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For almost all injecting drug users (IDUs), the first site of injection is the arm. Years after injection, IDUs may shift to using other sites for intravenous (IV) access. Although injection to sites other than the arm is associated with higher risks, literature is limited regarding this behavior. We aimed to determine the prevalence and associated factors of using IV access points other than the arm among a national sample of IDUs in Iran. Data came from the National Drug Dependence Survey, 2007, which had enrolled 863 IDUs with at least one daily injection. Data on socio-demographics, pattern of drug use, and injection-related behaviors were entered into a logistic regression to determine predictors of injection to sites other than the arm. From all participants, 54.8% reported current injection sites in areas other than the arm. The other injection sites were the femoral venous sinus (17.0%), followed by the groin (14.5%) and neck (11.5%). Logistic regression revealed that living alone [odds ratio (OR) = 1.789, 95% confidence interval (CI) = 1.218–2.629], being Sunni (OR = 3.475, 95% CI = 1.775–6.801), having higher family income (OR = 1.002, 95% CI = 1.001–1.003), higher age at first drug use (OR = 1.039, 95% CI = 1.009–1.069), longer injection duration (OR = 1.071, 95% CI = 1.041–1.102), and more injection frequency (OR = 1.255, 95% CI = 1.072–1.471) were associated with higher likelihood of using injection sites other than the arm. Using sites other than the arm for IV injection is linked to socio-demographics, drug use data, and injection-related characteristics that can be used by policy makers. This information can be used for harm reduction planning.

Background: Despite the popularity of kidney transplantation in the current era, second and third kidney transplantation are not yet widely accepted and practiced. Each center has its own regulations and experiences and there is no accepted protocol for third kidney transplantation. We report here our 15 years of experience with third kidney transplantation. Methods: This is a report of all the third kidney transplantations performed in Baqiyatallah Hospital, Tehran, Iran, between 1991 and 2006. Demographic data, surgical techniques, complications and outcomes are reported. Results: Of the nine third kidney transplant patients, six were male. The median age was 43 years (32-52). All of the patients received kidney from living donors. All operations were performed by a midline incision and the grafts were placed at the midline, in the intraperitoneal space. For arterial anastomosis, we used internal iliac, right common iliac and both the right external iliac and inferior mesenteric artery in 4, 4 and 1 case(s), respectively. For venous anastomosis, we used vena cava, common iliac and external iliac veins in 3, 5 and 1 case(s), respectively. During the follow up period (38 months), 6 grafts (66.6%) were functioning. None of the graft rejections were due to surgical complications. Wound dehiscence occurred in two patients. No other surgical complications including infection, lymphocele or hemorrhage were observed. Conclusion: Third kidney transplantation is a field that has not been fully explored. The rate of complications seems to be not much higher than the first transplantation. Defining a standard protocol seems necessary.

Background:Heparin has long been used to prevent thrombosis in the permanent central venous hemodialysis catheters (PermCath). Other alternatives for heparin with fewer side-effects have recently been considered. We compared normal saline (0.9%) with heparin for flushing PermCath with regards to catheter patency and prevention of heparin complications.Materials and Methods:Chronic kidney disease patients who were candidate of PermCath placement were randomly assigned into two groups of heparin and saline. In the heparin group, the PermCath was flushed with heparin (1000 IU), and in the saline group, it was flushed with saline 0.9%. Patients were followed for 24 hours, and outcomes included catheter thrombosis, maneuver needed to maintain catheter patency, and bleeding from catheter site.Results:Ninety six patients were included (age = 63.1 ± 11.2 years, 54.2% male). No one experienced catheter thrombosis. Two patient (4.2%) in the heparin and three ones (6.1%) in the saline group required catheter manipulation (P = 0.520). Four patients (8.5%) in the heparin and three ones (6.1%) in the saline group experienced bleeding (P = 0.476); differences between heparin and saline groups in the amount of bleeding (225.0 ± 62.4 vs. 200.0 ± 113.5 cc, P = 0.721) and bleeding time (6.5 ± 1.2 vs. 5.3 ± 1.5 min, P = 0.322) were not significant. In the heparin group, no significant increase was observed in PTT over time; baseline 30.9 ± 3.4, 12 h 31.8 ± 3.4, 24 h 31.2 ± 6.6 (P = 0.628).Conclusions:Flushing PermCath with normal saline 0.9% is as effective as heparin in maintaining patency of the catheter, while it may reduce the risks associated with heparin.

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International Journal of Case Reports and Images (IJCRI) is an international, peer reviewed, monthly, open access, online journal, publishing high-quality, articles in all areas of basic medical sciences and clinical specialties.Aim of IJCRI is to encourage the publication of new information by providing a platform for reporting of unique, unusual and rare cases which enhance understanding of disease process, its diagnosis, management and clinico-pathologic correlations.IJCRI publishes Review Articles, Case Series, Case Reports, Case in Images, Clinical Images and Letters to Editor.

Quadricuspid aortic valve is a rare anomaly, and most patients require surgery for aortic regurgitation in the 5th or 6th decades of life; only a few cases of aortic valve repair in childhood have been reported. A 3-year-old boy was scheduled for ventricular septal defect closure and aortic valve repair. Quadricuspid aortic valve was an incidental finding at operation; it was repaired by joining the left anterior and right anterior cusps. At the 9-month follow-up, the patient had no more than mild aortic regurgitation. We emphasize the importance of detecting this anomaly, especially in children with aortic valve regurgitation.

Background:This study was performed to compare the outcome and complications of axillobrachial and femorofemoral graft as upper and lower limb arteriovenous shunt prostheses.Materials and Methods:In a prospective cohort study, we observed and followed-up all cases with a new insertion of ePTFE between February 2006 and February 2009. Assessment of patency and the complication rates of their prostheses were the essential parts of this observation.Methods:In a prospective cohort study, we observed and followed-up all cases with a new insertion of ePTFE between February 2006 and February 2009. Assessment of patency and the complication rates of their prostheses were the essential parts of this observation.Results:A total of 69 grafts were performed. Forty-nine of them were successfully followed-up (18 femorofemoral and 31 axillobrachial grafts). Immediate primary patency was 100%. For axillobrachial type, primary patency at 1, 3, and 6 months, respectively, was 86%, 60%, and 47%. Secondary patency at 1, 3, and 6 months was 86%, 75%, and 50%, respectively. For femorofemoral type, primary patency at 1, 3, and 6 months, respectively, was 88%, 40%, and 34%. Secondary patency at 1, 3, and 6 months was 94%, 47%, and 41%, respectively. (P > 0.05) Complications included a puncture-site hematoma, thrombosis, infection, venous hypertension, need of an excision and pseudoaneurysm formation. Pseudoaneurysm rate difference between the two groups was interestingly significant, while others were relatively similar; however, the rates were different.Conclusion:The significant difference of aneurysm rate among our two groups, besides the insignificant difference of other complications and also the similar primary and secondary patency rates, manifest a brilliant guidance chart for the surgeons in order to choose the most compatible site for inserting ePTFE grafts (Gore-tex) as arteriovenous shunt prostheses for HD accessing.