Handlebar hernia with intra-abdominal extraluminal air presenting as a novel form of traumatic abdominal wall hernia: Report of a case

An 18-year-old male was admitted to our Emergency Department with a traumatic abdominal wall hernia (TAWH) of the left lower quadrant (LLQ) after suffering hypogastric blunt injury and urogenital lacerations in a motorcycle accident. Upright chest X-ray showed a small amount of right infradiaphragmatic free air, and a computed tomographic (CT) scan demonstrated an abdominal wall hernia. At surgery, no impairment was found in the digestive tract, and an abdominal herniorrhaphy was performed. It is suggested that the free air had passed through a connection between the scrotal laceration and the contralateral abdominal defect via the subcutaneous space and was palpated as emphysema. This is a new type of TAWH, which suggests that blunt abdominal trauma may result in negative pressure in the subcutaneous and peritoneal cavity, and this could reflect the pathophysiology of TAWH.     

Cerebral energy metabolism in patients with brain lesions at normo- and hyperbaric oxygen pressures

Summary The object of this study was to ascertain the oxygen tolerance limit and the oxygenation state of the injured brain in man. While breathing air, oxygen and hyperbaric oxygen at pressures of 1.5 and 2.0 atmospheres absolute (ATA), the cerebral arteriovenous differences (AVD) for O₂, glucose, lactate, pyruvate and blood gas pressures and pH values were measured. The balance of the cerebral glucose metabolism was calculated. The results showed that the injured brain did not tolerate the exposure to an oxygen pressure of 2.0 ATA for 10 to 15 min, but exposure to 1.5 ATA for 35–40 min was tolerated and had a favorable effect on the glucose or energy metabolism of the brain as well as on the clinical course. There was a distinctly increased cerebral glycolysis while breathing air indicating insufficient oxygen delivery to the brain. The change from breathing air to oxygen resulted in a distinct inhibition of cerebral glycolysis, which indicated improved cerebral oxygenation and energy production and gave evidence for a Pasteur effect regulating the glucose metabolism of the injured brain in man. At an inspiratory oxygen pressure of 1.5 ATA we had a nearly balanced cerebral glucose metabolism indicating an adequate cerebral oxygenation and energy formation. Further increase in inspiratory oxygen pressure to 2.0 ATA (performed only in group A) increased cerebral glycolysis considerably. This was assumed to be due to cerebral oxygen poisoning resulting in disturbed oxidative energy formation. Following this alteration an extreme reduction of the cerebral glucose uptake appeared, probably due to a disturbance of the specific glucose transport system. These metabolic alterations were not accompanied by seizures or any other clinical neurological manifestation. In group B, exposed to 1.5 ATA, such alterations of the cerebral glucose metabolism did not appear. A nearly balanced cerebral glucose metabolism was found at inspiratory oxygen pressures of 1.0 and particularly of 1.5 ATA, indicating an improved oxygenation and energy production of the affected brain. Finally, a renewed increase of the cerebral glycolysis occurred following the change from breathing oxygen to air. This again indicated an insufficient oxygen delivery to the affected brain.

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Zusammenfassung Ziel dieser Arbeit war es, die Wirkung verschiedener inspiratorischer O₂-Drucke auf den zerebralen Glukose- bzw. Energiestoffwechsel zu untersuchen. Dabei sollte insbesondere die Sauerstoff-Toleranzgrenze und der Zustand der Oxygenierung des geschädigten Hirns bestimmt werden. Unter Luft-, Sauerstoff und hyperbarer Sauerstoffatmung, d. h. bei Drucken von 1,5 und 2,0 Atmosphären, wurden die arterio-hirnvenösen Differenzen (AVD) für O₂, Glukose, Laktat, Pyruvat sowie die Blutgasdrucke und die pH-Werte gemessen. Die Bilanz des zerebralen Glukosestoffwechsels wurde bestimmt. Die Ergebnisse zeigten vor allem, daß das geschädigte Hirn eine Sauerstoffbelastung von 2,0 Atmosphären mit einer Expositionszeit von 10 bis 15 min nicht toleriert. Dagegen wurde eine Sauerstoffbelastung von 1,5 Atmosphären mit einer Expositionszeit von 35–40 min vertragen und hatte einen günstigen Einfluß auf den zerebralen Glukose- bzw. Energiestoffwechsel sowie auf den Krankheitsverlauf von traumatischen oder ischämischen Hirngewebsveränderungen. Während der Luftatmung fand sich eine erhebliche Steigerung der zerebralen Glykolyse, was auf eine mangelhafte O₂-Versorgung des Hirngewebes hinwies. Der Wechsel von Luft- auf Sauerstoffatmung führte zu einer deutlichen Hemmung der zerebralen Glykolyse. Dies zeigte eine Besserung der zerebralen Sauerstoffversorgung und Energieproduktion an und wies auf einen Pasteur Effekt bei der Regulation des Glukosestoffwechsels des geschädigten Hirns hin. Bei einem inspiratorischen Sauerstoffdruck von 1,5 Atmosphären war eine praktisch ausgeglichene Bilanz des zerebralen Glukosestoffwechsels nachweisbar, was für eine ausreichende Sauerstoffversorgung und Energiebildung des Hirns sprach. Der weitere Anstieg des inspiratorischen Sauerstoffdruckes auf 2,0 Atmosphären, der nur in Gruppe A durchgeführt wurde, bewirkte jedoch eine erhebliche Steigerung der zerebralen Glykolyse. Es ist anzunehmen, daß diese Stoffwechseländerung durch eine zerebrale Sauerstoffvergiftung hervorgerufen wurde, die vor allem zu einer Störung der oxydativen Energiegewinnung führte. Anschließend trat eine extreme Reduzierung der zerebralen Glukoseaufnahme auf, die am ehesten durch eine Störung des spezifischen Glukosetransportsystems des Hirns bedingt war. Diese Stoffwechselstörungen gingen nicht mit epileptischen Anfällen oder sonstigen klinisch-neurologischen Veränderungen einher. Bei den Patienten der Gruppe B, die nur mit einem Sauerstoffdruck von 1,5 Atmosphären belastet wurden, traten derartige Veränderungen des zerebralen Glukosestoffwechsels nicht auf. Eine praktisch ausgeglichene Bilanz des zerebralen Glukosestoffwechsels wurde bei inspiratorischen Sauerstoffdrucken von 1,0 und vor allem von 1,5 Atmosphären nachgewiesen und zeigte eine Besserung der Sauerstoffversorgung und Energiebildung des geschädigten Hirns an. Schließlich beobachteten wir nach dem Wechsel von Sauerstoff- auf Luftatmung einen erneuten Anstieg der zerebralen Glykose, was wiederum auf eine insuffiziente Sauerstoffversorgung des Hirns hinwies.

     

The clinical utility of provocative radionuclide oesophageal transit in the evaluation of non-cardiac chest pain

We combined edrophonium provocative testing with the technique of radionuclide oesophageal transit (RET) in 30 consecutive patients with non-cardiac chest pain (NCCP) and 12 controls. The oesophageal transit time of aqueous technetium-99m sulfur colloid was determined before and after intravenous infusion of 80 g/kg edrophonium chloride (ED). Patient symptoms during provocative RET (P-RET) were recorded. Thirteen (43%) of the patients had abnormal study results, whereas all control subjects had normal results. Three groups considered abnormal were observed: (a) in two patients (6%), the pain was reproduced and transit pre- and post-ED administration was prolonged (>15 s); (b) in six patients (20%), the pain was reproduced, but transit was normal pre- and post-ED; (c) in five patients (17%), transit pre- and post-ED was prolonged, but no pain was reproduced. In five patients (17%), ED prolonged the transit time > 15 s without pain, but the baseline transit was normal. Transit time was measurable in 23 patients. Mean pre-ED transit time was 10.2 ± 7.4 s (mean ± SD) and post-ED, 12.4 ± 8.0 s (P=0.3). We conclude that ED has no significant effect on transit time, and the pain induced by ED rarely correlates with an abnormal transit; P-RET provides additional information to baseline RET, increasing sensitivity, and may be a useful screening method in the evaluation of patients with NCCP.     

Urogenital injuries in childhood: A strong association of bladder trauma to bowel injuries

We analysed the inter-relationships of the cause and the type of trauma, the presence of pelvic fracture, the associated intraabdominal organ injuries,and the morbidity and mortality rates in 154 patients presenting and being treated for UGT between 1983 and 1997.The cause of injury was blunt in 77% of cases and penetrating in 13%. The most frequently injured organs were kidney followed by urethra and bladder. Bowels, liver and spleen were the most frequently associated injured organs. Moreover, bladder injuries were strongly associated with bowel injuries (p < 0.0001). Hemodynamically normal 49 children with minor or major kidney injuries were managed conservatively. Hemodynamically non-stable 11 patients were explored.The majority of urogenital injuries can be managed conservatively evenwhen associated with intraabdominal organ injuries. Solid genitourinary organ injuries may accompany more frequently to intraperitoneal solidorgan injury. Whereas, non-solid genitourinary organ injuries may more frequently associated with injuries of intraperitoneal hollow viscus. This revised version was published online in August 2006 with corrections to the Cover Date.     

Prevalence of Personality Disorders Among Combat Veterans with Posttraumatic Stress Disorder

Many combat veterans with PTSD have co-occurring symptoms of other forms of psychopathology; however, there have been limited studies examining personality disorders among this population. The few extant studies typically have assessed only two or three personality disorders or examined a small sample, resulting in an incomplete picture and scope of comorbidity. This study assessed all DSM-III-R personality disorders in 107 veterans in a specialized, inpatient unit. Using the Structured Clinical Interview for DSM-III-R Personality Disorders, 79.4% of the participants were diagnosed with at least one personality disorder: 29.9% received only one diagnosis, 21.5% had two, 15.9% had three, and 12.1% had four or more. The most frequent single diagnoses were Avoidant (47.2%), Paranoid (46.2%), Obsessive-Compulsive (28.3%), and Antisocial (15.1%) personality disorders.(116B)(116B-2)(323-E112)     

Ataque de Nervios and History of Childhood Trauma

Objective: Ataque de nervios is a common, self-labeled Hispanic folk diagnosis. It typically describes episodic, dramatic outbursts of negative emotion in response to a stressor, sometimes involving destructive behavior. Dissociation and affective dysregulation during such episodes suggested a link to childhood trauma. We therefore assessed psychiatric diagnoses, history of ataque, and childhood trauma in treatment-seeking Hispanic outpatients (N = 70). Significantly more subjects with an anxiety or affective disorder plus ataque reported a history of physical abuse, sexual abuse, and/or or a substance-abusing caretaker than those with psychiatric disorder but no ataque. In some Hispanic individuals, ataque may represent a culturally sanctioned expression of extreme affect dysregulation associated with childhood trauma. Patients with ataque de nervios should receive a thorough traumatic history assessment.     

A Correlational Test of the Relationship Between Posttraumatic Growth,Religion, and Cognitive Processing

The present study examined the degree to which event related rumination, a quest orientation to religion, and religious involvement is related to posttraumatic growth. Fifty-four young adults, selected based on prescreening for experience of a traumatic event, completed a measure of event related ruminations, the Quest Scale, an index of religious participation, and the Posttraumatic Growth Inventory. The three subscales of the Quest Scale, the two groups of rumination items (soon after event/within past two weeks), and the index of religious participation were entered in a standard multiple regression with the total score of the Posttraumatic Growth Inventory as the dependent variable. The degree of rumination soon after the event and the degree of openness to religious change were significantly related to Posttraumatic Growth. Congruent with theoretical predictions, more rumination soon after the event, and greater openness to religious change were related to more posttraumatic growth. Present findings offer some confirmation of theoretical predictions, and also offer clear direction for further research on the relationships of religion, rumination, and posttraumatic growth.     

“Amnesia” for Summer Camps and High School Graduation: Memory Work Increases Reports of Prior Periods of Remembering Less

Claims regarding amnesia for childhood sexual abuse have often been based on studies of adults' responses to questions of the form, “Was there ever a period of time when you remembered less of the abuse than you do now?” In this experiment, 43 adult (mean age = 42) participants rated their current and prior memories of several nontraumatic childhood/adolescent events. Reports of prior periods of less memory were fairly common. Participants then engaged in “reminiscence” or “enhanced” retrieval activities directed toward remembering more about a selected target event. Following retrieval, 35% of the reminiscence condition participants reported prior poor memory for the target event, as did 70% of the enhanced condition. These results highlight the need for appropriate control conditions in retrospective studies of amnesia for childhood trauma.     

Hair cell loss and regeneration after severe acoustic overstimulation in the adult pigeon

The extent of hair cell regeneration following acoustic overstimulation severe enough to destroy tall hair cells, was determined in adult pigeons. BrdU (5-bromo-2′-deoxyuridine) was used as a proliferation marker. Recovery of hearing thresholds in each individual animal was measured over a period of up to 16 weeks after trauma. In ears with loss of both short and tall hair cells, little or no functional recovery occurred. In ears with less damage, where significant functional recovery did occur, there were always a few rows of surviving hair cells left at the neural edge of the basilar papilla. In the region of hair cell loss, numerous BrdU labeled cells were found. However, only a small minority of these cells were regenerated hair cells, the majority being monolayer cells. Irrespective of the extent of the region of hair cell loss, regenerated hair cells were observed predominantly in a narrow strip at the transition from the abneural area of total hair cell loss and the neural area of hair cell survival. With increasing damage this strip moved progressively towards the neural edge of the papilla. No regeneration of hair cells was observed in the abneural region of total hair cell loss, even up to 16 weeks after trauma. The results indicate that there is a gradient in the destructive effect of loud sound across the width of the basilar papilla, from most detrimental at the abneural edge to least detrimental at the neural edge. Both tall and short hair cells can regenerate after sound trauma. Whether they do regenerate or not depends on the degree of damage to the area of the papilla where they normally reside. Regeneration of new hair cells occurs only in a narrow longitudinal band, which moves from abneural into the neural direction with increasing damage. In the area neural to this band, hair cells survive the overstimulation. In the area abneural to this band, sound damage is so severe, that no regeneration of hair cells occurs. As a consequence morphological and functional deficits persist.     

脑疝复位天幕切开与常规手术治疗重型脑外伤脑疝的临床对照研究

目的　比较脑疝复位天幕裂孔切开与常规去骨瓣手术治疗重型脑外伤引起脑挫裂伤脑水肿、颅内血肿出现脑疝晚期患者的手术效果。方法　共收治重型脑外伤脑疝晚期患者5 6例,分为2组:脑疝复位组31例;常规手术组2 5例。患者术前GCS计分均为3～5分、双瞳孔散大或有不同程度散大,所有患者都经头颅CT扫描确定脑损伤情况。结果　患者术后存活者随访1a ,脑疝复位组:恢复良好/中残1 0例、重残/长期昏迷7例、死亡1 4例(45 %) ;常规手术组:恢复良好/中残1例、重残/长期昏迷3例、死亡2 1例(84 %) (P <0 .0 5 )。脑疝复位组术后大脑后动脉梗死、应激性溃疡、脑积水发生率明显低于常规手术组(P均<0 .0 5 )。结论　脑疝复位天幕裂孔切开治疗重型脑外伤引起脑挫裂伤脑水肿、颅内血肿出现脑疝晚期患者疗效明显优于常规去骨瓣手术。