Asymmetries in Visual-Spatial Processing Following Childhood Stroke.

The authors compared hemisphere-based and cognitive-domain-based hypotheses for visual-spatial deficits in children with stroke (n = 33) and children without stroke (n = 43). Children with unilateral left (n = 14) or right (n = 7) injury showed less efficient search for the visual field contralateral to their injury. Right-hemisphere injury was associated with deficient global-level processing and coordinate spatial judgments. Left-hemisphere injury resulted in relatively intact local versus global processing and categorical versus coordinate judgments. Bilateral injury (n = 12) resulted in disruption of visual search across visual fields and relative deficits in global-level processing and coordinate spatial judgments. Recovery of visual-spatial processing in children following childhood stroke is task specific. Certain visual-spatial functions typically mediated by the left hemisphere appear less vulnerable to disruption. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Lateral distraction injury to the lumbar spine. Report of spontaneous reduction

STUDY DESIGN: A patient with a lateral distraction injury of the lumbar spine that reduced spontaneously and not associated with any thoracic or abdominal injury is reported. SUMMARY OF BACKGROUND DATA: A brief summary of the clinical presentation is given as is the surgical technique employed. Lateral distraction injuries of the thoracolumbar spine associate a distraction injury with lateral bending in the frontal plane, causing unilateral disruption of the ligamentous and osseous restraints. The have been associated with life-threatening thoracic and abdominal injuries. Closed reduction of this spine injury is not believed to be feasible. CONCLUSIONS: This case introduces interesting new features to this spine lesion. It is the first reported case with documented spontaneous reduction.     

Management of 53 cases of testicular trauma

Fifty-three patients with testicular injury were investigated. Four (8%) had bilateral testicular injury and 15 (28%) had associated injuries, such as penile, spermatic cord, epididymal disruption, thigh, urethral, perineal skin avulsion, femoral vessel disruption and axillary venous injury. The mode of testicle trauma was blunt in 36 (63%) and penetrating in 21 (37%) cases. Early exploration was done in 43 (81%) patients including 4 with bilateral testicular injury: hematoma evacuation in 23 (49%), partial orchiectomy in 16 (34%) and total orchiectomy in 8 (17%) cases, respectively. Otherwise, delayed exploration, due to the late presentation of more than 3 days after trauma, was done in the remaining 10 (19%) patients: hematoma evacuation in 6 (60%) and partial orchiectomy in 4 (40%) cases. The testicle salvage rate was 49/57 (86%), depending on the nature of testicular trauma. Hospitalization for uncomplicated cases was 4.82 +/- 1.85 days, with prolongation to 10.79 +/- 3.64 days (p < 0.05) for patients having associated injuries. Exploration is advocated in all cases of hematocele, irrespective of testicle contusion or rupture. As minimal, the blood-clot from the tunica vaginalis sac should be evacuated, which would relieve disability and hasten recovery.     

Mortality and neurologic morbidity after repair of traumatic aortic disruption

BACKGROUND: Traumatic disruption of the thoracic aorta frequently results in death before operative repair. The determinants of mortality after repair, however, are uncertain. In addition, intraoperative strategies for reducing the incidence of spinal cord injury remain controversial. METHODS: The records of 45 consecutive patients undergoing repair of traumatic disruption of the thoracic aorta at a single institution during a 9-year period were reviewed in a retrospective fashion. Patient age ranged from 15 to 81 years (mean age, 33.9 years). Twenty-two patients (49%) had multiple associated injuries, and 8 (18%) had isolated aortic injuries. Nine patients (20%) experienced preoperative hypotension (systolic blood pressure of less than 90 mm Hg). Repair was performed with partial bypass in 22 patients, a heparinized shunt in 2, and no distal perfusion (clamp and sew technique) in 21. RESULTS: Nine patient (20%) died after operation. Multivariate logistic regression analysis of preoperative and intraoperative variables identified advancing age and preoperative hypotension as independent predictors of operative death. The presence of associated injuries was not an independent predictor of operative death. All 4 patients with injuries proximal to the aortic isthmus died. Ten patients were excluded from analysis of spinal cord injury either because of preoperative neurologic deficit or because of death before postoperative evaluation. Six (17%) of the remaining 35 patients had development of paraplegia: 5 of the 15 patients having the clamp and sew technique, 1 of the 2 with a shunt, and 0 of the 18 patients with bypass (p < 0.05, clamp and sew versus bypass). In the clamp and sew group, patients in whom paraplegia developed had significantly longer aortic clamp times than those without neurologic injury (40.6 +/- 4.4 minutes versus 28.7 +/- 2.9 minutes, respectively; p < 0.05). CONCLUSIONS: Advancing age, preoperative hypotension, and perhaps injury location are important determinants of death after repair of traumatic disruption of the thoracic aorta. Adjunctive perfusion with partial bypass should be used during repair to reduce the incidence of spinal cord injury.     

Mucosal injury and disruption of intestinal barrier function in HIV-infected individuals with and without diarrhea and cryptosporidiosis in northeast Brazil

The effects of AIDS-related diarrhea--with and without cryptosporidiosis and microsporidiosis--on intestinal function and injury were studied in 40 AIDS patients and 13 healthy volunteers from Fortaleza, Brazil. The differential urinary excretion of ingested lactulose and mannitol was used as a marker of barrier disruption and overall villous surface area. HIV-infected patients with diarrhea had a 2.8-fold higher lactulose to mannitol excretion ratio than HIV-positive patients without diarrhea and a 10.4-fold higher ratio than healthy volunteers. Moreover, those with crypotosporidial infection had a lactulose to mannitol ratio almost 6-fold greater than those without diarrhea and nearly 3-fold higher than those with non-cryptosporidial diarrhea. This effect involved both decreased mannitol excretion (decreased intestinal absorptive area) and increased lactulose excretion (mucosal barrier disruption). The single patient with microsporidial infection had a nearly 3-fold higher ratio than healthy volunteers. Alpha1-antitrypsin tests were positive in two of five (40%) HIV-positive patients with cryptosporidial infections compared with none of 12 HIV-infected patients with non-cryptosporidial diarrhea. These findings confirm that HIV infection is associated with profound intestinal dysfunction and injury, even in those without diarrhea. Disruption of the intestinal barrier is even greater, however, in HIV-infected patients with cryptosporidial diarrhea, with potential nutritional consequences.     

Immediate management of posterior urethral disruptions due to pelvic fracture: therapeutic alternatives

PURPOSE: We retrospectively reviewed the results of 3 types of initial management of pelvic fracture urethral disruption in children. MATERIALS AND METHODS: From 1980 to 1994, 35 boys 2 to 15 years old (mean age 8.1) with prostatomembranous urethral disruption were treated, including 17 who also had associated injuries. Immediate treatment included suprapubic cystostomy and delayed urethroplasty in 19 patients (group 1), urethral catheter alignment without traction and concomitant suprapubic cystostomy in 10 (group 2), and primary retropubic anastomotic urethroplasty in 6 (group 3). RESULTS: In all patients in groups 1 and 2 severe urethral obliteration developed. Four group 3 patients (66%) had a stricture at the site of anastomotic repair. After delayed urethroplasty 16 group 1 (84%) and all 10 group 2 patients were continent. However, only 3 group 3 patients (50%) achieved continence. Retrospectively associated bladder neck injury occurred in 5 of the 6 incontinent boys. Erections were observed before and after treatment in all but 3 children. Unstable pelvic ring fractures (type IV) comprised 28% of all pelvic fractures with a high rate of associated injuries. CONCLUSIONS: As described, urethral alignment was not beneficial for avoiding urethral obliteration. Therefore we recommend suprapublic cystostomy as the only form of initial treatment in these cases. Urinary incontinence seems more likely related to associated bladder neck rupture and the severity of pelvic fracture rather than to initial treatment or delayed urethral repair. Consequently, when associated bladder neck injury is present, we advocate immediate surgical repair.     

Cell density-dependent mitogenic effect and -independent cellular handling of epidermal growth factor in primary cultured rat hepatocytes

Brain swelling is a serious complication associated with focal ischemia in stroke and severe head injury. Experimentally, reperfusion following focal cerebral ischemia exacerbates the level of brain swelling. In this study, the permeability of the blood-brain barrier has been investigated as a possible cause of reperfusion-related acute brain swelling. Blood-brain barrier disruption was investigated using Evans Blue dye and [14C]aminoisobutyric acid autoradiography in a rodent model of reversible middle cerebral artery (MCA) occlusion. Acute brain swelling and cerebral blood flow (CBF) during ischemia and reperfusion were analyzed from double-label CBF autoradiograms after application of the potent vasoconstrictor peptide endothelin-1 to the MCA. Ischemia was apparent within ipsilateral MCA territory, 5 min after endothelin-1 application to the exposed artery. Reperfusion, examined at 30 min and 1, 2, and 4 h, was gradual but incomplete within this time frame in the core of middle cerebral artery territory and associated with significant brain swelling. Ipsilateral hemispheric swelling increased over time to a maximum (>5%) at 1-2 h after endothelin-1 but was not associated with a significant increase in the ipsilateral transfer constant for [14C]aminoisobutyric acid over this time frame. These results indicate that endothelin-1 induced focal cerebral ischemia is associated with an acute but reversible hemispheric swelling during the early phase of reperfusion which is not associated with a disruption of the blood-brain barrier.     

Neonatal hind-paw injury disrupts acquisition of an instrumental response in adult spinal rats.

The present study was designed to evaluate the impact of neonatal injury on adult spinal plasticity in rats. Subjects were randomly assigned to 1 of 4 experimental conditions: (a) hind-paw injury at Postnatal Day (PD) 2, (b) hind-paw injury at PD 5, (c) anesthesia exposure only on PD 2, or (d) anesthesia exposure only on PD 5. Subjects receiving a unilateral neonatal hind-paw injury showed decreased mechanical threshold (hyperalgesia) on the previously injured hind paw throughout development. This decrease in threshold survived spinal transection (at T2) at 12 weeks of age. Injured subjects also showed significant impairment in a spinal instrumental learning task performed by the previously injured hind paw. This disruption of learning indicates a disruption of spinal plasticity that may be due to induction of long-term changes in nociceptive processing within the spinal cord. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Purposeful delay in the repair of a traumatic rupture of the aorta with coexistent liver injury

Purposeful delay in the repair of traumatic aortic injury by appropriate medical management is indicated when the risk of immediate thoracotomy is high. A grade V liver injury implies parenchymal disruption of greater than 75% of a hepatic lobe. We report the successful management of a patient with a class IB proximal descending aortic transection and concomitant grade V liver injury that precluded aortic repair until its resolution.     

Amyloid precursor protein accumulates in white matter at the margin of a focal ischaemic lesion

Amyloid precursor protein (APP) is transported by fast anterograde axonal transport. Since disruption of this transport results in APP accumulation, APP has been proposed as a sensitive marker of axonal injury. In the present study, axonal injury in subcortical white matter and myelinated fibre tracts permeating the striatum, 24 h after permanent middle cerebral artery occlusion in the rat, has been examined by assessing the location and extent of APP immunoreactivity. Increased APP immunoreactivity was present in both areas. This was localised to a circumscribed zone immediately adjacent to the boundary of the ischaemic lesion in grey matter. The amount of APP immunoreactivity was associated with the volume of the ischaemic lesion in individual animals. Increased APP immunoreactivity in subcortical white matter and myelinated fibre tracts at the margin of the ischaemic zone may prove to be a valuable marker for assessing strategies to protect axons after an ischaemic insult.     

Dislocations of the upper extremity in children

Traumatic dislocations and subluxations of the upper extremity in children have been surveyed. The elbow joint is most commonly dislocated and is dislocated more frequently in children than in adults. Severe neurovascular injury may be associated with dislocation of this joint. The most common subluxation is that of the radial head, secondary to a "pulled elbow." Otherwise dislocations and subluxations of the upper extremity are uncommon in children, apparently because of the relative weakness of the epiphyseal plate. Most of these injuries are the result of predictable indirect forces. Principles of reduction and immobilization are based on the unique anatomic structure of the joint involved and the known anatomic disruption resulting from the trauma.     

Blunt traumatic disruption of the thoracic aorta: a rare injury in children

Rupture of the thoracic aorta secondary to blunt chest trauma is an exceedingly uncommon injury in pediatric patients. We present a case of blunt traumatic aortic disruption in a 10-year-old child who was successfully managed by primary aortic repair using partial cardiopulmonary bypass. The epidemiology and pathophysiology of this injury, with particular reference to children, is reviewed. The ongoing controversies regarding the diagnosis and operative management of this injury are summarized.     

Epithelial cell shedding in acute renal injury

1. To address the postulate that sublethally injured tubular cells may be shed from renal epithelium while still viable, studies were undertaken in vivo in human 'acute tubular necrosis' and in rabbit models of renal tubular injury. 2. Substantial numbers of viable tubular cells were voided in the urine. When placed in culture, these cells gave rise to monolayers, confirming viability. The majority of intact cells demonstrated markers of proximal tubule. 3. In vitro studies of human renal proximal tubular cells exposed to hypoxia/anoxia showed rounding and retraction associated with disruption of actin microfilaments. Phalloidin stabilized the filaments and prevented the changes in cell shape indicative of altered adherence.     

Stressful life events, psychological well-being, and parenting in African American mothers.

The association of stressful negative life events with mothers' psychological well-being and parenting was examined in 79 African American mothers living in 1 and 2-percent households. Findings reveal that family disruption and work problems were associated with lower maternal acceptance. Family disruption was also positively associated with mothers' firm control of behavior. Family disruption and work-related stress also were negatively associated with mothers' self-esteem. Health-related stress was positively related to mothers' psychological distress. Mothers' self-esteem was positively associated with mothers' acceptance and negatively related to firm control. Mothers' self-esteem mediated the association of family disruption and work-related stress with mothers' acceptance. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Neurochemical mechanisms in brain injury and treatment: a review

This article reviews cellular energy transformation processes and neurochemical events that take place at the time of brain injury and shortly thereafter emphasizing hypoxia-ischemia, cerebrovascular accident, and traumatic brain injury. New interpretations of established concepts, such as diffuse axonal injury, are discussed; specific events, such as free radical production, excess production of excitatory amino acids, and disruption of calcium homeostasis, are reviewed. Neurochemically-based interventions are also presented: calcium channel blockers, excitatory amino acid antagonists, free radical scavengers, and hypothermia treatment. Concluding remarks focus on the role of clinical neuropsychologists in validation of treatment interventions.     

Fractures and dislocations of the cervical spine in children

Correct diagnosis of fractures and dislocations of the cervical spine in children requires an awareness of the pseudosubluxation and other normal variants noted in x-ray films of patients in this age group. Fractures of the odontoid process occur frequently and almost always can be treated by closed reduction and external fixation until union occurs. Fractures of the lower cervical spine are difficult to detect roentgenographically, and x-ray changes can belie the severity of soft tissue injury and cord trauma. Instability tends to persist in adolescent patients after cervical spine injury because of the combination of epiphyseal and posterior ligamentous disruption. Neoplastic, inflammatory, and congenital lesions render the cervical spine vulnerable to injury and can permit major damage to result from minor stress.     

Anesthesia induction for laryngeal mask insertion--comparison of propofol with midazolam and propofol with thiopental

STUDY DESIGN: Radiographs and charts of 61 patients sustaining cervical spine trauma were studied prospectively to determine the incidence of vertebral artery injuries and possible correlative factors. Statistical analysis was conducted using chi-square testing of a two-way classification system. OBJECTIVES: To elucidate the incidence of vertebral artery injuries associated with cervical spine trauma, and to determine the value of various factors in predicting the existence of a vertebral artery injury. SUMMARY OF BACKGROUND DATA: During a 7-month period, 61 patients (41 male patients, 20 female; average age, 40.3 years) with cervical spine trauma were studied. METHODS: All patients admitted to the authors' hospital with cervical spine injuries underwent magnetic resonance imaging and magnetic resonance angiography of their cervical spine. All magnetic resonance angiographies were examined for vertebral artery injury. Data on demographics and the injury were recorded. RESULTS: Complete disruption of blood flow through the vertebral artery was demonstrated by magnetic resonance angiography in 12 of the 61 patients (19.7%). Ten of the 12 patients (83%) had either flexion distraction or flexion compression injuries. Age, sex, mechanism of injury, neurologic impairment, and associated injuries were not statistically significant in predicting the presence of a vertebral vessel occlusion. CONCLUSION: The findings in this study may support the need for vertebral vessel evaluation in selective patients, particularly those with flexion injuries and with neurologic symptoms consistent with vertebral artery insufficiency syndrome that do not correlate with the presenting bone and soft-tissue injuries.     

Competitive inhibition of swine kidney copper amine oxidase by drugs: amiloride, clonidine, and gabexate mesylate

Carotid artery injuries from seat belt shoulder straps have been reported involving primarily the internal carotid artery. This paper describes a case of common carotid artery disruption and tracheal transection after a shoulder strap seat belt injury. A successful method for management of this rare injury is presented. Repair involved autogenous arterial replacement in a contaminated field using an interposition graft of superficial femoral artery.     

Operative cholangiography and special technical consideration in the management of severe injury of the liver

The majority of hepatic injuries can be adequately managed by control of bleeding locally at the site, debridement and ample drainage. In some instances, severe blunt trauma and high velocity missile wounds may result in the disruption of intrahepatic structures and significant devitalization of the parenchyma of the liver, necessitating hepatic resection. Operative cholangiography was found to be useful in the evaluation and management of this type of severe injury to the liver. It is simple, practical method to recognize and localize a major disruption of the parenchyma of the liver and bile ducts; to help decide whether or not segmental, sublobar or labor hepatectomy should be performed, and to detect bile leaks from the divided bile ducts after resection of the liver. A modified technique for performing hepatic resection during an emergency situation was suggested to be more suitable than the classic technique. This is based on finger dissection along the line of injury and individual ligation of bile ducts and vessels as they are exposed within the parenchyma of the liver instead of isolation and ligation of the main inflow vessels and of the major ducts at the hilus and retrohepatic ligation of the hepatic veins.     

The non-operative management of collateral ligament injuries of the knee joint

Severe knee ligament injuries are frequently underestimated, and this results in later problems of chronic instability. A history of an appropriate mechanism coupled with immediate reduction in function should arouse suspicion of a major disruption. Examination with the patient under anesthesia may be required to assess the extent of the injury. If the lesion is an isolated collateral tear, the intact cruciate ligaments prevent wide displacement. Such an injury can be managed non-operatively. A long leg plaster at 90 degrees for 2 weeks followed by 4 weeks in a cast brace with motion from 45 degrees to 100 degrees is recommended. The knee is then protected in a brace during athletic activities for approximately 6 months. Thirty collateral ligament tears have been managed in this fashion. Only one has significant residual complaints. It is emphasized that an isolated collateral ligament tear is a positive diagnosis, and associated cruciate lesions must be ruled out. The recovery is faster in those patients managed non-operatively than in those who have surgical repair. There has not been a problem with late instability.