Tehran University Medical Journal

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Background: Abdominal compartment syndrome (ACS) is a clinical entity that develops from progressive, acute increases in intra-abdominal pressure (IAP) and adversely affects all vital organ systems In this study, the development of intra-abdominal hypertension (IAH) and ACS in a surgical ICU population is described and examined.
Methods: Over a one-year period (2004), urinary bladder pressure (UBP) was measured prospectively in all surgical patients with abdominal problems admitted to the ICU of the Imam Hospital complex. UBP of >20 cm H2O indicated IAH. ACS was defined as the development of multiple organ dysfunction including peak airway pressure (PAP) >50 cm H2O, Horowitz quotient <150 torr or urine output <0.5 ml/kg/hr in the setting of IAH. Data were gathered on all patients with IAH and ACS.
Results: We evaluated some 353 patients, consisting of 165 elective laparatomies and 188 emergency cases, including 28 trauma patients. The incidence of IAH and ACS was 2 and 1 per cent (7 and 3 patients, respectively). The mean IAP of these seven patients was 29.8 cm H2O. No elevated IAP was observed after elective laparotomy (165 patients), nor in emergency cases with temporary abdominal wall closure (29 patients). APACHE II score, PAP and worst base deficit were significantly higher in patients with elevated IAP. None of the three patients with ACS underwent decompressive laparotomy. The mortality rate for patients with elevated IAP was 85%, significantly higher than the total study population.
Conclusion: IAH is a rare disease of the rarity of IAH, routine measurement of IAP is necessary only in high-risk patients. Prophylactic temporary abdominal wall closure may prevent IAH and ACS in high-risk patients. Patients with elevated IAP have dismal outcomes. Critical care practitioners should become familiar with different aspects of IAH and ACS, including decompressive laparotomy.

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Background: The health risk associated with chronic exposure to organic solvents investigated in several epidemiologic studies indicates a significant relationship between solvent exposure and glomerulonephritis. Solvents are the most commonly used chemicals in industry. According to European statistics 43% of all solvent consumption takes place in the painting industry, 10% in metal cleansing, 6.7% in adhesives and 3.9 percent in the laundry (dry cleaning) industries. Although BUN and creatinine indicate massive loss of glomerular function, microalbumin is a sensitive urinary marker for nephrotoxins in the early detection of solvent-induced effects on the glomerulus. The purpose of our study was to use microalbumin, serum BUN and serum creatinine levels to identify occupational solvent-induced effects on the glomerulus.
Methods: Renal dysfunction was monitored by microalbumin, BUN and creatinine serum levels in a cohort study of 92 workers currently exposed to solvents (solvent group). A control group of 92 individuals were selected from parts of the same factory not exposed to solvents. All individuals in the study were men, without diabetes or hypertension. The percentage of smokers was equal between the two groups. The solvent group was selected using environmental monitoring of organic solvents in different parts of the painting room. The individuals were chosen by simple random selection. Exclusion factors included less than one year of work in the painting room, use analgesic or aminoglycoside one month before the study and medically diagnosed renal disease, such as glomerulonephritis or renal failure. Data was gathered using a questionnaire requesting demographic information, history of present and past diseases, present and past occupational history, drug history, history of illness in their colleagues and safety conditions at work (use of safety gloves, masks, clothing, goggles and general and local ventilation). The results analyzed with SPSS 11.5.
Results: Several studies showed that solvents cause renal disorder (tubular and glomerular), although glomerulonephritis is more prevalent. The mean age of the solvent group was 28.6 ±2.7 years and was 33.7 ±7 years in control group (p<0.05). The mean duration of solvent exposure was 4.8 ±1.5 years. Statistically meaningful differences were found between solvent and control groups for microalbuminuria, increased serum BUN and creatinine levels (p<0.05), although there was no significant correlation between these parameters and the duration of exposure (p>0.05).
Conclusion: The results suggest that kidney dysfunction results from chronic occupational exposure to solvents at levels found in automobile painting rooms in Iran. We recommend increased monitoring of workers using solvents and increased review and enforcement of safety regulations regarding such use of solvents.

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Background: Myasthenia Gravis (MG) is a neuromuscular disorder with weakness of skeletal muscles. Thymectomy is now recognized as a treatment modality in MG. The aim of this study was to evaluate the clinical effect of thymectomy on MG.

Methods: MG patients with history of thymectomy at a tertiary referral center during twelve year period were included. The medical records were reviewed and telephone survey was conducted to evaluate the effects of thymectomy.

Results: Sixty MG patients, 46 females and 14 males, aged 30.4±11.1 years, underwent open (n=48) or video-assisted thoracoscopic thymectomy (n=12) during study period. The mean dosage of preoperative pyridostigmine was 235.4±86.2mg/day. This figure reached to 129±18mg/day after thymectomy (p<0.0001). 17 patients (28.3%) had complete remission (complete freedom of symptoms without medications). Improve-ment (improved symptoms or less medication requirement) was seen in 34 patients (56.6%). There was no response to surgical therapy in six patients (10%). Three patients (5%) had experienced progression of disease postoperatively. Overall, benefit of thymectomy was observed in 85% of patients. Age, sex, duration and severity of disease, quantity of preoperative drugs, surgical approach, and presence of thymoma did not affect the outcome. Satisfaction was stated as excellent in 17%, good in 43%, moderate in 35% and poor in 5% of patients after operation.

Conclusion: Thymectomy is an effective treatment for MG which leads to less severity of disease and less drug requirement. It would be considered in all myasthenic patients regardless of age, sex, duration and severity of disease and presence of thymoma.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 !mso]> ject classid="clsid:38481807-CA0E-42D2-BF39-B33AF135CC4D" id=ieooui> Background: Polyethylene glycol (PEG) solution can induce complications when used as preoperative bowel preparation. The aim of this study was to compare two methods for mechanical bowel preparation in elective operations of colon.
Methods: In a randomized clinical trial, 129 patients elected for anastomosis of colon and referred to the surgical clinic of Imam Khomeini Hospital of Tehran between March 2008 and March 2009 were included. They were randomly allocated into two groups of PEG1 (1liter of PEG or 70gr plus 15 mg bizacodil, n=63) and PEG4 (4 liter of PEG), according to the way of bowel preparation and on the day before surgery, they received oral and IV prophylactic antibiotics and cleared solutions. In the morning of the surgery, they received their medication during 240 minutes. Then, they underwent anastomosic surgery of colon. The principle variables recorded were nausea, vomiting, flatulence, Na and K in the night before surgery, patients' and surgeons' satisfaction from bowel preparation and postoperative infection and leakage.
Results: The majority of the patients were male (62%). Nausea (28.57% vs. 98.48%, p=0.001), flatulence (36.51% vs. 95.45%, p=0.001), and vomiting (4.76% vs. 75.76%, p=0.001) were significantly lower in PEG1 and the patients' satisfaction were significantly higher (59.02% vs. 1.52%, p=0.001) Peroperative Na was significantly higher in PEG4 group (141.21±3.63 vs. 139.94±2.97mg/l, p=0.001) and serum K was significantly lower (3.55±0.25 vs. 3.76±0.21, p=0.001). Surgeons' satisfaction were significantly higher in PEG4 group (good to very good 72.73% vs. 43.54%, p=0.001). Postoperative infection of surgical site, anastomosis leakage and ICU admission were comparable between study groups.
Conclusions: Bowel preparation with 1 liter of PEG plus 3 bizacodile pills instead of 1 liter of PEG in patients undergoing elective anastomosis of colon is not only associated with lesser nausea, vomiting, flatulence, but also increases the patients' satisfaction and tolerance, lessens electrolyte disturbances and do not influence postoperative infection of surgical site and anastomosis leakage.

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Background: Management of acute abdomen usually does not necessitate accurate pre-operative diagnosis but the surgeon should make a decision about the need for emergent laparotomy. This fact is somehow different for localized peritonitis (e.g. acute appendicitis) in which the clinical presentation directs straightly to the diagnosis. However, acute appendicitis has lots of differential diagnoses, finding the normal appendix during laparotomy is just a start point to look for other diagnoses. Omental torsion is a rare cause for acute abdomen that is usually missed. Knowing about this rare condition and its frequently encountered presentation at the operating room (sero-sanguinous fluid coming out of peritoneal cavity) may prevent missing the diagnosis and doing a malpractice.
Case report: Report a 9 year- old boy presented with acute abdomen which turned out to be an omental torsion after the operation.
Conclusion: Knowledge about this rare condition "omental torsion" and its clinical and intra operative presentations may prevent missing the diagnosis and a malpractice.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Appendicitis is more common during the second and third decade of life and appendectomy scar is important in terms of cosmetic issues. The scar is an important factor in the patient's satisfaction. Conventional teaching has an emphasis on the closure of skin incision with "separate" sutures. The aim of this study was to reconsider this dogma.
Methods: Among 321 patients with acute appendicitis who came to the emergency unit of Imam Khomeini Hospital in Tehran, Iran since april 2007 till april 2008, 278 (86.6%) patients had uncomplicated appendicitis and were enrolled in our clinical trial. The patients were randomly assigned to two groups of interrupted suture closure (n=139) and subcuticular suture closure (n=139). Anesthesia method and surgical technique were similar between the two groups. All patients were followed up post-operatively (four weeks) for the presence of infectious drainage, pain, erythema, swelling and warmness at the surgical site.
Results: The patients' sex and their mean age were not statistically different between the groups. There was no significant difference in the frequency of surgical site complications between the two groups (five cases in the "interrupted" group and eight cases in the "subcuticular" group p=0.415).
Conclusion: This study showed that appendectomy incision closure with subcuticular sutures did not increase the risk of wound complications. From the point of better cosmetic outcome of subcuticular sutures, this method may be the method of choice for the closure of appendectomy incisions in uncomplicated appendicitis.

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Background: Gall stone is an important health problem in the world for which different risk factors have been characterized. Gall stone and cardiovascular disease have common risk factors. Homocysteine is accepted as one of the risk factors for cardiovascular disease. We aimed to study the effect of homocysteine level on gall stone formation.
Methods: 54 patients with gall stone-related diseases and 54 patients without stone (control group) were studied from January 2007 to December 2008. Control group consisted healthy subjects with ultrasound proven normal gallbladder. Serum homocysteine level was checked in both groups. Homocysteine level of equal or more than 15 mmol/l was considered as abnormally high.
Results: Cases included 43 women (79.6%) and had mean age of 50.76±15.23 years. Homocysteine level was significantly higher in patients with gallstone in comparison to control group (p=0.014). Risk of gall stone increased 3.4 times in persons who have homocysteine level equal or greater than 15mmol/l (p=0.019). The mean level of homocysteine was higher in men than women (p=0.03). The mean level of homocysteine did not differ significantly in patients with simple gallstone and patients with gallstone-related inflammation disorders (cholecystitis, cholangitis, and pancreatitis). Additionally, one unit increase in BMI level was associated with 1.12 times increase in the risk for gall stone formation (p=0.035).
Conclusion: The homocysteine level is increased in patients with gall stone-related diseases. Homocysteine may be considered as a risk factor of gall stone formation.

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Background: Prevalence of Abdominal Aortic Aneurysm (AAA), estimated by various studies, ranged from 4.1% to 14.2% in men older than 60 years. Most cases of AAA are asymptomatic and often discovered incidentally. Approximately the initial presentation in 12% of cases of AAA is sudden rupture with subsequent high mortality. This study was performed to evaluate the prevalence and screening necessity of AAA among Iranian men older than 65 years old.

Methods: In this cross-sectional study, men older than 65 years, who referred for ultrasound examination to three different centers in Tehran, Iran at the year 2008 were included for evaluation of size of the abdominal aorta and presence of AAA.

Results: A total of 240 men older than 65 years enrolled in this study. AAA was found in 24 of the participants with prevalence rate of 10% in the studied population. Mean diameter of detected aneurysms was 3.931.435 cm. In 4 (1.7%) subjects, aneurysms greater than 5.5 cm in diameter were detected. One of these four subjects had the history of coronary artery disease and one was cigarette smoker. Three out of four had history of hypertension.

Conclusion: Considering the estimated prevalence rate of AAA by the current study and the population of Iranian men older than 65, implementing of mass screening for AAA in this group would detect 986 asymptomatic cases each year. Therefore, the authors recommend further studies about the cost-effectiveness of mass screening for AAA among Iranian men above 65 years.

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Background: Deposition of bilirubin in neurons causes permanent neuronal injury. Bilirubin exhibits an affinity for the phospholipids of plasma membrane like N-methyl-D-aspartate (NMDA) receptors. Magnesium is an NMDA antagonist and it acts against the neurotoxic effects of bilirubin. We compared pre- and post-phototherapy serum magnesium level of neonates with hyperbilirubinemia to find the best time of discharge and evaluate new management techniques such as magnesium supplementation.

Methods: In this semi-experimental study, we evaluated neonates admitted in Ali Asghar Children's Hospital in Tehran, Iran with signs of icter from 2009 to 2010. The inclusion criteria included age less than four weeks, no history of magnesium sulfate administration in the mother and absence of sepsis.

Results: From 106 patients with icter, 50.9% were male and 49.1% were female neonates. Their mean gestational age was 37.341.286 (33-41) weeks and the mean birth weight was 3172.12436.936 (2022-4300) grams. The frequency of underlying causes of hyperbillirubinemia included: ABO mismatch 9.34%, Rh incompatibility 4.7%, breastfeeding 16% and breast milk 44.3%. There was a significant difference (P≤0.001) between serum magnesium levels before (2.24mg/dl) and after phototherapy (2.12mg/dl). There were no significant differences between serum magnesium values in the two sexes (male=2.28, female=2.19), among different gestational age groups (<34 wks=2.35, 35-37 wks=2.27, >38 wks=2.17), between different birth weight groups (1500-2500 g=2.4 and >2500 g=2.23) or severity of hyperbilirubinemia (mild=2.23, moderate=2.21 and severe=2.29).

Conclusion: Phototherapy decreases the total magnesium concentration and magnesium administration will prevent bilirubin neurotoxicity in icteric neonates.

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Background: Musculoskeletal disorders (MSDs) are the most common reported occupational health problem which cause high financial burden and reduce efficiency of workers. MSDs are often multifactorial. This study was done to determine the frequency of MSDs and their relation to occupational stress among office workers.

Methods: 332 office workers were recruited in descriptive-analytical study. To assess the frequency of MSDs, we used Nordic questionnaires and to assess the occupational stress, we used the general Nordic questionnaire for psychological and social factors at work (QPS Nordic+34 questionnaire). The collected data were processed and analyzed.

Results: Our study showed that the frequency of MSDs among office workers was higher than the general population and the stress index was higher (P=0.002) among the office workers with MSDs than employees without it.

Conclusion: This study showed that occupational stress was a risk factor for MSDs, especially in the upper extremities.

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Background: Traumatic amputation of upper limb above the level of the elbow, are rare injuries that a surgeon may be faced with a handful of cases during his career. Even with advanced techniques in microvascular surgery, the survival of the transplanted limb that cut off completely from the arm is relatively weak. Case Presentation: Four injured people (patient) in Imam Khomeini Hospital during 1999-2013 in Tehran University of Medical Sciences were treated. Two patients had complete amputation of limb and other patients suffered from complete cutting in artery and vein along with neurological and soft tissue damages. There was not any ischemia or gangrene. However, efficiency of limbs with damages in peripheral nerves was not significant. The main reason was lack of immediate repair of the damaged nerves. In the recent examination, after discharge, the performance of the limb is firstly related to the conditions of the nerve system and secondly it depends on the severity of the injury in each of the muscles. However, none of the patients were dissatisfied of any situation and they were prepared to make any cooperation for improving the condition of their transplanted limb. Conclusion: Transplantation of the amputated limb can be done in spite of limited resources. Any delay in repairing damaged nerves will result great reduction of final organs’ performance. A limb, made from the own body, always take precedence to prosthesis, even when the efficiency is low.

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