Iatrogenic injury of the spinal accessory nerve. Results of repair

We reviewed the results of repair of the spinal accessory nerve in seven patients seen between September 1994 and January 1996. The nerve had been injured during biopsy of a cervical lymph node in six patients and during removal of a bullet in one. The average interval between the time of the injury and the repair of the nerve was eight months (range, three to fourteen months). An end-to-end repair of the nerve was performed in six patients, and a neurolysis was done in one. The average duration of follow-up was thirty-two months (range, twenty-four to thirty-nine months). Postoperatively, all seven patients had relief of pain and stiffness in the shoulder girdle. Manual muscle-testing revealed normal strength of the trapezius, which was comparable with that on the unaffected side. Four patients regained normal function of the shoulder. Three patients reported a stretching sensation or discomfort in the neck, periscapular discomfort, and fatigue of the extremity when lifting heavy objects or performing overhead activities. However, these residual symptoms were mild and tolerable and thus were different in nature from the preoperative pain and stiffness. Iatrogenic injury of the spinal accessory nerve should be suspected if a patient has pain or stiffness in the shoulder girdle and a history of a recent operation on the neck. The nerve should be explored if spontaneous recovery does not occur.     

Evaluation of nerve recovery from minimal-duration crush injury

The recovery of damaged peripheral nerves has been the subject of multiple studies. The effects of an inadvertent clamping of a nerve has not been well examined. An experiment was performed to evaluate the effects of a minimal-duration crush injury on the rat sciatic nerve and to determine if walking track analysis was useful in evaluating the short-term functional deficit. Ten Sprague-Dawley rats underwent high-pressure, short-duration crush injuries. Walking track analysis was done regularly for 3 weeks. Histological specimens for light and electron microscopy were taken at postoperative days 3, 7, 14, 21, and 42 from similar animals. There was significant decrease in function by the second week, which then improved to control levels after week 3. Toluidine blue and electron microscopic findings confirmed the clinical course, while routine histological findings tended to lag behind the return of function. Walking track analysis appears to be an effective method of evaluating the short-duration nerve crush injury.     

Diagnosis and treatment of iatrogenic ureteral injury

Diagnosis and treatment of 17 patients who sustained 20 iatrogenic ureteral injuries were analyzed. Primary operations in which ureteral injury occurred are almost gynecologic procedures and general surgery. Injuries were managed by ureteroureterostomy in four, ureteral stent in one, removal suture ligation and ureteral double J-catheter in one, ureteroneocystostomy in ten, psoas-hitch technique and ureteroneocystostomy in one, nephrectomy in two. All patients with appropriate repair were followed-up periods of three to five years. Renal function of these patients had optimal results. When ureteral injury occurs, B-US, IVU, cystoscopy, retrograde ureterography or infusion of dye may be useful. An appropriate repair should be chosen according to length and position of ureteral injuries. Reoperation was optimal in two to three weeks. Immediate recognition of accidental ureteral injury provides optimal results. Patients with unrecognized injuries had suboptimal results.     

The diagnosis of simulation in forensic psychiatric practice

The author discusses one of the most important problems in practical forensic psychiatry, simulation of mental disorders. Classification of simulation types is presented, major neuromental disorders enumerated which are simulated by subjects accused of crimes, methods of diagnosis and general regularities typical of all types of simulation behavior are described.     

Microvascular compression of the accessory nerve in torticollis spastica

The paper deals with the pathogenesis of torticollis spastica and potential modes of their treatment. The findings indicate that changes in the root of nerve XI are essential in the pathogenesis of this abnormality. Despite comparatively small materials, much higher efficiency of micro-decompression of the accessory nerve is shown.     

Spirituality in medical practice

Body, mind, and spirit are integrally connected. Medical training in the Western world has been strong concerning the more easily measured physical aspects, and on the mental needs it has been virtually mute on how to minister to the spiritual needs of our patients. Learning the spiritual aspects of medical care is not a typical part of the medical school curriculum, and yet it is emerging as something that our patients want and expect us to do as part of our caring for them. Herein I discuss the role of spirituality in medical practice, how it relates to alternative medical practices, methods to use to grow spiritually, and ways to apply your spirituality to medical practice.     

Evaluation and treatment of pain: aspects for nerve injury and rehabilitation

Pain, or at least discomfort in the form of hypersensitivity, is always a sequela to nerve injury and nerve repair. A carefully planned pain evaluation and treatment program has been shown to result in a decrease in pain and improved function. For a hand therapist, the commitment to evaluation and management of pain is a personal as well as a professional dedication. Patients may greatly vary in their responses to injury, symptomatology, and treatment interventions. Although the hand therapist can successfully intercede with many patients, it is often advantageous to involve a clinical psychologist. Psychosocial and psychophysiologic data can be imperative in evaluating the possibilities of patient outcome with regard to pain, evaluation, and treatment. Psychophysiologic information is likely to increase the hand therapist's evaluation and treatment potency. A psychological assessment and/or intervention is appropriate at several points of treatment--for example, after an appropriate interval of healing time in which an injury should resolve itself, after a major invasive procedure such as surgery, or when a condition is chronic and all other avenues of treatment have been unsuccessful.     

Computers in the medical practice

This article is part of a series covering the ever-expanding role of computers in the medical office and practice by Glenn L. Gordon, MD, FACIP. Dr. Gordon is Director, Center for Digestive and Liver Diseases, Clinical Instructor of Medicine at St. Louis University School of Medicine, President of Audrain County Medical Society, Immediate Past President of American Cancer Society-Audrain Unit, and State Council MSIM/ASIM Delegate. This is the first of a series of articles covering the expanding role of computers in our medical practice from office management programs to the Internet. This month's article covers the computerized medical record and what it can do for you.     

House calls in medical practice

The frequency of daily home visits by practicing physicians has been investigated. A multiple regression analysis indicates that the number of daily home visits is reduced linearly with decreasing age and with increasing specialization of the doctor. With these variables taken into account, urban-rural differences cannot be demonstrated.     

Specialized practice in forensic psychology: Opportunities and obstacles.

In recent years, there has been a proliferation of the need for psychology practitioners to provide expertise to the legal system on a wide variety of topics. One of the difficulties for psychologists has been that the demand for such services has at times outstripped the capacity of the field to train practitioners to provide these services in a competent and ethical manner. Furthermore, many psychologists are not aware of the types of knowledge and training required to perform these services. This article describes the knowledge base and skills that distinguish the specialty of forensic psychology and the types of training required to practice in this field. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ethical concerns in modern medical practice

Differentiation of HL-60 cells along the granulocytic lineage by DMSO in the presence of transforming growth factor-beta and low concentrations of 1,25-dihydroxyvitamin D3 leads to the upregulation of 5-lipoxygenase activity in 100,000 g supernatants and intact cells to levels which are comparable to normal granulocytes. Similarly, differentiation of the human monocytic cell line Mono Mac 6 by 1,25-dihydroxyvitamin D3 and transforming growth factor-beta strongly upregulates the 5-lipoxygenase pathway. Here, we describe an assay system for leukotriene biosynthesis inhibitors which is based on the in-vitro differentiation of HL-60 and Mono Mac 6 cells. Different leukotriene biosynthesis inhibitors like the nonredox type inhibitor ZM 230487, the redox type inhibitor BW A4C and the FLAP inhibitor MK886 were tested and the results were compared with an assay system based on normal human granulocytes. ZM 230487, BWA4C and MK886 showed similar potencies in these cell lines as compared to normal leukocytes. Thus, the in-vitro differentiation of HL-60 and Mono Mac 6 cells provides an excellent model for the screening of drugs affecting the 5-lipoxygenase pathway.     

Malingering behavior in private medical practice

OBJECTIVE: This study investigated the influence of the fetal environment on the healing characteristics of adult skin. SUMMARY BACKGROUND DATA: The remarkable ability of the fetus to heal without scarring is poorly understood. The unique qualities of fetal wound healing may be caused by the fetal environment, the fetal tissues, or a combination of both. There are numerous differences between the prenatal and postnatal environments that may play a role in the unique fetal response to injury. METHODS: Full-thickness adult sheep skin was transplanted onto the backs of 60-day-gestation fetal lambs (term, 145 days of gestation). The adult skin grafts were thus perfused by fetal blood and bathed in amniotic fluid. Previous work has demonstrated that, before midgestation, fetal lambs do not reject allogenic skin grafts. Forty days later (100 days of gestation), incisional wounds were made on both the adult skin graft and the adjacent fetal skin. The wounds were harvested 14 days postwounding and analyzed by both light microscopy and immunohistochemical testing using antibodies to collagen types I, III, and VI. RESULTS: The wounds in the adult skin grafts healed with scar formation. This observation contrasts strongly with the scarless healing of the incisional fetal skin wounds. CONCLUSIONS: This study suggests that scarless fetal skin healing properties are intrinsic to fetal skin and are not primarily the result of the fetal environment.