Penetrating gunshots to the head and lack of immediate incapacitation II. Review of case reports

Because of the enhanced intracranial tissue disruption (see companion paper) and the functional significance of the central nervous system, penetrating gunshot wounds of the head commonly result in immediate incapacitation. However, in the last century numerous publications reported sustained capability to act following penetrating gunshot wounds of the head. These are reviewed. A large number of case reports had to be excluded from re-examination because of doubtful capability to act or lack of morphological documentation. There remained 53 case reports from 42 sources for systematic analysis. Favourable conditions for sustained capability to act are present in cases where the additional wounding resulting from the special wound ballistic qualities of the head (see companion paper) are minimized. Thus, more than 70% of the guns used fired slow and lightweight bullets: 6.35 mm Browning, .22 rimfire or extremely ineffective projectiles (ancient, inappropriate or selfmade). A centrefire rifle or a shotgun from close range were never employed in cases involving intracerebral tracts. A coincidence of several lucky circumstances made sustained capability to act possible in two cases of military centrefire rifle bullets passing longitudinally between the frontal lobes without direct contact with brain tissue. Only two large handguns resulting in intracerebral wounding were used: one firing a .38 special bullet, which solely wounded the base of the right temporal lobe and one firing a .45 lead bullet, which seriously injured the left frontal lobe but whose trajectory was limited to the anterior fossa of the skull.Of the trajectories, 28% were outside the neurocranium. At least 70% of the craniocerebral tracts passed above the anterior fossa of the skull, wounding the frontal parts of the brain. Apart from a neurophysiological approach, this preference can be explained by the fact that the base of the anterior cranial fossa and the sella turcica area serve as a bony barrier protecting the parts of the brain located in its shadow relative to the trajectory against cavitational tissue displacement and associated overpressures. This is particularly true of the brain stem. Intracerebral trajectories not located above the anterior fossa were caused by slow and lightweight bullets preferring one temporal lobe. Additionally, one parietal and one occipital lobe were each injured once by a very ineffective projectile and by a 7.65-mm bullet reduced in velocity. Not a single case of injury to the brain stem, the diencephalon, the cerebellum or major paths of motor conduction and only one grazing shot of the anterior parts of the nucleus caudatus (basal ganglia) were described. Morphological signs of high intracranial pressure peaks (cortical contusion zones, indirect skull fractures, perivascular haemorrhages) and secondary missiles were poorly documented. It is suggested that these findings are at least very rare and not obvious in cases of sustained capability to act.     

Adverse drug events in hospitalized patients A comparison of doctors, nurses and patients as sources of reports

Objective: This study investigated the relative value of adverse drug events reported by doctors, nurses and patients. Methods: The study was conducted on a total of four wards: the paediatric and internal medicine wards (including geriatric patients) of two peripheral hospitals in the Netherlands. Adverse drug events were collected by spontaneous reporting (doctor and nurse reports) and by daily ward visits, during which the patients were interviewed by a hospital pharmacist (patient reports). Criteria for relative value of the reported adverse drug events were the number of potentially serious reactions, the number of reactions not mentioned in the patient information leaflet and the number of reactions reported to new drugs (5 years or less on the Dutch market). No formal causality assessment was applied. Results: Over a period of 2 months in 1996 (Hospital I) and 2 months in 1997 (Hospital II) a total of 620 patients were included in the study and adverse drug events were reported in 179 (29%) of these cases. Doctors reported a statistically significant larger number of serious (26% of all doctor reports; odds ratio (OR) 3.2; confidence interval (CI) 1.2–8.7) and unknown (39%; OR 2.5; CI 1.0–6.0) adverse drug events than patients themselves during the daily ward visit. Doctors also reported more serious and unknown adverse drug events than nurses. Adverse reactions to new drugs were reported during the daily ward visit only (8% of all daily ward visit reports). Conclusion: This study reconfirms that doctors are the main source for reports of serious and unknown adverse drug events in hospitalized patients. However, patients themselves seem to report more adverse reactions to new drugs (during the daily ward visit). By focusing on patients using new drugs, the daily ward visit might become cost-effective. This needs to be explored in future studies. Received: 10 September 1998 / Accepted in revised form: 30 November 1998     

乙型脑炎疫苗致过敏性休克个案报道文献分析

目的：分析近10年来国内文献中，乙型脑炎（简称乙脑）有关接种疫苗致过敏性休克的个案报道，为减少乙脑计划免疫所出现的过敏性休克及相关处理提供参考。方法：采取适当检索策略，搜索中国学术期刊全文数据库（1994～2004年）中乙脑疫苗致过敏性休克的个案报道。分别从刊物、作者单位、乙脑疫苗生产厂家、患者年龄、性别、过敏史、接种次数、过敏性休克发生时间、治疗时间等多角度进行分析。结果：共获得文章34篇（36例）。1例为初种时发生，18例为复种时发生，17例接种次数不详。过敏性休克出现的平均时间为22．6min，最早1min，最晚60min。71．2％的过敏性休克伴随其他不良反应，以荨麻疹居多（57．1％）。36例中有5例死亡，其余均治愈，完全治愈所需时间最短为0．5h，最长为11d。结论：乙脑疫苗致过敏性休克的发生可能与免疫次数有关。在乙脑疫苗接种工作中，应该严格执行免疫程序，掌握过敏性休克的抢救知识，做好应对过敏性休克的准备。     

腹腔镜治疗阑尾周围脓肿25例报告

目的：探讨腹腔镜手术治疗阑尾周围脓肿的手术方法及临床疗效。方法：回顾分析2010年4月至2013年4月为25例阑尾周围脓肿患者行腹腔镜手术的临床资料。其中18例行阑尾切除加脓肿病灶清除术，7例行脓肿引流术。结果：25例均顺利完成腹腔镜手术，手术时间平均（60．25±30．12）min，平均住院（7．53±3．44）d。术后2例发生切口脂肪津化，切口延迟愈合：余均无并发症发生。结论：腹腔镜手术治疗阑尾周围脓肿是安全、可行的，应根据患者病情采取合适的术式。     

肝肉瘤样癌1例报告

正肝肉瘤样癌(sarcomatiod hepatocellular carcinoma,SHC)是一种原发于肝脏的罕见恶性上皮性肿瘤,具有恶性程度高、预后极差的特点,甚至有报道1年存活率几乎为零。吉林大学第一医院收治肝肉瘤样癌患者1例,现报道如下。1病例资料患者男性,61岁,半年前无明显诱因出现肝区钝痛,未经系统检查治疗,入院前4 d出现肝区疼痛加重,门诊行腹部CT     

Challenges in Consolidated Reporting of Hematopoietic Neoplasms

This article focuses on the challenges of generating comprehensive diagnostic reports in hematopathology. In particular, two main challenges that diagnosticians face are (1) interpreting and understanding the rapid advances in molecular and genetic pathology, which have gained increasing importance in classifications of hematopoietic neoplasms, and (2) managing the logistics of reporting ancillary studies and incorporating them effectively into a final synthesized report. This article summarizes many important genetic findings in hematopoietic neoplasms, which are required for accurate diagnoses, and discusses practical issues to generating accurate and complete hematopathology reports.     

Conservative management of renal artery pseudoaneurysm following partial nephrectomy

A bleeding renal artery pseudoaneurysm is a recognised complication occurring after partial nephrectomy. The bleeding is usually suspected when a patient presents with haematuria following the procedure and the reported management is with radiologically guided embolisation. We report a case of renal artery pseudoaneurysm successfully managed conservatively, giving another potential management option in non-torrential haemorrhage.