Does preliminary optimisation of an anatomically correct skull-brain model using simple simulants produce clinically realistic ballistic injury fracture patterns?

Ballistic head injury remains a significant threat to military personnel. Studying such injuries requires a model that can be used with a military helmet. This paper describes further work on a skull-brain model using skulls made from three different polyurethane plastics and a series of skull 'fills' to simulate brain (3, 5, 7 and 10% gelatine by mass and PermaGel™). The models were subjected to ballistic impact from 7.62 × 39 mm mild steel core bullets. The first part of the work compares the different polyurethanes (mean bullet muzzle velocity of 708 m/s), and the second part compares the different fills (mean bullet muzzle velocity of 680 m/s). The impact events were filmed using high speed cameras. The resulting fracture patterns in the skulls were reviewed and scored by five clinicians experienced in assessing penetrating head injury. In over half of the models, one or more assessors felt aspects of the fracture pattern were close to real injury. Limitations of the model include the skull being manufactured in two parts and the lack of a realistic skin layer. Further work is ongoing to address these.

How sharp is sharp? Towards quantification of the sharpness and penetration ability of kitchen knives used in stabbings.

Stabbing is the most common method for violent death in the UK. As part of their investigation, forensic pathologists are commonly asked to estimate or quantify the degree of force required to create a wound. The force required to penetrate the skin and body by a knife is a complex function of the sharpness of the knife, the area of the body and alignment with cleavage lines of the skin, the angle of attack and the relative movement of the person stabbing relative to the victim being stabbed. This makes it difficult for the forensic pathologist to give an objective answer to the question; hence, subjective estimations are often used. One area where some degree of quantification is more tractable is in assessing how sharp an implement (particularly a knife) is. This paper presents results of a systematic study of how the different aspects of knife geometry influence sharpness and presents a simple test for assessing knife sharpness using drop testing. The results show that the radius of the blunt edge at the tip is important for controlling the penetration ability of a kitchen knife. Using high-speed video, it also gives insight into the mechanism of knife penetration into the skin. The results of the study will aid pathologists in giving a more informed answer to the question of the degree of force used in stabbing.

The continued value of central histopathological review of testicular tumours.

AIMS: Central histopathological review of testicular tumours prior to definitive treatment can have an important impact on patient management. This study was designed to assess the continued value of central review in the light of increasing subspecialization and increased numbers of consultant histopathologists. MATERIALS AND RESULTS: The original and review reports of 291 testicular cancer specimens from 1998 to 2002 were analysed, looking particularly at major diagnosis, vascular invasion and the tumour elements within non-seminomatous germ cell tumours (NSGCT). When a diagnosis was altered any effect on subsequent patient management was assessed. There was a discrepancy in tumour type in 11 cases (4%) compared with 6% in 1992-1997. The commonest change was from seminoma to NSGCT or combined germ cell tumour (5/11). There was also diagnostic difficulty with spermatocytic seminoma (3/11). The clinical management of all 11 cases was influenced as a result of the review diagnosis. Discrepancies in vascular invasion were noted in 13 of the 126 NSGCTs (10%) compared with 20% in 1992-1997. Differences in NSGCT tumour elements, though clinically less important, were frequent in both groups. CONCLUSIONS: There continues to be a small number of significant and clinically important errors identified following central histopathological review of testicular tumours. This study highlights the value of central review and supports its continued practice in the management of testicular tumours.

Profiles of quality improvements in heart failure care.

The Health Care Financing Administration, with its National Heart Failure project, has made heart failure care one of its targets for quality improvement. Previous columns have highlighted the clinical and epidemiologic background for the National Heart Failure project. This column provides "real-world" examples of hospitals improving care for their heart failure patients. (c)2001 by CHF, Inc.

Variations among hospitals in the quality of care for heart failure.

CONTEXT: Determining variations in quality of care among hospitals can help direct attention to poorly performing institutions. PRACTICE PATTERN EXAMINED: The proportion of patients with congestive heart failure meeting various quality criteria in 69 hospitals. HOSPITAL SELECTION: The hospitals were voluntary participants in a quality improvement program in five states (Colorado, Connecticut, Georgia, Oklahoma, and Virginia). PATIENT SELECTION: All patients with congestive heart failure discharged from the participating hospitals during a 15-month period in 1995 to 1996 (or, for hospitals with more than 50 eligible patients, a random sample of 50 patients). The total sample consisted of 2077 patients. DATA SOURCE: Documentation in the hospital medical record of left ventricular function, discharge medications, and discharge instructions. RESULTS: Left ventricular function was determined in 72% of patients (range across hospitals, 18% to 97%). Among patients with left ventricular systolic dysfunction, 79% were prescribed an angiotensin-converting enzyme inhibitor (range, 54% to 94%). Only 23% of the patients prescribed angiotensin-converting enzyme inhibitors received the target dose (range, 0% to 60%). Sixty-four percent of patients were counseled about the importance of a low-sodium diet at discharge (range, 25% to 97%), but only 8% were counseled about daily weight monitoring (range, 0% to 30%). CONCLUSION: Our results show substantial hospital-to-hospital variation in the quality of care for patients with heart failure.

The National Heart Failure Project: a health care financing administration initiative to improve the care of Medicare beneficiaries with heart failure.

This is the second in a series describing Health Care Financing Administration (HCFA) initiatives to improve care for Medicare beneficiaries with heart failure. The first article outlined the history of HCFA quality-improvement projects and current initiatives to improve care in six priority areas: heart failure, acute myocardial infarction, stroke, pneumonia, diabetes, and breast cancer. This article details the objectives and design of the Medicare National Heart Failure Quality Improvement Project (NHF), which has as its goal the improvement of inpatient heart failure care. (c)2000 by CHF, Inc.

Increasing influenza and pneumococcal vaccination and tuberculosis screening among residents of Colorado long-term care facilities.

Persons residing in long-term care facilities are especially vulnerable to potentially preventable morbidity and mortality caused by influenza, S. pneumoniae, and tuberculosis. This project's objective was to increase the rates of pneumococcal vaccination, tuberculosis screening, and annual influenza vaccination. Intervention consisted of staff training videos, sample policies, and educational materials for residents and their families. At baseline during the 1995-1996 flu season, 84% of Colorado long-term care residents were vaccinated for influenza; 16% of residents had ever received pneumococcal vaccination; and 59% had been screened for tuberculosis. At remeasurement during 1997 to 1998, influenza vaccination rates were up to 89%, p = 0.006. The percentage of residents who had ever received pneumococcal vaccination increased to 48% at remeasurement, p < 0.001. Tuberculosis screening rates increased to 83%, p < 0.001. Following an educational intervention targeting both residents and staff, residents were significantly more likely to receive all three preventive services.

Hypertriglyceridemia in patients with psoriasis treated with cyclosporine.

Eight patients received cyclosporine at doses of 2.0 to 7.5 mg/kg/day. Seven of these patients had increased fasting plasma triglyceride levels with cyclosporine therapy compared with pretreatment values, which peaked after 1 month of therapy. Four patients experienced elevations in fasting triglycerides, over the upper limits for age- and sex-matched controls, which were at least two times higher than their baseline values. It was striking that all four of these patients had previously had hypertriglyceridemia while using etretinate and three of these patients had preexisting hypertriglyceridemia before both etretinate and cyclosporine therapy. Triglyceride elevation did not correlate with cyclosporine levels. Thus cyclosporine, similar to etretinate, unmasks a latent tendency for mild to moderate hypertriglyceridemia. Fasting triglyceride levels should be monitored during cyclosporine therapy, especially after 1 to 2 months of use, and in patients with preexisting increased triglycerides and/or a history of etretinate use.