"Bomb explosion on the Nis express" - lessons from a major incident, Kosovo 16 Feb 2001

On Friday 16 February 2001, terrorists detonated a bomb under a civilian coach travelling from Nis in Serbia to Gracanica in Kosovo. 10 people were killed at the scene. 13 casualties were treated in the British KFOR hospital (Reynolds Hospital) in Pristina. Another 8 casualties were evacuated to the American KFOR hospital at Camp Bondsteel. The incident provided a unique opportunity for co-operation between British, American, Russian, German and French KFOR hospitals, as well as with Serbian clinicians and forensic pathologists. This article analyses the medical management of this major incident, identifies the lessons to be learned from it, and also provides enough detail for teaching scenarios.     

Twelve-year experience with left atrial resection in the treatment of non-small cell lung cancer

Background

We retrospectively reviewed our 12-year experience in the surgical treatment of non-small cell lung cancer invading the left atrium. End points of the study were overall survival and factors potentially affecting survival.

Methods

Nineteen consecutive patients with lung cancer invading the left atrium underwent surgery. Three patients with N2 disease underwent induction chemotherapy. Patients with either incomplete resections or pN2 disease received postoperative chemoradiotherapy.

Results

Five-year survival was 14%, and the median survival time was 25 months. These figures refer to a very homogeneous group of patients with respect to the extent of atrial infiltration. Patients with N2 disease tended to have a worse outcome than patients with N0 or N1 disease (p = 0.06). The 3 patients with N2 disease who underwent induction chemotherapy were alive and disease-free at 30, 15, and 11 months from surgery. Survival was not affected by histology, type of surgery, or completeness of resection. Three patients with residual cancer in the atrial resection margin underwent postoperative chemoradiotherapy and are alive at 25, 17, and 15 months after surgery.

Conclusions

In spite of the poor survival rates we report, the present experience suggests that more-favorable results could be expected by the routine preoperative use of positron emission tomographic scan staging, a more-extensive assessment of atrial invasion, the application of induction chemotherapy in patients with N2 disease, and postoperative chemoradiotherapy in patients with tumors abutting the atrial resection margin.     

Review: IgA anaphylactic transfusion reactions. Part I. Laboratory diagnosis, incidence, and supply of IgA-deficient products

Despite yielding a definitive diagnosis in fewer than 20 percent of anaphylactic transfusion reactions, investigation for IgA deficiency and the presence of presumably pathogenic IgG anti-IgA is useful in patient management. Individuals with demonstrated anti-IgA are thereafter committed to receiving IgA-depleted cellular products or IgA-deficient plasma and derivatives to prevent recurrent severe reactions. Unfortunately, in populations of IgA-deficient individuals screened for anti-IgA, the predictive value of the test in the absence of a prior reaction is quite low. Anti-IgA testing is complex and limited to a few reference laboratories, many of which still employ a labor-intensive hemagglutination assay developed in the late 1960s. Timely decisions regarding further transfusion management of patients experiencing anaphylaxis often rely upon more rapidly obtained assays of the IgA concentration as an indicator of the likelihood of subsequent demonstration of anti-IgA. The scarcity of IgA-deficient banked plasma products and dedicated plateletpheresis donors has led to the development of American Rare Donor Program policies designed to appropriately allocate these precious resources. The test methods used to establish the diagnosis of IgA deficiency and identify the approximately one third of these individuals with anti-IgA are discussed, along with the incidence of abnormal tests in various populations. Also presented are testing recommendations for the identification of an IgA-mediated mechanism for transfusion-associated anaphylaxis and qualification of patients to receive rare IgA-deficient plasma-containing products.     

Ouabain-induced hypertension alters the participation of endothelial factors in alpha-adrenergic responses differently in rat resistance and conductance mesenteric arteries

1. This study compares the role of endothelial factors in alpha-adrenoceptor contractile responses in mesenteric resistance (MRA) and superior (SMA) mesenteric arteries from ouabain-treated (8.0 microg day(-1), 5 weeks) and untreated rats. The role of the renin-angiotensin system was also evaluated. 2. Ouabain treatment increased systolic blood pressure. In addition, ouabain reduced the phenylephrine response in SMA but did not alter noradrenaline responses in MRA. 3. Endothelium removal or the nitric oxide synthase (NOS) inhibitor (l-NAME, 100 microm) increased the responses to alpha-adrenergic agonists in both vessels. After ouabain treatment, both endothelial modulation and the l-NAME effect were increased in SMA, while only the l-NAME effect was increased in MRA. Endothelial NOS expression remained unaltered after ouabain treatment. 4. Indomethacin (10 microm) similarly reduced the noradrenaline contraction in MRA from both groups; in contrast, in SMA, indomethacin only reduced phenylephrine-induced contractions in segments from untreated rats. Co-incubation of l-NAME and indomethacin leftward shifted the concentration-response curves for noradrenaline more in MRA from ouabain-treated rats; tetraethylammonium (2 mm) shifted the noradrenaline curves further leftward only in MRA from untreated rats. 5.Losartan treatment prevents the development of hypertension but not all vascular changes observed after ouabain treatment. 6. In conclusion, a rise in endothelial NO and impaired prostanoid participation might explain the reduction in phenylephrine-induced contraction in SMA after ouabain treatment. An increase in the modulatory effect of endothelial NO and impairment of endothelium-dependent hyperpolarizing factor effect might explain why the ouabain treatment had no effect on noradrenaline responses in MRA.     

Management of iatrogenic vaginal constriction

OBJECTIVE: To prospectively assess the outcomes of four approaches to the surgical management of iatrogenic vaginal constriction. METHODS: A prospective study was initiated to evaluate all women who presented to our practice with the complaint of apareunia or dyspareunia secondary to postoperative vaginal constriction. All participants were initially offered and failed a trial of manual dilation. Between 1997 and 2002, 20 women underwent one of four surgical procedures: Z-plasty, vaginal incision of constriction ring, vaginal advancement, or placement of free skin graft. All 20 participants have been followed postoperatively, including assessment of dyspareunia and postoperative vaginal length and caliber. RESULTS: Three patients underwent Z-plasty, eight had incision of vaginal ring or ridge, eight had vaginal advancement, and one underwent placement of a free skin graft. Mean follow-up was 17 months (range, 3-32 months). Subjective cure was defined as resumption of pain-free vaginal intercourse. Objective cure was defined by findings on physical examination. The overall subjective and objective cure rates were 75% and 85%, respectively. CONCLUSION: The appropriate surgical procedure depends on the site and extent of the vaginal constriction, the state of the surrounding tissue, and the overall length and caliber of the vagina.