comparison of outcomes of routine early angiography versus delayed ischemia-guided angiography after thrombolytic therapy in ST segment-elevation myocardial infarction

Thrombolytic therapy continues to be the common treatment in acute ST elevation myocardial infarction in the majority of heart centers worldwide. However, thrombolytic therapy is associated with high re-occlusion and re-infarction rates. So, most patients now undergo early diagnostic angiography and possibly angioplasty of the culprit artery but the controversy about the timing of angiography after thrombolysis continues to remain unresolved. In this prospective cohort study, we compared the outcome of early invasive strategy versus delayed invasive approach in ST-elevation MI patients who had received successful thrombolytic therapy. Primary endpoint of the study was Major Adverse Cardiovascular Events or MACE [the combined rate of death, re-infarction, major bleeding and cerebrovasular events. Secondary endpoints were re-infarction and re-hospitalization rate. The study comprised 142 patients of which 87 had a routine angiography in less than 10 days of acute event and 55 underwent ischemia-guided angiography after 10 days of index event. Stenting of the culprit vessel was done in 60% of the routine angiography group and 63% of the ischemia-guided group. The patients were followed for 8.8 +/- 2.8 months after the index event. The primary endpoint occurred in 6.9% of routine angiography patients and 10.9% of the control group [P= 0.4]. The rate of re-infarction was significantly higher in the delayed invasive arm than routine early invasive arm [10.9% vs. 1.1, P:0.01],and mostly occurring before angiography. Routine angiography as soon as possible after thrombolysis can reduce re-infarction and was not associated with any increased risk of adverse events in our study

Pulmonary thromboendarterectomy in chronic thromboembolic pulmonary hypertension: a report of 15 cases

Chronic thromboembolic pulmonary hypertension [CTEPH] is a serious and underdiagnosed disorder with significant morbidity and mortality. It is thought to result from single or recurrent pulmonary thromboemboli arising from the sites of venous thrombosis, often from the lower limbs. Surgical correction of anatomical obstructions [endarterectomy of pulmonary artery] is the treatment of choice in these patients, and the patients outcomes are good. The mortality rate in some centers is about 5%, but in others it is up to 30%. We started pulmonary endarterectomy in Shaheed Rajaie Heart Center [RHC] in Iran four years ago. Pulmonary thromboendarterectomy is performed under hypothermia and total circulatory arrest with cardiopulmonary bypass. All patients are evaluated in our hospital for known risk factors of deep vein thrombosis and pulmonary emboli. Right heart catheterization and measurement of pulmonary artery pressure and vascular resistance are performed in some of the patients and left heart catheterization in those who are over 45 years of age. CT angiography of the pulmonary artery with multi-slice CT scan is done in all patients before and after endarterectomy. Patient selection for successful endarterectomy is based on CT angiography and perfusion lung scan with consideration of pulmonary vascular resistance in some cases. During a 4-year period, 15 patients [5 female and 10 male] underwent this type of surgery in RHC. Their mean age was 35.87 [min. 18, max. 55] years old. The mean pulmonary artery systolic pressure by echocardiography was 87.60 mmHg [min. 55mmHg, max. 140 mmHg, SD 23.26 mmHg] and the mean pulmonary artery pressure was 46.43mmHg [min. 23 mmHg, max. 60 mmHg, SD 11.70 mmHg]. Mean surgery time was 5.33 hours [min. 4hrs, max. 14 hrs, SD. 2.46 hrs], mean bypass time was 138 minutes [min. 84, max. 220, SD=43.28 minutes], mean intubation time was 49.88 hours [min. 7 hrs, max. 216 hrs, SD 61.66 hrs], and intensive care unit stay time was 5.43 days [min. 3, max. 9, SD=1.98]. Two fatalities occurred due to bleeding and shock. The mortality rate was 20%. IVC filters were placed in a minority of the patients who had clear-cut evidence of lower extremity deep vein thrombus as a cause of pulmonary thromboembolic events. Pulmonary endarterectomy is the treatment of choice in CTEPH with an acceptable mortality rate and a good prognosis. It is possible to perform this procedure without recourse to more sophisticated evaluations with an acceptable mortality rate in patients who have segmental lobar or main pulmonary artery organized clot

Urologic diseases in the Islamic Republic of Iran: what are the public health priorities?

This study was designed to estimate the burden of urologic diseases in the Islamic Republic of Iran as a practical method for defining public health priorities. Using World Health Organization guidelines for national burden of disease studies, 6 steps were performed: selecting diseases to include; dynamic modelling of diseases; gathering data about urologic diseases; computing the local disability weights of urologic diseases; data analysis with DisMod II; and computing the disability-adjusted life years for each disease. Renal calculus, acute cystitis, chronic prostatitis, benign prostate hyperplasia, male infertility and adult polycystic kidney disease comprised the greatest burden

[Renal transplantation in children with cystinosis]

Cystinosis is an inherited metabolic disease in which transfer of cystine out of lysosome is impaired. This phenomenon leads to accumulation of cystine in different organs and causes organ dysfunction. Growth retardation is seen in these patients and later they go on to develop renal failure needing dialysis or renal transplantation. The aim of this study was to evaluate the outcome and complications of renal transplantation in patients with cystinosis. In this case series study in years 1996-2006 all patients with renal failure due to cystinosis who received renal transplantation, were followed for 43 +/- 1/1 months, Before operation, all patients were examined to determine if they are appropriate candidate for renal transplantation and after operation DPTA scan was performed to evaluate graft function and in later follow up necessary lab tests were done. All patients received triple immunosuppressive therapy including cyclosporine, prednisolone and Mycophenolate Mofetil. In the presence of rejection symptoms such as fever and a rise in creatinine, graft rejection was confirmed by DPTA scan and sonography of transplanted kidney. Patient survival was 100% and 4 years graft survival was 86.7%. Mean creatinine level before operation was 5.44 +/- 2.58 and post operation was 0.86 +/- 1.03 and at the last follow-up was 1.51 +/- 1.45 mg/dl, mean GFR at the last follow-up was 54.1 +/- 31.2 ml/min/1.73m2. Six [40%] patients were on dialysis before operation, 5 [33%] had acute rejection and 5 [33%] suffered from UTI after the operation. Growth retardation was seen in all of patients. Thirteen patients [86%] were affected by CMV infection and 6 [40%] by CMV disease; that were treated successfully by Ganciclovir for 2 weeks. One patient was affected by vessel thrombosis in post operation period and one patient had graft loss due to kink of vessel after operation. Renal transplantation in patients with cystinosis has favorable outcome. It is the treatment of choice for patients with cystinosis and End Stage Renal Failure [ESRF]

Risk factors and laboratory diagnostics for post renal transplant tuberculosis: a case-controlled, country-wide study on definitive cases

Tuberculosis [TB] is a common cause of morbidity and mortality in renal transplant recipients. It is usually misdiagnosed because of lack of medical awareness and its infrequency in renal transplant recipients. 44 cases [0.3%] with post-transplant TB out of 12820 patients who had renal transplants performed between 1984 to 2003 were found from the hospital records of 12 major kidney transplantation centers in Iran. These cases were compared with 184 healthy transplant subjects whose transplants were performed by the same surgical team as the controls. The mean age of cases and controls was 37.7 [13-63] and 35.6 [8-67] years [p=0.3], respectively. The mean duration of pre-transplantation hemodialysis was 30.3 [3-168] months in cases and 18.2[1-180] months in controls [p=0.03]. A past history of tuberculosis was detected in 2 cases and 1 control [p=0.3]. The mean doses of initial and maintenance immunosuppressive drugs in cases and controls were not significantly different. A total of 25 cases [56.8%] and 60[32.6%] controls had rejection prior to diagnosis of TB [p=0.004; OR=2.7, CI95%: 1. 3-5.6]. To our knowledge, this is the first study that demonstrated increasing risk of post-transplant TB by extending the duration of pre-transplant hemodialysis and the number of post-transplant rejection episodes. Further study is needed to clarify our new findings specifically in respect of different immunosuppressive regimens

[[Vital perfusion-fixation technique through carotid arteries for preparation of histologic sections from periodontium and jaw boneof dog]]

Adequate processing of tissues before histologic slices is necessary for preparation of proper histologic sections in animal studies. Fixation is one of the most important and early laboratory stages of tissue processing. Amount of penetration time of fixator material, into deep layers and central portions of hard tissues, is important factor for prevention of cell lysis. The purpose of vital perfusion technique is immediate and rapid fixation of tissue, before tissue lysis and necrosis. After general anesthesia, the common carotid artery and jugular vein were isolated through a vertical incision and dissection of muscles, in both sides of the neck. The carotid arteries, were clamped, then normal saline and 10 percent formalin were injected respectively, through one branole. While heart rate and respiration slowed down, the content of jaw vessels were normal saline and formalin. Oral rnucosa became completely pale and muscles got stiff. Formalin was observed in vessels and between tissues. The histologic sections had favorable quality. Signs of tissue lysis were not observed and small vessels were also empty from blood. The vital perfusion fixation technique from carotid arteries can make rapid fixation of the periodontal tissue and jaw bone of dog and prevent tissue changes. This method can facilitate other laboratory stages for preparation of histologic sections

Modern status of laparoscopic surgery in the urology of iran and world

First, we would like to introduce laparoscopic procedures conducted at Labbafinejad Medical Center [1057 cases], some of which were performed for the first time in Iran and some others were conducted for the first time worldwide, by which Iran has been known as a leading country among Mediterranean countries in laparoscopic urology. 1. Laparoscopic ileocystoplasty [to extend bladder by ileum with intestinal anastomosis] simultaneously with laparoscopic Malon to control stool incontinence [First case in the world] [9 cases] 2. Laparoscopic urethrocystoplasty [First case in the world] [2 cases] 3. Radical laparoscopic prostatectomy by an innovative technique with no suture [35 cases] 4. Laparoscopic antireflux in children by Lich method [40 cases] 5. Laparoscopic retroperitoneal and pelvic lymphadenectomy [10 cases] 6. Laparoscopic pyeloplasty [to repair pelvic obstruction] [60 cases] 7. Laparoscopic donor Nephrectomy [220 cases] 8. Laparoscopic Nephrectomy [71 cases] 9. Laparoscopic adrenalectomy [14 cases] 10. Laparoscopic adrenalectomy [25 cases] 11. Laparoscopic surgery of retrocaval ureter [3 cases] 12. Laparoscopic removal of ureteral and pelvic stones [140 cases] 13. Nephropexy [1 cases] 14. Varicocelectomy [110 cases] 15. Laparoscopic repair of hydrocele and hernia [32 cases] 16. Laparoscopic therapy of renal cyst [30 cases] 17. The detection and treatment of ectopic testis [247 cases] 18. Partial adernalectomy [4 cases] 19. Histrosalpingoanorectomy [4 cases]

role of ureteroscopy in the treatment of renal transplantation complications

To determine the feasibility, safety, and efficacy of diagnostic and therapeutic ureteroscopy in renal allograft ureters. We reviewed 1560 consecutive renal allografts have been preformed between June 1989 and February 2002. Twenty-eight patients [1.8%] had indication for endoscopic procedure on allograft ureter. Six patients had obstructive ureteral calculi with a history of failed ESWL, 3 had suspected ureteral stricture, 9 had upward migrated ureteral stents and 10 had ureteral stricture at ureteroneocystostomy site. Ureters were anastomosed to bladder using Leadbetter- Politano and Lich-GreGoire methods in 6 and 22 cases, respectively. Ureteroscopies were performed with semi rigid 9.8F wolf ureteroscope. Identifying and introducing the ureteral orifice was successful in 19 [68%] cases. If we exclude 10 patients with ureteral stricture, ureteroscopy was successful in 13 out of 18 [72%]. Four ureteral calculi [67%] were removed with ureteroscope.Seven out of nine migrated stents [78%] were retrieved. Four patients with ureteral stricture at ureteroneocystostomy site [40%] had successful ureteral dilatation and double J ureteral catheters were also inserted. Diagnostic ureteroscopy was successful in all cases. Two complications including one urinary leakage and one symptomatic urinary tract infection occurred that were managed conservatively. Ureteral endoscopy was safe and effective method for management of urological complications after RT [renal transplantation]. This procedure can be considered as the first choice compared with percutaneous and antegrade modalities

comparison of augmentation cystoplasty before and after renal transplantation with the control group

We compared two surgical methods of augmentation cystoplasty [AC], before and after renal transplantation, and the outcomes of both methods with transplant patients with normal bladder function. 1520 kidney transplantations were performed at Shahid Labbafinejad Center between March 1988 and February 2002 of which 36 cases was accompanied with AC. In 20 patients [group A] AC was performed before transplantation. This group consisted of 14 males and 6 females with a mean age of 26.1 [13-39] at the time of transplantation. Sixteen patients consisting of 11 males and 5 females [mean age 27.3, 12-44] underwent AC after transplantation. Eventually 40 transplant patients with normal bladder function were assigned in the control group including 18 males and 22 females with a mean age of 31.2 [11-55] [group C]. Normal graft function was achieved in 16, 13, and 33 patients of groups A, B, and C respectively over the mean follow-up of 70, 59, and 76 months [p<0.7]. Mean serum creatinine during the follow-up was 1.48 +/- 0.4, 1.7 +/- 1, and 1.4 +/- 0.55 for groups A, B, and C respectively. 9, 12, and 17 patients [26, 64, and 34 cases] with UTI requiring hospital admission were observed in the 3 groups respectively. The incident of UTI and the resultant hospitalization in group B was more than the one in group C [p<0.03], but it did not differ significantly from group A to group C. AC is a safe and effective method to improve the lower urinary system function and with the exception of increased risk of UTI following AC after transplantation [group B], there is no considerable difference in the complication rates between AC before and after renal transplantation. As a result, we can perform AC before or after kidney transplantation in patients with dysfunctional lower urinary tract system up to their specific conditions

Endourology: a comparison between laparoscopic and open pyeloplasty in patients with ureteropelvic junction obstruction

To compare clinical and radiological outcomes, complications, and hospital stay in laparoscopic and open pyeloplasty. From February 2002 to February 2003, 69 patients with ureteropelvic junction obstruction [UPJO] were assigned into two groups. Thirty-seven patients underwent transperitoneal laparoscopic pyeloplasty and 32 underwent open surgical pyeloplasty. Clinical symptoms were assessed before and after surgery, subjectively. Radiological assessment was also done three months postoperatively. Mean operative time was 3.2 hours and 2.2 hours in laparoscopic and open pyeloplasty groups, respectively. Intraoperative bleeding was trivial in both groups and no complication or conversion to open surgery occurred. Postoperative complication rates were 24% and 6% in laparoscopic and open pyeloplasty groups, respectively. Mean hospital stay was similar [6.2 days] in the two groups. Mean follow-up was 16.5 months versus 11.4 months. Clinical and radiological success rates were 89% and 83.8% for laparoscopy group versus 96.5% and 87% for open pyeloplasty group. Due to recurrence of stricture, repeated surgery was performed in 4 patients of laparoscopy and 1 of open pyeloplasty groups. Laparoscopic pyeloplasty is a less invasive method with less pain, cosmetic advantages, no long incision, and outcome comparable with open surgery. Hospital stay is also not longer than that in open surgeries. Hence, laparoscopic pyeloplasty can be a substitute for skilled surgeons

PCNL in the management of lower pole caliceal calculi

Several therapeutic methods are used in the management of lower pole caliceal calculi. This survey has been conducted to evaluate the safety and efficacy of percutaneous nephrolithotomy in the management of lower pole calculi. Fifty-five patients, 43 males and 12 females with a mean age of 41.5 [range 11 to 75] years, who had suffered from lower pole caliceal calculi and treated by standard percutaneous nephrolithotomy [PCNL] between 1997 and 2001, were enrolled in this study. The stones were classified as follows: small [less than 25 mm], intermediate [25 to 34 mm] and large [more than 35 mm]. Mean follow-up was 6.2 months [range 2 weeks to 34 months]. The stones were completely extracted by one session PCNL in 43 patients [79%]. Repeat PCNL was needed in one patient and another method was used for stone extraction in another patient. Regarding the size of stone, 88%, 79%, and 74% of small, intermediate, and large stones were completely extracted, respectively. No major complication was noted. PCNL has high success rate in patients with stones larger than 2 cm and its morbidity would be low, provided that it is performed by skilled surgeons

Monthly variations of urinary stone colic in Iran and its relationship to the fasting month of Ramadan

Objective: To compare the prevalence of Renal Colic [RC] in Ramadan [the month of fasting for Moslems] with other months of the lunar year

Material and Methods: Records of 574 subjects, who were admitted in the two medical centers of Varamin [a city in a hot region of Iran], were reviewed in order to estimate the time trend of RC

Results: This study included 398 males [69.3%] and 176 females [30.7%]. Twenty-seven males [62.8%] and 16 females [37.2%] were admitted in Ramadan; and 371 males [69.9%] and 160 females [30.1%] in other months [p<0.4] of the year. RCs were more common in June [68 patients, 11.8%], July [65 patients, 11.3%] and November [60 patients, 10.5%]. Forty-three subjects [7.5%] admitted in Ramadan; the frequency was not significantly different from mean admission of the year [48.3 +/- 17 patients]. There was also no significant difference between frequency of admissions in Ramadan and mean admission during cold half of the year [36.8 +/- 18.34 patients, p = 0.3]. Mean admission [64.4 +/- 3.3 patients] in warm seasons were significantly higher than Ramadan [p < 0.001]

Conclusion: Lack of difference in the two groups indicates that higher temperature rather than fasting as a cause for RCs

Transureteral lithotripsy

From Sep. 1984 to Aug. 1990, 99 patients were treated for ureteral stone using the ureteroscope. In five patients ureteroscopy was repeated for a second stone. In one patient the procedure was diagnostic in nature and in the rest of the patients it had a curative value. In 60 patients the stone was removed by electrohydraulic and basket combination and in 25 cases, dilatation alone was enough. Rate of success was 84.6%, with a 10% rate of complications. We conclude that TUL is the treatment of choice for ESWL- resistant stones or in patients with ureteral anomalies