Gunshot wounds to the head in civilian practice

An aggressive surgical strategy was applied to cranial gunshot wound victims at Cook County Hospital in Chicago from 1983 to 1992. A series of 480 patients with an overall mortality rate of 34% is presented. A total of 150 patients underwent craniotomy with an operative mortality rate of 21%. Criteria for operation were Glasgow Coma Scale scores of 3 through 7 without hypotension or fixed and dilated pupils or Glasgow Coma Scale scores of 8 through 15 with intracranial bone fragments or significant clot. This study supports previous reports that even patients with severe neurological deficits and massive cerebral damage can benefit from aggressive treatment and make satisfactory recoveries.     

Gunshot wounds of the extremities in children

A ten-year review of gunshot trauma in Manitoba was prompted by an increasing incidence in gunshot trauma in children. Of 54 children treated from 1964 through 1973 60% sustained injury to one or more extremities. Fifteen children sustained long bone fractures, usually complete and often comminuted. All fractures united and there was only one instance of osteomyelitis. The major complication in gunshot wounds to the skeletally immature was limb length inequality secondary to epiphyseal plate injuries. This complication occurred in nine children. In three children there was in epiphyseal growth disturbance, even though the missile did not appear to pass through the plate but only in close proximity to it. Joint contractures secondary to skin loss and resulting subsequent skin contracture were also common. The amount of debridement required following gunshot trauma in children appears to be somewhat less than is recommended for similar injuries sustained by adults in time of war.     

Gunshot wounds to the mandible and midface: evaluation, treatment, and avoidance of complications

As American society becomes progressively violent, an ever-increasing number of gunshot wounds are being seen across the United States. Particularly challenging are injuries that involve the mandible and midface, not only because of problems with reconstructing bone and soft-tissue defects but also because of emergent problems with airway obstruction and neurovascular compromise. We present 40 cases of gunshot wounds to the mouth, mandible, and maxilla treated at Wake Forest University Medical Center during the past 7 years. The focus of this retrospective analysis is on emergency evaluation and treatment, complications encountered, and operative techniques used for reconstruction. Special emphasis is placed on recognizing and avoiding the complications of these injuries.     

Gunshot wounds: 10-year experience of a rural, referral trauma center

The 10-year experience of a Level II trauma center with 122 gunshot wounds referred from a large rural area was analyzed to illustrate differences from the experience of urban centers. Most frequent causes of injury were attempted suicide in 38 (31%) patients, hunting mishaps in 32 (26%), unintentional accidents in 29 (24%), and intentional assault in 18 (15%). Of weapons specified, rifles were documented in 48 (39%) instances, shotguns in 25 (21%), and handguns in 24 (20%). Body regions injured were the trunk in 47 (39%) patients, head in 35 (29%), lower extremity in 31 (25%), and upper extremity in 29 (24%). Twenty-five patients (20%) died as a result of their injuries. The cause of death was brain injury in 18 (72%), exsanguination from truncal wounds in 5 (20%), myocardial infarction in 1 (4%), and multiple organ failure in 1 (4%). We conclude that the distributions of cause and type of gunshot wounds are unique in a rural setting. These differences have profound consequences in designing effective prevention programs for our area and support the design of more efficient trauma systems for rural North America.     

Surgical injury to ureter

The "reduzierte Wechsler-Intelligenztest für psychiatrische Kranke (WIP)" by Dahl, a short form of the German version (HAWIE) of the Wechsler-Bellevue Intelligence Scale, comprising the subtests Information, Similarities, Picture Completion and Block Design was applied in a replication study to a heterogeneous group of 420 mental patients. Results show a sufficiently high level of agreement (multiple correlation) between the present test and the HAWIE-IQ. With this result and a sample independence of the correlation, two of the requirements of board clinical application of the WIP are met. On the other hand Dahl's assumption that the WIP represents the optimal (quadruple)combination of subtests of the full scale was not confirmed. Criticisms of the WIP in the literature are discussed. On the basis of previous studies and the present investigations it is held that the WIP is a useful contribution to measurement of general ability in a clinical setting.     

Gunshot injuries of the sacrum

Gunshots to the sacrum are unusual and present several management problems. Associated injuries and particularly sacral bleeding are troublesome. Conventional methods of hemostasis are not suitable in this setting as the spinal blood supply is very complex because it is largely derived from the longitudinal spinal arteries originating intracranially. Attempts at proximal control are difficult and could lead to neurological injury. We successfully managed brisk bleeding in three patients with sacral gunshots. After the major intra abdominal hemorrhage had been controlled, attention was turned to the sacral wounds that had been packed with sponges up to that time. The sacral defect was closed with bone wax to control bleeding definitively. Methyl cellulose was then put over the bone wax and the periosteum of the sacrum and posterior peritoneum (mobilized if necessary), sutured over the methyl cellulose. Post operatively the patients are carefully monitored for developing neurological deficit that would necessitate immediate sacral laminectomy and decompression. We advocate tamponading of the sacral wound with bone wax, covered by methyl cellulose and kept in place and held firm by the periosteum and posterior peritoneum sutured over it as a successful interim or definitive form of therapy.     

Iatrogenic injuries to the distal ureter during gynecologic interventions

The contemporary bioethical standards: autonomy, freedom, objectivity, privacy, beneficence, and fidelity are maximally appropriate to the health care setting. It is a common but erroneous belief that they are instruments for the analysis of dilemmas. They are not. They are instruments for the analysis of the character-structure of the person whose role in the dilemma is that of beneficiary. When the bioethical standards are used in this way they produce an understanding that tends to unite nurse and patient in harmonious interactions. These interactions produce results appropriate to ethical agents in a human context. These results are not accidental.     

Low-velocity gunshot wounds to extremities

Several therapeutic modalities in the management of low-velocity gunshot wounds to extremities were investigated. Local excision of wound margins, irrigation, and primary or delayed primary closure without the use of the operating room or prophylactic antibiotics produced results which were comparable to those obtained with a more aggressive surgical protocol.     

Ileal ureter

Clinically apparent involvement of the heart and nervous system occurs in a relatively small number of patients with sarcoidosis. The diagnosis of myocardial and neurological sarcoidosis is difficult because anatomic presence of granulomas without clinical dysfunction is an important feature of sarcoidosis. The chest radiography is abnormal in 8 of every 10 patients with myocardial or neurosarcoidosis. Serum angiotensin-converting enzyme and gallium uptake studies may provide some indication of the extent and severity of the granulomatous process. Corticosteriods are the mainstay of therapy but chloroquine or hydroxychloriquine, methotrexate, and azathioprine are also effective. Prognosis of myocardial and neurological sarcoidosis is poor.     

Non-iatrogenic injuries of the ureter

Despite a rapid increase in disabled elderly in Japan, the burden of the caregiver has not been properly assessed due to a lack of objective measurements. Our study was aimed at adapting and validating the Zarit Caregiver Burden Interview (ZBI) in Japan, which is one of the most widely used measurements for caregivers' burden in the United States. Sixty-six caregivers answered the self-administered questionnaire, involving the Japanese version of the ZBI and questions regarding their caregiving situation. Our study demonstrated that the Japanese version of the ZBI had equally as high reliability and validity as the original version. The Japanese ZBI had a high test-retest reliability (r = 0.76) and internal consistency (Cronbach's alpha = 0.93). The total score of the ZBI was highly correlated with the caregivers' score of the Center for Epidemiologic Studies Depression Scale (CES-D) score (r = 0.50), as well as a single global rating of burden (r = 0.71). It was also shown that demographic distribution of the score of the Japanese version had a similar trend to that of the original version. Caregivers who looked after patients with behavioral disturbances were found to have a significantly higher ZBI score than those who looked after patients without behavioral disturbances, which is consistent with previous findings. It is concluded that the Japanese version of the ZBI can be used to measure feelings of burden of caregivers in the Japanese population and can be used for cross-cultural comparison.     

Lymphoepithelioma-like carcinoma of the ureter

We reported a case of the biliary cystadenoma of the liver. The cystic mass had lobulation and septation and showed marked hyperintensity on T1-weighted images and hypointensity on T2-weighted images; MR findings were very unusual for cystadenoma. The content of the cystic mass was jelly-like, thick mucinous fluid without intracystic hemorrhage. We concluded that these unusual signal intensities of the cyst were due to hyperproteinous mucinous fluid.     

A selective approach to the management of gunshot wounds to the back

PURPOSE: To study corneal changes after endocapsular phacoemulsification cataract extraction and intraocular lens (IOL) implantation with a 3.5 mm clear corneal sutureless incision or a 5.0 mm clear corneal incision with an absorbable suture. SETTING: Northwest Kansas Eye Clinic, Hays, Kansas, USA. METHODS: In a prospective study, 200 eyes were randomly distributed into two groups. Group A comprised 100 eyes that had a silicone IOL inserted through a 3.5 mm sutureless clear corneal incision. Group B comprised 100 eyes that had a 5.0 mm poly(methyl methacrylate) (PMMA) IOL inserted through a 5.0 mm clear corneal incision; one half of the closures used a single radial suture (Group B1), and the other half, an X suture (Group B2). Preoperatively, corneal topography and corneal endothelial cell counts were performed. Six to 8 months postoperatively, they were repeated and evaluated. Differential topography was used to determine the difference between the preoperative and postoperative corneas. During the final postoperative visit, IOL centration was evaluated. RESULTS: All closures produced only minimal changes in the corneal topographic indices. The postoperative corneas closely resembled the preoperative corneas. Polar K values showed a slight astigmatic shift in all groups. Group B2 was the only one to exhibit a with-the-rule shift. The change in endothelial cell counts was minimal and comparable in all three groups. CONCLUSION: The small amount of change in the corneal indices, especially in surface regularity, indicates that all corneas were relatively comparable and stable 6 to 9 months postoperatively regardless of the type of incision and closure method.