Lodged bullet or bullet penetration? Re-entry of a projectile and pseudo-shot

In an extended suicide an 11-year-old boy was killed by two shots into the back. In spite of corresponding entry and exit points one of the projectiles was found inside the body. By laying open the respective bullet track, examination of the deformations of the bullet, on which a total of three ricochet points were identified, and a second visit to the scene both the order in which the shots were fired and the reason why one of the projectiles was lodged inside the body, although there was an exit point, could be clarified: On firing the second shot the victim had been lying on the wooden threshold of a door, from which the projectile ricochetted. The terms "reentry" and "pseudo exit point" are discussed. The retention of the bullet in the depth of an alleged exit wound emphasizes the importance of post-mortal X-ray examinations.     

Findings in gunshot wounds from tandem projectiles

Tandem projectiles are unusual events which can cause erroneous case interpretations if one is unfamiliar with them. This paper presents two such cases. The first case involved three .32 caliber bullets, two of which became lodged in a revolver barrel because of faulty ammunition. A third fired bullet subsequently pushed itself and the lodged bullets out of the barrel resulting in a single entrance wound with three bullets in the body. The second case involved a 20 gauge shotgun shell which apparently was inadvertently loaded into a 12 gauge shotgun. This resulted in an unusual entrance wound and unusual X-rays with fragments of the 20 gauge shotgun shell, as well as 12 gauge shotgun shell wadding, being removed from the same wound. The pertinent findings in such cases are discussed so that they may be correctly identified when they occur.     

Aging-related clinical and health services research in Canada

Penetrating injuries, by definition, result in retained bullets or fragments. Usually, these fragments are removed surgically during wound debridement. Occasionally, the position of the bullet may preclude removal if it is thought that surgery could exacerbate neurologic damage. Complications from retained fragments are uncommon. One rare complication is the spontaneous migration of the fragment. Two cases of spontaneous migration of retained bullets are presented. In both cases neurologic deterioration was noted and computed tomographic imaging was diagnostic. In one case, this complication delayed transfer from the acute care hospital to rehabilitation. In the other case, the migrating bullet was removed during the inpatient rehabilitation stay. Each person improved neurologically after the migrating bullet fragment was removed. Additionally, functional progress was marked in both persons and symptomatic relief noted. Rehabilitation physicians caring for survivors of penetrating brain injuries need to be aware of this potentially devastating phenomenon.     

Site of entrance wound and direction of bullet path in firearm fatalities as indicators of homicide versus suicide

In a retrospective study, 288 firearm deaths were analysed to identify factors indicating homicide. The cases were classified as suicides (213), homicides (54), accidents (14) and undetermined cases (7). A number of factors, related to the circumstances and the autopsy findings, were studied. Whereas 41% of the homicide victims were females, women only constituted 1.4% of the suicide victims. The mean age was 37 and 50 years among homicide and suicide victims, respectively. Most suicides were committed at or in the vicinity of the residence, whereas a majority of the homicides occurred elsewhere. The majority of the suicide victims had either left a suicide note or had medical records of previous psychiatric illness. In all groups, shotguns were the most frequent weapon used. Fifty-seven percent of the homicide victims, but only three percent of the suicide victims had sustained more than one gunshot wound. One-third of the homicide victims were shot at close range. Alcohol was present in one-third of both homicide and suicide victims. Whereas 38% of the homicidal gunshot wounds had their entrances at anatomical regions typical of suicide, the direction of the bullet path often differed from the directions recorded in suicides. Hence, in this material, an entrance wound in the right temple indicated suicide, but in combination with a direction back-to-front, the wound was more likely to be homicidal. This study suggests that an estimation of the direction of the internal bullet path should be conducted in firearm fatalities, and that this factor may assist in the determination of the manner of death.     

The syndrome of acute central cervical spinal cord injury after gunshot lesion. Case report

The authors describe a unique case in which a bullet was lodged in the spinal canal at the C2-3 level. The patient exhibited clinically the syndrome of acute central cervical spinal cord injury. The pathogenesis is discussed with reference to three similar cases in the literature.     

An investigation of the viral pathogenesis of Kikuchi-Fujimoto disease. Lack of evidence for Epstein-Barr virus or human herpesvirus type 6 as the causative agents

Histiocytic necrotizing lymphadenitis of Kikuchi and Fujimoto is a well-defined clinicopathologic entity of unknown cause. Both the Epstein-Barr virus (EBV) and human herpesvirus type 6 (HHV-6) have been suggested as potential etiologic agents. Twenty cases of Kikuchi-Fujimoto disease were studied for the presence of EBV DNA and HHV-6 DNA by the polymerase chain reaction (PCR), and in situ hybridization in the case of EBV. Cellular DNA from sections of formalin-fixed, paraffin-embedded lymph node tissue was amplified using the PCR technique and oligonucleotide primers to the EBV BamH1 W, lymphocyte-determined membrane antigen, or the EBNA-1 region. These studies were performed in three separate laboratories. In addition, 12 cases were examined by in situ hybridization, eight of which had shown at least one positive PCR signal for EBV. The presence of HHV-6 was assessed by PCR using primers to part of the pZVH14 sequence. Biopsy specimens from eight patients (40%) showed a strong positive signal for EBV in at least one laboratory, while an additional three specimens (15%) showed a weaker positive signal. Five cases studied showed rare positive cells by in situ hybridization, and one case had scattered positive cells. All samples lacked HHV-6 genomic templates. These findings indicate that HHV-6 does not play a role in the pathogenesis of Kikuchi-Fujimoto disease and do not implicate EBV as a causal agent for Kikuchi-Fujimoto disease, since EBV was detected in only a fraction of cases with a low number of positive cells detected by in situ hybridization. Further, some discrepancies were identified in the positive results for EBV in samples studied by multiple laboratories. These results indicate that inconsistent results by PCR may occur with very low levels of viral genomes and that different laboratories perform DNA amplification at different efficiencies. Alternatively, laboratory contamination may give rise to false-positive results. Therefore, a positive result for EBV should be interpreted with caution and should be confirmed by repeated study (PCR) or by independent methodology (in situ hybridization).     

Chromosome aberrations in atypical chronic lymphocytic leukemia: a cytogenetic and interphase cytogenetic study

To define better the chromosomal profile of atypical chronic lymphocytic leukemia (aCLL), cytogenetic and interphase cytogenetic studies were performed in 43 cases, using mitogen-stimulated cultures and DNA probes detecting the two most frequently occurring aberrations in CLL, ie +12 and 13q14 deletions. All cases showed monoclonal CD5/CD19-positive lymphocytosis, with more than 10% large lymphocytes and/or prolymphocytes in peripheral blood smears and reactivity with FMC7, or bright expression of surface immunoglobulins in a fraction of the cases. Karyotype aberrations were detected in 27 of 43 cases (62.8%). Recurrent chromosome changes were +12 (nine cases), 13q14 aberrations (five cases), 11q anomalies (three cases), 6q21-q23 abnormalities and 4q anomalies with different breakpoints (two cases each). Additional chromosome changes were seen in four cases with +12, in three cases with 13q14 anomalies, in two cases with 11q anomalies, in one case with 6q and 4q anomalies. Trisomy 12 was associated with 13q14 anomalies in three cases, one of which also had an 11q abnormality; other associations, found in one case each, were: 13q14 deletion with a 6q anomaly, 11q anomaly with 13q- and 7q-, a 6q anomaly with 7q- and +12. Interphase cytogenetics confirmed the results of chromosome banding analysis and showed that six patients with normal karyotype or no mitosis in fact had concomitant +12 and 13q14 deletion in four cases and isolated +12 or 13q14 deletion in one case each, with a resultant 76% overall incidence of cytogenetic abnormalities. The presence of +12, 13q14 deletions, 11q, and 6q21-q23 anomalies in 19 cases was associated with a 2-month median interval between diagnosis and start of treatment, as compared with a 24-month median interval in 14 cases with normal karyotype or non-recurrent chromosome changes (P = 0.003). We conclude that aCLL is characterized by a relatively high incidence of chromosome anomalies, with recurrent chromosome changes, involving chromosomes 12, 13q14, 6q21q23, 11q, and, possibly, 4q. The presence of complex karyotypes, with concomitant abnormalities of 13q, +12, 6q, 11q, suggests that the development of sequential chromosome changes, rather than any single specific anomaly, may underlie leukemogenesis in this cytologic subset of CLL, partially accounting for the relatively aggressive clinical course.     

Structure of Bcl-1 and IgH-CDR3 rearrangements as clonal markers in mantle cell lymphomas

Mantle cell lymphoma represent a clinicopathologically distinct entity of malignant non-Hodgkin's lymphoma (NHL) and are characterized by a specific chromosomal translocation t(11;14)(q13;q32) involving the cyclin D1 gene also designated as bcl-1/PRAD1 gene on chromosome 11 and the heavy chain immunoglobulin joining region on chromosome 14. We have established a PCR method to amplify t(11;14) junctional sequences in DNA from fresh frozen and paraffin-embedded tissue by bcl-1-specific primers in combination with a consensus immunoglobulin JH primer. A total of 65 cases histologically classified as mantle cell lymphoma (MCL) were analyzed for the presence of a t(11;14) translocation and monoclonal IgH-CDR3 rearrangements. From 26 patients with classical MCL and three cases with the anaplastic variant of MCL fresh frozen biopsy material was available for DNA extraction. We detected a bcl-1/JH rearrangement in 12 out of 29 samples (41%). In 36 cases paraffin-embedded lymph node tissue was the only source of DNA. In this material we found a bcl-1/JH rearrangement in six out of 31 samples with intact DNA (20%). To confirm the specificity of the PCR and to determine the bcl-1/JH junctional region sequences as clone-specific marker in individual patients we characterized the junctional DNA sequences by direct PCR sequencing in 16 cases. Interestingly we found that six bcl-1/JH junctions harbored DH segments in their N regions indicating that bcl-1/JH rearrangements can occur in a later stage of B cell ontogeny during which the complete VH to DH-JH joining or VH-replacement takes place. To investigate the suitability of IgH-CDR3 as sensitive molecular marker for those MCL patients in which a t(11;14) translocation can not easily be amplified, we additionally analysed 60 cases for the presence of monoclonally rearranged IgH genes by IgH-CDR3-PCR. A monoclonal IgH-CDR3 PCR product could be identified in 24 out of 29 fresh frozen samples (79%) whereas only 11 out of 31 samples (36%) with paraffin-derived DNA were positive. We demonstrate that automated fluorescence detection of monoclonal IgH-CDR3 PCR products allows the rapid and sensitive monitoring of minimal residual disease also in cases that lack a PCR amplifiable t(11;14) translocation. In combination with allele-specific primers the procedure may improve current experimental approaches for detection of occult MCL cells at initial staging and residual disease during and after therapy.     

Granulomatous Pneumocystis carinii pneumonia: DNA amplification studies on bronchoscopic alveolar lavage samples

Three HIV positive subjects presented with symptoms and radiographic changes suggestive of Pneumocystis carinii pneumonia. Methenamine silver staining of bronchoscopic alveolar lavage (BAL) fluid was negative (from one sample in one patient and two samples in the other two patients). Open lung biopsy was performed because of uncertain clinical progress and diagnosis; all three patients were found to have multiple pulmonary granulomata encasing numerous P carinii organisms. DNA amplification, using P carinii specific oligonucleotides, was performed on stored bronchoscopic BAL samples. P carinii specific amplification product was detected by ethidium bromide staining after electrophoretic separation on agarose gel in one case, and by the more sensitive technique of oligohybridisation in all three cases. In granulomatous P carinii pneumonia organisms are rarely identified in bronchoscopic alveolar lavage samples using histochemical staining, but are detectable by DNA amplification, although not at levels which can be readily distinguished from low, subclinical infection.     

Measuring lateral skin temperature profile of premature infants in incubators with thermography

Tuberculosis is still one of the most widespread infection known to mankind. Although lung is the predominant site of disease, a sizeable population in Pakistan gets intestinal disease. Clinical presentation, radiologic and endoscopic examination provide clues to the diagnosis. However, a definitive diagnosis requires biopsy material with granulomas and/or caseation complemented by acid fast staining and culture. There are many occasions when biopsy material is scanty and even in some intestinal resection cases histologic evaluation fails to confirm or rule out tuberculosis. Therefore, an investigation was conducted to assess the efficacy of PCR in the detection of mycobacterial DNA in paraffin embedded intestinal tissue. In this study 12 histologically confirmed cases of intestinal tuberculosis and 2 cases with non specific inflammation but clinically suspected for abdominal tuberculosis were selected. One case of rectal polyp was included to serve as a negative control. M. tuberculosis DNA was amplified in 8 out of 12 histologically confirmed cases and in 2 cases diagnosed with non specific inflammation. Amplified products were obtained in 6 out of 10 PCR positive specimens with IS6110 region specific primers while 4 samples were negative, suggesting the absence of insertion sequence 6110 in these strains. However, amplification was obtained in these negative specimens with a second primer pair confirming them as M. tuberculosis complex species. On the basis of this study we conclude that; (1) Processed and paraffin embedded tissue material is suitable for PCR analysis, (2) PCR assay can be used to complement the diagnosis of intestinal tuberculosis especially in situations where a definite conclusion can not be drawn by conventional methods, (3) M. tuberculosis species lacking insertion sequence 6110 element are present in our population. Therefore, several primer pair sets should be included when applying PCR for the detection of mycobacterial DNA.     

Allergic bronchopulmonary disease caused by Curvularia lunata and Drechslera hawaiiensis

Three patients who developed bronchoceles caused by fungi other than Aspergillus sp are described. The first patient presented for investigation of a lesion at the right hilum on chest radiograph and a raised blood eosinophil count. A bronchogram showed complete block of the apical segmental bronchus which at operation was shown to be caused by inspissated material. The second patient was investigated because of a cough productive of plugs of sputum and irregular opacities in both upper zones on chest radiograph and a raised blood eosinophil count. This only cleared after one month on high dose oral prednisone therapy. The third patient with a previous history of left lingular pneumonia and bronchiectasis of the lingular segment of the left upper lobe was investigated three years later for right basal shadowing and a raised blood eosinophil count. The radiograph cleared after one month on high dose oral prednisone treatment. The aetiological agents in these cases were dematiaceous hyphomycetes, fungi ubiquitous in nature, and also agents of plant disease. The causal fungi, Curvularia lunata and Drechslera hawaiiensis, have on a few occasions been reported as causing human disease but in cases quite dissimilar to the three reported here. Septate branching dematiaceous mycelium was consistently seen in the clinical material and isolated from successive sputum specimens from each patient. Immunodiffusion tests from the third patient gave positive results for both fungi. Intraperitoneal inoculations of C lunata and D. hawaiiensis into Swiss white mice proved the pathogenicity of these isolates.     

Fatal multiple drug intoxication following acute sertraline use

A 53-year-old Caucasian male victim of suicide was suspected of overdose with sertraline and alprazolam after death-scene investigation. The concentration of sertraline, a selective serotonin reuptake inhibitor, was determined by a gas chromatograph with mass selective detection. The concentration of alprazolam, a triazolobenzodiazepine, was determined by high-performance liquid chromatography. The sertraline concentration was reported at 1.0 mg/L in peripheral blood, which is greater than previously reported in other postmortem cases in which death was attributed to a multiple drug overdose. The N-desmethylsertraline concentration was reported at 0.2 mg/L in peripheral blood, which is far less than in other postmortem cases and suggests acute intoxication in this case. The alprazolam concentration was reported at 33 microg/L in heart blood, which is within the therapeutic range. The cause of death was multiple drug intoxication following acute use of sertraline, the manner of death was suicide, and the mechanism of death is an unexplained drug interaction and/or toxicity.     

Superficial veins of the lower limbs

This study, limited to the superficial veins of 123 limbs (108 normal and 15 suffering from frank varicose disease) and only vessels with a caliber of at least 2 mm, reveals a certain degree of constancy of anatomical pattern. The initial network is defined embryologically and subsequent haemodynamic phenomena model the final veins. In particular, the topography of the main perforating veins is relatively fixed. Due to their double antihypertensive valve and aspirating pump function while walking, these vessels drain into saphenous veins. They are beneficial when they return reflux into the deep vessels. Conversely, perforator incompetence contaminates the superficial network in the case of deep reflux. The perforating vessels also have a relatively fixed position in relation to other structures: the main saphenous collateral veins, their duplicated branches, their communicating veins and the main valves. This results in large junctions typically associating a saphenous valve, one or several collateral veins, one or several communicating veins, and one or several perforating veins. Typical examples are the garter junction for the long saphenous vein, and the junction of the tip of the calf for the short saphenous vein. Other haemodynamic levels are situated at various sites, particularly in the leg, reflecting the existence, in some cases, of symmetrical "mirror", medial and lateral perforating veins. Morphological analysis of 15 limbs with obvious varicose veins of the trunk of the long saphenous vein defined the routes of transmission of reflux to the leg. Finally, the authors present several technical considerations which they hope will be useful for Doppler operators and surgeons.     

Subfascial endoscopic perforator ligation: an analysis of early clinical outcomes and cost

PURPOSE: Early results of subfascial endoscopic perforator surgery (SEPS) were examined. Data on ulcer healing, complications, and costs are presented. METHODS: Data were prospectively collected for all patients who underwent SEPS at our institution. A concurrent control group was not available because primary open perforator ligation is no longer performed at our hospital. Preoperative assessment included duplex scanning (valve closure times and perforator mapping), plethysmography, and phlebography. Completeness of therapy was assessed with postoperative duplex mapping of perforating veins. Clinical status was monitored after surgery, and actual costs, including equipment, personnel, and facilities management, are reported. RESULTS: Eighteen procedures were performed in 15 patients (mean age, 52 years; range, 42 to 65 years). Two patients underwent bilateral SEPS, and one patient underwent a second procedure on the same leg. Active ulceration (class 6) was present in 14 of 18 limbs (78%), recently healed ulcers (class 5) in two of 18 (11%), and lipodermatosclerosis with edema (class 4) in two. Deep venous insufficiency was present in 14 of 18 (78%). The number of perforating veins ligated per leg ranged from 0 to 12 (mean, 4.3). Follow-up ranged from 3 to 64 weeks (mean, 22 weeks). Complete ulcer healing occurred in eight of 14 limbs (57%) at a mean of 14 weeks. Reduction in ulcer size was noted in four of 14 (29%), and two limbs were not improved. There were no new ulcers. Residual perforating veins were noted in four of 18 limbs. None of the limbs with residual perforating veins had complete healing of ulceration. Operating room costs were higher than those associated with limited-incision open perforator ligation ($2570 vs $1883). CONCLUSION: These preliminary data suggest that when used as part of a treatment plan to correct deep and superficial venous insufficiency SEPS results in a high rate of wound healing, with no recurrent ulceration in this series. Increased operating room costs associated with longer operations and greater disposable expenses will likely be overcome by shortened length of stay and diminished wound complications. These findings emphasize the importance of ligating all incompetent perforating veins, as ulcer healing was never achieved when residual perforating veins were found at follow-up.     

Allele frequencies of six highly polymorphic DNA loci in the Croatian population

The organization of synthetic oligopeptide trivaline (1) complexes with four types of circular superhelical DNA preparations was studied by electron microscopy. The DNA molecules in the preparations investigated had different sizes ranging from 2.9 kb to 21.0 kb. Two plasmids contained bent DNA sequences from minicircles of kinetoplast DNA of Leishmania gymnodactili and Trypanosoma boissoni. The main structures in all preparations observed were circular compact particles which coincide in their appearance and compaction coefficient (3,5-3,7) with triple rings described earlier. But along with triple rings the new types of compact structures were observed having the shape of a ring with attached rod or the shape of two compact rings attached to each other by a region of compact fiber. The latter structures could be observed in significant quantities in case of DNA preparations longer than 10 kb. The conclusions can be made that due to TVP stimulated compaction of circular DNA molecules compact fibers containing both two or three DNA duplexes arranged side by side can be formed. It is shown that presence of bent DNA sequences stimulates the formation of structures containing more than one triple ring. It demonstrates the possibility of the primary DNA structure influence on the compaction process in case of the circular molecules. The new ways of circular DNA folding described can be of importance for understanding of DNA organization in different cell structures.     

Localising the cause of an undiagnosed fever

Prenatal diagnosis of tyrosinaemia type I can be achieved in cultured amniotic cells and in chorionic villus material by testing the activity of fumarylacetoacetate hydrolase and by DNA analysis, and in amniotic fluid by succinylacetone measurement. This specific metabolite can be measured either by gas chromatography-mass spectrometry or by delta-aminolevulinate dehydratase inhibition assay. In a series of 65 at-risk cases tested with the enzyme inhibition assay, one case out of the 18 with the disease had a normal level of succinylacetone. This case is presented.     

Rosaceous lymphedema: a rare variant of a common disorder

Surgical reconstruction of the trachea is a relatively complex procedure. We had 20 cases of tracheal stenosis. We have a modest experience of 16 tracheal reconstructions for acquired tracheal stenosis. Two patients underwent laser treatment while another two died before any intervention. The majority of these cases were a result of prolonged ventilation (14 cases), following organophosphorous poisoning (11 cases), Guillain-Barré syndrome, bullet injury, fat embolism and surprisingly only one tumor, a case of mucoepidermoid carcinoma, who had a very unusual presentation. There were 12 males and 4 females in this series, age ranging from 12-35 years. The duration of ventilation ranged from 1-21 days and the interval from decannulation to development of stridor was between 5-34 days. Six of them were approached by the cervical route, 5 by thoracotomy and cervical approach, 2 via median sternotomy and 3 by thoracotomy alone. Five of them required an additional laryngeal drop and 1 required pericardiotomy and release of pulmonary veins to gain additional length. The excised segments of trachea measured 3 to 5 cms in length. All were end to end anastomosis with interrupted Vicryl sutures. We have had no experience with stents or prosthetic tubes. Three patients developed anastomotic leaks which were controlled conservatively. Almost all of them required postoperative tracheo-bronchial suctioning with fibreoptic bronchoscope. We had one death in this series due to sepsis.     

Experiments on animals to investigate the suitability of perforating corneal sutures (author's transl)

Injuries of the cornea in rabbits are treated with perforating sutures using non-traumatic material (nylon and silk 9-0). Postoperative examinations with fluorescein showed the absence of fistulas along the suture in all cases. Histological examinations of the lacerations and sutures three respectively five weeks after the operation did not reveal any epithelial growth in the anterior chamber nor endothelial growth in the suture canal. We believe, therefore, that the use of perforating corneal sutures no longer presents any risks, especially when materials of up to 15-0 are used which are readily available.     

HTLV-I and HTLV-II infections in hematologic disorder patients, cancer patients, and healthy individuals from Rio de Janeiro, Brazil

Between 1986 and 1993, 18 patients with complete or impending fractures of the humerus were treated using Hacketall rods in association with semi-liquid methylmetacrylate after excision of the metastatic lesion. Methylmetacrylate was always injected proximally and distally to the curetted bone through drill holes. Fourteen patients had a pathological fracture and four presented with an impending lesion. The mean age at time of surgery was 62 years (range: 42-83). The primary tumour was a breast carcinoma in 10 cases, bronchogenic squamous cell carcinoma in three cases and hypernephroma, multiple myeloma, malignant melanoma, rectal adenocarcinoma and unknown primary tumour in one case each. The left arm was involved in seven cases and the right in 11. All patients experienced immediate relief from the pre-operative pain, although three patients complained of a residual discomfort during motion. In these three cases the residual pain can easily be managed with use of oral non-morphinic drugs. The functional aspect was not evaluated in two patients who died in the early post-operative period as a result of their general condition. In 15 patients, the post-operative range of motion was at least 80% of a normal humerus mobility. One patient encountered motion limitation because of an important lymph oedema. There was no infection, one patient had a temporary radial palsy with a complete restoration after a period of 5 days. No migration of the material was observed during an average follow-up of 9 months (range: 1-24).     

Incident Causation Model for Improving Feedback of Safety Knowledge

In order for the construction industry to improve its poor safety performance it needs to learn from its mistakes and put the lessons learned to good use. This need calls for effective feedback mechanisms that can transmit information derived from incident investigation to be utilized in safety planning. The feedback should be at two levels; first, feedback to the Safety Management System that had failed, and second, feedback to the safety planning of future projects. The first level of feedback can be achieved by basing the investigation on an incident investigation model that explicitly identifies system failure. The second level of feedback can be achieved if both incident investigation and safety planning share the same incident causation model, such that the information from each process can be retrieved and utilized in the other process smoothly. One prerequisite to fulfill the two levels of feedback is the development of an incident causation model. In this paper, the modified loss causation model (MLCM), which is able to meet the above-mentioned purposes, will be presented. The MLCM is developed based on an extensive literature review and application on 140 actual accident cases obtained from Singapore’s Ministry of Manpower, Occupational Safety Department. In this paper, the model’s application will be demonstrated through a case study, which involves codification of investigation information based on an actual incident report, and a safety planning process based on a hypothetical case.