Assault-related facial fractures: does the injury mechanism matter?

This study clarified the injury characteristics and occurrence of associated injuries in patients with assault-related facial fractures. Data from 840 assault-related facial fracture patients were included; demographic factors, facial fracture type, associated injuries, alcohol use, and injury mechanisms were recorded. Assault mechanisms most often included combinations of different mechanisms (57.5%) and resulted in the victim falling (50.1%). The perpetrator was most commonly a stranger (52.5%) and acted alone (57.7%). A total of 123 patients (14.6%) had associated injuries, with the most common being traumatic brain injury. Associated injuries occurred most frequently in patients with combined fractures of the facial thirds (24.2%) and upper third fractures (42.9%). The most significant differentiating factors for associated injuries were the number of perpetrators, falling, the use of an offensive weapon, and if the events of the assault remained unknown. In adjusted logistic regression analyses, statistically significant associations with associated injuries were found for age (odds ratio (OR) 1.05, 95% confidence interval (CI) 1.03-1.07; P < 0.001), falling due to the assault (OR 2.87, 95% CI 1.49-5.50; P = 0.002), and upper third facial fractures (OR 6.93, 95% CI 2.06-23.33; P = 0.002). A single punch also caused severe injuries and should therefore not be overlooked, as this can be as dangerous as other assault mechanisms.

Primary treatment of ruptured blood blister-like aneurysms with stent-assisted coil embolization: report of two cases.

Blood blister-like aneurysms (BBAs) are among the most hazardous cerebrovascular aneurysms to treat; microsurgical treatment of these small, wide-necked, and exceptionally fragile aneurysms place patients at significant risk of morbidity or mortality. We report two cases of ruptured BBAs attempted to be treated for the first time with stent-assisted coil embolization solely and review the current literature on treatment options. Our patients underwent stent-assisted coil embolization of the aneurysms in the acute stage of subarachnoid hemorrhage (SAH). One patient was successfully treated without procedure-related complications. The other patient died after surgical internal carotid artery (ICA) occlusion, carried out after intraoperative rerupture of the aneurysm during the endovascular treatment. In the successful case, 8-month and 19-month follow-up angiograms demonstrated incomplete (>90%) occlusion with residual filling of the aneurysm neck, which did not need additional coil embolization. Even though stent-assisted coil embolization of ruptured BBAs in the acute stage appears to be a technically feasible treatment option, the present stent-related endovascular technology has potentially hazardous drawbacks.

Neurosensory recovery after trauma to the orbital floor: a prospective trial with dexamethasone.

Our aims were to document the occurrence of neurosensory disturbances of the infraorbital nerve six months after operation for an orbital blow-out fracture, and to find out whether dexamethasone facilitates neurosensory regeneration. Patients were randomly assigned to one of two groups: the study group was given a total of dexamethasone 30mg, whereas the control group were given neither glucocorticoid nor placebo. Each patient's infraorbital neurosensory state was recorded preoperatively, immediately postoperatively, and six months later. A total of 18 patients were included, eight of whom had neurosensory disturbances six months after the initial trauma that was not affected by dexamethasone. Six of the seven patients who had a delay of seven days or more between trauma and operation had significantly prolonged disturbance at the 180-day clinical follow up compared with those in whom it was less than seven days (p=0.005). Other possible predictors made no significant difference. Although dexamethasone did not facilitate sensory recovery, its benefits in the management of pain and reduction of swelling may justify its use in the management of facial trauma in selected patients.

Postoperative nausea and vomiting in facial fracture patients: A Randomized and controlled trial on the effect of dexamethasone.

This study aimed to establish the incidence of postoperative nausea and vomiting (PONV) in facial fracture patients. The specific aim was to investigate the effect of perioperative dexamethasone on PONV. A total of 119 adult patients with facial fractures were analysed in this prospective study. Patients were randomized to receive perioperatively either a total dose of 30mg of dexamethasone i.v. and i.m., or no glucocorticoid (control). PONV was evaluated every 6hours during the first postoperative 24hours and when pain medications were given. PONV occurred in 20 out of 119 patients (16.8%). The only significant (P=0.016) association with PONV was postoperative administration of opioids. Slightly more cases of PONV occurred for patients who had not received dexamethasone (20%) compared to those who had (13.6%). PONV was also non-significantly more common in patients ≥40 years (21.3%) than in patients < 40 years (12.1%), after orbital floor reconstruction (28.0%) compared with mandibular (11.6%) and zygomatic (15.6%) fractures surgeries, and also after anaesthesia lasting >97minutes (21.7%) compared with a shorter duration (11.3%). Alternative medications should be used for prevention of post-surgery nausea and vomiting in facial fracture patients.

The value of quantitative analysis of glucose utilization in detection of myocardial viability by PET.

To study whether absolute quantitation of regional myocardial glucose utilization (rMGU) enhances detection of myocardial viability, 70 nondiabetic patients with prior myocardial infarction and angiographically confirmed coronary artery disease were studied with [18F]FDG PET after oral glucose loading. Forty-eight patients were also revascularized and underwent echocardiography after revascularization to detect wall motion recovery. The rMGU was calculated in eight myocardial segments in each patient and the results were compared to normalized (relative) [18F]FDG uptake values. In normal segments (n = 225), rMGU was 56 +/- 18 mumole/min/100 g (mean +/- s.d.) and relative [18F]FDG uptake 97% +/- 12%. The interindividual variation of rMGU in normal myocardium was greater than the intraindividual variation (s.d. 31% versus 11%). The respective values for relative [18F]FDG uptake were 9% and 10%. Both rMGU and [18F]FDG uptake were significantly reduced in segments with scarring observed visually during bypass surgery (29 +/- 19 mumole/min/100 g and 45% +/- 22%, n = 26). The rMGU and [18F]FDG uptake were higher in segments that recovered after revascularization (53 +/- 17 mumole/min/100/g and 110% +/- 21%, n = 27) than in those that did not (37 +/- 20 mumole/min/100 g and 65% +/- 24%, n = 63). However, due to larger variability of rMGU values, normalized [18F]FDG uptake was superior to rMGU in separating normal and scar segments as well as in predicting wall motion recovery. We conclude that rMGU variability is notable and is caused mainly by variations between patients. Interindividual variation is reduced by normalization, which results in more accurate assessment of myocardial viability. Thus, static imaging and semiquantitative analysis are sufficient for the clinical assessment of myocardial viability.

Euglycemic hyperinsulinemic clamp and oral glucose load in stimulating myocardial glucose utilization during positron emission tomography.

To enable assessment of myocardial viability, myocardial glucose utilization has commonly been stimulated by oral glucose loading. To compare the effects of glucose loading and insulin and glucose infusion (insulin clamp) on PET fluorodeoxyglucose ([18F]FDG) myocardial scan image quality and regional myocardial glucose utilization rate (rMGU), eight patients with angiographically documented coronary artery disease and previous myocardial Q-wave infarction were studied twice, once during insulin clamp and once 1 hr after oral glucose loading. The rMGU rates were derived by graphic Patlak analysis in 33 normal, 10 scar and 6 "hot spot" myocardial segments. Infusion of insulin and glucose gave stable plasma-glucose and serum-insulin levels during imaging. In contrast, glucose loading caused marked changes in plasma-glucose and insulin concentrations. The image quality was clearly superior and the fractional utilization rates of [18F]FDG were twice as high during insulin clamp than after glucose loading (p less than 0.0001). Due to the higher plasma-glucose levels after glucose loading, the calculated rMGU in normal, scar and hot spot myocardial segments was comparable between the two protocols. The insulin clamp technique makes it possible to adjust and maintain a metabolic steady state during the PET study. It does not alter [18F]FDG uptake patterns in different myocardial areas when compared to the standard glucose loading protocol, but this technique results in superior image quality and permits the use of smaller [18F] FDG patient doses.

Measurement of intima-media thickness of common carotid arteries with high-resolution B-mode ultrasonography: inter- and intra-observer variability.

High-resolution B-mode ultrasonography enables quantitative measurement of the thickness of the intima-media layer of superficial large arteries noninvasively. We investigated the inter- and intra-observer variability of this measurement in the common carotid arteries in 10 randomly selected men. The maximal right and left carotid intima-media thickness (IMT) was measured with calipers during the scanning from frozen images by four observers in a blinded fashion. Three observers also repeated the scanning and the measurements twice with a week's intervals, with no knowledge of the previous readings. The inter-observer coefficient of variation (CV) was 10.5%. The intra-observer CV (mean of right and left CCA) was 5.4-5.8% for the three observers who carried out the measurements three times. The mean absolute difference between the first and third measurement was 0.087 mm. The intra-observer variation accounted for only 4% of the total measurement variability, 96% being attributable to inter-observer variation. These data show that most of the measurement variability in ultrasonographic B-mode IMT measurements is due to differences between observers, whereas the within-observer variability over time appears proportionately very small.

Late results of surgical and nonoperative treatment of carotid stenosis. Eighty-four patients documented by angiography in 1974-1976.

The long-term results of carotid endarterectomy are controversial. Here we report the late results of 44 surgically and 40 non-surgically treated patients with carotid stenosis documented by angiography in 1974-1976. The groups were similar with respect to sex-distribution, age, length of follow-up time (median 123.0 and 130.0 months in the surgical and non-surgical groups, respectively) and the occurrence of risk factors. Hypertension was more frequent (p less than 0.05) in the surgical group, as was medical treatment, mostly anticoagulants (p less than 0.06). The angiographic findings were also more severe in this group (p less than 0.001). During the follow-up period the occurrence of cerebrovascular complications (death, stroke and/or TIA) was more frequent in the nonoperated than in the operated group; however, survival of the patients was similar, as the cardiovascular deaths were an equalizing factor. The quality of life in patients alive examined for clinical and neurologic status and by neuropsychological tests and interview was similar, except that the operated patients were more satisfied. The progression of atherosclerosis in the carotid artery assessed by Duplex scanning was more frequent in the nonoperated group. Differences in medical treatment did not explain the results. Thus it is concluded that the late results were better in the operated patients with carotid stenosis than in the nonoperated ones.

Vasoactive and atherogenic effects of cigarette smoking: a study of monozygotic twins discordant for smoking.

The mechanism by which atherosclerotic disease is induced by cigarette smoking has not yet been identified unequivocally. Chronic cigarette smoking and the generation of vasoactive prostanoids and the size of carotid atherosclerotic plaques were studied in nine pairs of identical male twins discordant for smoking for over 20 years. The urinary excretion of 2,3-dinor-thromboxane B2 (thromboxane B2 metabolite) of the smoking twin was significantly higher (on average 1.8 times higher) in every pair and that of 2,3-dinor-6-keto-prostaglandin F1 alpha (prostacyclin metabolite) was significantly higher (on average 1.3 times higher) in eight of the nine pairs. The ratio of excretion of these metabolites was significantly higher, being 4.0 (95% confidence interval 2.7 to 5.4) among the smokers compared with 2.9 (2.1 to 3.8) among the non-smokers, thus favouring a mechanism of vasoconstriction. Excretion of the thromboxane B2 metabolite was related to the urinary concentrations of nicotine metabolites. Atherosclerotic plaques detected by ultrasonography in the carotid arteries were significantly larger among smokers but did not correlate with the urinary excretion of prostacyclin and thromboxane B2 metabolites or intensity of smoking. Smoking was concluded to induce activation of platelets by an effect mediated by nicotine. The increased prostacyclin production, on the other hand, suggested a compensatory mechanism for the general vasoconstrictive properties of cigarette smoking.

Lowered peripheral resistance in arteries of legs with venous ulcer.

In the literature there is disagreement concerning the existence of arteriovenous shunting in legs with venous ulcer(s). The aim of this study was to find out if there are differences in resistance in the arteries of ulcer legs and non-ulcer legs and if it is possible to investigate this with a non-invasive Doppler method. Eleven patients, aged 34-87 years, with venous ulcer only in one leg, were investigated using angiography and duplex scanning. Angiography showed premature venous filling and Doppler examination showed lowered peripheral resistance in the arteries of every ulcer leg. Lowered peripheral resistance was found only in one non-ulcer leg, which, however also had signs of venous stasis. Our results clearly show that there is lowered peripheral resistance in arteries of legs with venous stasis. The possible significance of this phenomenon in the pathogenesis of venous leg ulcer is discussed.

Renal vein ethanol concentration during ablation of renal cell carcinoma.

Absolute ethanol is an effective embolizing material for the ablation of renal cell carcinoma with a balloon catheter. We have measured the renal vein ethanol concentration during embolization in 9 patients in order to determine whether toxic levels are achieved. Total occlusion of the embolized arteries was obtained using an average of 12.9 ml (range 8-18) ethanol. Renal vein ethanol concentration varied from trace amounts to 0.79%. There was a significant correlation of the maximum renal vein concentration with the ethanol dose per tumor size. The authors conclude that the renal vein ethanol concentration remains sufficiently low to be harmless when a proper balloon occlusion is used. The optimum ethanol dose may be a function of tumor size.

Ankle arthrography in acute injuries.

Ankle arthrography has proved to be a simple, quick, and useful method in evaluating the ligamentous ruptures in connection with ankle injuries. The observations of the present authors are based on almost 5000 arthrographies . On the lateral side, the ligamentous ruptures spring up in an anteroposterior direction so that the FTA ligament is ruptured first, and, in a continuing injure mechanism, the FC ligament is the next to be ruptured. Isolated ruptures of the FC ligament do not occur. The rupture of the FTP ligament does not appear in arthrography. The rupture of the deltoid ligament is rarer and it usually appears in connection with a pronation lateral rotation injury, especially if the patient has a high fibular fracture and there is no simultaneous fracture of the medial malleolus. The ruptures of tibiofibular ligaments are connected with pronation lateral injuries and fractures of the fibula, if the fracture is situated at the level of the talo-crural joint line or cranial to it.