The trend of mortality rates following hospitals downgrading and closures due to outbreak of COVID-19 in Fars province: A comparative cohort study.

Background and Aims: Hospitals are one of the most important healthcare centers for providing the patients with different medical needs. Several different factors might cause hospitals to downgrade their services or departments or close down overall. One of the most multifaceted reasons for hospital downgrading or closure is infectious disease outbreaks. In this regard, we aimed to evaluate the effects of hospital closure and downgrading due to the COVID-19 pandemic on the mortality rate of the people residing in Fars province, Iran. Methods: We gathered mortality information, including the cause of death, age, sex, place, and time of death of all deceased cases occurring during a period of 3 years, from February 20, 2018 to March 2021 from the forensic medicine and also the Department of Biostatistics in Shiraz University of Medical Sciences. Results: A total of 71,331 deaths have been reported since 2018 through the first quarter of 2021, with 57.9% of total mortality cases attributed to male gender. The total mortality counts ranged from 4229 to 9809 deaths per quarter, from which the minimum rate was reported in the first quarter of 2018 and the maximum in the fourth quarter of 2020. Based on the causes of death, diseases of the circulatory system were shown to be the all-time most frequent cause of death, accounting for a total of 42.8% of recorded deaths, followed by neoplasms (9.77%) and diseases of the respiratory system (9.45%). Conclusion: Although the large number of deaths at the time of the pandemic are immediately due to COVID-19 infection, deaths due to a notable number of other causes have had a significant increase which, along with the specific trend of place and causes of death, shows that the downgrading and closure of hospitals have had a significant impact on overall population mortality.

Unexpected Findings of Regulatory Factor X6 Gene Mutation and Severe Hepatic Macrovesicular Steatosis in a Neonate with Congenital Left Ventricle Diverticulum: A Case Report.

Herein we present a case of a neonate with congenital left ventricular diverticulum (LVD), a rare anomaly, with an unusual course and unexpected findings. The neonate was born at 35 weeks in Namazi Hospital (Shiraz, Iran) and presented with a pulsatile umbilical mass immediately after birth. Based on multiple imaging modalities, the presence of a connection between the left ventricular apex and the umbilicus was confirmed. Percutaneous closure of LVD was unsuccessful. The patient's clinical course deteriorated after developing sepsis and multiorgan failure. The patient passed away before any corrective surgery could be performed. Unexpected findings in post-mortem evaluation were severe hepatic macrovesicular steatosis (suggestive of metabolic liver disease) and regulatory factor X6 (RFX6) heterozygous missense mutation in whole-exome sequencing.

Iatrogenic L5 Nerve Injury Following Decortication of the Sacral Ala in Posterolateral Lumbosacral Fusion Surgery.

STUDY DESIGN: Cadaver study. OBJECTIVES: To investigate the risk of the L5 nerve injury following sacral ala decortication performed during lumbosacral posterolateral fusion surgery. METHODS: Fourteen fresh cadaver pelvises were dissected through an anterior approach and the L5 nerves on both sides were explored and macroscopically examined by direct observation. Then, the corticotomy of the sacral ala was performed at 0°, 20°, and 30° angles to the sagittal plane through the posterior approach. The site of sacral ala decortication was checked on each side and its distance to the L5 nerve root was measured. RESULTS: The tip of the osteotome was in the danger zone (5 mm medial to 5 mm lateral to the L5 nerve) in all cases (100%) where the osteotome had 0° angle to the sagittal plane. For those with a 20° angle, the osteotome tip laid in the danger zone in 83% and intermediate zone (between 6 to 15 mm lateral to the nerve) in 17% of cases. For those with a 30° angle, the tip was in the safe zone (>15 mm lateral to the nerve) in all cases (100%). CONCLUSION: Osteotomy of the sacral ala with <30° angle to the sagittal plane risks injury to the L5 nerve; whereas osteotomy angle >30° would not cause any injury to the nerve. It should be considered as a possible cause of iatrogenic L5 nerve injury in patients undergoing posterolateral lumbosacral fusion.

Feasibility of Medial Pectoral Nerve to Musculocutaneous Nerve Transfer Using Medial Antebrachial Cutaneous Nerve of Forearm Graft: Histopathologic and Anatomical Evaluation.

AIM: To evaluate the compatibility of medial antebrachial cutaneous nerve of the forearm (MACN) with medial pectoral (MPN) and musculocutaneous (MCN) nerves for the anastomosis from anatomical and histopathologic aspects. MATERIAL AND METHODS: Ten brachial plexus specimens from five cadavers were dissected. The distances of the distal ends of MPN and MACN and proximal ends of MACN and MCN were measured from coracoid. Histopathologic slides from the four mentioned nerve ends were provided. The number of fascicles, cross-section diameter, and area of each nerve ends were measured. RESULTS: The distance of proximal and distal ends of MACN were adjacent to MPN and MCN. The mean number of fascicles (4.5 ± 1.2 vs. 2.9 ± 1.0), area (6.0 ± 2.5 vs. 2.8 ± 2.4) and diameter (2.7 ± 0.6 vs. 1.8 ± 0.7) of the distal end of MACN was significantly more than MCN. The mean number of fascicles (4.4 ± 1.4 vs. 2.6 ± 0.5), area (5.6 ± 2.4 vs. 2.0 ± 1.0) and diameter (2.6 ± 0.6 vs. 1.6 ± 0.4) of the proximal end of MACN was significantly more than MPN. The mentioned parameters were similar between MCN and MPN. CONCLUSION: Our study reveals that MACN is not a proper graft for MCN and MCN anastomosis due to the incompatibility of its diameter, area, and number of fascicles.

Effectiveness and Safety of Triangular Fibrocartilage Complex Injection Regarding Anatomical Landmarks: A Cadaveric Study.

Background Triangular fibrocartilage complex (TFCC) injections can be applied using anatomical landmarks or under the guide of ultrasound (US). US is not always available, and the physician may rely on the anatomical landmarks. Objective The study aims to evaluate the effectiveness and safety of TFCC injection with anatomic landmarks. Methods Forty wrist specimens from cadavers were randomly assigned to four rapid blue stain injection groups as follows: Group A: perpendicular to skin with 5 mm depth; Group B: perpendicular to skin with 10 mm depth; Group C: 45-degree angulation to skin surface, oriented from proximal to distal with 10 mm depth; and Group D: 45-degree angulation to skin surface, oriented from distal to proximal with 10 mm depth. TFCC specimens were excised and evaluated with microscopy, and adjacent neurovascular structures were checked for any injury. Results Injections in group A were more accurate than others, in which 8/10 injections were successful. Group C injections were least accurate in that only 4/10 were successful. The other remaining groups (groups B and D) revealed similar results (5/10 were successful). However, statistical analyses did not show any significant difference ( p -value = 0.35). No injury to neurovascular structures was seen. Conclusion Needle placement perpendicular to skin with 5 mm depth and just medial to ulnar styloid can be used as an accurate method of palpation-guided technique for TFCC injections.

Autopsy diagnosis of leptomeningeal carcinomatosis, the first manifestation of gastric adenocarcinoma: a rare case report and review of the literature.

This study aimed to report an unusual presentation of an advanced gastric adenocarcinoma. Leptomeningeal carcinomatosis is a rare event in gastric adenocarcinoma. It is much more uncommon as the primary manifestation in post-mortem evaluation of the cause of death in a patient presenting with headache and neurological signs and symptoms. Herein, we discuss our experience with a case of gastric adenocarcinoma, who was diagnosed after death, presenting with neurological signs and symptoms of leptomeningeal carcinomatosis. A 52-year-old gentleman presented with intractable headache and neck pain as well as vertigo. His physical examination showed only decreased deep tendon reflexes. He died after a short period of coma. Post-mortem evaluation showed numerous signet ring cells in the subarachnoid space as well as gastric malignant ulcer. In patients with intractable headache with no identifiable cause, meningeal involvement and infiltration should be considered as the probable underlying cause. Radiologic findings are not significant; however, lumbar puncture can be diagnostic.

Can We Release All Calcaneal Attachments of the Superior Peroneal Retinaculum During Extensile Lateral Approach to the Calcaneus?

During extensile lateral approach to the calcaneus, in order to see all fractured fragments and subtalar joint, all soft tissues including insertion site of superior peroneal retinaculum (SPR) on the calcaneus should be released. The aim of this study was to evaluate the probability of peroneal tendon dislocation by releasing all soft tissues attached to the calcaneus. In 10 fresh cadavers, after standard extensile lateral approach to the calcaneus in right side, all soft tissues attached to the lateral wall of the calcaneus were excised. In the left side of each cadaver, all soft tissues inserted to the superior border of calcaneal tuberosity in addition to the lateral wall of the calcaneus were cut out. Probable anterior dislocation of peroneal tendons in the retromalleolar groove was assessed by placing a clamp into the peroneal tendon sheath from distal to proximal and advancing it to the retromalleolar groove. Also by careful dissection, any instability of peroneal tendons was visualized. Not any anterior dislocation of peroneal tendons to the lateral malleolus tip was seen in any stage of the procedure. Insertions of the SPR to the fascia of the deep posterior compartment of the leg and the Achilles tendon sheath are the main soft tissue stabilizer of the peroneal tendons in the retromalleolar groove. So resection of the insertion site of the SPR to the calcaneus might not result in the peroneal tendon instabilities.

First survey of forensically important insects from human corpses in Shiraz, Iran.

The presence of insects on human cadavers has potential judicial value in medicolegal cases. This research emphasized the important role of insects in postmortem decomposition. It was conducted to investigate the composition and abundance of insects from human corpses during autopsies in legal medicine. It was implemented in the city of Shiraz, south Iran. Insects associated with human corpses were carefully collected and put into labelled vials. They were then identified using valid taxonomic keys. Fifteen outdoor (67%) and indoor discovered cadavers were examined. All but one was covered at the time of discovery. From these several species of entomofauna played important roles in the minimum postmortem interval (minPMI) estimate. Insects included the orders of Diptera and Coleoptera. Overall, 14 different species of arthropods were identified. Within Diptera, 2 families of Sarcophagidae and Calliphoridae were present in 73% of the cases with Calliphora vicina Robineau-Desvoidy and Chrysomya albiceps Wiedemann accounting for about half of the cases. The latter family members, Calliphoridae, were more frequently (52%) collected in autumn and winter. Only 4/15 outdoor cadavers had beetles. Four species of Coleopterans; namely Dermestes frischii Kugelann, Nitidula flavomaculata Rossi, Creophilus maxillosus Linnaeus and Saprinus chalcites Illiger; were recorded for the first time from 3 corpses in Iran. The presence and diversity of different insects on human corpses could contribute to the advancement of forensic entomology knowledge and the refined estimates of minPMI in medicolegal cases.