Air Transport of Patients with Unstable Aortic Aneurysms Directly into Operating Rooms

Objective. The purpose of this study was to describe an air transport service's protocol for direct transport of patients with abdominal aortic aneurysm leak (AAAL) into receiving hospital operating rooms (ORs). Methods. This retrospective consecutive-case analysis examined AAAL patients undergoing nurse-paramedic Boston MedFlight (BMF) transport during 1999–2004, who were taken directly into ORs at four academic centers. BMF uses a rotating roster system to assign receiving hospitals when referring physicians have no preidentified receiving facility, but this practice may prolong patient transport or be associated with less diagnostic certainty, andthus more delay, at receiving hospitals. Thus, the study compared “Roster” versus “Non-roster” patients' time andoutcome end points. Continuous nonparametric data (e.g., time intervals) were described with median andinterquartile range (IQR). Chi-square andKruskal-Wallis tests were used for univariate comparisons; regression analysis assessed dependent variables while adjusting for covariates (e.g., transport mileage). Results. There were 29 direct-to-OR transports, with median distance of 30 miles. All patients had AAAL diagnosis confirmed; 51.7% survived. System performance for end points was similar as assessed between Roster versus Non-roster patients. Conclusions. Interfacility direct-to-OR transport of AAAL patients is feasible. Use of a roster system allows for timely transport facilitation for patients needing specialized care; roster patients achieve similar end points as did patients who had already-identified receiving hospitals upon air medical transport request.     

Spontaneous migration of bullet from arm to forearm and its ultrasound guided removal

Spontaneous migration of a retained bullet is rare. We are presenting here a case of a 24-year-old male with spontaneous migration of bullet from arm to forearm. At the time of initial injury, bullet was left inside the arm as it was deep and patient had no complaints. Three months after injury, he started complaining of pain over forearm and tingling sensations in the forearm and hand over median nerve distribution. Radiographs showed bullet in the proximal forearm. The bullet was than precisely localized and removed under ultrasound guidance. This case report emphasizes the fact that spontaneous migration of bullet in extremities may occur and have the potential to cause neurovascular damage. Removal under ultrasound guidance is a viable option in such locations.     

Pseudo-aneurysm of mitral aortic intervalvular fibrosa: Two case reports

The fibrous body between the mitral and aortic valve, known as mitral-aortic intervalvular fibrosa (MAIVF) is prone to infection and injury resulting in pseudo-aneurysm formation. Because of its relative rarity, we are far from making any conclusion regarding the natural history and appropriate therapeutic strategy for this condition. We report two cases of this condition with two different and rare etiologies with strikingly different natural courses, providing insight into the natural course and timing of surgery in this rare entity.     

Metastatic Differentiated Thyroid Carcinoma: ClinicopathologicalProfile and Outcome in an Iodine Deficient Area

Reports on metastatic differentiated carcinoma in endemic goiter regions are scarce. The aim of this study was to look into the clinicopathological profile and outcome of patients with metastatic differentiated thyroid carcinoma (DTC) of endemic origin. This was a retrospective study of 28 cases of metastatic DTC out of a total of 140 DTC patients managed between 1990 and June 1999. Demographic data, clinicopathological profile, operative and radioiodine ablation therapy details, and follow-up findings were noted. The overall incidence of distant metastases in our series was 20%. Mean age was 48.5 +/- 12.8 years (32.1%patients were < 45 years). Most metastases were detected synchronously (85.7%) and were multiple, with the skeletal system being the commonly affected site. Out of 22 cases having skeletal metastases, 6 patients were young (< 45 years). Though most patients with skeletal metastases had follicular carcinoma (FTC), 4 cases had papillary thyroid cancer (PTC). Near total or total thyroidectomy was done in 26 cases. Sixteen patients required regional lymph node dissection. Resection of metastases was performed in 9 cases.Histopathological diagnosis was PTC, FTC, and poorly differentiated carcinoma in 32.1%, 50.0%, and 17.9% of cases, respectively. Most patients had good symptomatic palliation following administration of I131 therapy. In 17.9% of cases there were locoregional recurrences. There was an overall 28.6% mortality. Two patients expired in the perioperative period. Six others died in follow-up (all within 3-9 months). In contrast to iodine sufficient regions, the incidence of metastases was high; the majority of cases had synchronous, symptomatic skeletal metastases. Skeletal metastases were not infrequent even in cases of PTC and in young patients. One-third of the cases were young. Though survival was poor despite aggressive management, significant symptomatic palliation could be achieved in most cases.