3-in-1 Block with Bupivacaine VS Bupivacaine Plus Dexamethasone in Acute Pain Control for Patients Undergoing Hip Nailing Surgery: A Double Blind Randomized Controlled Trial

Background: Femoral 3-in-1 block is one of the most effective methods in cases of hip nailing surgery because of its ease, low cost, and fewer complications. This study aims to evaluate the effect of adding dexamethasone to peripheral nerve block solution.Methods: Forty-four ASA (I,II & III) patients aged between 50-80 years, scheduled for elective hip-nailing surgery who met inclusion and exclusion criteria were enrolled in this double blind randomized controlled trial. Patients were allocated into two groups randomly; at the end of the surgery, femoral 3-in-1 nerve block was performed with 40 ml of bupivacaine 0.25% solution with or without 8 mg dexamethasone. Pain score was measured for 24 hours.Results: We found no significant difference in pain intensity scores until hour 0.5 and the scores were below 1. Thereafter, the VAS scores increased, yet it remained below 3 in the first 12 postoperative hours. Morphine was administered during hours 12-24 in both groups, when VAS scores reached to about 4. The total amount of morphine consumption was a little lower in the case group, although the difference was not statistically significant. Conclusion: Adding dexamethasone to bupivacaine 0.25% for 3-in-1 block has no more benefit than bupivacaine 0.25% alone for acute postoperative pain management after elective hip nailing surgery

Reduction in labor pain by intrathecal midazolam as an adjunct to sufentanil / 대한마취과학회지

BACKGROUND: Anesthesia today has strived to decrease labor pain in a tolerable and controllable fashion. Intrathecal midazolam has been introduced as an adjunct to analgesics. The study was planned to assess the efficacy, safety and duration of analgesia produced by intrathecal midazolam adjunct to sufentanil in decreasing labor pain. METHODS: In a randomized clinical trial 80 parturient included in the study. The two groups were matched for age, cervical dilation, gravid, gestational age, and other demographic characteristics. Combination of sufentanil and midazolam administered intrathecally to experimental group and compared to sufentanil group. Time to reach maximum block, and pain score was measured and recorded. RESULTS: Groups were matched for age and weight and other demographic characteristic. No significant adverse effect was seen in both groups including decrease in Apgar score. Duration of analgesia was 92.0 +/- 12.7 in sufentanil group and 185.2 +/- 15.2 minutes in midazolam and sufentanil group which was significantly different (P = 0.002). Numeric rating scale score was significantly lower in midazolam group compare to sufentanil group at 120 min (P = 0.01), 150 min (P = 0.0014), and 180 min (P = 0.001). CONCLUSIONS: Intrathecal midazolam as an adjunct to opioid could significantly enhance analgesia in labor pain with no significant adverse effect. Intrathecal injection of midazolam is an appropriate alternative to parenteral or epidural analgesia in small hospital settings.

[Subclavian vein cannulation success or failure in neonates and children]

Central vein cannulation [CVC] allows administration of large volumes of fluids in short times and at high osmolaritiy for rehydration, volume replacement, chemotherapy and parenteral nutrition. Percutaneous central venous line insertion has replaced peripheral venous cut-down as the primary mode of short term venous access in children. 3264 subclavian vein cannulations in neonates and children were analyzed regarding successful attempt for catheterization and early complication rates after the procedure retrospectively. We had 1340 newborn patients [first 28 days of life] in our study population. In this group, only 55cannulations were failed, 1 patient were complicated with pneumothorax, in 21 cases guide wires became malfunction and only in 981 cases attempts to cannulation were successful in first attempt. In the remaining 1924 patients, 1 month to 8 years old, only 14 attempts to cannulation of subclavian vein was failed and in 1655 cases cannulation performed successfully at first attempt. CVC success rate was significantly higher in children older than 1 month compare to less than 1 month age [P=0.03]. Cannulation of central vein in neonates and children in a skilled hand would be performed with great success rate and low complications but in neonates less than 1 month age it has higher failure rate

Immunohistochemistry study in a case of nephrogenic adenoma of bladder

Nephrogenic adenoma is a rare benign lesion of bladder that may be confused with malignant lesions. There is a strong relation with urinary tract irritation and intravesicle instrumentations. Nephrogenic adenoma was initially thought to originate from urothelial metaplasia; however, no solid proof is available. We present a case of 55-year-old lady with urinary problem. Cystocopic examination showed a sessile mass, and biopsy revealed circumscribed proliferation of tubules, cysts, and papillae that were lined by low cuboidal to columnar epithelial cells. Nephrogenic adenoma can be a significant diagnostic pitfall due to the presence of certain histological features such as the presence of enlarged nuclei with prominent nucleoli. Immunohistochemistery study was strongly positive for CK7, P504S, CD10, and EMA, but negative for CK20, PSA, and P63

The Relationship Between Serum 25 Hydroxy Vitamin D Levels and Asthma in Children

PURPOSE: Asthma and other allergic disorders have increased over the past decades in nearly all nations. Many studies have suggested the role of vitamin D deficiency in both T-helper1 and T-helper2 diseases; however, the association between vitamin D, allergy, and asthma remains uncertain. In this study, the associations of 25-hydroxy vitamin D3 levels with asthma and with the severity of asthma were evaluated. METHODS: This cross-sectional study was conducted on 50 asthmatic children and 50 healthy controls aged 6-18 years. Serum 25-hydroxy vitamin D3 levels were determined and compared between the two groups. The relationship between serum vitamin D levels and pulmonary function test outcomes and eosinophil counts were examined in asthmatic patients. RESULTS: Univariate analysis of the relationship between asthma and vitamin D showed that decreased vitamin D levels were associated with significantly increased odds of asthmatic state (P=0.002). In a multivariate analysis after adjustment for age, body mass index, and sex, the relationship between vitamin D and asthma increased. In asthmatic patients, 25-hydroxy vitamin D levels had direct and significant correlations with both predicted FEV1 (R2=0.318; P=0.024) and FEV1/FVC (R2=0.315; P=0.026). There were no associations between vitamin D level and eosinophil counts, duration of disease, and the number of hospitalization or unscheduled visits in the previous year (P>0.05). CONCLUSIONS: These results showed that serum 25-hydroxy vitamin D levels were inversely associated with asthma, and there was a direct and significant relationship between vitamin D levels and pulmonary function test outcomes in asthmatic children. An interventional study in asthmatic patients with low serum vitamin D concentration may establish a causal relationship between asthma and vitamin D.

Para-aortic lymphadenopathy associated with Kawasaki disease

Kawasaki disease is an acute vasculitis that occurs mainly in children. Cervical lymphadenopathy is one of the major presenting manifestations of Kawasaki disease. We report a case of Kawasaki disease with para aortic lymphadenopathy, as an unusual feature in this disease. This 2.5 year old girl presented with persistent high grade fever, erythematous rash, bilateral non prurulent conjunctivitis, red lips, and edema of extremities. Laboratory results included an elevated erythrocyte sedimentation rate, leukocytosis, anemia, and positive C-reactive protein. On second day after admission she developed abdominal pain. Ultrasonography of abdomen revealed multiple lymph nodes around para aortic area, the largest measuring 12mmx6mm. Treatment consisted of aspirin and high dose intravenous gamma- globulin. Ultrasonography and CT scan of abdomen performed one week later showed disappearance of the lymph nodes. There are few previous reports of lymphadenopathy in unusual sites such as mediastinum in Kawasaki disease. Para aortic lymph nodes enlargement might be an associated finding with acute phase of Kawasaki disease. In these patients a close observation and ultrasonographic follow up will prevent unnecessary further investigation

Histopathologic findings of pneumatocele in a patient with hyper-IgE syndrome, compatible with cystic adenomatoid malformation

Hyper-immunoglobulin E syndrome is a rare primary immunodeficiency disease characterized by recurrent abscess formation, respiratory tract infections and very high titers of serum IgE associated with peculiar face and skeletal features. We report a seven-year old girl presenting with persistent productive cough and history of chronic eczematoid facial lesions since infancy and two episodes of hospitalizations due to pneumonia and perianal abscess. Additionally, in physical examination finger tip clubbing, laxity of joints and crackles in both lungs were detected. Immunologic work up revealed markedly raised IgE level and eosinophilia. The patient was diagnosed as hyper IgE syndrome based on his clinical and laboratory findings. Chest X-ray revealed multiple large cystic lesions in left lung which were confirmed by spiral CT-scan. Pneumonectomy specimen examination showed cystic adenomatoid malformation, characterized by the presence of various cysts lined by epithelium in different sizes. There are few reports of cystic adenomatoid malformation in children. To our best known, this is the first report of cystic adenomatoid malformation in a child with hyper IgE syndrome. Early diagnosis and surgical therapy are helpful in prevention of repeated infections in these patients

evaluation of new classification of allergic rhinitis in patients referred to a clinic in the city of Shiraz

Allergic rhinitis is the most common cause of allergic diseases. The recent guidelines of Allergic Rhinitis and its Impact on Asthma [ARIA] group, classified it to intermittent [less than 4 days per week and for less than 4 weeks] and persistent [more than 4 days per week or lasting more than 4 weeks regardless of the number of days per week]. The present study evaluates the patients with ARIA classification. The patients referred to Motahhari Clinic [Shiraz, Iran] were evaluated. Age, sex, seasonal or perennial, intermittent or persistent type, duration, sneezer or blocker, diurnal change and presence of allergic conjunctivitis were recorded. The patients who had one or more symptoms of; impairment of sleep, daily activity or work in school or troublesome symptoms had moderate to severe disease and those who did not have these problems have mild disease. The information of 96 patients [46 male and 50 female] were analysed [mean age +/- SD: 24.45 +/- 10.37 years]. The mean duration of disease was 4.26 +/- 4.12 years, was more in female [P<0.05]. Seasonal allergic rhinitis was presentxin 49 [52%] patients; 30 male, 19 female [P=0.007], perennial in 15 [16%], 1 male, 14 female and mixed type in 29 [30%]; 11 male, 18 female. Mild intermittent rhinitis was diagnosed in only 2 [2%] patients, 1 male and 1 female, mild persistent rhinitis in 23 [24%]; male 11, female 12; moderate/severe intermittent rhinitis in 4 [4%]; 3 male, 1 female; and moderate/severe persistent rhinitis in 56 [58%]; 22 male, 34 female [P<0.05]. Fifty-seven percent were more sneezer and 36% were more blocker type, sneezers suffered more in days and others more at nights. Others were both sneezer and blocker. Sixty percent had allergic conjunctivitis too, 76% of them were moderate/severe persistent, and 85% were in seasonal or mixed groups. Eleven patients [12%], in persistent group, had history of asthma. Family history of allergic rhinitis and asthma was found in 53% and 25% of patients, respectively. According to new guidelines for classification of allergic rhinitis, most of the patients are moderate to severe types. The classification of allergic rhinitis to seasonal and perennial disease is not proportional to intermittent and persistent types of classification

Hair loss as a sign of Kawasaki disease

Kawasaki disease is a multi system disorder with varying clinical expressions. This disease is an acute systemic vasculitis of unknown etiology that has recently recognized as a leading cause of acquired heart disease in children of many developed countries. We describe an unusual instance of hair loss in a patient with Kawasaki disease. A 26 months old boy developed prolonged high fever, bilateral conjunctival infection, arthralgia and erythromatosis skin rash. He was admitted to the hospital with the diagnosis of Kawasaki disease. Laboratory results included an erythrocyte sedimentation rate [ESR] above 100 and platelet count > 1000,000. The patient developed acute and unprovoked scalp hair loss. He was treated with intravenous immunoglobulin [IVIG] 2 g/kg and aspirin 100 mg/kg/day with complete improvement of signs and symptoms. This report documents hair loss as an uncommon presentation of Kawasaki disease

Cutaneous finding in anti thymocyte globulin induced serum sickness

Polyclonal anti-thymocyte globulin [ATG] is used as an immunosuppressive agent in the treatment of aplastic anemia [AA]. Serum sickness is a recognized side effect of ATG. We observed abnormal skin manifestation in patient with aplastic anemia who had been treated with ATG. We conclude that abnormal immune function caused by aplastic anemia and ATG and corticosteroids may aggravate the signs of serum sickness

Evaluation of the serum levels of immunoglobulin and complement factors in beta thalassemia major patients in Southern Iran

Beta-thalassemia major is one of the major health problems in our country. Many studies have confirmed the fact that, these patients have an increased susceptibility to bacterial infections. In this study, we have assessed the humoral immune system in 68 thalassemic patients by measuring their serum concentration of Immunoglobulin G [IgG], IgM, IgA, C3 and C4 in order to find out a responsible immune defect. Sixty eight beta-thalassemia major patients were enrolled randomly from referrals to Dastgheib clinic of thalassemia. The same number of case controls with matched age and sex were selected from healthy people without any history of recent or recurrent infections. Serum IgG, IgM, IgA, C3 and C4 levels were assessed using Single Radial Immunodiffusion [SRID]. Serum levels of IgG, IgM and IgA were significantly higher [P<0.01] and those of C3 and C4 were significantly lower [P<0.01] in thalassemic patients than the controls. Considering the result of analytic tests, it was revealed that, thalassemia patients show much more increase in serum immunoglobulin levels as they get older. Splenectomized patients had higher serum IgG and IgA levels than non-splenectomized patients but had no difference in serum IgM, C3 and C4. Serum ferritin level had no correlation with the changes of humoral immunity; however, patients with serum ferritin level >2500ng/ml had higher serum IgM level. These results can be due to continuous exposure to antigens, repeated infections, chronic liver disease and splenectomy but not iron overload. The only probable cause of humoral immune deficiency found in these patients is a defect in serum complement levels

Case Report: Churg-Strauss Syndrome in an 8-year-old girl

Churg-Strauss Syndrome [CSS] is a small vessel granulomatous vasculitis that characteristically affects the middle age group and is extremely rare in children. We describe an 8-year-old girl with a prolonged history of cough and eosinophila that initially was labelled as pulmonary tuberculosis, but after complementary assays, associated with skin biopsy, eosinophilic fibrinoid vasculitis, CSS was eventually diagnosed. In this case, due to her young age and more prevalence of infectious lung diseases in our area, there was a few months delay for correct diagnosis and treatment. After meeting the CSS criteria the appropriate treatment was started and her condition improved

Evaluation of asthmatic patients referred to Jahrom Hospital and Clinic

Asthma is the most common chronic respiratory disease of children in the world. Serial studies in the world have showed an increased prevalence of bronchial asthma. In this study, the children younger than 12 years old referred to Jahrom hospital and clinic due to asthma were selected. We issued 100 questionnaires, according to International Study of Asthma and Allergies in Childhood [ISAAC] criteria and were completed by the physicians. The ratio of male to female was 1 to 9. The patients who were under the age of 4, 3 and 1 year were 82%, 60% and 15% respectively. Passive smoking was present in 56% of the patients, and 22% had pets at home like cat, dog or bird. Home dampness was present in 33%. Ninety percent of patients had used breast feeding during the first year of life. Seventy percent of patients had family history of asthma. Food allergy was present and could trigger asthma in 15%. The result of ISSAC questionnaire showed that during the last year wheezing was present in 10%, 6% had 1-3 attacks and 4% had 4-12 attacks. Sleep disturbance by wheezing had occurred in 5% but cough in 16%. Thirteen percent of patients had wheezing after exercise. In Jahrom town the climate is warm and dry. In this town asthma in children is more common among the children who are younger than 4 years old. The risk factor like smoking at home, pets and home dampness should be eliminated from their environment

Anticardiolipin antibodies in juvenile rheumatoid arthritis and systemic lupus erythematosus

Antiphospholipid antibody syndrome [APS] can either occur as a primary syndrome or associated with other autoimmune diseases such as systemic lupus erythematosus [SLE]. Anticardiolipin antibody [aCL] of IgG and/or IgMisotype in blood, measured by a standardized ELISAis the most acceptable laboratory criteria. APS IgGisotype, particularly IgG2 subclass is more strongly associated with thrombosis. This study was done to determine the prevalence of IgG aCL and its subclasses in relation to APS symptoms, in a group of juvenile rheumatoid arthritis [JRA] and juvenile systemic lupus erythematosus [SLE] patients. In this prospective study, 28 JRAand 16 SLE patients, aged 3-18 years, were enrolled. IgG aCLwas assayed by standard aCL ELISA. IgG subclasses were also assayed by ELISA on sera with medium to high titers of aCL.ACL assay was performed on at least two occasions for each patient, over 3-6 months period of follow up. 29% [8/28] of JRApatients and 44% [7/16] of SLE patients had aCL. Six of SLE patients displayed APS related manifestations: hemolytic anemia, thrombocytopenia, arterial occlusion, valvular heart disease, livedo reticularis and pulmonary hypertension, but none of them had persistant medium or high titer of aCL. The lack of association of high titer of aCL with APS related symptoms was observed in two patients. The IgG subclasses were primarily IgG1 and IgG3. The prevalence of IgG aCL in this group of pediatric SLE and JRA is not uncommon but it's relation to clinical manifestations is not clear. IgG1 and IgG3 subclasses were not associated with thrombosis, which is in agreement with previous studies

prevalence allergic rhinitis among 11-15 Years-old children in Shiraz

Allergic rhinitis is one of the most common forms of allergic disorders affecting children. The prevalence rate of allergic rhinitis differs among countries and even among regions within the same country. To determine the prevalence of childhood allergic rhinitis and the presence and significance of eosinophilia in nasal secretions. 4584 children aged 11-15 years-old of both sexes with allergic rhinitis were studied. The study was done during a four-season period. After physical examination of the nose, smear was taken from nasal secretions and it was stained. The results compared with nasal smears related to 340 healthy children controls. 445 cases [9.7%] were diagnosed as having allergic rhinitis, on the basis of clinical criteria. Significant nasal eosinophilia was present in 274 [62%] of children with allergic rhinitis. 226 students [5.8%] of Shiraz school children had proven or classic allergic rhinitis. Allergic rhinitis is one of the major health problems among children in Shiraz. Eosinophilia of nasal secretions had a diagnostic specificity of 96% and sensitivity of 62%and seems to be having a moderate value as screening test for nasal allergy

Congenital lobar emphysema. Report of three cases

Congenital lobar emphysema is a rare cause of respiratory distress during infancy which is cured by surgery. We are reporting three cases of congenital lobar emphysema with different presentations of the disease. Chest x-ray was the basis of diagnosis but confirmatory lung computerized tomography was also used. The emphysematous lobe was left upper lobe in two infants and right upper and middle lobes in the third one. Resection of the affected lobes was performed with good results