Prevalence, characteristics, and risk factors of non-alcoholic fatty liver disease in North East of Iran: a population-based study.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is a common dietary disorder caused by fatty changes in the liver parenchyma and hepatocytes without alcohol consumption. The present study aimed to investigate the prevalence, characteristics, and risk factors of NAFLD in the Mashhad Persian Cohort Study population. METHOD: The present population-based cross-sectional study included all PERSIAN Organizational Cohort study in Mashhad University of Medical Sciences (POCM), Mashhad, Iran by census sampling method. Eligible participants were divided into two groups due to their NAFLD condition (NAFLD positive or NAFLD negative). All enrolled participants were evaluated based on their clinical aspects, anthropometric measures, laboratory tests, and ultrasound features. Statistical analysis was conducted using SPSS software version 16 (SPSS Inc., Chicago, USA -version 16). A P-value less than 0.05 was considered as the significance level. RESULTS: A total of 1198 individuals were included in the study, of which 638 (53.3%) were male and the rest were female. The mean age of the participants was 46.89 ± 8.98 years. A total of 246 patients (20.53%) were NAFLD positive, of which 122 (49.59%) were in grade 1, 112 (45.52%) were in grade 2, and 12 (4.87%) were in grade 3. The prevalence of fatty liver was significantly higher in males than in females (p < 0.001). There were significant differences between NAFLD positive and NAFLD negative participants in terms of having a history of hypertension (P = 0.044), body mass index (P < 0.001), body fat percentage (P = 0.001), waist circumference (P < 0.001), liver craniocaudal length (P = 0.012), fasting blood sugar (FBS) (P = 0.047), aspartate aminotransferase (AST) (P = 0.007), and alanine aminotransferase (ALT) (P = 0.001). Further analysis revealed a strong significant association between BMI, previous history of hypertension, higher levels of serum ALT, and NAFLD (P < 0.05). CONCLUSION: It can be concluded that ultrasound findings accompanied by laboratory AST and ALT level enzymes could be a cost-benefit approach for NAFLD early diagnosis. The craniocaudal size of the liver could be a beneficent marker for estimating the severity of the disease; however, more studies are recommended to evaluate this variable for future practice against the issue.

Multiple renal angiomyolipomas with asymptomatic nontraumatic pulmonary fat embolus: A case report.

Although retroperitoneal bleeding and massive hematuria are potential complications of angiomyolipoma (AML), the pulmonary embolism as a presenting symptom is extremely rare. It is important to be aware that benign AMLs can present with pulmonary fat embolism.

Oncogenic fusion transcript analysis identified ADAP1-NOC4L, potentially associated with metastatic colorectal cancer.

PURPOSE: Fusion transcripts are transcriptome-mediated alterations involved in tumorigenesis and are considered as diagnostic, prognostic, and therapeutic biomarkers. In metastatic colorectal carcinoma (mCRC), fusion transcripts are rarely reported. The main challenge is to identify driver chimeras with a significant role in cancer progression. METHODS: In the present study, 86 RNA sequencing data samples were analyzed to discover driver fusion transcripts. Functional assays included clonogenic cell survival, wound-healing, and transwell cell invasion. Quantitative expression analysis of epithelial-mesenchymal transition (EMT), apoptotic regulators, and metastatic markers were examined for the candidate fusion genes. Kaplan-Meier survival analysis was performed using patient overall survival (OS). RESULTS: A variety of driver fusions were identified. Fourteen fusion genes (51% of mCRC), each at least found in two mCRC samples, were determined as oncogenic fusion transcripts by in silico analysis of their functions. Among them, two recurrent chimeric transcripts confirmed by Sanger sequencing were selected. Positive expression of ADAP1-NOC4L was significantly associated with an increased risk of poor OS in mCRC patients. In vitro transforming potential for the chimera, resulting from the fusion of ADAP1 and NOC4L was assessed. Overexpression of this fusion gene increased cell proliferation and enhanced migration and invasion of CRC cells. In addition, it significantly upregulated EMT and anti-apoptotic markers. CONCLUSIONS: ADAP1-NOC4L transcript chimera, a driver chimera identified in this study, provides new insight into the underlying mechanisms involved in the development and spread of mCRC. It suggests the potential of RNA-based alterations as novel targets for personalized medicine in clinical practice.

Temporal changes of lung computed tomography findings pulmonary COVID-19 infection.

OBJECTIVES: COVID-19 infection demonstrates characteristic findings in chest CT. The optimal timing of repeated CT scans still needs to be clarified, and the optimal time to assess imaging clearance in COVID-19 is still unknown. It is crucial to have a roadmap of the imaging course of COVID-19 pneumonia to develop guidelines for prompt diagnosis of pulmonary complications, especially fibrosis, at the earliest stage. PURPOSE: To assess the temporal changes of chest CT findings in patients with COVID-19 pneumonia and evaluate the rate of a complete resolution and determine the patients are at excessive risk for residual parenchymal abnormalities. MATERIALS AND METHODS: This retrospective observational study included 48 patients with real-time polymerase chain reaction-confirmed COVID-19 who were admitted to three academic hospitals. These patients underwent at least one initial chest CT before or after admission and at least one follow-up CT scan four weeks or more after the onset of the symptoms. All chest CTs were categorized according to time of performance into four groups, including the first week, second week, third-fourth week, and more than 28 days. Lung involvement was categorized as predominantly alveolar (ground-glass opacity and consolidation), organizing pneumonia, and reticular patterns. The severity of involvement was also evaluated by the reader. RESULTS: Forty-eight patients and a total of 130 chest CT scans were evaluated. The alveolar pattern showed a gradual decrease in frequency from 91% in the first week to 9% after the fourth week of the disease but the organizing pneumonia pattern gradually increased with disease progression and the frequency of reticular pattern increased significantly after third week. Complete resolution of CT findings was seen in 17 patients (13.1%) and was significantly more prevalent in patients of younger age (p value<0.001) and with lower initial CT severity scores (p value=0.048). CT severity scores in the second week were significantly higher in ICU admitted patients (p value=0.003). CONCLUSION: There are temporal patterns of lung abnormalities in patients with COVID-19 pneumonia. The predominant CT pattern was alveolar infiltrate in the first and second weeks of the disease, replaced with an organizing pneumonia pattern in the third and fourth weeks. Progression of lung involvement was correlated with ICU admission due to the highest CT severity score in the second and third weeks of presentation but not in the first week in patients who were admitted at ICU. Complete CT resolution was significantly more common in patients of younger age and lower initial CT severity scores.

Evaluation of Normal Renal Size and its Influencing Factors: A Cross-Sectional Study on the Adult Population of Mashhad.

Background: The normal range of kidney size is a controversial issue among different populations given to its impressibility by multiple factors, therefore, this study aimed to provide valid reference ranges for kidney dimensions in the adult population of Mashhad. Also, we assessed the association of kidney size characteristics with some personal predisposing factors. Methods: This cross-sectional study was conducted on 938 healthy individuals. Ultrasound measurement, physical examination, and laboratory analysis were performed. Demographic, dietary, and anthropometric data were obtained. The variables were categorized into 5 groups each, and data analysis were performed using the following statistical tests: Pearson correlation test, variance analysis, t-test, and chi-square test. A value of p<0.05 was considered statistically significant. Results: Weight had the most association with kidney size followed to a lesser extent by height and age. Even after adjustment for other confounding variables, weight remained as an independent factor, while this effect was resolved for height and age. Also, all values for renal function, body bio-impedance, blood pressure components, and water intake were notably correlated with kidney size. Conclusion: This study determined the normal kidney size in healthy adults. We also declared the normal range of kidney size is a dynamic concept and should be assessed for each individual separately according to their personal determinative factors.

Decreased Pulmonary Artery Bifurcation Angle: A Novel Imaging Criterion for the Diagnosis of Chronic Pulmonary Thromboembolism.

Background: Chronic pulmonary thromboembolism (CTEPH) is an unusual complication of acute pulmonary embolism (PE), which is now considered to be treatable. In modern multi-detector scanners, a detailed evaluation of pulmonary artery geometry is currently possible. This study aimed to evaluate the changes in pulmonary artery bifurcation angle (PABA) in the follow-up computed tomography angiography (CTA) of patients with acute PE. Methods: In this cross-sectional study, the records of two tertiary-level academic hospitals were gathered from 2012 to 2019. Pulmonary artery (PA) bifurcation angle and diameter were measured. Chi square test, independent samples t test, Mann-Whitney, and Pearson's tests were employed to compare data. To evaluate the cut-off point, we utilized receiver operating characteristic (ROC) curve analysis. The accuracy, sensitivity, and specificity of pulmonary artery bifurcation angle changes were calculated. A P value <0.05 was considered to be significant. Results: Forty-six patients were included in the study. No significant differences were found between patients with and without CTEPH, and PABA in the dimeters of PA trunk, right PA, and left PA in the first CTA images (P values of 0.151, 0.142, 0.891, and 0.483, respectively), while in the secondary CTA, the mean PABA was significantly smaller in patients with CTEPH (P=0.011). In the receiver operating characteristic (ROC) analysis, delta angle revealed an area under the curve of 0.745 and an optimal cutoff of 0, leading to a sensitivity of 64%, specificity of 87%, and accuracy of 76% for diagnosing CTEPH. Conclusion: We showed a significant decrease in PABA in patients developing CTEPH. This parameter can be easily measured in lung CTA.

Relationship between the prevalence and severity of non-alcoholic fatty liver disease and coronary artery disease: Findings from a cross-sectional study of a referral center in northeast Iran.

Background and Aim: Non-alcoholic fatty liver disease (NAFLD) is becoming increasingly prevalent worldwide, and cardiovascular diseases are the most common cause of death in NAFLD patients. The present study aimed to evaluate the possible relationship between the presence and severity of NAFLD and coronary artery disease (CAD). Methods: A cross-sectional study was conducted on 296 patients (122 men and 174 women, with mean age 54.10 ± 9.33 years) referred to the catheterization laboratory of Imam Reza Hospital affiliated to the Mashhad University of Medical Sciences, Mashhad, Iran, for elective coronary angiography to investigate the presence and severity of CAD. Additionally, all patients underwent abdominal ultrasonography (USG) to detect NAFLD and its severity. Results: Among the 296 patients, 187 (63.2%) had CAD and 160 (50.1%) had NAFLD. NAFLD patients had significantly higher prevalence of obesity (odds ratio [OR] = 1.047, 95% confidence interval [CI] = 1.002-1.094), hypertension (OR = 1.909, 95% CI = 1.027-3.55), hyperlipidemia (OR = 3.474, 95% CI = 1.862-6.482), and CAD (OR = 2.009, 95% CI = 1.100-3.669). The percentage of patients with normal vessels was higher in the non-NAFLD group, followed by the group with mild and severe NAFLD (P < 0.001). However, single- and multi-vessel disease incidences among the non-NAFLD, mild, and severe NAFLD groups were 36.1, 43.1, and 63.7%, respectively. Interestingly, the percentage of patients with two-vessel stenosis was significantly higher in severe NAFLD patients than mild and non-NAFLD patients (P < 0.001). Conclusion: The prevalence and severity of NAFLD were independently associated with CAD. Mild NAFLD was primarily observed among patients with normal and non-obstructive coronary artery patients, while severe NAFLD was more frequent in extensive CAD patients with multi-vessel disease.

Evaluation of the relationship between inpatient COVID-19 mortality and chest CT severity score.

OBJECTIVES: There is scarce data available on the prognostic application of chest CT. The main purpose of this study was to evaluate the performance of a semi-quantitative CT severity score in identifying the risk of mortality in COVID-19 patients. METHODS: This retrospective cohort study was performed on 262 hospitalized COVID-19 patients. The CT severity score was assessed by two independent radiologists using a method previously used to score the severity of acute respiratory distress syndrome on thin slice lung CT. RESULTS: Multivariate regression analysis showed increasing odds of in-hospital death associated with older age, and the presence of coronary artery disease at the time of admission. The mean CT severity score was 7.5 in the survivor group and 14.5 in the deceased group. Overall, the lower zones were the most frequently affected sites in COVID-19. There was significant difference between the survivor and deceased groups regarding CT severity scores. Multivariate regression analysis showed increasing odds of in-hospital death associated with higher CT severity score at admission. CONCLUSIONS: Our results show that mortality was significantly higher in patients with higher CT severity score even after adjustment for clinical, demographics and laboratory parameters. However, this study is performed retrospectively and needs to be validated in a prospective study.

A Multicenter Survey on the Trend of Chest CT Scan Utilization: Tracing the First Footsteps of COVID-19 in Iran.

BACKGROUND: Chest computed tomography (CT) scan has been used widely to diagnose COVID-19 in Iran. OBJECTIVES: To trace the footsteps of COVID-19 in Iran by exploring the trend in using chest CT scans and its economic impact on radiology departments. Methods: In this cross-sectional study, the number of imaging examinations from 33 tertiary radiology departments in 9 large cities of Iran was collected from September 23, 2019 to March 20, 2020 (Months 1 to 6) and the corresponding months in 2018-2019. RESULTS: A 50.2% increase was noted in the chest CT scan utilization in 2019-2020 compared to 2018-2019. This increase was +15%, +15%, +27%, +2%, +1% in Months 1-5 of 2019-2020, respectively. In Month 6 of 2019-2020, a 251% increase in the acquisition of chest CT scans was observed compared to the Month 6 of 2018-2019. Following negative balance of revenue from Month 1 to 5 with respect to the inflation rate, the total income in Month 6 was further 1.5% less than the same Month in 2018-19. CONCLUSION: The observed peak in chest CT utilization in Month 3 prior to the surge in Month 6 could be explained by the seasonal influenza. However, unawareness about an emerging viral disease, i.e. COVID-19, might have underutilized chest CT in Months 4 and 5 before the official announcement in Month 6. The unbalanced increase in the workload of radiology departments in the shortage of cardiothoracic radiologists with the simultaneous decrease in income initiated a vicious cycle that worsened the economic repercussions of the pandemic.

Pain in percutaneous liver core-needle biopsy: a randomized trial comparing the intercostal and subcostal approaches.

PURPOSE: Effective pain control during and after percutaneous core needle liver biopsy is important with regard to ethical considerations and patient comfort. In this randomized double-blind study, we compared post-biopsy pain in the patients undergoing liver core-needle biopsy using either subcostal or intercostal approaches. METHODS: All patients referred for ultrasound-guided CNLB between July 2017 and January 2018 to our interventional radiology department were randomized into two groups. Biopsy was performed through intercostal approach in the first group and through subcostal approach in the second group. The intensity of pain 0, 2, and 4 h after the procedure was compared in two groups using a 100-mm visual analogue scale. All biopsies were performed without procedural IV sedation. If patients' discomfort  demanded administration of IV analgesics during or after the procedure, then the patients were excluded from the study. RESULTS: In patients without routine procedural IV sedation, there was no significant difference in the pain level between the intercostal and subcostal groups immediately after the procedure (p = 0.055), but we found a significant difference in the pain level between the two groups 2 (7.5 mm, p = 0.001) and 4 (2 mm, p = 0.001) h after the procedure. CONCLUSION: The minimum amount of change in the VAS score that is considered clinically important is 13 mm on a 100-mm scale. Pain differences at 2 and 4 h in the two groups in this study were statistically but not clinically significant. Therefore, the authors suggest the use of subcostal route for ultrasound-guided liver biopsy whenever possible, but the results do not warrant the routine use of post-procedure analgesics in whom biopsy is performed via intercostal route.

Impact of Propranolol on Preventing Renal Dysfunction in Patients with Cirrhosis.

BACKGROUND One of the earliest diagnostic signs of hepatorenal syndrome in patients suffering from liver cirrhosis is an increase in the renal vascular resistive index (RI). In this study, the impact of propranolol on decreasing this index and to postpone the probability of hepatorenal syndrome has been investigated. METHODS In the current research, 30 patients with liver cirrhosis with different age and sexes have been enrolled. Demographic data and complete medical history have been collected using a specific questionnaire. At first, renal artery Doppler ultrasonography was performed to determine the RI. The patients were then treated with propranolol, and under supervision, the dose of the drug was increased gradually every 3 to 5 days to reach the target of 25% decrease in resting heart rate. One month after reaching the target dose of the medicine, Doppler ultrasonography was repeated for the patients and the second RI was compared with the pretreatment ones. RESULTS According to our results after treatment with propranolol, a significant decrease of RI was observed (p < 0.01). However, there was no significant difference in the glomerular filtration rate (GFR) before and after treatment with propranolol (p = 0.290). In our study, we found that administering propranolol was associated with significant changes in RI and GFR between the patients with compensated and decompensated cirrhosis (mean change: -0.005 ± 0.017 vs. -0.058 ± 0.045; p < 0.01 for RI and -4.226 ± 17.440 vs. 13.486 ± 12.047; p < 0.01 for GFR in patients with compensated and decompensated cirrhosis, respectively). CONCLUSION Propranolol reduces renal vascular RI in patients with cirrhosis. The response rates in the patients with decompensating cirrhosis were significantly higher than the patients with compensating cirrhosis.

Hemorrhagic Colloid Cyst Presenting with Acute Hydrocephaly.

Colloid cysts are benign slow-growing cystic lesions located on the roof of the third ventricle that usually present with symptoms related to gradual rise of intracranial pressure. They mostly remain asymptomatic and sometimes grow progressively and cause diverse symptoms associated with increased intracranial pressure such as headache, diplopia, and sixth cranial nerve palsy. Here we report a 47-year-old female who presented to the emergency department with acute severe headache and nausea/vomiting. On MRI examination acute hydrocephaly due to hemorrhagic colloid cyst was detected. Acute hemorrhage in colloid cysts is extremely rare and may present with symptoms of acute increase in the intracranial pressure. Intracystic hemorrhage is very rarely reported as a complication of colloid cyst presenting with paroxysmal symptoms of acute hydrocephaly.

Association between clinical and sonographic synovitis in patients with painful knee osteoarthritis.

AIM AND OBJECTIVE: To evaluate the association between ultrasonographic findings of inflammation (effusion, synovitis) and clinical findings in patients with primary painful knee osteoarthritis. METHOD: This cross-sectional study was performed on 142 patients with primary painful knee osteoarthritis (American College of Rheumatology criteria) in whom the visual analogue scale of pain was 30 or more. Clinical parameters were evaluated by a rheumatologist using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score while the ultrasonographic examination was performed by a musculoskeletal radiologist in our center. Knee joint synovitis and effusion were defined as synovial thickness ≥ 4 mm and depth of fluid in the suprapatellar recess ≥ 4 mm, respectively. RESULTS: Sixty-eight (47.9%) patients demonstrated neither synovitis nor effusion, 37 (26.1%) had only effusion, 11 (7.7%) had only synovitis and 26 (18.3%) had both effusion and synovitis in the ultrasonographic examination. There was significant association between ultrasonographic knee arthritis (defined as presence of synovitis or effusion) and WOMAC pain sub-score, WOMAC physical function sub-score and WOMAC total score. No significant association was noted between sonographic signs of arthritis and WOMAC joint stiffness sub-score. We also found significant correlation between ultrasonographic synovitis and WOMAC pain sub-score (P < 0.001), WOMAC physical function sub-score (P < 0.001) and total WOMAC score (P < 0.001). CONCLUSION: This study revealed a positive correlation between ultrasonographic synovitis and total WOMAC score, WOMAC pain and physical function sub-score. There was no association between sonographic signs of arthritis and WOMAC joint stiffness sub-score.

Effect of saffron on liver metastases in patients suffering from cancers with liver metastases: A randomized, double blind, placebo-controlled clinical trial.

OBJECTIVE: Cancer represents the second cause of mortality in the world. Saffron as a medicinal plant is known for its anti-cancer and anti-depressant properties. In this randomized double blind clinical trial, the effects of saffron on response to treatment in patients suffering from liver metastasis were evaluated. MATERIALS AND METHODS: Thirteen patients suffering from liver metastases who referred to Ghaem and Imam Reza hospital, Mashhad, Iran were included in this study and then divided into two different groups. Both groups received chemotherapy regimen. Patients in group one were treated with saffron capsule (50 mg, twice daily) during chemotherapy periods whereas patients in group two received placebo. A sum of the longest diameter were calculated and compared for all lesions in IV contrast CT scan before and after the treatment. RESULTS: from 13 patients included in this study, six patients quit and seven continued until the end. In saffron-treated group, two patients showed partial and complete response (50%) whereas in placebo group, no response was seen. Also, two deaths in placebo and one in saffron group occurred. CONCLUSION: This research suggests that saffron might be useful in patients suffering from liver metastasis. However, further investigations with larger sample size are required.

Hepatic alveolar echinococcosis.

 Alveolar hydatid disease is a highly malignant form of echinococcosis caused by the larvae of the cestode echinococcus multilocularis. Alveolar hydatid disease always affects the liver and can metastasise to the lung and brain. Early diagnosis and precise evaluation of the localization as well as the extent of lesions are essential for treatment. In this report, we present ultrasound and computed tomography findings in a patient with hepatic alveolar echinococcosis. The patient, who was presented with hepatomegaly, jaundice, and an infiltrative solid tumor, diagnosed by ultrasound and computed tomography. In contrast to hydatid cyst caused by echinococcus granulosus, this is a rare disease in Iran.

Comparing color Doppler ultrasonography and angiography to assess traumatic arterial injuries of the extremities.

BACKGROUND: Traumatic events are one of the major causes of arterial injuries. Physical examination is not a good predictor of the extent of injuries and arteriography is considered as the gold standard for this purpose. In the recent years, noninvasive modalities are increasingly replacing diagnostic arteriography. Color Doppler ultrasonography (USG) is an excellent method to investigate arterial diseases. OBJECTIVES: The present study aimed to evaluate the diagnostic value of color Doppler USG compared to conventional angiography in traumatic arterial injuries of extremities. PATIENTS AND METHODS: Seventy-five patients with extremity trauma suspicious for arterial injury were examined by color Doppler USG just before angiography. Doppler pattern and flow states were assessed, then angiography was performed. The results of duplex USG were compared with angiography. RESULTS: Color Doppler USG had a sensitivity of 95% and specificity of 98% in diagnosis of arterial injury. Positive and negative predictive values of Doppler USG were 92.5% and 94.2%, respectively. CONCLUSIONS: Color Doppler USG can be used as a reliable modality with acceptable sensitivity and specificity values to screen hemodynamically stable patients with limb trauma suspicious for arterial injury.

Effects of Intravenous and Catheter Directed Thrombolytic Therapy with Recombinant Tissue Plasminogen Activator (Alteplase) in Non-Traumatic Acute Limb Ischemia; A Randomized Double-Blind Clinical Trial.

OBJECTIVE: To evaluate the efficacy and safety of intravenous and catheter directed thrombolysis by recombinant tissue plasminogen activator (Alteplase) in the patients with non-traumatic acute limb ischemia (ALI). METHODS: This was a randomized clinical trial being performed between 2009 and 2011 in Mashhad University of Medical Sciences. We included those patients who were<75 years, with symptoms of less than 14 days duration, ALI of grade IIa and IIb (according to Rutherford classification) and absence of distal run off. Baseline assessment of peripheral circulation performed in all the patients. Patients were randomly assigned to undergo intravenous (n=18) or catheter directed thrombolysis (n=20) with Alteplase. The primary endpoint of the study was improvement of clinical status measured by Rutherford classification, ankle brachial index (ABI), visual analogue scale (VAS) score measured at 1, 3 and 6 months. The secondary endpoint of the study was complete or near complete recanalization of the occluded artery. RESULTS: A total number of 38 patients with mean age of 54.13±13.5 years were included in the study. There were 23 (60.5%) men and 15 (39.5%) women among the patients. Overall 3 (7.9%) patients had upper and 35 (92.1%) lower extremity ischemia. There was no significant difference between two study groups. None of the patients experienced major therapeutic side effects. Both ABI and VAS score improved in patients who have received first dose of t-PA within 24-hourof ALI. There was no significant difference between two study groups regarding the 6-month clinical grade (p=0.088), VAS score (p=0.316) and ABI (p=0.360). The angiographic improvement was significantly higher in CDT group (p<0.001). CONCLUSION: Intravenous and catheter directed thrombolysis with t-PA is a safe and effective method in treatment of acute arteriolar ischemia of extremities. However there both intravenous thrombolysis and CDT are comparable regarding the clinical outcome.

Chronic hemodialysis access-induced distal ischemia (HAIDI): distinctive form of a major complication.

PURPOSE: Hemodialysis access-induced distal ischemia (HAIDI) is an uncommon but potentially devastating complication. HAIDI is classified as acute, subacute and chronic based upon the time of onset. The aim of this study was to determine the prevalence, severity, patients' characteristics and the underlying etiologic mechanism of chronic HAIDI using color Doppler ultrasonography (CDUS). METHODS: Between June and August 2010, 676 hemodialysis patients with arteriovenous access (AVA) were evaluated for clinical evidence of chronic HAIDI. In the case-control part of the study, CDUS findings were compared between ischemic patients and asymptomatic matched controls. Also, patients with chronic HAIDI were followed up until February 2014, access ligation, kidney transplantation or death. RESULTS: Eighteen chronic HAIDI patients were diagnosed (2.66%). Cold hand and cold sensation were the most common signs and symptoms of hand ischemia, respectively. Fifteen patients were classified in stage 1. Patients with proximal autogenous arteriovenous fistula, younger age, more previous AVAs and less access age were more likely to develop chronic HAIDI. Excessive fistula flow was found in the majority of ischemic patients (83.3%). The mean fistula flow was significantly higher in cases compared to controls (p=0.001). Eleven patients with chronic HAIDI were successfully treated by conservative measures alone until the end of follow-up (n=3), kidney transplantation (n=4) or death (n=4). CONCLUSIONS: CDUS is a useful adjunctive diagnostic tool to determine the etiology of chronic HAIDI. Conservative measures combined with close follow-up can be used as the first step in the management of chronic HAIDI patients with mild symptoms.

Moyamoya disease mimicking encephalitis.

Moyamoya disease is a rare vaso-occlusive illness with an unknown etiology characterized by stenosis of the internal carotid arteries with spontaneous development of a collateral vascular network. A 15-month-old girl was referred to the emergency ward of Imam Reza Hospital due to decreased level of consciousness, focal seizures and fever during the previous 24 hours with an impression of encephalitis. Physical examination revealed left side hemiparesis; however brain CT-Scan did not show any significant lesions. Initial therapy with vancomycin, ceftriaxone and acyclovir was administered. CSF analysis did not show any abnormality and the blood as well as CSF cultures results were negative. Brain MRI showed hyperintensity at right frontal and parietal regions, suggesting vascular lesion. Magnetic resonance angiography (MRA) showed bilaterally multiple torsions in vessels at the basal ganglia consistent with moyamoya vessels. In all children exhibiting encephalitis, vascular events such as moyamoya disease should be considered. Brain MRI is a critical tool for this purpose. Common causes of encephalitis such as herpes simplex should also be ruled out.

Evaluation of the incidence of complications of lost gallstones during laparoscopic cholecystectomy.

BACKGROUND AND AIM: Recently, an increasing number of reports in the literature have shown various complications of lost gallstones. This study aimed to evaluate patients with lost stones in the peritoneal cavity for any related complications for at least 12 months after the operation. MATERIALS AND METHODS: In a 3-year prospective study, of 900 patients with laparoscopic cholecystectomy, 50 patients with lost stones in the peritoneal cavity were enrolled as the case group. On the same day or the day after, an uncomplicated case was assigned to the control group. Postoperative complications were checked on the 10th day and 1, 6, and 12 months after surgery. They were also visited if they had any complaints at any time. All suspicious cases and also all patients in the last follow-up visit underwent abdominal ultrasonography and were observed for signs of abdominal and port site collections, abdominal and port site stone, abscess, and mass. RESULTS: In 50 cases (34 female and 16 male with a mean age of 59 y), the surgeon was doubtful about proper stone extraction. The mean duration of operation for patients with a ruptured gall bladder was 49.6+30.3 minutes, and in others, it was 27.9+11.7 minutes. During the early postoperative period, fever was detected in 3 (6%) patients in the case group and in 1 (2%) patient in the control group, which was resolved spontaneously. Postoperative pain on the 10th and the 30th days, unrelated to the lost stone, was resolved with analgesics. Abdominal collection was found in 8 (16%) patients in the case group and 5 (10%) patients in the control group, which was not significant. All these patients underwent ultrasonography-guided percutaneous aspiration. The aspirate was serous, and the patients' clinical findings were not clinically significant. CONCLUSIONS: According to the study, serious complications related to the lost stones indicate prophylaxis as the best therapeutic approach for such patients. The patients should be informed about lost stones and their possible complications. Also, conversion to open surgery is not advised.