Spontaneous Adrenal Hematoma in a Pregnant Woman; a Case Report.

Spontaneous adrenal hematoma is a very rare condition and its prevalence has been reported to be about 1% in previous studies. Although various causes have been proposed to explain its incidence in existing case reports, the etiology and pathology of this condition is still not known. The present study presents a case of spontaneous adrenal hematoma in a pregnant 31 year old womanwithout history of trauma or other probable risk factors of hemorrhage, presenting to the emergency department with chief complaint of pain in the right flank.Diagnostic measures, imaging and laparotomy,confirmed the diagnosis of spontaneous adrenal hematomafor her.

Comparison of percutaneous versus open surgical techniques for placement of peritoneal dialysis catheter in children: A randomized clinical trial.

UNLABELLED: Background This research compares the outcomes of percutaneous technique and open surgical peritoneal dialysis catheter placement in children. METHODS: In this randomized controlled trial, between 2010 and 2011,a total of 35 pediatric uremic patients were enrolled and randomized into two study groups. Follow up data included duration of operation (minute), duration of hospitalization (days) and onset time of peritoneal dialysis. Complications were considered as mechanical and infectious. RESULTS: The percutaneous procedure was significantly faster than the open surgical technique (9.5 ± 1.81 versus 27.00 ± 2.61 minutes, p= 0.0001). The onset of dialysis was earlier in percutaneous insertion. There were no cases of hollow viscous perforation, early peritonitis and exit site infection at the 3rd, 7th, and 14th day in both groups. Complications in open surgical group were include wrapped omentum in 4 (23.5%), catheter malposition in 3 (17.6%),delayed exit site infection in 2 (11.7%), Incisional hernia in 1 (5.8%)and hemoperitoneum in 2 (11.7%)cases. Complications in percutaneous insertion group were include catheter malposition and wrapped omentum each in one case. CONCLUSION: Percutaneous method with secure insertion of the catheter reduced the rate of some complications. Although they were not statistically significant, this technique reduces the time of hospitalization and operation without need to general anesthesia. The onset of dialysis was earlier significantly. Trial registry code: IRCT2013091514670N1.

Heparin compared with normal saline to maintain patency of permanent double lumen hemodialysis catheters: A randomized controlled trial.

BACKGROUND: Heparin has long been used to prevent thrombosis in the permanent central venous hemodialysis catheters (PermCath). Other alternatives for heparin with fewer side-effects have recently been considered. We compared normal saline (0.9%) with heparin for flushing PermCath with regards to catheter patency and prevention of heparin complications. MATERIALS AND METHODS: Chronic kidney disease patients who were candidate of PermCath placement were randomly assigned into two groups of heparin and saline. In the heparin group, the PermCath was flushed with heparin (1000 IU), and in the saline group, it was flushed with saline 0.9%. Patients were followed for 24 hours, and outcomes included catheter thrombosis, maneuver needed to maintain catheter patency, and bleeding from catheter site. RESULTS: Ninety six patients were included (age = 63.1 ± 11.2 years, 54.2% male). No one experienced catheter thrombosis. Two patient (4.2%) in the heparin and three ones (6.1%) in the saline group required catheter manipulation (P = 0.520). Four patients (8.5%) in the heparin and three ones (6.1%) in the saline group experienced bleeding (P = 0.476); differences between heparin and saline groups in the amount of bleeding (225.0 ± 62.4 vs. 200.0 ± 113.5 cc, P = 0.721) and bleeding time (6.5 ± 1.2 vs. 5.3 ± 1.5 min, P = 0.322) were not significant. In the heparin group, no significant increase was observed in PTT over time; baseline 30.9 ± 3.4, 12 h 31.8 ± 3.4, 24 h 31.2 ± 6.6 (P = 0.628). CONCLUSIONS: Flushing PermCath with normal saline 0.9% is as effective as heparin in maintaining patency of the catheter, while it may reduce the risks associated with heparin.

Supraglottic paraganglioma originated from superior laryngeal nerve.

Neurogenic tumors, especially paraganglioma of larynx, are rare. In this article, we present a 64-year-old woman who complained of intermittent dysphagia to solid foods. Further evaluation revealed a supraglottic paraganglioma and she was treated successfully by total excision of tumor.

Placement of long-term hemodialysis catheter (permcath) in patients with end-stage renal disease through external jugular vein.

BACKGROUND: The number of patients with End-Stage Renal Disease (ESRD) has progressively increased in the population. Kidney transplantation is the specific treatment for such patients; however a majority of patients will require hemodialysis before kidney transplantation. The present study aims to investigate using the external jugular vein (EJV) for Permcath placement in these patients. MATERIALS AND METHODS: This descriptive and analytical study was conducted in Alzahra Medical Center, Isfahan, in 2012. Catheters were inserted by cutting down the right EJV. The patency rate and potential complications were studied. The obtained data was analyzed using SPSS 21.0. RESULTS: Out of 45 live patients, within three months of surgery, 40 patients (81.6%) had no complications and dialysis continued through Permcath. Permcath Thrombosis occurred in two patients (4.4%). Catheter infection led to the removal of it in one patient (2.2%) 1.5 months after surgery. And accidental catheter removal occurred in one patient. CONCLUSION: Placement of the permcath in the external jugular vein can be a safe, uncomplicated, and reliable method for patients requiring hemodialysis, and can be a life-saving alternative in patients without accessible internal jugular vein.

The role of folic acid on the hyperhomocysteinemia in the Buerger's disease (Thromboangiitis Obliterans).

BACKGROUND: The mechanism underlying Buerger's disease (BD) is still unknown. Recently, thrombophilic conditions predisposing to a hypercoagulable state have been hypothesized as triggers for BD. The aim of the study is to evaluate the prevalence of the hyperhomocysteinemia and level of the anticardiolipin antibodies, and the role of folic acid on the hyperhomocysteinemia and on the rate of the amputations in the patients with BD. MATERIALS AND METHODS: In an experimental placebo-controlled double-blinded study, between 2004 and 2010, thirty patients with BD were randomly assigned into two groups (14 patients in a drug group and 16 patients in the placebo group). Drug or placebo was administered, and they were followed in 2 and 6 months for homocysteine, Anticardiolipin antibodies and the risk of amputations. RESULTS: At the beginning of the study homocysteine level was higher than normal in 19 patients (63%). There was a significant decrease in homocysteine level during 6 months in folic acid group (P < 0.001), but there was no change in the placebo group. None of our patients had elevated Anticardiolipin antibodies, and there was no change in the level of Anticardiolipin antibody during study. High level of homocysteine did not associate with more amputations during 6 months of study (P > 0.05). CONCLUSION: This study shows the hyperhomocysteinemia in BD, and the benefit of folic acid treatment in homocysteine lowering, but folic acid doesn't inhibit the risk of major and minor amputation during 6 months of follow-up. Longer follow-up may reveal the role of folic acid in these patients.

The comparison of the complications of axillobrachial and femorofemoral arteriovenous shunt prostheses in hemodialysis, a 3 year study in Alzahra general hospital.

BACKGROUND: This study was performed to compare the outcome and complications of axillobrachial and femorofemoral graft as upper and lower limb arteriovenous shunt prostheses. MATERIALS AND METHODS: In a prospective cohort study, we observed and followed-up all cases with a new insertion of ePTFE between February 2006 and February 2009. Assessment of patency and the complication rates of their prostheses were the essential parts of this observation. METHODS: In a prospective cohort study, we observed and followed-up all cases with a new insertion of ePTFE between February 2006 and February 2009. Assessment of patency and the complication rates of their prostheses were the essential parts of this observation. RESULTS: A total of 69 grafts were performed. Forty-nine of them were successfully followed-up (18 femorofemoral and 31 axillobrachial grafts). Immediate primary patency was 100%. For axillobrachial type, primary patency at 1, 3, and 6 months, respectively, was 86%, 60%, and 47%. Secondary patency at 1, 3, and 6 months was 86%, 75%, and 50%, respectively. For femorofemoral type, primary patency at 1, 3, and 6 months, respectively, was 88%, 40%, and 34%. Secondary patency at 1, 3, and 6 months was 94%, 47%, and 41%, respectively. (P > 0.05) Complications included a puncture-site hematoma, thrombosis, infection, venous hypertension, need of an excision and pseudoaneurysm formation. Pseudoaneurysm rate difference between the two groups was interestingly significant, while others were relatively similar; however, the rates were different. CONCLUSION: The significant difference of aneurysm rate among our two groups, besides the insignificant difference of other complications and also the similar primary and secondary patency rates, manifest a brilliant guidance chart for the surgeons in order to choose the most compatible site for inserting ePTFE grafts (Gore-tex) as arteriovenous shunt prostheses for HD accessing.

Convulsive syncope as presenting symptom of carotid body tumors: Case series.

Carotid body tumor (CBT) is paraganglioma and mainly found in the carotid bifurcation. The manifestations of the tumor are variable; in most cases, it presents as a non-symptomatic slow-growing mass, rarely compression of carotid body induces bradycardia and hypotension and repeated syncope, prolonged syncope can cause convulsion. Convulsive syncope occurred in 0.03% of patients with syncope. In this paper, we report three cases with CBT and convulsive syncope for which surgery was done and patients did not experience syncope again.

Four cases of adhered permanent double lumen hemodialysis catheters (Permcath).

Between September 2010 and January 2012, four patients in our hospital were observed to have permanent dialysis catheters that adhered to either the SVC or right atrium. The first patient underwent intraoperative fluoroscopy and was scheduled for cardiac surgery. Unfortunately due to metabolic disturbances, the patient's condition deteriorated and she died before surgery.  The second patient underwent cardio-thoracic surgery with mid-sternotomy and cardio-pulmonary bypass. The catheter was removed and another access route for hemodialysis was established. The third case was scheduled for interventional venocavagraphic exploration of the adhered Permcath. An endovascular snare was passed through the guide wire, which separated the catheter from the SVC. Finally, the fourth patient was a known case of Von Willebrand disease who was scheduled for interventional angiographic Permcath removal. Unfortunately, a few hours following the attempt at surgical removal of the Permcath, her condition deteriorated and she died. Several methods have been used to manage an adherent Permcath. It is assumed that the longer the catheter is in place, the probability of adhesion to the central veins increases. Histological changes have been demonstrated in the venous wall adjunct to the catheter.  Interventional venacavagraphic exploration of the catheter and snaring the adherent site of the catheter seems to be a valuable option.

Thermal stability and decomposition kinetic studies of acyclovir and zidovudine drug compounds.

Investigations on thermal behavior of drug samples such as acyclovir and zidovudine are interesting not only for obtaining stability information for their processing in pharmaceutical industry but also for predicting their shelf lives and suitable storage conditions. The present work describes thermal behaviors and decomposition kinetics of acyclovir and zidovudine in solid state, studied by some thermal analysis techniques including differential scanning calorimetry (DSC) and simultaneous thermogravimetry-differential thermal analysis (TG/DTA). TG analysis revealed that thermal degradation of the acyclovir and zidovudine is started at the temperatures of 400°C and 190°C, respectively. Meanwhile, TG-DTA analysis of acyclovir indicated that this drug melts at about 256°C. However, melting of zidovudine occurred at 142°C, which is 100°C before starting its decomposition (242°C). Different heating rates were applied to study the DSC behavior of drug samples in order to compute their thermokinetic and thermodynamic parameters by non-isothermal kinetic methods. Thermokinetic data showed that both drugs at the room temperature have slow degradation reaction rates and long shelf lives. However, acyclovir is considerably more thermally stable than zidovudine.

Biotransformation of methyl tert-butyl ether by human cytochrome P450 2A6.

Methyl tert-butyl ether (MTBE) is widely used as gasoline oxygenate and octane number enhancer for more complete combustion in order to reduce the air pollution caused by motor vehicle exhaust. The possible adverse effects of MTBE on human health are of major public concern. However, information on the metabolism of MTBE in human tissues is scarce. The present study demonstrates that human cytochrome P450 2A6 is able to metabolize MTBE to tert-butyl alcohol (TBA), a major circulating metabolite and marker for exposure to MTBE. As CYP2A6 is known to be constitutively expressed in human livers, we infer that it may play a significant role in metabolism of gasoline ethers in liver tissue.

Comparing the outcomes of open surgical procedure and percutaneously peritoneal dialysis catheter (PDC) insertion using laparoscopic needle: A two month follow-up study.

BACKGROUND: This study was performed to compare the outcomes of open surgical procedure and percutaneously peritoneal dialysis catheter (PDC) insertion using laparoscopic needle. METHODS: This randomized clinical trial study was conducted in the Nephrology Department in Noor Hospital, Isfahan, Iran between 2009 and 2010. 64 uremic patients were randomized into two study groups using random allocation software. Thirty four catheters were inserted percutaneously (P group) and 30 catheters were placed surgically (S group). Collected information included demographic data, body mass index, and cause of renal disease, duration of operation and length of hospitalization. Outcomes were considered as mechanical and infectious complications. RESULTS: There were no significant differences in age, gender, the mean of body mass index, having history of hemodialysis, diabetes mellitus, hypertension, ischemic heart disease, and length of hospitalization. Hemopenitoneom was more frequent in S group than P group (13.3% versus 3.2%; p < 0.0001). There was no significant difference between two groups in early peritonitis, early leakage, hernia, hollow viscous perforation, catheter obstruction, and malpositioning and the time of peritoneal dialysis onset. Outflow failure and the exit site infection were more frequent in S group than P group (p < 0.0001). Mean of the operative time was longer in S group than P group (27.70 ± 2.79 minutes versus 10.48 ± 1.91 minutes, p < 0.001). CONCLUSIONS: Percutaneous catheter insertion has fewer rate of complications and is less time consuming in comparison with surgical method.

Prognostic factors and outcome of traumatic diaphragmatic rupture.

BACKGROUND: Traumatic diaphragmatic hernias commonly occur after blunt and penetrating trauma. The difficulties in diagnosing traumatic diaphragmatic rupture due to coexisting injuries and the silent nature of the diaphragmatic injuries at the first admission are the most common causes of delayed diagnosis. METHODS: The medical records of 34 patients (28 male, 6 female; mean age 32.3 years; range 1 to 68) treated for post-traumatic diaphragmatic hernias between August 2004 and June 2008 in Alzahra Hospital were analyzed retrospectively. RESULTS: Rupture of the diaphragm was left-sided in 22 (64.7%) and right-sided in 11 (32.4%) and bilateral in 1 (2.9%) of the patients. Blunt trauma accounted for the injuries of 22 patients (64.7%). In the first operation, diagnosis was established preoperatively in 15 patients (44.1%) and intraoperatively in 13 (38.2%). The diagnosis was missed in 6 (17.7%) patients in the first operation. Strangulation of the viscera was seen in three patients. The longest interval between the onset of trauma and diagnosis was approximately three years in one case. Multiple associated injuries were observed in 22 patients (64.7%), the most common of which were spleen injury (38.2%), fractures of the extremities and hemothorax (29.4%) and liver injury (26.5%). Postoperative complications were seen in nine patients (26.5%). Mortality of isolated blunt traumatic rupture was 0%. Hemorrhagic shock, young age and associated injuries significantly increased the mortality and morbidity. CONCLUSION: Despite the fact that the incidence of diaphragmatic hernia is uncommon, it should be suspected in all blunt or penetrating traumas of the thorax and abdomen. Because late complications are usually associated with high morbidity, the presence of such an injury should be excluded before terminating the exploratory procedure.

Room-temperature ionic liquids as electrolytes in electroanalytical determination of traces of 2-furaldehyde from oil and related wastewaters from refining processes.

Three different ionic liquids, 1-ethyl-3-methylimidazolium tetrafluoroborate, [EMIM][BF(4)]; 1-butyl-3-methylimidazolium trifluoromethanesulfonate, [BMIM][OTf]; and 1-butyl-1-methylpyrrolidinium bis(trifluoromethanesulfonyl)imide [bmpyrr][NTf(2)] were studied as electrolytes in the electroanalytical quantification of 2-furaldehyde using square wave and differential pulse voltammetries. On applying a cathodic scan, a well-defined 2-electron wave was observed corresponding to the reduction of 2-furaldehyde to furfuryl alcohol. The electrochemical stability of the ionic liquids as electrolytes for analytical aspects and electrokinetic studies was investigated using a glassy carbon electrode (GCE). The measurements were carried out in a designed double-wall three-electrode cell, using two platinum wires as the quasi-reference and counter electrodes. Differential pulse voltammetry was found to be the most sensitive method at GCE. The detection limits of 1.4, 19.0 and 2.5 microg g(-1) were obtained for the determination of 2-furaldehyde in [EMIM][BF(4)], [BMIM][OTf] and [BMPyrr][NTf(2)], respectively. At a concentration of 50 microg g(-1), the maximum relative standard deviation (n=3) was 4.9%. The effect of water content of the ionic liquids on their potential windows and waveforms was also investigated. The proposed method was successfully applied to the determination of 2-furaldehyde in real samples, especially in oil matrices.

Influence of intralumenal and antibiotic-lock of vancomycin on the rate of catheter removal in the patients with permanent hemodialysis catheters.

Infection of permanent catheters (Permcath) in hemodialysis (HD) patients can lead to catheter removal. The successful use of an antibiotic-lock to treat infection has reported good results in the treatment of catheters' infections. This study was designed to evaluate the impact of the intraluminal vancomycin in comparison with intravenous antibiotic administration. We included 67 (37 males and 30 females) chronic HD patients requiring Permcath insertion at our tertiary care hospital from July 2004 to June 2007. We studied two subgroups: an intervention group, which received 500 mg vancomycin infusion via both lumens of the Permcath and antibiotic lock of 1.5 mL each 48 hours with 1 g i.v. ceftriaxone every 12 hours for 7 days, followed by oral antibiotics according to the culture for three weeks; and a control group, which received 500 mg intravenous vancomycin with daily 100-150 mg amikacin intravenously. Our endpoint was the rate of catheter removal. The patients characteristics including age, sex, time of insertion of the catheter and number of dialysis sessions per week did not differ between both subgroups. Of 28 patients in the intervention group, there was one catheter removal, and of 39 patients in the control group, there were 22 catheter removals, (P< 0.001). We conclude that administration of vancomycin as an antibiotic-lock in permcaths is more effective than its mere intravenous injection, and can increase the life span of catheters.

The effect of ligation of the distal vein in snuff-box arteriovenous fistula.

Arterio-venous fistula (AVF) in the snuff-box region is one of the current techniques used for creating a vascular access in patients undergoing dialysis. The aim of this study is to find out whether ligating the distal vein in AVF in the snuff-box will bring about any change in the efficiency and complications of the fistula. Sixty patients (30 males, 30 females) suffering from chronic renal failure, who had been admitted for creating an AVF, were randomly divided into two groups after having filled out consent forms. After the AVF was made, the distal vein was ligated in the first group, but not in the second group. The patients were discharged after being given the necessary advice on how to take care of their fistula. They were examined on post-surgical days 1, 30 and 90. Early efficiency in the ligated and non-ligated groups was 100% and 96.7% respectively while late efficiency in the two groups was 90% and 83.4%, respectively (P > 0.05). The most common complication in both groups was thrombosis (11.7%). Venous hypertension and edema were observed in two patients (both from the non-ligated group) and infection of the surgical site was observed in only one patient. Our study suggests that, considering the high efficiency level and low complication rate, AVF at the snuff-box region constitutes one of the best possible vascular accesses for patients undergoing hemodialysis. Ligation of the distal vein prevents the development of venous hypertension in the fistula.

Application of intravenous electrocardiography for insertion of central veins dialysis catheters.

One fifth of the inserted dialysis catheters in the internal jugular or subclavian veins may be misplaced. Appropriate positioning of the catheter tip is sometimes difficult. We attempted to use intravenous electrocardiography (ECG) to guide catheter tip positioning in 30 hemodialysis patients (17 (57%) were men, and the mean age was 43 +/- 12 years). who required vascular accesses for dialysis by insertion of double lumen temporary catheters via the jugular veins. Before cathe-terization, standard ECG on the long lead D II was performed and P-wave height was recorded. P-wave voltage was also measured via the blue (venous) and red (arterial) lumens, using the guide wire as an electrical conductor. After confirmation of the appropriate position of the catheter tip at the superior vena cava (SVC)-right atrial junction using chest radiography, the ECG lead corres-ponding to the right hand was connected to the guide wire lodged inside the lumen of the blue catheter. P-wave height in the long lead D II was recorded. The guide wire was withdrawn so as to bring its tip tangent to the tip of the red catheter. ECG was performed on the long lead D II in a similar manner, and the P-wave height was recorded. The mean P-wave voltage in normal ECG and intravenous ECG (red and blue catheter tips) measured 1.27 +/- 0.38 mm, 3.10 +/- 0.95 mm, and 5.42 +/- 1.76 mm, respectively. The difference between the mean P-wave voltages measured in standard and intravenous ECG (blue and red catheter tips) was statistically significant (P< 0.05). We conclude that the dialysis catheter tip can be positioned appropriately via the measurement of the P-wave height by intravenous ECG and using the sinoatrial node as an accurate landmark. This method can complement the chest radiography in the appropriate placement of the central vein catheters.

Effects of the arteriovenous fistula on pulmonary artery pressure and cardiac output in patients with chronic renal failure.

INTRODUCTION: Access to the vascular system is necessary in patients with chronic renal failure planned to undergo dialysis. One of the complications of end-stage renal disease patients is pulmonary hypertension (PHT). Temporary arteriovenous access closure and successful kidney transplantation causes a significant fall in cardiac output and pulmonary artery pressure (PAP), indicating the possibility that excessive pulmonary blood flow is involved in the pathogenesis of the disease. We attempted to study the relationship of PHT with arteriovenous fistula (AVF) creation, as well as to assess the relationship between AVF flow and fistula characteristics. METHODS: Fifty patients were included in the study. Echocardiography was used to evaluate systolic PAP, cardiac output (CO), and ejection fraction (EF) before creating the AVF. After a follow-up interval of at least 6 months, a second echocardiographic assessment and a Doppler sonographic assessment of their fistula flow were carried out. Complete data were available for 34 patients. RESULTS: Study data were collected from 34 patients, 28 males and 6 females with a mean age of 52 yrs ranging from 15-78 yrs. The data showed a statistically significant positive correlation between fistula flow and PAP2 and PAP changes (p <0.05). Mean fistula flow was 1322 ml/min in patients without PHT and 2750 ml/min in patients with PHT. This difference (1428 ml/min) was statistically significant (p=0.03). We found a significant negative correlation between PAP1 and EF1 and PAP2 and EF2 (p <0.05). In addition, the mean EF2 in patients without PHT was 57% in contrast to 46% in patients with PHT. Mean fistula flow in radial fistulae (mean=422 ml/min, range: 370-474 ml/min) was significantly less than brachial fistulae (mean=1463 ml, range: 270-3300 ml/min) (p=0.03). Mean systolic PAP2 of 14.8 mmHg in transplanted patients was 5.9 mmHg less than those who were not transplanted (20.7 mmHg). Diabetes was the most common cause of renal failure and diabetics had a significant reduction in their EF (15.5%) compared with non-diabetic patients (1% reduction) (p=0.016). CONCLUSION: Fistula flow, PAP and EF of all patients should be checked at least 6 months after fistula creation. Patients with higher fistula flow rates and patients with diabetes mellitus need to be more closely observed. In addition, elderly patients with significant cardiac and other comorbidities may be more prone to develop symptoms after AVF creation.

Non iatrogenic paediatric vascular trauma of the extremities and neck.

AIM: Vascular trauma in children is uncommon. Considering the complexity of these injuries, we have tried to determine their demographic data, the different factors changing their outcome, the different modalities of management, and their outcomes. PATIENTS AND METHODS: We reviewed the medical records of 52 pediatric patients of less than 15 years f age for about ten years (1996 to 2006) .The review was followed by physical examination done by two surgeons. Vascular injuries included blunt and penetrating injuries to the neck and extremities. Their management included conservative management, primary closure, end-to-end anastomosis, graft interpositioning, and fasciotomy. RESULTS: The patients included 41 males and 11 females and their mean age was 9.7 years (ranging from 3 to 14 years). Males were significantly more (78%) involved. Penetrating upper extremity injuries were the most common cause of vascular injury in the paediatric population (65% on the right side). The most common mechanism was cutting the hand by glass (most of them on the ulnar side). These vascular injuries per se did not cause any disability in the upper extremities. The outcome of these injuries depended more on simultaneous nervous injury and to a lesser extent, on tendon injury. There was no significant long-term difference between ligation and anastomosis of the radial and ulnar arteries. Lower extremity vascular injuries had significantly higher mortality and morbidity. CONCLUSION: As the reconstructive procedures to manage vascular injuries are technically difficult, we suggest conservative managements to be applied first. Prompt surgical intervention is necessary if there are any critical signs of ischaemia or unsuccessful conservative management.