Severe laryngeal injury caused by blunt trauma to the neck: a case report

Acute blunt laryngeal trauma can be a life-threatening event and often poses a difficult airway management problem. Patients may be unable to supply important anemnestic facts because of aphonia or intubation as a result of their injury. Therefore the immediate recognition and appropriate initial assessment and treatment are vital for a successful outcome. The first step is assuring an appropriate airway, either by careful intubation or temporary tracheotomy. An assessment of potential vascular and oesophageal injuries must be undertaken. The use of computerized tomography (CT) with contrast material is especially useful in identifying and localizing the damage caused by blunt neck injuries. Laryngeal fractures, air in the soft tissues and the extravasation of contrast material in the neck are all helpful in assessing the injuries before surgical intervention. Immediate initial surgery is aimed at stabilizing the cartilaginous framework and repairing the mucosa. We present a case of severe laryngeal injury caused by blunt trauma to the neck; our evaluation, treatment and the outcome.     

Imaging of acute thoracic aortic injury due to blunt trauma: a review

Special AT-rich sequence-binding protein 1 (SATB1), a DNA-binding protein expressed predominantly in thymocytes, recognizes an ATC sequence context that consists of a cluster of sequence stretches with well-mixed A's, T's, and C's without G's on one strand. Such regions confer a high propensity for stable base unpairing. Using an in vivo cross-linking strategy, specialized genomic sequences (0.1-1. 1 kbp) that bind to SATB1 in human lymphoblastic cell line Jurkat cells were individually isolated and characterized. All in vivo SATB1-binding sequences examined contained typical ATC sequence contexts, with some exhibiting homology to autonomously replicating sequences from the yeast Saccharomyces cerevisiae that function as replication origins in yeast cells. In addition, LINE 1 elements, satellite 2 sequences, and CpG island-containing DNA were identified. To examine the higher-order packaging of these in vivo SATB1-binding sequences, high-resolution in situ fluorescence hybridization was performed with both nuclear "halos" with distended loops and the nuclear matrix after the majority of DNA had been removed by nuclease digestion. In vivo SATB1-binding sequences hybridized to genomic DNA as single spots within the residual nucleus circumscribed by the halo of DNA and remained as single spots in the nuclear matrix, indicating that these sequences are localized at the base of chromatin loops. In human breast cancer SK-BR-3 cells that do not express SATB1, at least one such sequence was found not anchored onto the nuclear matrix. These findings provide the first evidence that a cell type-specific factor such as SATB1 binds to the base of chromatin loops in vivo and suggests that a specific chromatin loop domain structure is involved in T cell-specific gene regulation.     

Cost of cardiac care in the three years after coronary catheterization in a contained care system: critical determinants and implications

OBJECTIVES: We sought to determine the clinical, angiographic, treatment and outcome correlates of the intermediate-term cost of caring for patients with suspected coronary artery disease (CAD). BACKGROUND: To adequately predict medical costs and to compare different treatment and cost reduction strategies, the determinants of cost must be understood. However, little is known about the correlates of costs of treatment of CAD in heterogeneous patient populations that typify clinical practice. METHODS: From a consecutive series of 781 patients undergoing cardiac catheterization in 1992 to 1994, we analyzed 44 variables as potential correlates of total (direct and indirect) in-hospital, 12- and 36-month cardiac costs. RESULTS: Mean (+/-SD) patient age was 65+/-10 years; 71% were men, and 45% had multiple vessel disease. The initial treatment strategy was medical therapy alone in 47% of patients, percutaneous intervention (PI) in 30% and coronary artery bypass graft surgery (CABG) in 24%. The 36-month survival and event-free (death, infarction, CABG, PI) survival rates were 89.6+/-0.2% and 68.4+/-0.4%, respectively. Median hospital and 36-month costs were $8,301 and $28,054, respectively, but the interquartile ranges for both were wide and skewed. Models for log(e) costs were superior to those for actual costs. The variances accounted for by the all-inclusive models of in-hospital, 12- and 36-month costs were 57%, 60% and 71%, respectively. Baseline cardiac variables accounted for 38% of the explained in-hospital costs, whereas in-hospital treatment and complication variables accounted for 53% of the actual costs. Noncardiac variables accounted for only 9% of the explained costs. Over time, complications (e.g., late hospital admission, PI, CABG) and drug use to prevent complications of heart transplantation became more important, but many baseline cardiac variables retained their importance. CONCLUSIONS: 1) Variables readily available from a comprehensive cardiovascular database explained 57% to 71% of cardiac costs from a hospital perspective over 3 years of care; 2) the initial revascularization strategy was a key determinant of in-hospital costs, but over 3 years, the initial treatment become somewhat less important, and late complications became more important determinants of costs.     

Bringing political ecology into critical medical anthropology: a challenge to biocultural approaches

This essay presents an effort to incorporate the "environment" into critical medical anthropology. Rather than relying upon the multifactorial approach characteristic of medical ecology or biocultural approaches in medical anthropology, it urges critical medical anthropologists to turn to the burgeoning literature on eco-Marxism, eco-socialism, or political ecology in their efforts to develop a political ecology of health. Given that political ecologists generally advocate democratic eco-socialism as a meaningful alternative to the capitalist world system, this essay also presents a critical examination of the environmental record of post-revolutionary societies.     

Latex sensitivity: a public health care challenge

Latex sensitivity is becoming epidemic in the health care arena. Providers of health care need to be aware of the signs and symptoms, the treatments, and the consequences of latex sensitive reactions. In this article, I will provide information about latex sensitivities that will enable health care workers and their patients to have a better understanding of the phenomena. Resource information is provided for the latest information pertaining to latex sensitivities to aid in the education of health care providers and their patients.     

The school nurse practitioner: providing improved health care to children

School nurse practitioners have the competence to participate in providing a broad range of direct primary health care and services to the school-age child. Greater utilization of these specially prepared and highly qualified nurse practitioners as providers of health care in the school is a practical and effective method of adding to the quality, availability, and continuity of health care for the school-age child.     

Becoming a primary care nurse practitioner: challenges of the initial year of practice

The transition from student to primary care practitioner is exciting and challenging and offers seemingly limitless opportunities. This article presents results of a model generated from a longitudinal study of 35 newly graduated primary care nurse practitioners during their first year of practice. Stages of development include laying the foundation (recuperating from school, negotiating the bureaucracy, looking for a Job, and worrying); launching (feeling real, getting through the day, battling time, and confronting anxiety); meeting the challenge (increasing competence, gaining confidence, and acknowledging system problems); and broadening the perspective (developing system savvy, affirming oneself, and upping the ante). Anticipatory guidance is offered for new graduates and their mentors and colleagues. Mentors can provide crucial information about appropriate expectations and create key structures to facilitate new practitioners' needs for consultation and advice.     

Management of acute laryngeal injury: a critical review

The approach to management of 30 cases of laryngeal trauma coming to open exploration is outlined. Eighteen patients had blunt trauma and 12 had penetrating wounds. Four cases resulted in airway compromise and all were in the blunt trauma group. Although significant granulation tissue response occurred in only eight of 30 cases, it was present in three of the four concluding with stenosis. It is demonstrated that the use of a stent, with a tissue graft, when mucosal approximation cannot be accomplished, facilitates prevention of endolaryngeal distortion and webbing and maintenance of skeletal framework integrity; its use did not predispose to granulation tissue development. A principal etiologic factor in those patients who had good airway but only a fair voice was arytenoid fixation, this despite anatomic reduction when subluxation occurred. Recurrent nerve injury was identified in only one patient. Foremost in management is suspicion and recognition of laryngeal injury in the multiple trauma patient. Once the urgent problems of hemorrhage, shock, and airway are attended to, attention must be directed to a systematic evaluation of the neck and larynx.     

Traumatic head injury: A challenge to rehabilitation psychologists.

Traumatic head injury is a tragedy for all whom it affects. Many families of injured individuals report that the most painful aspects of the injury are the lack of accurate information available to them at all points following the injury and the fact that, because a head injury's effects are so different from those of other illnesses and injuries, no one seems to understand. It is hoped that this Special Issue of Rehabilitation Psychology will not only help more people to understand, but will also impel some readers to participate in the search for answers. In pulling these papers together, I struggled with the question of whether to include papers from the wide spectrum of rehabilitation efforts in which psychologists are involved (including neuropsychological assessment, cognitive retraining, vocational rehabilitation, etc.), or to focus on one major area. Given the increasing number of books that provide the broader perspective, I have chosen the latter route, including papers dealing with the psychosocial issue that is a prerequisite for success in other areas—how patients and their families come to terms with the injury and its consequences. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Avulsion of common bile duct after blunt abdominal injury: a review of the literature

Injury to the common bile duct following blunt injury of the abdomen has been reported in 82 previous cases in the literature that we have reviewed. An additional rare case of complete avulsion of the common bile duct at its junction with the pancreas is presented here. Diagnosis has usually been late, peritonitis has commonly been present and 33 per cent of the cases ended fatally. Although diagnosis is often late, there have been many attempts at primary repair; we describe a new technique of delayed repair, which involved intermittent closure of the common duct and was successful in increasing its diameter by the time of the second operation. The initial injury was treated by a cutaneous choledochostomy and 2 jejunostomy tubes, one for decompression and drainage and the other for feeding and replacement of bile. The final repair consisted of a choledochojejunostomy, jejunojejunostomy and T-tube drainage of the common juct. The patient is completely well after two years.     

Continuity of care: a challenge for ambulatory oncology nursing

Continuity of care has many facets and challenges both as a philosophy and in practice. In an abstract sense, it represents an ideal to which health care professionals strive. It is becoming a professional and consumer expectation that each health care professional contribute to continuity of care. Although a variety of organizational models for providing continuity of care have been established in which nursing plays a prominent role, recent research suggests that some frontline nursing personnel may not fully understand their responsibility to continuity of care. There is a need for nursing curricula in both basic and continuing education programs to address continuity of care concepts, models, and methodologies to strengthen awareness of patient care needs across the disease continuum and across care settings. Performance expectations that include professional accountability for continuity of care also encourage greater attention to this issue.     

Multisystem complications of bulimia: a critical care case

Bulimia is an eating disorder characterized by behaviors which can lead to very serious health problems. Behaviors such as binging and purging and abuse of emetics, diuretics, or laxatives can cause serious complications, sometimes of a critical nature. Nurses must maintain a high index of suspicion for this disorder and use skillful assessment and intervention to prevent the critical multisystem complications of bulimia.     

Implementation of the acute care nurse practitioner role

In this article, the experiences of two new acute care nurse practitioners working at the University of Pittsburgh Medical Center are described. Included are the experiences they encountered in initiating the role and some of the responsibilities they assumed.     

Graduate education in primary care: the challenge

One can summarize the current status of calcium antagonists to treat heart failure as follows: Usually there is a favorable acute response to these drugs in heart failure patients but long-term effects in the patients treated with nifedipine, diltiazem, and verapamil have produced rather disappointing results. Thus, they should not be used routinely in heart failure patients. Their main problems were related to the negative inotropic effects of the drugs, the lack of reduction in ventricular filling pressure, and activation of the neurohumoral systems which have an adverse effect on cardiovascular performance, for example, renin-angiotensin. In contrast, the second-generation calcium antagonists have more selective vasodilating properties and fewer negative inotropic properties, which, I believe, justifies their use in selected heart failure patients. Unfortunately, there are no large randomized controlled long-term trials to evaluate morbidity and mortality in heart failure patients treated with these agents. One can rationalize that the symptomatic elderly patient with isolated diastolic dysfunction can be treated effectively with calcium antagonists but, once again, there are no major trials evaluating any drug in the management of patients with isolated diastolic function not due to hypertrophic cardiomyopathy. Rationale for using calcium antagonists could be best supported in patients with active ischemic heart disease and symptoms of heart failure. In this instance the coronary vasodilator effects may relieve myocardial ischemia and, by that mechanism, improve myocardial systolic and diastolic function.     

The role of the general practitioner in postnatal care: a survey from Australian general practice

BACKGROUND: Despite the practice of routine postnatal check-ups, many women experience problems in the months after childbirth. General practitioners (GPs) are involved in routine postnatal care, yet little research has been undertaken to explore this role. AIM: To report the views of Australian GPs as to what physical examination and discussion should take place at the routine six week postnatal check-up and to determine the influence of gender on the approach to the check-up. METHOD: Postal survey of 1104 Australian GPs, yielding an eligible sample of 1022. RESULTS: A total of 715/1022 (70%) usable surveys returned. Over 65% of GPs recommend routine examination of the abdomen, blood pressure, perineum, vagina, pelvic floor, and breasts at the six week check-up. Fewer than a half the sample believed that physical problems (urine and bowel symptoms, back problems), sexual issues, relationship and parenting issues should be routinely discussed. After controlling for age, practice location, obstetric practice, and qualifications, the sex of the GP remains an important factor influencing the GP's approach to postnatal care. Female GPs are three times more likely to believe that maternal feelings should be discussed routinely and about twice as likely to believe that infant sleeping/behaviour, maternal sleeping/diet/tiredness, coping with other children, relationship with partner, and household work should form part of the routine discussion with all recent mothers. CONCLUSIONS: Sex of practitioner and older age (60 years or more) are the two most important influences on a GP's approach to postnatal care. This study indicates a need for GPs to shift their focus from routine examination to indicated examination to allow more time to discuss common postnatal problems.