Placental complications in subsequent pregnancies after prior cesarean section performed in the first versus second stage of labor

OBJECTIVE

To examine whether prior cesarean delivery (CD) in the first stage of labor (non-progressive labor in the first stage - NPL1), when compared with CD in the second stage of labor (non-progressive labor in the second stage - NPL2), is associated with different rates of third stage placental complications in the subsequent delivery.

METHODS

A retrospective cohort study, of all deliveries following a CD due to NLP1 or NLP2 that occurred between the years 1988 and 2013, was undertaken. Multiple gestation pregnancies, known uterine malformations or uterine fibroids were excluded. Rates of third stage complications (retained placenta, adherent/increta/percreta placenta, manual removal of the placenta) were compared between the groups. Univariate analysis was followed by multivariate analysis.

RESULTS

During the study period, there were 3828 subsequent deliveries of parturients who were operated due to NPL1 and NPL2 (72.91 and 27.09%, respectively). Rates of manual removal of the placenta as well as adherent placenta were significantly higher among parturients following CD due to NPL2 (28.4 versus 24.0%, p = .04, 1.2 versus 0.4% p < .01, respectively). In a multivariate analysis controlling for possible confounders, adherent placenta was found to be independently associated with vaginal delivery following CD due to NPL2 (odds ratio 2.98, 95% confidence interval 1.30-6.77).

CONCLUSIONS

Prior CD due to NPL2 as opposed to NPL1 is independently associated with adherent placenta in the subsequent delivery. A higher index of suspicion may be needed when evaluating these women during pregnancy as well as during management of the delivery.

Assessment of maternal GBS colonization and early-onset neonatal disease rate for term deliveries: a decade perspective

Objective To assess the maternal group B streptococcal (GBS) colonization rate and neonatal early-onset GBS (EOGBS) disease in term deliveries, a decade apart. Methods This was a retrospective computerized study between 2005 and 2016. A universal GBS culture-based approach gradually replaced the GBS risk-oriented screening. A vaginal-rectal culture taken at 35-37 weeks was recorded at admission for delivery. Results We identified 149,910 term deliveries during the study period. GBS status was recorded in 53,879 (35.9%) cases. The GBS screening rate constantly increased from 20% in 2005 to 47.5% in 2016. GBS colonization rates significantly decreased, from 50.3% in 2005 to 31.7% in 2016, P<0.001. Overall, EOGBS disease was diagnosed in 37 term neonates (0.25 per 1000 live births.). The rate of EOGBS in neonates decreased dramatically from 0.361 per 1000 deliveries between 2005 and 2009 to 0.19 per 1000 deliveries between 2010 and 2016 (P<0.05). During the latter period, over 35% of the deliveries were screened for GBS. Remarkably, 64.9% of the EOGBS originated in the non-screened population. Conclusion The universal screening policy was associated with a significant decrease in neonatal EOGBS and therefore should be adopted. Further national surveillance studies should be performed in order to validate this approach.

Delayed diagnosis of intrapartum uterine rupture - maternal and neonatal consequences

Objective: To assess the maternal and neonatal outcomes following delayed diagnosis of uterine rupture (diagnosis during the early postpartum period) in comparison to women with an intrapartum diagnosis of uterine rupture.Methods: Retrospective study of electronic medical records (EMR) from 2005 to 2018 in a single large academic tertiary care. Demographic, obstetric and maternal characteristics and outcomes were retrieved and compared. Univariate, followed by multivariate analyses were applied to evaluate the association between maternal and neonatal outcomes. Only complete uterine ruptures were included. The primary outcome of this study was defined as hysterectomy rates. Secondary outcomes were maternal and neonatal morbidity parameters.Results: During the study period, 143 parturients with uterine rupture were identified from 174,189 deliveries (0.08%). Of these, 29 (20.3%) had delayed diagnosis with a median time from delivery to the operation of 4.5 hours (IQR 0.83-28 hours). Factors that were identified as independent risk factors for delayed diagnosis: an unscarred uterus (aOR 27.0, 95% CI 6.58-111.1), epidural analgesia during labor (aOR 7.9, 95% CI 2.32-27.05) and grand-multiparity (aOR 4.6, 95% CI 1.40-14.99). Maternal outcomes demonstrated that parturients with a delayed diagnosis had significantly higher rates of blood transfusions, puerperal fever, and hysterectomy (p<.001 for all). In a multivariate model, the delayed diagnosis was found to be independently associated with hysterectomy (aOR 4.90, 95% CI 1.28-19.40). There were no differences regarding to neonatal outcomes.Conclusion: Parturients with delayed diagnosis of uterine rupture have unique characteristics and poorer maternal outcomes. It is possible that awareness of this population will enable earlier diagnosis and may help improve outcomes.

Adherence to no-cost oral contraceptives among active-duty servicewomen

BACKGROUND

We aimed to evaluate the adherence to no-cost oral contraceptives (OC) among young single women and to identify factors associated with non-adherence.

METHODS

Retrospective cohort study included all single female soldiers who received free-of-charge OCs from military pharmacies in Israel between 2006 and 2015. Military pharmacies' dispensing registries were queried to assess the number of OC packages dispensed. Women were included in the study if their service continued for a period of at least 12 months from the time of receiving their first OC pack. Study outcomes were twelve cycles medication possession ratio (MPR), which is defined as the number of OC packs dispensed over a 12-cycle period divided by 12, presented as a percentage, and factors associated with the OC MPR as evaluated by multivariable regression analysis.

RESULTS

During the study period, there were 3 05 923 active servicewomen aged 18-24 years. A total of 82 203 (26.9%) women were dispensed at least one pack of OCs. The mean MPR was 51.8% (35.2%). Only 14% of women had good adherence (MPR ≥90%). Multivariate regression models showed that non-adherence (MPR <90%) was more common among servicewomen (adjusted OR (95% CI)): who failed to graduate from high school (1.9 (1.54-2.33)) and with combat or combat-support type of service (1.66 (1.30-2.13)). Other social/ethnic factors, including first-generation immigrant (1.13 (1.05-1.21)), sub-Saharan African origin (1.28 (1.04-1.58)), lower IQ scores (1.28 (1.22-1.34)) and combat-support type of service (1.22 (1.12-1.34)) were associated with non-adherence, but to smaller degrees. Neither income nor health status predicted adherence in this population receiving no-cost OCs.

CONCLUSIONS

Overall, 12 cycles OC adherence was universally low among active servicewomen. Adherence demonstrated small, but significant, associations with sociodemographic factors, with the lowest levels of adherence predicted by low educational attainment and combat service.

Twin pregnancy outcomes after metabolic and bariatric surgery

BACKGROUND

The effect of bariatric surgery (BS) on twin pregnancy outcomes is unclear.

OBJECTIVES

We examined associations of BS with maternal and perinatal outcomes among women with twin gestation.

SETTING

A university hospital.

METHODS

A retrospective case-control study of twin deliveries during 2006 through 2017. The study group comprised all women with twin pregnancy who had undergone BS and delivered during the study period. A control group was established by matching preoperative body mass index, age, parity, and delivery year.

RESULTS

Data from 66 women with twin gestation were analyzed, 22 postBS and 44 matched control parturients. Compared with the control group, the study group had lower rates of gestational diabetes (9.1% versus 36.4%, P = .02) and gestational hypertensive disorders (0% versus 25.0%, P = .01); hemoglobin levels were lower at both early pregnancy (median 12.3 versus 13.4 g/dL, P < .001) and after delivery (9.3 versus 10.5 g/dL, P < .001). Median neonatal birthweights and the proportion of small-for-gestational-age infants were comparable between the groups. The degree of birth weight discordance between the twins was higher (17.2% versus 8.8%, P < .001) in the control group.

CONCLUSIONS

In this study involving twin gestations, pregnancy outcomes were more positive among women who had undergone BS; as noted by reduced prevalences of gestational diabetes and gestational hypertensive disorders as well as a lesser degree of birth weight discordance. Nevertheless, BS was associated with lower hemoglobin levels during pregnancy and the postpartum period. Future studies are warranted to confirm our findings and evaluate the long-term outcomes of newborns of postBS mothers.

The recurrence risk of group B Streptococcus in consecutive deliveries

Background: Group B streptococcus (GBS) is a significant cause of neonatal morbidity and mortality. GBS maternal colonization status was found to be transient, intermittent, or chronic and screening during each subsequent pregnancy was advised. Recent studies showed that GBS colonization rate was higher among women with history of GBS positive in prior pregnancy.Objective: To establish the cumulative risk of group B streptococcus (GBS) colonization in consecutive subsequent term deliveries as referred to the first delivery GBS colonization status.Study design: A retrospective cohort study, based on a validated computerized database at a tertiary single center between the years 2005-2016. Pregnant women preform vaginal-rectal culture at 35-37 weeks of gestation. We analyzed records of term primiparas women that had records of up to three additional term consecutive deliveries and GBS colonization status.Results: 8641 primiparas met inclusion criteria; 3972 (46.0%), 993 (11.5%), and 243 (2.8%) had second, third, and fourth consecutive deliveries with recorded GBS status respectively. The overall colonization rate for primiparas was 28.4%. The cumulative rates and cumulative risks of repeated GBS positive colonization at the second, third and fourth term consecutive deliveries were 62.0%, 6.93 (95% CI 5.96-8.06), 68.0%, 5.05 (95% CI, 3.67-6.93), and 66.1%, 2.96 (95% CI, 1.54-5.68), respectively. Notably, after a negative GBS colonization in the first, second, and third repeated deliveries, the rate and cumulative risk of GBS positive in each consecutive delivery was significantly lower: 18.2%, 0.14, (95% CI 0.12-0.17), 19.4%, 0.21 (95% CI 0.15-0.28), and 21%, 0.26 (95% CI 0.13-0.51) for the second, third, and fourth consecutive deliveries, respectively.Conclusion: GBS colonization status at the time of first pregnancy is a milestone for the colonization risk in subsequent term deliveries. This risk evaluation may influence the decision-making process for future screening and intrapartum antibiotic prophylaxis for term consecutive deliveries.

The impact of epidural analgesia on the mode of delivery in nulliparous women that attain the second stage of labor

Objective: We aimed to evaluate the impact of epidural analgesia on the mode of delivery of nulliparous women with a term single fetus in vertex presentation (NTSV) that attained the second stage of labor.Study design: A single-center retrospective study provided a strict and constant department protocol for epidural analgesia practice and obstetric interventions, between 2005 and 2014. Epidural users were compared to nonusers. The primary outcome was the mode of delivery. Secondary outcomes were diagnosis of prolonged second stage of labor and maternal and neonatal morbidities. The outcomes were evaluated by adjusted multivariate analyses (Adjusted Odds Ratios (aOR), 95% CI).Results: During the study period, 25,643 NTSV attained the second stage of labor; 18 676 (73%) epidural users and 6967 (27%) nonusers. Epidural users had an increased risk of instrumental delivery 2.48, [2.22-2.76], along with a lower risk of cesarean delivery 0.38, [0.29-0.50]. Notably, the diagnosis of prolonged second stage of labor was comparable among the study groups 0.99, [0.89-1.12]. The epidural users had a significantly higher risk of early postpartum hemorrhage 1.15, [1.04-1.27]. The risk for neonatal morbidity was comparable among the study groups 1.21 [0.90-1.63].Conclusion: Epidural analgesia in a population of NTSV that attains the second stage of labor is associated with a higher risk of instrumental delivery, nonetheless with a reduced risk of cesarean delivery; independent of the length of the second stage of labor is and safe for the neonate.

Recurrent unintended pregnancies among young unmarried women serving in the Israeli military

Background

Unintended pregnancy is a major public health problem with known risk factors, however, little is known about the prevalence of variables associated with recurrent unintended pregnancy (RUP) among young, unmarried women.

Methods

A retrospective cohort study of unmarried women aged 18–21 serving in the Israeli military between 2013 and 2015. Multivariable logistic regression analysis was used to examine associations between RUP and women’s education, IQ, immigration status, country of origin, socioeconomic status and history of psychiatric illness.

Results

Of 129,638 women drafted by the Israeli military during the study period, 1720 women with unintended pregnancies had a follow up period of at least a year. Three hundred and eighty-nine of them had RUP (22.6%). Multivariable models comparing women with no unintended pregnancies and women with RUP revealed that RUP was more common among (adjusted relative risk; 95% confidence interval) women who had not graduated from high school (6.9; 4.99–9.55), who had low (90–99) IQ scores (3.9; 2.88–5.39) those reporting Africa as the country of origin (2.5; 1.37–4.59) and those from a lower socioeconomic neighborhood (1.6; 1.18–2.05). Multivariate regression modeling comparing women with single unintended pregnancies and women with RUPs showed that recurrent unintended pregnancy was more common among women who had not graduated from high school (3.2; 2.04–4.84) and those who had a low (90–99) IQ score (1.9; 1.32–2.61).

Conclusion

Rate of RUP is high among women serving in the Israeli military. These women have unique epidemiological characteristics. This may serve in identifying populations at high risk and thus may enable policy maker to offer at least to this population Long-Acting Reversible Contraception (LARC) methods. We encourage policy makers to consider the provision of LARC methods to all servicewomen who had an unintended pregnancy.

Prolonged operative time of repeat cesarean is a risk marker for post-operative maternal complications

Background

Repeat cesarean delivery (CD) accounts for approximately 15% of all annual deliveries in the US with an estimated 656,250 operations per year. We aimed to study whether prolonged operative time (OT; skin incision to closure) is a risk marker for post-operative maternal complications among women undergoing repeat CD.

Methods

We conducted a cross-sectional retrospective study in a single tertiary center including all women who underwent repeat CD but excluding those with cesarean hysterectomy. Prolonged OT was defined as duration of CD longer than the 90th percentile duration on record for each specific surgeon in order to correct for technique differences between surgeons. Bi-variate analysis was used to study the association of prolonged OT with each one of the following maternal complications: post-operative blood transfusion, prolonged maternal hospitalization (defined as hospitalization duration longer than 1 week post-CD), infection necessitating antibiotics, re-laparotomy within 7 days post-CD, and re-admission within 42 days post-CD. A multivariate regression analysis was performed controlling for maternal age, ethnicity, parity, number of fetus, gestational age at delivery, trial of labor after cesarean, anesthesia, and number of previous CDs. The adjusted odd ratio was calculated for each complication independently and for a composite adverse maternal outcome defined as any one of the above.

Results

A total of 6507 repeat CDs were included; prolonged OT was highly associated (P value < 0.000) with: post-operative blood transfusion (4.4% vs. 1.5%), prolonged hospitalization (8.4% vs. 4.0%), infection necessitating antibiotics (2% vs. 1%), and readmission (1.8% vs. 0.8%) when compared to control. The composite adverse maternal outcome was also associated with prolonged OT (20.2% vs. 11.2%, p < 0.000). These correlations remained statistically significant in the multivariate regression analysis when controlling for confounders.

Conclusions

Among women undergoing repeat CD, prolonged OT (reflecting CD duration greater than 90th percentile for the specific surgeon) is a risk marker for post-operative maternal complications.

Risk factors associated with neonatal thrombocytopenia in pregnant women with immune thrombocytopenic purpura

Objectives: To characterize the risk factors associated with neonatal thrombocytopenia among pregnant women with immune thrombocytopenic purpura (ITP).Methods: We reviewed the records of ITP patients who delivered during 2006-2016 at our medical center.Results: Of 253 pregnancies, median maternal age at diagnosis was 29 [25-33] years, 222 (87.7%) had previously-diagnosed ITP and 31 (12.3%) were diagnosed with new-onset ITP during pregnancy. Baseline characteristics were comparable between the groups except for a higher proportion of nulliparity among those with new-onset disease (p = .002). Maternal nadir platelet count was significantly lower among those with new-onset compared to previously diagnosed ITP (median 62 × 10⁹/L versus 81 × 10⁹/L, p = .005). Neonatal thrombocytopenia (<150 × 10⁹/L) was encountered in 24 (9.5%) pregnancies and required treatment in 12 (50%) of them. Neonatal platelet count was directly correlated with maternal platelet count at delivery (r = 0.23, p = .01), with significantly lower maternal platelet count among those whose newborns experienced thrombocytopenia (p < .001). Neonatal thrombocytopenia followed a higher proportion of pregnancies of women with new-onset than previously diagnosed ITP (22.6 versus 7.7%, p = .02). In multivariate analysis, the presence of new-onset ITP (odds ratio [95% CI]: 4.88 (1.68, 14.16), p = .004) was the only independent predictor of the development of neonatal thrombocytopenia.Conclusion: Neonatal thrombocytopenia presented following almost one-tenth of pregnancies with ITP. New pregnancy-onset disease was the only prognostic marker for neonatal thrombocytopenia. This finding could contribute to risk stratification and individualized patient management.

Blunt Scrotal Trauma in Soldiers-Epidemiology and Outcome

INTRODUCTION

Blunt scrotal trauma (BST) is common among soldiers but its incidence and outcome are unknown. The purpose of this study was to estimate the incidence, clinical findings, and outcome of BST in soldiers referred to a primary care field physician.

MATERIALS AND METHODS

The medical records of soldiers in their military services who sustained BST and were evaluated by primary care field doctors over a 10-year period were reviewed. Anamnestic data, physical findings, primary care physician decisions, hospitalization, and surgery rates as well as final outcomes were analyzed.

RESULTS

The medical records of 382,036 soldiers were reviewed and 668 cases (0.175%) of BST were identified. All patients complained of scrotal pain and 10% of dysuria. The most common physical findings included: scrotal tenderness (71.7%), scrotal edema (16.2%), and scrotal hematoma (4.8%). In 11.8% of the visits microhematuria was found in urine dip stick. A total of 243 patients (36.4%) were referred to emergency department, but only 9 (3.7%) were hospitalized. Of these, 3 patients underwent surgical exploration due to suspected testicular rupture in ultrasonography. Finally, testicular rupture was found only in 1 patient. This testis was sutured. In another patient testicular torsion was found and orchiectomy done. 168 patients (25.1%) developed prolonged scrotal pain lasting for more than 2 weeks after the trauma.

CONCLUSIONS

Blunt testicular trauma is not an uncommon phenomenon among soldiers. Surgical intervention is rarely needed and in 99.6% of cases seen by general practitioners supportive management is suffice. The phenomenon of prolonged post-traumatic testicular pain, developing in a quarter of the patients after BST pain deserves more research.

The value of a registry negative urine pregnancy test for the prediction of a future unintended pregnancy among young women

BACKGROUND

Performance of urine pregnancy test in general adolescents' clinic reflects caregiver or woman's concern that there might be a pregnancy. We aimed to assess whether young-unmarried women in whom a negative urine pregnancy test was registered would be at increased risk of a future unintended pregnancy.

METHODS

The study cohort included consecutive women drafted by the Israeli military between 2013 and 2015. The risk of unintended pregnancy was compared between women with a negative urine pregnancy test (n = 2774), the study group, and those in whom urine pregnancy test was not carried out (n = 126,659), the control group.

RESULTS

During the study period, 2147 (1.7%) women experienced an unintended pregnancy. The risk of unintended pregnancy was significantly higher in patients in whom a past pregnancy test was negative 4.3% (n = 118), as compared with the control group 1.6% (n = 2028) (odds ratio [OR], 2.7; 95% confidence interval [CI], 2.23-3.26). In multivariate analysis history of a negative pregnancy test results was an independent predictor for a future unintended pregnancy (adjusted OR, 2.0; 95% CI, 1.63-2.52).

CONCLUSIONS

A history of a negative pregnancy test among young conscripted women is a significant risk indicator for a future unintended pregnancy. Directed efforts should be made in this particular vulnerable group of patients.

Endometriosis-associated malignant transformation in abdominal surgical scar: A PRISMA-compliant systematic review

BACKGROUND

Endometriosis-associated malignant transformation in abdominal surgical scar (EAMTAS) is a very rare and aggressive phenomenon. Our current article aims to provide a clinical overview, focusing on risk factors affecting survival.

METHODS

We performed a Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review based on prior reviews and case reports regarding the phenomenon published as abstracts in English, from January 1980 to November 2016. Overall, we identified 47 cases, and we included another case from our institution. We further contacted previous investigators to receive updated follow-up regarding their patients. We analyzed the data, focusing on risk factors that might affect overall survival.

RESULTS

All the patients reported in the literature had a uterine surgery, mainly caesarean section. The median time-lag from first surgery to the diagnosis of cancer was about 19 years. Clear-cell carcinoma (CCC) was the most prevalent histology (67%), followed by endometrioid adenocarcinoma (15%). Most of the patients were treated by extensive surgery and chemotherapy and/or radiation. Overall 5 years survival was about 40%. Median overall survival was 42 months (95% confidence interval of [18.7, 65.3]). Although our review is currently the largest in the literature, we cannot draw any statistical significant results due to the limited number of patients reported. According to univariate Cox-regression models, a tendency toward worse prognosis was shown for 3-year disease-free survival clear cell histologic-type (P = .169), and tumor diameter ≥8 cm in nonclear-cell histology, 18 months postdiagnosis (P = .06).

CONCLUSION

EAMTAS is a rare and aggressive disease. It is mostly related to cesarean section scars and is diagnosed many years postsurgery. Clear-cell histology tends to endure from the worse prognosis. The treatment is mainly extensive surgery and adjuvant chemotherapy and/or radiotherapy.

Chronic scrotal pain in young adults

OBJECTIVE

Chronic scrotal pain (CSP) is a common and well recognized symptom of young males presenting to primary care units. Historically, CSP is defined as a testicular pain lasting for over 3 months. However, its etiology and outcome are poorly understood and its management is largely empirical. This study was conducted to examine the frequency, spectrum of pathology and outcome of CSP among young adults.

RESULTS

The medical records of 382,036 young males were reviewed for anamnestic information, physical findings, primary care physician decisions, and final outcome. CSP, defined as scrotal pain longer than 14 days, was recorded in 3084 patients (0.8%). The total number of primary physician's visits due to this complaint was 16,222, with a mean of 5.3 visits per patient (range 1-37). Varicocele was the most common physical finding (54.1%). Other common findings were inguinal hernia (4.5%), genital infection (4.3%), hydrocele (4.2%) and referred pain (3.3%). 252 patients (8.2%) underwent surgical treatment but orchiectomy was not necessary in any patient. In 34.4% no specific etiology could be found. Neither malignant tumors nor testicular torsion were diagnosed in any patient. The prevalence of the diagnoses was similar between the different time groups-15-29 days, 30-59 days and more than 60 days. Considering the similar etiologies CSP over a wide spectrum of time we suggest defining CSP as testicular pain lasting longer than 14 days.

Unintended pregnancies among women serving in the Israeli military

OBJECTIVE

The objective was to identify the prevalence of and variables associated with unintended pregnancy among young, unmarried women serving in the Israeli military.

STUDY DESIGN

We performed a retrospective cohort study of unmarried women drafted by the Israeli military between 2013 and 2015 at the age of 18 years. We used multivariable logistic regression to examine associations between unintended pregnancy and women's education, IQ, immigration status, country of origin, neighborhood socioeconomic status and history of psychiatric illness.

RESULTS

Most women (n=127,262) did not become pregnant while serving in the Israeli military. Unintended pregnancy was reported by 2365, with an additional 6 women reporting pregnancy resulting from sexual assault and 5 an intended pregnancy. Annual rates of unintended pregnancy among young women serving in the Israeli military declined from 1.69% in 2013 to 1.56% in 2014 and 1.33% in 2015. In multivariable models, unintended pregnancy was more common among women soldiers who had not graduated from high school (adjusted relative risk [RR], 5.3; 95% confidence interval [CI], 4.69-6.04) and those who were first-generation immigrants (adjusted RR, 2.1; 95% CI, 1.90-2.35).

CONCLUSION

Unintended pregnancy is rare among women serving into the Israeli military.

IMPLICATIONS

Increasing contraceptive use among women who have not graduated from high school may further reduce rates of unintended pregnancy among women serving in the Israeli military.

The clinical findings in young adults with acute scrotal pain

BACKGROUND

Acute scrotal pain (ASP) is a common symptom of young adults. Testicular torsion is the most important diagnosis in these cases. It is a medical emergency in which the diagnosis must be made rapidly to prevent testicular loss. This requires a high index of clinical suspicion and prompt surgical intervention. This study was conducted to examine the spectrum of diagnoses in young man with ASP in a prehospital setting, the frequency of significant diagnoses, and their outcomes.

METHODS

The medical records of young adults in their obligatory military service presenting with ASP to primary care clinics from 2004 to 2014 were reviewed using the keywords: pain, testis, torsion, and orchialgia. Anamnestic data, physical findings, primary care physician decisions, and final outcomes were analyzed.

RESULTS

A total of 9922 medical visits were recorded. Idiopathic scrotal pain, varicocele, scrotal trauma, and genital tract infections were the most common diagnoses. In 3 visits (0.03%), testicular cancer was diagnosed. Testicular torsion was the etiology of ASP in only 12 (0.12%) visits, and 60% the testes were salvaged. The mean duration of symptoms in the salvaged group was 6.33 hours; and in the nonsalvaged group, 44 hours.

CONCLUSIONS

Testicular torsion is the etiology of ASP in only 0.12% of the visits to the primary care clinic. Patient delay before attending the primary care is responsible for most of the testes lost. Patient education in addition to high index of suspicion of primary care physicians is needed for salvage of more testicles.

Doxycycline induced oesophageal ulcers in a navy ship crewmember

A healthy 25-year-old crewmember of a navy ship was diagnosed with suspected pneumonia and prescribed 100 mg twice a day of doxycycline for 10 days. During the 7th day of treatment the patient joined his navy ship to sail aboard and 2 days later, immediately after taking the doxycycline capsule, he felt a forceful pain in the median chest which was followed with odynophagia of both solid foods and liquids. The patient adhered to the administration guidelines of the doxycycline, except drinking 330 mL of beer, 3 h before taking the capsule. A working diagnosis of atypical chest pain, possibly due to oesophagitis, was made. The patient was advised to fast and rest and treatment with intravenously (IV) H2-receptor antagonist, clear fluids and analgesics was started. Later on, due to lack of improvement in the patient's status and the potential risk of future deterioration, a decision was made to evacuate the patient to a hospital. Gastroscopy, revealed 3 ulcers in the mid-oesophagus and the patient was hospitalised for treated of IV antacids and fluids with gradual improvement. This case emphasizes the limitation of diagnosing and treating a common side effect in the middle of the sea and the potential risk in taking medications with alcohol.

Needle Thoracotomy in Trauma

Tension pneumothorax is one of the leading causes of preventable death in trauma patients. Needle thoracotomy (NT) is the currently accepted first-line intervention but has not been well validated. In this review, we have critically discussed the evidence for NT procedure, re-examined the recommendations by the Advanced Trauma Life Support organization and investigated the safest and most effective way of NT. The current evidence to support the use of NT is limited. However, when used, it should be applied in the 2nd intercostal space at midclavicular line using a catheter length of at least 4.5 cm. Alternative measures should be studied for better prehospital management of tension pneumothorax.

[CHRONIC MYELOID LEUKEMIA IN A YOUNG MALE PRESENTING WITH BILATERAL CALF PAIN DUE TO LEUKOSTASIS]

Chronic myeloid Leukemia (CML) is a chronic myeloproliferative disorder, caused by the unregulated proliferation of granulocytes at different stages of development and maturation. Leukostasis is one of the complications of CML, causing partial or total occlusion of microvasculature with a variety of clinical manifestations, mostly ophthalmic, neurologic or respiratory. Recently, we encountered a 21-year old soldier, who complained of severe bilateral calf pain which began a few months earlier during training. He underwent complete ambulatory orthopedic evaluation which was unrevealing, and finally presented to the hospital casualty department where CML was diagnosed on the basis of an elevated WBC count and morphologic findings. Bilateral retinal hemorrhages due to leukostasis were noticed at fundoscopy. The calf pain resolved completely after leukapheresis and initial cytoreductive therapy and was in retrospect attributed to peripheral leukostasis. To the best of our knowledge this is the first report of CML presenting with bilateral calf pain due to Leukocytosis and possible leukostasis. This case report highlights the importance of differential diagnosis in cases of calf pain and the awareness of this rare manifestation of CML.

Pre-hospital intra-osseous freeze dried plasma transfusion: a case report

Background

Hemorrhage and coagulopathy are among the leading causes of death in combat and are considered the leading causes of preventable deaths. Plasma, in the form of Fresh Frozen Plasma (FFP) is considered a key component in the Damage Control Resuscitation performed within hospitals. Freeze-Dried Plasma (FDP) can be stored at room temperature and therefore is potentially useful in pre-hospital conditions. Our case report join to few cases where FDP was administered at the point of injury. It is also unique as it describes an intra- osseous administration given to pediatric patient.

Case report

M.S. otherwise healthy 13 year old girl was injured due to gunshots and grenade blast. On the first triage by the IDF medical teams she suffered from: Severe hemorrhagic shock, (Blood pressure could not be measured, Heart rate 163), superficial wounds to her face, (forehead and Rt. Eye), gunshot wounds with active bleeding from her Lt. Arm and her RT. Knee (Mangled Extremity Severity Score (MESS) 8) and open fractures of left elbow and right thigh. A peripheral intravenous catheter was established and 1 g tranexamic acid in 500 ml of Hartman fluid were administered. Due to difficulties in establishing a functioning intra-venous line, an intra-osseous catheter was established and one unit of FDP (250 ml) was given in the field. She was transferred by a military medical team to a regional civilian hospital for further treatment. Upon arrival to the hospital her blood pressure and heart rate were significantly improved. After three weeks of hospitalization M.S. was discharged and she was returned to her homeland.

Conclusion

We have described the successful use of FDP for pre hospital resuscitation of a 13 year old girl suffering from severe hemorrhagic shock as a result of gunshots and grenade blast. This case report demonstrates that intra-osseous FDP administration for as part pre hospital resuscitation of children has a favorable outcome.