Toll-like receptor family (TLRs), pattern recognition receptors, is expressed not only on immune cells but also on non-immune cells, including cardiomyocytes, fibroblasts, and vascular endothelial cells. One main function of TLRs in the non-immune system is to regulate apoptosis. TLRs are the central mediators in hepatic, pulmonary, brain, and renal ischemic/reperfusion (I/R) injury. Up-regulation of TLRs and their ligation by either exogenous or endogenous danger signals plays critical roles in ischemia/reperfusion–induced tissue damage. Conventional TLR-NF-κB pathways are markedly activated in failing and ischemic myocardium. Recent studies have identified a cross talk between TLR activation and the PI3K/Akt pathway. The activation of TLRs is proposed to be the most potent preconditioning method after ischemia, to improve the cell survival via the mechanism involved the PI3K/Akt signaling pathway and to attenuate the subsequent TLR-NF-κB pathway stimulation. Thus, TLRs could be a great target in the new treatment approaches for myocardial I/R injury.

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The side effects of heparin include hemorrhage, osteoporosis, telogen effluvium, hypoaldosteronism, hypersensitivity reactions (urticaria and anaphylactic shock), hypereosinophilia, vasospastic reactions (pain, cyanosis and severe itching or burning plantar sensations), erythematous infiltrated plaques, skin necrosis and thrombocytopenia [1].Stevens-Johnson Syndrome (SJS) is a life threatening cutaneous adverse drug reaction. The incidence of SJS is evaluated from one to two cases per million person-years [2]. We hereby report SJS as a rare complication of heparin.A 61-year-old married woman, from central Iran was hospitalized due to acute pancreatitis and pancreatic abscess. Heparin prophylaxis was initiated, subsequent to which mucocutaneous lesions appeared [Table/ Fig-1]. Dermatology consultation was done and the required treatment was started.The patient had a history of diabetes mellitus, hypothyroidism and hypertension. She received tablet prednisolone 50 mg 1/2 bid, tablet metoprolol 50 mg bid, tablet lorazepam 2 mg 1/2 qhs, tablet alprazolam 0.5 mg daily.For the present condition, fluconazole and pantoprazole were prescribed. She was irritable, had insomnia, persecutory and visual hallucinations because of severe lip and oral mucosa burning. Psychiatric consultation was requested for delirium. The patient had a history of insomnia without mood or psychotic disorder. The psychiatrist prescribed tablet doxepin 25 mg/every night, tablet chlorodiazopoxide 10 mg/12 hourly, and tablet halopridol 0.5 mg/8 hourly. The patient responded favourably to drugs. Naranjo score was 9 in our case. Irritability decreased significantly and the patient was able to get adequate sleep. She was discharged after 48 hours with a good general condition. The skin. Eur J Intern Med. 2016;28:17-24. REFERENCES

Cutaneous actinomycosis of finger is very unusual, chronic granulomatous disease caused by a group of anaerobic or microaerophilic Gram-positive filamentous bacteria that normally colonize the mouth, colon and urogenital tract. Actinomycosis of finger is rare but clinically important condition that requires suitable evaluation for guiding appropriate therapy. We hereby report a case of cutaneous actinomycosis of the right finger- a rare site, in a 34-year-old female patient which underwent usual treatment of surgical excision. This patient complained of existence of a mass and tenderness in the pulp of right index finger. The X-ray of hand revealed no significant abnormality. The patient was treated successfully with surgical excision. Surgery detected five small nodules measuring 0.5 to 1 cm in size. Histopathologic examination of the biopsy from the lesions confirmed diagnosis of cutaneous actinomycosis. Here, we report a cutaneous actinomycosis in a 34-year-old female located in the index finger.

Introduction: Frequency of extended-spectrum beta-lactamases (ESBLs) and its variants may vary in different geographical areas, as reports indicate their spread in some certain communities. The aim of this study was to determine the frequency of ESBLs in strains of Klebsiella and E. coli, isolated from patients hospitalized in teaching hospitals of Yazd. Methods: This cross-sectional study was carried out on samples including E. coli and Klebsiella strains collected from laboratories of Shahid Sadoughi and Shahid Rahnemoun hospitals in Yazd, Iran in the period of 2011-2012. The colonies which were positive in lactose Eosin methylene-blue (EMB) medium were identified by biochemical methods, and 270 strains of Klebsiella and E. coli were isolated. Collected data and information were analyzed using Fisher's exact test and descriptive statistics such as mean in SPSS software, version 15, at a significant level of 0.05. Results: In this study, 270 samples were examined, including 152 samples of E. coli (56.3%) and 118 samples of Klebsiella pneumonia (43.7%). Among the 152 samples of E. coli, 45 strains (30%) were producers of ESBLs. In addition, among the 118 samples of Klebsiella pneumonia, 44 strains (37.3%) were producers of ESBLs. E. coli strains showed the most resistance to Cefotaxime (100%), Ceftazidime (97.7%), and Cefepime (75.5%) respectively and Klebsiella strains showed the most resistance to Cefotaxime (100%), Ceftazidime (100%) and Cefepime (79.5%), respectively. Conclusion: Frequency of ESBLs in Klebsiella strains was higher than E. coli strains. No significant relationship was found between frequency of ESBLs and age or gender. In addition, E. coli strains showed the highest sensitivity to Imipenem, Amoxicillin/clavulanate, and Ciprofloxacin, while the highest antibiotic sensitivity of Klebsiella strains was shown to be to Piperacillin, Imipenem, and Amoxicillin/clavulanate.

A two-day-old female neonate, weighing about 2910gms at birth was presented with swelling in the lower abdomen, above the pubic area. She was born at 37 weeks gestational age with caesarean section delivery. There was no evidence of urinary or fecal incontinence. Physical examination revealed a low-set umbilicus, a defect between umbilical and symphysis pubis and widening of the symphysis pubis. On physical examination, spinal alignment was not normal. Labia majora were separated and the anus was in normal site but the patient had widened perineum [Table/ Fig-1].The vital signs were as follow: pulse rate 138 beats/ min, temperature 36.7°C, respiratory rate 40 breaths/min, and O 2 saturation 95%.The laboratory tests including haemoglobin, White Blood Cell (WBC) count, neutrophils, lymphocytes, platelet count, blood glucose, Blood Urea Nitrogen (BUN), serum creatinine, sodium; potassium, serum albumin, Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT) and C-Reactive Protein (CRP) all were in normal range. The urine analysis and serum biochemistry were normal. Echocardiography (ECG) revealed a normal heart. The neonate was made NPO and was monitored. The neonate was infused intravenously by dextrose10% with 3meq/kg NaCl. The X-ray revealed widening of the symphysis pubis (more than 4cm) and scoliosis [Table/ Fig-2]. Ultrasonography revealed absence of the left kidney with a normal right kidney.Cystography was performed for evaluating bladder volume and vesico ureteral reflux. . Bladder volume was normal and there was no evidence of vesicoureteral reflux.As the pubic diastasis was greater than 4cm, pelvic osteotomy was planned to repair the abdominal wall and pubic diastasis. An Orthopedic surgeon performed osteotomy of innominate bone in the superior part of acetabulum and closed symphysis pubis [Table / Fig-4]. The osteotomy site was fixed by pin. Bladder and urethra was freed from the abdominal wall. Then, the pubic was closed with 0 silk sutures. The abdominal wall was closed successfully. Repairing of perineum and external genitalia was delayed to 3 to 6 month later. The surgeon explained the disease to the parents and noticed them about another surgery next 3 to 6 month. It was informed that patients with this problem usually have normal urinary continence and internal sphincter mechanisms usually are intact. We requested adequate nutrition, use of postoperative antibiotics, ureteral stenting catheter and postoperative immobilization. DisCussionVariants of the bladder exstrophy complex are rare. Pseudoexstrophy is an exstrophy variant which has all the characteristics of the classical exstrophy without urinary tract defects [1]. The incidence of classic exstrophy is approximately 1 in 40,000 births. Exstrophy variants are less common [2], and pseudo-exstrophy of bladder has been described as an uncommon condition [3]. Keywords: Congenital anomaly, Musculoskeletal defects, Surgical managementAbdolhAmid Amouei 1 , mohAmmAd bAghi YAzdi 2 , FAtemeh ehSAni 3 , mojtAbA bAbAei zArch 4 aBstRaCt Pseudo-...

Introduction: Trichotillomania (TTM) is a type of impulse control disorder with chronic hair pulling. It effects on behavior, feelings, thoughts and quality of life. Case Presentation: The patient is a 28 year-old single woman that was referred to hair transplantation. She was worried about her appearance, cosmetic problems and marriage. The physician noticed that she is a patient with trichotilomania type of impulse control disorder. After confirming the diagnosis of trichotillomonia by a psychiatrist, pharmacotherapy begun with Rispridone 1 mg at night, Fluvoxamine 50 mg/daily and Clomipramine 5 mg at night. Over nine months of treatment there were significant reductions in hair pulling. She was followed up and finally, the response was acceptable. Conclusions: TTM is a poorly understood disorder that requires more studies. Despite what we know about TTM, those with the disorder report not receiving enough information for diagnose and treatment. However, the information presented in this paper can help us to prevent this disorder, reduceing the prevalence and selecting the appropriate treatment.