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INTRODUCTION AND IMPORTANCE: Congenital diaphragmatic hernia (CDH) is rare, occurring in 1 in 2000 to 4000 live births, and is typically diagnosed in neonates. Bochdalek hernia is the most common type, usually presenting as a left-sided posterolateral defect. Adult presentations of CDH are uncommon and often incidental. This report discusses a young adult with an undiagnosed CDH, emphasizing the importance of clinical awareness. CASE PRESENTATION: A 26-year-old man presented with flu-like symptoms and stable vital signs. He reported chronic postprandial shortness of breath that improved with standing. Physical examination revealed decreased breath sounds on the left side. A chest X-ray identified a left diaphragmatic hernia, confirmed by spiral chest computed tomography. Although advised to undergo surgery, the patient opted for discharge against medical advice. CLINICAL DISCUSSION: Bochdalek hernia, comprising over 95 % of CDH cases, is usually left-sided due to a defect in the pleuroperitoneal membrane. Adults with CDH often present with nonspecific symptoms or the condition is discovered incidentally. Our patient adapted to his symptoms by standing after meals, which provided relief. Surgical intervention is recommended to prevent organ damage, with various techniques available, including open and endoscopic surgery. This case highlights the necessity of clinical vigilance in diagnosing CDH in adults. CONCLUSION: Adult congenital diaphragmatic hernia, though rare, requires prompt surgical treatment to prevent organ damage. Recognizing subtle symptoms is crucial for diagnosis. This report contributes to the limited literature on adult-diagnosed CDH, stressing the need for clinical awareness and timely management.

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OBJECTIVE: Hospitals are expected to be able to provide quality services during disasters. However, hospital capacity is limited and most hospital beds are almost always occupied. The aim of this study was to determine the feasibility of increasing hospital surge capacity during disasters through identification of patients suitable for safe early discharge. METHODS: This cross-sectional study was conducted from May 2017 to February 2018 in two phases. In phase I, the Early Discharge Checklist was developed by a multidisciplinary panel of experts. Then in phase II, the checklist was used to assess the dischargeability of 396 in-patients in general wards of hospitals in Alborz province, Iran. Data were analyzed through the SPSS software (v. 22.0) and the results were presented by descriptive and analytical statics at a significance level of less than 0.05. RESULTS: Of 396 patients, (64.65%) were male, (68.9%) were married, and (38.6%) aged more than 54. Moreover, (34.6%) patients were dischargeable. Patients in cardiology wards were more dischargeable. At follow-up assessment, 33.3% of patients had been discharged after 48 hours. There was a significant relationship between patient dischargeability and 48-hour hospitalization status (p=0.001). Dischargeability had no significant relationships with patients' demographic characteristics (p>0.05). CONCLUSION: A considerable percentage of in-patients are dischargeable during disasters. The Early Discharge Assessment Checklist, developed in this study, is an appropriate tool to provide reliable data about early dischargeability in disasters.

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OBJECTIVE: Early discharge of some in-patients is the effective measure to create hospital surge capacity in disasters. However, some of these patients may need to post-discharge continuity of care. The aim of the current study then is to explore the barriers of continuity of care, and to provide suitable solutions for potentially dischargeable patients during disasters. METHODS: This qualitative study was conducted in Iran in 2017. The data was collected via unstructured interviews with 24 disaster professionals; and analyzed by content analysis method. RESULTS: Identified barriers to the continuity of care were classified into seven categories, 'lack of disaster paradigm'; 'challenges of pre-hospital system'; 'insufficient coordination and cooperation'; 'inadequate hospital preparedness'; 'lack of using available resources and capacities'; 'poor patients' knowledge' and 'poor planning'. The suggested solutions for post-discharge continuity of care were: creation of registry and follow-up system; removing pre-hospital challenges; including disaster management courses in medical school curriculum; promoting hospital preparedness by All-Hazard Approach; and effective use of available resources. CONCLUSION: Understanding the barriers to continuity of care for discharged patients for adopting policies based on experiences of health care providers can help planners to design and implement effective programs, which will enhance patients' access to necessary care.

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BACKGROUND: The aim of this study was to examine the association between the responses of headache to IV morphine and the findings of brain CT scan in minor head injury (MHI), and to propose a new risk indicator to identify patients requiring CT scanning. METHODS: A total of 1857 MHI patients ≥15 years of age, presenting with headache and a GCS score of 14 or 15 were included in the study. Intravenous morphine sulfate was administered, and thereafter, patients were assessed for the relief or persistence of headache. Subsequently, a brain CT scan was obtained from all patients. RESULTS: Patients were divided into two age groups: 15-60 and >60 years. There was a significant association between the response of headache to morphine and the result of brain CT in both age groups (p<0.001). In patients aged between 15 and 60, none whose headache had responded to morphine showed any abnormal findings in CT scan (sensitivity=100%). In the >60 group, sensitivity was 58.3% for abnormal CT and 71.4% for neurosurgical intervention. CONCLUSION: This study suggests that a headache not relieved by morphine is a risk indicator for intracranial injury. This protocol can be used in rural areas with limited access to CT scan as an adjunct to the existing criteria for selecting patients with MHI for CT scanning.

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