Evaluation of pulmonary regurgitation following tetralogy of fallot repair

Pulmonary regurgitation [PR] is the most important residual lesion remaining after the repair of Tetralogy of Fallot [TOF]. Through a thorough review of the data, statistics of patients undergoing pulmonary valve replacement following total correction for TOF and analyzing these data, the following study was performed and presented below. Database search for medical records of patients undergoing pulmonary valve replacement following total correction for TOF was performed and the data gathered, analyzed, and presented. The age of the patients [22.21 +/- 6.98 years old], time elapsed between the two operations, right ventricular ejection fraction [mildly decreased, 18.6%; moderately decreased, 67.9%; and severely decreased, 12.2% of cases], aneurysm in the outflow tract of the right ventricle [20.8%], tricuspid regurgitation [56.6%], tricuspid steno sis [1 case], valve type used for pulmonary valve replacement [biologic, 86.6%; metallic, 11.2%; and homograft, 1.9%], pulmonary artery pressure [<25mmHg, 34 cases [64.2%]; 25mmHg - 50mmHg, 7 cases [13.2%]; 50mmHg-75mmHg, 1 case [1.9%], and > 75mmHg, 1 case] were evaluated. Although right ventricular volume overload due to severe pulmonary regurgitation after repair of TOF can be tolerated for years, there is now evidence that the compensatory mechanisms of the right ventricular myocardium ultimately fail and that if the volume overload is not eliminated or reduced, this dysfunction may be irreversible. In light of those data and with better understanding of risk factors for adverse outcomes late after TOF repair, many centers are now recommending early pulmonary valve replacement before symptoms of heart failure develop

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

Persistence of goitre in children post-salt iodization in Islamic Republic of Iran: autoimmune status

We evaluated the prevalence of autoimmune thyroiditis in a random sample of 1188 schoolchildren aged 8-13 years with normalized iodine intake in the Islamic Republic of Iran. The prevalence of goitre was 39.6%; the majority had palpable but non-visible goitre. Of a subsample of 500 children, median urinary iodine excretion [18/8 microg/dL] indicated normal iodine intake. Thyroid peroxidase [TPO] antibody was positive in 3.7% of children and was significantly correlated with the prevalence of goitre and hypothyroidism. No correlation was seen between urinary iodine excretion and positive TPO antibody, mean TPO antibody, hypothyroidism or prevalence of goitre. Autoimmune thyroiditis explains some cases of goitre but other goitrogenic factors need to be evaluated

Serum folate and vitamin B[12] status in healthy Iranian adults

To assess the serum folate and vitamin B[12] status in healthy Iranian adults, we designed a population-based cross-sectional study of 1200 individuals aged 20-80 years. Finally 984 participants [507 men and 477 women] were assessed. The mean serum folate was 4.61 [SD 2.40] ng/mL and the mean serum vitamin B[12] level was 265.6 [SD 170.9] pg/mL. Overall 1.0% were folate deficient and 25.8% had low vitamin B[12] levels according to the manufacturer's reference ranges [folate < 1.5 ng/mL and vitamin B[12] < 160 pg/mL]. The mean serum folate and vitamin B[12] levels were significantly lower in men. The prevalence of vitamin B[12] deficiency was considerably higher than folate deficiency. Implementation of preventive measures seems to be necessary

Effect of menopause and renal function on vitamin D status in Iranian women

The effects of menopause and renal function on serum parameters of the vitamin D-endocrine system were studied in a cross-sectional sample of 676 healthy women aged 20-74 years in Shiraz. Low serum 25-hydroxyvitamin D [25-OHD] was found in 52.9% of the women. Serum parathyroid hormone [PTH] increased significantly over the age span in premenopausal women [r= 0.13, P= 0.02]. In premenopausal and postmenopausal women, serum levels of 25-OHD, phosphorus and calcium were stable across the age span. There was no significant correlation between creatinine clearance or serum PTH [r= -0.016, P= 0.66] and 25-OHD [r= 0.012, P= 0.74]. The high prevalence of vitamin D deficiency warrants consideration of dietary supplementation

Comparison of validity of decision rules in identifying primary osteoporosis in post menopausal women: a comparison

Clinical decision rules have been designed and developed to assist physicians in identifying the patient with osteoporosis. The aim of this study was to evaluate the performance of three decision rules in an Iranian post menopausal population. Three osteoporosis risk indices, the osteoporosis self assessment tool [OST], osteoporosis risk assessment instrument [ORAI], and the body weight criterion for 5573 out patients without any risk factors for secondary osteoporosis or receiving active bone medication and with negative history of prior fragility fraction were calculated. BMD at spines and femoral neck were measured via dual x-ray absorptiomety and the patients categorized to normal, osteopenic and osteoporotic according to WHO criteria. The sensivity, specifity, positive predictive value negative, predication value and area under receiver operating curve in identifying the osteoporotic women were determined for each decision rule and compared. In this study, the prevalence of osteoporosis was 30.8%, 20% in lumbar spines and neck of femur, respectively. The sensivity of these risk indices in indentifying women with osteoporosis ranged from 70% to 84/1% and the specificity ranged from 44.6-65.6%. The area under curve [ROC] in identifying those patients with osteoporosis was significantly better for OST [0.75] and ORAI [0.74] compared with the body weight criteria [0.66]. The negative predicative value ranged from 80% to 93%, while positive predication values ranged from 33% to 54%. Our data provide evidence showing OST, ORAI to be useful clinical tools, assisting clinicians in making decisions regarding which women need to be to referred for BMD testing but more evidence however needed is to confirm validity of body weight criterion

Hyperglycemic crises in diabetic patients

Diabetic ketoacidosis [DKA] and hyperosmolar hyperglycemic state [HHS] are two important causes of mortality and morbidity in patients with diabetes. Mortality rates are <5% in DKA and about 15% in HHS, much of which are avoidable with appropriate management. The prognosis is worsened with aging, hypotension, coma and concomitant life-threatening illnesses. The criteria for DKA and HHS are somewhat arbitrary, although glucose level is higher and ketone body level is minimal in HHS, they are two extremes in a spectrum of diabetic metabolic decompensation. In general, DKA occurs in type 1 and most often HHS occurs in type 2 diabetes; however, each type of diabetes may be associated with DKA or HHS. Both conditions are associated with marked dehydration, electrolyte disturbances and insulin deficiency and increased counter-regulatory hormones, so treatment consists of water and electrolyte replacement and insulin administration. Recognition and treatment of precipitating factors and frequent monitoring of patients are considered the most crucial aspects of the management

Hyperhomocysteinaemia, hyperlipidaemia and risk of venous thromboembolism in Shiraz

To assess the risk of venous thromboembolism [VTE] associated with hyperhomocysteinaemia [hyper-Hcy] and hyperlipidaemia, we performed a case-control study. Fasting total homocysteine [Hcy], triglyceride and cholesterol levels were assessed in 43 patients with VTE and 43 controls. Mean Hcy level was significantly higher in the test group. Odds ratio [OR] for VTE in patients with hyper-Hcy was 2.7, with the association stronger in women and those under 50. The OR for those with both hypertriglyceridaemia and hypercholesterolaemia was significantly greater in those under 50. Increased risk for venous thrombosis was found among those under 50 having both lipid abnormalities

effect of levothyroxine therapy on the recurrence rate of goiter after subtotal thyroidectomy in iodine deficient area

One hundred and two patients with subtotal thyroidectomy performed for benign thyromegaly were studied in Fars province, an area of iodine deficiency in southern of Iran. Group A, 40 patients who received levothyroxine 100mg per day postoperatively. Group B, 62 patients who did not receive levothyroxine. The recurrence rates were 5% and 47% in groups A and B respectively. The recurrence rate was higher in patients with multinodular goiter and diffuse thyromegaly than those with a single nodule. This study indicates that in iodine deficient areas, the patients should receive levothyroxine post-operatively for prevention of recurrence until iodine supplementation is available for the whole population

Visceral leishmaniasis as fever of unknown origin

Visceral leishmaniasis is the second most common cause of fever of unknown origin in our study. This disease is not common in adults, although it's endemic among the pediatric age group. The majority of the affected individuals were young. High grade spiking fever, chills and splenomegaly were unique findings. Other common findings were neutropenia, anemia, abnormal liver function tests, sterile pyuria and microscopic hematuria. Except for 1 case, parasites were absent from tissue biopsies [e.g. bone marrow, liver, lymph node]. Diagnosis was suggested by indirect fluorescent antibody [IFA] and confirmed by response to meglumine antimonate [Glucantime] and decline of IFA titer on follow-up

Prevention of pregnancy-induced hypertension by low dose aspirin

One hundred and twelve pregnant women with three risk factors for pre-eclampsia [primigravidity, twin pregnancy and history of previous preeclampsia] were screened with the roll-over test, at 28th to 30th weeks of gestation. Forty women with positive roll-over test [increase of more than 15mm Hg in diastolic blood pressure] were treated either with a daily dose of aspirin [21 women] or placebo [19 women] during the third trimester of pregnancy, up to one week before delivery. Only two patients [9.5%] in the aspirin-treated group developed pregnancy-induced hypertension, versus 7 patients [37%] in the placebo group: P<0.01. None of the control group with negative roll-over test developed hypertension. We conclude that low dose aspirin [100mg/day], taken in the third trimester of pregnancy by women with positive roll-over test, will significantly reduce pregnancy-induced hypertension