The impact of a bullet by firearm is a mortal entity that in recent years has been on the rise due to the increase in crime, confrontations, among other acts of violence. Brain injuries by firearm account for 33.3% of all fatal injuries from this type of weapon. This resulted in a significant number of disabilities with its burden cost at a global level. The types of bullet injuries to the head include: penetrating (inlet without outlet), perforating (through and through), tangential (not enter the skull, causing coupe injury), ricochet (intracranial bouncing of bullet) and careening (rare, enter skull but not brain, runs in the subdural space). There are several situations that can occur once the bullet enters the body or into the intracranial cavity. Unmatched association of the bullet trajectory with the final position of the bullet within the body raise the suspicion for additional phenomena involvement, this can be explained by either internal bullet ricochet or internal bullet migration. The former usually represents an active movement and the latter is a passive movement. Intracranial ricocheting of bullets forms up to 25% of all penetrating bullet injuries to the skull. Such bullets types are commonly tumbling and have an unpredictable trajectory. The surgical management for intracranial bullet injury developed over decades from the time of Harvey Cushing and the World War I till the present. Now, the accepted intervention ranges from simple wound care to a proper surgery that includes hematoma evacuation, removal of only accessible bone fragments and foreign bodies, dural repair and wound debridement with or without decompressive craniectomy. Also, intracranial pressure monitoring is generally indicated. We reported a thirty-three years old male, victim of homicidal bullet injury to the head, presented with Glasgow Coma Scale score of 8 (best eye response: 2, best motor response: 4, best verbal response: 2), upon examination a right parietal (near vertex) inlet without outlet was found. The poor prognostic factors in this patient included bi-hemispheric involvement, associated acute subdural hematoma with interhemispheric extension, ricochet type of injury and effacement of sulci. Intracranial ricocheted-bullet injury is a special entity of bullet injury to the head with its particular ballistics and management that deserve highlighting by the trauma team to gain fluent treatment and better outcome.

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Objective: To determine the survival rate of tuberculosis (TB) patients and to identify the important factors associated with the survival of these patients in southern Iran. Methods: The present retrospective cohort study extracted and reviewed available medical records of 134 TB patients undergoing TB treatment centre, during 2005 to 2016. The Survival rate of patients for the outcome of the interval from diagnosis until death was plotted using life table and Kaplan-Meier survival curve. Cox proportional hazard regression model was used to examine the simultaneous effect of variables on survival rate. The significance level was considered to be 0.05. Results: In this study, 64.2% of the participants were male, 73.1% had pulmonary TB and 5.22% had HIV. The survival rate of one, five and thirteen years after diagnosis were 93%, 78% and 69%, respectively. The risk of death in patients with extrapulmonary TB (95% CI=1.96-15.83, P=0.001) was 5.58 times higher than in patients with pulmonary TB. The risk of death in smokers with TB (95% CI=1.74-2.46, P<0.001) was 2.07 times higher than in non-smoker patients, and also the risk of death increased to 1.10 times more for a one-year increase in patient age (95% CI=1.06-1.14, P<0.001). Conclusions: The risk of death in patients with extrapulmonary TB and TB smokers was higher than other patients. Therefore, timely diagnosis and proper treatment of patients with extrapulmonary TB as well as the development and integration of smoking cessation programs are underlined and emphasized in the formulation and implementation of the National Tuberculosis Control Program.

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Intracerebral hemorrhage secondary to thrombolysis in patients with acute myocardial infarction is a catastrophic condition. Several factors predispose to intracranial bleeding including low body weight, female sex, advanced age, use of oral anticoagulants prior to the administration of fibrinolytic therapy, diastolic blood pressure (greater than 110 mm Hg), among others. Optimal medical management involves multidisciplinary roles of hematology, neurosurgery and critical medicine. In this illustrative case, a classification and management algorithm were proposed for patients with complications hemorrhage associated with thrombolysis after myocardial infarction.

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Otoacariasis is the presence of ticks and mites in the auditory canal. A 50-year-old Iranian man was subjected at the an ear, nose, and throat clinic at Rouhani Hospital in Babol with complaint of left ear pain. Otoscopic examination showed mite infestation in the left auditory canal. The infestation was eradicated with the 2% H₂O₂ solution. Treatment began by applying oral ciprofloxacin (500 mg/day) twice daily for 7 d. We report the rare case of an ear canal infestation with the Rhizoglyphus and their eradication with 2% H₂O₂ solution.

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Rhabdomyolysis is the breakdown of striated muscle cells resulting in leakage of cell matter into the extra-cellular space. It can present with myalgia, muscle weakness and swelling. Episodes of passing of dark tea-coloured urine have also been reported. Raised creatinine kinase is diagnostic of rhabdomyolysis. Raised serum myoglobin levels and presence of myoglobin in the urine (myoglobinuria) help to support the diagnosis. The aetiology for rhabdomyolysis can be both traumatic and non-traumatic. In the case of trauma, individuals with crush injuries trapped in cars or under collapsed buildings , struggling against restraints, immobilized and in the same position for hours due to injuries, comatosed states or positioning during prolonged surgeries and those with high voltage electrical injuries are at increased risk of rhabdomyolysis. Non-traumatic causes of rhabdomyolysis include hyperthermia, metabolic myopathies, drugs and toxins ingestions, electrolyte abnormalities and infections. The mechanism of rhabdomyolysis is often multifactorial. In the case of trauma, direct injury to cell membranes as well as hypoxia from direct compression leading to adenosine triphosphate depletion leads to breakdown of striated muscle cells.. The lysed cells release myoglobin, creatine kinase, urate and phosphate into the interstitium. Direct heme protein-induced toxicity on nephrons can result in acute kidney injury. We report a case of traumatic rhabdomyolysis and share the latest in the literature on the understanding of the subject as well as that of myoglobinuria, with which it is often associated with.

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Objective: To estimate the incidence and related risk factors of sepsis between road traffic injuries (RTIs) and non-RTIs. Methods: Clinical data of 339 patients with severe trauma who were admitted into ICU in both Third Affiliated Hospital of Army Military Medical University and ChongGang General Hospital from January 2012 to December 2015 were retrospectively analyzed. Twenty items of potential risk factors affecting sepsis were evaluated by univariate and multivariate Logistic Analysis with the purpose of drawing a comparison between RTI patients and non-RTI patients. Results: There were 154 cases of RTI and 185 cases of non-RTI entering the study period. The significant independent risk factor of sepsis in RTIs was SOFA 11 (OR=4.821; 95% CI=1.901-12.226; P=0.001). The significant independent risk factors of sepsis in non-RTIs were SOFA 11 (OR=12.410; 95% CI=2.559-60.185; P=0.002), tracheal intubation (OR=8.913; 95% CI=2.322-34.206; P=0.001), APACHE II 15 (OR=3.684; 95% CI=1.750-7.753; P=0.001). Conclusions: The clinical medical personnel should not give equal treatment to RTI patients and non-RTI patients admitted in ICU in that factors predicting sepsis within above two groups are different. The sample volume should be increased and validated in further prospective research.

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Objective: To determine whether endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) can rapidly distinguish among lung cancer, tuberculosis and sarcodosis, and to explore its sensitivity and specificity. Methods: Clinical data of patients with enlarged mediastinal or hilar lymphadenopathy who underwent EBUS-TBNA at our hospital between September 1, 2012 and June 30, 2015 for were retrospectively analyzed. The sensitivity, specificity, positive predictive value, and negative predicted value [including 95% confidence interval (CI)] were calculated.. Results: A total of 299 lymph nodes from 201 patients underwent EBUS-TBNA were selected and no serious complications occurred. EBUS-TBNA showed a sensitivity of 87.9% (124/141) (95% CI: 81%–92%), a specificity of 100.0% (124/124) (95% CI: 97%–100%), and a negative predicted value of 41.3% (95% CI: 23%–61%) in the detection of lung cancer. The sensitivity and specificity of diagnosis of mediastinal tuberculosis lymphadenitis were 72.4% (21/29) (95% CI: 53%–87%) and 100.0% (95% CI: 82%–100%); while sensitivity and specificity of diagnosis of sarcoidosis were 71.4% (5/7) (95% CI: 29%–96%) and 100.0% (95% CI: 91%–100%). Conclusions: The sensitivity and specificity of EBUS-TBNA do not significantly differ for a diagnosis of lung cancer versus tuberculosis or sarcodosis.

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Objective: To compare effect of immunoprevention or immunotherapy based on denderitic cells (DCs), or supernatants on pancreatic carcinoma and hepatocelluar carcinoma in vitro and in vivo. Methods: DCs and monouclear cells (immunoeffecetor cells) were stimulated with hGM-CSF, hIL-4, hTNF-α, PC3 TA or BEL7402 TA and hIL-2, then DCs and immunoeffector cells were cocultured, and supernatants were harvested. In vitro, the immunoeffector cells were divided into A0 group (without DCs stimulated), A1 group (DCs stimulated, cultured with cytokines cocktail), A2 group (DCs stimulated, cultured with cytokines cocktail and tumor antigen, DCs vaccine). Cytoxicity assay was performed with lactate dehydogenase method. In vivo, the nude mice were allocated in 3 groups: prevention group, receiving immunoeffector cells activated by DCs vaccine 2 days before inoculation with PC3 or BEL7402; treatment group, receiving immunoeffector cells activated by DCs vaccine after development of implanted tumor in all nude mice; control group, receiving equivalents amount of RPMI1640 cultured liquid. On the 45th day, all the nude mice were sacrificed and the tumor was weighed. Results: The maximal inhibition rate of the A0, A1 and A2 were 3.5%, 68.1%, 81.0% in the BEL7402; 4.5%, 33.0%, 62.4% in the PC3. The differences in tumor weight among three groups were significant, but the differemce were not significant between the PC3 and BEL7402. Conclusions: DCs vaccine or supernatants may play an important role in treating and preventing against malignant tumor.

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Patients with primary or secondary tumors in the central nervous system may have seizures resulting from direct tissue damage, metabolic abnormalities, infection, or toxic side effects of medications. In pediatric patients, it is more frequent to use drugs to control secondary epilepsy. In this article, we discuss the main nuances of antiepileptic drugs for the proper management of children with central nervous system tumors.

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