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Leon Trotsky (1879) Options
Daemon
Posted: Friday, November 7, 2014 12:00:00 AM
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Leon Trotsky (1879)

Trotsky was a Russian Communist revolutionary whose ideas form the basis of Trotskyism, a Communist ideology based on the theory of worldwide revolution. He was a key figure in the 1917 Bolshevik Revolution in Russia and organized the Red Army in the civil war that followed. After a power struggle with Joseph Stalin in the 1920s, Trotsky was exiled from the USSR. In 1940, he was assassinated in Mexico by a Spanish Communist with alleged ties to Stalin. From whom did he borrow the name "Trotsky"? More...
L.Rai
Posted: Friday, November 7, 2014 1:07:32 AM

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Trotsky was a Russian Communist revolutionary whose ideas form the basis of Trotskyism, a Communist ideology based on the theory of worldwide revolution. He was a key figure in the 1917 Bolshevik Revolution in Russia and organized the Red Army in the civil war that followed. After a power struggle with Joseph Stalin in the 1920s, Trotsky was exiled from the USSR. In 1940, he was assassinated in Mexico by a Spanish Communist with alleged ties to Stalin. From whom did he borrow the name "Trotsky"?

To answer the question:

...It was at this time that he changed his name to "Trotsky"—the name he would use for the rest of his life. It is said he adopted the name of a jailer of the Odessa prison in which he had earlier been held...

"Your life matters more than you will ever know, so live it well"
pedro
Posted: Friday, November 7, 2014 4:26:15 AM

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Leon Trotsky is an anagram of rotten yolks. Be more careful next time you change your name Piero.

All good ideas arrive by chance- Max Ernst
JUSTIN Excellence
Posted: Friday, November 7, 2014 7:06:08 AM

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Location: Veinau, Baden-Wuerttemberg Region, Germany

"if Trotsky is finished the threat will be eliminated" Supreme Commander of the Soviet Union told Pavel Sudoplatov and his chief Lavrenti Beria in March 1939. Sudoplatov claimed in his autobiography, Special Tasks, that he personally selected Ramón Mercader for the task of carrying out the assassination of Leon Trotsky.

Through his lover Sylvia Ageloff's access to the Coyoacán house, Mercader, as Jacson, began to meet with Trotsky personally, posing as a sympathiser to his ideas, befriending his guards and doing small favors.

On 20 August 1940, Mercader attacked and fatally wounded Trotsky on the head with an ice axe while the exiled Russian was in his study. The blow failed to kill Trotsky instantly, who got up and grappled with Mercarder. Hearing the commotion, Trotsky's guards burst in the room and nearly beat Mercader to death, but Trotsky, heavily wounded but still conscious, ordered them to spare his attacker's life and let him speak. Caridad and Eitingon were waiting outside the compound in separate cars to provide a getaway; but when Mercader did not return they left and fled the country.

Trotsky was taken to a hospital in the city and operated on but died the next day, as a result of severe brain injuries.




Head injury is a major cause of morbidity and mortality in all age groups. Currently, there is no effective treatment to reverse the effects of the primary brain injury sustained, and treatment is aimed at minimizing the secondary brain injury that can occur due to the effects of ischaemia, hypoxia and raised intracranial pressure. An understanding of the epidemiology of head injury is essential for devising preventive measures, to plan population-based primary prevention strategies and to provide effective and timely treatment including provision of rehabilitation facilities to those who have suffered a head injury.

The aim of this little review is to describe the descriptive epidemiology of traumatic brain injury (TBI), its causes and preventive measures targeted at the ‘at-risk’ population.

Definition and classification of traumatic brain injury

While studying the epidemiology of TBI, it is important to realize that definitions, coding practices, inclusion criteria for patients and items of data collected have varied between studies. This has made it difficult to draw meaningful comparisons of rates and risk factors between populations. The term ‘head injury’ is commonly used to describe injuries affecting not just the brain but also the scalp, skull, maxilla and mandible and special senses of smell, vision and hearing. Head injuries are also commonly referred to as brain injury or traumatic brain injury, depending on the extent of the head trauma. TBI is usually considered an insult or trauma to the brain from an external mechanical force, possibly leading to temporary or permanent impairments of physical, cognitive and psychosocial functions with an associated diminished or altered state of consciousness.

While studying the epidemiology of head injury, it is important to understand that patients with TBI like Trotsky may not survive before reaching hospital or may even present after a delay to primary care; they may present to an accident and emergency department, with subsequent admission to an observation or neurosurgical ward or a neurosurgical intensive care. Following admission, they may not survive the injury or may be discharged home or to a rehabilitation facility or long-term institutional care. This information is essential for planning, resource allocation and efficient delivery of treatment and rehabilitation services to patients with TBI.

Burden of traumatic brain injury

TBI is an important global public health problem. It is a major cause of disability. Survivors often suffer cognitive, mood and behavioural disorders. The societal cost of the disability following TBI can be substantial due to loss of years of productive life and a need for long-term or lifelong services. Worldwide, it has been estimated that around 10 million TBIs serious enough to result in hospitalization, long-term or lifelong disability, or death occur annually. In the USA, an average of 1.4 million TBIs occur each year, including 1.1 million A&E department visits, 235 000 hospitalizations and 50 000 deaths. In a recent report, it was estimated that about 5.3 million people have some TBI-related disability, impairment, complaint, or handicap in the USA. Similarly, it has been estimated that about 6.2 million people in the European Union have some form of TBI-related disability.

Causes of head injury

The most common causes of TBI are RTAs, falls, ‘struck by’ or ‘struck against’ events, assault/violence and sporting or recreation activities. The majority of reports show RTAs as the leading cause of TBI followed by falls (which is reported as the leading cause in a few studies). In a review of studies from the EU, 21%–60% of TBIs were caused by RTAs (from a low of 21% in Norway and UK to a high of 60% in Sweden and Spain); 15%–62% were caused by falls (15% in Italy, 62% in Norway). One study from Glasgow, Scotland, reported violence/assault (28%) as the second most common cause after falls (46%). Overall, it has been estimated that, in the EU, 40% of TBIs are caused by RTAs, 37% are caused by falls, 7% are caused by violence/assault and 16% by other causes. It may be realized that the cause–effect relationships between the mechanisms of injury and TBI is confounded by age, gender, car ownership, urban residence and socioeconomic factors.


Mechanisms of Injury

* Primary injury is a function of the energy transmitted to the brain by the offending agent.
ο Very little can be done by healthcare providers to influence the primary injury.
ο Enforcement of personal protective measures (eg, helmet, seatbelts) by the command is essential prevention.

* Secondary injury results from disturbance of brain and systemic physiology by the traumatic event. Hypotension and hypoxia are the two most acute and easily treatable mechanisms of secondary injury.

ο Other etiologies include seizures (seen in 30%–40% of patients with penetrating brain injuries), fever, electrolyte disturbances (specifically, hyponatremia or hyperglycemia), and infection.
ο All of the above conditions can be treated.
ο Elevations of ICP may occur early as a result of a space-occupying hematoma, or develop gradually as a result of brain edema or hydrocephalus.
ο Normal ICP is 5–15 mm Hg, with normal cerebral perfusion pressure (CPP = MAP-ICP) usually around 70–80 mm Hg.
ο Decreases in perfusion pressure as a result of systemic hypotension or elevated ICP gradually result in alteration of brain function (manifested by impairment of consciousness), and may progress to global brain ischemia and death if not treated.

Patient Assessment and Triage

During the primary and secondary assessment, attention should be placed on a complete examination of the scalp and neck. Fragments that enter the cranial vault with a transtemple, transorbital, or cross midline trajectory should be suspected as having associated neurovascular injuries.

Wounds are typically contaminated by hair, dirt, and debris and should be copiously irrigated clean with control of scalp hemorrhage but not at the expense of delaying definitive neurosurgical treatment! Scalp hemorrhage can be controlled with a head wrap, scalp clips, or surgical staples; a meticulous plastic surgical closure is only appropriate after intracranial injuries have been ruled out.
_ The most important assessment is the vital signs.
_ Next is the level of consciousness, best measured and recorded by the Glasgow Coma Scale (GCS) ( see link: http://www.glasgowcomascale.org/ )
_ Triage decisions in the patient with craniocerebral trauma should be made based on admission GCS score.

ο A GCS < 5 indicates a dismal prognosis despite aggressive comprehensive treatment and the casualty should be considered expectant.
ο A GCS > 8 indicates that a casualty may do well if managed appropriately.

♦ In general, neurologically stable patients with penetrating head injury can be managed effectively in the ICU with airway and ventilatory support,
antibiotics, and anticonvulsants while awaiting surgery.
♦ An exception to this would be a deteriorating patient with a large hematoma seen on CT—this should be considered a surgical emergency.

ο Casualties with GCS 6–8 can be the most reversible, with forward neurosurgical management involving control of ICP and preservation of CBF. (cerebral blood flow)
_ Another important assessment is pupillary reactivity. A single dilated or nonreactive pupil adds urgency and implies the presence of a unilateral space-occupying lesion with secondary brain shift. Immediate surgery is indicated.
ο The presence of bilateral dilated or nonreactive pupils is a dismal prognostic sign in the setting of profound alteration of consciousness.

_ Radiographic evaluation

ο Deployable CT scanners in standard ISO shelters are increasingly available in the field environment. To keep the scanner operational, a qualified maintenance chief should be married to the scanner (“crew-chief” concept).

♦ CT is the definitive radiographic study in the evaluation of head injury, and should be employed liberally as it greatly improves diagnostic accuracy and facilitates management.
ο Skull radiographs still have a place in the evaluation of head injury (especially penetrating trauma like that ice axe!!).

♦ In the absence of CT capability, AP and lateral skull radiographs help to localize foreign bodies in cases of penetrating injuries and can also demonstrate skull fractures.
♦ This can help direct otherwise “blind” surgical intervention initially to the side of the head where the fracture is identified.
ο Cervical spine injury is uncommon in the setting of penetrating head injury.

♦ Closed head injury is commonly associated with injury of the cervical spine.
♦ Assume the presence of cervical spine injury and keep the cervical spine immobilized with a rigid collar until standard AP, lateral, and open-mouth radiographs can be obtained to exclude injury.
♦ CT once again is useful in evaluating casualties with a high suspicion for spinal injury.

Management

_ Medical

ο Primary tenets are basic but vital; clear the airway, ensure adequate ventilation, and assess and treat for shock (excessive fluid administration should be avoided).
ο In general, patients with a GCS < 12 should be managed in the ICU. (intensive care unit)
ο ICU management should be directed at the avoidance and treatment of secondary brain injury.
♦ PaO2 should be kept at a minimum of 100 mm Hg.
♦ PCO2 maintained between 35 and 40 mm Hg.
♦ The head should be elevated approximately 30°.
♦ Sedate patient and/or pharmacologically paralyze to avoid “bucking” the ventilator and causing ICP spikes.
♦ Broad-spectrum antibiotics should be administered to patients with penetrating injuries (a third-generation cephalosporin, vancomycin or Ancef, Unasyn or meropenen if acinetobacter suspected).
♦ Anaerobic coverage with metronidazole should be considered for grossly contaminated wounds or those whose treatment has been delayed more than 18 hours.
♦ Phenytoin should be administered in a 17-mg/kg load, which may be placed in a normal saline piggyback and given over 20–30 minutes (no more than 50 mg/min, because rapid infusion may cause cardiac conduction disturbances).
◊ A maintenance dose of 300–400 mg/d, either in divided doses or once before bedtime, should be adequate to maintain a serum level of 10–20 µg/L.

♦ Measure serum chemistries daily to monitor for hyponatremia.
♦ Monitor and treat coagulopathy aggressively.
♦ Monitoring of ICP is recommended for patients with GCS< 8 (in essence, it is a substitute for a neurologic examination).
◊ A simple fluid-path monitor usually works well and allows CSF drainage. It may then be coupled to a manometer or to a multifunction cardiac monitor similar to a central venous catheter or arterial line.
_ Administer prophylactic antibiotic.
_ Make an incision just at or anterior to the coronal suture, approximately 2.5–3 cm lateral to the midline
_ A twist drill craniostomy is performed, the underlying dura is nicked, and a ventricular catheter placed into the frontal horn of the lateral ventricle (encountered at a depth of 5 to 6 cm). Catheter should be directed toward the medial epicanthis on the coronal plane, and the tragus in the sagittal plane.
_ Even small ventricles can be easily cannulated by aiming the tip of the catheter toward the nasion in the coronal plane.
_ Ventricular catheters are highly preferable; acceptable substitutes are an 8 F Robinson catheter or pediatric feeding tube.
_ A key feature of this technique is to tunnel the drain out through a separate incision 2–3 cm from the primary one, thus reducing the risk of infection.

◊ The goal of management is to maintain a CPP of 60 – 90 mm Hg.
◊ A sustained ICP > 20 mm Hg should be treated.
_ Sedation, head elevation, and paralysis.
_ CSF drainage if a ventricular catheter is in place.
_ Hyperventilation to a PCO2 of 30 to 35 mm Hg only until other measures take effect. (Prolonged levels below this are deleterious as a result of small vessel constriction and ischemia.)
_ Refractory intracranial hypertension should be managed with an initial bolus of 1g/kg of mannitol and intermittent dosing of 0.25–0.5 g/kg q4h as needed.
_ Aggressive treatment with mannitol should be accompanied by placement of a CVP line or even a PA catheter because hypovolemia may ensue.
_ Any patient who develops intracranial hypertension or deteriorates clinically should undergo prompt repeat CT.

◊ Mild hypothermia may be considered in isolated head injury, but avoid in the multitrauma patient.
♦ Treat hypovolemia with albumin, normal saline, hypertonic saline, or other volume expanders to create a euvolemic, hyperosmolar patient (290–315 mOsm/L).
♦ Blast over-pressure CNS injuries.
◊ Supportive medical therapy is usually sufficient. Only in rare cases is an ICP monitor, ventriculostomy, or cranial decompression necessary. In the absence of hematomas the use of magnesium has been beneficial. Structures particularly sensitive include optic apparatus, hippocampus, and basal ganglia. Delayed intracranial hemorrhages have been reported. Additionally, these patients have a higher susceptibility to subsequent injury and should be evaluated at a level 4/5 facility. Repetitive injury and exposure to blast over-pressure may result in irreversible cognitive deficits.



_ Surgical

ο Goals: prevent infection and relieve/prevent intracranial hypertension.

ο Indications for emergent exploration.
♦ Space-occupying lesions with neurological changes (eg, acute subdural/epidural hematoma, abscess).
♦ Intracranial hematoma producing a > 5 mm midline shift or similar depression of cortex.
♦ Compound depressed fracture with neurological changes.
♦ Penetrating injuries with neurological deterioration.

ο Relief of ICP with hemicraniectomy/duraplasty/ventriculostomy.
♦ A large trauma flap should be planned for the evacuation of a mass lesion with significant underlying edema in the supratentorial space.
♦ The flap should extend a minimum of 4 cm posterior to the external auditory canal and 3–4 cm off midline. Exposing the frontal, temporal, and parietal lobes allows for adequate cerebral swelling and avoids brain herniation at the craniotomy edge.
♦ A capacious duraplasty should be constructed with a subdural ICP/ventricular catheter in place, allowing monitoring and drainage from the injured hemisphere.

ο Shave hair widely and scrub and paint the scalp with betadine.
ο General anesthesia for major cases.
ο Administer empiric antibiotics (third-generation cephalosporin).
ο Positioning can be adequately managed with the head in a doughnut or horseshoe-type head holder. For unusual positioning of the head, such as to gain access to the subocciput, use a standard three-point Mayfield fixation device.
ο Make a generous scalp incision to create an adequate flap.

♦ The flap should have an adequate pedicle to avoid ischemia.
♦ Retraction of the scalp flap over a rolled laparotomy sponge will avoid kinking the flap, which also may lead to ischemia.

ο The skull should be entered through a series of burr holes that are then joined to create a craniotomy flap.

Burr holes alone are inadequate to treat acute hematomas, but are of diagnostic utility in the absence of CT scanner. Exploratory burr holes may miss subfrontal or interhemispheric hematomas
♦ The bone work may be done with a Hudson brace and Gigli’s saw, though a power craniotome is certainly preferable if available

ο A dural opening, using the entire expanse of the cranial opening (with enough edge left to close the dura at the end of the case), should be created.

♦ The base of the dural opening should be on the side near any neighboring major venous sinus to avoid injury to large draining veins and aggravation of cerebral edema.

ο The hematoma should then be gently evacuated with a combination of suction, irrigation, and mechanical removal.
ο Meticulous hemostasis should be achieved and the dura closed.
ο Approach to penetrating injury with neurologic changes is aimed at removal of devitalized brain and easily accessible foreign bodies.

♦ Perform copious irrigation with an antibiotic solution (such as bacitracin) and a concerted attempt made to achieve watertight dural closure (again, using pericranium, among others, as needed).
♦ Tension-free scalp closure is also essential, but replacement of multiple skull fragments in an attempt to reconstruct the skull defect is not appropriate in the battlefield setting.

◊ Excellent results can be achieved with cranioplasty after evacuation out of the theater and a sufficient delay to minimize risk of infection.

ο If a duraplasty is required, pericranium, temporalis fascia, or tensor fascia lata may be used.
ο Tack-up sutures should be placed around the periphery and in the center of the dural exposure to close the dead space and discourage post-operative epidural hematoma formation.
ο Replace bone flap and secure with wire or heavy suture.

♦ If severe brain swelling precludes replacement of the bone flap it can be discarded or preserved in an abdominal-wall pocket.

ο The galea of the scalp should generally be closed separately with an absorbable suture, and with staples used to close the skin.

♦ A single layer closure with heavy monofilament nylon is acceptable but should definitely include the galea, with the sutures remaining in place at least 10 days.
♦ A subgaleal or epidural drain may be used at the discretion of the surgeon.

ο Apply a snug dressing using roller bandages around the entire head.

Evacuation of the Severely Head-Injured Patient

The trip is always longer than advertised. Transport only patients who can be expected to survive 12–24 hour movements, due to unexpected delays, route changes, or diversion in the tactical situation. A post-operative, craniotomy patient should first be observed for 12–24 hours prior to transport. Evacuating immediately may lead to the inability to treat delayed postoperative hematomas that may occur.

ο All patients with GCS < 12 are ventilated.
ο Patients with GCS < 8 require ICP monitoring.
ο Ventriculostomies should be placed, position confirmed, secured, and working prior to departure.
ο The critical care evacuation team must be confident in the ability to medically treat increased ICP and troubleshoot the ventriculostomy.
ο Medical management of ICP in flight is limited to the use of head-of-bed elevation (30°–60°), increased sedation, thiopental, ventricular drainage, and mild hyperventilation. Loading a patient head-of-bed first limits the effect of takeoff on ICP.
ο The escort of a severely head-injured patient must be able to manage the airway, ventilator, IV pumps, IV medicines, suction, in addition to ICP and CBF.
ο Patients with possible intracranial pathology who may deteriorate inflight should be neurosurgically maximized on the ground prior to departure (eg, placement of a ventriculostomy or evacuation of a hematoma).
ο If a head-injured patient (GCS > 12) deteriorates in flight and is not already intubated, intubation should be performed and planned. Ensure rapid sequence intubation medicines, IV access, and airway equipment (especially Ambu bag, ventilator) are working and available.
ο The most difficult part of an evacuation is from the CSH (Combat Support Hospital) to the CASF/MASF (Contingency Aeromedical Staging Facility/Mobile Aeromedical Staging Facility). Typically, battery life of the ventilator and monitors, and supplies of oxygen can be depleted before the exchange of the patient to the CASF/MASF. Although electric power is available on Black Hawks and FLA (ground ambulance), it is rarely used.
ο Prior to departure from the CSH the following precautions must be taken by the escort:

♦ Ensure knowledge of patient injuries and clinical course. (Have narrative summary and pertinent radiographs in hand.)
♦ Ensure adequate medicines for minimum of 3 days.
♦ Ensure monitors, ventilators, and suction and IV pumps all have adequate battery life.
♦ Ensure adequate oxygen supplies, and that the escort has the familiarity with and the ability to switch oxygen tanks.
♦ Have an alternate battery-operated, tactical light source to read monitors during transport.
♦ Assemble patients on the stretcher to avoid iatrogenic injuries to limbs, organizing tubes, lines, electrical leads, and wires so as not to become snared during movements. (When available, a SMEAD (Small Medical Emergency Aeromedical Device) shelf attached to the stretcher allows monitors to be secured and elevated off the patient’s body.)
♦ Ensure that limbs (toes and fingers) and torso are covered and insulated during the trip to prevent hypothermia.
♦ During movements ensure central lines, a-lines, and ventricular catheters do not become dislodged. Ensure lines and tubes are sutured or otherwise secured.
♦ Ensure the ventriculostomy does not develop an airlock. Venting the tublet can be performed with a 21 - gauge needle.

Outcome after severe head injury

Like Leon Trotsky suffered…. After severe injury….. many patients regain an independent existence and may return to pre-morbid social and occupational activities. Inevitably, some remain severely disabled requiring long-term care, including a very small proportion (<2%) who are left in a vegetative state.

Vegetative and minimally conscious states

The vegetative state is a clinical condition of complete unawareness of the self and the environment accompanied by sleep–wake cycles with either complete or partial preservation of hypothalamic and brainstem autonomic functions. The persistent vegetative state (PVS) can be judged to be permanent 12 months after traumatic injury in adults and children. Permanency is recognized after 3 months for non-traumatic injury in adults and children. In adults who are in a vegetative state at 1 month post-injury, 33% will die by 12 months, 15% will remain in PVS, and 52% will recover consciousness, although only 7% will make a good recovery as defined by the GOS (Glasgow Outcome Scale).

The Minimally Conscious State (MCS) is a condition of severely altered consciousness in which there is minimal but definite behavioural evidence of self- or environmental awareness. The natural history and long-term outcome have not yet been fully characterized.

Long-term outcome

Risk for Alzheimer’s disease

For the past 20 years there has been considerable interest in the relation between traumatic brain injury and the future development of Alzheimer’s disease (AD). It has been suggested that traumatic brain injuries reduce ‘cognitive reserve’, resulting in increased vulnerability to developing the disease. The literature is conflicting, but it would appear that patients who sustain severe TBIs may be at a slightly increased risk of developing AD. There is no evidence that patients who have mild TBIs are at increased risk.

Progressive neurological disease, including punch drunk syndrome

The effects of repeated neuronal damage are cumulative; when this exceeds the capacity for compensation, permanent evidence of brain damage ensues. It is well recognized that repeated concussive or subconcussive blows as experienced by various athletes, and particularly boxers, sometimes induces the development of neurological signs and progressive dementia. This condition, known as ‘dementia pugilistica’, may develop some years after the last injury and is most likely to develop in boxers with long careers who have been dazed, if not knocked out, on many occasions. In a detailed study of the brains of 15 ex-boxers, one of the characteristic patterns of damage was the presence of many neurofibrillary tangles diffusely throughout the cerebral cortex and the brainstem. These tangles broadly conformed to the topographic pattern found in Alzheimer’s disease.

More recently, other athletes involved in contact sports who have sustained repeated minor concussion have been studied using neuroimaging and neuropsychological assessment. There is evidence that three or more concussions in high school and university athletes are associated with small but measurable cumulative effects, and increased risk for future concussions. This subject has recently been reviewed.

Genetic factors and outcome from head injury

Apolipoprotein E4 (APOE 4) is a lipid transporter in the brain and cerebrospinal fluid. It is the product of a single gene. The presence of APOE 4 alleles, especially in the homozygous condition, appear to be associated with worse outcome after TBI, although other studies have had contradictory results. APOE 4 is believed to play a role in the inflammatory response and neuronal repair following trauma. It has been associated with age-related cognitive impairment, decreased synapse–neurone ratio, increased susceptibility to neurotoxins and hippocampal atrophy.

Conclusion

A variety of parameters can be used to measure the nature of the outcome following a head injury. The severity of the primary injury is of paramount importance, but other factors including age and the burden of secondary insults are important. Repeated trauma and genetic factors may contribute to long-term sequelae, as may co-morbidities such as alcohol and substance abuse.

References:

1) Jennett B, Snoek J, Bond MR, Brooks N. Disability after severe head injury: observations on the use of the Glasgow Outcome Scale. J Neurol Neurosurg Psychiatry 1981; 44: 285–93.

2) The Multi-Society Task Force on PVS. Medical aspects of the persistent vegetative state (part 2). N Engl J Med 1994; 330: 1572–9.

3) Bryden J. How many head injuries? The epidemiology of post head injury disability. In: Wood R, Eames P, eds. Models of Brain Injury Rehabilitation. Baltimore, Johns Hopkins University Press, 1989; 17–26.

4) Junque C, Bruna O, Mataro M. Information needs of the traumatic brain injury patient’s family members regarding the consequences of the injury and associated perception of physical, cognitive, emotional, and quality of life changes. Brain Inj 2010; 11: 251–8.

5) Christakis NA. Death Foretold. Chicago, The University of Chicago Press, 1999.

6) Buckman R. How to Break Bad News: A Guide for Healthcare Professionals. Baltimore, The Johns Hopkins University Press, 1992.

7) Deamon’s http://encyclopedia.thefreedictionary.com/Ram%C3%B3n+Mercader

You can have a read with detailed pictures for surgery at http://justinexcellence.tumblr.com/post/102002213441/leon-trotsky The pictures of which I scanned and pasted from Emergency War Surgery Textbook for I am not able to find such clear illustration elsewhere on the internet. The rights of the post are held by the respective artist(s), clinician(s) and organization(s). Credit should be given to the respective owners and creator.




über laboratorium dauernd zur Naturtreue
NeuroticHellFem
Posted: Friday, November 7, 2014 8:55:48 AM

Rank: Advanced Member

Joined: 7/22/2014
Posts: 2,292
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pedro wrote:
Leon Trotsky is an anagram of rotten yolks. Be more careful next time you change your name Piero.


I got bored one day & filled pages & pages of anagrams of my name. Some of them were hilarious, one of them was Neurotic Hell Fem.

When you make an assumption, you make an ass of u & umption! - NeuroticHellFem
monamagda
Posted: Friday, November 7, 2014 9:22:13 AM

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Trotsky's pen names and pseudonyms

Leon Trotsky used a lot of pseudonyms, pen names and alias all his life, for various reasons (political persecution first by Czarist and later by Stalinist repression organs, living under illegal or half-legal conditions, factual prohibition of publishing and so on). He used those alias as writer, editor and contributor as well as in false passports.
The name 'Leon Trotsky' [Russian: Lev Trotskii, or Lev Davidovich Trotskii, cyrillic: Лев Давидович Троцкий] itself is a pseudonym which was adopted by young Lev Davidovich Bronshtein [cyrillic: Лев Давидович Бронштейн] — his real name by birth — when he had to put a name into a falsified passport which he needed to escape from his first Siberian banishment in 1902. By the way, it was said that 'Trotsky' [Троцкий] was simply the name of one of his prison guards in Odessa.
After the October Revolution, for legal or citizen requirements (in order not to oblige his sons who had the name of her mother [Trotsky's companion N.I. Sedova], i.e. Sedov, to change their names, Trotsky officially took the name of his companion, i.e. Lev Davidovich Sedov. However, this change of name obviously was a pure technical matter; thus, Trotsky, so far as we know, neither published nor signed any document using his passport name 'Sedov'.

Trotsky's [Bronshtein's] pseudonyms are also listed here : http://www.trotskyana.net/Leon_Trotsky/Pseudonyms/trotsky_pseudonyms.html
pedro
Posted: Friday, November 7, 2014 9:33:50 AM

Rank: Advanced Member

Joined: 5/21/2009
Posts: 13,060
Neurons: 63,022
NeuroticHellFem wrote:
pedro wrote:
Leon Trotsky is an anagram of rotten yolks. Be more careful next time you change your name Piero.


I got bored one day & filled pages & pages of anagrams of my name. Some of them were hilarious, one of them was Neurotic Hell Fem.



So you must be the legendary Flouncier Helmet?

All good ideas arrive by chance- Max Ernst
NeuroticHellFem
Posted: Friday, November 7, 2014 10:08:09 AM

Rank: Advanced Member

Joined: 7/22/2014
Posts: 2,292
Neurons: 2,582,305
Location: Lilyfield, New South Wales, Australia
pedro wrote:
NeuroticHellFem wrote:
pedro wrote:
Leon Trotsky is an anagram of rotten yolks. Be more careful next time you change your name Piero.


I got bored one day & filled pages & pages of anagrams of my name. Some of them were hilarious, one of them was Neurotic Hell Fem.



So you must be the legendary Flouncier Helmet?


That's a bit creepy that you bothered to work that out. Did you make like the constipated mathematician?
(He worked it out with a pencil.)
I briefly considered the username 'Hellfire Emo c-'.

When you make an assumption, you make an ass of u & umption! - NeuroticHellFem
striker
Posted: Friday, November 7, 2014 4:03:29 PM
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Joined: 5/30/2014
Posts: 1,698
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what a voracious activist
pedro
Posted: Friday, November 14, 2014 10:43:25 AM

Rank: Advanced Member

Joined: 5/21/2009
Posts: 13,060
Neurons: 63,022
NeuroticHellFem wrote:
pedro wrote:
NeuroticHellFem wrote:
pedro wrote:
Leon Trotsky is an anagram of rotten yolks. Be more careful next time you change your name Piero.


I got bored one day & filled pages & pages of anagrams of my name. Some of them were hilarious, one of them was Neurotic Hell Fem.



So you must be the legendary Flouncier Helmet?


That's a bit creepy that you bothered to work that out. Did you make like the constipated mathematician?
(He worked it out with a pencil.)
I briefly considered the username 'Hellfire Emo c-'.




On reflection, Chloe Mint-Refuel sounds more plausible but that might just be Friday talking.

All good ideas arrive by chance- Max Ernst
excaelis
Posted: Friday, November 14, 2014 8:06:32 PM

Rank: Advanced Member

Joined: 6/30/2010
Posts: 10,981
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Location: Toronto, Ontario, Canada
Lovin' Chloe Mint-Refuel ! So classy an' all !

Sanity is not statistical
excaelis
Posted: Friday, November 14, 2014 8:06:59 PM

Rank: Advanced Member

Joined: 6/30/2010
Posts: 10,981
Neurons: 32,652
Location: Toronto, Ontario, Canada
Lovin' Chloe Mint-Refuel ! So classy an' all !

Sanity is not statistical
excaelis
Posted: Friday, November 14, 2014 8:10:41 PM

Rank: Advanced Member

Joined: 6/30/2010
Posts: 10,981
Neurons: 32,652
Location: Toronto, Ontario, Canada
"No More Heroes"


Whatever happened to Leon Trotsky?
He got an ice pick
That made his ears burn

Whatever happened to dear old Lenny?
The great Elmyra,
And Sancho Panza?


( The Stranglers )

Sanity is not statistical
NeuroticHellFem
Posted: Saturday, November 15, 2014 7:50:42 AM

Rank: Advanced Member

Joined: 7/22/2014
Posts: 2,292
Neurons: 2,582,305
Location: Lilyfield, New South Wales, Australia
More arse than class I'm afraid. Whistle

When you make an assumption, you make an ass of u & umption! - NeuroticHellFem
excaelis
Posted: Monday, November 17, 2014 12:10:27 AM

Rank: Advanced Member

Joined: 6/30/2010
Posts: 10,981
Neurons: 32,652
Location: Toronto, Ontario, Canada
Surely not. I can sense the breeding in every post.

Sanity is not statistical
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