Tehran University Medical Journal

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Two factors changed the clinical course of infective endocarditis dramatically: 1) The discovery and evolution of techniques for identifying and treating its microbiologic causes and 2) Valvular surgery. We retrospectively evaluated 43 (33.5%) patients (8 female, 35 male) from 4 to 65 years old of 128 patients with infective endocarditis who underwent surgical intervention. Indication for surgery were: Refractory congestive heart failure 14 (32.5%), prosthetic valves 10 (23.2%), large vegetation 6 (13.9%), recurrent endocarditis 4 (9.3%), ring abscess 4 (9.3%), brucella endocarditis 2 (4.6%), staph aureus endocarditis 3 (6.9%) and recurrent emboli 2 (4.6%). 30 to 50% of patients with infective endocarditis are operated during the active phase of the disease, this percentage is higher in case of aortic valve endocarditis, prosthetic valve endocarditis, some microorganisms such as staph aureus, gram negative bacilli, fungus and brucella. We suggest that internists refer patients for surgical intervention with infective endocarditis as early as possible in the active stage of infection.

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Spontaneous pneumothorax is a medical condition that potentially may be dangerous. Although several methods for management of this problem have been propounded, there is a great disagreement among the specialists about how to treat it and when more invasive treatments are indicated.
Materials and Methods: This study carried out in two phases. In first phase, 26 patients who had admitted to Imam Khomeini hospital from March 20, 1996 to March 19, 2000 and 50 patients admitted to Baqiatallah hospital between March 20, 1992 and March 19, 2002 with the diagnosis of spontaneous pneumothorax were studied retrospectively. In second phase, these patients were followed up.
Results: 39 patients (51.3%) had primary spontaneous pneumothorax, 35 patients (46.1%) secondary spontaneous pneumothorax and 2 (2.6%) neonatal spontaneous pneumothorax. 67 patients were male and 9 patients were female (male to female ratio: 7.5/1). Mean age of the patients was 35±20 years. Age peaks were the age group between 20 to 25 years old and age group more than 60 years old. Conducted treatments were observation in 3.9%, simple aspiration in 2.6%, thoracostomy alone in 81.6%, thoracostomy and chemical pleurodesis in 2.6%, thoracotomy and mechanical pleurodesis in 3.9%, thoracotomy and pleurectomy in 5.3% of cases. Mean duration of hospitalization was 8.9±7.3 days. Relapse of pnemothorax was seen in 36.9% of the followed patients. Mortality was 17.4% and all died patients had secondary spontaneous pneumothorax.
Conclusion: It seems that the management of spontaneous pneumothorax should be re-evaluated and the exact indications for conservative or more invasive methods of treatment should be defined.

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Neutropenic state with fever is exactly regarded as a medical emergency, with high mortality and morbidity rate, unless treated urgently and correctly. Every attempt should be made to find and establish the offending organism, but postponing treatment until obtaining culture results is not advised. Controversy exist on which antibiotic regimen to be used while waiting for culture results. Many antibiotic regiments both monotherapy or combination treatments have been used with varying result. The objective of this study is to compare the efficacy of cefriaxon monothenapy with ceftazidim. Plus Amikacin as initial empiric antibiotic therapy in febrile neutropenic patients.
Materials and Methods: We performed a randomized, single blind clinical trial in 57 adult (age>12 years), neutropenic (PMN<1000) patients with fever (Temperature, oral >38.5c) in Hematology ward, Imam khomeini hospital. After careful physical exam and obtaining blood & urine samples for culture, the patients were randomized to each of the two arms: Cefriaxon 2 grams daily, intravenously (arm A) and Ceftazidim 2g thrice daily plus amikacin 500 mg twice daily (arm B). Patients with shock, organ failure or previous antibiotic intake (during 48 hour before fever) were excluded. If needed, dose adjustment of drugs were allowed. Effervescence in 3 days following initiation of treatment, lasting 48 hours or more, were regarded as effective (positive result).
Results: During a twelve months period of study, a total of 57 patients (17female, 40male) were included. They were randomly selected to each arm of empirical treatment. Of 28 pts in arm A, 19 (67 percent), the treatment was effective, compared to 15 of 29 (51.7 percent) in groups B. The duration of fever after initiation of treatment was 37.9 ± 17 hours in arm A and 40. 1 ± 20 h in arm B. Blood and / or urine culture was equally positive in two arms (25 percent in arm A and 27.6 percent in arm B).
Conclusion: Cefriaxon monotherapy is at least equally effective in low risk neutropenic patients with fever compared to combination of ceftazidim plus amikacin at a decreased cost and probably (expected) less adverse side effects in our patients.

 

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Opioids are increasingly being recognized as the primary treatment for cancer pain management. Optimal treatment of cancer pain involves assessing its characteristics, considering different management strategies, evaluating side effects and adverse drug reactions and establishing the most appropriate therapeutic regimen. This study was designed to review the current status of pain management for advanced cancer cases using opioid analgesics.
Materials and Methods: A questionnaire was used to collect data on demographics, disease characteristics, and opioids use indicators in 700 cases of advanced cancer patients.
Results: A total of 700 cancer cases, 42 percent females and 58 percent males, between 17-80 years age range (Mean age of 57.25) were studied retrospectively. Cancers of breast (21 percent), colorectal (12 percent), lung (7 percent), stomach (7 percent) and bone either primary or metastatic (6 percent ) in women and stomach (17 percent), lung (12 percent), colorectal (11 percent), prostate (9 percent ), and bone (8 percent ) in men were the most common causes of opioids prescription in study group respectively. Advanced primary cancer (in 52 percent), bone metastasis (in 32 percent), and treatment complications (in 7 percent ) were considered as physical basis for pain in patients. Morphine (by injection), Opium (by oral intake) and methadone (injection and/or oral) were the most common opioids prescribed. Using equianalgesic conversion chart, the daily dosages and therapeutics schedules of morphine administration were as follows:
43 percent received 21-30 mg. in 2-4 divided doses
27 percent received >30 mg. in 3-5 divided doses
21 percent received 11-20 mg. in 2-3 divided doses
9 percent received 5-10 mg. in 1-2 divided doses
Conclusion: Pain management of cancer patients is not adequate and opioid use is not rational. New educational and managerial strategies are needed to optimize cancer pain treatment in routine medical practice. To overcome current barriers, WHO stepwise model for cancer pain control and palliative care is recommended. Publishing Standard Treatment Guidelines for different levels of health care system is another recommended approach to optimize cancer pain.

 

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Background: Hyperuricemia is one of the oncologic emergency that occurs most often in patients with hematologic disorders particularly leukemia and high-grade lymphoma. This study was conducted in order to determine the prevalence of hyperuricemia with respect to prophylactic treatment (in particular allopurinol) in patients with lymphoproliferative disease in the pediatric hematologic ward of Imam Khomeini Hospital, Tehran.
Methods: In this retrospective cross-sectional study, 316 children (75 females, 241 males) under the age of 12 years participated. Among the subjects, 66 patients (20.9%) had lymphoma and 250 patients (79.1%) had leukemia.
Results: Of the 56 (17.7%) patients diagnosed with hyperuricemia, 13 with lymphoma (19.7%) and 43 (17.2%) with acute lymphoblastic leukemia, 52 patients showed hyperuricemia after induction of chemotherapy (p<0.001). Hyperuricemia was more prevalent in patients with more advanced disease (50.9% in stage IV, p<0.001). Hyperuricemia was more frequent in male patients (p<0.001). Among the 217 patients who had received prophylaxis (hydration, alkalization, allopurinol), 19 (8.7%) subjects had hyperuricemia compare to 37.3% in the group of patients who did not receive prophylactic treatment (p<0.001).
Conclusion: From the literature reviewed, a recombinant form of the urate oxidase enzyme (rasburicase) is a safe and effective alternative to allopurinol to rapidly control plasma uric acid concentrations in patients with hematologic malignancy at high risk for tumor lysis during induction of chemotherapy. In this respect, we recommend a prospective study to compare allopurinol and rasburicase in children with leukemia and lymphoma.

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Background: Rheumatoid arthritis (RA) is a chronic inflammatory disease with several factors that contribute to its manifestation and continuation. One of the factors that initiate RA is emotional stress, which is in direct relationship with the sufficiency or insufficiency of the neuro-endocrine axis. Therefore, any stress that is not resolved in the neuro-endocrine axis might lead to RA and, as the stress continues, it causes the continuation of the disease. The aim of this study is to determine the effect of stress on continuation of RA and to find curative methods and, ultimately, the best method for treatment.

Methods: One hundred rheumatoid arthritic patients (80 females and 20 males), having a final diagnosis of RA based on the guidelines of the American College of Rheumatology and onset of disease within the last 12-36 months, were studied as case and control subjects. Data was collected using interviews and questionnaires that reflected their life events with stress as a serious factor in their disease. The patients were divided into two groups: group A with stable stress and group B with unstable stress. The same treatment method was given to both groups. The results of the treatment were evaluated and compared after two years of follow up. Results: There was significant improvement in the patients in group B with unstable stress over that of the patients in group A with stable stress (P<0.0001). Conclusion: The present study shows that a considerable number of RA patients suffer from serious stress that affects their clinical path and improvement, and is quite visible in the health indexes and continuity of the disease. The results further showed that stress can play an important role in the initiation and continuation of RA. Therefore, by identifying and making efforts to remove the stress factors using anti-anxiety drugs, the disease can be better controlled.

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Background: Cow's milk protein allergy (CMPA) is the most common food allergy during the first year of life. Strict avoidance of specific foods is the only accepted treatment for food-induced allergic reactions. This is often an unrealistic therapeutic option, since cow's milk is a basic food that is extensively used in infant formula. The recent preliminary experience of oral desensitization to cow's milk by Meglio & Patriarca seems promising. The object of this study was to investigate the desensitization of children with CMPA to cow's milk.

Methods: All the patients referred to the Allergology Department of the Children's Medical Center Hospital, Tehran from March 2004 to November 2005 suspected to have CMPA were evaluated. The patients were included in the intervention or control groups of the study. For the intervention group, Meglio's protocol was performed. We observed and examined the control group for at least 6 months. Eventually both groups were reevaluated for the symptoms and persistence of positive specific IgE for cow milk proteins.

Results: We enrolled 20 patients for oral desensitization and 13 patients were enrolled in the control group. Both groups were similar with regard to the mean age, sex and clinical symptoms. In 18 (90%) of the intervention subjects, oral desensitization with cow's milk was successfully performed. The entire protocol was completed by 14 (70%) of the intervention subjects. At the end of the six-month observation period, all the patients in the control group were still symptomatic after ingestion of cow's milk. The levels of specific IgE for cow's milk in the intervention group decreased significantly, which was not observed in the control group.

Conclusion: We successfully desensitized 90% of our CMPA patients. Considering that all the patients in the control group remained symptomatic after the period of observation and our promising results in oral desensitization with cow's milk, we can safely propose this protocol as a hopeful alternative in the treatment of CMPA. We speculate that oral desensitization to cow's milk does not alter the natural outcome of CMPA, but substantially increases the threshold dose necessary to elicit allergic symptoms.

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Background: Depressive disorders in children and adolescents are chronic and highly morbid. Few studies are carried out on antidepressant drugs for depressed youths, especially specific noradrenergic agents. Reboxetine is a selective norepinephrine reuptake inhibitor. This study was designed to evaluate the effect of reboxetine in childhood and adolescent depression.

Methods: Twenty patients of both genders, aged 7-17 years old, with major depressive or dysthymic disorders, as classified by the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), participated in an 8-week clinical trial before-after study of reboxetine. Clinical semistructured interviews, based on the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children (K-SADS), were carried out. Reboxtine was initiated at a dose of 1 mg/day and increased up to 6 mg/day. Patients were assessed for changes in: depressive symptoms using the Children's Depression Inventory (CDI) and global functioning by the Children's Global Assessment Scale (C-GAS). Side effect questionnaire was also administered.

Results: There was a significant decrease in the ineffectiveness subscale (C factor) of CDI (p=0.006). Although the CDI scores decreased by 32.69%, this change was not significant (p=0.39). No significant change in C-GAS (p=0.2) was observed. Adverse effects were relatively mild to moderate and transient. The most common adverse effects were decreased appetite and sedation.

Conclusions: Reboxetine is relatively well tolerated and improves feelings of ineffectiveness among depressed children and adolescents however it does not improve all depressive symptoms. Double-blind, placebo and active comparator controlled studies and larger sample sizes are indicated.

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Background: Patch forms of glyceryl trinitrate (GTN), also known as nitroglyceril, have proved useful in the management of dysmenorrhea. Increased intrauterine pressure due to exaggerated myometrial contractions is an important factor in the pathogenesis of dysmenorrhea. In a recent study, it was found that GTN caused a significant reduction in the contraction frequency of human myometrial strips. The object of this study is to evaluate the efficacy of GTN ointment in treating primary dysmenorrhea.

Methods: In this double-blind randomized placebo-controlled study, we enrolled 112 unmarried subjects with the complaint of moderate to severe primary dysmenorrhea. They were between 18-30 years of age with normal BMI (19-27) and all had normal results upon examination by pelvic ultrasound. None of these patients had a history anemia, previous pelvic surgery or cardiovascular diseases. Randomly divided in two groups using odd and even numbers, 56 of the subjects received 5 mg 1% GTN ointment and another 56 received a placebo. Before starting the treatment, severity of pain was recorded using a visual scale method. Ointment A (GTN 1%) or ointment B (placebo) was applied to special papers which were in turn applied to the skin of the abdomen below the umbilicus, and left there for the entire treatment period of four hours. The severity of pain and side effects of the treatment were recorded at intervals of 15 min, 30 min, 1 h, 2 h and 4 h after application the treatment. After four hours, the treatment was removed and the skin checked for erythema.

Results: There was no difference in severity of pain 15 min after treatment, but pain was less severe in the GTN group from the 30-min interval through the 4-h interval, with the least pain felt at the 2-h interval. This decrease in pain lasted through the 4-h interval. Side effects, which were more common in the GTN group than the placebo group (P<0.05), included headache (48.3% vs. 19.5%, respectively), dizziness and flushing.

Conclusions: GTN performed well in relieving primary dysmenorrheal discomfort however, the side effect of headache reduced its efficacy and tolerability.

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Background: Hyperhydrosis, excessive sweating, can profoundly affect the quality of life of the patient, with severe impairment of daily activities, social relationships and occupational activities. The purpose of this study was to evaluate the outcome of thoracoscopic sympathectomy in patients with palmar hyperhydrosis.

Methods: In a clinical trial at Imam Khomeini, Milad and Velenjak Hospitals from 2003 to 2006, 33 patients older than five years of age with palmar hyperhydrosis underwent thoracoscopic sympathectomy of T₂ and T₃ ganglions. The variables regarding operation duration, length of hospital stay and early post-op complications were recorded. In addition, the quality of life of the patients was evaluated using the DLQI questionnaire, while the satisfaction of the patients was evaluated using the visual analogue scale before, immediately after and six months after the operation.

Results: The mean age of the patients was 23 years and 63.6% of our patients were female. The sites of hyperhydrosis were hand, foot and armpit in 72.7% of the patients. In 90.91% of the cases, disease onset occurred during childhood and 78.79% of the patients had a family history of hyperhydrosis. Hyperhydrosis impaired function and had social, interpersonal and emotional effects in 72.7% of the cases. The mean duration of the operation was 40.3 minutes and the mean hospital stay was 1.45 days. The most common early post-op complications were atelectasis (7.57%), short-term pulmonary complications (3.03%) and pleural effusion (3.03%). Compensatory hyperhydrosis occurred in 60% of the cases, while 18.75% experienced gustatory sweating. Palms were reported to be totally dry immediately after and six months after the operation in 81.82% of the cases, while 18.18% reported acceptable levels of perspiration. The mean level of satisfaction immediately after and six months after the procedure was 0.81. All patients felt improvement in all aspects of their lives immediately after and six months after the operation. In terms of quality of life, the mean of DLQI score was significantly lower immediately after and six months after operation (18.78 ± 501 vs. 1.60 ± 0.81 and 1.64 ± 1), indicating that symptoms had less effect on the patients' lives. All patients were willing to re-experience the operation if necessary.

Conclusion: Thoracoscopic sympathectomy is an effective and safe therapeutic modality for palmar hyperhydrosis with a great rate of success and a slight chance of complica-tions. This operation results in a remarkable improvement in various aspects of the patients' lives. Willingness to re-experience the operation indicates the high degree of satisfaction.

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Background: Hyperuricemia is one of the oncologic emergency that occurs most often in patients with hematologic disorders particularly leukemia and high-grade lymphoma. This study was conducted in order to determine the prevalence of hyperuricemia with respect to prophylactic treatment (in particular allopurinol) in patients with lymphoproliferative disease in the pediatric hematologic ward of Imam Khomeini Hospital, Tehran. Methods: In this retrospective cross-sectional study, 316 children (75 females, 241 males) under the age of 12 years participated. Among the subjects, 66 patients (20.9%) had lymphoma and 250 patients (79.1%) had leukemia. Results: Of the 56 (17.7%) patients diagnosed with hyperuricemia, 13 with lymphoma (19.7%) and 43 (17.2%) with acute lymphoblastic leukemia, 52 patients showed hyperuricemia after induction of chemotherapy (p<0.001). Hyperuricemia was more prevalent in patients with more advanced disease (50.9% in stage IV, p<0.001). Hyperuricemia was more frequent in male patients (p<0.001). Among the 217 patients who had received prophylaxis (hydration, alkalization, allopurinol), 19 (8.7%) subjects had hyperuricemia compare to 37.3% in the group of patients who did not receive prophylactic treatment (p<0.001). Conclusion: From the literature reviewed, a recombinant form of the urate oxidase enzyme (rasburicase) is a safe and effective alternative to allopurinol to rapidly control plasma uric acid concentrations in patients with hematologic malignancy at high risk for tumor lysis during induction of chemotherapy. In this respect, we recommend a prospective study to compare allopurinol and rasburicase in children with leukemia and lymphoma.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 There are limited published investigations about adherence to antiretroviral and its determinants. Many determinants influence on adherence to therapy. The effects of some determinants on adherence are controversial. More studies are needed to be fulfilled about adherence and its determinants to compile strategies. Key to the success of antiretroviral therapies is the ability and willingness of HIV-positive individuals to adhere to antiretroviral regimens. There are different definitions for full adherence. In the most studies, adherence is defined as taking ≥95% of prescribed medication. Adherence rate needs to be >95% to prevent virologic failure and for complete supper-ssion. The consequences of poor adherence include not only diminished benefits for the patient, but also the public health threat of the emergence of multidrug-resistant viruses, as these resistant strains can then be transmitted from a patient to their contacts. Evaluating adherence has proven to be difficult and there is no gold standard for evaluating adherence to medication. Adherence is assessed in various ways. The most studies evaluate adherence to treatment by using patient's self report and the pill count method but these are methods known to overestimate adherence. Some determinants are associated with adherence include: age, gender, addiction specially injection drug users, alcohol consumption, depression, social support, level of education, work situation, adverse antiretroviral effects, pregnancy, type of antiretroviral drug regimen, number of pills and daily doses received, severe traumas, social and psychological factors, and relationship between clinician and patient.0

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Background: Penetrating thoracoabdominal stab wounds may cause diaphragmatic and abdominal organ laceration. However, 15-20% of these cases who are stable and managed by conservative treatment might have hidden diaphragmatic injuries, which could ultimately lead to chronic diaphragmatic hernia. Therefore, a safe and exact diagnostic method for the detection of occult diaphragmatic injuries is very valuable. In this study we have assessed the diagnostic value of thoracoscopy in occult diaphragmatic injuries resulting from penetrating thoracoabdominal stab wounds.

Methods: From March 2005 to October 2007, 30 hemodynamically stable patients with penetrating thoracoabdominal injuries, not requiring emergent exploration, were enrolled in this study. All subjects underwent thoracoscopy to evaluate probable diaphragmatic injury. Diaphragmatic injuries were repaired via thoracoscopy or laparatomy. All patients were evaluated for chronic diaphragmatic hernia by CT-scan six months later.

Results: The mean patient age was 26.2 years, with a male/female ratio of 5:1. Using thoracoscopic exploration, we observed five (16.7%) hidden diaphragmatic injuries, three (9.9%) of which were repaired using the thoracoscopic approach and two (6.6%) by laparatomy. Lung parenchymal laceration was seen in two patients (6.6%), for whom the repair was performed using thoracoscopy. Intra-abdominal injury was seen in one patient (3.3%), which was repaired by laparatomy. After thoracoscopy, there were no complications or evidence of chronic diaphragmatic hernia in the chest and abdominal CT-scans performed six months later. Therefore, the diagnostic accuracy of thoracoscopy in occult diaphragmatic injuries in our study was 100%.

Conclusion: With its high degree of diagnostic accuracy, low degree of invasiveness, as well as its utility in treatment, we recommend thoracoscopy for all clinically stable patients with penetrating thoracoabdominal stab wounds.

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Normal 0 false false false EN-GB X-NONE AR-SA MicrosoftInternetExplorer4 Background: Pleural malignant mesothelioma is an uncommon but extremely invasive tumor which originates from mesothelial cells and usually occures after prolonged exposure to asbestos. The aim of this study was to clinicopathologically evaluation of 40 patients with pleural malignant mesothelioma and the main factors influencing their prognosis.
Methods: In this study patients with definitive diagnosis, who had been followed up for at least three years were studied based on gender, age presenting symptoms, and clinicopathological patterns.
Results: Male to female ratio of the study patients was three to one any the average age of them was 55 years. Chest pain was the most common symptoms in 34(85%) patients. Most of the study patients were in Buchard stage I (37/5%) and the epithelial form was the most common pathological pattern 25(62.5%). 19(47.5%) of cases received only radiotherapy and chemotherapy. Extrapleural pneumonectomy was performed on eight (20%) patients, seven (17.5%) patients underwent decortication and pleurectomy beside adjuvant therapy and 15% of the cases rejected any type of treatment. Surgical mortality occurred in one patient and the most common surgical complication was wound infection. The average survival rate was 12±1.2 months and the main factors influencing it were the patient's physiologic status, pathological form, stage of the disease and the pattern of pleural involvement.
Conclusions: Because the low survival rate after multimodality invasive treatments in mesothelioma, aggressive therapeutic methods were recommended in selected patients

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Surgical methods for treatment of tricuspid valve (TV) endocarditis include repair, replacement and partial or complete exicion. The aim of this study was to assess the results of these different techniques.
Methods: Sixty seven patients were enrolled in this retrospective study. This study was carried-out between April 1997 and July 2007 in Imam Khomeini hospital. Decision of methods of choice for surgery was according to intraoperative findings.
Results: The mean age was 25.52±7.35 years and 74.36% were male. The most common bacteria was Staphylococcus areus (62.30%). Most of patients (74.60%) were IV drug abuser. The most common treatment modality was TV reconstruction (56.72%) and after that was TV replacement (29.85%) and the last one was complete TV excision (13.43%). Eight patients (11.94%) needed emergent TV replacement. The morbidity rate was 28.36% and the mortality rate was 13.51%. Thirty seven patients were followed. In follow-up period it was shown that postoperative Ejection Fraction (EF) and End-Diastolic Right Ventricle Diameters (EDRVD) values did not differ from preoperative values, but Pulmonary Artery (PA) pressure and Tricuspid Regurgitation (TR) severity were significantly lower compared with preoperative values. The postoperative function class did not show any changes compared with peroperative values.
Conclusion: Considering the specific epidemiology of patients with infective endocarditis, who are suffering from TV regurgitation, in some patients, it would be better to consider replacement instead of repair. This could be due to sever deformities and diffuse damage of TV leaflets from infection in our patients.

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Background : Open fractures are associated with an increased risk of infection and healing complications. Management of open fractures is based on the following principles: assessment of the patient, classification of the injury, antibiotic therapy, debridement and wound management, Fracture stabilization, early bonegrafting, and supplemental procedures to achieve healing.
Methods : In a case- control retrospective study we evaluated 33 patients with open tibial fracture (type two gustillo) who were admitted in sina General hospital in Tehran, Iran during years 1999-2009 and were treated uniformly with external fixation as primary treatment in our center as case group and the other 33 patients with the same method and another 33 patients who had not been infected as control group. W e compared the folders of case and control groups retrospectively. 
Results : There was no statisticant difference between two groups in mean age, gender, the mechanism of trauma and body mass index (p >0.05 ), while statistically significant difference between them in smoking habitus, blood transfusion, first debridment time, diabet mellitus, femoral shaft fracture (p <0.05 ).
Conclusions: Accompanying femoral fracture is the sign of high energy trauma and it is logical that it is an important risk factor for infection. In our study the time of the first debridment stablished as a significant factor influencing the infection rate in tibial open fracture. In some studies smoking had been recognized as a significant factor influencing in tibial bone open fracture our study reveals the same.

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Normal 0 false false false EN-US X-NONE AR-SA MicrosoftInternetExplorer4 Background: Empyema is one of the most common and important thoracic diseases which can lead to some sort of debilitating consequences if does not managed properly. Surgery usually is indicated in the third stage of the disease which contains more and devastating complications that do not respond to the other treatment options. This investigation evaluates the role of thoracoscopy (minimal invasive surgical intervention) in the management of second stage of empyema.
Methods: In a prospective investigation, 54 patients with stage II of empyema were selected and divided in two groups. In control group, patients were treated with chest tube thoracic drainage plus antibiotics administration, on the other side, Thoracoscopic diagnosis and drainage was added to the modalities of the control group. Thoracoscopy is aimed to explore the total thoracic cavity for releasing the fibrous bands and adhesions and draining of the loculated abscess. At the end of procedure plural cavity wash out and chest tube insertion were done.
Results: The rate of complication was 35% and 8% (p<0.05) in control group and investigated group, respectively. The average admission days were significantly greater in control group (the investigated group got better faster) (p<0.05). The need for thoracotomy was 7 time greater in control group (p<0.05).
Conclusion: Application of Thoracoscopy for stage 2 of empyema is a safe modality which can be advised for all of the patients. This minimally invasive technique can decrease complications rate, need for thoracotomy and hospital admission time.

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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: Coarctation of aorta is narrowing of proximal descending aorta. Interventional procedures such as balloon angioplasty & stent implantation has been progressively in use as alternatives for surgery in increasing number of children with diagnosis of coarctation of aorta. The aim of this study was to evaluate the use of endovascular stent in children with coarctation of aorta.

Methods: We evaluated effectiveness and safety of stenting in all patients younger than 18 years old with coarctation and re-coarctation of aorta which treated by stenting between years 2004-9 at rajaei - heart centre in Tehran, Iran.

Results: we studied 53 patients younger than 18 years old with a follow up of six months. Totally 54 stents were implanted. Mean (±SD) age of the patients was 11.6±4.2yrs. Seventeen cases (32%) were younger than 10 years old, and 36 cases (68%) were 10 years and older. Mean (±SD) weight was 39.24±18kg. 16 cases weighting less than 25kg. Peak systolic pressure gradient (SPG) decreased from 46.26±17.07 to 1.03±0.19mmHg after procedure (p<0.001). There was no significant difference (p<0.001) in the gradient before and after stenting in the patients with native coarctation (Vs re-coarctation cases), less than 25 kg and under 10 years old groups. Complications developed in 44% of cases while dominantly were minor except in two cases re-dilatation of stent was not needed during six month of follow-up of the patients.

Conclusions: Stenting of coarctation of aorta can decrease complications and can be used safely in children weighing bellow 25kg and in children below 10yrs old.

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Background: Bickerstaff's brainstem encephalitis (BBE) is a very uncommon central nervous system disease with unknown etiology. As it is usually responsive to treatment, the diagnosis this disease is important. It seems There is no reported Bickerstaff's brainstem encephalitis case in Iran.
Case presentation: An 83 year old woman presented with vertigo, ataxia and dysarthria from a week prior to admission. Her T2 weighted MRI revealed high intensity lesions in the pons area. She received treatment with impression of ischemic stroke. After few days, lower extremities became weak symmetrically and deep tendon reflexes depressed. Deep sensory loss was noted too. The EMG-NCV studies showed acute polyneuropathy and in CSF examination increased protein content was noted. The patient improved after IVIG and corticosteroid therapy with impression of Bickerstaff's brainstem encephalitis.
Conclusion: In spite of severe initial presentation, Bickerstaff's brainstem encephalitis has a good prognosis if it diagnosed and treated properly. Although clinical features is too important, but paraclinical work up are necessary to diagnose this syndrome.