[Hepatic artery aneurysm rupture after lumbar stenosis surgery. Medico-legal thinking]. / Rupture d'un anévrisme de l'artère hépatique après chirurgie de canal lombaire étroit. Réflexions médico-légales.

INTRODUCTION: Distinguishing between therapeutic contingency and surgical complication is sometimes not easy, especially when rare events occur. We report the case of a patient who presented with an intraperitoneal haemorrhage following laminectomy and discuss the implications of surgery in this complication. CASE REPORT: A 77-year-old woman, suffering from radiculopathy due to lumbar stenosis underwent a laminectomy in the prone position. On admission she presented with high blood pressure and obesity as significant comorbidities. A few hours after surgery, she collapsed and underwent a thoraco-abdominal CT-scan. The examination revealed a ruptured hepatic artery aneurysm. It is the first case published in the medical literature after lumbar surgery. The aim of this article was to discuss the responsibility of the surgeon and surgery, particularly the surgical positioning of the ruptured aneurysm. CONCLUSION: After reviewing the literature we did not find any evidence to attribute the rupture of this hepatic artery aneurysm to lumbar surgery. This adverse event could be attributed to therapeutic contingency. In cases of patient complaint, this situation depends on national solidarity.

Marcadores para la detección precoz de las alteraciones del metabolismo hidrocarbonado tras un infarto agudo de miocardio / Markers for early detection of alterations in carbohydrate metabolism after acute myocardial infarction

OBJETIVO: Las alteraciones del metabolismo hidrocarbonado no conocidas son frecuentes en los pacientes con infarto agudo de miocardio, sin que exista un consenso en que pacientes estudiar para su identificación precoz. Nuestro objetivo es evaluar qué variables al ingreso se asocian al diagnóstico posterior de una alteración de dicho metabolismo. DISEÑO: Estudio de cohortes prospectivo. Ámbito: Servicio de Medicina Intensiva del Hospital Universitario Virgen de la Arrixaca (Murcia), España. PACIENTES: Un total de 138 pacientes ingresados en la UCI con infarto agudo de miocardio sin diabetes conocida ni de novo fueron, transcurrido un año, estudiados mediante un test de sobrecarga oral de glucosa. Variables principales: Se recogieron variables clínicas y parámetros analíticos al ingreso y trascurrido un año. Además, al año, se realizó una sobrecarga oral de glucosa y se estudió la capacidad diagnóstica para la diabetes de las variables al ingreso mediante las curvas ROC y análisis multivariable. RESULTADOS: Entre 138 pacientes estudiados, 112 (72,5%) presentaron una alteración del metabolismo hidrocarbonado, incluido un 16,7% de diabetes. La HbA1c se asoció independientemente con el diagnóstico de diabetes (RR: 7,28, IC 95%: 1,65-32,05, p = 0,009) y presentó la mejor área bajo la curva ROC para diabetes (0,81, IC 95%: 0,69-0,92, p < 0,001). CONCLUSIONES: En los pacientes con infarto agudo de miocardio, la HbA1c ayuda a identificar aquellos con alteración del metabolismo hidrocarbonado transcurrido un año. De esta forma, su determinación en este grupo de pacientes puede ser utilizada para identificar a aquellos que precisan un estudio mas detallado para establecer un diagnóstico precoz

OBJECTIVES: Undiagnosed abnormal glucose metabolism is often seen in patients admitted with acute myocardial infarction, although there is no consensus on which patients should be studied with a view to establishing an early diagnosis. The present study examines the potential of certain variables obtained upon admission to diagnose abnormal glucose metabolism. DESIGN: A prospective cohort study was carried out. SETTING: The Intensive Care Unit of Arrixaca University Hospital (Murcia), Spain. PATIENTS: A total of 138 patients admitted to the Intensive Care Unit with acute myocardial infarction and without known or de novo diabetes mellitus. After one year, oral glucose tolerance testing was performed. Main outcomes: Clinical and laboratory test parameters were recorded upon admission and one year after discharge. Additionally, after one year, oral glucose tolerance tests were made, and a study was made of the capacity of the variables obtained at admission to diagnose diabetes, based on the ROC curves and multivariate analysis. RESULTS: Of the 138 patients, 112 (72.5%) had glucose metabolic alteration, including 16.7% with diabetes. HbA1c was independently associated with a diagnosis of diabetes (RR: 7.28, 95% CI 1.65 to 32.05, P = .009), and showed the largest area under the ROC curve for diabetes (0.81, 95% CI 0.69 to 0.92, P = .001). CONCLUSIONS: In patients with acute myocardial infarction, HbA1c helps identify those individuals with abnormal glucose metabolism after one year. Thus, its determination in this group of patients could be used to identify those subjects requiring a more exhaustive study in order to establish an early diagnosis

[Markers for early detection of alterations in carbohydrate metabolism after acute myocardial infarction]. / Marcadores para la detección precoz de las alteraciones del metabolismo hidrocarbonado tras un infarto agudo de miocardio.

OBJECTIVES: Undiagnosed abnormal glucose metabolism is often seen in patients admitted with acute myocardial infarction, although there is no consensus on which patients should be studied with a view to establishing an early diagnosis. The present study examines the potential of certain variables obtained upon admission to diagnose abnormal glucose metabolism. DESIGN: A prospective cohort study was carried out. SETTING: The Intensive Care Unit of Arrixaca University Hospital (Murcia), Spain. PATIENTS: A total of 138 patients admitted to the Intensive Care Unit with acute myocardial infarction and without known or de novo diabetes mellitus. After one year, oral glucose tolerance testing was performed. MAIN OUTCOMES: Clinical and laboratory test parameters were recorded upon admission and one year after discharge. Additionally, after one year, oral glucose tolerance tests were made, and a study was made of the capacity of the variables obtained at admission to diagnose diabetes, based on the ROC curves and multivariate analysis. RESULTS: Of the 138 patients, 112 (72.5%) had glucose metabolic alteration, including 16.7% with diabetes. HbA1c was independently associated with a diagnosis of diabetes (RR: 7.28, 95%CI 1.65 to 32.05, P = .009), and showed the largest area under the ROC curve for diabetes (0.81, 95%CI 0.69 to 0.92, P = .001). CONCLUSIONS: In patients with acute myocardial infarction, HbA1c helps identify those individuals with abnormal glucose metabolism after one year. Thus, its determination in this group of patients could be used to identify those subjects requiring a more exhaustive study in order to establish an early diagnosis.

An unusual case of attempted suicide by a depressive woman: self-inflicted intracranial stabbing.

Self-inflicted stab injury to the skull, particularly in the neurocranium, is a rare method used to commit suicide. Herein is presented a case of a 26-year old woman with a temporal wound found by her partner in their home. No weapon was found in the approximate environment and the victim said that she fell. A CT scan performed at admission to the emergency room was interpreted as being compatible with injury from falls. A second CT scan in a neurosurgical unit suggested a cranio-cerebral injury from a sharp object; aggression was suspected. The discording elements led to an interview with a psychiatrist and diagnosis of attempted suicide through the action of a knife in the context of severe depression. This is a rare case that implicates a depressive woman and stabbing directly to the neurocranium.

[Hymenal examination of under age children with a context of sexual assault]. / Examen de l'hymen chez les mineures dans un contexte d'agression sexuelle.

The hymeneal examination is often considered as the key of the gyneacological examination of a young girl victim of sexual assault, mainly because the concept of penetration is important under the French criminal code. However, the amount medical literature related to this topic is poor. The hymen examination must be conducted under strict conditions, by qualified personnel and as soon as possible after the alleged assault.The only kind of anomaly that can confirm a penetration is an injury to the posterior hymen extending up its base. The sensitivity of this sign is, however, low and its absence does not suggest that of penetration. A vaginal penetration does not always break the hymen, especially among adolescents. Moreover, the hymen can heal and thus it makes the examination difficult when it occurs a long time after the facts. Examination of the hymen is rarely the decisive factor in the forensic assessment of a young victim of sexual assault.