Liver Transplant for Patients With Neuroendocrine Tumor: A Report of 2 Exceptional Cases and Literature Review.

Patients with neuroendocrine tumors with unresec-table liver involvement can benefit from liver transplant. There is a specific set of guidelines for neuroendocrine tumors with liver metastasis that involve less than 50% of the liver. However, beyond those guidelines, there are reports of exceptional criteria patients who benefited from liver transplant. Here, we present 2 unusual cases of patients with exceptional circumstances and with neuroendocrine tumors who underwent liver transplant. The first case describes a patient with an extremely rare neuroen-docrine tumor of the proximal common bile duct that caused liver biliary cirrhosis. The patient underwent tumor resection and liver transplant concurrently. The second case describes a patient with a neuroendocrine tumor of unknown primary origin with more than 50% hepatic involvement who received a liver transplant after downstaging. In our center, patients with unresectable hepatic metastases from neuroendoc-rine tumors are currently selected for liver transplant based on well-established criteria. However, these 2 cases did not meet the criteria for consideration of liver transplant; thus, multidisciplinary team sessions were held to discuss these 2 cases. After a period of nonsurgical treatment and evaluation of the tumor behavior, we selected the patients as candidates for liver transplant based on the favorable tumor behavior and favorable response to treatment. For both patients, we did not observe any signs of tumor recurrence during follow-up. The outcomes were acceptable, and the patients tolerated treatment well. Considering the favorable tumor pathology (G1 phase and low Ki67 index), we suggest that more studies should be conducted to evaluate the outcomes of patients with low-grade tumors and that the criteria for patients with low-grade tumors could be extended based on such future data.

Accuracy of ultrasonography in diagnosing acute appendicitis during pregnancy based on surgical findings.

Background: Acute appendicitis is the most common nonobstetric surgical problem in pregnancy. Common signs and symptoms of appendicitis are less reliable during pregnancy due to physiological changes; thus, the role of imaging becomes prominent. Thus, in the present study, we aimed at assessing the accuracy of sonography in diagnosing acute appendicitis during pregnancy. Methods: In this prospective analytic study, among 1000 patients diagnosed and treated as acute appendicitis, clinical and sonographic findings of 58 consecutive pregnant patients, who underwent appendectomy, were recorded and analyzed. All surgically resected samples were evaluated and confirmed through histological evaluation. Sonographic criteria were utilized to judge the results for appendicitis. Diagnostic test performance characteristics (sensitivity, specificity, predictive values, and likelihood ratios) were calculated. Results: The mean age of the patients was 27.1±4.9 years, and the most common clinical symptom was right lower quadrant pain. There was no significant difference in the mean leukocyte count between the appendicitis group and normal appendix group (p=0.768). Left shift was also unrelated with the appendix pathology (p= 0.549). The sensitivity, specificity, predictive values (positive and negative), and likelihood ratios (positive and negative) were 80%, 75%, 91.4%, 52.9%, 3.2, and 0.26, respectively during all trimesters of pregnancy. Conclusion: Ultrasonography is the initially preferred imaging modality in pregnant women suspected of having acute appendicitis with an acceptable sensitivity; however, application of other imaging modalities such as CT scan or MRI is recommended after inconclusive ultrasonography results.

Effect of Baseline Red Blood Cell Distribution Width on Short- and Intermediate-term Mortality of Patients Under Primary Percutaneous Coronary Intervention: A Survival Analysis.

OBJECTIVE: Considering the limited studies specifically evaluating the role of Red blood cell distribution width (RDW) in primary percutaneous coronary intervention (PCI), we aimed to investigate the role of baseline RDW in short- and intermediate-term cardiovascular events in ST-elevation myocardial infarction patients under primary PCI. METHODS: This is a historical cohort registry analysis of 1161 patients with ST-elevation myocardial infarction under primary PCI. According to inclusion criteria, 838 patients were allocated for analysis. Patients with RDW levels of 13.6% or higher were considered as high RDW group (third tertile). All the individuals were followed up for in-hospital and 6-month mortality along with readmission and composite major adverse cardiac events. RESULTS: In-hospital deaths occurred in 53 (6.3%) patients and at 6-month follow-up 79 (9.4%) cases of mortality were documented. In-hospital and 6-month mortalities showed a significant trend in favor of high RDW group (13.3% vs. 5.9%, P = 0.003; 19.7% vs. 7.9%, P < 0.001, respectively). Multivariate analysis showed that high RDW was significantly and independently associated with higher rates of 6-month mortality (hazard ratio: 2.909; 95% confidence interval: 1.166-7.257; P = 0.022). RDW was also a significant predictor for 6-month mortality independent of anemia (hazard ratio: 2.811; 95% confidence interval: 1.047-7.551; P = 0.040). CONCLUSIONS: We found a significant association between high RDW and in-hospital and 6-month mortality as well as the occurrence of major adverse cardiac event. Meanwhile RDW was found to be a significant predictor for 6-month mortality independent of anemia. Thus, it would be beneficial to use RDW as a risk stratification index to identify high risk intent-to-treat patients.

Relationship Between Red Blood Cell Distribution Width and Mortality of Patients with Acute Myocardial Infarction Referring to Tehran Heart Center.

OBJECTIVE: Coronary heart disease is the most common cause of death in most countries and also in Iran. Among novel prognostic markers suggested in recent studies for coronary heart disease, red blood cell distribution width (RDW) has been found to be associated with poor prognosis. Therefore, we aimed to evaluate the relationship between RDW and 6-month mortality and cardiovascular events after the initial attack of myocardial infarction (MI). METHODS: Medical records of 642 patients with MI were investigated for basic and clinical characteristics, as well as patients' first hemoglobin, RDW, and mean corpuscular volume at the time of admission. Then based on patients' time of hospitalization, they were followed up by telephone for readmission and mortality 6 months later. RESULTS: Mean ± SD age of patients was 62.7 ± 12.7 years. In 6-month telephone follow-up, 443 patients (69%) had readmission. Six-month mortality occurred in 70 patients (10.9%). Patients with RDW level of 14.6% and higher were significantly older (P < 0.001). Three percent of patients with low RDW and 14.8% in high RDW group had renal failure (P < 0.001). Six-month mortality was observed in 24.3% of patients with high RDW and 7.9% of those with low RDW (P < 0.001). In multivariate logistic regression analysis, RDW (odds ratio: 1.98, 95% confidence interval: 1.06-3.68, P = 0.03), age, and ejection fraction were significant independent prognostic factors for mortality. CONCLUSIONS: Six-month mortality was significantly higher in patients with MI with high RDW. Thus given that RDW is an inexpensive and available laboratory test, it could be used for mortality risk assessment and follow up the patients for stricter control of other modifiable risk factors.

Does hypertension remain after kidney transplantation?

Hypertension is a common complication of kidney transplantation with the prevalence of 80%. Studies in adults have shown a high prevalence of hypertension (HTN) in the first three months of transplantation while this rate is reduced to 50- 60% at the end of the first year. HTN remains as a major risk factor for cardiovascular diseases, lower graft survival rates and poor function of transplanted kidney in adults and children. In this retrospective study, medical records of 400 kidney transplantation patients of Sina Hospital were evaluated. Patients were followed monthly for the 1st year, every two months in the 2nd year and every three months after that. In this study 244 (61%) patients were male. Mean ± SD age of recipients was 39.3 ± 13.8 years. In most patients (40.8%) the cause of end-stage renal disease (ESRD) was unknown followed by HTN (26.3%). A total of 166 (41.5%) patients had been hypertensive before transplantation and 234 (58.5%) had normal blood pressure. Among these 234 individuals, 94 (40.2%) developed post-transplantation HTN. On the other hand, among 166 pre-transplant hypertensive patients, 86 patients (56.8%) remained hypertensive after transplantation. Totally 180 (45%) patients had post-transplantation HTN and 220 patients (55%) didn't develop HTN. Based on the findings, the incidence of post-transplantation hypertension is high, and kidney transplantation does not lead to remission of hypertension. On the other hand, hypertension is one of the main causes of ESRD. Thus, early screening of hypertension can prevent kidney damage and reduce further problems in renal transplant recipients.

Bilateral tibial lengthening over the nail: our experience of 143 cases.

INTRODUCTION: Using lengthening over an intramedullary nail as a technique for cosmetic purposes improves the individuals' quality of life and provides more satisfactory results due to less external fixator period. METHODS: This study reports a case series of 143 individuals who underwent bilateral tibial lengthening over an intramedullary nail for cosmetic purposes together with the review of parameters related to the surgery and complications. Level of satisfaction was measured with the standard visual analog scale at least 1 year after removal of external fixator. RESULTS: In this study, mean (SD) age of patients was 26.6 (7.26) years. 85 (59.4%) participants were male and 58 (40.6%) were female. Mean end lengthening of all individuals was 6.65 cm. The mean external fixator period was 93.7 days. Complication rate was 0.74 per segment but it decreased to 0.45 when pin-tract infection was excluded. Complications were categorized based on Paley et al.'s classification as 129 problems, 85 obstacles and no sequelae. Interestingly, 44 (30.8%) individuals had no problem and obstacle. CONCLUSIONS: Lengthening over an intramedullary nail provides bone formation in equal quality to that obtained by the conventional Ilizarov method, along with lower rate of complications. The large number of individuals involved in our study is a remarkable benefit which could be used as an appropriate sample to compare results for outcomes and complications.

Effects of massage therapy and presence of attendant on pain, anxiety and satisfaction during labor.

PURPOSE: To investigate the effects of massage and presenting an attendant on pain, anxiety and satisfaction during labor to clarify some aspects of using an alternative complementary strategy. METHODS: 120 primiparous women with term pregnancy were divided into massage, attendant and control groups randomly. Massage group received firm and rhythmic massage during labor in three phases. After 30 min massage at each stage, pain, anxiety and satisfaction levels were evaluated. Self-reported present pain intensity scale was used to measure the labor pain. Anxiety and satisfaction were measured with the standard visual analog scale. RESULTS: Massage group had lower pain state in second and third phases (p < 0.05) in comparison with attendant group but reversely, the level of anxiety was lower in attendant group in second and third phases (p < 0.05) and satisfaction was higher in massage group in all four phases (p < 0.001). The massage group had lower pain and anxiety state in three phases in comparison with control group (p < 0.05). Data analysis of satisfaction level showed higher values in four phases in massage group compared with control (p < 0.001) and comparison of attendant and control groups showed higher satisfaction in attendant group in phases 2, 3 and 4 as well (p < 0.001). Duration of active phase was lower in massage group (p < 0.001). CONCLUSIONS: Findings suggest that massage is an effective alternative intervention, decreasing pain and anxiety during labor and increasing the level of satisfaction. Also, the supportive role of presenting an attendant can positively influence the level of anxiety and satisfaction.