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.

Study of methacholine positivity in patients with chronic cough at Masih Daneshvari hospital, Tehran, 2007-08

While airways reactivity is among the characteristics of asthma, 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.

Circulating soluble tumor necrosis factor receptor as a marker for diagnosis of pulmonary embolus.

The purpose of this clinical study was to determine the relationship between plasma soluble tumor necrosis factor receptor (T.N.F.R.) and pulmonary embolism. The histological evidence of the interaction between leukocytes and the venous wall of a thrombosed vein, as well as the over-production of TNF in plasma prompted us to assay a more stable polypeptide, namely TNF receptor, as potential markers for pulmonary embolism. Five mL of plasma were obtained from twenty patients, ranging in the age from 24 to 74 years, who had been diagnosed as having pulmonary embolism through pulmonary angiography, and 20 healthy volunteers in the same age group. The samples were then studied by enzyme-link immunosorbent assay (ELISA) for measurement of soluble TNF receptor. Patients with pulmonary embolism maintained a higher serum concentration of soluble TNF receptors. It appears that plasma measurement of soluble TNF receptor could be used as a clinical test for diagnosis of pulmonary embolism.

Diagnosis of pulmonary embolism by use of urinary TNF alpha and its soluble TNF receptor I.

The purpose of this clinical study was to determine the concentration of soluble tumor necrosis factor in urine of patients with pulmonary embolism (PE), verses voluntary control individuals. Sixteen patients (ages 24 to 74 years) with diagnosis of PE, documented by ventilation perfusion scan or pulmonary angiogram, were the subjects of this study. Ten cc of urine was obtained from each patient and subjected to a solid-phase enzyme-linked immunosorbent assay thus determining the soluble tumor necrosis factor (TNF) receptor I (R I) and TNF alpha levels in these samples. In this pilot study of PE cases, a statistically significant elevation in urinary levels of TNF alpha and soluble TNF R I was demonstrated in PE patients. The average urinary soluble TNF R I in normal subjects was 1,029 pg/mL and in PE patients the average TNF R I was 3,734.4 pg/mL. The clinical diagnosis of PE is a challenging problem for the physician. Late diagnosis and delayed management of this condition could be associated with massive PE. Although pulmonary angiography is the gold standard for diagnosis of PE, it requires expensive equipment, trained radiologists, and the patient could be at risk of sensitivity to contrast agents.

Diagnosis of deep venous thrombosis by use of soluble necrosis factor receptor.

The purpose of this clinical study was to find a relationship between soluble tumor necrosis factor (TNF) receptor, deep venous thrombosis (DVT), and pulmonary emboli (PE). Clinical diagnosis of deep venous thrombosis and pulmonary emboli is a major dilemma for the clinician. Most existing tests are technician dependent, are expensive, or require sophisticated equipment. Advances in molecular biology will permit investigation of the value of TNF receptor as a test for screening, diagnosis, and evolution of DVT and PE. Forty patients with diagnosis of DVT, documented by real-time ultrasound imaging, were the subject of this clinical study. Five cc of plasma from each patient was studied by enzyme-linked immunosorbent assay (Elisa) for measurement of soluble TNF receptor. Significantly increased concentration of plasma-soluble TNF receptor was present in patients with DVT as opposed to normal individuals. There was a close relationship between plasma concentration of soluble TNF receptor and evaluation of the disease. In this preliminary clinical study, it appears that plasma measurement of soluble TNF receptor could be used as a clinical test for diagnosis of DVT and PE.

Experimental prosthetic vein valve. Long-term results.

Chronic venous insufficiency is a disease that carries significant morbidity and represents a sizeable burden to the health care system. Current medical and surgical therapies are associated with a high incidence of failure. This has prompted the development of a synthetic vein valve for the treatment of chronic venous insufficiency. Nine dogs underwent the implantation of ten valves into the femoral veins. Initial studies showed the valves to be competent and patent. However, over a two-year period dense ingrowth of intimal hyperplasia rendered the valves functionless.

Early results with cryopreserved saphenous vein allografts for infrainguinal bypass.

PURPOSE: Cryopreserved saphenous vein allografts (CSVA) are available for use in arterial reconstructions; however, patency rates in the infrainguinal position are not well described. METHODS: We reviewed our experience with 38 patients who underwent 43 infrainguinal bypasses with CSVA as the conduit. The group includes 21 women and 17 men with a mean age of 69 +/- 11 years. Mean follow-up is 8.2 +/- 5.5 months. Logistic regression was used to analyze five variables in an attempt to identify predictors of success or failure: distal anastomosis to the popliteal artery versus a crural artery, one-vessel versus two- or three-vessel runoff, postoperative anticoagulation versus none, primary reconstructions versus reoperations, and one segment versus two segments of CSVA required. RESULTS: The cumulative patency rate at 12 months by life-table analysis is 66%. Logistic regression revealed that primary reconstructions were more likely to succeed than reoperations (p = 0.03) and operations completed with one segment of CSVA were more likely to succeed than those requiring more than one segment of vein (p = 0.03). CONCLUSIONS: We conclude that (1) the short-term patency of infrainguinal bypasses with CSVA suggests that they may be acceptable alternatives to prosthetic grafts in the below-knee position, and (2) primary reconstructions performed with one segment of CSVA are more likely to succeed.

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.

A complication of the Greenfield filter: fracture and distal migration of two struts--a case report.

This is a case report of a 41-year-old woman who required surgical removal of a Greenfield filter 7 months after placement. The filter developed several complications. Two struts were noted to be completely separated from the filter and lodged in the infrarenal vena cava. The filter had migrated to a resting position in the right renal, vein with two struts perforating the renal vein and inferior vena caval junction. The perforating struts were intraperitoneal and were found to impinge on the right ureter with seromuscular involvement of the second portion of the duodenum. No free perforation was noted at the time of exploration.

Surgical treatment of primary aortoduodenal fistula.

Primary aortoduodenal fistula is a rare and potentially fatal condition. Awareness of its existence, precise diagnostic evaluation, and early surgical intervention are essential for the survival of the patient. Although early experience indicated that interruption of the fistula, repair of the enteric defect, oversewing of the aorta and extraanatomic bypass was the procedure of choice, in situ aortic replacement with a prosthetic graft seems to be a viable option. This article includes a case report of a primary aortoduodenal fistula and review of the literature.

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.

Histopathology of veins and venous valves of patients with venous insufficiency syndrome: ultrastructure.

Vein and vein valve biopsies were obtained from venous insufficiency syndrome (VIS) patients undergoing venous valve transplants. Normal control biopsies were obtained from other non-VIS procedures. The specimens were examined using light and transmission electron microscopy (TEM). Biopsies from VIS patients showed a variety of changes from what was considered normal structure. Most histopathologic changes were noted in the endothelium and subendothelial layer of the vein valve and wall, and in the media of the vein wall. These changes included 1) erosion of the endothelium with consequent adherence of blood elements, 2) intact endothelium with a thickened subendothelial zone which was populated with migrated smooth muscle and perhaps other cell types, 3) occurrence of abnormal or over-abundant collagen, and 4) thickening of the media with changes in the smooth muscle population therein.

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.

Intraventricular hemorrhage due to rupture of arteriovenous malformations.

From 96 cases of intraventricular hemorrhage (IVH), 7 (7%) were due to rupture of arteriovenous malformation (AVM). 1 patient with a giant AVM had a primary IVH. Others had intracerebral hematoma (ICH) with rupture into the ventricular system. The severity of IVH (SIVH) correlated with neurological deficits on admission and with outcome of 6 (85%) patients and was considered as a reliable radiological prognostic indicator. 1 (14%) patient deceased and 4 (57%) survived with no or minor, 1 (14%) with moderate and 1 (14%) with major disability. Reviewing the literature, the conclusion is made, that in this relatively benign form of IVH, an active neurosurgical attitude regarding immediate evacuation of large ICHs and IVHs and if within reach AVMs is justified.

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.

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.

Primary spinal extradural hydatid cyst.

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

Experimental prosthetic vein valve.

Medical and surgical management of venous insufficiency syndrome (VIS) has produced disappointing results despite the recent introduction of new surgical techniques. This has prompted the investigation of a sutureless prosthetic vein valve. Ten prosthetic sutureless vein valves have been tested to date. The valves are of two types, one constructed of platinum, the other of titanium. Fourteen to eighteen months post-insertion into the femoral vein or vena cava of mongrel dogs, five valves remain patent as shown be venography. The sutureless prosthetic vein valve is a promising development in the treatment of venous insufficiency.

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.