Acta Medica Iranica
Volume:50 Issue: 8, Aug 2012

Percutaneous dilatation tracheostomy (PDT) is one of the most frequent interventions in ventilator dependant ICU patients. Ciaglia and Griggs are two common PDT techniques. Few studies are available comparing these two methods, but there is no data available to compare these two techniques in Iranian population. The aim of this study was to compare Ciaglia and Griggs technique in our population in order to recognize advantages and disadvantages of each technique in order to identify the most beneficial one. This study is a comparative clinical trial conducted on 100 consecutive ICU admitted patients who needed prolonged intubation; half of them underwent PDT with Ciaglia method and other half with Griggs method. Procedural time and short term complications including bleeding, vital signs instability and technical errors were compared in both two methods. Both groups were comparable in demographic characteristics. Griggs method performed significantly faster than Ciaglia method (P=0.001). Complications such as high grade bleeding (P=0.01) and cardiac dysrhythmias (P=0.07) were less in Ciaglia technique than Griggs. Skin incision smaller than required was reported more with Griggs method than Ciaglia (P=0.03). We conclude that PDT with Ciaglia method is safer with less complications than the Griggs method. We suggest use of Ciaglia for less experienced operators.

Aluminum phosphide poisoning (ALPP) still has no efficient and approved antidote. Supportive care and hemodynamic monitoring are the only choices of treatment. We proposed a new lavage formulation in addition to evaluation of its efficacy and defining the impact of clinical characteristics of patients on their prognosis. During eight months period of time, 120 patients were enrolled to the study and randomly received two different gastric lavage protocols. Our new lavage protocol had positive impact on patient's survival and the P-value in comparison with the classic gastric lavage method was close to significant level (P=0.054). On hospital arrival indication for intubation-ventilation as well as sense of thirst, sore throat and absence of nausea indicate worse outcome. Using our novel approach, indication for intubation-ventilation as well as sense of thirst, sore throat and absence of nausea can be considered as applicable prognostic factors in survival of ALPP patients. Further studies are required to set this approach as preferred treatment.

Following failure of systemic chemotherapy, transarterial chemoembolization (TACE) is an available method to control unresectable liver metastases from colorectal carcinoma (CRC). The aim of present study was to evaluate the efficacy of chemoembolization for inoperable metastatic liver lesions from CRC. Forty-five CRC patients with liver metastases resistant to systemic chemotherapy were enrolled in our study. For each patient, three session of TACE were conducted with 45 days interval. A combination of mitomycin, doxorubicin, and lipiodol were used for TACE. A tri-phasic computed tomography scan and biochemical laboratory tests were performed for all patients at baseline and 30 days after each TACE. Image analysis included measurement of lesion diameters as well as contrast enhancement. Eleven patients deceased before completing three session and the final analyses were performed on the remaining 34 patients. Evaluation of a total 93 lesions in all patients after chemoembolization sessions revealed a 25.88% reduction in anteroposterior (AP) diameter, 33.92% transverse (T) diameter, and 42.22% in product of APxT diameter of lesions (P<0.001 for all instances). CT scan showed a total disappearance of 33% of lesions and evident reduction in contrast enhancement in 16% of them. There were no changes in contrast enhancement in 51% of lesions. Evaluation of single largest lesion in each patient revealed 57.32% reduction in AP diameter, 59.66% in T diameter, and 62.17% in product of APxT diameters (P<0.001 for all diameters). TACE offers a viable option for CRC patients with unresectable liver metastases by significantly reducing lesion size and contrast enhancement.

Stem cell-based therapies have recently opened up new horizons for treatment of various types of diseases including diabetes mellitus. However, long-term efficacy and safety of these novel modalities still remain a serious question. Hereby, we aim to report the one-year follow-up results in the diabetic patients who underwent fetal liver-derived hematopoietic stem cell allotransplantation. Fifty six patients with type one (n=30) and type two (n=26) diabetes, aged 10-58 years old (32.8 ± 16.3) were divided into the intervention and placebo group. The patients in the intervention group underwent fetal liver-derived hematopoietic stem cell transplantation while the patients in the placebo group received 5 ml of normal saline both via an intravenous route. The patients were visited at regular intervals to evaluate the efficacy of transplantation in glycemic control as well as possible complications. In the 6th month of the follow-up, there was a significant decrease in HbA1c levels in all groups without any rise in the fasting c-peptide. However, none of the precipitants transiently or continuously became insulin free in the first year after transplantation. It can be concluded that, in this study, fetal liver-derived hematopoietic stem cell transplantation had no significant effects on glycemic control. The heterogeneity of our patients might account for the negative results. Hence, longer follow-up results will be reported in the near future.

Adenotonsillar hypertrophy and obstructive sleep disordered breathing can lead to attention deficit/hyperactivity disorder (ADHD). The purpose of this study was to evaluate effect of adenotonsillectomy on improvement of ADHD symptoms in a quasi-experimental (before and after) study. The efficacy of adenotonsillectomy on improvement of ADHD symptoms of 35 children aged 5-12 years with adenotonsillar hypertrophy and ADHD was evaluated six months after surgery. Diagnosis of ADHD was based on the DSM-IV criteria in three subtypes (predominantly inattentive type, predominantly hyperactive-impulsive type and combined type). Seventeen boys (49%) and eighteen girls (51%) with mean (± SD) age of 7.4 ± 3.8 years (range: 1-10 years) were evaluated. Frequency of combined type of ADHD decreased significantly six months after adenotonsillectomy (54.3% versus 22.9%, P=0.003). ADHD inattention score (2.26 ± 1.93 versus 0.96 ± 0.45, P=0.005), hyperactivity score (4.23 ±3.57 versus 3.57 ±8, P=0.03) as well as ADHD combined score (9.66 ±2.58 versus 7.2 ±3.67, P=0.0001) improved significantly after surgery. Upper air way obstruction due to adenotonsillar hypertrophy might be an important and treatable cause of ADHD and should be considered in evaluation of affected children. Adenotonsillectomy in these children is associated with improvements in ADHD symptoms.

Varicose veins are an extremely common medical condition (present in 5-30% of adults). Surgery remains the gold standard of care in patients with varicose veins, however several newer interventions have been recently introduced which need to be evaluated. During the standard surgery it is imperative to demonstrate and ligate the tributaries of the saphenofemoral junction in combination with stripping of the great saphenous vein. We studied 228 patients with varicose veins who underwent surgery during two years. The number and name of tributaries at the saphenofemoral junction, presence of external pudendal artery and its relationship to the saphenofemoral junction were recorded. The number of tributaries varied from 2 to 7 at the first five centimeters of the great saphenous vein. The average number of branches was 3.87 and the most common branch was the superficial external pudendal vein. The external pudendal artery was identified during all surgical exploration. It crossed anterior to saphenofemoral junction in 39.5% and posterior in 60.5%. Anatomical variations in venous branches at the saphenofemoral junction are varied (from 2 to 7), so it is recommended to explore the location of varicose veins precisely to ensure appropriate surgical technique

Brain death is defined as the permanent, irreversible and concurrent loss of all brain and brain stem functions. Brain death diagnosis is based on clinical criteria and it is not routine to use paraclinical studies. In some countries, electroencephalogram (EEG) is performed in all patients for the determination of brain death while there is some skepticism in relying on EEG as a confirmatory test for brain death diagnosis. In this study, we assessed the validity of EEG and its abnormalities in brain death diagnosis. In this retrospective study, we used 153 EEGs from medical records of 89 brain death patients in organ procurement unit of the Iranian Tissue Bank admitted during 2002-2008. We extracted and analyzed information including EEGs, which were examined by a neurologist for waves, artifacts and EEG abnormalities. The mean age of the patients was 27.2±12.7 years. The most common cause of brain death was multiple traumas due to accident (65%). The most prevalent artifact was electrical transformer. 125 EEGs (82%) were isoelectric (ECS) and seven EEGs (5%) were depictive of some cerebral activity which upon repeat EEGs, they showed ECS patterns too. There was no relationship between cause of brain death and cerebral activity in EEGs of the patients. In this study, we could confirm ECS patterns in all brain death patients whose status had earlier been diagnosed clinically. Considering the results of this study, it seems sensible to perform EEG as a final confirmatory test as an assurance to the patient's families.

To explore the abnormalities in Iranian athlete's electrocardiogram and find any relation with body fat. 239 international athletes were involved in this cross sectional study. Body-fat percentage and resting 12-lead ECGs were recorded from all participants. Of 239 participant athletes, 212 were male and 27 female. 60% of participants had sinus bradycardia. A total of 84% of the athletes demonstrated at least 1 abnormal ECG finding. Average values for the PR, QRS and QT intervals, P-wave duration and QRS axis were in normal range. Frequencies of various ECG abnormal findings in all athletes were as follows: right axis deviation 4.2%, left ventricular hypertrophy 6.2%, sinus arrhythmia 5.8%, right bundle branch block (RBBB) 24.2% (incomplete RBBB 16.8%, complete RBBB 7.4%), ST elevation 72.5%, prolonged QT interval 1.7%, T inversion 3.1% and Mobitz type I 1.2%. The athlete's ECG response to treadmill stress test was normal with no ischemia or arrhythmia. The means of BMI and body-fat percentage were 24.04 ± 3.5 kg/m² and 9.15 ± 2.12%, respectively. Pearson correlation coefficient between body-fat percentage and ST changes was 0.65 (P=0.008) in anterior leads and 0.198 (P=0.017) in lateral leads. Also, the correlation coefficient between the body fat percentage and right bundle branch block was 0.36 (P=0.013). The results of current study support the inclusion of ECG in athlete's cardiac screening before they engage in vigorous exercises in order to detect the potentially fatal arrhythmias.

Tubal ectopic hydatidiform mole is an uncommon but very important complication of pregnancy. The clinical manifestation is the same as ectopic pregnancy and in all of the cases management was the same as tubal ectopic pregnancy. We present a case of tubal ectopic pregnancy that after laparotomy and salpingectomy, pathologic examination reported hydatidiform mole within ectopic gestational tissue. So, a high index of suspicious is necessary for prompt diagnosis and correct fallow up of the patient.

Aluminum phosphide (AlP) as 3 g tablet is widely used in Iran to protect stored food grains from pests. Hyperglycemia following its ingestion has been already reported in the recent years but severe hypoglycemia is uncommon. Here, we report a 19 year old male who attempted suicide with one tablet of AlP and demonstrated severe hypoglycemia. Despite restoration of blood glucose concentration to normal, he failed to respond to supportive treatment and died. The possible mechanisms leading to severe hypoglycemia are discussed. Though severe hypoglycemia is rare following AlP poisoning, physicians managing such patients should be aware of it.

Variations in the origin of axillary artery branches are common. But, distinctly abnormal course of its posterior circumflex humeral branch is rare. We are reporting a case of posterior circumflex humeral artery (PCHA) originating from the axillary artery, passing through lower triangular space to reach the scapular region where it accompanied the axillary nerve and posterior circumflex humeral vein to pass around surgical neck of humerus, deep to the fibers of deltoid. Other variations observed in this specimen were the radial collateral artery arising from the PCHA, middle collateral artery arising directly from the brachial artery and absence of profunda brachii artery. PCHA forming a hair pin loop, traversing through lower triangular space instead of quadrangular space taking a long course is being reported for the first time. Further, the clinical and surgical importance of this case especially in relation with quadrangular space syndrome and relevant literature is discussed.

Chorea is brief, quasi-purposeful, irregular muscle contractions, not repetitive or rhythmic, but flows from one muscle to the next and athetosis is slow, writhing, continuous, worm-like movements of distal extremities (chiefly the fingers) which show bizarre positioning without posturing. Metabolic causes have been documented earlier, note worthy of that being Diabetes. Choreoathetosis has been reported earlier in diabetes mostly in an elderly female, diagnosed most often by Brain MRI. We report a case of hemichoreoathetosis in a male diabetic, whose involuntary movement completely resolved with glycemic control and diagnosis was easily confirmed with just a Brain CT.

Child maltreatment happens in all countries and cultures. Children as the vulnerable part of the societies are subject to rage, abuse and maltreatment and need special multidisciplinary attention to get proper protection and care. Appropriate legislation, community education, advocacy in media and attention of care givers and children health providers may alter the trend of child abuse in communities. In order to raise awareness about child abuse for healthcare professionals, in this report we introduce a disastrous case of 4 years old boy who was attacked by his father which presented to Children's Medical Center in Tehran. The living environment of the victim was a dysfunctional family and an addict father as the risk factors of dangerous circumstances for a child.