rare case of gestational gigantomastia with hypercalcemia: the challenges of management and follow up

Background: Gigantomastia is a breast disorder marked by exaggerated rapid growth of the breasts, generally bilaterally. Since this disorder is very rare and has been reported only in sparse case reports its etiology has yet to be fully established. Treatment is aimed at improving the clinical and psychological symptoms and reducing the treatment side effects; however, the best therapeutic option varies from case to case

Case Presentation: The present report described a case of gestational gigantomastia in a 30-year-old woman, gravida 2, parity 1, 17 week pregnant admitted to Pars Hospital, Tehran, Iran, on May 2014. The patient was admitted to hospital at week 17 of pregnancy, although her breasts initially had begun to enlarge from the first trimester. The patient developed hypercalcemia in her 32nd week of pregnancy. The present report followed this patient from diagnosis until the completion of treatment

Conclusion: Although gestational gigantomastia is a rare condition, its timely prognosis and careful examination of some conditions like hyperprolactinemia and hypercalcemia is essential in successful management of this condition

randomized placebo-controlled trial of clonidine impact on sedation of mechanically ventilated ICU patients

Clonidine has sedative and analgesic properties. Randomized studies examining these properties in mechanically ventilated ICU patients are scarce. This study was designed to assess the impact of clonidine on sedative agent use in mechanically ventilated patients. In a prospective, randomized, double blind, placebo-controlled study in a general ICU of a university medical center in Tehran, Iran, 40 patients, over 18 years on mechanical ventilation for 3 days or more randomized into 2 equal groups of clonidine and placebo. Clonidine arm received usual sedation and enteral clonidine 0.1 mg TID and escalated to 0.2 mg TID on the second day if hemodynamics remained stable. Ramsay Sedation Score was used to assess sedation. Opioids and midazolam were used in all patients. 10 patients in clonidine and 3 in placebo arms had history of drug abuse [P = 0.018]. The mean of sedatives used in the clonidine/placebo arms [mg/day] were; MED [Morphine Equivalent Dose] 91.4 +/- 97.9/112.1 +/- 98.8 P=0.39, midazolam 7.1 +/- 7.9/8.3 +/- 9.2 P=0.66 and propofol 535.8 +/- 866.7/139.1 +/- 359.9 P=0.125. After adjusting for addiction and propofol, clonidine reduced MED use by 79.6 mg/day [P=0.005] and midazolam by 5.41 mg/day [P = 0.05]. Opioids and midazolam need reduced by clonidine co-administration regardless of history of drug abuse. Acceptable side effect profile and the lower cost of clonidine could make it an attractive adjunct to sedative agents in ICU

Magnesium sulfate in exacerbations of COPD in patients admitted to internal medicine ward

The purpose of this study was to examine the effect of intravenous magnesium sulfate on patients with COPD exacerbation requiring hospitalization. In this randomized clinical trial 30 patients with COPD exacerbation were studied. Patients were randomly assigned to group A [case] who concurrent with standard therapy received 2 g magnesium sulfate in normal saline infused in 20 minutes on days one to three and group B [control] who received standard medications and placebo. PEFR and FEV1 were measured by before, 45 minutes and third day of entering the study. Vital signs HR, BP, RR, temperature and SpO2 were monitored during hospitalization. 21 males and 9 females patients with mean age of 68 +/- 9 years, case 67 +/- 10 and control 70 +/- 8 were studied [15 patients in each arm of study]. The mean pretreatment FEV1 was 26% +/- 12, and 35% +/- 18 in case and control groups respectively [P=0.137]. FEV1 after 45 minutes in case group was 27% +/- 9 and control group 36% +/- 20 [p=0.122]. FEV1 after 3 days of study was 32% +/- 17 in case and 41% +/- 22 in control groups [P=0.205]. The mean pretreatment PEFR was 126 +/- 76 l/min in case and 142 +/- 62 l/min in control groups [P=0.46]. Changes in PEFR were not significant 45 min [p=0.540] and 3 days [p=0.733] of the administration of intravenous magnesium sulfate. Duration of hospital stay between the two groups did not show any significant difference. This study showed that administration of intravenous magnesium sulfate in hospitalized patients with COPD exacerbation neither revealed any significant bronchodilating effect nor reduced duration of hospital stay

Comparative study of intravenous paracetamol and fentanyl for pain management in ICU

Pain in ICU patients should be managed effectively and safely. Fentanyl and Paracetamol are used frequently in ICU. However experience using IV Paracetamol in the setting of critically ill patients is limited. We evaluated the analgesic effect and adverse reactions of intravenous Paracetamol compared to Fentanyl in ICU patients with mild to moderate pain. Forty patients in a general ICU were randomized into two groups of IV Paracetamol and IV Fentanyl in a single blinded fashion. Pain was assessed by Visual Analogue Scale [VAS] before drug administration and six hourly for 48 h of 1 g IV Paracetamol every 6 h for 48 h in the first group and 25 [micro]g Fentanyl intravenously every three hours for 48 h in the second group. Patients were monitored for significant adverse reactions particularly of CNS and hepatic nature. Results showed the age, sex and pain score before analgesia was matched in both groups. Pain scores were similar in both groups at 24 h 2.60 [+/- 1.2] and 2.40 [+/- 1.5] and at 48 h 2.25 [+/- 0.96] and 2.05 [+/- 1.1] in Paracetamol and Fentanyl groups respectively. Clinical and laboratory adverse reactions were also similar in both groups. The analgesic properties of Paracetamol and Fentanyl were similar in this study. We did not observe any significant adverse effects in the two groups. Clinical and laboratory findings including liver functions remained without any statistically significant difference in two groups. This study demonstrates intravenous Paracetamol may be as safe and effective as Fentanyl in ICU patients with mild to moderate pain

Carbapenem restriction and its effect on bacterial resistance in an intensive care unit of a teaching hospital

Development of antibiotic resistance in Intensive Care Units [ICUs] is a worldwide problem. The purpose of this study was to evaluate the effect of an antibiotic stewardship program [ASP] by carbapenems restriction on gram-negative antimicrobial resistance in ICU. The study was designed in a 21 bedded general ICU of a teaching hospital with two wings [one and two] in Tehran, Iran. Carbapenem prescription in ICU1 was restricted to only the culture proven multi-drug-resistant bacteria with the absence of sensitivity to other antimicrobial agents. Carbapenem had to be prescribed by a trained ICU physician with close consultation with infectious disease specialist and the clinical pharmacist posted in ICU. Post-prescription reviews and de-escalations were carried out by the same team on regular basis. Restriction policy was commenced in January 2011 in ICU1. All documented infections and resistance patterns of isolated pathogens were recorded in both ICUs during two periods of 6 months before and 9 months after restriction policy implementation. During this study bacterial growth was detected in 51.5% of 1601 samples. Carbapenem administration was decreased from 6.86 to 2.75 DDD/100 patients day [60% decreases] pre-restriction and post-restriction respectively. Significant increase in sensitivity of pseudomonas to imipenem was observed in ICU1 comparing with pre-restriction period six months post restriction [p = 0.000]. Sensitivity of Klebsiella and Acinetobacter to imipenem did not change significantly during the study period. Our study demonstrated that restriction of carbapenems can increase sensitivity of P. aeroginosa to imipenem

Comparison between the preventive effects of ranitidine and omeprazole on upper gastrointestinal bleeding among ICU patients

Critically ill patients may develop visible gastric mucosal injury and stress ulcer soon after admission to an intensive care unit causing upper gastrointestinal bleeding as an important complication. Histamine-2 receptor antagonist [H2RA] prophylactic therapy has been documented to significantly decrease the incidence of upper GI bleeding in critically ill patients. This study was carried out in order to compare the effects of intravenous doses of ranitidine and enteral form of omeprazole suspension on preventing GI bleeding among ICU patients. This study was a double-blind randomized clinical trial conducted on patients admitted to the ICU at the Imam Hossein Hospital in Tehran, Iran. The patients were randomly divided into two groups of A and B. In group A, ranitidine was used as the prophylactic drug against GI bleeding with the dosage of 50 mg two times a day accompanied by placebo gavages through nasogastric tube. In group B, 20 mg of a suspension of omeprazole two times a day was gavaged in addition to 2[cc] of a parenteral placebo drug. Of 198 patients admitted to the ICU, 69 patients did not meet the inclusion criteria and a total of 129 patients enrolled in this study. During the study 14[20.58%] cases in the ranitidine group and 3[4.9%] in the omeprazole group developed significant GI bleeding. Incidence of GI bleeding showed a significant difference between the two groups using the chi-square test. Of the 68 patients receiving ranitidine, 44 [67.7%] died. This rate was 38 in those receiving omeprazole [62%]. Of the patients given ranitidine who faced overt GI bleeding, 12 [85.7%] died. This rate was 3 in the omeprazole group [100%].This study showed a statistically significant difference between omeprazole and ranitidine in preventing overt GI bleeding among ICU patients; but it failed to indicate any difference in prophylaxis of clinically important GI bleeding between the two drugs

[Ginger extract reduces delayed gastric emptying and nosocomial pneumonia in ARDS patients hospitalized in ICU]

About 20% of patients who are hospitalized in ICU have ALI/ARDS. Their feeding is usually via enteral nutrition. Delayed gastric emptying [DGE] is a major problem in patients with enteral nutrition, and they are at increased risk for aspiration and subsequent development of pneumonia. The purpose of this study was to evaluate the effect of Ginger extract on DGE and developing nosocomial pneumonia in patients with adult respiratory distress syndrome [ARDS] who are hospitalized in intensive care unit [ICU]. In this double- blind randomized clinicl trial, thirty two ARDS patients, who were on mechanical ventilation and fed via nasogastric tube, were randomly divided two groups. Experimental group [n=16] received ginger extract, and control group [n=16] received coconut oil. The amount of feeding tolerated at the first 48 hours of feeding and within study period, nosocomial pneumonia, number of ICU free days, number of ventilator free days and morality were evaluated during 21 days of intervention. Nosocomial pneumonia was significantly less frequent in the ginger extract group [6.3% in the ginger extract group versus 31.3% in the control group. p= 0.07]. There was no significant difference between two groups in mortality rate. The mean number of ventilator free days was 11.25 +/- 4.73 days in ginger group versus 7.18 +/- 5 days in control group [p=0.02]. The mean number of ICU free days was 4.43 +/- 3.5 days in control group versus 7.06 +/- 3.2 days in ginger group [P=0.04]. This study showed that gastric feed supplementation with ginger extract might reduce DGE and help to reduce the incidence of ventilator associated pneumonia [VAP] in ARDS patients