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The traumatology of the face and neck, in sports practice and especially for team sports, is more and more frequently observed. This increase is explained by the intensification of the physical preparation of sportsmen, amateur and of course professional, whose physical mass and speed imply increasingly violent and repeated contacts.
The face and the neck do not escape this commitment. If, in the majority of cases, these are simple bruises, larger lesions are not uncommon and require, from the site of the accident, that is, from the field, a precise diagnosis and a course to be kept irreproachable.
Paradoxically, examination of the facial wounded person will not begin with the face and contuse region involved, but the practitioner must first and foremost ensure control of breathing, consciousness and eventual bleeding , and verify the integrity of neighboring bodies indirectly affected by the trauma, but representing the real urgency. This approach is unnatural and the physician’s discomfort is increased by the impressive and theatrical side of the facial lesion (haemorrhage and hematoma, easy and sometimes spectacular), but the latter must not lose sight of the fact that, whatever the injury, is in the vast majority of cases without a prognostic impact. It is not the same with an attack of the brain, the eye and the cervical spine, among others.
For each region, we will insist on the first three decisions that the sports physician must take in the field following his first examination:
• a simple contusion without the associated lesion and the athlete may resume the match;
• an isolated lesion without potential gravity which requires a temporary exit, the athlete being able to resume the match after treatment of the wound in the locker room;
• a more severe traumatic pathology, with a doubt about a lesion of a neighboring organ, the athlete must leave the field permanently and eventually be transported to a hospital structure for imaging assessment and therapeutic management.
The consultation, the day after the match in the sports doctor’s office, corresponds to the same approach, with, at the slightest doubt, a request for further examinations and treatment in specialized settings.
The three priorities:
Arriving in the field to examine an injured sportsman with cervicofacial impact, the practitioner must first of all ensure the following three priorities: breathing, consciousness and bleeding.
The injured person is sometimes lying on the ground and, from the outset, the doctor has to remove his tooth protector (more and more often worn by sportsmen), make an oral examination by removing the fragments of earth and possible dental flakes and check his breathing. If consciousness disorders occur, the lateral safety position will avoid the risk of inhalation in case of vomiting. The notion of falling language, too often referred to, corresponds in fact to a rocking of the base of language on the susglottic stage of the larynx, blocking the air passage.
Let us recall that an obstacle to breathing sitting at the level of the larynx and above is translated by an inspiratory bradypnea, with cornea and pulling by bringing into play the accessory respiratory muscles (notably intercostals).
It is necessary to have a set of Guédel cannulas in his emergency kit because it allows, by luxating the jaw, to restore airway permeability in an unconscious wounded. This situation is exceptional but the sports physician must be able to cope with it.
It is a reflection of the state of the brain and must be an obsession for the practitioner who examines the wounded.
The main clinical sign is of course the loss of consciousness which, immediately, must lead the doctor to the following decisions:
• the final exit of the athlete, even if the latter resumes his mind and wants to continue the game: this exit is not negotiable;
• the transfer by one of the club’s leaders to the emergency room of the neighboring hospital to benefit from a cerebral CT without injection which will eliminate a possible extradural hematoma;
• monitoring by a close relative in the case of a normal CT scan and when any doubt is raised (no vomiting or new consciousness disorders, strictly normal neurological examination) or hospitalization at the slightest doubt in the first 24 hours.
In the vast majority of cases, this is a nasal or epistaxis hemorrhage.
The player must of course leave the field. The doctor wears examination gloves. It is enough, first, to blow it to eliminate the clots present in the nasal pit, then to make sit and compress his nostrils with his fingers aided with a compress, head leaning forward so that the bleeding ceases .
This bidigital compression can be facilitated by a vestibular tampon, by positioning in the nostril of the haemostatic product, Coalgan or better Surgicel coated with HEC ointment. The compression lasts ten minutes, checking that there is no posterior flow at the level of the oropharynx. In the absence of obvious lesion (fracture of the nose), the player can, depending on his condition, resume the course of the game.
Sometimes this is not enough, and an anteroposterior tamponing by hemostatic tampon, introduced by the nostril in a plane strictly perpendicular to the face, and especially not in the direction of the root of the nose and the eyes, must be put in place. This tamponage is sometimes difficult to perform, if not impossible in case of preexisting deflection of the nasal septum which thus blocks access to the nasal cavity.
At an ultimate stage, and in the face of the failure of these previous means, particularly in the case of uncontrollable posterior bleeding with vomiting of clots and blood, the use of a urine catheter (No. 12) swollen with 10 cm 3 of physiological saline to block the choanal orifice and the cavum allows the haemorrhage to be controlled before transferring the injured person to the nearest hospital emergencies.
Haemorrhage on wounds is easily controlled by local compression with sterile and antiseptic compresses.
The player must exit temporarily if the simple suture is sufficient to treat the wound without seriousness, but in case of complication, the suture will be carried out in a specialized medium and the exit will be definitive.
Neighborhood lesions / elimination diagnoses:
The paradox of the maxillofacial examination is that it examines first what is not maxillofacial, in other words the organs of the vicinity likely to be harmed by the physiological mechanism of the wound. This priority is justified by the potential severity of neighboring lesions such as the cervical spine, the eye and the brain.
We shall not return to the latter (previous chapter).
Once again, this research must be an obsession, and it is only once the certainty has been obtained from the normality of the examination that we can devote ourselves to the management of the facial wound itself.
The cervical spine:
The associated involvement of the cervical spine during trauma of the face is quite conventional and is observed regularly. This joint involvement is explained by the hyperextension movement followed by a brutal cervical flexion secondary to the impact on the face (shot of the rabbit).
All lesions can be seen, from the sprain to the dislocation, through the fracture of the vertebral body.
The examination begins with neck pains, tingling sensations in the upper limbs and examination verifies the muscular strength of the upper limbs and pain caused by the careful palpation of the cervical spine. At the slightest doubt, the wearing of the minerva, split into extension, is the rule; the athlete having definitively left the field lying on a stretcher.
The control of the eyeball and the sight is also a priority, the visual prognosis in the case of a lesion suffering from no delay.
Two pictures must be feared: the wound of the eyeball and the physiological section of the optic nerve.
The wound of the eyeball:
This circumstance is extremely rare, but the diagnosis is not always easy. Indeed, the impact in the orbital region causes a reflex palpebral occlusion which it is difficult to overcome for the uninitiated. It will be necessary to be patient to succeed in spreading both eyelids, but a sign is already very evocative before this stage: the difference of intraocular pressure by palpating the two globes through the eyelids in a comparative way. The player goes out of the field anyway and the examination in the locker room allows to evaluate the visual acuity or even to identify the wound.The illico transfer to the nearest ophthalmological emergencies (make sure that neighboring emergencies have a guard ophthalmologist …), after having closed the orbit with a sterile ophthalmic compress, is the rule.
The physiological section of the optic nerve:
This diagnosis is more difficult to evoke and yet it is not difficult to ask. The physiological mechanism is that of a violent impact on the eyeball by a ball (tennis, handball …). The ocular globe is in some sort appended in the orbit by a wire which is the optic nerve.
Under the impact of the shock, it will be propelled towards the bottom of the orbit and then return suddenly causing traction back and forth on the optic nerve which will result in an intraneural edema, thus blocking the transmission of visual information to the cortex.
After the player’s exit, the latter will confirm a decrease in unilateral visual acuity, but most often blindness with luminous perception or not. The diagnosis will be confirmed clinically by the search for the photomotor reflex (shrinking of the pupillary diameter to the luminous stimulation): the direct photomotor reflex (on the injured side) will have disappeared, the pupil remaining in a position of mydriasis. On the other hand, the contralateral, by stimulating the healthy side, will cause the pupil to close on the injured side, this attesting to the cut of the visual channels.
The urgency is then absolute.
The athlete is transferred within one hour to a reference ophthalmological center.
The complementary review will comprise two parts:
• functional examinations, in particular visual evoked potentials, the prognostic value of which is paramount in finding or not a trace;
• Imaging: the CT of the orbit without injection but especially the nuclear magnetic resonance which will authenticate the edema or even the hematoma within the optic nerve.
The patient is hospitalized for intravenous medical treatment of corticosteroids at high doses, of the order of 1 g per 24 hours, possibly coupled with an operation of decompression of the optic nerve.
There are two possibilities for this decompression:
• the neurosurgical approach, by the superior approach of the super-internal surface of the orbit;
• the transethmoidosphenoidal pathway, at the lower end of the inner wall and the optical canal, performed in otolaryngol- ogology.
The duration of hospitalization is eight to 15 days, the work stoppage depends on the professional activity of the person concerned (three to six months), his sports career is over and the rate of recovery varies according to the teams.
The wounds of the face and neck:
It is important to distinguish simple wounds from complex or potentially dangerous wounds that must be taken care of by the specialist surgeon.
The treatment of the simple wound is relatively stereotyped:
• the casualty leaves the court temporarily;
• the suture is made in the locker room on an elongated subject at rest;
• after wound disinfection and local anesthesia with adrenaline-free xylocaine, we use two Gillies hooks to remove both sides of the wound, remove any foreign bodies (earth or other) and check bone fracture. A single plane is sufficient using a nonabsorbable wire 4 or 5/0;
• the wound is protected by a bandage and sterile compresses;
• the player can resume the course of the game;
• the threads will be withdrawn on the fifth day post and there will be no stoppage of sporting and / or professional activity.
Note that we avoid the use of adrenaline xylocaine for two reasons:
• it is potentially allergenic by the sulfites that are used to stabilize the mixture, allergy to pure xylocaine being much rarer;
• Adrenaline has cardiovascular effects that we do not consider desirable in an athlete who has just stopped his effort.
It goes without saying that the player’s anti-tetanus vaccination will be up to date. . .
The criteria for delaying the wound suture, due to its complex nature, are as follows:
• reaching an orifice of the face: nostril, mouth, eyelid;
• the attainment of an underlying noble organ: the facial nerve, the trigeminal nerve, the lacrimal ducts, the Stenon canal;
• Exposure of cartilage: nose, auricle;
• the existence of an underlying fracture, synonymous with an open fracture;
• contused and complex wounds;
• the cervical sore;
• the particular case of bites and amputations.
In accordance with these criteria, the athlete must leave the field permanently, the wound must be disinfected and sealed with sterile compresses but not sutured, and the athlete must be taken to a competent specialist for a specific treatment within six hours.
The attainment of an orifice of the face:
Whatever the orifice, from the moment the wound is transfixing and the orbicular muscle (mouth, eyelid), or wing cartilage (nose), the closure of this wound exposes to functional or aesthetic sequelae which must discourage the non-specialist (notch of the nasal orifice or the lip, lagophthalmia for the eyelid, salivary leak for the mouth).
The athlete will definitely leave the field, the wound will be disinfected and not sutured, and, carrying a simple protective dressing, the injured person will be conducted within 12 hours for a specialized management.
Let us emphasize the particular case of the deep wound of the upper eyelid which will sever the levator muscle of the eyelid; if not diagnosed, it will lead to a cicatricial ptosis of the eyelid, evident a few days later to the comparative examination.
The attainment of an underlying noble organ:
The facial nerve:
The motor nerve of the face, the lesional diagnosis is relatively easy provided it is rigorous and stimulates by contracting the muscle group located downstream of the wound; his paralysis in a comparative examination attests to the section of the nerve branch which commands it.
This is the case with wounds in the following regions:
• behind the brow for the frontal branch, which controls the wrinkles of the forehead;
• the region of the crow’s feet for the orbicular branch, which controls the closing of the eyelids, in particular the upper one;
• the cheek for the wings of the nose and the labial commissure;
• the mandibular rim for the chin strap, which controls the lower lip and chin.
The wound will not be sutured, the player leaving the field definitely is sent within six hours to a specialized center for a microsuture of the nerve, the recovery being able to go from 12 to 18 months. The discontinuation of sports activity is a function of the sequelae caused by the nerve injury (eg a section of the orbicular branch with an inability to close the eye will result in a cessation of activity for at least 12 months).
The trigeminal nerve:
It is the sensory nerve of the face. It is branched into three terminal branches which emerge through juxta-osseous orifices, explaining that their involvement is seen mainly in the case of associated fractures:
• V1, or upper branch, emerging at the internal part of the eyebrow, in the vicinity of the root of the nose.
Its lesion by direct wound leads to an anesthesia of the hemifront;
• The V2, or middle branch, exits under the orbital rim and is threatened in the event of fracture of the orbital floor or of the mite. The anesthesia observed concerns the internal part of the juxtanarinary cheek, the wing of the nose, the upper hemilèvre and the gingiva of the incisivocanin block;
• the V3, or lower branch; a great part of the journey is made in the mandible, explaining that its attack is seen mainly in fractures of the horizontal portion of the mandible. The anesthesia concerns the lower hemilèvre and the gingiva of the lower incisivocanin block.
The treatment obeys the same principles as for the facial nerve, knowing that microsuture is very rarely achievable because of the proximity of the bone. Only a release of the nerve, contused by a bony fragment, can lead to recovery within eight to 12 months, but the consequences of anesthesia in a region of the face are less restrictive than paralysis, with the exception of V1, which results in salivary leakage and fluids during feeding.
The lacrymal pathways:
Their opening in a wound facing the lower eyelid near the inner canthus results in tears emerging through the wound edges when the lacrimal sac is pressed in the lower part of the lid the internal angle of the eye.
In the slightest doubt, exploration of the wound after catheterization of the lachrymal tract by a competent ophthalmologist is the rule.
The Stenon Canal:
It is the drainage channel of the parotid gland, salivary gland located in front of the ear lining and extending around the lobule.
The wound is jugal, rather anterior and deep, and the massage of the parotid gland causes the arrival of saliva between the two edges of the wound.
The suture will be made by an experienced ENT, after catheterization of the Stenon canal from its opening in the oral cavity, in front of the upper premolar.
The catheter is left in place for four to six weeks to avoid secondary stenosis, a source of infectious parotitis; the sports stop is of the same duration.
Exposure of an underlying cartilaginous structure:
It is basically the nose in the lower part and the auricle.
However, it is necessary to qualify this type of wound according to the state of the cutaneous wounds in front of the wound:
• the wound is clear, the skin is vital, not contused, with a minimal degree of septicity and at a distance from an orifice, nostril or external auditory canal: the suture in the locker room can be carried out and the resumption of the match envisaged under cover of a protective dressing;
• either the wound is more complex from the start, with fragments of skin whose coloring makes one doubt its survival (ecchymosis or hematoma, dermabrasion): it is better to abstain and accompany the injured athlete within six hours for a catch in specific charge by a confirmed ENT.
The latter will realize, after trimming and careful disinfection of the wound, the suture of the cutaneous fragments by reconstituting “ the puzzle “ and sacrificing those whose vitality is doubtful. Local anesthesia is usually sufficient, a dressing molded by sterile cotton impregnated with physiological saline supplementing the management, to remould all the reliefs, especially of the pavilion, and to avoid a secondary hematoma. This type of dressing will be maintained for about ten days, the threads being removed after ten to twelve days; the interruption of the sport goes up to 15 days, with protection during the recovery.
Antistaphylococcal antibiotherapy and control of tetanus vaccination are also necessary.
The stitches on the cartilage are of no interest because of the molding during the dressing and, moreover, they can tear the cartilage.
We shall draw nearer to this situation the otumatoma or effusion of blood from the auricular. This subcutaneous bleeding is secondary to a cartilaginous fracture.
It is observed very frequently in the fronts in rugby, especially players in the front row. The prevention of this type of injury is the wearing of a headband, or even today a helmet, which avoids direct contact with the flag during the melee.
The treatment is based on the puncture of the blood collection as soon as it appears in the locker rooms with the sterile trocar; then applying a thick circular bandage maintained by a helmet allowing the game to resume. The sterile molding dressing helps to apply the skin of the horn to its cartilaginous support and must be kept five days in place. In case of recurrence, after new puncture with the unsuccessful trocar, the drainage will be done by an ENT. The latter will practice either cutaneous incisions of a few millimeters or a fenestration, that is to say an opening of the cartilage in the form of a square, opposite the collection posteriorly, in the retro-auricular groove, supplemented by a new tight dressing and antibiotic therapy. Bourdonnets, transfixing points of the pavilion caught in “ sandwich “ with tulle fat, are then inevitable to reapply the skin.
Do nothing, leads to fibrosis of the auricular pavilion and to those famous aspects of “ cauliflower “ pavilion that everyone knows.
The underlying fracture:
It is the perfect trap. It should always be borne in mind that a wound may correspond to a deep fracture, synonymous with an open fracture. This trap is all the more unforgivable because the wound will prevent the formation of edema at the level of the adjacent soft parts, which makes the maxillofacial examination easy. The other means of diagnosis are the hooks of Gillies, which, by spreading the banks of the wound, will allow to see directly the fracture and / or fragments bone. Some sites are very often affected by such an association, wound and fracture, as the nasal awning, the cheekbone, the zygomatic arch.
If this happens, it is preferable not to close the suture, to avoid the creation of the edema. The player leaves definitively and is routed on a hospital structure for an imaging balance. Two possibilities then exist at the end of the balance sheet:
• either the fracture is not displaced and only the suture will be performed, with antibiotic coverage and a stoppage of sport activity of three to four weeks depending on the site of the fracture;
• either the fracture is displaced and the reduction with osteosynthesis under general anesthesia and suture of the wound will be carried out urgently within six to 12 hours, then hospitalization of three to seven days depending on the site of the fracture. The end of any sporting activity can last up to six weeks.
Contused and complex wounds:
When the wound to be treated is unusual in its extent, the doubtful vitality of the integument of the neighboring body, the combination of the open wound and the dermabrasion, it is better to entrust the sportsman to an experienced surgeon who will follow the wounded person, use appropriate means (directed healing, cover flap in case of cartilage exposure, screening for sepsis) to achieve complete healing with minimal aesthetic or functional sequelae.
The cervical sore:
The neck represents a very special topography in the event of a wound, because of the richness of the underlying vessels present and the presence of the larynx, the first stage of the airway.
With regard to wounds, the anatomical limit in depth, like the peritoneum for the abdominal wounds, is the skin muscle.
Any wound that does not reach the skin can be considered superficial and can be taken care of in locker rooms. Still it is necessary to be able to explore this wound correctly by spreading the banks and controlling the bleeding. In case of doubt, abstention is the rule.
Any wound that reaches the muscle of the skin should be examined under general anesthesia to control the large vessels in the neck, especially the venous arteries leading to a bleeding recurrence after a misleading period of calm.
Amputations and bites:
With regard to the tearing, particularly of the auricular, it is necessary to preserve carefully any pedicle, even narrow, which still connects the fragment torn from the face. In this case, a suture with reinsertion can be performed with a good chance of success, the suture being done within six hours post-traumatic and the careful and daily follow-up in specialized environment.
When the amputation is complete, reimplantation may be attempted if the fragment has been stored at a temperature close to 5 ◦ C (do not place it directly in contact with ice), with the accident going back to less than eight hours. If these conditions are not met, sophisticated surgical techniques should be used by nursing the cartilaginous model, which has been removed from its skin under the skin and reused four weeks later or, if it is unusable, more complex reconstruction techniques.
The human bites in sports practice are exceptional and come within a forensic framework. They are particularly septic and require careful dressing and disinfection by suturing them within a maximum of 12 hours. Beyond that, it is better to move towards dressings and directed healing, with a secondary correction per flap one year after the bite.
The trauma of the face region by region:
For each region concerned, we will take the most frequently encountered break. We will eliminate the fractures disjunctions of the facial mass (called de Lefort) and the orbitonasal and orbitonasomaxillary dislocations, which I have never encountered in sporting practice, because at the moment, a fortunately insufficient impact power in team sport.
The frontal region:
Frontal impact is very common in contact team sport, rugby in particular. It can be the cause of a loss of consciousness and poses the problem of an extradural hematoma on fracture of the frontal bone, happily rare eventuality.
The peculiarity of this region is the fracture of the frontal sinus, situated above the root of the nose and the arch of the eyebrow in its internal third. In fact, there is great variability in the size and pneumatization of the frontal sinus from one subject to another. The fracture of the frontal sinus is aimed at the subject with a highly developed frontal sinus, the latter representing an area of weakness with direct impact.
The clinical picture is relatively poor. In the absence of a wound, edema and a very pronounced ecchymosis quickly sit at the root of the nose. The deformation of the soft parts is evident and sometimes the palpation perceives, through the integuments of the forehead, a snowy crepitus reflecting the presence of air coming from the sinus and signing the fracture.
The player must leave the field permanently.
In the nearest hospital, a CT scan without and with injection is needed to detect the dreaded complication of this fracture: fracture of the posterior wall of the sinus, causing a possible intracranial hematoma made of the adhesion of the dura mater to the posterior wall and of a cerebrospinal rhinorrhea.
In the case of an isolated fracture of the anterior wall, if it is not displaced, there is no operative indication. The sportsman is arrested for four weeks.
When the fracture is displaced, it can also be accompanied by a frontal anesthesia by lesion of the V1 and surgical exploration is the rule, usually by bicoronal way to avoid a scar that is too visible. The ENT will check the permeability of the nasofrontal canal, as obstruction of the latter may be the source of second-rate infectious complications. After a possible release of the sensitive branch of the bone fragments, the latter will be replaced with an osteosynthesis by microplates or steel wires to reconstitute the bone curve. When the permeability of the nasofrontal canal is uncertain, the surgeon will make the decision to permanently exclude the sinus by removing the entire mucous membrane lining it and filling it with bone powder (among others).
When the fracture involves the anterior and posterior walls, the surgical procedure responds to the same principle, but it takes place in a neurosurgical environment, with simultaneous repair of a hard-merian breccia and a possible hematoma.
The complication is the cerebrospinal breccia with rhinorrhea of cerebrospinal fluid on a fracture irradiating on the anterior stage of the base of the skull. This rhinorrhea is the second cause of a formidable meningitis. That is to say all the attention that must be given to this type of trauma. The rhinorrhea may appear in a staggered manner within 15 days of the accident. It is characterized by its positional syndrome, occurring leaning forward, rock water, especially one-sided. Its diagnosis will be confirmed by a test strip identical to that used for the urine, which will detect the presence of sugar, which in no case exists in the nasal secretions. The injured person must then be immediately addressed in a neurosurgical environment for further examination in the search for the origin of the breach and then a surgical exploration of the anterior stage of the base of the skull with fistula filling with, as a sequel, an anosmia due to the section of the olfactory branches during this exploration.
The athlete’s unavailability will be of the order of four to six months.
This region mainly responds to the malar bone that represents the typical fracture.
The trauma of this region is frequent in sporting practice.
In most cases, it is a simple ecchymosis with edema in front, with no sign of fracture. The player may leave a few minutes to benefit from the application of an ice bladder on the impact, and in the absence of loss of knowledge and visual discomfort, he may return to his field position.
The signs of fracture of the malar are quite easy to highlight, the player having left the field definitely:
• an asymmetric periorbital glare;
• edema and chemosis of the eyelids;
• a pain in palpation of the bone insertions: an internal third of the orbital border, the foot of the malarus, the finger being engaged in the mouth at the level of the upper vestibule, an external third of the eyebrow.
There are also possible signs of complications of this fracture:
• a depression of the cheekbone with respect to the healthy side, signing the displacement.
• diplopia in the glance upwards, by fracture line irradiated on the orbital floor.
• sub-orbital anesthesia by V2 lesion, extended to the nose wing, upper lip and vestibule.
• limitation of the mouth opening by prolonged fracture in the zygomatic arch.
The player will be driven in hospital for a CT without injection of the face that will appreciate the displacement and the state of the orbital floor. The ophthalmological assessment with visual acuity and Lancaster’s test to assess a possible diplopia will complete the assessment:
• either this closed fracture is without displacement and without complication: there is no operative indication. The athlete must stop any activity for four weeks before resuming the championship;
• either this fracture is displaced and / or complicated: the injured person must undergo surgery once the oedematous phase has disappeared, ie between the fifth and the tenth day after the accident. The fracture is reduced by the Ginestet hook placed percutaneously under the malar or the upper vestibule, the bone usually being maintained by an osteosynthesis (miniplaque, microplate or steel wire) after the suture frontal and orbital rims where these consolidation gestures will be performed.
The orbital border, which is approached by the subpalilebral, subciliary or transconjunctival route, will be the site of a release of the suborbital nerve (V2) in the event of anesthesia and an exploration of the orbital floor in the event of diplopia. The duration of hospitalization is two to three days. Stopping activity for four to six weeks depending on the complication and visual sequelae. The sequellar diplopia leads to the end of the athlete’s career.
Trauma to this region immediately involves controlling the visual acuity and integrity of the eyeball to eliminate the two major emergencies in this region, the wound of the eyeball and the physiological section of the optic nerve (elimination diagnoses) .
The player is forced out of the field because the inability to properly open the eyelids on the traumatized side prevents him from pursuing any sporting activity. Examination in locker room made on a seated player, after possibly removing his lenses, must lead to the diagnosis of fracture of the floor of the orbit, typical fracture of this region.
This fracture is encountered in the absence of an associated fracture of the malar, due to the movement of the orbital contents which, under the impact, will strike the orbital floor, which yields under the impact. The signs of this fracture are rather stereotyped:
• a lower and upper palpebral hematoma quickly formed;
• edema of the eyelids;
• an enophthalmos.
These unilateral signs will very quickly prevent a reliable examination, the examiner trying to hold the eyelids open with one hand to look for a diplopia when looking up. The sensitivity of the territory of the suborbital nerve is explored, the latter being often injured in this type of fracture. The athlete must under no circumstances blow his or her nose, the sudden insufflation of air into the nasal cavity and the maxillary sinus situated under the orbit causing the air to pass through the fracture of the floor with a pneumo-orbit, palpation of a snowy crepitation of the eyelids and an increased compressive risk on the intraorbital content.
The injured person is transferred to the neighboring hospital for CT without injection of the facial mass confirming the diagnosis.
The assessment will be completed by an ophthalmologic examination, with visual acuity and Lancaster test.
There is an operative indication with exploration of the orbital floor in the following situations:
• sub-orbital nerve anesthesia;
• muscle or muscular hernia manifested in CT, the source of an enophthalmia;
• a diplopia confirmed by the Lancaster test.
The surgical procedure is delayed between the fifth and tenth post-traumatic days, once the edematous phase is regressed. The pathway is transconjunctival, subciliary or subpalilebral, depending on the extent of bone loss of the floor and the surgeon’s habits. After checking for reduction in the blockage of the right lower muscle by incarceration and then reducing the latter, repair is performed by the bone fragments still in place for small losses of substance up to the autografts (taken from the patient himself) bone (parietal bone) or cartilaginous (auricular conch) and biomaterials (vicryl trellis or fine silastic blade) for the larger ones. The autografts have the advantage of very good tolerance, but they prolong the operating time due to their removal. Biomaterials are exposed to the risk of rejection and extrusion, especially for silastic, with myositis of the secondary lower right and final diplopia, but avoid the surgical time of the sampling.
The duration of the hospitalization is on average three days and the unavailability of four to six weeks. Orthoptic rehabilitation is sometimes necessary, the final diplopia condemning the player to stop his career.
In the absence of these three situations, there is no surgical indication, the athlete simply having to be put to rest for four weeks.
The preauricular region:
The fracture of this region is that of the zygomatic arch which constitutes the lateral counterforce of the face and is very exposed to lateral impacts.
The clinical picture is composed of spontaneous pain caused by impact and fracture, palpable and visible depression in comparison with the other side, and especially limitation of buccal opening by contusion of the temporal muscle under ( Table 1 ).
The athlete is sent to the reference hospital to benefit from imaging with lateral Hirtz images and especially CT without injection of the facial mass.
Surgery is performed in case of limitation of the mouth opening and / or unattractive penetration of the arch. Reduction under general anesthesia is most often done with the Ginestet hook, but other techniques have been described by balloon or rugine slipped surgically under the arch. Sometimes, in the case of unstable reduction, osteosynthesis is required by steel wires or mini pipes arranged by the hemicoronal route. The duration of the hospitalization is two days and the sport stopped for an average of three weeks.
We shall not return here to the wounds and others of the pavilion, but to a particular circumstance of this region: the auricular blast.
This blast is not due to an explosion, but to a simple slap that, given a priori accidentally, will cause a shock wave on the eardrum.
The clinical picture associates immediate signs, with otalgia and deafness then tinnitus of acute timbre, even instability and rotatory vertigo.
The athlete leaves the field and the otoscopy seeks moderate otorrhagia, hyperemia of the eardrum, or even a perforation with tympanic rupture.
The instillation of auricular drops is formally forbidden, the ear being occluded by an occlusive dressing.
The opinion with an ENT is imperative within 24 hours, in order to realize an audiogram. This will make it possible to differentiate the following tables:
• a perceptual fall on the treble with tinnitus, intact tympanum, requiring medical treatment by Vastarel, with 15 days rest;
• a greater perceptual fall in a wider frequency band, with disabling tinnitus, the state of the eardrum being variable.Treatment involves corticosteroids and Vastarel, sometimes hospitalization of four to eight days and a four-week stop, with no guarantee of recovery;
• a much more marked perceptual fall, dizziness, tympanic rupture. The patient is hospitalized and has CT scan of the rock in search of a pneumolabyrinthe synonymous with opening of the inner ear, which requires a surgical exploration of the middle ear under general anesthesia to fill the opening (the fistula) of the inner ear. This surgery is framed by intravenous medical treatment of corticosteroids, antibiotics and Vasterel per os. The duration of hospitalization is ten days; the end of any sporting activity can last up to two months.
The nasal pyramid:
The nose is surely the area most frequently affected in sports traumatology for reasons that Edmond Rostand has perfectly explained in Cyrano de Bergerac.
Four entities must be distinguished from nasal trauma:
• simple contusion;
• fracture of the nose closed without displacement;
• fracture of the nose closed with displacement;
• open fracture of the nose.
The simple contusion results in localized edema on impact, with transient pain without epistaxis and perfect integrity of the nose in its form. The sportsman leaves temporarily. The examination confirms the absence of a septum hematoma (see next chapter), the bladder limits the edema and the player can resume his place.
The fracture of the nose not displaced closed is expressed by a hematoma in the bezel of the two orbits of fairly rapid appearance with marked edema and uni- or bilateral epistaxis.
There is no wound in relation to impact. The player leaves the field definitely. The epistaxis is controlled by the usual means and the gentle palpation of the nasal awning regains pain caused in relation to the fracture focus and confirms the absence of displacement. It is quickly difficult to evaluate because the edema settles. In any case, the athlete is brought to the neighboring hospital for a radiological assessment including an incidence of the clean bones (profile), a Blondeau, a Gosserez appreciating the displacement in the lateral direction.
The fracture line is visualized, the absence of confirmed displacement. In case of doubt, a secondary examination by an ENT, five days after the trauma, once the oedematous phase has passed, will reassess the displacement. In case of doubt, CT without injection of the facial mass allows better visualization of the lesions. There is no surgical indication, anti-inflammatory treatment may be prescribed; antibiotic therapy is debatable. The athlete will be unavailable for three weeks, the time of consolidation of the fracture.
The displaced closed fracture corresponds to the same clinical picture with the exception of displacement. The most frequent trips are:
• unilateral lateral trauma fracture resulting in traumatic bone depression and lateral deflection of the nasal aperture;
• the fracture disjunction of the nasal aperture where the two clean bones are fractured and dislocated as a whole on the opposite side to the lateral trauma, the nose taking an S-shape;
• the fracture of the nasal aperture where the clean bones retreat in profile under the anteroposterior impact, the nose taking the form of a horse saddle or nasal saddle.
The surgical indication is justified in order to reduce displacement and eliminate any aesthetic sequelae.
The operation takes place between the fifth day and the 12th post-traumatic day, under general anesthesia during a 24-hour hospitalization or even outpatient surgery.
The surgeon will reduce the fracture by introducing a guardian into the nasal cavity of the fractured clean bone and exerting external pressure with his other hand to reproduce the reverse movement of that at the origin of the displacement. The restraint is ensured by a plaster and a bilateral wiping removed the next day. The plaster is kept for seven days, with the sport stopped for three weeks.
The open fracture is defined by a wound facing the impact. The paradox in this case is the very small edema due to cutaneous opening. This fact makes it possible to appreciate much more easily the displacement and the reality of the fracture by spreading the banks of the wound with the hooks of Gillies. A bony fragment sometimes causes hernia through the wound. The doctor must refrain from suturing the wound, as we saw in a previous chapter.
The player leaves the field definitely and is accompanied to the nearby hospital for a radiological assessment.
At the end of this assessment, there are two scenarios:
• either the fracture is not moved. The cutaneous suture is performed under local anesthesia. There is no hospitalization; antistaphylococcal antibiotic therapy is prescribed over seven days and the duration of the player’s unavailability is three weeks;
• either the fracture is displaced and the player is operated within 24 hours, with reduction of the fracture and suture at the same operative time. The hospitalization is 24 hours, the injured is discharged under antibiotic therapy, the plaster is removed on the seventh day postoperatively and the sons, the sports activity being stopped for three weeks.
The particular case of the partition. The bulk hematoma:
Any traumatized nose must have an endonarinary examination, using an otoscope to visualize the septum. If the latter is deviated, nothing says that this deviation is secondary to the trauma, it can be ancient. If the septum is flatly dislocated, obstructing the nasal cavity, with a wound of the nasal mucosa, its recent character is hardly doubtful. The reduction of the fracture of the clean bones is then accompanied by a trial of realignment of the partition with the installation of splints on either side of it to keep it in place over a period of eight to ten days. This realignment is random because of the unstable nature of the cartilage relative to the bone.
The hematoma of the septum is observed in adolescents because of the predominance of the cartilaginous nose (lower half) whereas in adults, the bone becomes the majority, the cartilage constituting only a third of the nasal pyramid.
The fracture of the cartilage of the septum without mucous wound causes the formation of an anterior hematoma of the nasal fossa, soft on palpation and purplish under examination, obstructing the nasal process. Its diagnosis is fundamental because, unknown, the hematoma is infected between the tenth and the 15th post-traumatic day, resulting in a purulent melt of the cartilage which supports the nasal awning leading to a very unsightly and difficult nose to correct. The identified hematoma is drained under general anesthesia, the patient being hospitalized for 24 hours, with a broad-spectrum antibiotic prescribed over a period of eight days.
We have already mentioned this in the fracture of the frontal sinus.
It can also be observed in the case of a so-called “ outdated “ nose fracture, that is to say in the case of a fracture with impact on the root of the nose, the fracture line irradiating on the anterior floor of the base of the nose skull. Diagnosis is made in relation to the extent of CT lesions, all attention to be focused on a flow of “ rock water “ liquid with positional syndrome, occurring on one or both sides, a reagent strip identifying sugar in its breast, which means that it is with certainty cerebrospinal fluid.
The procedure to be followed is the same as for the frontal sinus.
We mean by cheek the region situated below the cheekbone and which corresponds to the anterior wall of the maxillary sinus. The typical fracture is the fracture of the maxillary sinus, essentially its anterior wall. This type of lesion is relatively rare, because it is protected by other more significant reliefs (the nose and the cheekbone).
The diagnosis is based on local edema, a possible perceptible sinking on palpation, a discrete epistaxis and the perception of snowy crepitation, synonymous with air suffocation in the skin of the cheek due to the opening of the sinus. It may be associated with anesthesia in the sub-orbital nerve area in case of fracture irradiated to the orbital rim.
The player must leave the field permanently and be taken to the neighboring hospital for CT of the facial mass.
Any fouling is forbidden to avoid any insufflation of air in the soft parts of the cheek. There is no surgical indication, because this type of fracture has no consequence, neither aesthetic nor functional. The only exception is an involvement of the suborbital nerve which must be treated surgically and freed from any bone and / or edema. The player’s unavailability is three weeks.
The jaw and the chin:
This region corresponds to the mandible, whose fracture possibilities are very varied. They are responsible for possible aesthetic and functional sequelae, but also disorders of the dental articulation that make it specific.
They are frequent in sports traumatic pathology.
Their classification is above all topographical and we will distinguish schematically the fractures:
• the toothed portion or horizontal branch, including the symphysis;
• the angle;
• the rising branch;
• the condyle.
The most frequent fractures in the adult are parasymphyseal, adjacent to the median line and the angle, due to the areas of weakness represented by the wisdom tooth socket (angle) and the orifice of exit of the lower dental nerve (parasymphyseal). They are sometimes bifocal, parasymphyseal and angle, or rising branch for example.
In children and young adolescents, it is the fracture of the condyle that dominates, most of the time following a fall on the chin.
Due to the frequency of the mucous and gingival wounds, because of the adhesion of the latter to the bone, the fractures of the mandible, especially the toothed portion, are open fractures, although the gravity is less severe than open fractures on the skin.
The clinical picture is stereotyped, following a direct impact on the jaw or chin:
• pain with spontaneous impact and palpation;
• limitation of mouth opening;
• a modification of the dental articulation (the injured person will say that he does not feel his teeth as before), with a lateral deviation of the jaw at the mouth opening (fracture of the condyle);
• a wound of the gum and mucosa on the endobuccal examination, in case of fracture of the horizontal toothed portion.
The player must leave the field for a close examination in the locker room after the removal of his mouth guard. Dental articulation disorder (limitation or deviation), endobuccal wound or dental nerve anesthesia (loss of sensitivity of the lower vestibule and lower hemilèvre) confirm the probable fracture.
The injured person is taken to the nearest hospital to benefit from the following radiological assessment:
• orthopantomography, the most frequent radiological incidence for exploring the mandible;
• condylar incidences, open mouth, closed mouth;
• CT without injection of the facial mass;
• at the end of imaging, the fracture is confirmed and the treatment is put in place.
For condyle fractures, two types of treatment are currently proposed according to the surgeon’s training school:
• functional treatment, with re-education of liquid chewing initially for three weeks if the occlusion is good, or by a preliminary intermaxillary blockage of five to eight days, then mixed, then normal that allows a good recovery of the function without necessarily a good anatomical reduction of the fragments;
• or surgical treatment (osteosynthesis or screws) to restore good continuity of the bone fragments. The proponents of the functional treatment emphasize the difficulties of this surgery: risk of facial nerve injury during the approach, devascularization of the condyle, infectious risk due to the opening of the articular cavity.
For fractures of the horizontal portion, the angle and the rising branch, here again two types of treatment are conceived, but in a complementary way:
• in the first 24 hours, osteosynthesis is favored by mini- or maxiplaques, possibly supplemented by intermaxillary blockade in case of unstable fracture. It will make it possible to resume a feeding by natural way rather quickly and to prevent any ankylosis of the temporomandibular joints.
This surgery is done under general anesthesia, the first ways to position the osteosynthesis being endobuccales. In the first step of a parasymphyseal fracture, the surgeon controls the exit of the lower dental nerve, trying to release it in the case of a bone splinter or local compression causing anesthesia in the lower territory ;
• when the diagnosis is made after the first 24 hours, it will be wiser to set up an intermaxillary blockage to prevent the fracture of the fracture site, blocking fractures and being left in place for three weeks. The resumption of mastication will be more difficult here, with a greater risk of ankylosis.
The duration of hospitalization in case of mandibular osteosynthesis is on average five days, the duration of the discontinuation of sports activity from six to eight weeks.
The luxation of the temporomandibular joint is, on the other hand, rather rare outside a preexisting laxity known to the player. The jaw is blocked in opening, the injured being unable to close his mouth. It is not recommended, except for certain preexisting laxity, to attempt a Nelaton maneuver to reduce this dislocation, as it may involve a fracture of the condylar region on one or both sides. A radiological assessment at the neighboring hospital is a prerequisite before any attempt, which sometimes requires general anesthesia.
The traumatology of the cervical region was quite exceptional in the practice of team sports until the last few years when rare and serious accidents appeared.
The cervical region corresponds to the larynx, and the closed trauma of the larynx leads to emergency situations, with dyspnea, the larynx being the first stage of the respiratory tract. The direct impact is prohibited by the regulation of all team sports, but it is observed when the defender, taken against the foot, tends desperately to the arm to prevent the advance of the attacker (we speak of “ tie “ ), or when the attacker opposes the defender’s opposition using his elbow.. .
These are closed trauma and the examination of the wounded player, lying on the ground, obeys the same rules that we listed at the beginning of this chapter:
• reassure the conscious casualty;
• release the buccal cavity from any secretion, foreign body and dental apparatus;
• dislocate the jaw, avoiding excessive manipulation of the cervical spine (associated lesion);
• placing the injured person in a lateral position;
• fit a Guedel cannula to remove the base of the tongue.
Intubation should only be considered in cases of acute asphyxia, as it is particularly uncertain in the case of fracture of the larynx. In practice, if the injured person breathes properly by himself, it is important to do nothing.
Wearing a cervical spine should be easy because of the risk of the associated lesion; the wounded man emerged from the field in a stretcher, in an elongated position.
The cervical examination looks for subcutaneous emphysema synonymous with laryngeal breccia, the injured complaining of an embarrassment to swallow and a possible change of voice.
The injured person is immediately transferred to the nearest hospital by a medical vehicle.
Arrived at the hospital emergency room, the ORL examination by fibroscopy and the degree of respiratory discomfort will make it possible to distinguish three stages:
• there is no respiratory discomfort, fibroscopy does not find any abnormality, the injured person can benefit from cervical and laryngeal CT without injection which will confirm the integrity of the airway: the athlete can go home. He will be at rest for eight days;
• same situation, but fibroscopy finds mucosal lesions and hematomas within a larynx with conserved anatomy, there is no laryngeal mobility disorder, no detectable fracture. The injured passes his cervical CT, little modified with, sometimes, however a fracture of the larynx isolated and simple. It will be kept 24 hours in surveillance because of the risk of secondary respiratory worsening by edema, treated then by aerosols, corticosteroids and antibiotherapy. The player’s unavailability is three weeks;
• respiratory discomfort, inspiration dyspnea with bradypnea, larynx with fibroscopy is the site of minor lesions with edema, hematoma and mucosal lesions: a tracheotomy under local anesthesia is necessary.
This has a triple advantage:
• ensuring an adequate aviation sector;
• allow general anesthesia if necessary;
• avoid aggravating laryngeal lesions by intubation.
Once the tracheotomy is performed, the injured person receives a CT scan to assess the lesions and decide on a possible intervention, sometimes by external anesthesia to restore the anatomy. The duration of the hospitalization is eight days, the cessation of activity from two to three months. The sequelae are not uncommon, especially in the form of dysphonia.
All these cervicofacial lesions are at the origin of any sequelae and / or handicaps leading to a premature end of career or a recovery without ever being able to recover the previous level, especially in professional sport. In addition, the impacts at the origin of these injuries are sometimes at the limit of the practice of the game, punishable on the ground, but also before a civil or criminal court sometimes. That is to say the importance of the initial management by the doctor of the sport accompanying the team, or receiving the athlete the day after the match and redressing a diagnosis.
The orientation of the player to a competent surgeon or to the right emergency structure for ophthalmological care, for example, is of prime importance.
But the role of the sports doctor goes beyond that. In association with his colleagues, he must alert the federations in the event of a resurgence of some cervicofacial lesions previously absent from the ground, this recrudescence testifying to a sporting evolution which will have to be framed and prevented by an evolution of the rules of the sport in question sports practices to be abandoned.


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Structure and Scope of the Foreign Relations Series
This volume is part of a subseries of volumes of the Foreign Relations series that documents the most important issues in the foreign policy of the administration of Jimmy Carter. It is one of two which document U.S. policy toward Iran during the Iranian Hostage Crisis of 1979–1981. This volume ends in September 1980. A subsequent volume, Foreign Relations, 1977–1980, Volume XI, Part 2, Iran: Hostage Crisis, September 1980-January 1981, will cover the Algiers Accords of January 1981 and the release of the hostages.
For the immediate period leading up to the hostage crisis, readers should consult Foreign Relations, Volume X, Iran: Revolution, January 1977-November 1979 upon its publication. Two volumes on oil and energy topics are also of importance for understanding the global and economic aspects of the crisis: Foreign Relations, 1969–1976, Volume XXXVI, Energy Crisis, 1969–1974 and Foreign Relations, 1969–1976, Volume XXXVII, Energy Crisis, 1974–1980. This volume provides documentation on the U.S. strategic response to the Iranian Revolution in the Persian Gulf and Middle East in general. For documentation on the beginning of the Iran-Iraq War, see Foreign Relations, 1977–1980, Volume XVIII, Middle East Region; Arabian Peninsula.
Focus of Research and Principles of Selection for Foreign Relations, 1977–1980, Volume XI, Part 1
The focus of this volume is on U.S. efforts to resolve the U.S.-Iranian crisis over the hostage taking. Members of the Carter administration met almost daily for the first several months of the crisis, mostly as the Special Coordination Committee, and less often in the form of the Policy Review Committee or as the National Security Council. Additionally, the Department of State prepared “Sitreps” and “Updates” on a daily basis to keep track of a crisis that grew in complexity. One of the demands of this volume was to sift through the voluminous material and separate out those events, people, and decisions that truly moved the crisis from stage to stage. Additionally, there were Iranian domestic developments stemming from the Iranian Revolution that impacted the crisis. In the absence of direct diplomatic communications between the United States and Iran, the role of a number of official and unofficial intermediaries in resolving the crisis is documented. While the volume’s principal focus is on Washington policymaking, an effort was made wherever possible to keep the focus on the hostages [Page X] themselves. The former Shah of Iran is also an important element in the volume. Until his death in July 1980, his movements in exile provoked Iran into continued efforts to obtain his extradition and his alleged fortune. Another, and not insubstantial focus of the volume, is on policy discussions within the administration concerning rescue efforts.
The volume can be divided into three main sequences: the initial embassy takeover and response by the Carter administration, efforts to negotiate with Iran through various intermediaries, and the resort to military force in the attempted rescue mission and its fallout. These developments took place against the backdrop of one of the twentieth century’s most significant revolutions, the scale and historical background of which confounded U.S. policymakers who nevertheless made tremendous efforts to understand. Their frustrations with the situation are all too obvious.
Several themes are apparent by volume’s end. First, the Carter administration, for all its effort, lacked appropriate leverage to influence Iranian developments. The hostages were held in the heart of a major city by non-governmental actors. Communication with members of the Iranian Government, therefore, was of little avail. Military power was also judged to be proven ineffective. The fact that the whereabouts of all of the hostages was unknown limited planning options. Moreover, the lack of an institutional structure for effective inter-service coordination of special operations activities hindered the execution of the rescue attempt. Other military actions were considered, but were deemed too risky in the context of Cold War confrontation with the Soviet Union. Economic sanctions were hampered by a lack of international support. Furthermore, Iran itself was relatively economically insulated from dependence on foreign supplies.
The editor wishes to acknowledge the assistance of officials at the Carter Library, Atlanta, Georgia. Special thanks are due to Mark Ellcessor and David Robarge of the History Staff of the Center for the Study of Intelligence of the Central Intelligence Agency, who were extremely helpful in arranging full access to the files of the Central Intelligence Agency. Douglas Richards and Mike Johnson of the Joint Chiefs of Staff were likewise extremely helpful in expediting access to the records of the Joint Chiefs of Staff and Delta Force papers held by the JCS relating to the hostage rescue mission. The Office of the Historian wishes to thank Greg Perett of the Office of Information Programs and Services for coordinating the declassification review of this volume within the Department of State. Additional thanks are due to the Historical Programs Staff at the Central Intelligence Agency, the Office of Access Management at the National Security Council, and the Govern [Page XI] ment of Switzerland for assisting with the declassification of this volume.
Linda Qaimmaqami collected documentation for this volume and selected and edited it, under the supervision of Edward C. Keefer, then General Editor of the Foreign Relations series. Chris Morrison assumed responsibility for resolving issues of compilation and review during the final stages of production. Kerry Hite coordinated the interagency declassification review, with the assistance of Chris Tudda and Carl Ashley, Chief of the Declassification Division. Heather McDaniel, Kerry Hite, and Rita M. Baker performed the technical and copy editing under the supervision of Mandy A. Chalou, Chief of the Editing and Publishing Division.

domain: politics


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Aizawl, June 20: Ten more people, including an eight-year-old boy, have tested positive for coronavirus in Mizoram, taking the state’s tally to 140, officials said on Saturday.
Four of the new patients are from Mamit district while three are from Champhai, two from Serchhip and one from Khawzawl district, a report released by the state Information and Public Relations Department said.
Seven of the new patients had returned from Maharashtra and three had returned from Delhi, it said.
Apart from the eight-year-old boy, the remaining nine patients are aged between 21 and 46, the report said.
Nine of the patients are asymptomatic. One has developed coronavirus symptoms and has been admitted to a dedicated COVID-19 Health Centre, it said.
Of the 140 total cases, 131 are active while nine people have recovered.
Mizoram had reported its first COVID-19 case on March 24 and the patient, a 52-year-old pastor who had travelled to the Netherlands, was cured of the disease on May 9.
The northeastern state next reported 12 COVID-19 cases on June 1. Since then, the state has witnessed a spike in the number of cases, taking the count from one to 140 in just three weeks. (PTI)

domain: geography


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(Here's the video that actually shows him speaking. I had a totally different picture of him in my mind!)
I swear I can watch this every day. Makes me want to get back into the trenches of teaching.
I happened upon a review of it in the Seattle P-I. I especially loved this part:
...learning is not pretty. It is a fist fight of the mind and the only way to comprehend and appreciate what we have learned, [is] to pick ourselves back up and continue.
~ Jeremy Tolbert
"Slam Poet Taylor Mali on What Teachers Make"
That could just as well be about life, no?

domain: psychology


Weezer have announced that their next album will be released on October 27.
The pop-rockers, led by Rivers Cuomo, made the announcement on their official website, Weezer.com.
The band are yet to reveal the title and tracklisting of the album yet – although in a message on the site they promised that there would be “more to come” soon.
The release will be the follow-up to last year’s self-titled album, often dubbed ‘The Red Album’, due to its colour scheme.
Weezer debuted three new songs live at the Jisan Valley Rock Festival in South Korea last month.


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We noticed that you're using an unsupported browser. The Tripadvisor website may not display properly.We support the following browsers: Windows: Internet Explorer, Mozilla Firefox, Google Chrome. Mac: Safari.
a pleasant day for lunch in a nice place was ruined by a very unpleasant owner who, on a remark related to the meat served, apparently threw the last leftovers on offer to the guests on the terrace of the restaurant, causing intolerance and quarrel that was not needed at all, the advice is to avoid the restaurant. , and the owner needs old advice that the guest is always right! Too bad because there is a lot of potential for the development of catering near Zagreb, like this never again !! (robertkR2211QE, May 2020)

domain: travel


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About Monash Health
Monash Health provides a wide range of healthcare services to communities across south eastern Melbourne, uniquely integrating primary, secondary and tertiary health services. With world-renowned research and teaching facilities coexisting in one organisation, over 1.3 million residents (24% of Victoria’s population) can access our services.
We aim to assist older adults to restore, improve or maintain their independent functioning and wellbeing following a recent hospital or emergency department admission or deterioration in health. This is a critical role to assist in delivering occupational therapy services supporting this objective.
Monash Health Community and Allied Health
Our shared vision is One Team: Making a Difference Together. Underpinning this vision are the following principles:
We provide quality care focused on the person in the context of their life
We are inter-professional and innovative with a can-do attitude
We view change and challenge as great opportunities
Our integrated and inter-professional service provides the highest quality patient-centred care across the continuum, underpinned by a robust governance structure and contemporary service improvement methodologies. As a recognised leader in health delivery, we are driven by our model of care and we work diligently to ensure that our structure supports a true and committed person-centred approach.
About the Role
Your target client group will include frail, older people, people from culturally and linguistically diverse backgrounds and people from Aboriginal and Torres Strait Islander Communities. Working as part of an interdisciplinary team, your key activities will include:
Working collaboratively with others to provide clinical care to patients/clients and their families/carers in the community;
Applying your specialised knowledge to effectively plan, coordinate and deliver high quality, professional care and evidence-based education for patients/clients and their families and carers within a flexible service delivery model.
Must have current drivers licence
Relevant professional practice in working with older people and younger adults with disabilities and the frail aged, including but limited to, those with neurological, orthopaedic conditions.
Experience of working in Community Health or a community setting
Commitment to working within a Team with demonstrable understanding of the importance of effective communication with, and accountability to, the Team.
Demonstrated ability to work with individuals from diverse cultural and linguistic backgrounds
Demonstrated skills in assessment, care planning, service provision and the ability to function both independently and within an interdisciplinary team.

domain: medical


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- Cowboys news: Keeping keep track of of all the hottest Cowboys roster cuts Blogging The Boys
- Final Cowboys roster projection: Who will Dallas slash from deep teams at D-line and in the secondary? Dallas Information
- Dallas Cowboys: Is this rookie sixth-rounder a starter by 2021? The Landry Hat
- Jerry Jones sums up Dallas Cowboys’ preseason with views on Zeke, Amari, Donovan Wilson Fort Really worth Star-Telegram
- Information: Quinn waves goodbye to forged, Cowboys projected wins in 2019 Cowboys Wire
- Watch entire coverage on Google Information
Cowboys news: Keeping track of all the latest Cowboys roster cuts – Blogging The Boys
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domain: sports


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Developmental Biology - Mitochondria|
Better together! Mitochondrial fusion supports cell division...
Mitochondria are the powerhouses of the cell. New research from Washington University in St. Louis shows that when cells divide rapidly, their mitochondria fuse together. In this configuration, a cell uses oxygen more efficiently for energy. Fused mitochondria also produce a biochemical byproduct — aspartate — key to cell division.
The lab of Gary Patti PhD, the Michael and Tana Powell Associate Professor of Chemistry in Arts & Sciences, reported their work in the journal eLife. It shows how mitochondria combine to help cells multiply in unexpected ways.
As cancer cells are known to divide at a runaway pace, these new findings may help in cancer diagnosis and treatment.
"Most studies of proliferating cells are conducted in the context of cancer, where scientists are comparing a cancer tissue that's rapidly growing with normal tissue that surrounds the tumor or a normal tissue from a different patient," said Conghui Yao, a PhD candidate in Patti's lab at Washington University and first author of the new study. "These kinds of comparisons are physiologically relevant but have some disadvantages.
"A tumor is very complicated. Not only because it is made up of different kinds of cells, but also because the environment of a tumor is different from that of healthy tissue," she adds. A tumor needs nutrients to grow, but doesn't have the blood vessel infrastructure typical of other healthy tissue. As a result, tumors are often starved for oxygen. Even in the presence of abundant oxygen, cancer cells get energy through a less efficient fermentation process.
Instead of using oxygen to burn glucose in their mitochondria, cancer cells use an "aerobic glycolysis" process that turns glucose into lactate — a process called the Warburg effect.
Although the Warburg effect has been observed in rapidly dividing cells for more than 90 years, it still isn't fully understood. The earliest explanations suggested that mitochondria in cancer cells are damaged in a way that prevents them from producing energy normally. Yao is familiar with the Warburg effect and its implications. So she set up an experimental system to allow her to turn cell division on and off, and was surprised to see dividing cells consumed a lot of oxygen.
"Much of the literature had suggested dividing cells would do the opposite," says Yao. "So we looked into not only why our dividing cells were consuming more oxygen, but also how they were able to consume more oxygen." Part of the beauty of Yao's initial experiment was its simplicity. She was able to measure metabolism in one specific type of cell under two distinct conditions - when the cell was dividing and when it was not dividing. That's also how she was able to hone in on the particular structural change to mitochondria which was driving the efficiencies she observed.
"Dividing cells had the same amount of mitochondria per protein or per mass, compared to non-dividing cells. But, we noticed these dividing cells were significantly longer."
Gary J. Patti PhD, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.
Longer because adjacent mitochondria had fused into one - making multiple, adjoined mitochondria into bigger, more efficient, energy-generating machines. Yao discovered another surprise. These "mega-mitochondria" were particularly good at creating a molecule called aspartate, essential for cells replication. "Recent work from other labs had taught us that one of the most important reasons dividing cells need to consume oxygen is to make aspartate. So it made sense that mitochondrial fusion in dividing cells would increase aspartate levels," explains Yao.
Yao and Patti are not the first to observe mitochondrial fusion. But, they are among the first to interrogate mitochondrial fusion with metabolomic technology — a process that can target malignant cancer cells.
Patti: "It is often said that rapidly dividing cancer cells increase fermentation at the expense of decreasing oxygen consumption for mitochondrial activity. Our results suggest that at least some rapidly dividing cells increase both processes under normal oxygenated conditions. Since use of nutrients by rapidly dividing cancer cells is the basis for various drugs and diagnostic tests, these findings may have important clinical significance — and may represent a metabolic vulnerability in cancer."
Proliferating cells often have increased glucose consumption and lactate excretion relative to the same cells in the quiescent state, a phenomenon known as the Warburg effect. Despite an increase in glycolysis, however, here we show that non-transformed mouse fibroblasts also increase oxidative phosphorylation (OXPHOS) by nearly two-fold and mitochondrial coupling efficiency by ~30% during proliferation. Both increases are supported by mitochondrial fusion. Impairing mitochondrial fusion by knocking down mitofusion-2 (Mfn2) was sufficient to attenuate proliferation, while overexpressing Mfn2 increased proliferation. Interestingly, impairing mitochondrial fusion decreased OXPHOS but did not deplete ATP levels. Instead, inhibition caused cells to transition from excreting aspartate to consuming it. Transforming fibroblasts with the Ras oncogene induced mitochondrial biogenesis, which further elevated OXPHOS. Notably, transformed fibroblasts continued to have elongated mitochondria and their proliferation remained sensitive to inhibition of Mfn2. Our results suggest that cell proliferation requires increased OXPHOS as supported by mitochondrial fusion.
Cong-Hui Yao, Rencheng Wang, Yahui Wang, Che-Pei Kung, Jason D Weber and Gary J Patti.
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Mar 28 2019 Fetal Timeline Maternal Timeline News
Schematic of the metabolic differences between quiescent and proliferating fibroblasts.
The increase in OXPHOS is supported by mitochondrial fusion. Image: eLife


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Dutchess County Senior Amateur set to tee off
Sure, part of the allure of this tournament is its convivial atmosphere, old golf buddies having a chance to catch up and enjoy themselves.
But be not fooled by “senior amateur” in the title. This competition is, indeed, for seasoned veterans who still can pepper the ball all over the course.
The Dutchess County Senior Amateur begins on Friday at McCann Memorial Golf Course in Poughkeepsie. The two-day tournament, in its 12th year, will feature several of the top golfers in the area — regardless of the over-50 age requirement.
READ: With family by his side, Hamburger wins sixth Senior Amateur
“A lot of them have lived their lives in this area, grown up around each other, and they’re close,” said Brian Viola, in his first year as committee chair for the tournament. “But the competition is still there. It gets competitive.”
The golfers will be divided into three age brackets of 50-59, 60-69 and 70-plus.
The tournament runs Friday and Saturday with McCann, a par-72 course with 18 holes, hosting both days. The competition will be held in honor of Ron Jensen, the beloved former pro at McCann who died last August at age 74.
“I'm sure the tournament will be as successful as it has ever been,” said Jim Bernard, the former committee chair who stepped down after 30 years. “It’s a wonderful event and the people enjoy it.”
The pool of 33 players will include Jim Hamburger and Fred Newswanger, the winners of the previous two years. Bernard also will be competing.
Hamburger won last year, totaling a 145 over the two days. Newswanger, the 2015 champion, shot a 146 and was narrowly edged. Steve Stuetzle, who won the title in 2014, also will be competing.
“It’s a fun tournament for the competitors and great event,” said Viola. “It's definitely a benefit to the course, and for Dutchess County overall.”
Stephen Haynes: firstname.lastname@example.org, 845-437-4826, Twitter: @StephenHaynes4
Dutchess County Senior Amateur
Where: McCann Memorial Golf Course in Poughkeepsie
Who is eligible: Dutchess County residents 50 and older, or must possess a registered handicap at a Dutchess County club.
Friday tee times:
7:36 a.m. — Jim Hamburger, Steve Stuetzle, Don Silvestri, Barry Winter
7:45 — Kevin Zamudio, David Weyant, John Craig, James Hilaire
7:54 — Stew Blake, Ed Boone, Fred Newswanger, Mark Webber
8:03 — Warren Wynshaw, Bob Bohlig, Jack Cowan, Jr.
8:12 — Dan Morano, Jack Seaboldt, Don Walsh
8:21 — Pat Flynn, Mark Johnson, John McCabe, Don Meyer
8:30 — Doug Barton, Todd Jackson, Bill Starzyk, Mike Dunsmore
8:39 — Dion Morrow, Herb Ortiz, Bob Silver
8:48 — George Bajcar, John DeAngelis, Bob Boschen
8:57 — Ralph DeStefano, Art Smith, Jim Bernard

domain: news


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Hans Kelsen, a prominent Austrian jurist and legal philosopher, left an indelible mark on the field of jurisprudence with his groundbreaking work, the "Pure Theory of Law." This theory, which emerged in the early 20th century, revolutionized the way legal scholars and practitioners conceptualize and analyze the nature of law. Kelsen's Pure Theory of Law represents a departure from traditional legal thought, offering a systematic and abstract framework that seeks to uncover the essence of law, its structure, and its role in society. This comprehensive exploration delves into the key tenets, contributions, criticisms, and enduring relevance of Kelsen's Pure Theory of Law.
Foundations and Key Tenets:
At the core of Kelsen's Pure Theory of Law is the pursuit of a "science of law" that is free from extraneous moral, political, or sociological considerations. Kelsen sought to establish a comprehensive and systematic understanding of law as a self-contained normative system. He argued that law should be analyzed independently of its relation to morality, economics, or other disciplines, aiming to create a unified and coherent framework.
1. Basic Norm (Grundnorm): Central to Kelsen's theory is the concept of the "Grundnorm," or the basic norm, which serves as the foundational norm upon which the entire legal system rests. The Grundnorm is a hypothetical construct that represents the ultimate source of validity for all legal norms within a given legal order. It is through the Grundnorm that legal norms derive their authority and legitimacy.
2. Hierarchy of Norms: Kelsen proposed a hierarchical structure of norms, wherein legal norms are interconnected in a pyramid-like arrangement. The Grundnorm occupies the apex of this hierarchy, while lower-level norms are derived from and dependent upon higher-level norms. Kelsen's pyramid of norms reflects the relationship between different legal provisions, illustrating how they are interconnected and subordinated.
3. Normativity and Validity: Kelsen emphasized the normative character of law, asserting that legal norms prescribe behaviour and impose obligations on individuals within a given legal system. For Kelsen, the validity of a legal norm is determined by its connection to the Grundnorm and its alignment with other norms in the hierarchy.
Contributions and Significance:
Hans Kelsen's Pure Theory of Law introduced several groundbreaking contributions that continue to shape contemporary legal thought:
1. Methodological Rigor: Kelsen's approach introduced a level of methodological rigor that paved the way for a more systematic analysis of legal systems. By isolating law from external factors, he aimed to create a coherent and precise framework for studying legal norms and their interrelations.
2. Autonomy of Law: Kelsen's emphasis on the autonomy of law sought to free legal theory from normative judgments and moral considerations. This allowed for a clearer understanding of the structure and functioning of legal systems without being mired in subjective ethical debates.
3. Hierarchy and Legal Order: Kelsen's hierarchical model of norms provided a tool for comprehending the organization and structure of legal systems. This perspective highlighted the interplay between different levels of norms, shedding light on how laws are connected and interdependent.
4. Separation of Law and Morality: Kelsen's separation of law from morality sparked extensive debates within legal philosophy. His assertion that law can exist independently of moral values challenged traditional conceptions and encouraged scholars to reconsider the relationship between law and ethics.
Critiques and Challenges:
While Kelsen's Pure Theory of Law has earned widespread recognition, it has not been without criticism:
1. Overemphasis on Positivism: Critics argue that Kelsen's insistence on isolating law from morality and other external factors results in a narrow and incomplete understanding of the complexities of legal systems. The exclusive focus on formal legal norms may disregard the real-world implications of legal decisions.
2. Elusiveness of the Grundnorm: The concept of the Grundnorm has been a subject of debate and scepticism. Critics question the practicality of identifying and defining a single foundational norm that underpins an entire legal system.
3. Normative Vacuum: By divorcing law from morality, Kelsen's theory has been accused of creating a normative vacuum where questions of justice, ethics, and fairness are sidelined. This limitation raises concerns about the practical implications of his theory in addressing pressing legal and social issues.
Despite these critiques, Kelsen's Pure Theory of Law continues to exert a significant influence on legal scholarship and practice:
1. Analytical Clarity: Kelsen's emphasis on precision, hierarchy, and normative structure provides legal scholars with a valuable analytical framework for dissecting complex legal systems and understanding the interplay between different norms.
2. Legal Positivism: Kelsen's theory aligns with the legal positivist tradition, contributing to ongoing debates surrounding the nature of law and its relationship with morality and other normative considerations.
3. Jurisprudential Debate: Kelsen's theory has sparked enduring debates within jurisprudence, encouraging scholars to explore the boundaries of legal theory, the autonomy of law, and the role of normativity in legal systems.
4. Comparative Law: Kelsen's focus on the formal structure of legal norms has been particularly influential in comparative legal studies, enabling scholars to analyze and compare the organization of legal systems across different jurisdictions.
Hans Kelsen's Pure Theory of Law represents a seminal contribution to legal philosophy, offering a systematic and abstract framework for understanding the nature of law and its role in society. While it has elicited both admiration and critique, its enduring significance lies in its methodological rigour, emphasis on autonomy, and the analytical tools it provides for exploring complex legal systems. As legal scholars and practitioners continue to grapple with questions of legality, normativity, and the relationship between law and morality, Kelsen's Pure Theory of Law remains a foundational text that enriches the ongoing discourse within jurisprudence.

domain: library


text:
The German listed car rental company Sixt will buy about 100,000 electric cars from the Chinese manufacturer BYD in the coming years. A first order will consist of several thousand cars, some of which will be available this year, Sixt said on Tuesday.
Initially, only customers in Germany, France, the Netherlands and Great Britain will be able to use the electric vehicles. Sixt’s range will be further electrified until 2028, with a total of 100,000 cars from the Chinese carmaker.
BYD is one of the largest manufacturers of electric cars in the world. The company is currently entering the German market and also sees the deal as an opportunity to showcase its vehicles to potential customers. “BYD’s goal is to inspire Sixt customers with its electric vehicle offerings,” said BYD CEO Michael Shu.

domain: economics


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The Trinidad and Tobago Chamber of Industry and Commerce (T&T Chamber) which has repeatedly called for the matter of the long outstanding VAT refunds to be settled, is now calling on Finance Minister Colm Imbert to state how he intends to pay the remaining refunds owed to businesses after proposed VAT bonds are issued.
They believe this will not cover all the outstanding monies.
Imbert indicated last week that at the end of March 2023, outstanding VAT refunds tallied at $7.8 billion.
However, the Chamber is demanding immediate clarification regarding payment.
“Clarification on how the balance of arrears will be paid, and over what period is urgently required. In all of the discussions about payments of these long overdue refunds there have been no details of how the interest due on these cash refunds will be addressed,” the Chamber said in a statement.
Although it acknowledges the announcement by Imbert, to settle outstanding VAT refunds with the issuing of VAT bonds in the aggregate sum of $3 billion and noted that in this instance while the payout is a move in the right direction and is in keeping with the minister’s previous commitments to settle outstanding VAT refunds, this bond issue together with the proposed cash payments does not settle the full value of $7.8 billion owed to the business community.
The Chamber reiterated that outstanding VAT refunds continue to negatively impact the business community — from small to large businesses, across all industries and sectors, and by extension the wider economy.
It further said that based on feedback from members of the Chamber the delay in issuing refunds has forced businesses to increase their capital required to operate in Trinidad and Tobago, as the financing of VAT refunds has now become a part of the investment costs associated with doing business.
“In the globally competitive environment this reduces the attraction to invest in new projects.
“We note the Government’s approach as positive and we respectfully request further information on the plans for payment of the balance,” the Chamber said.
It again emphasized that the prolonged process not only hampers a healthy business environment but can also negatively impact the economy.


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Washington authorizes Alitalia to exceptionally operate flights between Italy and the United States, as well as transport passengers of Etihad Airways and Kenya Airways who have arrived in our country. Among the tracks, however, are some that the new Alitalia – scheduled to take off from April 2021 – does not intend to operate, and others it plans to launch in the following years. Curiosity arises from reading documents exchanged before Christmas between US legal advisors for the Italian company and the US Department of Transportation.
On December 4, attorneys for the specialist law firm KMA Zuckert – whose offices are a stone’s throw from the White House – asked the Transportation Department to agree to place the EY flight code on communications operated by Alitalia aircraft between Rome Fiumicino and New York – JFK, Boston, and Miami. , Los Angeles, San Francisco, Washington, Chicago, and between Milan Malpensa and New York – JFK. Five days later they submitted another similar request, this time to enter the KQ (Kenya Airways) code for interchange flights between the Romanian airport and American cities.
How it works
This means that travelers from Abu Dhabi and Nairobi to the United States will be able to purchase a ticket with the first flight operated by Etihad and Kenya Airways to Rome Fiumicino (and Milan Malpensa) and the second operated by Alitalia to the designated US cities. On the contrary, from the United States, a traveler can purchase a flight to Abu Dhabi and Nairobi that includes a stopover in Rome (or Milan) as part of trade exchange agreements, i.e. sharing flight codes.
On December 22, officials from the Ministry of Transport responded to both requests, giving the green light under agreements between transport companies and states. But what Washington does not realize is that an undeclared mandate has a consequence. The industrial plan announced a few days ago by Italia Trasporti Aereo – the new public company created to relaunch the Alitalia brand – does not plan to operate commercial flights to Milan Malpensa, including those bound for New York.
Not only. There is also some difference in the communications from Roma Fiumicino. Because if the New York, Boston, Washington, Miami and Los Angeles lines are expected to be rolled out immediately in the ITA business plan, other routes must start at a later time. For example, the flight to Chicago should take off again in 2022, the flight to San Francisco – in fact, it never left because it was scheduled for June 2020, but then the Coronavirus arrived – it should not start before 2023.
Alitalia’s sources explain in the extraordinary administration of Courier service That the request was sent regardless of Italia Trasporti Aereo’s movements and to protect the airline’s current assets. If the new company buys all or part of these assets, it will be up to the summit – General Manager and General Manager Fabio Lazerini and President Francesco Caillot – to decide whether to exploit this option or revolutionize the system of trade agreements and thus to act differently.


Mercedes Benz S Class Coupe arrives UK in this September 2014.
The same scenario of comfortable and performance features added in this new Mercedes Benz S Class Coupe.
Mercedes Benz S Class Coupe Models
The Mercedes Benz S class coupe only available with two engines from launch: 4.7 litre V8(eight cylinder) engine
Mercedes Benz S 500 AMG Coupe
S500 Coupe will available in early 2015. It includes 4.7 litre V8(eight cylinder) engine.
- Priced at £96,565 OTR
Active Parking Assist with reversing camera, convertible panoramic roof, an ultra sharp 12.3″ TFT display screen, the clever magic vision control system and choice of nine metallic paint options come as standard.
Mercedes Benz S 63 AMG Coupe
S63 AMG Coupe powered by 5.5 liter eight cylinder engine generates 585hp and 900Nm of torque provides effortless performance.
- Priced at £125,595 OTR
S63 AMG Coupe includes seat comfort package, smooth magic body control, outstanding Burmester surround sound system with 13 high performance speakers, Head up display, TV tuner, 360 degree camera and night view assist system.
Mercedes Benz S 65 AMG Coupe
If you are looking for more powerful performance compare to S 63 AMG than S65 AMG Coupe is available for more performance.
S65 AMG coupe produce 630 hp and develops 1000 Nm of torque.
- Priced at £183, 065 OTR
The S class coupe have more sharp lines at sides, a long bonnet and slopping roof. The coupe looks very stunning. And The panoramic roof adding a new spark. Mercedes have added great luxuries and lavish interior and exterior.
The S class coupe looks very sensation from outside and inside. There is no doubt about the performance and quality as this is Mercedes Benz car.


'Urge LG not to put obstacles in regularisation of teachers'
Deputy CM Manish Sisodia hopes that the LG will "support this noble cause".
NEW DELHI: With the Delhi Cabinet having cleared the Bill for regularisation of guest teachers, the fate of 15,000 teachers lies in the hands of Lieutenant Governor Anil Baijal, the administrative head of the Capital. Deputy Chief Minister Manish Sisodia has urged the LG to approve the decision.
"Am so happy for Guest teachers. I urge BJP n Hon'ble LG not to put any obstacle in it but to support this noble cause," Sisodia said on Twitter on Wednesday.
Delhi has around 17,000 guest teachers, of whom only 15,000 will be regularised.
The remaining teachers failed to make the cut as they did not fulfil the necessary criteria.
Earlier, the Delhi government had failed to get the approval as former LG Najeeb Jung raised the issue of teaching experience.
This year, in June, the incumbent LG Baijal issued a tender for regularisation of guest teachers, which the government asked to be revoked as the education Department was in dark about it.
Meanwhile, the BJP-led Opposition hit back at the government and alleged politicisation of the issue.
Leader of Opposition Vijender Gupta said: "The Bill approved by the Kejriwal Cabinet to regularise guest teachers is devoid of administrative, financial and legal sanctions."
Gupta appealed to the government that instead of taking political decisions, where the fate of thousands of expecting teachers is concerned, it should recourse to lawful methods based on due procedure.
"During two and half years of its being in power, it has not regularised even a single employee despite poll promises," Gupta claimed.
However, BJP has said it will support passage of the bill in the Assembly.
Reiterating the same tone, Delhi Pradesh Congress Committee chief Ajay Maken said that the government should be asked why it took so long to pass the bill.
He said the whole issue will turn political between allegations and counter allegations by AAP and BJP, but the guest teachers will not be benefitted.
Meanwhile, the Delhi Guest Teachers Association has welcomed the move of regularisation and said that they will meet the LG and urge him to approve the bill.
The teachers have asserted that it has been a long fight for them and have expressed the decision as the first step towards their victory.
"We have been fighting for a long time. We welcome the step by the government and in the next week we will meet the LG and urge him to approve the bill," a senior teacher of the organisation said.


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In December 2010, 18-year-old UK fashion student Ben Cowburn (right) overdosed on drugs, killing himself and leaving behind a baffling and unnerving story. Cowburn, who had moved to London in 2009, had reportedly been in a relationship with a famous television actor that may or may not have led him to a compromised emotional state. Fueled in part by promises of gifts (in exchange for Cowburn's styling work), the romantic relationship was also heavily infused with drugs, alcohol, and, as some believe, unwanted sexual attention.
The comedian, who in the inquest was referred to only as “Mr X” to protect his identity, allegedly showered the teenager with gifts before taking him to drink and drug-fuelled parties.
The inquest also heard of how Mr Cowburn was persuaded to strip in front of a group of men and of how the comedian occasionally crept into his bed for sex.
Cowburn's parents were reportedly wary of the situation from the beginning as the comedian likely already had a stylist and did not need the student's help. When their relationship did end, Cowburn attempted suicide several times before being admitted to Longreach hospital.
David Taylor, a nurse, told the inquest that the student had felt embarrassed and ashamed and thought he had been groomed by the man, although claimed the sexual relationship had been entirely consensual.
A different story from the Metropolitan Police claimed that when Cowburn could not pay for a cab to leave one of the actor's parties he was offered a bed and woke up to find the man lying next to him. The police noted that Cowburn's sister, Laura, said that she had been led to believe that he had been raped.
However, police decided there was no conclusive evidence that the teenager, who had sent Facebook messages to the celebrity, had been physically coerced into sex and therefore there were no grounds for questioning Mr X.

domain: law