and sexual satisfaction. The baseline questionnaire also included whether they had ever been diagnosed by a physician as having diabetes. Only men with regular sexual partners were included. RESULTS: Individuals with diabetes at baseline had significantly greater dysfunction in all 5 sexual function domains. In multivariate adjusted analyses diabetes was significantly associated with all sexual dysfunction domains. The associations remained significant after adjusting for numerous predictors of sexual dysfunction. CONCLUSIONS: The presence of diabetes at baseline was significantly associated not only with erectile dysfunction but with all aspects of sexual dysfunction, including sexual drive, ejaculatory function, sexual problems and sexual satisfaction in this population based sample of men residing in Olmsted County.     

Randomized clinical trial comparing radially expanding trocars with conventional cutting trocars for the effects on pain after laparoscopic cholecystectomy

Background Trocar incisions are important sources of pain the first days after laparoscopic cholecystectomy. Radially expanding trocars may cause less pain than conventional cutting trocars. Methods In a patient- and observer-blinded trial, 80 patients were randomized to undergo laparoscopic cholecystectomy using either radially expanding trocars (radial group) or conventional cutting trocars (cutting group). Two 10-mm and two 5-mm trocars were used in both treatment groups. All the patients received standardized anesthetic and analgesic treatment. The primary outcome was incisional pain. Pain was registered during mobilization using a visual analog scale (VAS) and a verbal rating scale (VRS) before and 6 h after the operation, and at postoperative days 1 and 2. The needs for a fascial incision to retract the gallbladder, active surgical hemostasis, and supplementary requirements of opioids during the hospital stay were registered. In addition, 2 days after the operation, the incidence and severity of suggilations at the trocar incisions were measured. Results Data from 77 patients were available for statistical analysis. In the radial group, 23 patients needed fascial incision for gallbladder retraction compared with 11 patients in the cutting group (p = 0.006). No significant intergroup differences in VAS or VRS pain scores or any other variable were found. Conclusions The use of radially expanding trocars has no effect on incisional pain after laparoscopic cholecystectomy.     

Integrity of the lateral femoral wall in intertrochanteric hip fractures: an important predictor of a reoperation

BACKGROUND: Reoperations after intertrochanteric fractures are often necessitated by fracture displacement following mobilization of the patient. The biomechanical complexity of the fracture, the position of the implant, and the patient's characteristics are known to influence postoperative outcome. We investigated the importance of an intact lateral femoral wall as a factor in postoperative fracture displacement after fixation with a sliding compression hip screw. METHODS: Two hundred and fourteen consecutive patients with an intertrochanteric fracture were treated with a 135 degrees sliding compression hip screw with a four-hole side-plate between 2002 and 2004. The fractures were classified on preoperative radiographs according to the AO/OTA classification system. The status of the greater and lesser trochanters, the integrity of the lateral femoral wall, and the position of the implant were assessed postoperatively. Reoperations due to technical failure were recorded for six months postoperatively. RESULTS: Only 3% (five) of 168 patients with an intact lateral femoral wall postoperatively underwent a reoperation within six months, whereas 22% (ten) of forty-six patients with a fractured lateral femoral wall were operated on again (p < 0.001). Multivariate logistic regression analyses combining demographic and biomechanical parameters showed a compromised lateral femoral wall to be a significant predictor of a reoperation (p = 0.010). Seventy-four percent (thirty-four) of the forty-six fractures of the lateral femoral wall occurred during the operative procedure itself. A fracture of the lateral femoral wall occurred in only 3% (three) of the 103 patients with an AO/OTA type-31-A1.1, A1.2, A1.3, or A2.1 intertrochanteric fracture compared with 31% (thirty-one) of the ninety-nine with an AO/OTA type 31-A2.2 or A2.3 fracture (p < 0.001). CONCLUSIONS: A postoperative fracture of the lateral femoral wall was found to be the main predictor for a reoperation after an intertrochanteric fracture. Consequently, we concluded that patients with preoperative or intraoperative fracture of the lateral femoral wall are not treated adequately with a sliding compression hip-screw device, and intertrochanteric fractures should therefore be classified according to the integrity of the lateral femoral wall, especially in randomized trials comparing fracture implants.     

Effect of body mass index on the outcomes of patients with upper and lower urinary tract cancers treated by radical surgery: Results from a Canadian multicenter collaboration

ObjectiveTo evaluate the effect of body mass index (BMI) on the outcomes of patients with urinary tract carcinoma treated with radical surgery.Materials and methodsData were collected from 10 Canadian centers on patients who underwent radical cystectomy (RC) (1998–2008) or radical nephroureterectomy (RNU) (1990–2010). Various parameters among subsets of patients (BMI<25, 25≤BMI<30, and BMI≥30 kg/m²) were analyzed. Kaplan-Meier and multivariate analyses were performed to assess the effect of BMI on overall survival, disease-specific survival, and recurrence-free survival (RFS).ResultsAmong the 847 RC and 664 RNU patients, there was no difference in histology, stage, grade, and margin status among the 3 patient subsets undergoing either surgery. However, RC patients with lower BMIs (<25 kg/m²) were significantly older (P = 0.004), had more nodal metastasis (P = 0.03), and trended toward higher stage (P = 0.052). RNU patients with lower BMIs (<25 kg/m²) were significantly older (P = 0.0004) and fewer received adjuvant chemotherapy (P = 0.04) compared with those with BMI≥30 kg/m²; however, there was no difference in tumor location (P = 0.20), stage (P = 0.48), and management of distal ureter among the groups (P = 0.30). On multivariate analysis, BMI was not prognostic for overall survival, disease-specific survival, and RFS in the RC group. However, BMI≥30 kg/m² was associated with more bladder cancer recurrences and worse RFS in the RNU group (HR = 1.588; 95% CI: 1.148–2.196; P = 0.0052).ConclusionsIncreased BMI did not influence survival among RC patients. BMI≥30 kg/m² is associated with worse bladder cancer recurrences among RNU patients; whether this is related to difficulty in obtaining adequate bladder cuff in patients with obesity requires further evaluation.