Profound Bradycardia following Patent Ductus Arteriosus Closure; A Rare but Correctable Event

Proximity of the vagus nerve to  a patent  ductus  arteriosus (PDA) can cause traction  or  entrapment  of vagus nerve during surgical closure of the in rare occasions. This can lead to a life threatening postoperative bradycardia. Herein, we report a case of bradycardia caused by unexpected irritation of the vagal trunk by the end of operation. The patient was managed by re-opening the chest, lung retraction and removal of mediastinal pleura sutures. The vagal trunk entrapped in the suture line was released immediately. Heart rate accelerated and hemodynamic restored after a short period of observation. The operation terminated as routine, patient extubated in OR and discharged within 24 hours with no further complication. This irritation of vagus results in vagal bradycardia during or by the end of operation. Awareness of a surgeon of this issue can minimize the risks and complications of the open closure of PDA.

Short-term Outcome of Open Appendectomy in Southern Iran: A Single Center Experience

OBJECTIVES

To evaluate the short-term outcome of open appendectomy, the rate of negative appendectomy as well as pathology reports after surgery in patients with suspected acute appendicitis.

METHODS

This was a retrospective cross-sectional study being performed in Nemazee hospital affiliated with Shiraz University of Medical Science during a 2-year period between 2008 and 2010. The medical records of all consecutive patients who underwent open appendectomy in our center due to acute appendicitis were included in the study. The elective and laparoscopic appendectomies were excluded. The demographic information, clinical findings, laboratory investigations and the histopathological examination of the appendix were recorded and reported.

RESULTS

A total of 337 patient including 137 (36.4%) females, and 240 (63.6%) males with the mean age of 16.26 ± 9.81 (range 3 to 76) years were stduied. Anorexia (64.7%) and fever (20.7%) were more prevalent symptoms. The mean duration between pain initiation and operation ranged from 0 to 14 days with mean 1.88 ± 1.63 days. Right lower quadrant (RLQ), periumbilical, epigastria, left lower quadrant (LLQ), and Right upper quadrant (RUQ), pain were manifest in 78.8%, 41.6%, 12.2%, 3.2%, and    1.3% of patients, respectively. Pathological evaluation of the appendix showed appendicitis in 70.4% of patients.

CONCLUSION

The higher rate of negative appendectomy accounts for wasteful tapping of medical resources and causing further complication in patients. Therefore it is essential to conduct more accurate studies to detect the root cause of the disease. This would help improve the management of appendicitis which is an emergency condition with high incidence.

Non alcoholic fatty liver disease in southern Iran: a population based study

BACKGROUND

Population based studies on prevalence and risk factors of NAFLD in Iranian population are few. The prevalence of NAFLD and non alcoholic steatohepatitis (NASH) in Iranians varies from 2.9% to 7.1% in general population and 55.8% in patients with type 2 diabetes mellitus.

OBJECTIVES

To determine the prevalence and determinants of non alcoholic fatty liver disease (NAFLD) in a sample of adult Iranian general population.

PATIENTS AND METHODS

This was a cross-sectional study being performed in Shiraz, southern Iran during a 10-month period from November 2010 to September 2011 through cluster random sampling of Iranian general population in Shiraz region. All individuals undergone anthropometric, blood pressure measurements, thorough medical history and physical examinations. Laboratory measurements included fasting blood glucose (FBS), lipid profile, complete blood count (CBC) and liver function tests. NAFLD was diagnosed by transabdominal ultrasonography.

RESULTS

819 subjects were included in this study among which were 340 males (41.5%) and 479 females (58.5%) with the mean age of 43.1 ± 14.1 years. NAFLD was diagnosed in 176 (21.5%) subjects. Patients with NAFLD were significantly older (P < 0.001), had higher proportion of male gender (P = 0.004) and had higher BMI (P < 0.001). They also had higher prevalence of hypertension (P < 0.001), high FBS (P < 0.001), high cholesterol (P = 0.026), high triglyceride (P < 0.001) and high waist circumference (P < 0.001). Taking all these together, patients with NAFLD had significantly higher prevalence of metabolic syndrome when compared to healthy subjects (P < 0.001).

CONCLUSION

The prevalence of NAFLD in this group of Iranian adult general population is 21.5%. NAFLD in Iranian population is associated with male gender, old age, obesity, and features of metabolic syndrome.

Correlation between thrombophilia and recurrent pregnancy loss in patients with polycystic ovary syndrome: a comparative study

BACKGROUND

Patients with polycystic ovary syndrome (PCOS) have an increased prevalence of thrombophilia, leading to higher rates of pregnancy loss. The aim of this study was to determine the association between thrombophilia and recurrent pregnancy loss (RPL) in patients with and without PCOS.

METHODS

In this comparative case-control study, we included 60 patients with RPL (≥3 consecutive pregnancy losses at <20 weeks of gestation) and PCOS (Group 1), 60 patients with PCOS and without RPL (Group 2), 60 patients with RPL and without PCOS (Group 3), and 60 healthy individuals (Group 4). These four study groups were compared regarding serum levels of testosterone, fasting insulin, homocysteine (Hcy), plasminogen activator inhibitor activity (PAI-Fx), protein C, protein S, antithrombin III, activated protein C ratio (APCR), factor V Leiden, prothrombin G20210A, and methylene tetrahydrofolate reductase gene mutations.

RESULTS

Patients in Group 1 had significantly higher levels of testosterone (p = 0.026), dehydroepiandrosterone sulfate (p = 0.035), fasting insulin (p = 0.015), Hcy (p = 0.036), and PAI-Fx (p = 0.008) compared to Group 3. They also had higher proportions of APCR (p = 0.009) and a higher prevalence of factor V Leiden mutations compared to Group 3 (p = 0.001). However, there was no significant difference in protein C (p = 0.088), protein S (p = 0.514), or antithrombin III (p = 0.627) between the four study groups.

CONCLUSION

Hyperinsulinemia, hyperandrogenemia, hypofibrinolysis, and hyperhomocysteinemia as well as APCR and factor V Leiden mutations are associated with RPL in patients with PCOS.

Time analysis of fatal traffic accidents in Fars Province of Iran

OBJECTIVE

To analyze the time factor in road traffic accidents (RTAs) in Fars Province of Iran.

METHODS

This study was conducted in Fars Province, Iran from November 22, 2009 to November 21, 2011. Victims'information consisted of age, sex, death toll involving dri- vers or passengers of cars, motorcycles and pedestrians, and site of injury etc. Accidents were analyzed in relation to hour of the day, season of the year, lighting condition including sunrise, sunset, daytime and nighttime.

RESULTS

A total of 3 642 deaths (78.3% were males, and the ratio of males to females was about 3.6:1) were studied regarding their autopsy records. There was a steady increase in fatal accidents occurring at midnight to 15:59. The risk of being involved in a fatal traffic accident was higher for those injured between 4:00 to 7:59 than at other times (OR equal to 2.13, 95% CI 1.85-2.44). The greatest number of fatal RTAs took place in summer. Mortalities due to RTA during spring and summer were more pronounced at 20:00 to 23:59 and midnight to 3:59, whereas mortalities in fall and winter were more pronounced from 12:00 to 15:59.

CONCLUSION

The high mortality rate of RTA is a major public health problem in Fars Province. Our results indicate that the time is an important factor which contributes to road traffic deaths.

Emergency Operating Room Workload Pattern: A Single Center Experience from Southern Iran

OBJECTIVE

To determine the epidemiology and pattern of emergency operating room workload in Nemazee hospital affiliated with Shiraz University of Medical Sciences, Shiraz, Iran.

METHODS

All surgical emergency operations which were performed in Nemazee hospital, Shiraz, Iran were collected over twelve months (September 2007 to September 2008). The data obtained included indications, presenting symptoms the services provided and the demographic information of the patients.

RESULTS

Overall number of recorded emergency operations in this cross sectional descriptive study was 3946, with males constituting 72% of the patients. The highest male/female ratio reported in trauma patients was 6.4:1 with the median age of 23 years, and the mean age of the operated patients was 27.8 years. Second to neurosurgery (19.64%) the general surgery was the busiest discipline in emergency operations (59.14%). Appendectomy (11.77%), double/triple lumen/central venous catheter insertion (9.4%), and fiber optic/rigid bronchoscopy (3.27%) were the commonest general surgical operations. Among trauma patients, neurotrauma was the commonest reason for operation (10%).

CONCLUSION

Based on a new approach toward emergency operating room workload, in our country and centre, we showed that it is necessary to devote particular and individualized attention to the fields of agenda and hospital management of emergency operations. This is due to a high emergency operating room workload and its unique characteristics in our centre in contrast to other hospitals and departments. Although a decision making and operational strategy is recently seen to improve the quality and quantity of emergency services available to our patients, there is still a gap between present and optimal emergency healthcare which should be provided for our residents.

Bilateral Vocal Cord Paralysis after Anterior Cervical Discectomy Following Cervical Spine Injury: A Case Report

Bilateral vocal cord paralysis is a rare and preventable complication of anterior cervical discectomy and fusion. Herein, we report a fatal case of bilateral vocal cord paralysis after anterior cervical discectomy and fusion (ACD/F). A 65-year-old man with cervical spine trauma and anterior cord syndrome, following car overturn presented to our emergency department. The patient had C6-T10 prolapsed discs for which ACD/F was performed. In the recovery room he developed stridor and respiratory distress immediately after extubation, and was reintubated. Otolaryngological evaluation revealed bilateral vocal cord paralysis. He later required a tracheostomy but finally died in a rehabilitation center after an acute coronary event. Awake fibroptic intubation is recommended in patients at high risk for preoperative recurrent laryngeal nerve injury. Intraoperative tracheal tube cuff pressure monitoring and modification of surgical approach to neck are recommended to prevent bilateral nerve damage.

Quality of life among Iranian patients with beta-thalassemia major using the SF-36 questionnaire

CONTEXT AND OBJECTIVE Patients with beta-thalassemia major (β-TM) experience physical, psychological and social problems that lead to decreased quality of life (QoL). The aim here was to measure health-related QoL and its determinants among patients with β-TM, using the Short Form-36 (SF-36) questionnaire. DESIGN AND SETTING Cross-sectional study at the Hematology Research Center of Shiraz University of Medical Sciences, in southern Iran. METHODS One hundred and one patients with β-TM were randomly selected. After the participants' demographics and disease characteristics had been recorded, they were asked to fill out the SF-36 questionnaire. The correlations of clinical and demographic factors with the QoL score were evaluated. RESULTS There were 44 men and 57 women of mean age 19.52 ± 4.3 years (range 12-38). On two scales, pain (P = 0.041) and emotional role (P = 0.009), the women showed significantly lower scores than the men. Lower income, poor compliance with iron-chelating therapy and presence of comorbidities were significantly correlated with lower SF-36 scores. These factors were also found to be determinants of worse SF-36 scores in multivariate analysis. CONCLUSIONS We showed that the presence of disease complications, poor compliance with iron-chelating therapy and poor economic status were predictors of worse QoL among patients with β-TM. Prevention and proper management of disease-related complications, increased knowledge among patients regarding the importance of managing comorbidities and greater compliance with iron-chelating therapy, along with psychosocial and financial support, could help these patients to cope better with this chronic disease state.

Explosive attack: Lessons learned in Seyed Al Shohada mosque attack, April 2008, Shiraz, Iran

Introduction:

The threat of explosive attacks has become a worldwide problem. Bombing is the preferred method of attacks. These attacks result in specific physical and psychiatric trauma. In this paper, we present an epidemiologic description of the physical injuries of patients who survived the explosive attack in Seyed Al Shohada mosque April 2008 Shiraz, Iran.

Materials and Methods:

All medical records of the patients admitted at Shiraz Hospitals on April 2008 due to Seyed Al Shohada mosque bombing attacks, Shiraz, Iran, were reviewed.

Results:

A total of 202 patients were referred to the hospitals over 24 h following the terrorist attack. One hundred sixty-four patients were admitted for short periods of observation (<24 h). Thirty-eight patients needed more than 1 day of hospitalization. The mean age of the patients was 26.2 (range 2 to 51) years. One hundred thirty-five (66.8%) patients were males. Twenty-six (12.8%) were children. Burn was the most prevalent cause of admission. Five (13.5%) patients needed chest tube insertion and eight (21%) needed skin grafts due to burn. Overall, 12 patients expired (5%). Three (25%) of them were children (2 and 6, and 11 years old). Mortality rate was significantly higher among the children than adults (P value <0.05). The most important cause of death was head trauma which was seen in five (41.6%) of the expired patients followed by burn (including air way burn) in four (33%), and internal bleeding in three (25%). Patients with head trauma had significantly a higher rate of mortality than other patients (P value <0.05).

Discussion:

Following a bombing attack, numerous victims were brought to the emergency unit suffering from a combination of multi-organ injuries caused by the blast, penetrating injuries caused by shrapnel and other debris, and burns. It is important for a physician to be familiar with the clinical features and treatments of explosive attacks victims. Early management of patients at the scene and hospital may save their life.

Reducing Social Disparity in Liver Transplantation Utilization through Governmental Financial Support

BACKGROUND

A high proportion of patients suffering from end stage liver disease are from low socioeconomic classes , which limits their access to liver transplantation as the most effctive treatment of this condition because of cost barrier.

OBJECTIVES

one of the most challenging aspects of liver transplantation is its affordability and utilization by those who need it the most.

PATIENTS AND METHODS

Since November 2005, Iran Ministry of Health had covered 100% of the costs of in-patient liver transplantation care. To determine the effects of this policy, patterns of utilization of liver transplantation were compared before and after implementation of the policy. Group one included 112 and group two included 120 individuals who received transplantation before (from early January 2003 to November 2005) and after (from November 2005 to the end of December 2007) the legislation entered into the effect, respectively. Socioeconomic characteristics of these patients were evaluated by data collected about house and car ownership, education level, employment status, and place of residence.

RESULTS

Coverage of the costs allowed more illiterate and semiliterate people (P = 0.032) as well as more unemployed or unskilled workers to receive transplantation (P = 0.021). The number of transplantations also increased in children and geriatric age group. This legislation also led to greater countrywide regional coverage of indigent patients.

CONCLUSIONS

This survey provides evidence that coverage of the costs by Ministry of Health was effective in reducing social discrimination in utilization of liver transplantation, and narrowed the gap between low and high socioeconomic classes in Iranian society.

Epidemiological characteristics of fatal pedestrian accidents in Fars Province of Iran: a community-based survey

OBJECTIVE

To determine the epidemiological characteristics of fatal pedestrian accidents in Fars Province of Iran.

METHODS

This cross-sectional study was conducted in Fars Province of Iran during a 29-month period from March 2009 to July 2011. The data were from the Fars Forensic Medicine Registry. In 4 923 recorded road traffic accident fatalities, 971 deaths were due to pedestrian accidents. The demographic and accident-related information were analyzed by SPSS version 11.5. P value less than 0.05 was considered significant.

RESULTS

The mean age of decedents was (47.2+/-26.2) years, ranging from 6 months to 103 years old. Males accounted for 69.8% of all deaths. Fatal accidents were most common in September; 56.1% of the fatal injuries occurred on intracity roads and 33.1% on extracity roads. Fatal head injuries were present in 60.54% of cases. Evaluation of the injury site and the cause of death found that they were significantly associated with age, interval between injury and death. Besides, the type of roads played an important role in mortality.

CONCLUSION

Although the clinical management of trauma patients has been improved in our country in the recent decade, decreasing the burden of injuries needs coordination among trauma system organizations.

Role of routine pelvic radiography in initial evaluation of stable, high-energy, blunt trauma patients

BACKGROUND

Pelvic fractures are among the most devastating traumatic injuries accompanied by high morbidity and mortality rate leading to catastrophic outcomes and haemodynamic consequences. Although Advanced Trauma Life Support (ATLS) recommends performing pelvic radiography in all major blunt trauma patients, several lines of evidence recommend that it can be limited to those blunt trauma patients who are haemodynamically unstable or have positive pelvic physical examination. Thus, we performed this study in order to evaluate the efficacy of routine pelvic radiography in haemodynamically stable, high-energy, blunt trauma patients.

METHODS

This was a prospective cross-sectional study including all the haemodynamically stable, high-energy, blunt trauma patients with negative pelvic physical examination referring to our trauma centre during a 5-month period (May-September 2010). Pelvic radiographies were performed and reviewed for abnormalities. In those who had negative pelvic physical examination and the radiography was not revealing enough, CT imaging was requested and reviewed.

RESULTS

During the study period, 1679 high-energy blunt trauma patients referred to our centre out of which 389 were haemodynamically stable and had negative pelvic physical examination. Pelvic radiography was found to be normal in all the patients except one (0.25%) who had pelvic fracture. Only three patients required CT imaging out of which two (0.5%) were found to be normal.

CONCLUSIONS

Pelvic radiography could be eliminated from the primary survey protocol of the patients with high-energy blunt trauma who are haemodynamically stable and have negative pelvic physical examination.

Fatal motorcycle accidents in Fars Province, Iran: a community-based survey

OBJECTIVE

To identify the main characteristics of victims of motorcycle accidents in Fars Province, Iran.

METHODS

This cross-sectional study was conducted in Fars Province which has the fourth largest population of all 31 provinces in Iran from March 2009 to June 2010. We included data from all 542 recorded cases of fatalities due to motor vehicle accidents. Data were recorded from the forensic medicine registry consisting of demographic and accident-related information. Demographic information consisted of name, age, sex, status of fatal victim (motorcycle driver vs passenger) and educational level.

RESULTS

Of the 2 345 autopsy records from the forensic medicine archives, 542 (23.1%) gave the cause of death as motor vehicle accidents. Mean age of these victims was (31.4+/-6.5) years, and the male to female ratio was 28. Head injury was the most common cause of death in these victims, and overall they tended to have a low level of education. Motorcycle accidents frequently involved younger age groups (15-35 years), and head trauma related with non-use of a helmet was the most common cause of death.

CONCLUSIONS

Head injury is frequent among victims in the province we studied. This situation may be related to the victims' low socioeconomic status and little education regarding traffic laws leading to speeding and disregard of these laws along with their weak enforcement.

Titering of 2009 pandemic H1N1 influenza virus hemagglutinin inhibition antibody in nonvaccinated pregnant women in Shiraz, Southern Iran

Influenza may cause severe complications for pregnant women. In this study antibody response against 2009 H1N1 influenza virus in pregnant women was investigated. This seroprevalance cross sectional and questionnaire based study was conducted using a convenient sampling method. Blood samples of pregnant women were checked for antibodies against 2009 H1N1 influenza virus using hemagglutination inhibition assay. An antibody titer level of ≥ 1:40 dilution was considered as the protective level. 167 (43.60%) of 383 pregnant women who participated in this study had protective antibody levels against this virus. 62 (35.63%) of 3rd trimester, 79 (46.74%) of 2nd trimester, and 21(52.50%) of 1st trimester pregnant women were immune respectively (χ2(for trend) = 8.20, p < 0.004). Lack of protective antibody level was significantly seen more in pregnant women of 3rd trimester of pregnancy (OR = 2.37, CI = 1.09-5.18). Pregnant women with higher education (OR = 1.67, CI = 1.02-2.73) and those with history of anemia (OR = 2.09, CI = 1.18-3.68) had more immunity. Older women (OR = 0.95, CI = 0.91-0.99) and those with history of psychological diseases (OR = 0.19, CI = 0.05-0.70) had less immunity. Vaccination of pregnant women, especially those who are in the higher trimesters of pregnancy, older, or less educated, against the 2009 H1N1 influenza virus should be continued.

Subclavian flap aortoplasty and preservation of left upper extremity circulation using an interposition graft

OBJECTIVES

To introduce a surgical technique to maintain left upper limb blood flow after subclavian flap aortoplasty (SFA).

METHODS

Five patients (9 to 23 months of age) with a diagnosis of long-segment aortic coarctation underwent conventional SFA. A Gore-tex graft was interposed between the stump and the proximal descending aorta to maintain perfusion of subclavian artery.

RESULTS

All patients had a patent Gore-tex graft and normal blood flow of the subclavian artery and left upper limb. One patient expired and four others were discharged with a mean follow-up of 48 months. On follow-up all patients had normal development of the left upper limb and no signs of limb ischemia. Echo findings revealed normal arch flow with normal flow in the Gore-tex graft and left upper extremity.

CONCLUSIONS

Interposing a Gore-tex graft between the subclavian artery stump and proximal descending aorta concomitant with SFA can be safely performed in infants with long-segment aortic coarctation, with preservation of left upper extremity circulation.

Hair follicle regeneration in skin grafts: current concepts and future perspectives

The repair and management of full-thickness skin defects resulting from burns and chronic wounds remain a significant unmet clinical challenge. For those skin defects exceeding 50%-60% of total body surface area, it is impractical to treat with autologous skin transplants because of the shortage of donor sites. The possibility of using tissue-engineered skin grafts for full-thickness wound repair is a promising approach. The primary goal of tissue-engineered skin grafts is to restore lost barrier function, but regeneration of appendages, such as hair follicles, has to be yet achieved. The successful regeneration of hair follicles in immunodeficient mice suggests that creating human hair follicles in tissue-engineered skin grafts is feasible. However, many limitations still need to be explored, particularly enriching isolated cells with trichogenic capacity, maintaining this ability during processing, and providing the cells with proper environmental cues. Current advances in hair follicle regeneration, in vitro and in vivo, are concisely summarized in this report, and key requirements to bioengineer a hair follicle are proposed, with emphasis on a three-dimensional approach.

Effect of oral clonidine on acute intraocular pressure rise after phacoemulsification: a prospective double-blind, randomized, clinical trial

OBJECTIVE

To determine the efficacy and safety of oral clonidine in decreasing the prevalence and intensity of postoperative intraocular pressure (IOP) rise in those undergoing phacoemulsification.

METHODS

This was a prospective randomized, double-blind, placebo-controlled, clinical trial including 62 patients (each with 1 affected aye) with senile cataract scheduled for phacoemulsification who were randomly assigned to receive preoperative oral clonidine (5 μg/kg, 31 patients) or placebo (1 tablet, 31 patients). The IOP was measured preoperatively and at 6, 12, and 24 h postoperatively. The prevalence and intensity of the acute postoperative IOP rise was compared between and within the groups.

RESULTS

There was no significant difference between the 2 study groups regarding the baseline characteristics and the baseline IOP (P=0.628). Patients who received placebo as premedication had significantly higher IOP at 6 (17.96±5.49 vs. 13.61±4.09; P<0.001) and 12 (16.90±4.11 vs. 13.96±3.25; P=0.003) h postoperatively compared with those who received oral clonidine. However, there was no significant difference between the 2 groups regarding the IOP at 24 h after operation (15.41±3.96 vs. 16.01±3.41; P=0.0539). The prevalence of acute IOP rise (>21 mmHg) was significantly higher in placebo group compared with clonidine group (25.8% vs. 9.6%; P=0.091).

CONCLUSION

Administering preoperative oral clonidine in a dosage of 5 μg/kg, 2 h before phacoemulsification, significantly decreases the prevalence and intensity of acute postoperative IOP rise in those undergoing general anesthesia. Oral clonidine is safe, cheap, and easily accessible and, thus, it is recommended for controlling the IOP after phacoemulsification, especially in high-risk patients.

The value of hysteroscopy in diagnosis of chronic endometritis in patients with unexplained recurrent spontaneous abortion

OBJECTIVES

We performed this study in order to investigate the role of chronic endometritis (CE) in unexplained recurrent spontaneous abortion (RSA) and to determine the correlation between hysteroscopic and histologic findings of CE in patients with unexplained RSA. We also tried to find out the relation between CE and primary vs. secondary RSA.

STUDY DESIGN

One hundred and forty-two consecutive patients with unexplained RSA and 154 fertile women were enrolled in this study. All the patients and controls underwent hysteroscopy and, at the same time, endometrial biopsy. CE was suspected when hysteroscopy revealed signs of focal or diffuse endometrial hyperemia or endometrial endopolyps (less than 1mm in size). Histopathologic diagnosis of CE was based on superficial stromal edema, increased stromal density, and pleomorphic stromal inflammatory infiltrate dominated by lymphocytes and plasma cells. Results were compared between cases and controls as well as those with primary (n=61) and secondary (n=81) RSA.

RESULTS

Patients with RSA had a significantly higher incidence of CE both hysteroscopically (67.6% vs. 27.3%; p<0.0001) and pathologically (42.9% vs. 18.2%; p<0.0001). The sensitivity, specificity, positive predictive value and negative predictive value of hysteroscopy in the diagnosis of CE were found to be 98.4%, 56.23%, 63.5% and 97.82% respectively. Patients with secondary RSA had a higher prevalence of CE both pathologically (83.9% vs. 45.9%; p<0.0001) and hysteroscopically (58.1% vs. 24.6%; p<0.0001).

CONCLUSION

CE is associated with unexplained RSA. Hysteroscopy, with high sensitivity and acceptable specificity, is suitable for the diagnosis of CE in those with unexplained RSA. CE should be taken into consideration in those with secondary unexplained RSA.