Significant Medical Histories Research Articles

Influence of Bronchopulmonary Diseases on the Course and Outcome of COVID-19: a Literature Review

The SARS-CoV‑2 coronavirus has become a major global health concern. Infection with SARS-CoV‑2 has caused millions of deaths worldwide, and the case fatality rate has been found to be largely related to pre-existing clinical conditions. The main clinical manifestation of COVID‑19 is the presence of respiratory symptoms. Severe complications of COVID‑19 are most often observed in people with significant medical histories. The SARS-CoV‑2 virus primarily attacks the respiratory system, causing pneumonia and acute respiratory distress syndrome, which can lead to severe systemic inflammation, multiple organ dysfunction, and death, especially in patients with pre-existing comorbidities. A number of meta-analyses strongly suggest that comorbid respiratory diseases, including chronic obstructive pulmonary disease and interstitial lung diseases, are factors in the development of severe forms of COVID‑19, worsening patient outcomes and survival rates. Studies have shown an association between adverse outcomes of COVID‑19 and the expression level of the angiotensin-­converting enzyme 2 (ACE2) in these patients. Regarding other respiratory system pathologies, such as bronchial asthma and cystic fibrosis, it is known that the main unfavorable factor is long-term immunosuppressive pharmacotherapy preceding infection. In this article, we highlight the main respiratory comorbidities to better understand the pathogenesis of COVID‑19.

Whole-Genome Deep Sequencing of the Healthy Adult Nasal Microbiome.

This study aimed to determine shifts in microbial populations regarding richness and diversity from the daily use of a popular over-the-counter nasal spray. In addition, the finding of nasal commensal bacterial species that overlap with the oral microbiome may prove to be potential probiotics for the "gateway microbiomes". Nasal swab samples were obtained before and after using the most popular over-the-counter (OTC) nasal spray in 10 participants aged 18-48. All participants were healthy volunteers with no significant medical histories. The participants were randomly assigned a number by randomizing software and consisted of five men and five women. The sampling consisted of placing a nasal swab atraumatically into the nasal cavity. The samples were preserved and sent to Northwestern University Sequencing Center for whole-genome deep sequencing. After 21 days of OTC nasal spray use twice daily, the participants returned for further nasal microbiome sampling. The microbial analysis included all bacteria, archaea, viruses, molds, and yeasts via deep sequencing for species analysis. The Northwestern University Sequencing Center utilized artificial intelligence analysis to determine shifts in species and strains following nasal spray use that resulted in changes in diversity and richness.

Effect of the OPHN1 novel variant c.1025+1 G>A on RNA splicing: insights from a minigene assay

This research analyzes the clinical data, whole-exome sequencing results, and in vitro minigene functional experiments of a child with developmental delay and intellectual disability. The male patient, aged 4, began experiencing epileptic seizures at 3 months post-birth and has shown developmental delay. Rehabilitation training was administered between the ages of one and two. There were no other significant family medical histories. Through comprehensive family exome genetic testing, a hemizygous variant in the 11th exon of the OPHN1 gene was identified in the affected child: c.1025 + 1G > A. Family segregation analysis confirmed the presence of this variant in the patient’s mother, which had not been previously reported. According to the ACMG guidelines, this variant was classified as a likely pathogenic variant. In response to this variant, an in vitro minigene functional experiment was designed and conducted, confirming that the mutation affects the normal splicing of the gene’s mRNA, resulting in a 56 bp retention on the left side of Intron 11. It was confirmed that OPHN1: c.1025 + 1G > A is the pathogenic cause of X-linked intellectual disabilities in the child, with clinical phenotypes including developmental delay and seizures.

Reliability and Agreement Assessment of Sarcopenia Diagnosis through Comparison of Bioelectrical Impedance Analysis and Dual-Energy X-ray Absorptiometry.

A unified diagnostic criterion has yet to be established for sarcopenia. Therefore, we analyzed the reliability and validity of sarcopenia diagnosis using bioelectrical impedance analysis (BIA) compared with the gold standard, dual-energy X-ray absorptiometry (DEXA), and evaluated the predictive accuracy of BIA for diagnosis. The clinical trial, involving a total of 239 participants, was conducted between December 2018 and September 2019 on healthy volunteers without significant medical histories. The participants underwent health assessments, followed by sequential DEXA and BIA measurements. In both the low and normal appendicular skeletal muscle (ASM) groups, there were significant differences in the right arm, left arm, right leg, left leg, ASM, and ASM index (ASMI) between DEXA and BIA across all age groups (p < 0.05). BIA tended to overestimate compared to DEXA, but ASMI values for males and females were consistent with the criteria for sarcopenia. Bland-Altman analysis showed that each segment in both the low and normal ASM groups fell within the limits of agreement (LOA). The diagnosis of sarcopenia using BIA was significantly different from that using DEXA. However, it exhibited a significantly high correlation, fell within the LOA, and demonstrated high predictive accuracy. BIA can be considered an effective tool for diagnosing sarcopenia.

Small Bowel Obstruction Due to Abdominal Cocoon Syndrome in Post-COVID-19 Patients.

Abdominal cocoon syndrome, also recognized as encapsulating peritoneal sclerosis, is an exceedingly rare medical condition characterized by an anomalous membranous envelopment of the small bowel. Despite its clinical rarity, the precise etiology and pathogenic mechanisms of this syndrome remain elusive. This comprehensive discussion presents a case series encompassing six patients who sought medical attention in the Emergency Room, all sharing a common presentation: severe abdominal distension and persistent constipation. Intriguingly, these symptoms manifested following recent severe coronavirus disease 2019 (COVID-19) infections. Remarkably, none of these patients had significant medical histories or had undergone prior surgical interventions, rendering their cases even more enigmatic. The defining feature across all six cases emerged during exploratory laparotomy, where a consistent finding stunned the surgical team: the discovery of a thick, fibrous membrane enveloping segments of the small bowel. The surgical procedure entailed meticulous dissection and subsequent removal of this membrane, with tissue samples dispatched for histopathological evaluation. This diagnostic approach conclusively confirmed the presence of abdominal cocoon syndrome in each of these patients. The focal point of our discussion revolves around a potential connection between recent severe COVID-19 infection, intensive care unit admissions, and the subsequent development of abdominal cocoon syndrome. This intriguing association compels further inquiry to unveil the precise pathogenesis of this syndrome, particularly within the context of COVID-19. Given the diagnostic complexities associated with abdominal cocoon syndrome, this report underscores the indispensability of maintaining a heightened clinical suspicion and the significance of rigorous intraoperative assessments to ensure timely diagnosis and effective management. Abdominal cocoon syndrome represents a rare and enigmatic medical condition characterized by its uncertain etiology. Our case series tantalizingly suggests a link between recent severe COVID-19 infection and the development of this syndrome. Nevertheless, comprehensive research endeavors are warranted to unravel the intricate mechanisms that underlie this intriguing association. In light of the diagnostic challenges associated with abdominal cocoon syndrome, this report underscores the pivotal role of exploratory surgery, in the absence of definitive radiological imaging, as the cornerstone for both diagnosis and therapeutic intervention. The pursuit of further investigations into the intricate relationship between COVID-19 and abdominal cocoon syndrome may ultimately yield the critical insights needed to demystify this complex medical enigma.

Neuropsychological Screening in Pediatric Multidisciplinary Clinics: Group Characteristics and Predictive Utility.

To evaluate the feasibility of administering caregiver-report neuropsychological screening measures in pediatric multidisciplinary clinics (MDCs) and investigate predictive utility for cognitive and academic difficulties on follow-up testing. The Pediatric Perceived Cognitive Functioning (Peds PCF) and Colorado Learning Difficulties Questionnaire (CLDQ) were administered to caregivers of youth with history of brain tumor (BT), non-central nervous system (CNS) cancer, or Fontan circulation as part of routine neuropsychological consultation in MDCs from 2017 to 2019. We examined cross-sectional differences on screening measures, and relationships between screening and intellectual and academic test performance in a subset who presented for follow-up neuropsychological evaluation. Receiver operating characteristic (ROC) curve analysis was used to identify suggested cut scores on screening measures for predicting who would most benefit from further evaluation. Screening was completed with 192 families. Children with history of non-CNS cancer (n = 29) had fewer parent-reported cognitive and academic concerns compared with either BT (n = 88) or Fontan (n = 75) groups. Peds PCF and CLDQ scores were related to intellectual and academic test performance in the group presenting for neuropsychological evaluation (n = 68). ROC curve analysis identified cut scores across screening measures with maximal sensitivity and specificity for detecting neuropsychological difficulties. It is feasible to utilize parent rating measures during neuropsychological consultation in pediatric MDCs. The Peds PCF and CLDQ demonstrated sensitivity to intellectual and academic difficulties in children with significant medical histories. Screening may be a helpful tool for pediatric neuropsychologists and other professionals during MDC consultation to inform clinical management.

Evaluating current chest imaging practices of pediatric patients with COVID-19: A retrospective analysis

PurposeThis retrospective analysis aims to examine the effectiveness of the current chest imaging guidelines regarding COVID-19 positive pediatric patients on our study group of patients aged 0 to 18. Materials and methodsWe examined clinical and imaging data of 178 pediatric COVID-19 positive patients confirmed by PCR admitted to the Children's Hospital of Los Angeles between March 6, 2020 and June 23, 2020. ResultsOf 178 patients, only 46 (27%) patients underwent any form of chest imaging. Thirteen (28%) of 46 imaged patients had positive chest X-rays (CXR) or computed tomography (CT) chest findings, with 8 (62%) of the 13 patients suggesting pneumonia or multifocal pneumonia, 3 (23%) patients having acute respiratory distress syndrome, and 2 (15%) patients demonstrating left sided pleural effusions thought to be the result of ruptured appendicitis unrelated to their COVID-19 diagnosis. All but one patient had significant prior medical histories with an associated comorbid medical condition. Of the 46 imaged patients, 17 (37%) patients had a negative chest X-ray, and 15 (33%) patients had suggestive findings of viral etiology. 132 patients were not imaged. ConclusionOur study population corroborated current chest imaging guidelines in pediatric patients. Chest imaging modalities such as CXR and CT should be reserved for patients who are severely symptomatic and/or possess prior comorbidities such as immunosuppression, diabetes, asthma, obesity, or where other differential etiologies must be entertained.

Efficacy of Melatonin in Children With Postconcussive Symptoms: A Randomized Clinical Trial.

Approximately 25% of children with concussion have persistent postconcussive symptoms (PPCS) with resultant significant impacts on quality of life. Melatonin has significant neuroprotective properties, and promising preclinical data suggest its potential to improve outcomes after traumatic brain injury. We hypothesized that treatment with melatonin would result in a greater decrease in PPCS symptoms when compared with a placebo. We conducted a randomized, double-blind trial of 3 or 10 mg of melatonin compared with a placebo (NCT01874847). We included youth (ages 8-18 years) with PPCS at 4 to 6 weeks after mild traumatic brain injury. Those with significant medical or psychiatric histories or a previous concussion within the last 3 months were excluded. The primary outcome was change in the total youth self-reported Post-Concussion Symptom Inventory score measured after 28 days of treatment. Secondary outcomes included change in health-related quality of life, cognition, and sleep. Ninety-nine children (mean age: 13.8 years; SD = 2.6 years; 58% girls) were randomly assigned. Symptoms improved over time with a median Post-Concussion Symptom Inventory change score of -21 (95% confidence interval [CI]: -16 to -27). There was no significant effect of melatonin when compared with a placebo in the intention-to-treat analysis (3 mg melatonin, -2 [95% CI: -13 to 6]; 10 mg melatonin, 4 [95% CI: -7 to 14]). No significant group differences in secondary outcomes were observed. Side effects were mild and similar to the placebo. Children with PPCS had significant impairment in their quality of life. Seventy-eight percent demonstrated significant recovery between 1 and 3 months postinjury. This clinical trial does not support the use of melatonin for the treatment of pediatric PPCS.

Importance of neuroimaging in normal tension glaucoma.

Primary empty sella syndrome (PESS) is caused by an increase in the cerebrospinal fluid (CSF) pressure or a defect in the diaphragma sellae, where the pituitary gland is absent or present as a thin membrane.[1] Optic nerve examination and visual field analysis show glaucomatous changes with normal intraocular pressures (IOPs). A 51-year-old male weighing 65 kg presented with gradual progressive painless diminution of vision in both eyes for 1 year with no significant medical or other histories. Best-corrected visual acuity (BCVA) oculus dexter (OD) was counting fingers near face and oculus sinister (OS) was 6/18. Intraocular pressures (IOPs) were normal. A relative afferent pupillary defect in the right eye (RE) was found. Color vision was defective. Gonioscopy revealed open angles in both eyes. Pachymetry was in the normal range. Fundus examination OD revealed a 0.7-cup disc ratio and in OS 0.8-cup disc ratio, with both eyes showing bayonetting, baring of circumlinear vessels, and nasalization of blood vessels, with rim pallor more than cupping suggesting neurophthalmic cause [Fig. 1].Figure 1: Fundus photographs showing advanced optic disc changes with rim pallor in RE and LETwo hourly diurnal fluctuations ranged normal. Visual field examination showed severe generalized depression, tubular field and absence of split fixation in the left eye (LE) [Fig. 2].Figure 2: LE visual field on octopus perimetry G program and M programAll systemic investigations were within normal limits. Magnetic resonance imaging revealed an empty sella [Fig. 3] and venography was non-significant.Figure 3: MRI of the brain and both orbitsNormal tension glaucoma (NTG) is a diagnosis made after excluding causes of burnout glaucoma and previous episodes of acute hemodynamic disturbances.[2] In PESS, nerve fibers in optic chiasm are perfused from the posterior communicating arteries, which pass round the infundibulum above the pituitary gland. If any mechanical changes occur near the pituitary or sella turcica, the arachnoid may be drawn inferiorly simultaneously pulling the optic chiasm and perfusion vessels downward with resultant optic nerve ischemic changes.[3] We need to remember this association between empty sella, NTG and resultant visual loss.[4] Hence, it becomes necessary to include neuroimaging as an added diagnostic tool in our armamentarium for NTG to avoid diagnostic delay and prevent visual disability. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Molar-incisor malformation: Eight new cases and a review of the literature.

Molar-incisor malformation (MIM) is a recently described dental abnormality. While MIM mimics dentin dysplasia, it presents in a localized pattern. Furthermore, it is speculated that MIM is caused by significant early-life medical history. The purpose of this study is to present a series of MIM cases and compare the findings with the literature. An extensive search of all published cases of MIM in the English-language literature was conducted. Additionally, an institutional review board-approved retrospective search was performed within the University of Florida oral pathology biopsy service archives. Radiographic consultation cases were also included. Cases lacking radiographs were excluded. Seventy-nine cases were identified in the literature, and eight cases were identified in our retrospective search. All but one case involved the permanent first molars. The average age at diagnosis was 9years. Many patients reported significant early-life medical histories. MIM usually affects the permanent first molars and may be linked to early-life medical conditions or interventions. Oral healthcare providers, especially paediatric dentists, should be aware of MIM to avoid misdiagnosing it as dentin dysplasia. Long-term follow-up studies with thorough medical history documentation are essential to understand the pathogenesis and aetiology and to create treatment guidelines.

Factores asociados a alopecia no cicatricial en mujeres adultas, estudio transversal entre enero diciembre 2013

Introducción. Alopecia significa caída patológica del pelo, de cualquier tipo y en cualquier lugar de la superficie cutánea. Se divide en dos grandes grupos: cicatricial y no cicatricial. Esta última, a pesar de ser una patología prevalente, no ha sido documentada en la población latinoamericana. Objetivo. Establecer la prevalencia y las variables asociadas a la alopecia, de interés en la población de estudio. Métodología. Estudio observacional de tipo analítico, realizado entre enero y diciembre de 2013. Se revisaron 169 historias clínicas de mujeres mayores de 18 años con alopecia no cicatricial. El análisis estadístico se realizó con Epi Info versión 7. Resultados. La edad promedio para el total de los casos fue de 38.5 años. La prevalencia estimada para las alopecias no cicatriciales fue de 12.1%; el 35.5% (IC 95% 28.31-43.22) fue diagnosticado como pérdida capilar de patrón femenino, el 19.53% (IC 95% 13.84-26.31) como alopecia mixta y alopecia areata, seguida del efluvium telógeno crónico con un 17.16% (IC 95% 11.8-23.7). La mayoría tenía algún antecedente médico de importancia, principalmente hipotiroidismo con 20.47% (IC 95% 13.8-28.5). De las pacientes evaluadas, el valor promedio de ferritina, tirotropina y hemoglobina fue 76.65 mcg/L, 3.08 ml U/L y 13.81 gramos/dl respectivamente. Se encontró asociación positiva, entre tipo de alopecia y ferritina (p &lt; 0.0001). Conclusiones. El presente estudio concluye que la ferritina sérica disminuida está relacionada con la fisiopatología del efluvium telógeno, lo que no ocurre en los trastornos tiroideos. Se requieren más estudios para establecer las variables asociadas en Colombia. [Cifuentes-Tang LI, Uribe-Caputi JC. Factores asociados a alopecia no cicatricial en mujeres adultas, estudio transversal entre enero y diciembre 2013. MedUNAB. 2018;21(1):59-66. doi: 10.29375/01237047.2677].

MP05: Injuries in refugee children presenting to a paediatric emergency department

Introduction: The number of refugees accepted to Canada grew from 24,600 in 2014 to 46,700 in 2016. Many of these refugees have young families and the number of child refugees has increased accordingly. Although child refugee health care has been in the forefront of media and medical attention recently, there is limited data on injury patterns in this population. Canadian Hospitals Injury Reporting and Prevention Program (CHIRPP) collects data on injuries in children presenting to the emergency department (ED). Our objective is to examine the clinical presentations and outcomes of refugee children with injuries presenting to a tertiary care paediatric ED. Methods: Our paediatric hospital has approximately 70,000 ED visits per year of which 13,000 are due to injuries and/or poisonings. The CHIRPP database was accessed to identify children with injuries presenting to our ED from April 2014 to March 2017 with Interim Federal Health Program (IFHP) registration status. All patient charts were reviewed to extract demographic and clinical care information. Results: There were 74 children with 81 ED visits during the study period of whom 19% were transferred from other facilities. Most of them (72%) were males with a mean age of 8.7 years (standard deviation 4.29). There were significant medical histories in 32% of children. The presentation to our ED (greater than 24 hours post-injury) was seen in 25% of visits. Twenty five percent of injured children were seen in our ED. The distribution of Canadian Triage Acuity Score (CTAS) scores 1, 2, 3, 4, and 5 were 0%, 16%, 37%, 46% and 1% respectively. However, subspecialty consultations were required in 69%, 60% and 27% of CTAS 2, 3 and 4 children respectively. Overall, 46% of all patients required subspecialty consults. The top three categories of injuries include fractures (23%), soft tissue injuries (20%) and lacerations (17%). More than half (56%) required diagnostic imaging. Most (89%) were treated in ED and discharged (average length-of-stay 3 hours 55 minutes) and 11% required admissions. 47% of children lacked primary care physicians. Conclusion: Almost half of refugee children with IFHP status require DI testing, sub-specialty consultations and primary care referrals when presenting to our ED with injuries. Follow up arrangements are needed as many do not have access to primary care providers. This demonstrates a need for securing primary care providers early for this vulnerable population.

Ocular Inflammatory Disease as a Predictor for In-Hospital Mortality in Patients Hospitalized with Disseminated Tuberculosis.

AimTo ascertain whether the presence of ocular inflammatory disease is a predictor for death in patients hospitalized with disseminated tuberculosis.MethodsThis is an IRB-approved retrospective study of patients admitted with a diagnosis of disseminated tuberculosis within a seven-year period (2002–2009). The following data was collected from each record: age, sex, details of previous surgeries or therapy, the findings of anterior segment examination, the findings of dilated indirect ophthalmoscopy, systemic findings, investigations done, treatment rendered, and final status (died or discharged).ResultsA total of 57 patients (29 males (50.8%), 28 females (49.2%) with ages ranging from 14 to 78 years (mean 41.7 years) were identified. Common presentations included fever, sepsis or neurological complaints such as headache or convulsions. Significant medical histories included acquired immune deficiency syndrome (AIDS) (n= 4), renal allograft transplantation (n=3), chronic renal failure on hemodialysis (n=3) and type 2 diabetes mellitus (n=6).Of these, 35 patients (61.4%) had ocular tuberculosis. These included 19 males (54.2%) and 16 females (46.8%) with ages ranging from 16 to 78 years (mean 43.3 years). Current medical conditions included AIDS, renal allograft transplantation and subsequent immunosuppressive therapy, chronic renal failure on hemodialysis, and type 2 diabetes mellitus. Forty-seven of the 70 eyes (67.1%) had evidence of ocular tuberculosis. Specific presentations included 42 eyes (89.1%) with choroidal tubercles and five eyes (10.9%) with chorioretinitis. Two patients (2.8%) had disc edema. Of these 35 patients, eight (22.8%) patients died whereas 27 (77.2%) were discharged.The remaining 22 patients (38.6%) had no ocular tuberculosis. These included 10 males (45.5%) and 12 females (54.5%) with ages ranging from 14 to 78 years (mean 39.1 years). Significant medical histories included type 2 diabetes mellitus. Of these 44 eyes, four eyes (9.09%) had non-proliferative diabetic retinopathy, two eyes (4.5%) had optic atrophy and two eyes (4.5%) had disc edema. One patient (4.5%) patient of this group of 22 died, whereas 21 (95.5%) were discharged.We analyzed the differences in survival with Fisher’s Exact test between patients who died in the hospital and those who were discharged (statistically insignificant at p value of 0.05). Outcomes of patients with two, three, or four risk factors were analyzed using unconditional logistic regression but all tests failed to reach statistical significance.ConclusionsThe presence of ocular inflammation was independent of final outcome, either singly or as part of a risk factor cluster.

Teaching clinical skills by utilising community patient volunteers – a program evaluation

Introduction: The newly established Ipswich regional campus of the University of Queensland School of Medicine experienced difficulty in accessing inpatients for clinical skills teaching during its initial two years of operation. The community patient volunteer (CPV) program was developed to address this problem. Volunteers with significant past medical histories or clinical signs were recruited from the local community and rostered to attend tutorials on campus several times per year. Students practised history taking, physical examination and developed clinical reasoning skills, under the guidance of their clinician tutor. An evaluation of this program was undertaken. Methods: Questionnaires were disseminated to Ipswich students and volunteers from 2010 and 2011. The surveys explored students’ views of the program compared with hospital-based bedside teaching, and volunteers reflected on their participation. Student performance on Objective Structured Clinical Examinations (OSCE) was compared between the base and regional cohorts. Results : Students and volunteers reported benefits from participation in the CPV program. The results of the Ipswich students’ Year 2 OSCE in 2010 and 2011 were similar to the results of the Brisbane cohort, with a significant positive difference in favour of the Ipswich students in the areas of history taking and communication skills for 2011. Discussion & Conclusions: Student learning was not disadvantaged by the use of the CPV program and may have been enhanced. Volunteers reported personal gains from participation.

A Venous Malformation Presenting as Toe Walking

A 13-year-old girl was referred for consideration of treatment with botulinum injection. She had been toe walking since the age of 3 years. This was first noticed on the right, but then became bilateral with persistent asymmetry. There was no significant birth, developmental, past medical or family histories. A diagnosis of idiopathic toe walking was reported. She underwent stretching exercises and serial casting. However, there was no obvious benefit. On examination, she had a fixed right equinus deformity with a prominent and slightly tender right calf. The rest of the clinical examination was unremarkable. Bedside ultrasound scanning demonstrated a diffuse echogenic lesion over the lateral aspect of the right calf. Magnetic resonance imaging demonstrated the presence of a vascular malformation within the muscles of the posterior compartment of the right calf (Figure 1, Figure 2). Doppler ultrasound confirmed slow blood flow in keeping with a venous malformation. Venous sclerotherapy was performed with reported improvement in her pain when walking. This was also hoped to improve her compliance with physiotherapy exercises.

Stratification of Patients in Long-Distance, International, Fixed-Wing Aircraft

IntroductionA growing number of individuals with significant medical histories travel for business and holidays. Precise anticipation and stratification of transport-relevant illness severity in the planning stage of an air medical evacuation is crucial for mission success and patient safety. MethodsWe developed a staging system (ie, Stratification of Air Medical Transport by Expression of Symptoms in Patients [STEP]) and applied it to 356 patients transported by a fixed wing aircraft between January 2010 and June 2011. Patients were stratified before transport, and the transport team performed independent staging of each patient during the actual transport. Data on transport modes, transport time, age, sex, diagnosis, the need for mechanical ventilation, and transport-related complications were collected. Data were analyzed for significant differences in STEP categories between operations staging and staging by the flight crew and for the correlation between operations STEP staging and actual transport acuity. ResultsComplete datasets were available in 353 of 356 patients. Differences between staging by operations and flight crew were documented in 31 cases (P = .809); in 18 of them, the flight crew considered the patient to be more severely affected than previously estimated. Decisions for specific transport mode and configuration were found to be adequate in all but 3 cases (99.15%). ConclusionSTEP is a useful tool to assess patient's illness/injury severity in the planning stage of a long distance, international, air ambulance transport and assists in choosing the appropriate mode and configuration of transport.

Index of Suspicion

Index of Suspicion

An autopsy case related to a terrorist attack using a ball-bearing bomb

We encountered an autopsy case related to a terrorist attack using a ball-bearing bomb. The decedent was a 51-year-old male without significant medical histories. During dinner in a restaurant, the perpetrator suddenly exploded a ball-bearing bomb, the blast from which blew the victim off his chair. The victim was found to be unresponsive, and pronounced dead. X-ray photographs taken before autopsy revealed six spherical shadows. Three penetrating wounds in the head, one in the neck and chest, and two in the left upper arm were observed in vivo. Six projectiles recovered from the body were identified as ball-bearings, one of which traveled through the midbrain, diencephalon, and left temporal lobe. Although blast injuries and penetrating wounds are often combined in bomb attack victims, penetrating brain injury would be the cause of death in this case. Lethal injuries to major organs can thus occur even though the destructive force of a ball-bearing bomb is weak. X-ray films were informative for detecting the ball-bearings in this case, suggesting that autopsy imaging is essential in cases of terrorism victims.

LIVING DONOR NEPHRECTOMY IS A SAFE PROCEDURE

A38 Aims: Voluntary donation of kidney by living donors has been steadily increasing in recent times. However, apprehension of complications related to the donor nephrectomy and long-term sequelae still haunt potential living donors. We analysed the incidence of post operative complications in those who underwent living donor nephrectomy. Methods: A retrospective study was conducted in donors who underwent living donor nephrectomy from July 2001 to December 2003 at our centre. All donors were evaluated according to a strict protocol. All donor nephrectomies were performed under endo-tracheal general anesthesia, through the eleventh rib excision loin approach. The donor’s age, sex, present and past significant medical and surgical histories, operative methods and various complications were reviewed, recorded and analysed. Results: One hundred and thirty donors, 78 males and 52 females with a median age of 31 years (<50years=125 & >50years=5) underwent living donor nephrectomy. Donors were usually discharged on the fifth POD (4 days–10 days). Seven donors (5.3%) experienced a complication in the post operative period. Two donors had apnea in the immediate post operative period, reintubated and were successfully extubated on the same day. Two patients had significant hemorrhage through the drain (200–600 ml) and one of them needed re-exploration. Two patients, each had acute gastric dilatation and sub acute intestinal obstruction respectively and recovered with conservative management. One patient had wound infection and was managed with antibiotics. None of our donors died due to the complications. Conclusions: Our study confirms that living donor nephrectomy is a very safe procedure associated with a very low morbidity. Although few donor deaths have been reported, none of our donors experienced a fatal complication. Morbidity and mortality in living donors can be avoided if the donors are evaluated with a strict protocol.

Twin gestations at a community hospital: comparing management styles of private versus resident and maternal–fetal medicine services

Objective: In 1990, we developed fixed criteria for transfer of multiple gestations to the maternal–fetal medicine (MFM) service. To evaluate these criteria and analyze outcome and quality of care for multiple gestations, a retrospective review of low-risk twin gestations was conducted.Methods: All low-risk twin pregnancies delivered by private and MFM/resident services in 1990–1997 were identified, pertinent data obtained from chart review, and results summarized.Results: Of the low-risk twin pregnancies (n = 491), 73% were seen by private services, 8.5% by MFM, and 18% by resident. Resident patients had a lower average maternal age and less infertility and were higher in parity and gravidity. A greater proportion of MFM patients had significant past medical histories, and more had undergone selective reduction. There was an increased use of oral tocolytics, a higher birth weight, and a higher mean gestational age in the private group. Total rate of cesarean deliveries for private patients was higher when compared with resident/MFM (52%–37%). The rate of combined procedures (vaginal followed by cesarean delivery) was significantly different with 4/90 resident/MFM and 33/151 private services second twins delivered abdominally (P = 0.02). A greater proportion of breeches were delivered vaginally, and there were more instrumental vaginal deliveries in the resident/MFM group (P = 0.02). Perinatal morbidity was not different among the groups.Conclusions: Outcome results are similar among private, MFM, and resident services. Differences in practice patterns result in a higher private services cesarean delivery rate. Good outcomes for both groups reflect adherence to management protocols. Use of version and inexperience with breech extraction were major contributors to the higher private cesarean delivery rate.