Necrosis of the femoral head after kidney transplantation

OBJECTIVE: Presentation of our experience in the treatment of war injuries to the thoracic esophagus at the Split University Hospital, Croatia, during the 1991-1995 wars in Croatia and Bosnia-Herzegovina. METHODS: Retrospective analysis of clinical and surgical data on patients with war injuries to the esophagus. RESULTS: Of 2494 treated injured persons, 5 patients (0.2%) had injuries to the esophagus. We performed temporary double-exclusion of the esophagus in all our patients, followed by gastric interposition after partial esophagegtomy in three patients and simple suturing with pericardial protection of the esophagus in one patient. One of our patients died after double-exclusion due to septic complications in spite of antimicrobial chemoprophylaxis regularly performed in all injured persons. Final surgical outcome and mortality rate (20%) in our patients were quite satisfactory. CONCLUSION: Prompt transportation, appropriate diagnostic methods and an adequate surgical treatment can markedly reduce mortality and complications rate in war injuries to the thoracic esophagus.     

Orientational research into dismissed managers in health care

One hundred and eighteen competitors, with spinal injuries, attending the First International Ex-Service Wheelchair Games, held in July 1993, were interviewed. Athletes from 17 countries attended. Sixteen competitors were tetraplegic and 102 paraplegic, their injuries are detailed below. The injuries had occurred on average 14.0 years previously: 35 injuries were war injuries a further 10 due to combat training. The paraplegic athletes had spent 9.6 months and the tetraplegic 12.3 months in hospital. Fifty-five spinal stabilizations had been performed, and this was associated with a reduced inpatient stay for the paraplegic athletes (7.7 months vs 11.3 months). Spinal fixation did not affect later employment. Thirty-one athletes worked, and the amount of pension had no significant bearing on the numbers working. There was a mean delay of 38.3 months from injury until return to sport, and only 11.8% of competitors took up sport in the initial rehabilitation period. The differences between operative treatment, inpatient stay and numbers working from the different countries are compared. Financing of attendance and training seemed to be informal, with just over half of the athletes financed by their governments. The role of sport in rehabilitation of those patients with spinal injuries, and specifically those injured whilst serving in the armed forces, is discussed.     

Gunshot injuries in Mobile County, Alabama: 1985-1987

Although much information about firearm fatalities has been published, few articles have characterized all types of gunshot victims, the weapons used, and the injuries sustained in a well-defined geopolitical unit. This study of 597 persons sustaining gunshot injuries serious enough to cause death or hospitalization in Mobile County Alabama during 1985-1987, addresses that deficit. The overall rate of these 597 seriously gunshot-injured victims was 53/100,000 population per annum. Of the 597 victims, 215 died, resulting in a rate of 18.9 per 100,000 population per annum. Demographic characteristics of the homicide victims, predominantly young black men, and the suicide victims, predominantly middle-aged and elderly white men, are similar to those reported from other parts of the country. Assault victims accounted for the largest (316) number of victims: again, young black men also constituted the largest demographic group among assault victims. Handguns accounted for 71% of the weapons used. No assault type weapons were employed. Head, neck, and chest wounds led with the greatest fatality rates. Information about nonfatally wounded victims, particularly data about the weapons, proved difficult to obtain. This was one of the many problems encountered in this type of project and, consequently, is discussed at some length. Additional population-based studies using prospective methods and a variety of investigators, including persons knowledgeable of firearms, are needed.     

Identification of war victims from mass graves in Croatia, Bosnia, and Herzegovina by use of standard forensic methods and DNA typing

The postmortem remains of sixty-one war victims were excavated from 6 mass graves in Bosnia and Herzegovina one and a half years after interment Using standard identification methods, including the matching of medical and dental records, the recognition of distinguishing characteristics such as the use of clothing and belongings, and video superimposition, 35 persons were identified. For the remaining 26 persons identification efforts continue. DNA typing was performed at the HLA DQA1 locus and five PM system loci. Results from DNA typing were confirmed by other methods. DNA profiles of family members of 150 missing persons are now being developed using the 6 loci. These DNA profiles will then be compared with those generated from the bone and teeth remains of the unidentified victims.     

Injury panorama and medical consequences for 1158 persons assaulted in the central part of Stockholm, Sweden

This retrospective study describes assaults, type of trauma, injury panorama, the abbreviated injury scale score and medical consequences for 1158 assaulted persons. All patients were examined by surgeons at the Emergency Department, Sabbatsberg's Hospital, Stockholm, Sweden, which is open around the clock. The police were not notified. The study group included all assaulted patients who attended and were examined at the Emergency Department from 1 April 1992 to 31 March 1993: 84% men and 16% women. Their median age was 25 years (range 13-86 years). Sixty-eight percent arrived at the Emergency Department between 11 p.m. and 4 a.m. In 44% the hospital staff registered in the case notes that the victims were drunk. Blunt trauma of low-energy type predominated, 44% were hit by fists and 30% by kicks. Penetrating trauma occurred in 10% of the assaults (knife 8%), and a combination of blunt and/or cutting trauma (bottle/ glass) in 10%. Eighty-two percent of the victims suffered an injury to the head, resulting in concussion in 116 cases, 4 skull fractures, 1 intracerebral contusion, 74 fractures of nose bones, 17 fractures of other face bones, and 6 mandible fractures. Two persons died because of knifestab wounds. Eighty-two percent of the victims had minor injuries, and 16% had moderate injuries according to the score on the Abbreviated Injury Scale (AIS). The present study shows that assault in the central part of Stockholm, Sweden, is mainly a problem involving young men, especially late in the evening, and that many of the victims are drunk. Injuries to the head due to low-energy trauma are the most common (hit by fists and kicks), but severe injuries seldom occur.     

War injuries of the arteries

The experience with military vascular injuries in the recent war in Crotia is reviewed. From April 1991 to October 1995, 197 wounded persons with 231 injuries of arteries were admitted to the University Hospital Rebro. The most common injuries were of lower extremity arteries (54.5%), and the most frequent method of repair was revascularisation with saphenous vein graft interposition. Fasciotomies were performed in 34% because of frequent associated injuries of bones (34.5%) and veins (46.7%). In 20.7% casualties pseudoaneurysms and arteriovenous fistulas were found. Postoperative thrombosis (9%) was a consequence of local infection, massive necrosis and sepsis. Amputation rate was 7.7%, and mortality 5.3%. These results are very satisfactory in comparison with the results in literature. This is a result of good organization of our war surgical service: rapid transportation of wounded persons to convenient surgical centres and high surgical skill.     

Psychologists and rehabilitation: New roles and old training models.

The role of psychologists in physical rehabilitation settings has expanded considerably over the past decades. Unfortunately, the lack of clarity regarding roles, functions, and research of psychologists in inpatient and outpatient rehabilitation settings has hampered efforts to establish guidelines for training graduate students to work in rehabilitative settings. Despite ongoing debate since the Princeton Conference in 1958, no guidelines have been recommended by Division 22 of the American Psychological Association (Division of Rehabilitation Psychology) for training doctoral students in clinical and counseling psychology programs for work in rehabilitation. This article asserts that psychology graduate students who want to work in physical rehabilitation settings should (a) have core training in psychology and (b) receive coursework and practica in working with persons who have chronic illnesses and injuries. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Social problem-solving abilities and adjustment to recent-onset spinal cord injury.

ABSTRACT. Objective: To examine the relation of social problem-solving abilities to psychological and physical adjustment of persons with recent spinal cord injuries (SCIs). Design: Correlational procedures were used. Participants: One hundred eighty-six persons with recent SCI completed self-report measures during inpatient rehabilitation; 94 returned for an annual evaluation. Main Outcome Measures: Acceptance of disability, career needs, and pressure sore diagnoses. Results: Greater negative problem orientation predicted each self-report outcome variable; completeness of lesion was the best predictor of pressure sore diagnosis. Conclusions: The problem orientation component appears to relate to self-reported adjustment among persons with SCI in a theoretically consistent fashion. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Neuropsychological assessment and the rehabilitation of persons with severe psychiatric disabilities.

Discusses barriers facing psychologists seeking appropriate testing material for use with persons with severe psychiatric disability (SPD), including lack of knowledge, understanding the meaning of impairment, and the need for individual testing and qualitative observations. A test protocol is offered, and findings from the author's practice are presented. Results reveal combinations of cognitive defects among persons with SPD and suggest that practical knowledge is crucial to the success of rehabilitation. The applicability of cognitive rehabilitation measures for persons who are brain-injured is discussed, and it is argued that such measures can contribute significantly to the rehabilitation of patients with SPD. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Spine and spinal cord war injuries during the war in Croatia

OBJECTIVE: The present report summarizes the experience of an evacuation hospital in southern Croatia in treating 96 patients with spine and spinal cord war injuries. METHODS: A retrospective review was done for 96 wounded persons (86 soldiers, 10 civilians) with spinal cord injuries from August 1991 through December 1995. The ages ranged from 15 to 59 years (mean, 28.3 years for soldiers, 38.5 years for civilians). Diagnostic procedures were plain radiography, computed tomography, and computed tomographic myelography. However, in most cases a more conservative surgical approach was used. RESULTS: The highest rates of admittance were recorded in 1992 (N = 38) and 1993 (N = 47). The lumbar spine was injured in 55% of the patients, the cervical and thoracic spines in 17.7%. All injuries were caused by projectiles from automatic rifles and sniper fire (51%) and from fragments of explosive devices (49%). Blast injury of the spinal cord was found in 10 patients. The most frequent complications caused by the fragments were wound infection, urinary tract infection, decubitus, and pneumonia. Four patients (4.2%) died in the hospital, and 43.0% of patients survived but were severely handicapped. CONCLUSION: Careful clinical examination combined with modern diagnostic imaging and use of broad-spectrum antibiotics reduced the need for surgical intervention in patients with spinal cord injuries.     

External causes of death among persons with developmental disability: the effect of residential placement

The authors analyzed death rates from external causes (accidents, injuries, homicides, etc.) for persons with developmental disability in California. There were 520 such deaths during the 1981-1995 study period, based on 733,705 person-years of exposure; this represents all persons who received any services from the state. Compared with the general California population, persons with developmental disability were at lower risk of homicide, suicide, and poisonings (standardized mortality ratios, 0.31-0.68), but higher risk of pedestrian accidents, falls, fires, and, especially, drowning (standardized mortality ratio=6.22). A major focus of the study was comparisons between different residential settings. Persons in semi-independent living had significantly higher risk than did those in their family home or group homes, with homicides rates being three times higher and pedestrian accidents rates being doubled, while persons in institutions had much lower risks with respect to most causes. Of the 28 deaths due to drug and medication overdoses, 79 percent occurred in supported living or small-group homes. Avoidable deaths could be reduced by making direct care staff more aware of the risks and better trained in acute care, along with improved monitoring of special incidents.     

Craniocerebral injuries at the Vukovar battlefield]

In Neurosurgical Clinic of Military Medical Academy 33 wounded persons with craniocerebral injuries (CCI) from Vukovar battlefield were treated from September 16 to December 3. After the follow-up period of average 48 months the outcome of treatment was analyzed compared to the clinical status on admission and to the extent of cerebral lesion. All wounded with minor CCI (GCS = 15) and majority with mild injuries (GCS = 13-14) had the good outcome, and all the wounded with severe injuries (GCS = 3-8) died (p < 0.01). After unilobar penetrating CCI the outcome was mostly good, but after multilobar and transventricular injuries the outcome was worse or lethal (p < 0.01). Total mortality rate was 27.3%. Our conclusion is that bad clinical status on admission and more extensive cerebral lesions correlate with worse outcome of treatment of war CCI.     

Persistent disability associated with ankle sprains: a prospective examination of an athletic population

The purpose of this study was to examine a young athletic population to update the data regarding epidemiology and disability associated with ankle injuries. At the United States Military Academy, all cadets presenting with ankle injuries during a 2-month period were included in this prospective observational study. The initial evaluation included an extensive questionnaire, physical examination, and radiographs. Ankle sprain treatment included a supervised rehabilitation program. Subjects were reevaluated at 6 weeks and 6 months with subjective assessment, physical examination, and functional testing. The mean age for all subjects was 20 years (range, 17-24 years). There were 104 ankle injuries accounting for 23% of all injuries seen. There were 96 sprains, 7 fractures, and 1 contusion. Of the 96 sprains, 4 were predominately medial injuries, 76 were lateral, and 16 were syndesmosis sprains. Ninety-five percent had returned to sports activities by 6 weeks; however, 55% of these subjects reported loss of function or presence of intermittent pain, and 23% had a decrement of >20% in the lateral hop test when compared with the uninjured side. At 6 months, all subjects had returned to full activity; however, 40% reported residual symptoms and 2.5% had a decrement of >20% on the lateral hop test. Neither previous injury nor ligament laxity was predictive of chronic symptomatology. Furthermore, chronic dysfunction could not be predicted by the grade of sprain (grade I vs. II). The factor most predictive of residual symptoms was a syndesmosis sprain, regardless of grade. Syndesmosis sprains were most prevalent in collision sports. This study demonstrates that even though our knowledge and understanding of ankle sprains and rehabilitation of these injuries have progressed in the last 20 years, chronic ankle dysfunction continues to be a prevalent problem. The early return to sports occurs after almost every ankle sprain; however, dysfunction persists in 40% of patients for as long as 6 months after injury. Syndesmosis sprains are more common than previously thought, and this confirms that syndesmosis sprains are associated with prolonged disability.     

Use of cardiopulmonary bypass to salvage patients with multiple-chamber heart wounds

BACKGROUND: The need for cardiopulmonary bypass in the treatment of penetrating heart injuries is debated. OBJECTIVES: To review our experience with penetrating heart injuries and determine the indications and outcome for cardiopulmonary bypass. DESIGN: Retrospective review. SETTING: A university-based, level I trauma center. PATIENTS: All victims of penetrating heart injury presenting between July 1, 1989, and December 31, 1995. METHODS: Medical records were reviewed for demographic and physiological data, operative findings, and outcome. RESULTS: Overall survival for 106 patients with penetrating heart injury was 55%. In an effort to resuscitate the heart, 4 patients with unresponsive cardiogenic shock were placed on cardiopulmonary bypass; none survived. Of 30 patients with multiple-chamber injuries, 11 presented with signs of life and 7 survived. Cardiopulmonary bypass was essential to repair complex injuries in 2 of the 7 survivors. CONCLUSION: Cardiopulmonary bypass was ineffective in salvaging patients with cardiogenic shock but was essential in some patients with complex multiple-chamber cardiac injuries that could not be exposed and repaired by other means.     

"Integrated psychotherapy": a new clinical challenge

Integrated psychotherapy according to Barolin wants to be embedded in the general health system and regards the whole "bio-psychosocial entity of man" using psychical means, which can take psychotropic as well as somatotropic effect. It should come out of an isolated ivory tower and seek coordination with each and everyone dealing with the "human entity": medical (like medication, physiotherapy, etc.), nursing, social work, administration, etc. Psychotherapeutic "schools" should serve as a solid base of learning. Practical use however should go beyond schools: patient-centered instead of school-centered. Integrated psychotherapy should reach all persons who need it, within their somatogenic and psychogenic problems, especially the physical ill, up to accompaniment of the dying, especially in rehabilitation, including social environment, old-age groups. For this it needs social integration accepting economic responsibility (in the sense of "social ethics") plus evaluation. Hence, theory and practice of integrated psychotherapy find themselves linked to a higher human-ethical postulate, with a marked communicative component.     

Auditory brainstem responses after radiotherapy for nasopharyngeal carcinoma

BACKGROUND: During the war in former Yugoslavia people endured great suffering. Although many had sought refuge in other countries, the majority remained within Bosnia-Herzegovina. Special service for women within the war zone was urgently needed. A Women's Therapy Center was established in Zenica, Bosnia-Herzegovina offering reproductive health services and psychosocial assistance. The aim of the study was to establish the most commonly occurring gynecological problems during different periods in the war and relate these to war traumas. METHODS: Information from 486 records of consecutive gynecological consultations in four different periods during in 1993/94 were retrospectively recorded. RESULTS: Vaginal discharge, pelvic pain, and amenorrhea were the most commonly occurring problems. A higher proportion of pregnant women requested legal abortion in the first period compared to later periods when the situation was improved. In 14 (3%) of the consultations a history of rape during the war was recorded. Additionally 42 (9%) had suffered from other types of war traumas. The reporting of war traumas was significantly related to suffering from pelvic pain (p < 0.05). CONCLUSIONS: The focus on the need of victims of rape during war has highlighted the need for reproductive services as part of emergency situations. The suffering of war traumas has to be taken into account in the handling of gynecological problems in this situation.     

A population-based study of tractor-related injuries: Regional Rural Injury Study-I (RRIS-I)

Although tractors account for the majority of fatal farming-related injuries, little is known about the magnitude of this problem. The study population in this article was obtained from the five state Regional Rural Injury Study-I (RRIS-I) database that included 3939 farm households and 13,144 persons interviewed during 1990. Rates were calculated for sociodemographic variables and various exposures; logistic regression was used to calculate the relative risks and respective confidence intervals. Among the total farming-related injury events (n = 764), 65 (8.4%) were related to regular tractor (> or = 20 horsepower) use (495 injured persons per 100,000 persons per year). The rates increased incrementally for those persons working between 20 to 39 and 60 to 79 hours per week (range, 529 to 1430 per 100,000 persons). Among the 12 rollover events, there were only three injuries. The majority of injury events occurred while persons were mounting or dismounting the tractor (42%). Although only 7% of the cases were hospitalized, 83% required some type of health care. Among all injured persons, 43% were restricted from regular activities for 1 week or more and 20% were restricted for 1 month or more; 28% continued to have persistent problems. The finding of the large proportion of events associated with activities of mounting and dismounting suggests a need to investigate specific design characteristics of the tractors associated with these events and, in general, the tractors to which the population is exposed.     

Head injury rehabilitation: Psychological issues and roles for the rehabilitation psychologist.

Points out that rehabilitation psychologists are critical members of the health care team in the provision of diagnostic, remediational, and consultative services to the victims of head injury, family members, and relevant social welfare and 3rd-party payers. The present authors consider the roles of the rehabilitation psychologist when the head-injured are involved in the legal process, including consulting with attorneys, serving as an expert witness, and acting as an advocate for clients. Case illustrations are provided of additional psycholegal issues, such as the use of psychological data as evidence, eligibility criteria for various programs, and the need for the psychologist to act as a liaison with educational and vocational systems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Review of 1198 cases of penetrating cardiac trauma

BACKGROUND: This study was a clinicoforensic analysis of the prevalence and outcome of traumatic cardiac injuries in Durban. METHODS: Between 1990 and 1992, 1198 patients sustained cardiac trauma. Seventy (6 per cent) reached hospital alive and 1128 (94 per cent) were taken directly to the mortuary. Seven hundred victims had suffered stab wounds, 494 gunshot wounds and four blast injuries. Gunshot injuries increased from 34 per cent in 1990 to 50 per cent in 1992. The mean (s.d.) age was 30.5 (5.4) years and the majority (91 per cent) were men. RESULTS: Thirty-five (50 per cent) of those who reached hospital alive died, including all four gunshot victims. Significant factors associated with survival were isolated injury, the presence of cardiac tamponade (univariate and multivariate analysis), right ventricular injury, single cardiac chamber injury and absence of pleural breach (univariate analysis alone). Delay in operative intervention was associated with a higher mortality rate. When analysing the patients who did not reach hospital alive, 202 (18 per cent) with tamponade due to an isolated stab wound were identified as a subset who might have been saved with prompt treatment. CONCLUSION: An increasing number of gunshot injuries in combination with delays in reaching hospital and in receiving treatment accounted for the high mortality rate in this unselected series.     

Clinical impressions of depression and physical stigma.

Examined 58 rehabilitation psychology trainees' reactions to individuals who were varied in interpersonal behavior and physical stigma. According to traditional notions, graduate students in clinical and counseling psychology programs should differ from graduate students in a rehabilitation counseling program in their emotional and cognitive reactions to persons with physical disabilities. Alternatively, interpersonal models of depression suggest that all trainees should have more pronounced emotional reactions and different cognitive expectations of a person who displays depressive behavior. Affective reactions and clinical impressions of Ss were moderated neither by the nature of their training nor by the presence of physical stigma. Trainees reported more feelings of sadness after seeing the depressed targets, and also reported more negative expectations of these persons in counseling. (PsycINFO Database Record (c) 2010 APA, all rights reserved)