Clinical characteristics, attendance outcomes and deaths of homeless persons in the emergency department: implications for primary health care and community prevention programmes.

OBJECTIVES: Persons experiencing homelessness (PEH) are known to be often excluded from primary health care and community prevention programmes leading to high use of hospital emergency departments (EDs). This study aimed to identify demographic features, clinical characteristics and attendance outcomes of PEH presenting to ED. STUDY DESIGN: Analysis of routinely collected data set. METHODS: Clinical presentations and drug prescription data of PEH who presented a major ED in the West Midlands region of England from 2014 to 2019 were extracted and analysed using descriptive and inferential statistics. RESULTS: During the study period, 3271 of 596,198 presentations were made by PEH; 74% PEH attendees were male. Drug- and alcohol-related conditions, as well as pain and injury constituted the most frequent reasons for presentation, contributing to over half of all presentations. A significantly higher proportion of males (n = 481, 20.3%) presented with drug and alcohol problems than females (n = 93, 11.2%) (P ≤ 0.001). However, pain was the primary reason for presentation for twice as many female patients (n = 189, 22.8%) compared with males (n = 305, 12.9%) (P < 0.001). Nearly one in five left the ED before being assessed and a total of 39 patients (1.2%) died in the ED and 785 (24.0%) required in-patient admissions to the same hospital. CONCLUSIONS: Drug, alcohol and pain including the need of opioid analgesics constituted the majority of presentations made by PEH in ED. The observed rate of death of PEH in ED is 12 times higher than the general population. A very high proportion of PEH also leave the ED before being treated. Future research should focus on strengthening community interventions, particularly to improve access to those at risk of dual diagnoses of substance misuse and mental health problems. Interventions involving multisector collaborations are needed to improve seamless discharge from ED and minimise repeat attendance. Gender differences in the nature of presentations and ED outcomes needs to be investigated further.

Intermittent absent end diastolic velocity of the umbilical artery: antenatal and neonatal characteristics and indications for delivery.

OBJECTIVE: To check whether there is a difference in indications for delivery, antepartum and neonatal characteristics in intermittent absent end diastolic velocity (iAEDV) compared to persistent absent or reversed end diastolic velocity (pA/REDV). METHODS: A retrospective study of 109 patients with iAEDV or pA/REDV from 19 to 39 weeks. The delivery indication was classified as maternal or fetal. The primary antepartum and maternal characteristics were age, parity, AMA, chronic hypertension, PEC, thrombophilia, lupus, diabetes, smoker, placenta previa, gestational age (GA) at diagnosis of IUGR and/or SGA, GA at diagnosis of elevated S/D, iAEDV or pA/REDV, GA at delivery, minimal/absent variability day of delivery, BPP ≤ 6 prior to delivery. The primary neonatal outcomes were birth weight, arterial cord pH, neonatal demise, necrotizing enterocolitis, intraventricular hemorrhage and length of stay in the NICU. RESULTS: Fetuses with iAEDV were diagnosed with an elevated S/D at a later GA (29.6 vs. 27.5 weeks, p < 0.03), delivered at a later GA (31.6 vs. 29.7 weeks, p < 0.01), had a higher birth weight (1336.6 vs. 933 g, p < 0.0004), were more likely to be delivered for maternal indications (42.9% vs. 20.27%, p < 0.01), had a higher cord arterial pH (7.28 vs. 7.21, p < 0.002) and were less likely to have an arterial pH at birth <7.2 (0% vs. 34.1%, p < 0.002). CONCLUSIONS: Although fetuses with iAEDV have an improved antenatal course as compared with pA/REDV, indications for delivery are more likely to be maternal and adverse outcome is common.

Geometric morphometric analysis of shape outlines of the normal and abnormal fetal skull using three-dimensional sonographic multiplanar display.

OBJECTIVES: Geometric morphometric analysis has been used to quantify differences in biological shapes. Cranial irregularities are described in anomalous fetuses but are qualitative and ill-defined. Our goal was to apply geometric morphometric statistical analysis using three-dimensional (3D) multiplanar display to quantify shape differences in normal and abnormal fetal skulls. METHODS: This was a retrospective pilot study of mid-trimester patients undergoing ultrasonography. 3D multiplanar display using spatial rotation was used to identify landmarks in coronal and transverse planes to establish a consistent fetal facial profile. Outline coordinates of the brow were determined by blinded examiners using computer software. Elliptical Fourier analysis (EFA) was used to obtain sets of functional coefficients. An atypicality index (AI) was determined from retained principal component (PC) scores. An AI > 95(th) percentile of the expected distribution defined outliers. RESULTS: Outlines were successfully identified in 38 patients (six abnormal). Using the AI, there were three outliers, all from abnormal fetuses (trisomy 18, trisomy 21, and campomelic dysplasia). Two fetuses with trisomy 21 and one with an unbalanced translocation had normal atypicality indices. CONCLUSIONS: 3D multiplanar display and geometric morphometric analysis enable quantification of fetal skull shape. An abnormal skull shape was identified in two of four aneuploid fetuses and no normal ones. Geometric morphometric analysis represents a promising new quantitative modality which, when applied with 3D sonographic multiplanar display, may be used to more objectively analyze fetal malformation. Larger prospective trials are needed to refine the technique and improve reproducibility.

Walker-Warburg syndrome: prenatal ultrasound findings.

The prenatal sonographic findings in a case of Walker-Warburg syndrome are described. The patient was not at risk for this condition. Ultrasound examination at 34 weeks' gestation revealed hydrocephaly, Dandy-Walker anomaly, and striking ocular abnormalities. From a review of the literature it appears that while intracranial abnormalities can lead to the diagnosis in cases at risk for this syndrome, ocular abnormalities are rather characteristic for this syndrome and they should be searched for in every case of hydrocephaly or encephalocele.

Hypoplastic pulmonary artery: an unusual entity mimicking pulmonary embolism during pregnancy.

Hypoplastic pulmonary artery is an unusual congenital malformation. We describe a case of hypoplastic pulmonary artery diagnosed during the third trimester of pregnancy. The clinical and radiologic features mimicked pulmonary embolism, including hemoptysis, chest pain, pleural effusion, mild hypoxemia, and a suggestive ventilation-perfusion scan. Accurate differentiation of this entity from pulmonary embolism is necessary to obviate the need for prolonged anticoagulation.