Tangential gunshot wound to the head: A case report with review of literature

Introduction. Tangential gunshot wounds (TGSW) to the head is the high-velocity bullet that does not penetrate the cranium but passes through the tissue adjoining the cranial cavity, creating a “gutter” wound and indirectly causing cerebral injury. This article presents a reporting case of TGSW to the head, discusses the mechanism underlying this traumatic injury and the possible complications resulting from it, and reviews of literature.  Case description. A thirteen-year-old schoolboy was admitted to the emergency department (ER) of the neurosurgery teaching hospital in Baghdad, Iraq, with a tangential gunshot to the head of an unknown source during civilian protests in Baghdad. In addition to a seizure attack in the ER, his Glasgow coma (GCS) scale was 13 initially. The computed tomography showed multiple bilateral brain contusions, interhemispheric haemorrhage, partially depressed fracture of the frontal bone midline, and a Paramedian to the left with a significantly depressed skull fracture. Then, an urgent decompressive craniectomy was performed. The postoperative course was uneventful, with rapid improvement in GCS of 15 one hour after surgery. On the six-month follow-up, the patient reported no further attacks of seizure. Conclusion. TGSWs are associated with good GCS and favourable prognosis in most cases unless the patient has been deteriorating or has an associated ICH. Moreover, in our case, the history taking, mechanism of the injury, rapid evolution, and radiological imaging have an essential effect on the outcome

MELD 3.0 adequately predicts mortality and renal replacement therapy requirements in patients with alcohol-associated hepatitis

Model for End-Stage Liver Disease (MELD) score better predicts mortality in alcohol-associated hepatitis (AH) but could underestimate severity in women and malnourished patients. Using a global cohort, we assessed the ability of the MELD 3.0 score to predict short-term mortality in AH. This was a retrospective cohort study of patients admitted to hospital with AH from 2009 to 2019. The main outcome was all-cause 30-day mortality. We compared the AUC using DeLong's method and also performed a time-dependent AUC with competing risks analysis. A total of 2,124 patients were included from 28 centres from 10 countries on three continents (median age 47.2 ± 11.2 years, 29.9% women, 71.3% with underlying cirrhosis). The median MELD 3.0 score at admission was 25 (20-33), with an estimated survival of 73.7% at 30 days. The MELD 3.0 score had a better performance in predicting 30-day mortality (AUC:0.761, 95%CI:0.732-0.791) compared with MELD sodium (MELD-Na; AUC: 0.744, 95% CI: 0.713-0.775; p = 0.042) and Maddrey's discriminant function (mDF) (AUC: 0.724, 95% CI: 0.691-0.757; p = 0.013). However, MELD 3.0 did not perform better than traditional MELD (AUC: 0.753, 95% CI: 0.723-0.783; p = 0.300) and Age-Bilirubin-International Normalised Ratio-Creatinine (ABIC) (AUC:0.757, 95% CI: 0.727-0.788; p = 0.765). These results were consistent in competing-risk analysis, where MELD 3.0 (AUC: 0.757, 95% CI: 0.724-0.790) predicted better 30-day mortality compared with MELD-Na (AUC: 0.739, 95% CI: 0.708-0.770; p = 0.028) and mDF (AUC:0.717, 95% CI: 0.687-0.748; p = 0.042). The MELD 3.0 score was significantly better in predicting renal replacement therapy requirements during admission compared with the other scores (AUC: 0.844, 95% CI: 0.805-0.883). MELD 3.0 demonstrated better performance compared with MELD-Na and mDF in predicting 30-day and 90-day mortality, and was the best predictor of renal replacement therapy requirements during admission for AH. However, further prospective studies are needed to validate its extensive use in AH. Severe AH has high short-term mortality. The establishment of treatments and liver transplantation depends on mortality prediction. We evaluated the performance of the new MELD 3.0 score to predict short-term mortality in AH in a large global cohort. MELD 3.0 performed better in predicting 30- and 90-day mortality compared with MELD-Na and mDF, but was similar to MELD and ABIC scores. MELD 3.0 was the best predictor of renal replacement therapy requirements. Thus, further prospective studies are needed to support the wide use of MELD 3.0 in AH