Study of methacholine positivity in patients with chronic cough at Masih Daneshvari hospital, Tehran, 2007-2008.

While airways reactivity is among the characteristics of asthma, it is not considered a sufficient condition diagnostically and the methacholine challenge is a non-specific diagnostic aid in cases of chronic cough and reactive airways disease. The aim of this cross-sectional study was to determine the metacholine response positivity and diagnosis of asthma in patients with chronic cough presenting to a hospital in Tehran during 2007 and 2008. Of 101 patients with chronic cough (with no history of sinusitis, recent pulmonary infection, bronchitis, gasteroesophageal reflux or underlying pulmonary conditions), 51.5% showed reactive airways disease to the methacholine test, 40.6% were unreactive and 7.9% were indeterminate. A positive methacholine challenge test was positively correlated with new wheezing. Although the methacholine challenge test is not a primary test for evaluating chronic cough, if no other reason for chronic cough is found, it may be a guiding test for asthma.

Uterine myometrium as a cell patch as an alternative graft for transplantation to infarcted cardiac myocardium: a preliminary study.

PURPOSE: Currently, only a small fraction of patients are able to receive reperfusion therapy for myocardial infarctions. We hypothesize that myometrial cell patch transplantation could be an alternative approach for the treatment of myocardial infarction. DESIGN: We performed a preliminary study to determine the feasibility of this novel therapeutic approach in a rabbit model. PROCEDURES: Six adult female New Zealand rabbits were used. Myocardial infarction was induced by left anterior descending artery ligation. A segment of uterus was removed via a laparotomy incision, and this uterine segment was transplanted as an autologous graft over the infarcted myocardium, which was then reinforced by greater omentum. Statistical methods and outcome measures: Hemodynamic measurements and histological studies. MAIN FINDINGS: All uterine myometrial patches survived in the test animals. Fluoroscopic hemodynamic measurements were made for ejection fractions at 8 weeks after the application of the uterine patch. Histological study demonstrated well-healed myometrial-myocardium junctions with minimum scar tissue. Angiogenesis occurred in the transplanted myometrium. Connexin 43 expression was demonstrated in the transplanted patches. CONCLUSION: Our noncontrolled preliminary rabbit experiments indicate that patches of uterine myometrium reinforced by greater omentum can be used as autologous transplant therapy for infracted myocardium. This is an innovative technique that could lead to future treatment for individuals who may suffer from an infarcted myocardium and may not be eligible for traditional reperfusion therapy.

Leiomyosarcoma of iliac veins.

Although malignant neoplasm of the venous system is rare, leiomyosarcoma of large veins (predominantly the inferior vena cava) constitutes more than 75% of this condition. Symptoms are subject to tumor location and stenosis or obstruction of the venous system. This report describes the cases of two patients with leiomyosarcoma originating in large veins. Venography is extremely important for diagnosis, however computerized axial tomography with dye enhancement is helpful to depict the neoplastic nature of this condition. Excision and replacement with autogenous vein or artery will provide better long-term patency.

Vein valve transplant.

The sequelae of deep vein thrombophlebitis, such as postphlebitic syndrome with or without ulcer, can be treated by direct surgery on the valve. The present surgical treatment of stasis ulcer includes removal of the incompetent communicating veins with excision of the ulcer and skin graft. If this operation is performed on patients who actually have deep venous incompetence, then a high incidence of reulceration and skin graft slough may be expected if there is no concommitant correction of deep venous incompetence. Experimental studies to restore venous valve function such as autogenous vein valve transplant, valvoplasty, homologous vein transplant, and synthetic valve procedures have been tried. It has been shown that with autogenous vein graft there are a lower incidence of thrombosis and a more effective restoration of valve competency than with other procedures. We operated on six patients utilizing an autogenous vein valve from the upper extremity to achieve hemodynamically functioning venous system of the lower extremity. Data on pre- and postoperative noninvasive evaluations and ascending and descending venography with the results of surgery will be discussed.

Status of vein valve transplant after 12 months.

Sequelae of the postphlebitic syndrome can now be treated by direct valve surgery. However, present surgical treatment of stasis ulcer, including removal of the incompetent communicating veins, ulcer excision, and skin grafting, remains essential to patient care. When done alone, perforator interruption and ulcer care are effective but allow a high rate of ulcer recurrence. Experimental studies to restore venous valve function have included autogenous vein valve transplantation, and synthetic valve procedures also have been tried. Clearly, the patency rate of an autogenous vein graft is better than any other procedure. Operations were done in 11 patients using an autogenous vein valve from the upper extremity to restore a normal-functioning venous valve in the lower extremity. Data on preoperative and postoperative measurements and ascending and descending venography indicate hemodynamic improvement of venous function in these extremities.

Muscle changes in venous insufficiency.

The diagnosis of venous insufficiency and hypertension was established in 53 patients using standard diagnostic methods including ascending and descending venography, venous pressure measurements, and photoplethysmography. Autogenous vein valve transplant, which is gaining acceptance as a treatment for this condition, was employed in this group of patients to relieve venous valvular insufficiency. Biopsy specimens of the gastrocnemius muscle were obtained before surgery in all 53 patients and studied pathologically. Three types of morphologic injury were encountered, suggesting that disuse, denervation, and ischemia may each be partially responsible for damage in skeletal muscle subjected to venous insufficiency and hypertension. Skeletal muscle injury probably explains the preoperative elevations of serum creatine kinase levels in many of our patients and may account for the failure of venous pressures to return to normal levels following surgery.

Primary spinal extradural hydatid cyst.

We report a rare case of spinal cord compression caused by a primary extradural hydatid cyst.

Surgical treatment of postphlebitic syndrome with vein valve transplant.

Sequelae of the postphlebitic syndrome can new be treated by direct valve surgery. The present surgical treatment of stasis ulcer, including removal of the incompetent perforators, ulcer excision, and skin grafting, remains essential. Excision of perforators and ulcer care are effective but are associated with a high rate of ulcer recurrence. Experimental studies to restore venous valve function include autogenous or homologous vein valve transplantation, valvuloplasty, and valve transposition. In 23 cases of vein valve transplantation and two transpositions, a normal autogenous vein valve from the arm was used to restore a normal functioning venous valve in the leg. Pre- and postoperative noninvasive and invasive testing indicates hemodynamic improvement of venous function in these legs. Follow-up direct venous pressure measurements did not show normalization and may indicate that more than one competent valve is necessary. Changes in muscle structure may play a role in the maintenance of venous pressure.

Experimental prosthetic vein valve.

The incidence of venous insufficiency is increasing, approximately 800,000 new cases are reported yearly in the United States. Medical treatment of venous insufficiency syndrome has been associated with a high incidence of failure. Although vein valve transplantation has resulted in improvement in the majority of cases, late degeneration and incompetency of the valve prompted us to devise a prosthetic vein valve for experimental use. Ten dogs underwent insertion of a prosthetic vein valve without anticoagulants. Between 3 and 8 months after insertion, ascending and descending venography revealed patency and competency of these valves.

Vein valve transplantation.

The vein valve transplantation has, in our experience, subjectively relieved symptoms in the majority of patients. More importantly, elevated venous pressure has been decreased in most patients. Thus, patients exhibiting signs of venous insufficiency syndrome as well as elevated venous pressure and proved valvular incompetence should be considered candidates for vein valve transplantation after an unsuccessful trial of medical management.

Continuous ambulatory venous pressure for diagnosis of venous insufficiency. Preliminary report.

We have found that the venous pressure slope during minimal exercise is a sensitive measurement of venous disease. This parameter differed greatly in our two study populations. Due to increased venous pressure, venous insufficiency syndrome patients have a greater volume of pooled blood, which results in smaller pressure changes with each muscle contraction. In patients with incompetent valves, blood flows in a retrograde fashion in the vein, which leads to a higher steady state minimal pressure and notably to a decreased venous pressure slope. Venous pressure slope is a particularly sensitive measurement and a good prognosticator of venous insufficiency syndrome before symptoms become disabling to the patient. Our data indicate a strong correlation between venous pressure slope and venographic results. In fact, patients with abnormal venographic results invariably have demonstrated venous pressure slopes in the abnormal range.

Iliocaval compression syndrome.

Iliocaval compression syndrome is a significant disorder in a number of patients who have lower extremity venous complaints. The diagnosis may be suspected by positive findings on exercise strain gauge venous plethysmography and unilaterally increased ambulatory venous pressures. The diagnosis is confirmed by ascending and, in some instances, descending venography which demonstrates the iliocaval compression with or without intraluminal web formation. Transstenosis pressure gradients may be measured to confirm the hemodynamic significance of the lesion. We advocate direct operative repair of the iliocaval junction with rerouting of the iliac artery and excision of the iliocaval webs with cephalic vein patch angioplasty. It provided good results in the present study when coupled with an adjunctive regimen of perioperative subcutaneous heparin and warfarin. Further investigation into the exact prevalence and significance of the iliocaval compression syndrome is needed. Only an aggressive approach to patients with lower extremity venous complaints will help clarify the exact prevalence and natural history of this disorder.

External ventricular drainage and passive vs. active neurosurgical intervention in the management of hypertensive intracerebral hemorrhage with rupture into the ventricles.

The mortality rate of hypertensive intracerebral hemorrhages (HICH) with ventricular rupture (VR) has been said to range between 60 and 86%. We report on 33 consecutive cases of HICH associated with VR, which were diagnosed by CT and treated by external ventricular drainage (EVD). Sixteen hemorrhages were in the capsulolenticulostriate area, and 6 were in the posterior fossa. A modification of the usual system of severity grading for intraventricular hemorrhages (IVH) in posterior fossa bleedings is suggested. Extent of IVH correlated with neurological deficit on admission in 29 patients (87%) and with outcome in 26 patients (78%). Following passive neurosurgical policies in which the deterioration of patient's clinical situation indicates the craniotomy, only one intracerebral hematoma (ICH) was partially removed. Twelve patients (36.5%) died, and 12 of the survivors had no or only a minor neurological deficit. The results are compared with those of a series of patients, reported by Hayashi et al., who were treated according to active neurosurgical policies in which the largeness of ICH and IVH indicates the craniotomy, whereby it is concluded that active neurosurgical intervention does not reduce significantly the mortality and morbidity of HICH with VR. The pathophysiological explanation for this is discussed on the basis of a review of reference literature.

Uncommon causes of intraventricular hemorrhage.

The advent of CT has lead to discovery of a wide variety of unusual causes of intraventricular hemorrhage (IVH) and hence to the shifts in the proportional incidence of its different etiologies. From 96 patients with IVH, 7 uncommon cases of intracerebral hemorrhage (ICH) associated with IVH, including 2 due to anticoagulation treatment, 1 because of thrombolytic therapy, 1 due to thrombocytopenia, 2 as operative complications and 1 due to metastatic brain tumor are presented. In patients with blood disorders-related IVH the clinical presentation was similar to 'stroke in evolution', and the severity of IVH correlated with neurological deficit on admission and outcome of 3/4. All of the patients were treated with external ventricular drainage (EVD), 1 underwent partial evacuation of ICH in addition. 4 (57%) patients, including 3 with coagulation defect deceased. The peculiar aspects of uncommon causes of IVH are discussed on the basis of a review of the literature. The authors suggest that a standardized differentiated protocol should be adopted for the management of every uncommon type of IVH. An active attitude towards the evacuation of blood disorders-related ICHs and IVHs seems to be justified.

Superficial femoral vein transposition in Klippel-Trenaunay syndrome.

Use of a superficial femoral vein in competent profunda vein transposition is appropriate in selected cases of Klippel-Trenaunay syndrome; this allows for improvement of venous insufficiency and relief of symptoms secondary to venous stasis.

Indications and results of vein valve transplant.

Approximately 250,000 people are affected by postphlebitic syndrome each year in the U.S. Its pathogenesis is related to the incompetence of vein valves in the leg caused by thrombophlebitis and congenital redundancy. "Indications and results of vein valve transplant" discusses the correction of postphlebitic syndrome. Preliminary results of the vein valve transplant have been previously reported. This report updates the follow-up of 46 patients up to 3 years after the operation. The significance of muscle changes that occur with venous insufficiency is illustrated, and two new modalities of preoperative evaluation and postoperative follow-up are introduced.

Brachial jugular autogenous spiral vein bypass for obstruction of subclavian vein.

Recent advances in venous reconstruction allow the surgeon to bypass obstructive lesion of the venous system successfully. Because of low pressure and low velocity flow in the venous system, and adjunct temporary arteriovenous fistula appears to be essential for patency of the venous bypass. The existing data has shown that autogenous vein is superior to prosthetic material for bypassing venous obstruction. We are presenting a 44-year-old patient who has failed medical treatment and successfully been treated by this method.

Surgical treatment of venous insufficiency.

The incidence of venous insufficiency syndrome (VIS) is increasing. Although clinical findings will help for diagnosis of this condition, invasive and non invasive tests confirm the diagnosis. Thermodilution, a new and unique technique, appears to be the only test for diagnosis and decision making for treatment of this condition. Overloading and increase muscle work appear to be present in cases of VIS. Cases of failed medical treatment and findings of increased flow, with venography evidence of grade IV venous insufficiency are generally subjected to surgical treatment. Ninety-four cases of severe VIS have been operated on since July 1980 with 75% excellent results.

P31-NMR studies of muscle in patients with venous insufficiency.

Increased interest in venous insufficiency has generated investigators to look for new insights to the pathophysiology of this disease. Previous clinical experience has revealed a relationship between venous hypertension and muscle atrophy in this group of patients. Phosphorous nuclear magnetic resonance studies has been done on a group of venous insufficiency patients to discover the biochemical changes.

Genetic alterations in chronic venous insufficiency.

We have previously reported on the possible role of mitochondrial myopathy with altered respiratory chain function in patients with chronic venous insufficiency. The lymphocytes of twelve individuals, eight with venous insufficiency and four controls were evaluated. The patients were all failures of vein valve transplant, had angiographic grade IV venous insufficiency and biopsy proven type II muscle atrophy in both the upper and lower extremities. All lymphocyte samples underwent mitochondrial DNA (mDNA) restriction enzyme analysis with either Kpn I, Eco RI, Ban HI, and/or Pst I. The analysis of the digested mDNA was performed utilizing Tris/Acetate agarose submarine gel electrophoresis. The patient group demonstrated a 100 to 200 base pair deletion in the mDNA. This preliminary study identifies a possible chromosomal deletion in the human genome which may be responsible for the pathogenesis of chronic venous insufficiency.