Autism and Pervasive Developmental Disorder Not Otherwise Specified are common developmental problems often seen by child neurologists. There are currently no cures for these lifelong and socially impairing conditions that affect core domains of human behavior such as language, social interaction, and social awareness. The etiology may be multifactorial and may include autoimmune, genetic, neuroanatomic, and possibly excessive glutaminergic mechanisms. Because memantine is a moderate affinity antagonist of the N-methylD-aspartic acid (NMDA) glutamate receptor, this drug was hypothesized to potentially modulate learning, block excessive glutamate effects that can include neuroinflammatory activity, and influence neuroglial activity in autism and Pervasive Developmental Disorder Not Otherwise Specified. Open-label add-on therapy was offered to 151 patients with prior diagnoses of autism or Pervasive Developmental Disorder Not Otherwise Specified over a 21-month period. To generate a clinician-derived Clinical Global Impression Improvement score for language, behavior, and self-stimulatory behaviors, the primary author observed the subjects and questioned their caretakers within 4 to 8 weeks of the initiation of therapy. Chronic maintenance therapy with the drug was continued if there were no negative side effects. Results showed significant improvements in open-label use for language function, social behavior, and self-stimulatory behaviors, although self-stimulatory behaviors comparatively improved to a lesser degree. Chronic use so far appears to have no serious side effects.
Objectives: Upon completion of this article, the reader will be able to (1) explain the incidence and potential complications of bullet embolization, and (2) recall the challenge of diagnosing this entity and the therapeutic possibilities available including endovascular retrieval. Accreditation: Tufts University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Credit: Tufts University School of Medicine designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Case PresentationA 46-year-old man presented to a local level 2 trauma center after sustaining a single gunshot wound to the right upper quadrant of the abdomen. The patient was hemodynamically unstable and was taken emergently to the operating room for exploration of the abdomen. He was found to have a through and through injury to the liver, small intestinal injury at two locations, and a single injury to the infrarenal vena cava. The Keywords ► penetrating trauma ► bullet embolization ► endovascular retrieval ► interventional radiology
AbstractBullet embolization after penetrating trauma is an infrequent but important phenomenon. It presents an unexpected sequelae to the otherwise predictable injury pattern of penetrating missile injury mechanism and poses a challenging diagnostic and therapeutic dilemma. Bullets from penetrating wounds can gain access to the vasculature and migrate to nearly every large vascular bed. Patients can be asymptomatic, but the potential complications can be devastating including limb-threatening ischemia, sepsis, endocarditis, cardiac valvular incompetence, pulmonary embolism, stroke, and even death. The exact incidence of bullet embolization is unknown, but it was estimated to be 0.3% during the Vietnam War and 1.1% in the recent conflict in Afghanistan and Iraq. The scarcity of the condition and the lack of concentrated experience at any single institution contribute to the controversies pertaining to the management approach. Traditionally, surgical extraction of embolized bullets may involve difficult and invasive surgical exposures. Recent advancement in endovascular techniques provides an additional option in this treatment algorithm. In this article, we describe a case of venous bullet embolization from the left iliac vein treated by a combined endovascular and surgical approach.
Pelvic fractures account for ∼3% of all fractures and usually occur in patients with polytrauma. Pelvic fractures usually indicate high energy transfer and a significant mechanism of injury, and they can involve massive hemorrhage. For this reason, mortality from pelvic trauma is high, ranging from 40% to 60% among patients in shock, and up to 90% in patients considered to be in extremis. Multidisciplinary approaches in the treatment of patients with pelvic fractures have resulted in improved outcomes for these complex and challenging injuries. In this article, we describe a case of a pediatric patient who suffered severe pelvic fracture with massive hemorrhage, requiring a multidisciplinary approach for control of hemorrhage and definitive repair of injuries.
The addition of a cervical MRI to the evaluation protocol of obtunded or comatose patients with an otherwise normal neurologic examination and a normal cervical CT did not provide any additional useful information to change the management of these patients.
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