Treatment of Early Deep Wound Infections after Arterial Reconstructions: A Meta-Analysis and Survey

BACKGROUND

Peripheral vascular graft infections, a serious concern after open lower extremity interventions, are treated using multiple strategies. Yet, there is no consensus on the optimal treatment. This study summarizes the literature and compares aggregate effect sizes between graft preservation with antibiotic beads and total graft excision.

METHODS

Manuscripts published between 1972 and 2019 were systematically queried using Ovid Medline and PubMed. Studies were included if they described early (≤4 months of the index procedure) infection-related outcomes after extracavitary and infrainguinal arterial graft infections that were managed with antibiotic-loaded beads or total excisions. Outcomes assessed included the prevalence of graft preservation failure, reinfection, and major amputation. To examine current preferences on this subject, a voluntary, anonymous survey was administered to practicing members of the Society for Clinical Vascular Surgery.

RESULTS

Six graft preservation studies (n = 147 patients) were included in the meta-analysis, based on PRISMA guidelines. The meta-analytic pooled proportion of patients with: (1) graft preservation failure was 0.09 (95% CI: 0.00, 0.46, I² = 88.8%), (2) reinfection was 0.04 (95% CI: 0.00, 0.18, I² = 79.7%), and (3) major amputation was 0.00 (95% CI: 0.00, 0.04, I² = 0%). Five studies addressing total excisions were identified via the systematic review however, their combined sample size (n = 28 patients) impeded use of a meta-analysis. Ninety (19%) licensed surgeons participated in the survey. In a hemodynamically stable, nonseptic patient, 67% (60) of respondents routinely excise the graft, while 31% (28) prefer preservation.

CONCLUSIONS

Study design and patient characteristic-related heterogeneity limited our ability to generate robust, clinical evidence-level outcome estimates. A prospective study is necessary to definitively establish the efficacy of antibiotic beads in the treatment and preservation of vascular graft infections.

Outcomes after Endovascular Stent Placement for Long-Segment Superficial Femoral Artery Lesions

BACKGROUND

Endovascular intervention is commonly pursued as first-line management of symptomatic, long-segment superficial femoral artery (SFA) disease. The relative effectiveness and comparative long-term outcomes among bare metal stents (BMS), covered stents (CS), and drug-eluting stents (DES) for long-segment SFA lesions remain uncertain.

METHODS

A retrospective cohort study identified patients with symptomatic SFA lesions measuring at least 15 cm in length who successfully received an endovascular stent (BMS, CS, or DES). The outcomes were patency, patient presentation upon stent occlusion, amputation-free survival (AFS), and all-cause mortality. Proportional hazards regressions and a multinomial logistic regression model were used to control for significant confounders.

RESULTS

A total of 226 procedures were analyzed (BMS: 95 [42%]; CS: 74 [33%]; DES: 57 [25%]). There were no significant differences among the 3 stent types with respect to age, prevalence of either diabetes or end-stage renal disease, or smoking history. The median length of the SFA lesion varied across the cohorts (BMS: 28 cm [interquartile range, IQR 20-30]; CS: 26 cm [IQR 20-30]; DES: 20 cm [IQR 16-25]; P = 0.002). The unadjusted primary patency of BMS at 12, 24, and 48 month following index stent placement was 57%, 47%, and 44%, respectively. This is compared to 62%, 49%, and 42% for CS, and 81%, 66%, and 53% for DES, respectively (log-rank P = 0.044). In adjusted models, however, there were no significant differences in primary patency among the stent types. Compared to CS however, DES was associated with improved primary-assisted patency (hazard ratio [HR] for patency loss: 0.35, P = 0.008) and secondary patency (HR: 0.32, P = 0.011). Across the entire follow-up period, stent occlusions occurred in 38 (40%) BMS cases, 42 (57%) CS, and 11 (19%) DES (P < 0.001). Of these, acute limb ischemia (ALI) occurred in 2 (5%) BMS cases, 14 (33%) CS, and 1 (9%) DES (P = 0.010). After adjustment, the relative risk of presenting with ALI as opposed to claudication was 27 times greater among patients re-presenting with occluded CS compared to BMS (P = 0.020). There were no significant differences in AFS or all-cause mortality across the 3 cohorts.

CONCLUSIONS

For long-segment SFA lesions, DES is associated with improved primary-assisted and secondary patency over long-term follow-up. In the event of stent occlusion, CS is associated with an increased risk of ALI.

Is international affective picture system (IAPS) appropriate for using in Iranian culture, comparing to the original normative rating based on a North American sample

Background

Previous studies have shown that cultural context has an influence on emotion and cognition. In this study the emotional response to international affective picture system (IAPS) was compared between Iranians and normative ratings of Americans young adults.

Method

One hundred and thirty eight Iranian university students (85 women, 48 men) age 18 to 52 (average= 31, SD = 7.76) enrolled in the study. Participants’ emotional response to IAPS images were rated in three dimensions (valence, arousal, dominance) using self-assessment Manikin (SAM) system. Then, valence, arousal, dominance scores were compared to those of 100 American undergraduates (50 females, 50 males) of the same age group, enrolled at Florida university and surveyed by Prof. PJ Lang in 2008.

Result

Our results indicate that there is complete correlation between the mean ratings of valence, arousal and dominance between Iranian and American participants. Also the results showed similarities in valence ratings, but arousal ratings especially in female participants were different. The relationship between arousal and valence showed a similar boomerang shaped distribution seen with the North American sample. Iranian sample showed positively offset and negative bias comparable to the American counterparts.

Conclusion

The results are promising in the sense that IAPS images can be used in studies within Iranian cultural context. However, arousal values require a modification for their proper application in Iranian cultural context.

Disclosure of interest

The author has not supplied his/her declaration of competing interest.

Association of the Addition of Oral Antibiotics to Mechanical Bowel Preparation for Left Colon and Rectal Cancer Resections With Reduction of Surgical Site Infections

Importance

Surgical site infections (SSIs) after colorectal surgery remain a significant complication, particularly for patients with cancer, because they can delay the administration of adjuvant therapy. A combination of oral antibiotics and mechanical bowel preparation (MBP) is a potential, yet controversial, SSI prevention strategy.

Objective

To determine the association of the addition of oral antibiotics to MBP with preventing SSIs in left colon and rectal cancer resections and its association with the timely administration of adjuvant therapy.

Design, Setting, and Participants

A retrospective review was performed of 89 patients undergoing left colon and rectal cancer resections from October 1, 2013, to December 31, 2016, at a single institution. A bowel regimen of oral antibiotics and MBP (neomycin sulfate, metronidazole hydrochloride, and magnesium citrate) was implemented August 1, 2015. Patients receiving MBP and oral antibiotics and those undergoing MBP without oral antibiotics were compared using univariate analysis. Multivariable logistic regression controlling for factors that may affect SSIs was used to evaluate the association between use of oral antibiotics and MBP and the occurrence of SSIs.

Main Outcomes and Measures

Surgical site infections within 30 days of the index procedure and time to adjuvant therapy.

Results

Of the 89 patients (5 women and 84 men; mean [SD] age, 65.3 [9.2] years) in the study, 49 underwent surgery with MBP but without oral antibiotics and 40 underwent surgery with MBP and oral antibiotics. The patients who received oral antibiotics and MBP were younger than those who received only MBP (mean [SD] age, 62.6 [9.1] vs 67.5 [8.8] years; P = .01), but these 2 cohorts of patients were otherwise similar in baseline demographic, clinical, and cancer characteristics. Surgical approach (minimally invasive vs open) and case type were similarly distributed; however, the median operative time of patients who received oral antibiotics and MBP was longer than that of patients who received MBP only (391 minutes [interquartile range, 302-550 minutes] vs 348 minutes [interquartile range, 248-425 minutes]; P = .03). The overall SSI rate was lower for patients who received oral antibiotics and MBP than for patients who received MBP only (3 [8%] vs 13 [27%]; P = .03), with no deep or organ space SSIs or anastomotic leaks in patients who received oral antibiotics and MBP compared with 9 organ space SSIs (18%; P = .004) and 5 anastomotic leaks (10%; P = .06) in patients who received MBP only. Despite this finding, there was no difference in median days to adjuvant therapy between the 2 cohorts (60 days [interquartile range, 46-73 days] for patients who received MBP only vs 72 days [interquartile range, 59-85 days] for patients who received oral antibiotics and MBP; P = .13). Oral antibiotics and MBP (odds ratio, 0.11; 95% CI, 0.02-0.86; P = .04) and minimally invasive surgery (odds ratio, 0.22; 95% CI, 0.05-0.89; P = .03) were independently associated with reduced odds of SSIs.

Conclusions and Relevance

The combination of oral antibiotics and MBP is associated with a significant decrease in the rate of SSIs and should be considered for patients undergoing elective left colon and rectal cancer resections.

Delayed gratification and adherence to exercise among patients with claudication

Few studies have explicitly identified factors that explain an individual's willingness to engage in community-based exercise for claudication. Identifying the unique characteristics of those inclined toward physical activity would inform interventions that encourage walking. We examined the utility of behavioral economics-related concepts in understanding walking among Veterans with claudication. Patients who received care at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, were surveyed on symptom severity, behavioral economics, stress, and depression. The primary outcome was a binary variable measuring current walking for exercise and defined as walking for at least 30 minutes every day. Multivariable logistic regression models were used to identify variables, both clinically and statistically significant, at a p-value < 0.05. Between April 2017 and March 2018, we received 148 (30%) responses. A total of 35% (n = 51) of respondents indicated that they walked recreationally for exercise compared to 65% (n = 94) who did not. Characteristics that were significantly associated with walking included regularly saving money (adjusted odds ratio (aOR) = 10.7, p = 0.001), seeking complex problem-solving (aOR = 0.12, p = 0.002), and severe symptoms (aOR = 0.24, p = 0.017). Individuals describing a preference for the future rather than immediate benefit also reported currently walking for exercise. Defining the characteristics of those who exercise may help inform strategies designed to increase walking among those who do not adhere to recommendations.

Health Care Resource Distribution of Texas Counties With High Rates of Leg Amputations

BACKGROUND

Lower extremity amputation rates associated with peripheral arterial disease in Texas are high and vary disproportionately among different populations. We sought to assess the impact of socioeconomic status and health care resource distribution on the geographic prevalence of lower extremity amputation in Texas counties.

MATERIALS AND METHODS

We collated 2005-2009 data on all 254 Texas counties. The primary outcome was the number of nontraumatic lower extremity amputations. Population-adjusted regressions identified factors that could explain increasing amputation rates.

RESULTS

We identified 33 counties with population-weighted amputation rates in the highest 25%. These counties had higher rates of diabetes, larger populations of people categorized as black, fewer health care resources, and lower health care utilization. In the presence of more emergency room visits, dual Medicare/Medicaid eligibility decreased total amputations. In counties with more than 70% rural communities, additional primary care providers also significantly decreased amputations per 100,000 residents (mean difference = -0.12, 95% confidence interval: -0.23, -0.0008).

CONCLUSIONS

Policy-driven strategic health care resource allocation at the local level may benefit patients in high-need, low-resource areas and promote a reduction in amputations.

Successful Smoking Cessation Associated with Walking Behavior in Patients with Claudication

BACKGROUND

Behavioral economics theories suggest that a preference for delayed benefits promotes positive behavioral change, a concept relevant to both smoking cessation and community-based exercise regimens for claudication. Given the high rate of smoking among older veterans, we were interested in examining the association between smoking cessation, exercise regimen adherence, and preferences for delayed versus immediate benefits.

METHODS

Between April 2017 and March 2018, patients with claudication at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, Texas, received questionnaires collecting information on social, behavioral, and psychological characteristics. A dual validation system, via the electronic medical record and survey data, measured the primary outcome-smoking cessation versus current smoking. Self-reported physical activity was measured through the validated Ainsworth's compendium of Physical Activities and binary survey questions. The Walking Impairment and Barratt's Impulsivity Questionnaires measured subjective symptom severity and behavioral economics factors, respectively. Multivariable, logistic regression models identified significant associations.

RESULTS

The survey was mailed to 500 patients who met the eligibility criteria. We received responses from 148 individuals (30%), and 67 of 141 (48%) indicated that they had successfully quit smoking. In unadjusted comparisons, the median cognitive complexity score in the smoking cessation group was higher than that in the current smoking group. A greater proportion of patients who reported walking for exercise (n = 46) also reported successful smoking cessation (28/46, 61%). Among those who were not walking for exercise (n = 88), more individuals reported current smoking (49/88, 56%). In the multivariable model, individuals who had successfully stopped smoking were older (odds ratio [OR]: 7.59, P < 0.001), more likely to walk for exercise (OR: 3.94, P = 0.009), more interested in the future than in the present (OR: 1.73, P = 0.030), and more likely to regularly save money (OR: 3.49, P = 0.046).

CONCLUSIONS

We found that participants who reported successful smoking cessation were more likely to report walking for exercise. Our findings suggest that adherence to walking may be less challenging for patients who have already successfully implemented and continue to implement another beneficial health behavior (smoking cessation). Patients with claudication who are current smokers may be less likely to adopt exercise recommendations.

Missing Data in Surgical Data Sets: A Review of Pertinent Issues and Solutions

Incomplete data is a common problem in research studies. Methods to address missing observations in a data set have been extensively researched and described. Disseminating these methods to the greater research community is an ongoing effort. In this article, we describe some of the basic principles of missing data and identify practical, commonly used methods of adjustment relevant to surgical data sets. Through an example data set, we compare models generated through complete case analysis, single imputation (SI), and multiple imputation (MI). We also provide information on the steps to conduct MI using Stata IC. In our comparisons, we found that differences in odds ratios were greatest between the results from complete case analysis compared to the SI and MI models indicating that in this case the reduction in statistical power has a non-negligible effect on the parameter estimates. Odds ratio estimates from the SI and MI methods were largely similar. In some instances, when compared to the MI method, the SI method tended to overestimate effect sizes. While in this example the differences in odds ratios do not vary greatly between the SI and MI methods, there are clear indications supporting the use of MI over SI. By describing the issues surrounding missing data and the available options for adjustment, we hope to encourage the use of robust imputation methods for missing observations.

A Multi-Component Strategy to Decrease Wound Complications after Open Infra-Inguinal Re-Vascularization

BACKGROUND

Wound complications remain a significant source of morbidity for patients undergoing open infra-inguinal re-vascularization. The purpose of this study was to determine the impact of several infection-control strategies on post-operative wound complications after open infra-inguinal re-vascularization.

METHODS

A retrospective cohort study was conducted among all patients who underwent an open infra-inguinal re-vascularization procedure before and after 2014. Since 2014, we have implemented strategies to reduce post-operative wound complications, including: (1) Decreasing the use of incisional skin staples, (2) increasing the use of negative pressure wound therapy (NPWT) dressings, and (3) implementing an outpatient elective decontamination protocol for methicillin-resistant Staphylococcus aureus. "Pre-era" is defined as the period between January 2012 and December 2013, before the implementation of infection control strategies; "Post-era" is between January 2015 and August 2016, after implementation. The primary outcome of interest is 30-day wound complications (infection or dehiscence). Multi-variable logistic regression analysis was used to identify significant predictors of wound-related complications between the two cohorts. Propensity score adjustment controlled for baseline patient characteristics, peri-operative variables, and surgeon experience.

RESULTS

A total of 338 open infra-inguinal procedures were performed: 175 in the pre-era and 163 in the post-era. Chlorhexidine skin preparation was used in the majority (321 [95%]) of cases. Comparing the periods, the post-era is characterized by a significant decrease in the use of groin staples (118 [67%] vs. 51 [31%], p < 0.001), and an increased application of NPWT dressings (6 [4%] vs. 66 [43%], p < 0.001). Thirty-five (37%) outpatient elective cases received the pre-operative decontamination protocol in the post-era. Compared with the pre-era, there was a decrease in the 30-day rate of wound complications (68 [39%] to 42 [26%], p = 0.011), and infection-related re-admissions (31 [17.7%] to 21 [12.9%], p = 0.220). When adjusting for patient characteristics, operative variables, and surgeon experience, post-era had significantly lower wound complications (odds ratio [OR] 0.33, p = 0.002) and re-operations (OR 0.16, p = 0.007). Among outpatient elective cases, the decontamination protocol was also independently associated with these two outcomes (wound complications: OR 0.05, p = 0.006; re-operations: 0.06, p = 0.002). The use of groin staples was an independent predictor of deep groin infections (OR 248, p < 0.001) and re-operations (OR 8.16, p = 0.032).

CONCLUSIONS

Wound complications after open infra-inguinal re-vascularization have decreased significantly after the implementation of several infection-control strategies. Findings suggest that skin staples should be avoided in groin wounds, and anti-staphylococcal decontamination protocols decrease wound complications and prevent re-operations.

RACIAL AND GEOGRAPHIC VARIATION IN LEG AMPUTATIONS AMONG TEXANS

BACKGROUND

The existence of racial and ethnic disparities in leg amputations rates is well documented. Despite this, approaches to addressing these alarming disparities have been hampered by the inability to identify at-risk individuals in a region and design targeted interventions. We undertook this study to identify small geographic areas in which efforts focused on high-risk individuals with peripheral artery disease (PAD) could address disparities in leg amputation rates.

METHODS

We used de-identified Texas state admission data to identify PAD-related admissions associated with an initial revascularization (leg angioplasty or leg bypass) or an primary leg (above-ankle) amputation between from 2004 through 2009.

RESULTS

21,273 major initial procedures were performed in Texas from 2004 through 2009 for PAD-related diagnoses, including 16,898 revascularizations and 4,375 leg amputations. A multivariate logistic regression demonstrated that an initial leg amputations done without revascularization was significantly associated with, among other variables: people categorized as black (odds ratio [OR] 1.79) or Hispanic (OR 1.42); those with Medicaid coverage (OR 1.89); and those treated at low volume hospitals (OR 1.78; p<0.001 for all). Four geographic regions were identified with significantly higher risk-adjusted leg amputation rates. Of the 349 Texas hospitals performing major procedures, 72 (21%) reported no revascularization procedures during the six year period studied.

CONCLUSIONS

Prevention efforts directed at specific geographic areas may be more likely to reach at-risk people with PAD and thereby reduce leg amputations disparities in Texas. Such efforts might also find strategies to direct patients toward higher volume centers with higher revascularization rates.

Getting stung by black scorpion Androctonus crassicauda

Importance of the correct diagnosis in the correct early management of a scorpion stung patient by using antivenom is not emphasized, particularly when there are little evidences. A 65-year-old female was brought to our emergency department with the chief compliant of being stung by an unknown object 3 h earlier while traveling in an intercity bus. She became agitated and simultaneously experienced tachycardia, very severe generalized sweating, cold and wet extremities, bilateral diffuse crackle in the base of lungs, tachypnea, and lethargy. With the primitive diagnosis of myocardial infarction, scorpion sting was documented as the cause of this combined cholinergic and adrenergic syndrome after the scorpion was found in the patient’s bed clothes. She dramatically responded to the administration of low dose of scorpion antivenom. This case dramatically responded to the antivenom administration, especially the cholinergic and sympathetic signs, pulmonary edema, and electrocardiographic changes were fully and almost immediately recovered. Scorpion antivenom may reverse life-threatening manifestations of scorpion envenomation if used early and in appropriate patients.

Study of defensive methods and mechanisms in developmental, emotional (internalization), and disruptive behavior (externalization) disorders

We need to find a way for adaptation with inherent unpleasantness of being human condition and conflicts that it caused, as we did not fail. Methods that we used for adaptation are named defense. This research have performed with the aim of study and compare defensive mechanisms and methods of Developmental, Emotional (Internalization), and Disruptive behavior (Externalization) disorders. Method, sample of this research included 390 family that are by available sampling method are selected. Tools of research were structured clinical interview of forth cognitive and statistical guide of psychopathic disorders for axis I and the way used for assess defensive mechanisms is defensive method 40 question's questionnaires of Andrews (1993). The data are compared by statistical methods comparison of averages and one way variance analysis and HSD tests and results show that undeveloped defensive mechanisms in by developmental disorder family (25.2 ± 3.7) mean and standard deviation, it is most used mechanism and in disruptive behavior disorder family by (11.2 ± 1.9) mean and standard deviation is used least mechanism and in developed mechanism of emotional disorder family by (7.8 ± 3.1) mean and standard deviation is most used mechanism and in developmental disorder family by (4.3 ± 1.5) mean and standard deviation is least mechanism in neuroticism patient, social phobia affected emotional disorder family (15.6 ± 2.6) and disruptive behavior disorder family have least mean and standard deviation (9.2 ± 1.7) (p< 0.005). Recent research shows significant of study defensive mechanism in psychopathic family of disorder children that affecting on the way of life of persons and interpersonal and intrapersonal relations and method of solving problem in family of them in life, so defensive mechanisms require more attention.

Effectiveness of group dialectical behavior therapy (based on core distress tolerance and emotion regulation components) one expulsive anger and impulsive behaviors

INTRODUCTION

The purpose of this study is to measure Effectiveness of group dialectical behavior therapy (based on core distress tolerance and emotion regulation components) on Expulsive Anger and Impulsive Behaviors.

MATERIALS & METHODS

Research method is a semi experimental socio-statistic approach consisting of experimental group (dialectical behavior therapy) and control group. Participants were patients referred to Amir Kabir Hospital in Arak who suffered from Expulsive Anger and Impulsive Behaviors. Based on stratified random sampling, 16 patients (women) were placed in each group. Research tools included the structured diagnosis interview according to DSM-IV-TR (2000), Barrat impulsivity scale(1994) Distress Tolerance Scale (2005) Difficulties of Emotion Regulation Scale (2004) and dialectical behavior therapy were done for two months,8 group-sessions).

FINDINGS

Dialectical behavior therapy was effective on Expulsive Anger and Impulsive Behaviors.

DISCUSSION & CONCLUSION

Distress tolerance and emotion regulation components were effective on Expulsive Anger and Impulsive Behaviors.

Acute colchicine overdose: report of three cases

Intentional acute toxicity by colchicine is not common but accompanies a high rate of complications and mortality. It is generally assumed to be an emergency in clinical toxicology. Rapid diagnosis and treatment can prevent death. The most common causes of death in this toxicity are acute cardiac failure, shock, and dysrhythmias with hematopoietic complications occurring in later stages. We report three cases of acute colchicine toxicity, two of which expired, with different presenting and ongoing signs and symptoms. We aimed to define the different possible clinical manifestations of the toxicity and review the probable treatments available for these patients.

Intestinal obstruction in acute inhalational toluene 2,4-diisocyanate gas toxicity

The isocyanates are widely used as precursors of polyurethane products, as well as carbamate insecticides. Toluene 2,4-diisocyanate (TDI) is one of the most important commercially used isocyanates. Humans may be exposed to TDI by inhalation, ingestion, dermal and eye contact. TDI is a powerful irritant to the mucosal membranes of the gastrointestinal and respiratory tracts, eyes and the skin. Pulmonary manifestations, especially occupational asthma, are the predominant manifestations after TDI toxicity. Herein, we present intestinal obstruction as an extraordinary manifestation of acute TDI toxicity after occupational exposure. TDI toxicity may cause intestinal obstruction.

Candidate genes that may be responsible for the unusual resistances exhibited by Bacillus pumilus SAFR-032 spores

The spores of several Bacillus species, including Bacillus pumilus SAFR-032 and B. safensis FO-36b, which were isolated from the spacecraft assembly facility at NASA's Jet Propulsion Laboratory, are unusually resistant to UV radiation and hydrogen peroxide. In order to identify candidate genes that might be associated with these resistances, the whole genome of B. pumilus SAFR-032, and the draft genome of B. safensis FO-36b were compared in detail with the very closely related type strain B. pumilus ATCC7061(T). 170 genes are considered characteristic of SAFR-032, because they are absent from both FO-36b and ATCC7061(T). Forty of these SAFR-032 characteristic genes are entirely unique open reading frames. In addition, four genes are unique to the genomes of the resistant SAFR-032 and FO-36b. Fifty three genes involved in spore coat formation, regulation and germination, DNA repair, and peroxide resistance, are missing from all three genomes. The vast majority of these are cleanly deleted from their usual genomic context without any obvious replacement. Several DNA repair and peroxide resistance genes earlier reported to be unique to SAFR-032 are in fact shared with ATCC7061(T) and no longer considered to be promising candidates for association with the elevated resistances. Instead, several SAFR-032 characteristic genes were identified, which along with one or more of the unique SAFR-032 genes may be responsible for the elevated resistances. These new candidates include five genes associated with DNA repair, namely, BPUM_0608 a helicase, BPUM_0652 an ATP binding protein, BPUM_0653 an endonuclease, BPUM_0656 a DNA cytosine-5- methyltransferase, and BPUM_3674 a DNA helicase. Three of these candidate genes are in immediate proximity of two conserved hypothetical proteins, BPUM_0654 and BPUM_0655 that are also absent from both FO-36b and ATCC7061(T). This cluster of five genes is considered to be an especially promising target for future experimental work.

Correlation between ankle-brachial index and microalbuminuria in type 2 diabetes mellitus

INTRODUCTION

Microalbuminuria is a reliable marker of diabetic nephropathy. Establishment of peripheral vascular complications leads to early diagnosis, prevention, and treatment of renal and cardiovascular complications. This study investigated the value of ankle-brachial index (ABI) for prediction of microalbuminuria in type 2 diabetic patients.

MATERIALS AND METHODS

Measurement of ABI with color Doppler ultrasonography was carried out for 206 patients with type 2 diabetes mellitus. An ABI Index less than 0.9 was defined as a predictive marker for atherosclerosis. Microalbuminuria and risk factors of atherosclerosis were compared between the patients categorized based on the ABI values.

RESULTS

The mean ABI was 1.1 ± 0.2 (range, 0.052 to 1.6), and 41 (20%) had an abnormal ABI (< 0.9). The correlations were significant between abnormal ABI and duration of disease (P = .04), cardiovascular event and cardiac care unit admission (P = .001), hypertension (P = .01), and dyslipidemia (P = .01). There was a significant correlation between ABI and microalbuminuria (odds ratio, 0.05; 95% confidence interval, 0.038 to 0.630; P < .001). A cutoff point of an ABI less than or equal to 1.04 had a sensitivity of 71.6% and a specificity of 64.2% for prediction of microalbuminuria.

CONCLUSIONS

The ABI is a noninvasive and reliable assay for detection of peripheral and cardiovascular complications, and also early stage of nephropathy in diabetic patients. In patients with an abnormal ABI, long-term follow-up for earlier detection and prevention of complications is helpful.

Prophylactic distal revascularization and interval ligation procedure during femoral vein transposition fistula creation in patients at high risk for ischemic complications

Femoral vein transposition arteriovenous fistula (FVt AVF) is a viable autologous option when upper extremity dialysis access sites have become compromised. High volume flow through the AVF can lead to ischemic complications, including steal syndrome (SS), and may threaten access and limb viability. Risk factors for SS include: age >60 years, female sex, diabetes, atherosclerosis, hypertension, and previous limb procedures. Two dialysis patients, who were at high risk for SS in their lower extremities as assessed during the preoperative evaluation for an elective FVt AVF, had a distal revascularization and interval ligation (DRIL) procedure concurrently performed. At 42 and 24 months from their respective surgeries, both patients are reliably using their lower extremity autologous access sites and have not developed any signs or symptoms of ischemia. DRIL may represent an effective surgical strategy that can prophylactically be used to minimize the incidence of ischemic complications during FVt AVF in carefully selected, high-risk patients.

The role of ultrasound in the visualization of the ingested medications in acute poisoning - a literature review

In the patients with medication poisoning, diagnosis and treatment may be complicated due to the decreased level of consciousness or lack of the patient cooperation. In this review, we tried to assess the role of ultrasonography in detection of the ingested medication in the stomach of the patients with suspected medication poisoning. Of the studies performed in this regard, only one managed to determine the extended phenytoin capsules in the stomach of a poisoned patient. In actual acute poisoning - even in the hands of an experienced ultrasonographer - detection of the medications in the patients' stomach seems to be difficult due to the presence of the food or lack of the water in their stomach. Also, after dissolution of the tablets or capsules or their passage from the pylorus, they can not further been visualized by ultrasound. We, therefore, conclude that ultrasonography is not an appropriate tool for diagnosis of the medication ingestion in acute poisoning.

Lipid emulsion improves Glasgow coma scale and decreases blood glucose level in the setting of acute non-local anesthetic drug poisoning--a randomized controlled trial

BACKGROUND

To date, no study has been performed to evaluate the antidotal effect of intravenous lipid emulsion on the poisoned patients' level of consciousness and routine metabolic profile tests in non-local anesthetic drug overdose.

OBJECTIVES

Our aim was to evaluate the effect of intravenous intralipid administration as an antidote on the poisoned patients' Glasgow Coma Scale (GCS), hemodynamic parameters, arterial blood gas analysis, and routine metabolic profile tests (i.e., urea, glucose, sodium, and potassium) in the setting of non-local anesthetic drug overdose.

MATERIAL AND METHODS

In this randomized controlled trial, a total of 30 patients with non-local anesthetic drug intoxication were enrolled and randomly assigned into case (n=15) and control (n=15) groups. In the case group, all patients received 10 cc/kg intralipid 10% infusion. The patients in the control group just received the supportive care. Patients' demographic and clinical characteristics and results of their laboratory tests were evaluated at presentation and 6 hours after that.

RESULTS

Mean age was 23 +/- 5 and 28 +/- 11 years in cases and controls, respectively. There were no significant statistical differences between these two groups regarding age, gender, elapsed time between intubation and extubation, and need for intubation and/or mechanical ventilation (p = 0.70 and p = 1.00, respectively). Also, systolic blood pressure, pulse rate, mean rate pressure product, respiratory rate, results of arterial blood gas analyses, serum sodium, potassium, urea, and creatinine on presentation and six hours later were not statistically significantly different between the two study groups. However, a significant difference was found between the two groups in terms of GCS difference (p = 0.048) and blood glucose six hours after presentation (p = 0.04).

CONCLUSIONS

In the setting of non-local anesthetic drug overdose, intravenous intralipid infusion can increase GCS and interestingly, decrease the blood glucose.

Tramadol-induced seizures and trauma

BACKGROUND AND OBJECTIVES

To determine the prevalence, type and site of the injuries due to tramadol-induced seizures in the patients who had referred after its overdose or use of its therapeutic dose.

MATERIAL AND METHODS

All patients referring to Loghman Hakim Poison Hospital (February 2009 to April 2010) due to tramadol-induced seizures were included. The patients' data including age, gender, ingested dose by history, route of exposure, manner of poisoning, previous history of suicidal attempts, previous history of drug or substance abuse, history of tramadol abuse, type of the seizure, number of episodes of seizure before presentation or after admission, site of the trauma, and type of injury were recorded.

RESULTS

A total of 232 patients were included in the study. Of them, 185 (79.7%) had referred within the first 6 hours after ingestion. The mean dose ingested by the history was 1416 +/- 1124 mg. History of tramadol abuse was positive in 114 (49.1%) patients. Seizure episodes had occurred once in 207 (89.2%), twice in 21 (9.1%), and three times in 4 (1.7%) patients. The prevalence of trauma was 24.6% (in 57 patients) with the most frequent site of trauma to the face (9.5%) followed by shoulder (4.3%), head (3%), trunk (1.7%), and upper extremities (1.3%). No statistically significant difference was found between patients with and without trauma associated with tramadol-induced seizures in terms of age, gender, ingested dose by history, positive history of addiction to other opioids, and number of episodes of seizure.

CONCLUSIONS

The only serious injury associated with this type of seizure was the head injury, present in approximately 1% of the patients.

Prevalence of pituitary incidentaloma in the Iranian cadavers

AIM

Although one-fourth of the pituitary tumors are inactive and silent, increased total volume of the pituitary gland exerts pressure on sella turcica and corrodes the clinoid processes, resulting in several problems. Therefore, determination of the prevalence of the concealed pituitary tumors is of major concern among clinical practitioners. This study was performed to determine the prevalence of these tumors in cadavers referred to the Iranian Legal Medicine Organization (Kahrizak, Tehran).

MATERIALS AND METHODS

This cross-sectional descriptive study was performed between June 2007 and February 2008. A total of 485 cadavers were selected by simple random sampling method. Pituitary glands were removed and then horizontally cut and four slides were prepared from each of them, stained by hematoxylin and eosin, and evaluated by a light microscope. For statistical analysis, SPSS software (version 16), Mann-Whitney U test, Kolmogorov-Smirnov nonparametric test (K-S test), and Chi-square test were used.

RESULTS

Of the 485 investigated cadavers, 365 (75.3%) were males with an average age of 42 ± 20.5 years and 120 (24.7%) were females with an average age of 44 ± 22 years. A total of 61 (12.6%) had concealed pituitary masses. No statistically significant difference was found between the mean age, sex, and body mass index (BMI) of the cadavers with and without concealed tumors (P=0.380 P=0.450, and P=0.884, respectively).

CONCLUSIONS

In the present study, the prevalence of the concealed pituitary adenomas was 12.6%. There was no correlation between age, sex, and BMI and the prevalence of the concealed masses.

Emerging roles for the transforming growth factor-{beta} superfamily in regulating adiposity and energy expenditure

Members of the TGF-β superfamily regulate many aspects of development, including adipogenesis. Studies in cells and animal models have characterized the effects of superfamily signaling on adipocyte development, adiposity, and energy expenditure. Although bone morphogenetic protein (BMP) 4 is generally considered a protein that promotes the differentiation of white adipocytes, BMP7 has emerged as a selective regulator of brown adipogenesis. Conversely, TGF-β and activin A inhibit adipocyte development, a process augmented in TGF-β-treated cells by Smads 6 and 7, negative regulators of canonical TGF-β signaling. Other superfamily members have mixed effects on adipogenesis depending on cell culture conditions, the timing of expression, and the cell type, and many of these effects occur by altering the expression or activities of proteins that control the adipogenic cascade, including members of the CCAAT/enhancer binding protein family and peroxisome proliferator-activated receptor-γ. BMP7, growth differentiation factor (GDF) 8, and GDF3 are versatile in their mechanisms of action, and altering their normal expression characteristics has significant effects on adiposity in vivo. In addition to their roles in adipogenesis, activins and BMP7 regulate energy expenditure by affecting the expression of genes that contribute to mitochondrial biogenesis and function. GDF8 signals through its own receptors during adipogenesis while antagonizing BMP7, an example of a ligand from one major branch of the superfamily regulating the other. With such intricate relationships that ultimately affect adiposity, TGF-β superfamily signaling holds considerable promise as a target for treating human obesity and its comorbidities.

Breast cancer in Iran: a review of 903 case records

A retrospective study was carried out in five main General District and Teaching Hospitals in Tehran (18 general surgical wards) to investigate breast cancer in Tehran, Iran. All patients who have had breast pathology during 1985-95 were reviewed. For each patient the following data were extracted from case records sex, age, type of disease (based on ICD-10 and ICD-O), breast cancer pathology, tumor size, lymph node involvement, pathological staging (based on TNM system), type of surgery, mass location and the affected side of breast. In all 3085 records were reviewed. Of these, in 903 cases the final diagnosis was breast cancer. The mean age of breast cancer patients was 47.1 (SD=12.3) y and the age-adjusted analysis showed that the observed number of breast cancer cases in the age group 40-49 was higher than expected (P<0.001). The majority of patients (71%) were patients with infiltrating ductal carcinoma, 70% had advanced disease (Stage III), and in 51% of cases the tumour was more than 5 cm in size. Finally it was found that two-third of patients (76%) underwent modified radical mastectomy. Although this study does not address true incidence, but rather frequency, the findings suggest that the Iranian breast cancer patients are relatively younger than their western counterparts and mostly have locally advanced disease. In terms of breast cancer screening programs, these findings have some implications for public health professionals in Iran.