St John's Hospital Research Articles

Advanced non-linear numerical modeling of masonry groin vaults of major historical importance: St John Hospital case study in Jerusalem

This study presents three advanced non-linear modeling strategies for the evaluation of the non-linear behavior under horizontal loads of a historical groin vault of major importance, located in Jerusalem. The vault exhibits the typical features of the Crusaders architecture, with the masonry of the bearing structure, such as the piers and the main arches, made of big stocky stones with a high quality surface finish, and the vaults made of smaller irregular cobblestones. The first model is based on a FE Concrete Damage Plasticity (FE-CDP) macroscopic approach implemented in Abaqus, where masonry is assumed elasto-plastic with damage in both tension and compression and scarcely resistant to tensile stresses. The second model is a non-commercial Rigid Body and Spring (RBS) model, where the structure is discretized into rigid elements and elasto-plastic with softening interfaces. The arches are modeled with a heterogeneous approach, whereas the vault itself through an isotropic material with quasi zero tensile strength and softening behavior. The last model is based on Kinematic Limit Analysis with adaptive mesh and consists of few rigid infinitely resistant NURBS elements (NURBS-KLA). For validation purposes, at the University of Florence a 1:5 scale model of the groin vault was tested under horizontal loads up to collapse, also in presence of FRP reinforcement glued at the extrados after the activation of the collapse mechanism in the unreinforced case. Excellent agreement with experimental results is obtained for all the models, both in terms of load carrying capacity prediction and active failure mechanism, also in presence of FRP reinforcement. The reliability of the procedures presented is therefore demonstrated.

Comparison of Central Line Care Practice of Staff Nurses before and after Implementation of Guidelines

Central line associated blood stream infections in children can be prevented when evidence based guidelines are followed by the nurses for post insertion care and maintenance of central venous catheters. This study aimed to compare the central line care practices of staff nurses before and after implementing the guidelines in pediatric intensive care unit (PICU). This experimental quantitative study was done at 12 bedded PICU, St John's Hospital over a period of 3 months from October 2016-December 2016. A purposive sample consisting of 15 staff nurses who are working in PICU were selected for this one group pre-test post-test designed study. Central line care practices of staff nurses were observed twice using an observational checklist consisting of 50 items by the researcher before and after implementing the guidelines. The practices were analyzed and scored using descriptive and inferential statistics. The findings showed that the mean post-test score was higher than the mean pre-test score in the study group. There was a significant association of the pre-test practice score with years of experience in PICU. The central line care practice guideline can be used as an effective tool for the maintenance of central venous catheters of children.

St John's Hospital (Morton House), Launceston, Australia: A history of the hospital and Dr William Russ Pugh's first operations under ether.

On 7 June 1847, William Russ Pugh, MD, performed two operations at the St John's Hospital and Self-Supporting Dispensary, Launceston, Tasmania, while his patients were rendered insensible by the inhalation of sulphuric ether. These operations are the earliest documented surgical operations under ether in Australia. St John's Hospital officially opened on 1 September 1845. The hospital may have closed in late 1853 because of financial difficulties. The two-storey Georgian-style building which served as the hospital was completed c1831-1832. It has served as a residence, school, boarding school, hospital, medical consulting rooms and commercial offices. The building is now known as Morton House. We could not identify the date when the name Morton House was adopted, or explain the origin of the name. The earliest identified use of this name is in May 1873 in a newspaper advertisement for boarders. No person with the surname Morton is known to have been associated with the building as an owner or as a tenant. The name Morton House may honour William T.G. Morton, MD, the Boston dentist who performed the first public demonstration of surgical etherisation on 16 October 1846.

Unravelling thyroid dysfunction in rheumatoid arthritis: History matters.

Autoimmune thyroid disease (AITD) frequently coexists with other systemic autoimmune conditions such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Due to the overlapping and nonspecific nature of symptoms, it is difficult to clinically uncover thyroidal illnesses in RA patients. This study was conducted to estimate the prevalence of thyroid dysfunction including the presence of anti-thyroid peroxidase (antiTPO) autoantibodies in patients with RA and to analyze symptomatology of thyroid dysfunction in patients diagnosed with RA. This cross-sectional, prospective study was conducted on 100 patients with RA, attending the Rheumatology Outpatient Department at St John's Medical College and Hospital, Bangalore, India. Twenty-two patients had biochemical evidence of thyroid dysfunction, hypothyroidism being the commonest (15/22 patients). Although fatigue and hair loss were the most common symptoms, only weight gain and cold intolerance were found to be statistically significant (P < 0.05) predictors of hypothyroidism and 32 patients were antiTPO positive. It was observed that equal numbers of patients developed hypothyroidism after diagnosis of RA and vice versa. History taking at the bedside to elicit symptoms, especially weight gain and cold intolerance, is quintessential to ensure timely diagnosis of hypothyroidism.

To word or not to word? That is the question

Background: Bartholin's abscesses/cysts affect 2% of women. Treatment options include conservative treatment, incision & drainage, marsupialisation, Bartholin's gland excision and insertion of a Word catheter (WC). The WC is an effective but relatively novel approach to outpatient management of vulval abscesses and cysts. The WC was introduced to NHS Lothian in May 2014 along with a departmental proforma and guideline. It was implemented across two hospitals- the Royal Infirmary of Edinburgh (RIE) and St John's Hospital (SJH), Livingston. This article describes the results of an audit of women managed with a vulval abscesses/cysts following the introduction of the WC to NHS Lothian. We specifically evaluate the effectiveness and acceptability of the WC, as well as the impact on surgically managed cases of vulval abscesses/cysts. Methods: We performed a retrospective audit of all identifiable cases of Bartholin's and vulval abscesses/cysts between June 2014 and June 2015. Cases were identified from completed proforma sheets, theatre coding and the gynaecology triage attendance diary. Following insertion of a WC, women were followed up by telephone within 23–25 days. The catheter is left in for a maximum of 4 weeks. The outcomes audited included appropriate use and completion of the proforma sheet, patient satisfaction, recurrence rates at 6months and need for theatre. We reviewed theatre cases separately and compared the numbers, average theatre waiting time and duration of hospitalisation before and after the introduction of the WC. Results: In RIE, fifty-six case notes were reviewed. 79% had WC insertion, 18% had marsupialisation and 3% were conservatively managed. One patient had surgical excision of the Bartholin's gland. The proforma was appropriately completed in 79% of cases. All women fitted with a WC were followed up within 23–25 days. Patient satisfaction rates were 84%. There were two cases of recurrences at 6 months. Before the introduction of the WC 43 women were managed surgically. Majority of these were done as emergencies. The average theatre waiting time was 5 days. In contrast, following the WC, only 11 cases were taken to theatre. This represented a 73% reduction in the number of theatre cases. At SJH, twenty-two case notes were reviewed. 32% had WC insertion, 32% had marsupialisation and 14% were conservatively managed. There were no recurrences at 6months It was difficult to access patient satisfaction at SJH as there was relatively poor proforma completion. However, following the introduction of the WC the number of theatre cases fell by an impressive 56%. Conclusion: The WC is a safe, effective and acceptable option in the management of vulval abscesses/cysts. It has the added benefit of reducing the pressure on theatre space and hospital inpatient beds.

Evaluation of procedure-related bleeding risk in patients receiving bivalirudin during percutaneous coronary intervention.

Bivalirudin has historically been considered an attractive anticoagulant during percutaneous coronary intervention (PCI) because of reduced bleeding complications reported by early trials. Bivalirudin use during PCIs has been a subject of controversy because of conflicting data and recent findings. To evaluate the clinical characteristics of patients receiving bivalirudin to determine if an opportunity to improve use exists based on risk of procedure-related bleeding. This was a single-center, retrospective, observational study (n = 100) of all adult patients who received bivalirudin during cardiac catheterization at St John Hospital and Medical Center from June to August 2013. The risk of bleeding complications associated with PCI was estimated using a clinical risk algorithm developed from the National Cardiovascular Data Registry (NCDR). Treatment with bivalirudin was safe and effective. Of the 100 patients who received bivalirudin, only 34% were identified as having a high risk of procedure-related bleeding according to the NCDR clinical risk algorithm. There was no incidence of stent thrombosis noted and only 1 case of provisional glycoprotein IIb/IIIa inhibitor use. No episodes of Thrombolysis in Myocardial Infarction (TIMI) major bleeding were noted in the study population; however, 1 patient met TIMI minor bleeding criteria. Limitations of this study include small sample size and retrospective nature of the study. Opportunities to establish a more cost-effective use of bivalirudin may exist through implementation of protocols incorporating the NCDR risk assessment model.

Building on a Legacy for the Era of Population Health

The 2011 Joplin tornado was a catastrophic EF5 multiple-vortex tornado that struck Joplin, Missouri, late in the afternoon of Sunday, May 22, 2011. It was part of a larger, late-May tornado outbreak and reached a maximum width of nearly 1 mile (1.6 km) during its path through the city. Mercy St John's Hospital (which had recently joined Mercy Ministries) suffered a direct hit and was rendered nonuseable. A total of 183 patients and nearly 200 coworkers/staff members were evacuated from the building within the next 90 minutes. Triage centers were set up outside as hospitals of other areas opened their doors for St John's patients and community members who had been injured. The tornado in Joplin destroyed Mercy St John's Hospital. Given this future, why did Mercy Ministries choose to rebuild an acute care facility rather than merely an outpatient system? The organization considered current community needs and the needs of the future. They also remembered their mission and the legacy of their heritage.

Use of gynaecological laparoscopy in a hospital ward in the West Bank, occupied Palestinian territory: a retrospective audit

Background Gynaecological laparoscopy is an important diagnostic and interventional method. It is widely applied, and increasingly accepted by the community because it is minimally invasive and is cheaper than the other methods. The introduction of gynaecological laparoscopy at Hebron Governmental Hospital, West Bank, occupied Palestinian territory (oPt), was an important step forward in service delivery. Despite several logistical barriers to adequate service provision in the biggest city in the oPt, the hospital serves more than 600 000 citizens with a small gynaecological ward (22 beds at the time of the study) and few funding sources compared with other hospitals in the oPt. Additionally our ward is the busiest compared with the gynaecological wards in other hospitals in the oPt. Our aim was to show that use of minimally invasive surgery such as laparoscopy can reduce hospital admission time and costs with a complication rate in the oPt that does not differ much from the international rate. Methods All gynaecological laparoscopic procedures (diagnostic and interventional) that were done between Jan 1, 2011, and Jan 1, 2013, in Hebron Hospital were included in this retrospective study. After obtaining written or verbal informed consent from all patients included in the study, data were gathered for inpatient stay and rates of complications. Our data were compared with those reported internationally in PubMed in recent years. We used SPSS (version 17.0) for the statistical analysis. The hospital's medical counsel provided ethics approval to undertake the study. Findings 200 women (mean age 28 years [range 25–35]) were admitted for gynaecological laparoscopic intervention: 65 for diagnostic laparoscopy and 135 for interventional laparoscopy. The inpatient stay in our ward was 1 day, similar to that reported internationally. The overall complication rate in the ward was 6% (six intraoperative and six postoperative complications). The complication rate reported in the Department of Obstetrics and Gynecology, St John Hospital and Medical Center, Detroit, MI, USA, was 9·8% between January, 1996, and June, 1996, and the overall complication rate in the Centre Hospitalier Universitaire Cochin Saint-Vincent-de-Paul, Paris, France, was 4·64 per 1000 gynaecological laparoscopies. Interpretation The use of laparoscopic gynaecology for diagnosis and treatment of emerging indications is an important advantage, especially for patients who have several logistical barriers to accessing health care in the oPt—eg, long distance from the hospital—because it can reduce the inpatient stay and the need for postoperative care. However, care must be taken with interventional laparoscopy to reduce the risk of complications. Funding Italian Association for Solidarity Among People.

First Steps: Exploring Use of a Prospective, Office-Based Registry as the Foundation for Quality Improvement in Cardiology Training

Teaching practice-based learning and improvement and systems-based practice are challenging. Cardiology fellows at St John Hospital & Medical Center participate in a national registry of outpatient cardiology care. We assessed the use of the registry, hypothesizing that it could serve as an effective foundation for studying ambulatory care, identifying gaps in care, and planning interventions to advance competence in practice-based learning and improvement and systems-based practice. Starting in 2009, trainees prospectively entered data for ambulatory cardiac patients into the PINNACLE Registry database where compliance with 28 performance measures was calculated and reported quarterly. Fellows met with the program director individually and in groups to identify performance gaps and to develop and implement plans for quality improvement. Cardiology fellows were surveyed annually to assess this process. Through March 2012, the fellows had completed 2400 patient visits. Participation was feasible because it was cost neutral, with data form completion averaging 5minutes. It was acceptable, with most fellows describing positive effects on practice-based learning and improvement without significant detriment to work flow. Performance achievement for drug therapies ranged from 69% (77 of 111) of the patients with atrial fibrillation receiving anticoagulation to 99% (486 of 489) of patients with coronary disease receiving lipid-lowering therapy. Gaps in system performance included low levels for diabetes screening (5%; 20 of 422) and lipid monitoring (10%; 58 of 573). Initial quality improvement projects addressed practice gaps with straightforward solutions. Improving system performance was more challenging. Using a registry in cardiology trainees' outpatient practice is feasible, acceptable, and valuable. It allows for planning and studying the effects of quality improvement projects.

Summary of: Predicting the choice of anaesthesia for third molar surgery – guideline or the easy-line?

To observe trends in choice of anaesthetic for mandibular third molar surgery in the Combined Department of Oral and Maxillofacial Surgery and Oral Medicine, based at the Edinburgh Dental Institute (EDI) and St John's Hospital (SJH) in Livingston. Data were collected retrospectively from electronic patient records for 301 consecutive new referrals for mandibular third molar surgery from general dental practitioners to each of the oral and maxillofacial departments in the EDI and SJH from the 1 September 2009 onwards. Date of consultation, grade of assessing clinician, age, gender, postcode, required surgical procedure, choice of anaesthetic and predicted difficulty of procedure were analysed. One hundred and fifty patients were seen at the EDI and 151 at SJH. There was no statistically significant difference in the proportion of male and female patients or age of patients presenting at each site. Seventeen patients (11.3%) were listed for a general anaesthetic, 21 (14%) for conscious intravenous sedation and 112 (74.7%) for local anaesthetic at EDI. At SJH 57 patients (37.7%) were listed for a general anaesthetic, 30 (19.9%) for conscious intravenous sedation and 64 (42.4%) for local anaesthetic. There was only a small difference in the difficulty of cases at the two sites, though there was a significant difference in socioeconomic deprivation between the two populations. Significantly more general anaesthetics are being prescribed for mandibular third molar surgery at SJH than the EDI. This finding is not related to difficulty of the cases presenting at each site but may be related to the nature of a maxillofacial clinic compared to a dedicated oral surgery centre. The difference in socioeconomic deprivation may have had an impact on patient decisions.

Predicting the choice of anaesthesia for third molar surgery – guideline or the easy-line?

To observe trends in choice of anaesthetic for mandibular third molar surgery in the Combined Department of Oral and Maxillofacial Surgery and Oral Medicine, based at the Edinburgh Dental Institute (EDI) and St John's Hospital (SJH) in Livingston. Data were collected retrospectively from electronic patient records for 301 consecutive new referrals for mandibular third molar surgery from general dental practitioners to each of the oral and maxillofacial departments in the EDI and SJH from the 1 September 2009 onwards. Date of consultation, grade of assessing clinician, age, gender, postcode, required surgical procedure, choice of anaesthetic and predicted difficulty of procedure were analysed. One hundred and fifty patients were seen at the EDI and 151 at SJH. There was no statistically significant difference in the proportion of male and female patients or age of patients presenting at each site. Seventeen patients (11.3%) were listed for a general anaesthetic, 21 (14%) for conscious intravenous sedation and 112 (74.7%) for local anaesthetic at EDI. At SJH 57 patients (37.7%) were listed for a general anaesthetic, 30 (19.9%) for conscious intravenous sedation and 64 (42.4%) for local anaesthetic. There was only a small difference in the difficulty of cases at the two sites, though there was a significant difference in socioeconomic deprivation between the two populations. Significantly more general anaesthetics are being prescribed for mandibular third molar surgery at SJH than the EDI. This finding is not related to difficulty of the cases presenting at each site but may be related to the nature of a maxillofacial clinic compared to a dedicated oral surgery centre. The difference in socioeconomic deprivation may have had an impact on patient decisions.

Surgery and sailing

Good morning. I would like to thank the association for the privilege and honor of serving as your 55th president this year. I have read all of the previous presidential addresses, and a common theme was the speakers using terms such as dread, burdened, and trepidation. This year I felt quite presidential for a while, and then realized I had the responsibility of coming up with an address and did not feel quite so presidential anymore. I do have the distinction of being the oldest to ever serve as your president. In addition, I am a PowerPoint virgin! It is an honor to be able to do this in conjunction with the 125th anniversary of the Grand Hotel where we have met and enjoyed a rich relationship since 1972. My introduction to the Midwest Surgical was as a resident at the University of Iowa in the mid-1970s. Every August or September, I would overhear several of my attendings, Drs Printen, Baker, Boyd, and Soper, all past presidents by the way, talk about what a great time they had at the recent meeting. So, I decided to become a member when I finished my training, which was a vascular fellowship at St John Hospital in Detroit. I came there for only 1 year intending to go back to the Midwest and do general and vascular surgery. My experience was so fantastic that I ended up staying and doing just vascular surgery. My 1 year has lasted 35 years, and now it has grown into a medical center! I would like to thank and pay tribute to the following people: my parents for providing me with my upbringing and education, especially my father who was a college professor, a department chairman, and my dean in college; the president of my university, Dr Emory Lindquist, who was a lifelong family friend and mentor; my chief resident and mentor in the surgical research laboratory as a medical student at the University of Kansas; Dr Arlo Hermreck for inspiring and confirming my decision to pursue a career in surgery; Dr Joe Grady, the Chief of General and Vascular Surgery and Director of the Vascular Fellowship at St John for many years, and also trained Drs Lloyd and Schroder, both past presidents as well; and Drs Cirocco, Hawasli, and Edhayan, among others. Dr Grady was the most influential person in my career. Finally, and most importantly, I would like to acknowledge my family—my wife Mary and my son Jonathan and his wife Jessica who are here today. Our daughter Christine died in 2008 but is with us in our memories. She always loved coming to this meeting. My wife, in particular, has been supportive over those many years of single parenting as a surgeon's wife. In deciding on a topic for this address, I decided to talk about 2 of my favorite things: surgery and sailing. When I am not in the hospital doing what a surgeon loves, operating, I like to be on my sailboat. I am fortunate to have my home, marina, and hospital all within about a mile of Lake St Clair, a 430–square mile lake. My sailboat is a 34-foot Pacific Seacraft cutter rigged sloop named the VASCUDOC. One cannot talk about sailing without mentioning the America's Cup. My favorite presidential address is by Dr John Bergan, a Chicago vascular surgeon and frequent Chicago-Mackinac sailor. His address to the Society for Vascular Surgery, “There Is No Second,” compared vascular surgery and yacht racing. “There Is No Second” referred to Queen Victoria watching the precursor to the first America's Cup race from her yacht. “Who is first?” Queen Victoria asked when only 1 solitary boat could be seen on the horizon coming to the finish. “The America,” replied her attendant. “Then who is second?” the Queen asked. “Your Majesty,” came the reply, “there is no second.” The America's Cup race has no second place.

Management of post-operative pain after caesarean section

Effective pain control after a Caesarean Section has many benefits, not only to the new mother, but to her family and the hospital. It is vital in aiding mobilisation, thus...

A review of smoking cessation services in women attending colposcopy clinics in Scotland

The most common reason for women being referred to colposcopy clinics is an abnormal smear suggesting pre-cancerous change within the cervix. It has been demonstrated that in women with low-grade lesions, smoking cessation led to a reduction in size of the cervical lesion over a 6-month period. Smoking is also recognised as an independent risk factor for treatment failure of cervical intraepithelial neoplasia. As ‘stop smoking’ services have become an integral part of the colposcopy clinic at St John's Hospital, Livingston, a national survey was undertaken. The aim of the survey was to establish what smoking cessation information, advice and support is available in colposcopy clinics throughout Scotland, and if staff had attended standardised training on raising the issue of smoking. The study demonstrated that 52% of colposcopy clinics in Scotland always establish smoking status but only 37% of clinics discuss the benefits of smoking cessation in relation to abnormal cervical smears. There was inaccurate and inconsistent written and verbal advice given on the benefits of cessation and whether women should cut down or stop smoking completely. The majority of staff had not attended standardised training on how to raise the issue of smoking and very few clinics have established referral pathways for smoking cessation support.

“R”Shiver me timbers: clinicians doing statistics! A novel approach to data analysis and data visualisation in modern medicine, an example using chronic lymphocytic leukaemia (CLL) data

“R”Shiver me timbers: clinicians doing statistics! A novel approach to data analysis and data visualisation in modern medicine, an example using chronic lymphocytic leukaemia (CLL) data

Lack of association of outcomes with treatment duration and microbiologic susceptibility data in Clostridium difficile infections in a non-NAP1/BI/027 setting

Concerns regarding the poor response of severe Clostridium difficile infection (CDI) treated with metronidazole have arisen over the last 5 y. We conducted a prospective, non-interventional study of CDI cases at our institution to evaluate the role of drug resistance, co-morbidities, and the emergence of hypervirulent strains on patient outcomes. A total of 118 adult inpatients with diarrhea and a positive stool for C. difficile toxin immunoassay had positive stool cultures and were included in the study. All 118 isolates had vancomycin and metronidazole susceptibility testing via the E-test method; rep-PCR was performed on 47 isolates. Of the 118 study patients, 107 were treated with either metronidazole or vancomycin. Initial therapy was metronidazole in 98.1% (n = 105) and vancomycin in 1.9% (n = 2) patients. Evaluable clinical response within 5 days of treatment was noted in 52.5% (52/99) of cases. The mean duration of treatment was 11.7 ± 7.2 days. The 30-day all-cause mortality rate was 24.6% (29/118). Recurrence occurred in 23.6% (21/89). A recent stay in the intensive care unit was associated with increased 30-day mortality (odds ratio 3.58, p = 0.012). There were no isolates resistant to metronidazole or vancomycin. Only 1 isolate was possibly related to the NAP1/BI/027 reference strain. No strain-related differences in deaths or recurrence were noted. Deaths related to CDI in our study appear to be related to multiple factors and did not appear to be independently related to antibiotic susceptibility, strain type, or treatment duration.

Pilot study: does mode of skin closure affect risk of infection after caesarean section?

AimsA pilot study to determine whether the method of skin closure affects wound infection rates following caesarean section (CS). To evaluate current practice and preference of skin closure methods following...

Iatrogenic arterial injuries of spine and orthopedic operations

To describe the results of contemporary management of iatrogenic arterial injuries following spine and orthopedic operations. Patients with major arterial injuries following spine and orthopedic operations in four teaching hospitals (Henry Ford Hospital, Detroit, Mich; Henry Ford Macomb Hospital, Clinton Township, Mich; St John Macomb Hospital, Warren, Mich; and St John Hospital, Detroit, Mich) over the last 10 years were studied. Data were collected on a continuous basis from vascular registries and analyzed retrospectively. Seventeen patients (8 spine, 9 orthopedic operations) had iatrogenic arterial injuries manifest as thrombosis or laceration with bleeding, pseudoaneurysm, or arteriovenous fistula. The majority of arterial lacerations with bleeding and pseudoaneurysms were treated with open surgical repair while the majority of thromboses and arteriovenous fistulae were treated with endovascular techniques. Fasciotomy was necessary in three of seven patients with arterial complications of knee and hip operations. There was no mortality or limb loss. Significant morbidity in the form of foot drop (1), iliac vein thrombosis (2), delayed ambulation due to hematoma and swelling of the lower extremity (2), and ischemic myonecrosis of calf muscles (1) occurred. Two patients launched legal action. Arterial injuries following orthopedic and spine operations can be successfully managed by both open and endovascular techniques. Significant morbidity and increased length of stay is common. Patient dissatisfaction with the complication and need for ensuing treatment can have significant medicolegal consequences.

900 Evaluation of the Evidence Based Approach to Management of Bronchiolitis: A Prospective Study at St John's Hospital, UK

Background and aims: To review current practice in management of bronchiolitis and assess compliance with evidence based national guidelines. Methods: Results: Total: 75 patients. There were 39 males & 26 females. Of these 42 were < 6 months and 33 were >6 months. All our patients had SaO2 measured on admission. Blood gas was done only in 6/75 (8 %) due to worsening respiratory distress and increase in oxygen requirements. CXR was done in 12 /75 for atypical chest sign or worsening respiratory distress. NPA was done for inpatients 25/33 of which 13 were positive. None received Ribavarine. 7/75 (9.3%) received Antibiotics- These children were unwell or had worsening respiratory signs, high temperature or non Blanching spots. Salbutamol was given in 9/75 (12%). Nebulised ipratropium was given in 6/75 (8%).2 patients required CPAP support.1 patient with severe distress & recurrent apnoea was transferred to a tertiary PICU. On discharge all patients had saturations above 94% and oral intake more than 75% of normal. Conclusions: A very safe and evidence based practice is being followed that ensures that children who are seriously unwell are picked up and receive specialist care immediately. Reduction of unnecessary investigations and inappropriate treatment has ensured appropriate use of resources.

137: Steroid Resistant Minimal Change Disease Associated With Thymoma: A Case Report

STEROID RESISTANT MINIMAL CHANGE DISEASE ASSOCIATED WITH THYMOMA: A CASE REPORT Rakesh Lattupalli, Quresh Khairullah, Keith Bellovich, Joel Topf. Division of Nephrology, St John Hospital and Medical center, Detroit, Mi, USA Background: The association of glomerulonephritis and thymic tumor was first described by Posner et al in 1980 . The association is quite low; <1% in surgical series. A total of 21 cases have been reported in the French and English literature. Minimal change disease (MCD) is the most frequent (67%) thymoma associated glomerular lesion. Fortunately the majority (84%) of these patients are steroid sensitive. We report a case of steroid resistant thymoma associated MCD. Case Report: A 63-year-old male with past medical history of diabetes mellitus for six years was referred for new onset nephrotic syndrome. Kidney biopsy revealed MCD. The proteinuria did not respond to steroids. Further diagnostic tests revealed a mediastinal mass. Following removal this was diagnosed as spindle cell thymoma. Post thymectomy hypoalbuminemia persisted despite modest reduction in proteinuria. The patient continued to have edema resistant to diuretic therapy and eventually was started on dialysis. Discussion: The pathogenesis of glomerular lesions in thymoma related minimal change disease remains controversial. The beneficial effect of immunosuppressive therapy in most patients suggests a link between the immune system and MCD. Animal studies suggest that thymectomy does not modify the nephropathy. Further studies of this association between nephrotic syndrome and thymoma are needed to define the specific immune dysregulation associated with this disorder.