Suicide by a rifle with a muzzle brake: a particular entrance wound

The authors describe a case in which a 21-year-old male committed suicide using a rifle equipped with a muzzle brake, placed in contact with his head. A muzzle brake for firearms is a device positioned at the mouth of a weapon, which dissipates the gases, that are generated subsequent to the gun being discharged. Generally, when a gun is pressed against an anatomical region, where the skin lies on the bone surface without interposition of other soft parts, the entrance wound consists of many lacerated branches, originating from a central lack of tissue. In this case report, the use of a rifle with a muzzle brake generated an unexpected wound, circular in shape, with a diameter of 0.8 cm. This lesion was surrounded by a bruised area, circular in shape, and an abrasion collar of the height of 0.5 cm. In addition, a muzzle imprint mark consisting of intradermal bruises, composed of a narrow red line concentrically encircling the entrance hole, was found. In order to analyze in detail if this particular entrance wound could be associated with a weapon equipped with the muzzle brake, ballistic tests – with weapons compatible with that used by the victim – were performed.     

Identification of a cannabimimetic indole as a designer drug in a herbal product

A cannabimimetic indole has been identified as a new adulterant in a herbal product being sold illegally in Japan for its expected narcotic effect. Liquid chromatography-mass spectrometry and gas chromatography-mass spectrometry analyses indicated that the product contained two major compounds. One was identified as a cannabinoid analog (1RS,3SR)-3-[4-(1,1-dimethyloctyl)-2-hydroxyphenyl]cyclohexan-1-ol (1) by direct comparison with the authentic compound, which we reported previously. The other compound (2) showed a molecular weight of 341 daltons, and accurate mass spectral measurements showed its elemental composition to be C₂₄H₂₃NO. Both mass and nuclear magnetic resonance spectrometric data revealed that 2 was 1-pentyl-3-(1-naphthoyl)indole [or naphthalen-1-yl-(1-pentylindol-3-yl)methanone] being identical to JWH-018, which was synthesized by Wiley and coworkers in 1998. This compound was reported as a potent cannabinoid receptor agonist possessing a pharmacological cannabimimetic activity.     

A Little to a Lot or a Lot to a Little?

PURPOSE: To determine whether a little dose to a large normal lung volume or a high dose to a small lung volume is more critical for induction of clinical pneumonitis. The second question is if dose-volume histogram (DVH) parameters are more reliable, if the lungs are analyzed as separate organs or as a whole organ. PATIENTS AND METHODS: We analyzed the clinical and DVH data from 49 patients treated for a thoracic malignancy using 3-D conformal treatment plans. 18 patients had developed a clinical pneumonitis (CTC II or III). The majority of patients (n = 48) received radiochemotherapy for non-small-cell lung cancer (NSCLC) with a combination of paclitaxel and carboplatin. Patients were generally treated 5 fx/week, single dose 2 Gy, using a two-series approach (shrinking field) up to a total dose of 60-70 Gy. For every individual patient, the overall dose distribution was recalculated in the Helax-TMS by means of adding dose plans according to the total dose applied in each series. The lungs were defined both as separate organs and as a whole organ. Low-dose volume (< or = 10 Gy, Vlow), moderate-dose volume (> 10-40 Gy, Vmod) and high-dose volume (> 40 Gy, Vhigh), as well as V10-V40 and mean lung dose (MLD) were defined from the cumulative DVH. Dose-effect relationships were fitted with a logistic regression model. RESULTS: Manifestation of clinical pneumonitis was within 3 months from termination of irradiation in all cases. For the ipsilateral lung, the incidence of pneumonitis was closely correlated to Vhigh. The pneumonitis rate increased from 13% up to 60%. By contrast, with increasing Vlow the pneumonitis rate dropped to < 10%. A similar but less pronounced effect was seen for the total lung. The lung volumes Vlow, Vmod and Vhigh of the ipsilateral, contralateral and whole lung were significantly correlated to the corresponding MLD. The incidence of pneumonitis increased with increasing MLD for the ipsilateral lung with a D50 of 32 Gy and a gamma 50 of 0.98. For the whole lung, the observed increase was less steep. MLD showed a close correlation to NTCP calculated by the Kutcher model. However, NTCP calculation overestimated the pneumonitis risk for the ipsilateral lung and underestimated the risk for the whole lung due to the steeper gradient. The logistic regression curve for the DVH parameters V10-V40 showed an increase of steepness toward higher doses. From the logistic regression curves, a DVH template indicating critical borders of V10-V40 was generated for the ipsilateral as well as for the total lung. CONCLUSION: Our data indicate that it is reasonable to disperse the dose outside the target volume over large areas in order to reduce the volumes of lung receiving > 40 Gy. Reducing the high-dose volume reduces the pneumonitis rate more than a corresponding reduction in the low-dose regions of the DVH. Landmarks for DVH optimization as defined in this analysis may serve as a basis for DVH contrains in IMRT planning. Separate organ analysis produced more reliable results and should be preferred to whole-organ analysis, if techniques mainly involving one side of the lung are applied. Further validation of these constraints is necessary prior to general recommendation.     

Ecografía intestinal en pediatría

Ultrasonography is the imaging technique of choice for studying the digestive tract in pediatric patients from the neonatal period to adolescence. Its dynamic character, absence of radiation, and scant preparation required make ultrasonography preferable to contrast-enhanced fluoroscopy, computed tomography, or magnetic resonance imaging. Technical advances in ultrasound, including high-resolution multifrequency probes, panoramic studies, color Doppler, Doppler with microvascularization, elastography, and contrast agents for use in children, have increased the sensitivity and specificity of this technique.Intestinal ultrasound is indicated for conditions with diverse etiologies and pathogenesis: congenital, infectious, inflammatory, tumor-related, and vascular. Knowledge of embryological development and the normal characteristics of the digestive tract help in identifying, recognizing, and interpreting the ultrasound findings of the different conditions in pediatric patients.This paper aims to show the indications for ultrasound studies of the digestive tract in children, the findings on these studies, and the management of the most common gastrointestinal conditions in pediatric patients.     

Establishing a contract for a PACS managed service

This review considers the process of contracting for a picture archiving and communication system (PACS) using the private finance initiative (PFI) managed service route. The PFI process is reviewed and the advantages and disadvantages of a managed service detailed. During contract negotiations several areas of conflict were encountered. These are discussed with an outline of how they were resolved. CONCLUSION: A contract for a PACS has been achieved by a large acute hospital Trust using a managed service provision through PFI. In detailing the specific problems encountered in the course of negotiations, it is intended that other Trusts entering on this course will be equipped and strengthened in the finalizing of satisfactory and robust contracts.     

CT-Guided Placement of a Drainage Catheter Within a Pelvic Abscess Using a Transsacral Approach

A 66-year-old man underwent CT-guided drainage catheter placement within a pelvic abscess with a diameter of 46 mm. We performed the drainage by a transsacral approach because it was considered the safest and most feasible approach. An 8G bone marrow biopsy needle was used to penetrate the sacrum to create a path for subsequent drainage catheter insertion. After withdrawal of the biopsy needle, a 6 Fr catheter was advanced into the abscess cavity through the path using the Seldinger technique. Except for bearable pain, no procedure-related complications occurred. Twenty-nine days after the placement, the catheter was withdrawn safely and the abscess cavity had shrunk remarkably.     

Hemodynamic during a postexertional asystolia in a healthy athlete: a case study

Hemodynamic events leading to spontaneous postexertional vasovagal syncope are not completely understood because of the lack of beat-to-beat data. We report a case study of a young athlete who undergoes a syncopal episode during the recovery period following a maximal cycle-ergometer test. The episode was monitored by an impedance cardiograph which can gather noninvasively beat-to-beat the flow of heart rate (HR), stroke volume (SV), cardiac output (CO), diastolic filling rate (SV/DT), and myocardial contractility index (PEP/LVET). The most important findings of this report are the dramatic reduction of SV/DT preceding the syncope, the increment of SV together with the reduction of HR preceding and following the syncope, the prompt recovery of CO values after the syncopal episode despite the bradycardia, and the reduction of PEP/LVET after the syncope. This report confirms the importance of active recovery immediately after strenuous exercise and supports the hypothesis that the reduction of SV/DT in the presence of an inotropic stimulation can trigger the vasovagal reaction.     

Going out on a limb for a difficult diagnosis: a case report

Sacral tumors with fetiform features are rare and pose a diagnostic challenge to the ultrasonologist. Sacrococcygeal teratomas (SCT) and parasitic twins can have very similar sonographic features but have different implications to an affected pregnancy. While postnatal histopathology is ultimately necessary to distinguish between a SCT and a heteropagus twin, certain characteristics, such as the presence of a vertebral column and the pattern and rate of tumor growth, may be useful to guide counseling and management decisions.     

Death of a seven-month-old child in a washing machine: a case report

The authors present a case which brings out a unique modality of child homicide by placing the baby in a washing machine and turning it on. The murder was perpetrated by the baby’s mother, who suffered from a serious depressive disorder. A postmortem RX and then a forensic autopsy were performed, followed by histologic examinations and toxicology. On the basis of the results of the autopsy, as well as the histology and the negative toxicological data, the cause of death was identified as acute asphyxia. This diagnosis was rendered in light of the absence of other causes of death, as well as the presence of typical signs of asphyxia, such as epicardial and pleural petechiae and, above all, the microscopic examinations, which pointed out a massive acute pulmonary emphysema. Regarding the cause of the asphyxia, at least two mechanisms can be identified: drowning and smothering. In addition, the histology of the brain revealed some findings that can be regarded as a consequence of the barotrauma due to the centrifugal force applied by the rotating drum of the washing machine. Another remarkable aspect is that we are dealing with a mentally-ill assailant. In fact, the baby’s mother, after a psychiatric examination, was confirmed to be suffering from a mental illness—a severe depressive disorder—and so she was adjudicated not-guilty-by-reason-of-insanity. This case warrants attention because of its uniqueness and complexity and, above all, its usefulness in the understanding of the pathophysiology of this particular manner of death.

     

Contained Rupture of a Thoracic Aortic Aneurysm Mimicking a Malignant Tumor: a Case Report

An 81-year-old man underwent F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) to evaluate a mediastinal mass, which was discovered during the investigation for hemoptysis. The periphery of the mass abutting the aortic arch demonstrated heterogeneously increased FDG uptake, whereas most of the central portion of the mass was photopenic. The mass turned out to be an atheromatous organizing hematoma associated with contained aortic rupture.     

Establishing a new practice as a team physician

The role of a team physician is an integral part of establishing a new practice. Regardless of the type of practice one enters, the team physician role provides an opportunity to establish an early referral base to build the foundation of a successful practice. Although this comes with great responsibility and significant time commitments, the joy of developing your practice doing what you enjoy most, sports medicine, makes these drawbacks less perceptible. Using all your potential resources and keeping your eye on the ball will simplify reaching the goal of having a happy, healthy, and rewarding career.     

Gamma-tocotrienol,a tocol antioxidant as a potent radioprotector

Purpose: To assess the radioprotective potential of gamma-tocotrienol.

Materials and methods: To optimise its dose and time regimen, gamma-tocotrienol (GT3) was injected subcutaneously (SC) at different doses into male CD2F1 mice [LD_50/30 (lethal radiation dose that results in the mortality of 50% mice in 30 days) radiation dose of 8.6 Gy with vehicle]. The mice were given 10.5, 11 and 11.5 Gy cobalt-60 radiation, and 30-day survival-protection was determined. Time optimisation was done by SC administration of GT3 at different intervals before irradiation. Dose reduction factor (DRF) was determined by probit analysis using mortality as the end point at six radiation doses. Protection from radiation induced pancytopenia was determined by enumerating peripheral blood cells from mice given GT3 and irradiated at 7 Gy.

Results: At an optimal dose of 200 mg/kg given SC 24 h before irradiation, GT3 had a DRF of 1.29. GT3 accelerated the recovery of total white blood cells, neutrophils, monocytes, platelets, and reticulocytes in irradiated mice, compared to vehicle-injected, irradiated controls.

Conclusion: GT3 is a radioprotectant having a higher DRF than any other tocols. The protection it provides close to the gastro-intestinal range indicate that GT3 can be considered as an ideal radioprotectant meriting further drug development stages for the ultimate use in humans.