Tehran University Medical Journal

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Background: Alkaloids are a group of nitrogenous compounds with potential effects on the physiological behavior of human and animals. Some of these compounds are considered important drugs in modern medicine, such as atropine and morphine. Plants are considered the most important source of alkaloids. Therefore, investigating the presence of alkaloids in different plants is very important. Usually, alkaloids in plants are identified by methods such as those of Dragendorf, Wagner and Meyer, among others, which require milligrams of alkaloids for identification. In the present study, a fast and sensitive procedure for detecting of alkaloids in plants is presented.
Methods: Twelve dried plants samples were investigated for the presence alkaloids. After extracting the total alkaloid into methanol using a Soxhlet extractor, a few milligrams of the extract was transferred to a separatory funnel, buffered to pH 4.7, the bromocresol green (BCG) solution (10-4 M) was added, mixed and extracted with CHCl3 until a yellow color was observed in the CHCl3 layer, indicating the presence of the alkaloid. The crude extracts were also investigated by the standard methods of Dragendorf, Wagner and Meyer for the presence of alkaloids.
Results: Investigation of the 12 plant samples for the presence of alkaloids by the standard reagents of Dragendorf, Wagner, and Meyer showed that only Camelia sinensis (flowers), Echium amoenum Fisch & Mey (flowers), and Stachys (aerial parts) are devoid of alkaloids, with all other samples positive for alkaloids. By the BCG procedure, similar results were obtained, except for the E. amoenum flower, which was positive. The minimum detectable limit for alkaloids by the BCG method is the equivalent of approximately 40μg atropine.
Conclusions: According to previous reports, only one of these plants does not contain alkaloids. All studied plants positive for alkaloids by standard reagents were positive by the BCG procedure. Stachys was negative for alkaloids by both the standard reagents and the BCG method, in agreement with previous reports. However, black tea, reported to contain xanthine alkaloids, was negative for alkaloids by both the standard reagents and the BCG method. Therefore, the BCG method is not suitable for the detection of xanthine alkaloids. Nevertheless, the microgram detectable limit for alkaloids indicates that the BCG method is very sensitive.

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Background: The induction of catalytic antibodies (abzymes) was first postulated by Pauling in 1948. Various catalytic antibodies have been detected recently in the sera of patients with several autoimmune pathologies such as systemic lupus erythematosus and rheumatoid arthritis. In addition, antibodies with DNase and RNase activity have been discovered in the milk and sera of healthy human mothers, which shows the physiologic role of these antibodies. In this study, we examined the proteolytic activity of antibodies in the sera of pregnant women.
Methods: IgG antibody fractions were isolated from the sera of 30 healthy pregnant women in the first trimester of pregnancy and 10 control samples (men and nonpregnant women) by subsequent steps of chromatographic purification on Protein G sepharose and sephacryl S-300. All patients were in their first pregnancy and aged 25-35 years. The conditions for proteolytic activity, such as type of buffer, pH and temperature, were optimized. The proteolytic activity of these antibodies was demonstrated by in-gel assay with gelatin as the substrate.
Results: Antibody treatments at the optimum temperature showed that some samples from pregnant women contain proteolytic abzymes, as demonstrated by in-gel assays. Western blot results confirmed that the proteolytic activity is an intrinsic property of the antibodies.
Conclusions: During pregnancy and immediately after delivery women very often experience autoimmune processes similar to those in patients with autoimmune disease. Because of their specific immune status, pregnant women can produce various catalytic antibodies with different enzymatic activity. These proteolytic abzymes might be involved in the direct clearance of antigens from blood.

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Background: Much has changed in neonatal care for extremely low birth weight (ELBW birth weight <1000g) infants over the recent years in Iran, resulting in an increase in their survival rate. We determined neonatal survival and short-term morbidity rates among ELBW infants, and the correlation of these factors with mortality risk.
Methods: All single live-born ELBW babies delivered at Vali-e-Asr Hospital over a four-year period were identified. Data that were prospectively collected included: maternal age, prenatal and perinatal complications, antenatal steroid use, birth weight, gestational age, route of delivery, sex, need for resuscitation, APGAR score, need for mechanical ventilation, and complications including respiratory distress syndrome (RDS), sepsis, jaundice, intraventricular hemorrhage (IVH), necrotizing entrocolitis (NEC) metabolic and hematologic and cardiac disorders. Information was statistically analyzed and a probability value of <0.05 was considered significant.
Results: A total of 93 neonates were included in the study. The survival rate in the delivery room was 36.6%. The lowest birth weight was 400g, with a mean birth weight of 850.43(±136.48)g, and the lowest gestational age was 22 weeks. The mean gestational period was 28.31(±2.77) weeks. The most frequent complication after birth was RDS(69.89%) and the least frequent was NEC (6.4%). Short and normal gestation was observed in 44.08% and 48.4% of the neonates, respectively. There was a significant relationship between neonatal mortality and the need for resuscitation after birth, RDS and need for a respirator (p<0.05). Furthermore, there was significant increase in mortality among neonates with gestational age <30 weeks, birth weight under 750g and lack of steroids before birth (p<0.05).
Conclusions: To enhance perinatal and neonatal care and decrease the rate of preterm labor, improved standard resuscitation and increased administration of antenatal steroids and respirators are required.

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Background: Radiation to some parts of the heart is unavoidable in the therapeutic course of primary tumors in many kinds of cancer, including breast cancer. The aim of this study was to assess the frequency of acute and subacute cardiac complications following radiotherapy in patients with left breast cancer.
Methods: In this study, we enrolled 53 patients with left breast cancer who underwent mastectomy or lumpectomy between September 2005 and September 2006 in Imam Khomeini Hospital Complex, and subsequently underwent chemotherapy with anthracyclines (<450mg/m²) and Endoxan plus taxane/fFluorouracil followed by radiotherapy. In all patients, electrocardiography and echocardiography were performed before initiation of radiotherapy, immediately after radiotherapy and again three and six months later to check for radiotherapy-induced cardiac complications such as pericardial effusion, valvular lesions, left ventricular dysfunction, conduction system disturbances and other variables.
Results: Thirty-nine patients completed the follow-up period. Among these, 10 (25.6%) patients experienced cardiac complications following radiotherapy. Among these, mild pericardial effusion in seven (53.85%) patients, mild mitral regurgitation in three cases (23.08%) and Right Bundle Branch Block (RBBB) in two cases (15.38%) were the most common complications. We found no correlation between cardiac complication and tumor dose, dose fraction and type of chemotherapy protocol. We noted no cases of new or more serious complications, such as cardiomyopathies or coronary artery disease, nor any changes in ejection fraction by the end of the follow-up period.

Conclusion: In patients with left breast cancer, acute and subacute cardiac complications following radiotherapy are not serious and have no clinical significance. Further studies are needed for more assessments in this area.

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Background: Chronic Subdural Hematoma (CSDH) is one of the most common challenges of neurosurgeons. Most predominant among the elderly, the incidence increases incrementally with age and might lead to permanent severe complications. The aim of this study is to outline the symptoms and signs and to compare the outcomes and complications among two groups of patients who underwent two different surgical procedures.
Methods: In a cross-sectional and descriptive-analytical study performed on 125 patients with CSDH from 2000 to 2005. Computed tomography scan was used for diagnostic imaging in all cases and magnetic resonance imaging was also obtained for six patients. In one center, group 1, which included 82 patients, underwent surgery with a single burr hole and closed drainage, and, at another center, group 2, which included 43 patients, was treated with a method using two burr holes and close drainage.
Results: Of the 125 patients, 102 were male and 23 were female. The mean age of patients was 65.79±16.41 years. The most common symptoms were weakness in extremities (78.4%), headache (72.8%) and decreased level of consciousness (24%), respectively. At presentation, 88 (70.4%) of the patients had several symptoms and 37 (29.6%) had only one symptom. A history of mild head trauma, such as falling, was observed in 83 (68%) of the patients. The interval between head trauma and the onset of symptoms ranged from 10 to 120 days (mean: 46 days). Hematoma recurred in five cases from group 1, whereas two cases from group 2 had recurrence of hematoma. Postoperative epidural hematoma developed in one case from group 2 and tension pneumocephalus also occurred in one group 2 patients.

Conclusion: As a treatment for CSDH, the single burr hole method was significantly better than the two burr hole method.

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Background: Hypopharyngeal cancer usually presents with cervical mass, hoarseness, radiated otalgia, and dysphagea in the advanced stages. Radical surgery followed by radiotherapy plays an important role in the treatment of patients with hypopharyngeal cancer. However, there is no general consensus as to which is the best method of reconstruction after surgical resection. The aim of this study was to evaluate the complications of pectoralis major myocutaneous flap (PMMF) and gastric pull-up (GPU) techniques to reconstruct a circumferential defect after laryngopharyngoeso- phagectomy.

Methods: We retrospectively reviewed the records of 64 patients who underwent radical surgery and reconstruction with either PMMF or GPU technique. Demographic characteristics, tumor location, proximal margin involvement, history of radiotherapy, presence of lymphadenopathy, cervical dissection, and postoperative complications such as fistula, anastomotic site stenosis, swallowing dysfunction, and stoma stenosis were compared between the two groups. Postoperative complications of the reconstruction methods were compared.

Results: A total of 64 patients, 43(67%) in GPU group and 21(33%) in PMMF group, were studied. The groups did not differ in demographic characteristics. The locations of the tumoral lesions were in larynx (n=7), proximal esophagus (n=5), posterior cricoid (n=5), pyriformis sinus (n=7), posterior wall (n=7), and miscellaneous (n=41). Six patients (6.3%) had proximal margin involvement, 19 patients (29.9%) had history of radiotherapy, 26 cases (40.6%) had lymphadenopathy, and 49 cases (76.5%) had cervical dissection. There was no significant difference between the two groups regarding stenosis or swallowing dysfunction rates, but fistula was seen lower following GPU compared with PMMF (p<0.001).

Conclusions: The GPU technique results in similar functional stenosis or swallowing dysfunction rates, but lower fistula compared with PMMF reconstruction.

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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: Chronic peritoneal dialysis is a safe method for the treatment of end-stage renal failure. Worldwide, patients on chronic peritoneal dialysis constititute approximately 15% of the total number of patients on dialysis. In Iran, very few people have access to chronic peritoneal dialysis, which is targeted by the Ministry of Health. This lack of access is primarily due to the high occurrence of mechanical complications. Improving catheterization procedures is an important way to extend the use of peritoneal dialysis in Iran. Thus, a prospective study was implemented to evaluate the outcome of a new laparoscopic technique for the insertion of peritoneal dialysis catheters under local anesthesia.
Methods: A total of 115 catheters (two-cuff, swan-necked, coiled) were inserted into the peritoneal cavity of 109 patients with end-stage chronic renal failure during a 16-month period. The method of insertion was a two-port laparoscopic technique with local anesthesia and sedation. All patients were followed for 12 to 28 months. We prospectively evaluated mechanical and infectious complications and survival rates of the catheters.
Results: The average age of the patients was 51.5 years (range: 15-84 years) 54.8% of these patients were female. The overall one-year and two-year catheter survival rates using this approach were 88% and 73%, respectively. Event-free catheter survival was 35%. The most common infectious and mechanical complications were peritonitis in 52 cases (45.2%) and temporary dialysate leakage in 10 cases (8.7%) respectively.
Conclusion: Laparoscopic insertion of peritoneal dialysis catheter with local anesthesia is a safe and simple procedure, giving reasonable rates of catheter survival and complications.

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Background: The clinical importance of yeast infections has increased in recent decades. There are 10-15 pathogenic Candida species. The current morphological and physiological methods for identification of Candida species are generally not easy to interpret and may be expensive or time-consuming. In the present study, we introduce and use a new approach for the identification and differentiation of medically important yeast species of Candida. In this method, size polymorphism of the internal transcribed spacer regions, ITS1 and ITS2, of the ribosomal DNA in various Candida species is used as the basis of species recognition.

Methods: The genomic DNA of 31 standard strains and 60 clinical isolates was extracted and PCR-amplified using two primer pairs (ITS1-ITS2 and ITS3-ITS4) separately. Both PCR products were mixed and analyzed after standard agarose gel electrophoresis. The species of the tested yeasts were identified by the electrophoretic patterns of the mixed PCR products of each sample, comparing the data obtained from the sequence analyses of ITS1 and ITS2 molecules.

Results: By this method, with the exception of C. albicans and C. dubliniensis, we were able to clearly differentiate nearly all common pathogenic Candida species, including C. albicans, C. glabrata, C. gulliermondii, C. parapsilosis, C. tropicalis,      C. krusei, C. kefyr, C. lusinaniae and C. rugosa. All standard and clinical strains were identified correctly, without expensive methods such as sequencing and capillary electrophoresis.

Conclusion: It seems that the PCR-FSP method introduced in this study is the easiest molecular approach for the identification of a wide range of pathogenic Candida species and is applicable for diagnostic and epidemiological purposes in reference laboratories.

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Background: Acute hepatitis is upon serious complications of halothane usage, can be associated with 50% mortality in severe cases. Use of halothane as inhalational anesthetic or use of it for maintenance of anesthesia is restricted/ prohibited in USA and most European countries. The occurrence of icterus and elevated liver enzymes after halothane anesthesia may be due to the drug induced hepatitis.

Case report: we report a 28 year old woman with acute hepatitis after cesarean section under halothane anesthesia, fortunately discharged to home 40 days after that. Other causes of hepatitis became role out in the patient.

Results: The usage of halothane should be restricted/ prohibited in our country because of its potentially serious and fatal complications and so existence of more safe but expensive alternatives.

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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: Central venous catheter (CVC) related infections are important complications of cathter application. This study assessed the usefulness of mupirocin in prevention and control of these infections.
Methods: In this randomized clinical trial, consecutive surgical patients requiring central venous catheter (for more than 2 days) in Amir-Alam Hospital from 2006-2008 were enrolled. Patients were divided in two groups in “case group” patients received topical mupirocin 2% every 48 hours at the time of insertion of catheter and dressing change and for “control group” mupirocin was not used. All of the patients received chlorhexidine and enoxoparin as complementary treatments. Two groups were comparable in regard of age, sex and risk factors.
Results: One hundred eighteen patients enrolled in the study (57 in case and 61 in control group) completed the study. 84 catheters in case group and 88 catheters in control group were inserted. The catheters in 90% of patients were inserted in jugular vein. At the end of study 29(16.8%) patients (16 in control versus 13 in case group) had catheter colonization (p=NS). Catheter related bloodstream infection was observed in 16(9.3%) patients (6 in case versus 10 in control group) (p=NS).Catheter related local infection was seen in 2(1.1%) patients of control versus none of mupirocin group. (p=NS).
Conclusions: Mupirocin was not effective to control and prevention of bacterial colonization and catheter related infection.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Standard thoracotomy necessitates division of thoracic large muscles leading to pain and impaired respiratory movements muscle sparing postero-lateral thoracotomy has been suggested as an alternative to reduce the aforementioned effect. The aim of this study was to compare muscle saving posterolateral thoracotomy with standard thoracotomy.
Methods: This study was a clinical trial. All patients who were candidates for elective thoracotomy were included and divided into two groups of muscle saving thoracotomy and standard thoracotomy randomly. Required time for opening and closing the chest, amount of prescribed narcotics, shoulder movements (flexion, extension, abduction and internal rotation), pulmonary function (FVC, FEV1, VC), development of seroma, and duration of hospitalization were assessed. Shoulder movements and pulmonary function were measured immediately before operation and 7 days later while pain measured in 1^st and 7^th post-operative days.
Results: 60 patients (42 males) entered the study and there were no significant differences regarding age and sex distribution between two groups (p>0.05). Mean duration of opening the chest in muscle saving thoracotomy was significantly longer than standard procedure while the duration of closing the chest wall was significantly shorter in muscle saving thoracotomy (p<0.05). FVC and range of motion of the shoulder were higher and post-operative pain was lesser in muscle saving thoraocotomy than standard thoracotomy (p<0.05). There were no significant differences regarding prescribed narcotics and duration of hospital stay (p>0.05). Seroma developed in 13% (n=4) of muscle saving group.
Conclusion: Muscle saving thoracotomy can be used as an appropriate alternative for standard postero-lateral thoracotomy in elective thoracic operations.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Dietary antioxidant vitamins, in particular vitamin C, can play a role in preventing the onset or progression of age-related visual impairment. The aim of this study was to determine the plasma ascorbic acid levels in normal individuals and in senile cataract patients.
Methods: The test group included fifty cataract patients, while the control group members were selected among medical staff and patients' companions after age matching with test group. The use questionnaire contained age, sex and location of residency (Urban or Rural). Five milliliter of drawn blood centrifuged and plasma ascorbic acid level was measured by spectrophotometry. Statistical analysis of plasma ascorbic acid concentrations were done using paired t-test.
Results: The mean plasma ascorbic acid level intest group and incotral group was 0.96±0.08 and 1.12±0.15mg/dl respectively. Plasma ascorbic acid level in test group was significantly lower than control group (p<0.0001). Aging was associated with a reduction in plasma ascorbic acid level in male while it showed no significant alteration in females. Rural and the female gender showed higher plasma ascorbic acid level.
Conclusions: This study revealed plasma ascorbic acid level in patients with senile cataract was lower than normal individuals. Antioxidant vitamins, in particular vitamin C, found in Mediterranean fruits and vegetables could be probably used in the prevention of cataracts, which is a major health service burden in many countries.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Diffuse large B Cell lymphoma (DLBCL) is the most common subtype of non-Hogkin lymphoma (NHL). We performed a retrospective study of patients with de novo DLBCL treated in the Medical Oncology department of Cancer Institute of Iran, Tehran to assess the clinicopathologic and immunohistochemistry correlation and prognosis of the patients.
Methods: World Health Organization (WHO) classification was used to reexamine 1470 biopsy specimens related to the years 1985-2006. After excluding five cases of T Cell large cell lymphoma, 50 Patients diagnosed as DLBCL.
Results: Median age of the patients was 45.5(20-85) years: 60% were male and 30% had primary extranodal disease. The most common extranodal sites were bone, gastrointestinal tract and Head and neck areas. The most common stages were stage II (32%), stage III (32%), stage IV (20%) and stage I (16%) retrospectively and 33% had B-symptoms. All of The Patients received chemotherapy (83% CHOP regimen) and 46% treated by radiotherapy after chemotherapy. With a mean follow up time of 32 months, median survival time was 34 (95% CI 24-40) months. Prognostic factors for survival were tumor stage, B-symptoms and early relapse (less than 6 months).
Conclusions: Our data showed the importance of Immunohistochemistry method in diagnosis of DLBCL. Although DLBCL is potentially curable with CHOP chemotherapy protocol, addition of monoclonal antibody (Anti CD20) and finding new prognostic factors to predict early relapse are clearly needed in Iran.

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Background : Septic Arthritis is an acute infection of intra-arthicular space. Delay in diagnosis and in appropriate treatment may lead to prolongation of treatment duration and poor outcome. We decided to evaluate clinical aspects of this disease in our department pediatric department, Imam Khomeini Hospital complex, Tehran, Iran during a 10 years period.

Methods : In a retrospective cross-sectional study, 60 patients with age from 1 month to 14 year-old during 1996-2005 were evaluated. The demographics characteristics, clinical observations (signs & symptoms) and paraclinic values were gathered from medical records and analyzed with statistical tests.

Results : Pain and Swelling was seen in all, joint limited motion in 80% ( 50 cases) claudicating in 64% ( 38 cases), fever in 80% ( 48 cases), monoarticular disease in 80% ( 48 cases) and polyarticular one in 20% ( 12 cases) of them. Hip was most Common involved joint 62% ( 37 cases), elevated ESR was seen in all patients. CRP was positive in 85% ( 51 cases). Leuckocytosis was found in 65/8% ( 17 cases) of cases. In infectious cases, Staphylococcus aurous was responsible organism in 65.6% ( 16 cases), klebsiella in 12.4% ( 3 cases), Streptococcus pneumonia in 12.3% ( 3 cases), group b streptococcus in 4.1% ( 1 case), Hemophilus Influenza type b in 4.1% ( 1 case) of study patients. With therapy ESR was normalized in 64% ( 39 cases) and CRP was normalized in all patients.

Conclusions: In general, all children with complaint of fever, pain, and limited joint motion or claudicating should be suspected for septic arthritis.

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Background: The inguinal hernia is a common disorder in general surgery. Different methods have been described for repair of these hernias. In modern methods, synthetic mesh is used to cover the wall defect and the most known method is Lichtenstein surgical repair. The laparoscopic totally extra peritoneal procedure (TEP) is a newer technique of repairing hernia. The aim of this study is to compare the outcomes of totally extraperitoneal laparoscopic inguinal hernia repair versus Lichtenstein open repair in patients with inguinal hernia. Methods: Among 50 patients, 25 cases underwent Lichtenstein procedure and 25 patients underwent TEP technique for repairing primary unilateral inguinal hernia. Findings during the operation have been recorded and the 12-months follow-up of patients in different views was performed through a questionnaire and then the results were compared. Results: The operation duration, the rate of complications and frequency of recurrence were similar in two groups but the hospital stay, postoperative pain, chronic groin pain and the required time to return to normal activity were significantly lower in patients who underwent the TEP method compared to the patients who underwent the Lichtenstein technique (p<0.001, p<0.001, p=0.012, p<0.001, respectively). Conclusion: The TEP surgical technique can be recognized as a safe method with acceptable results for patients and has significant effects on improvement of patients’ quality of life after hernia repair. Suitable results of this surgical method are achieved when the surgeon goes through the learning curve.

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Background: Pulmonary hydatic cyst is a common parasitic disease and health care problem in developing countries. In our study we assessed treatment outcomes of pulmonary hydatic cyst in our area. Methods: All patients presenting to Ghaem, Omid and Mehr hospitals of Mashhad- Iran since 1981 to 2008 with pulmonary hydatic cyst were enrolled in this study and demographic data, location and number of cysts, diagnostic methods, type of operations, out comes and rate of recurrence were statistically analyzed. Results: One thousand and twenty for patients enrolled in this study. The mean age was 30.6±16.1 years and male to female ratio was 1.2. The most common symptoms were cough (55.1%) and chest pain (33.8%). 53.8% of the patients had right side involvement, 40% had left side involvement and 6.2% had bilateral disease. Inferior lobe was the most common involved lobe. The cyst was intact in 52.6% and the other cases were complicated or perforated. The most common surgical technique was removing the cyst membrane without resection of pericyst and closure of air leaks (67.2%). The cyst was enucleated in 21.2% and parenchymal resection was performed in 10.3%. The mortality rate was 0.2% and morbidity occurred in 8.4% of patients. The most common complications were dead-space in pulmonary parenchyma in 3.4% of cases and wound infection in 1.5%. Conclusion: The best treatment for pulmonary hydatic cyst disease is surgery with low mortality and morbidity. The most common treatment is extraction of cyst membrane and closure of small air ways. Pulmonary resection should be reserved for complicated forms of disease.

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Background: Epidural catheters are seldom difficult to remove from patients. The breakage of the catheters is uncommon, troublesome and occasionally dangerous. Case presentation: A lumbar epidural catheter inserted in a 17 year-old man for applying anesthesia for internal fixation of femur fracture and subsequent postoperativeepidural analgesia. In the third postoperative day, during unsuccessful attempt for removing the catheter, it was broken and was retained in his back. A CT- scan was performed and shows a fragment of catheter in the sub- laminar ligament between L3 and L4 without any connection with epidural space. As the patient had no complaint the fractured fragment was left in site and he was just followed up in the clinic. Conclusion: The knowledge of practical method in locating the retained epidural catheter, and the indication for surgical removal are very important. CT- scan is useful in showing the mechanism and locating the epidural catheter entrapment and facilitating surgical follow-up.

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Background: Central venous catheters are useful instruments in monitoring of critical patients and are important roots for total parentral nutrition. The catheters are widely used in general wards and intensive care units. Their use may be associated with serious and rare complications.

Case presentation: We reported a 24 years old woman that admitted to Ghaem hospital Mashhad University of Medical Science, in Mashhad, Iran, because of penetrating chest wall injury and surgical exploration indicated due to massive hemorrhage. Central vein (right jugular vein) was canulated for resuscitation and monitoring. Superior vena cava was injured after canulation and presented with delay massive mediastinal hematoma.

Conclusion: We aim to introduce this rare complication and its management. This management could be conservative or surgical intervention according to severity of the vein damage.

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Background: The irritable bowel syndrome (IBS) is one of the most common chronic medical conditions. Various mechanisms, including altered gut flora and/or small bowel bacterial overgrowth, have been suggested to play a role in the development of gas-related symptoms aim of study. The clinical evidence of small intestinal bacterial overgrowth as an important etiology of irritable bowel syndrome continues to accumulate. Clinical symptoms of bacterial overgrowth and irritable bowel syndrome are similar however, a definitive cause-and-effect relationship remains unproven. It is unclear whether motility dysfunction causes bacterial overgrowth or gas products of
enteric bacteria affect intestinal motility in irritable bowel syndrome.

Methods: In a randomized double-blind placebo-controlled trial consisting of treatment with bismuth subcitrate. Primary efficacy variable was subjective symptoms frequency of abdominal pain, Number of bowel movement & Bloating/distension.

Results: 119 patients were enrolled (59 bismuth subcitrate and 60 placebo recipients). At the end of phase 2, all symptom scores dropped significantly both in bismuth subcitrate and placebo group (p<0.001). There was not a significant difference in symptom relief with bismuth subcitrate versus placebo administration.

Conclusions: There was not a significant difference in symptom relief with bismuth subcitrate versus placebo in IBS patients. Whether antibiotics can improve quality of life in patients with irritable bowel syndrome warrants further research.
Interventions: Participants were randomly assigned to receive 120mg bismuth subcitrate four times daily for 14 days (n=59) or placebo (n=60).