Skin Conductance Response during Laboratory Stress in Combat Veterans with Post Traumatic Stress Disorder

Skin conductance response is a commonly used psychophysiological measure due to the ease of collection and low cost. Skin Conductance Response (SCR) reflects sympathetic activation because palmar sweat glands are innervated by the sympathetic chain of the autonomic nervous system. There is also a high correlation between bursts of sympathetic nerve activity and SCR. Additionally, activation of cortical emotion regulation areas known to be altered in posttraumatic stress disorder is associated with elicitation of SCR.

A number of studies have assessed SCR in people with Posttraumatic Stress Disorder (PTSD). Most studies have observed increased reactivity to a variety of stimuli while others have not. However, no study has examined the relationship between SCR and the PTSD symptom clusters of re-experiencing, numbingavoiding, and hyper-arousal. Assessing the relationship between the individual PTSD symptom components and SCR may elucidate which aspects of PTSD psychopathology are most indicative of heightened sympathetic activity.

The primary objective of this study was to assess SCR in combat veterans with posttraumatic stress disorder compared to combatexposed and non-combat exposed controls in response to a laboratory stressor. The primary hypothesis was that combat veterans with PTSD would have increased SCR compared to controls. The secondary objective was to evaluate the relationship between SCR and posttraumatic stress disorder symptom clusters.

Ipsilateral Dislocation of Shoulder and Elbow Joints

The shoulder joint is the most frequently dislocated joint, closely followed by the elbow joint. However, simultaneous dislocations of both joints on the same limb seldom occur with only eight recorded in English literature. Fractures of the greater tuberosity or coracoid process can be associated with dislocations of either joints (shoulder and elbow), but a double dislocation without other associated injury is uncommon. This combination of injury can be easily missed if the patient is not properly examined at initial presentation  and hence result in a late or completely missed diagnosis of the shoulder dislocation. A case report of an ipsilateral dislocation after enduring minor trauma was reduced with intravenous sedation in the Accident and Emergency department and later made a very good, complete recovery of function.

A 40 year old female patient presented in the Accident and Emergency department after tripping over her cat and falling down a flight of stairs. She had previously consumed some alcohol. The patient complained of pain over her left elbow and shoulder joints which she consciously immobilised and refused to move. There was no neurovascular deficit.

Plain radiographs figures 1 and 2 of her left upper limb showed anterior dislocation of the shoulder joint and posterior dislocation of the elbow joints without any associated fracture.post-reduction plain radiographs.She was given entonox (Nitrous oxide and oxygen) and intravenous morphine in the Accident and Emergency department before both dislocations were reduced beginning with the elbow joint.

Get PDF Link

Surgical Management of Blunt Trauma

The relatively fixed position of the liver and its large size makes it more prone for injury in blunt trauma of the abdomen. Liver and spleen together, account for 75% of injuries in blunt abdominal trauma. Though liver is the second most commonly injured organ in abdominal trauma; it is the most common cause of death following abdominal injury. Compared to splenic injuries, management of liver trauma still remains a challenge in the best of trauma centres.

In the past, most liver injuries were treated surgically. However evidence confirms that about 86% of liver injuries have stopped bleeding by the time surgical exploration is performed and 67% of laparotomies done for blunt trauma abdomen are non-therapeutic. Imaging techniques especially Computerised Tomographic (CT) scan has created remarkable impact in managing liver trauma patients by reducing the number of laparotomies. About 80% of adults and 97% of children are presently managed conservatively worldwide at high volume trauma centres.

The large size of the liver, the friable parenchyma, its thin capsule and its relatively fixed position make it prone to blunt injury. Right lobe is more often involved, owing to its larger size and proximity to the ribs. Compression against the fixed ribs, spine or posterior abdominal wall results in predominant damage to segments 6, 7 and 8 of the liver (>85%). Pressure on right hemithorax may propagate through the diaphragm producing contusion of dome of right lobe of liver.

Liver’s ligamentous attachments to diaphragm and posterior abdominal wall act as sites of shearing forces during deceleration injury. Liver injury can also occur as a result of transmission of excessively high venous pressure to remote body sites at the time of impact. Weaker connective tissue framework, relatively large size and incomplete maturation and more flexible ribs account for higher chance of liver injury in children compared to adults.

Get PDF Link

Refractory Acute Myeloid Leukemia during Allogeneic Transplantation

CLS is one of the life-threatening early complications which usually occur during hematopoietic stem cell infusion or hematopoietic reconstruction process in addition to graft-versus-host-disease (GVHD) and infection. It is characterized by unexplained episodic capillary hyperpermeability, which causes the shift of fluid and protein from the intravascular space to the interstitial space. However, since the nonspecific signs and symptoms of CLS and the overlapping manifestations of early complications after transplantation, CLS tends to be easily confused with other early complications for clinicians. In this case, we report an adult with refractory acute myeloid leukemia who developed fatal CLS during allo-HSCT with review of the literature.

Allo-HSCT is a curative procedure for a subset of patients with hematologic malignancies. However, allo-HSCT is still associated with high treatment-related mortality due to severe infections and noninfectious complications. Especially during hematopoietic stem cell infusion or hematopoietic reconstruction process, a constellation of symptoms and signs including fever, erythrodermatous skin rash, and noncardiogenic pulmonary can be potentially fatal.

CLS is a severe early complication of HSCT characterized by weight gain, generalized edema, hypotension, and hypoalbuminemia. We present an allo- HSCT AML patient affected by fatal CLS during conditioning therapy with a short survival in which the crises have disappeared temporarily after treatment but eventually died of CLS recurrence.

What Disease Conditions could be Considered for Potential Therapeutic Kidney Donations?

The OPTN/UNOS Living Donor Committee, UNOS Policy Department, coined the term “therapeutic organ donor” to describe an individual who has an organ removed as a component of their treatment for a medical problem, and their removed organ is suitable for transplantation into a transplant candidate. The committee suggested that potential therapeutic donors may have conditions, such as renal cell carcinoma (with the tumor removed after recovery and before transplantation), ureteral trauma (a transected ureter), or maple syrup urine disease. Many chronic kidney disease (CKD) patients on a transplant waiting list are eagerly anticipating this new OPTN policy proposal. In this manuscript, we would like to concentrate on the kidney as a therapeutic organ and propose a list of renal conditions associated with “therapeutic donatable kidneys” which include “donatable kidneys that are nephrectomized due to urologic diseases”.

The shortage of donor kidneys is a serious problem in Japan, and this trend has become worse partly because altruistic donations and paired kidney exchange programs are not currently accepted in Japan, while ABO-incompatible living kidney transplantation has increased to 30%. In addition, restored kidney transplantation by “therapeutic kidney donation” was banned by the Japanese government in 2007, with the exception of transplantations conducted as part of clinical trials. 

This donor shortage crisis prompts dialysis-intolerant patients to seek transplantation and donor kidneys in foreign countries, leading to an increase in transplant tourism. To reverse this situation, the Tokushukai group launched two clinical trials of therapeutic kidney donation (TKD) in 2009, which are still ongoing, to transplant restored kidney allografts in patients without appropriate donors among their family members or who have used all of the possible living donors in their family.

Primary Mucosal Melanoma: Uncommonly Described Entity

Malignant melanoma arises by malignant transformation of the normal melanocytes. Distribution of malignant melanoma includes cutaneous (91.2%), ocular (5.3%), mucosal (1.3%), and unknown primary site (2.2%). Because of rarity and clinical challenges arising from different anatomic location, our understanding for the optimal management of mucosal melanoma remains limited. Malignant melanoma can arise from the mucosal epithelium of respiratory, alimentary, and genitourinary tracts, all of which contain melanocytes. The most common sites for primary mucosal melanoma include head and neck followed by anorectal, and vulvovaginal regions (55, 24, and 18%, respectively). Rarer sites are urinary tract, gallbladder, and small intestine.

Although melanocytes share same embryologic origin, mucosal melanomas behave more aggressively and have many different characteristics compared to cutaneous melanomas. Mucosal melanomas are multifocal in 20% cases, while cutaneous melanomas are multifocal in 5%. 40% of mucosal melanomas are amelanotic, while <10% of cutaneous melanomas. In the following section we described this uncommonly presented entity. 5 year survival for mucosal melanoma is 25%, while that for cutaneous melanoma it is 80.8%.

Etiopathogenesis

Mucosal melanoma arises in non-sun exposed parts of the body and risk factors are not properly defined. Incidence increases with age and > 65% of patients are older than 60 years . The difference between white and black population is less pronounced compared to cutaneous melanoma and mucosal melanomas are approximately twice higher among whites compared to blacks. The higher incidence in females compared to males is because of the predominance of genital tract melanomas in females, which account for 56.5% of mucosal melanomas among them . There is no difference in rates between genders for extragenital mucosal melanomas.

Pulmonary Embolism and Stanford Type B Aortic Dissection in the Same Patient

An 86-year-old female with a history of hypertension for more than 40 years was admitted to our hospital complaining of sudden chest pain 12 hours ago. Physical examination showed no abnormality but mild swellingof the right lower extremity. However, contrast-enhanced Computed Tomography Angiogram (CTA) demonstrated a Stanford type B Aortic Dissection (AD), bilateral pleural effusion, and Pulmonary Embolism (PE) in the left lower pulmonary artery, right pulmonary artery trunk (Figure 1). Meanwhile, Colored-Doppler Ultrasound confirmed the Deep Vein Thrombosis (DVT) in the right popliteal vein.

The patient underwent insertion of an inferior vena cava filter for prevention of further PE. At the same time, conservative therapy was taken for the type B AD. However, she still complained about aggravated chest pain, so another CTA was arranged which showed increased pleural effusion 5 days later

. 

Therefore Thoracic Endovascular Aortic Repair (TEVAR) was performed and a 36 mm × 36 mm × 200 mm stent-graft was implanted. The result was satisfying and the patient had a smooth recovery with no major adverse events.PE and Stanford type B AD causing chest pain in the same patient is rare with limited cases reported. CTA scanning is a valuable clinical tool for diagnosis.